Provincial Governments Support for the District
Health System
5 & 6 August 2004
District Health System Development
Cornerstone of the NHSThe development of the District Health System is a process of decentralisation of PHC to LGAligned Health Districts to LG boundariesRelationship to Metros and District Councils through SLA (Bs thru DC)
Principles and elements
Based on Alma Ata Declaration 1976, ANC policy and WHO in developing countries with principles accessibility, equity etc
ElementsGovernanceServicesCapacity DevelopmentSystems (HR HIS Finance etc)Community Participation
Gauteng
Move to PHC services
Hospicentric District Health System
Governance
Constitution - accessibility, equity etcNational Health Policy GHD District Health System through LGSome provinces -provincialised & then decentraliseLegislation NHB & Gauteng DHS ActCooperative GovernanceConsultation
SPHERE POLITICAL OFFICIAL ORGANISATION
CONSULTATIVE
NATIONAL National Health Council (MinMEC)
National Health Advisory Committee(PHRC)
South African Local Government Association(SALGA)
National Health Consultative Forum
PROVINCIAL Provincial Health Council(PHA)
Provincial Health Advisory Committee(PHAC)
(SALGA) H & W Gauteng
Provincial Health Consultative Forum
METRO/DISTRICT
District Health Council
District Health Advisory Committee
(SALGA) H & W Gauteng
DHCF Community
LOCAL Local HealthCouncil
Sub-District Health Committee
(SALGA) H & W Gauteng
LGHCFCommunity
COMMUNITY Ward Councillor
Health facility managers
Ward Health sub-committeeNGOs/CBOsYouth, Women etc CHW CDW
Ward CommitteeCommunity
Framework for Process
Joint Process of Province and Local Government officialsPrinciples and guidelines for joint District processes
Defined issues to develop a District
Service PlanDefinition of facilitiesPackage of PHC services with priority programmesReferrals systemWorkload ratiosStaffingFinance expenditureResources and gaps
Facilities
PHC pkg of services within health sub- district area:ClinicsMobiles & satellitesCommunity outreachCommunity Health CentresDistrict hospitals
Sub-District Area 300,000 popul.
Key outputs of this process
Single list of PHC facilities by typeLinkage of personnel and expenditure as well as activity data to facilities / cost centresAccurate information on current staffing by standardised category Affordable norm-based staff establishment for joint / devolved / integrated PHC services (management and facilities) Rationalisation for equity & cost efficiencyMeasurement of gap between current and future / ideal cost for improved PHC delivery in line with MTEF – joint District Health Plan
Priority programmes
EPI & outbreak response co-ordinationCommunicable diseasesMother and child servicesANC/PNC and Primary obstetric servicesYouth & school health servicesHIV/AIDS/STI/TBNutritionNon-communicable diseases and minor injuriesChronic diseases hypertension, diabetesRehabilitation
Support for priority programmes in Primary
Health CarePrevention, promotion, curative and rehabilitative PHC services at each facilityFacility and community outreach servicesNational Policy & provincial guidelinesVertical support from Provincial officeAt Health District -all programmes comprehensive & integrated (HIV/AIDS/TB specific co-ordinator)Report through line function supervisors
Ward Health Sub-committees
Community participation
Constitutional rightsPatients Rights CharterBatho Pele principles of public sectorCommunity developmentWard health sub-committeeshospital boardsCommunity based services
BackgroundProcess of community health committees started 1997/8 in terms of National District Health PolicyNational Health Bill, ANC Policy, RDP Committees were used to draft Gauteng Policy73% Clinic/Community Health Committees established and meetings heldDecember 2000 new LG elections –2001 establishment of Ward Committees
Background (contd)
2002 Provincial Health Authority requested a revised vision/policy
Estimated only 52 % committees functioning
Training ongoing by health workers
Functions – health surveys in community, advisory to health staff, health promotion, campaigns, NGO & client complaint monitoring
Progress ReportDistrict October 2003 March 2004
Johannesburg Workshops held May & October1560 persons attended. Establishment of new Ward Committees. Of 109 Wards assess 37% in place.Training Nov & May 2004
Workshop 31 January 2004. Progress on target of 60% for May on 13 March 2004
Ekurhuleni Workshop held on 22 October 2003
50 % community health committees to be realigned by January 2004 75% of by March
Workshops all 9 health sub-districts. New Ward committees May & June.Ward to establish health sub-committees July 2004.
Tshwane Nine meeting held August 2003 with 47 Wards only 14 with health sub-committees. Mamelodi meeting to be held-follow up December
Ward Committees election held October 2003.Names of health reps for 76 Wards submitted. Training May 2004.
Sedibeng No report for WHSC co-ordinators meeting
Workshop held 4 December 2003. Information session held 18 February- 5 Ward Health Sub-committees established.
West Rand Workshop held 16 July 2003 - targets end August & end September 2003. WHSC established in Westonaria in August 2003
Ward health sub-committees established in Merafong City. Training before June 2004
Metsweding No report. Workshops for Ward Health sub-committees to be held after National elections.
Challenges
Not all Ward Committees establishedNeeds political commitment of Ward CouncillorsHealth facility managers in Ward need to be ex officio for accountabilitySome Wards have 6 clinics - others noneRepresentatives of existing clinic committeesHealth & Social Welfare combined at Ward level
Ward Health and accountability
WARD COMMITTEE COMMUNITY DEVEL.WORKERS(CDW)
NGOs/CBOs WARD HEALTH SUB-COMMITTEE District Health Services
Training supervision Community Health Technical support
Workers (CHW)
Community
Community Health Workers (CHW)
Guiding principles for implementation of policy document on CHW
Background
NGO/CBO pivotal/effective means of services close to communitiesCadre of CHW both paid & unpaid are in health NGOs/CBOs across the countrySome CHW are being used in the formal sectorNo standardised training (HWSETA)Different procedures & contracts/SLANo National framework
Gauteng processes
Embarked on process to develop a Provincial policy on CHW
Formalising the funding & operational procedures
Conducting an audit of all health NGOs/CBOs and services
Workshop held to discuss training
GDOH policy
Need for standardised name of cadre (Ancillary/CHW) CHWStandardise service and supervisionNumbers CHW and areas of serviceMultiskilled (HBC, DOTS, HIV, VCT)Level NQF 1 and training decisions HWSETANot extension of formal health structureCost of roll –out & sustainabilityService Level Agreement and monitoring
Implementation Plan
Workshop & establish District/sub-district Task TeamsMinimum stipend R500 for those underTrain TB DOTS supporters (1000 by 3/05))Train HIV/AIDS in TB DOTSAlign all training modules: IMCI, mental Train all outstanding modulesIncrease stipend to R1000 when all modules complete (3years)
Aligning the CHW generic training
HIV/AIDS HBC
PMTCT/VCT
TB DOTS
IMCI/ Nutrition
ECD
Mental Health care
Care for disability
Implementation plan progress
Register of all CHW –District/sub-district
Training commenced on 1000 TB DOTS
Generic course –69 days
Travelling funded by districts
Registration - CHW must belong to funded NPO
Minimum stipends- R500 at end course 04/5
Career pathing –HWSETA accredit
Implementation progress
Implementation structures –Prov. steering, district, sub-district task teamsWorkshops heldTwo weekly meetingsMonitoring of progress with reportsTraining of NPO staff –will be trained in and financial and organisational management
Intersectoral collaboration
National, provincial ,and local governmentSocial Welfare, Education, housing, safety & security, Dev. Planning & LG etcNon-governmental organisationsuniversities & techniconsunionsprivate sector
Funding Primary Health Care services
Provincial subsidies to LGMunicipal own fundingStaffing to render PHC servicesPharmacy drugs and laboratory costsuse of facilities & equipmentDistrict Health Expenditure Review (DHER) cost per visit & capita per facilitycost centeringControl and PFMA
Funding of PHC 2003/4
• The definition of PHC services traditionally included Personal PHC and Environmental Health Services.
• The new definition of Municipal Health Services, for the sake of comparison of funding between the years, Environmental Health Services
• Environmental Health Services funding is NOT included in PHC funding.
Funding of services components :
Provincial Funding :• Own Services• LG Cash Subsidy• Drugs (Provincial facilities and LG)• Laboratory (Provincial facilities and LG)• Programs (AIDS and Nutrition)• District Management
Local Government own contribution
LG TOTAL PHC
Province Own services
LG Cash Susidy DRUGS LABS PROGRAMSDistrict
ManagementTotal
LG Own contribution
Total PHC Exp
Prov + LG
2003-04Johannesburg 235,928 40,090 97,937 10,597 22,659 76,269 483,480 157,251 640,731West-Rand 8,749 10,740 8,997 977 7,886 50,051 87,400 18,178 105,578
REGION A 244,677 50,830 106,934 11,574 30,545 126,320 570,880 175,429 746,309
Ekhuruleni 70,997 46,916 41,853 6,569 23,465 15,599 205,399 141,427 346,826Sedibeng 71,174 21,856 7,628 709 32,502 15,343 149,212 25,745 174,957
REGION B 142,171 68,772 49,481 7,278 55,967 30,942 354,611 167,172 521,783
Metsweding 4,270 770 2,817 97 940 3,600 12,494 2,132 14,626Tshwane 78,331 8,950 30,802 2,056 9,631 41,400 171,170 82,724 253,894
REGION C 82,601 9,720 33,619 2,153 10,571 45,000 183,664 84,856 268,520
GAUTENG 469,449 129,322 190,034 21,005 97,083 202,262 1,109,155 427,458 1,536,612
PROVINCIAL RESOURCES
VINCIAL AND LG FUNDING OF PHC SERVICES IN 2003-04
CLINIC SUPERVISORY MANUAL
Background
Implemented in Gauteng 2001Provincial Workshop November 2001District workshopsRegular, Red Flag and TB in-depthTwo to three monthly District reviewsProvincial Workshop August 2002Roll-out to EPI, STI, MCH & drug mgmtProvincial Workshop March 2004 & full roll-out
Review RegularDistrict Regular Impact Challenges
City of Joburg 40-60% Training needs, standards & support
Funct integration follow up & referrals
Ekurhuleni 50-60% Gaps identified Recording & action plans
City Tshwane 60-100% Absenteeism, equip & training
Funct integration & hosp referrals
Sedibeng 60-100% Ownership & teamwork
Contact tracing drug Mx
West Rand 80-70% Gaps identified, training needs
Absenteeism equip, turnover
Metsweding 30-100% Better teamwork Delay medicine supply, transport
In- depth ReviewsDistrict In-depth Impact Challenges
City of Joburg
30%
TB, STIs, EPI Training & supp TB/HIV tool
Drug shortages
Referral systems
Ekurhuleni
30%
TB, STIs, EPI Recording & training
New cards, protocols,DOTS
City Tshwane
70%
TB,STIs, EPI, Maternal, child, drug mx, DHIS
Identifies gaps & training
Maintain mx
Drug utilisation
Sedibeng
60%
TB STIs, EPI, chronic care, drug mx, DHIS
Gaps identified & training
Drug mx, standardisation of order system
West Rand
40%
TB, STIs, EPI, contraceptive
Identifies gaps Cover all sub-districts. Snr Mx
Metsweding
50%
TB, STIs, mater-nal,drug mx
Training & gaps identified
Drug supply & integration
Progress & challenges
Improvement of implementation to 75% overallAdoption by MEC and MMCs Jan 04Adoption in Strategic Plan and PMAsRoll-out all tools in 2004Specific drug/HIV/AIDS management emphasisQuality supervision = quality service (TQM input>process>output)
National principles on way forward
Definition of Municipal Health Services EHSPHC delegation by SLANational mechanism for transfer of staff (one public service)National mechanism for funding Provisional timeline startJuly 2004Interim measures
Joint Management Functional integration
Way Forward
Decentralisation of PHC services is going to take timeDistrict Health System also involves hospitals which are not for decentralis.Until all mechanisms are in placeServices continueWork together and find solutions through joint structures