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