Municipal Health ServicesThe Local Government PerspectiveEastern Cape Example

SALGAConsultative Meeting on Municipal and Primary Health

Care (Discovery Auditorium, Sandton)08 April 2011

Background

Legislative framework Constitution (Act 108, 1996)– Schedule 4B Local Government: Municipal Structures Act

(Act 117, 1998) – S84(i) National Health Act (61 of 2003) – Definitions &

S32(1) MINMEC decision – MHS and who should

render DORA Bill, 2006 – MHS – “Basic Service”

Introduction

SALGA requested the Eastern Cape to present on

our experience with the devolution of MHS

Eastern Cape one of the poorest provinces

The province consists currently of one Metro

(NMMM) and 6 District Municipalities

One aspirant metro (Buffalo City)

Governance arrangements

ECDoH facilitated and coordinated the Provincial Environmental Health Devolution Task Team (PEHDTT) - 2003 Chairperson of PEHDTT– alternated between ECDoH and LG. Consisted of Metro, DM and ECDoH environmental health

management Working Committees established to collect data

Also established District EH Devolution Task Teams at each DM and Metro Consisted of Local Government and Provincial EHPs Union representatives (Local Government & Government) Directors / Managers to whom EHPs report Politicians (Ad hoc feedback) Reported to District Management Team (ECDoH); Top

Management and Standing Committee and PEHDTT. ECDoH – reported to PHAC and PHC and subsequently to Parliament

Initial process

PEHDTT’s Working Committees collected data necessary

for the devolution of MHS e.g. Staff information; available

equipment.

Invited DWA – Share best practice with integration of

water function to the WSAs

Invited Unions (Government) and the Bargaining Council

to inform them and to get direction – S197 of LRA -

Medical Aid and Pension fund issues.

Regular PEHDTT meetings from 2003 till 2006 –

Aeroplane

Challenges

No further substantial progress with ECDoH – irregular meetings

Numerous national due dates were set for devolution (2004 then 2006 and the latest was April 2010) which resulted in: Provincial colleagues resigning – prolonged devolution

process. JGDM – 45% Provincial EHPs resigned in 18 months ADM – 5 Provincial EHPs resigned in one month

Provincial EHPs not benefiting from car allowances etc. >90% EHPs are without transport

Lack of establishment cost for provincial staff Provincial staff mostly without transport and equipment

Lack of an exit strategy from DoH such as DWAs.

Challenges (Cont. 1)

LG cannot populate organisational structures – wait for provincial staff

Shortage of EHPs at LG, services that are not properly structured and little to no growth opportunity for EHPs at DMs leads to frustration from LG’s own staff - JGDM 83% EHP staff turnover in past 5 years

Environmental health not regarded as priority Support from authorities Governments strategic monitoring of basic services – “Turn

Around Strategy” – LGTAS – did not reflect on MHS – weekly monitoring (R 1; R 2; New conservancy).

Challenges (Cont. 2)

Ratio of EHP per population (SA - 1:15 000) (WHO – 1:10 000) – Attitude of Management – can never have the ideal situation.

(Community Service EHPs – National Programme) – No transport, office accommodation, some accommodated without skilled EH support

Sustainable funding beyond 3 year funding from ECDoH (2009/10)– National Treasury model (MHS not income generator)

Equitable Share (Basic Services) not ring-fenced for EH – R2m only received R200k internally.

Results

After 2006 lack of progress through ECDoH, we resorted to SALGA EC

Meetings with MEC for Health and LGTA National surveys on the progress with the devolution of

MHS – 2006 and DBSA, 2007 – Presented at national forums – give momentum.

Interaction with National Treasury – costing Department Housing, Local Government and Traditional

Affairs made funding available - S78 municipal capacity assessments (R280 – R300k)

Follow up PEHDTT – Workshops (Nov 2009) Service Level Agreement ECDoH – funding – 3 years at 100% (2006/07 till 2008/09) Funding and transfer of staff not synchronised

Results (Cont.)

Presentations to SALGA EC resulted in buy-in SALGA EC – MHS Working Group established

Elevate to SALGA National SALGBC – 2010 - Working Group

Special Resolution submitted to April 2010 Local Government Summit

Appointment of permanent National Environmental Health Director Interaction at national level between DoH; COGTA and National

Treasury Functional integration initiatives between LG and ECDoH to use

provincial staff locally. ECDoH – negotiated with individual DMs for transfer A few DMs in advanced stage to receive provincial EHPs by 1 July

2011.

Recommendations

Develop a proper devolution framework and monitor its implementation.

COGTA should be more strategic – Municipal Turn Around Strategy (LGTAS) – focus on “basic services” but it does not reflect MHS

Do such surveys on a regular basis also for MHS – include legal requirements such as S78 capacity reports; budgets, inclusion of MHS in IDP, ornanisational structures and vacancy rates; progress with devolution and integration of MHS at DMs and Metros, etc.

Recommendations (Cont.)

Use and understanding of terminology which negatively affects Environmental Health / Municipal Health Services Health Services Environmental management

Facilitate a proper national costing study for MHS – National Treasury challenges our figures.

Clarify the use and preparedness of LG for accepting and managing Community Service EHPs.

“Usana olungakhaliyo lufela embele kweni”

CLAIM YOUR SPACE!!!!

Support for Municipal Health Services from National and Provincial Structures

InstitutionGood % Average % Poor %

EC Nat EC Nat EC Nat

NDoH 0 0 17 24 83 68

PDoH 33 24 17 44 50 29

DPLG 17 9 33 18 50 65

SALGA 0 3 17 21 83 53

SAIEH 0 3 67 32 17 59

Unions 17 24 17 24 33 34

Source: National devolution progress surveys - January and July 2006 and DBSA survey, 2007

Eastern Cape Province in relation to South Africa

MUNICIPALITIES Metropolitan = 6

District = 46

Local = 229

National EH Indicators – George, October 2004

Monitoring the Impact of MHS Policy Implementation January 2005

Financing EHS in SA May 2004

MINMEC Decision 21 August 2003

National Summit Polokwane May 2004

2 year transitional period

SALGA: Workshop on MHS March 2005, JHB

Draft National Environmental Health Policy October 2004

DBSA Development Dialogue on MHS, Midrand , March 06

9 October 2002 Cabinet decision

1 July 2004 Implementation

date

1 July 2005 First Municipalities

taking over functions

Developments with regard to the interpretation and implementation of MHS in South Africa since the Cabinet decision that EHS will be MHS and the function of Metropolitan and District Municipalities from 1 July 2004.

National Framework for the Devolution of EHS in SA – Implementation Strategy, March 2004

FFC Submission: Financing PHC and EHS in SA August 2004

SAIEH Conference – Municipal Health Services Feb 2006

MHS Conference, East London 28-30 November 2006

Time Line

Seminar on Implementing MHS, July 2006, Pretoria

DBSA Research, Delivery of MHS by DMs in SA, July 07

JOE GQABI DISTRICT MUNICIPALITY

Municipal Health Services March 2008

41%

Progress with the devolution/consolidation of MHS (New or extended service – Municipal Systems Act)

VariablesEastern Cape %

National %

Section 78 assessment undertaken 100 60

Approved S. 78 report 83 23

DMs Service Level Agreement with LMs 67 13

MHS part of Integrated Dev. Plan 83 60

MHS budgeted for 2006/07 100 27

Integrated Multi year budget approved 100 21

DMs take transfer of staff from LMs 40 27

Sewerage pump station

Sewerage Balance Drain – Engineering solution - >10 years

New Sewerage Pumps – 6 months after transfer of LM EHPs to DM

Sewerage spills in communities

Sewerage spills monitored weekly by EHPs

Broken sewerage connections – Who cares?

Politicians, Engineers and communities want structures.

MHS/EHS concerned with operations not causing a health hazard

to communities to prevent illnesses from occurring – sometimes

conflicting – substandard facilities.

Damage to infrastructure - maintenance

Housing development: Quality of Workmanship

Condition at landfill site – lack of control and management

Infrastructure damaged due to a badly managed landfill site

Local municipal workers offloading waste in non demarcated area on landfill site

MHS monitors and compliance enforce as part of pollution control and waste management

each year at least 3 million children under the age of 5 die due to environmental related illnesses

90% of Acute Respiratory Infections world wide

80-90% of Diarrheal cases -contaminated water and inadequate sanitation.

90% of malaria cases are attributed by environmental factors

Millennium Development Goals??

After 6 years of continued monitoring by EHPs – improved sewerage system – only clean for 2 months – Honey sucker services terminated – EHPs frustrated – what is my role and purpose?

Current cost of MHS – 2009/10

Expenditure Income Balance

Alfred Nzo DM 12,176,334 5,659,000 -6,517,334

Amatole DM 22,818,963 14,069,196 -8,749,767

Cacadu 11,402,877 4,741,000 -6,661,877

Chris Hani DM 23,818,521 11,400,000 -12,418,521

OR Tambo 19,749,963 20,779,000 1,029,037

Joe Gqabi DM 10,225,788 5,208,487 -5,017,301

NMMetro 29,162,483 13,726,000 -15,436,483

Buffalo City (Metro) 22,767,107 10,674,804 -12,092,303

152,122,037 86,257,487 -65,864,550

Future funding implications Eastern Cape - Shortfall

2009/10 2010/11 2011/12 2012/13

Expenditure 152,122,037 166,573,630 182,398,125 199,725,947

Income 86,257,487 86,257,487 86,257,487 86,257,487

Shortfall -65,864,550 -80,316,143 -96,140,638 -113,468,460

Per Capita Cost R23.58

Per Capita Income R13.37

Balance -R10.21

Equitable Share Allocation for MHS - Prediction to Reach R13/head

R -

R 2.00

R 4.00

R 6.00

R 8.00

R 10.00

R 12.00

R 14.0020

06/0

7

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

2013

/14

2014

/15

2015

/16

2016

/17

2017

/18

2018

/19

Financial Years

Per C

apita

R -

R 10.00

R 20.00

R 30.00

R 40.00

R 50.00

R 60.00

Per H

ouse

hold

Per Capita Cost NDoH Equitable Share per Household

5 – Yrs - DoH

Per Capita and Household Income and Expenditure for 2009/10 – MHS

0102030405060708090

100110120130

Income Cost Equitable Share

Per Capita and Household Income and Expenditure: MHS - 2009/10

Per Capita Per Household NDoH Target

NDoH – proposal – HST costing study