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2 Published by The Health Systems Trust 401 Maritime House Salmon Grove Durban 4001 Tel: Fax March ISBN Also available on the internet: Author: Jillian Nicholson Text advisors and content editors: Beth Englebrecht, David McCoy, Antoinette Ntuli Illustrator: Ian Lusted Design and layout: Jessica Nicholson Every attempt has been made to ensure that the information published here is accurate. However no responsibility is accepted for any loss or damage that may arise out of the reliance of any person upon any of the information in this book. This publication was supported with a grants from the Henry J. Kaiser Family Foundation (USA) and the Rockefeller Foundation.

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4 Bringing health closer to people has long been a goal for us in South Africa. Putting this idea into practice means that health care should be provided by local government, the sphere of government closest to people. The demarcation of the municipal boundaries, and the local government elections in the year 2000, signaled a critical step towards achieving this goal. This book provides information about the process of transformation of local government and what the devolution of health care to local government is likely to mean for the provision of health services. It has been written with health workers and legislators in mind, although it is likely to be of use to a wider audience including local government councillors and NGOs among others. Legislators have a critical role in overseeing policy implementation and this book will contribute to equipping them to monitor the decentralisation of health care services. As with every major change, it is inevitable that some uncertainty is created. The process of transformation is not yet complete. There are still many areas that remain unclear and many decisions that need to be taken. This book provides a useful interim guide that helps to answer some of the numerous concerns and questions that are frequently being asked about what is happening. Dr. Abe Nkomo Chair of the National Assembly Portfolio Committee on Health

5 What is local government and why is it important to the health system? Phases in the transformation of local government Two important features of the new system of local government Local government will be developmental Local government will have more power: changing from tiers to spheres The new municipalities: boundaries and categories Wall-to-wall municipalities Cross-border municipalities Three categories of municipality Powers and functions of these new municipalities Prioritising for development What about the health services? Financing local government Working together: the relationship between local, provincial and national governments The role of provincial governments Co-operation between municipalities Summary: the essential points of this section Changing the approach to health care in South Africa The Primary Health Care approach to health The District Health System Local government and the District Health System: issues to be finalised A legal framework for the health system How will health districts be aligned with new municipal boundaries? How will health districts be managed and controlled? How will health service be delivered? The transferring of health workers Funding for the new municipalities and health districts Ensuring equitable redistribution Summary: the essential points of this section

6 The system of government in this country is going t h rough important changes. With the finalisation of new municipal boundaries and the passage of the Municipal Systems and Municipal Stru c t u res Acts, local government is set to play a far more significant role than it has in the past. These changes mean that new management s t ru c t u res will have to be established, new functions taken on board and new lines of communication set up. This section gives some background to the development of local government in the country and explains the changes taking place and the new system that is being set up. Local government is the level of government that is closest to people. It a ffects how people live, work, raise families and spend their spare time. S t rong local government can help to improve basic services and facilities and build equity. It is there f o re very important for communities and their organisations to be involved in matters of local government. Since 1993, when an Interim Constitution was adopted for South Africa, local government has been going through a process of transformation. This transitional phase ended with local government elections on 5 December

7 Some of the reasons why it is important to be clear about the new local government system are: The national government has made a policy decision to have strong local government in South Africa that will be responsible, among many other things, for delivering municipal health services. The changes in local government directly affect the proper functioning of the District Health System. Legislators will be making decisions about local government that will have important implications for health delivery. What is the difference between local government and a municipality? In this book the term local government is used to describe the whole system of gove rnment at the local level. We talk about national, provincial and local govern m e n t. The word municipality is used to refer to a specific area of land, the residents and communities within it, its governing council and the staff employed by the council. There are three different kinds of municipalities. These are described on page 12. The apartheid system repressed the social, economic and political lives of South Africans. Most people lacked the basic necessities which government should provide housing, health care, water, sanitation and electricity, for example. Black people were excluded from national and provincial government and black municipalities had no power and no democratic base. They were administrative agents of the white provincial governments with no powers of governance of their own. 2

8 As you can see in the diagram, there was a top-down approach to governance. Local government was the lowest tier of government. National Government Provincial Government Local Government 3

9 The struggle for democratic rights at the local government level intensified in the 1980s, with organised mass action against the apartheid city stru c t u res. Communities and their org a n i s a t i o n s demanded improved services and opportunities and a much gre a t e r say in their local affairs. This led to the formation of local negotiating f o rums with re p resentatives from civic associations, community and residents associations, trade unions and political parties. By 1993 a National Local Government Negotiating Forum had been formed to coo rdinate the local forums and guide the transformation process. The 1993 Interim Constitution entrenched this right to transform local governance though negotiations with communities. There are three phases to this process: The Pre-Interim Phase: this was between 1993 and 1996 when the new Constitution was passed and the first local government elections were held. The Interim Phase: this was between 1996 and the second local government elections in December The final stage, which has now been reached, when a new local government system starts to operate. During the Pre-Interim phase the local forums were formally recognised. They were given responsibility for setting up transitional local government structures based on the principles of non-racism, democracy, and accountability. A number of different types of councils were established to replace the old apartheid structures. This included metropolitan transitional councils, local transitional councils, transitional representative councils, transitional rural and district councils. There were also some remaining areas that did not fall into any of these categories. 4

10 In 1996, people were elected onto these councils in the country s first democratic local government elections. Between 1996 and December 2000, the transformation process continued. Although many of the old racial barriers were removed, the new boundaries of the interim local governments still reflected a racial divide. The old white towns had Transitional Local Councils. The surrounding townships and rural areas had Transitional Representative Councils. So the system was still fragmented, with too many different types of local structures. There were huge inequalities and backlogs in the provision of services. Many of the new councils did not have the capacity to manage their funds and some became bankcrupt and ineffective. Both these problems continue today. In the final stages of transformation, the Municipal Demarcation Board was set up. Its job was to re-draw all the local government areas and to develop a system that would be sustainable, effective and efficient mass action against apartheid cities 1993 formation of local negotiating forums and National Local Government Negotiating Forum transitional local government structures set up 1996 first democratic local government elections final stages of transformation Municipal Demarcation Board establishes new municipal boundaries throughout the country December 2000 second democratic local government elections the end of the transitional stage. 5

11 South Africa s new local government system differs in fundamental ways from the old apartheid system and also from the transitional system that ended in December It is a new and exciting form of local government that gives substantially more power to municipalities and their residents. A culture of public participation in the affairs of local government is encouraged. This is what people in the 1980s were fighting for. Two central features of the new local government system are: The Constitution states that local government in South Africa must be developmental. This means local governments must work with their communities to improve economic and social conditions and to overcome inequality. Equitable redistribution is central to the system. To do this, more resources must be directed to the areas that have the least resources. In terms of the constitution, the objectives of local government are to: provide democratic and accountable government for local communities; ensure the provision of services to communities in a sustainable manner; promote social and economic development; promote a safe and healthy environment; encourage the involvement of communities and community organisations in the matters of local government. 6

12 This is a big change from the past, where local government was mainly concerned with providing services to white communities and with matters such as traffic regulation, issuing licences and looking after parks and recreation. Talking about tiers and spheres may seem like playing with words, but in fact the words are used to describe two very diff e rent systems. As you saw on page 4 the tier system is a top-down approach. Local government is the lowest level and the national government is all-powerful. The Constitution has specifically chosen to use the word spheres, to describe the national, provincial and local governments in the country. A s p h e re is a round shape. It does not have a top or a bottom. The diagram (right) and the picture on the next page show three spheres. You can see that one is not above the other and that at some points all spheres are linked to each other. They represent the system that has now been set in place in South Africa, where national, provincial and local governments function within a framework of co-operation. This is sometimes called a decentralised system. You can read more about this on page 16. National Government Local Government Provincial Government 7

13 Local governments are no longer just the agents of the provincial governments. They now have the power to make and carry out laws, raise taxes and govern themselves in all matters that have been allocated to them by the Constitution. They include municipal health services. However, these still need to be much more clearly defined. Although it is useful to see each sphere of government with its own areas of responsibility and authority, ultimately all spheres of government have joint and shared responsibility for ensuring that the basic services of the population are met. Therefore, it is important that the three spheres of government work towards a common vision of equitable, effective and efficient delivery. 8

14 South Africa now has new municipal boundaries and new types of municipalities, with new powers and duties. The Municipal Demarcation Board was given the responsibility of dividing the country into new municipalities. Every bit of land in South Africa is now part of a municipality, including all farming areas and are a s which fall under traditional leaders. We have wall-to-wall municipalities. 9

15 In order to make sure that each new municipality could provide developmental local government, the Board combined a number of areas that had previously been separate. Some rural and urban areas were combined to form one municipality; towns were sometimes combined with other towns and sometimes an urban area was extended to include an informal area close by. The number of municipalities has been reduced substantially, from 834 to 285. When it set the new boundaries the Demarcation Board looked at a number of different factors in each area. For example, it looked at the size of the population, employment and employment opportunities, the incomes of people, water supply and whether it would be financially possible for an area to provide the services that a local government has to provide. It looked at the existing health boundaries and the way that health services were co-ordinated. The Board was supposed to take into account everyday factors such as how the health services in the area were run, where children attended school, traffic flows and even newspaper deliveries! A c ro s s - b o rder municipality is a municipality that lies across the bord e r s of two provinces. There are six of these cro s s - b o rder municipalities. T h e re has been some confusion about which province is responsible for these. Here are some points to help clear up the confusion: Both provinces concerned must agree to the existence of the crossborder municipality. If they do not agree to it, then it will be deestablished and the Demarcation Board must make new boundaries that do not cross into another province. 10

16 In the case of a cross-border municipality, the Member of the Executive Council (MEC) for local government in both provinces must decide how the provinces are going to carry out their executive responsibilities towards this municipality. There are a number of options for this. They can share these responsibilities or they can delegate them to agencies to carry out. An agreement must also be reached about how the laws of the provinces will apply to that municipality. It is possible for an agreement to be reached where the laws of only one province will apply to the cross-border municipality. 11

17 The Constitution provides for three categories of municipality. Each has different powers and functions. There are six metropolitan areas in the country Cape Town, Durban, East Rand, Johannesburg, Pretoria and Port Elizabeth-Uitenhage. These are large urban areas incorporating one major city and a number of smaller towns. The entire area is divided into wards. Voters elect councillors onto a Metro Council that has authority for all local government matters in its area. A Category B municipality is a single local municipality. Voters in a Category B area elect councillors onto a Local Council. This Local Council may also decide to divide its area into wards. All local municipalities also fall under a district municipality and share some authority with the district municipality (see below). There are 232 of these Category B municipalities Category C municipalities have authority in an area that includes more than one Local Council. The category will have a District Council that will consist of some councillors voted directly onto it and some who re p resent the local councils within the district. Inside some Category C municipalities there will be some areas that do not have a Local Council. These are called District Management A reas. Residents of these areas do not have a local council of their own but fall directly under the District Council. The diagram on the next page shows the new municipal boundaries for the Western Cape. It is divided into local municipalities, district 12

18 management areas and district municipalities, with one metropolitan area. You can see from the map that district councils consist of a number of local councils, with some district management area. District Municipality Local Municipality Cape Town Metropolitan area District Management area Local Municipality All these municipalities have been legally established and their new boundaries, categories and names have been published in the Government Gazette. 13

19 All categories of municipalities must have the legal power and authority to govern their areas effectively. They will be able to make and carry out laws to promote developmental local government and will be responsible for the administration of their area. Section 156 (5) of the Constitution says: a municipality has the right to exercise any power concerning a matter reasonably necessary for, or incidental to, the effective performance of its functions. All municipal councils have to draw up development plans for their areas. These are called Integrated Development Plans (IDPs). Amongst other things, these plans must say how councils are going to provide necessary services, what they are going to prioritise and how they are going to make use of their resources. Councils have to make difficult choices when they develop these plans. They have to say where the money will come for the IDP. The IDP also has to say which department or 14

20 programme will be responsible for delivering all the services. These are important issues for health services. As far as health care is concerned, there are some very broad guidelines for local government but little clarity on the details: The Constitution says that municipal health services are the responsibility of local government. The Municipal Structures Act together with its Amendment Act says municipal health services are the responsibility of metropolitan and district municipalities, not local municipalities. The Constitution also says that health services generally are one of the matters that can be handed over from a national or provincial government to a municipality if the municipality has the capacity to take over this responsibility. As you can see, this is not very helpful. There is no clear definition of either health services or municipal health services so there is no clarity about what health services local government will be responsible for. Some provinces and local governments think that municipal health services should mean all primary health care services. Others argue for a narrower definition. 15

21 There is some speculation that municipal health services only mean environmental issues affecting health, such as the supply of clean water and sanitation. Decisions still have to be made through negotiation and agreement. A critical issue related to this, is funding. Municipal health services will be funded by the national government. Exactly how this will happen still has to be decided. Any additional functions will have to be financed from the provincial departments of health. What do you think about decentralisation? As you have seen, the new system of local government aims to give more powers and responsibilities to local government. This is a decentralised system. There are disadvantages and advantages to decentralisation in relation to health care. The advantages are: Decisions about health care and health management are made at local level which is closer to the people affected these decisions. Decisions are more likely to be appropriate for the needs of the people in an area than if they were made at national level. There is the possibility of better community participation in the health issues of their area. There will be greater accountability on the part of local authorities because the people of the area have elected Councillors. Some of the possible disadvantages which people raise are: Decentralisation can weaken the national Department of Health and lead to a lack of coordination between the various levels of a health system. 16

22 Unless funds and resources are distributed equitably, a decentralised system could lead to greater inequities in health and health care between municipalities. The interests of everyone may not be properly represented if powerful factions control decision-making and resources at a local level. Decentralisation may result in different working conditions and in unequal pay for the same work in different municipalities, leading to a form of fragmentation. Decentralisation can lead to job insecurity, confusion and a loss of morale amongst staff. Many of the municipalities in South Africa have been in a serious financial crisis. Some of the reasons for this are: They have had to finance the huge backlogs in services in poor areas that were neglected by the apartheid government. Lots of people do not pay rates and service charges. There has been poor financial management in some municipalities. Combining the old apartheid municipalities into a more efficient local government system has been very expensive. Municipalities are now faced with still more costs due to the increase of their responsibilities and functions. In many instances, it is unclear how these functions will be financed, but they do have the power to decide how they can raise more money to fulfil their responsibilities. Municipalities try to finance some of their day to day expenditure from their own revenue sources. They raise money from property rates, charges on services and taxes. 17

23 H o w e v e r, most municipalities, particularly in the rural areas, do not have a large enough tax base to bring in enough finance to cover all their needs and also receive grants from national and provincial governments. In some areas such as the former Transkei where the overall majority of the population live in poverty, local government will have little chance of raising their own revenue and will continue to be dependent on national revenues. In order to work towards equity, poorer municipalities should receive a larger portion of these funds. 18

24 In order to govern effectively, local government needs to have a voice in the provincial and national governments where laws are made, and where budgets are passed. Each province has a Local Government Association that re p resents all the municipalities in the province. Representatives from these pro v i n c i a l associations form a national association the South African Local Government Association (SALGA). These bodies can promote cooperation between municipalities, between local government and the p rovincial government and between local government and the national government. They are represented on the National Council of Provinces and at national level on the Local Government MINMEC which is a national committee dealing with all matters affecting local government. The members of MINMEC are the Minister for Provincial and Local Government Affairs, the nine provincial Members of the Executive Council for local government and Salga. Provincial governments play an important role in supporting local government. Some of the ways that they do this are: To provide strategic and policy direction. They help with the overall development of local government in the p rovince and making sure that the development plans of the municipalities are viable in terms of the development of the whole p ro v i n c e. They help build capacity, particularly in the poorer municipalities. They establish forums and processes so that local government can be included in the decisions that affect it. 19

25 They monitor municipalities to ensure that they fulfil their functions as set out in the Constitution. They monitor the financial state of municipalities. They intervene, if necessary, in the affairs of a municipality. Municipalities can gain a lot by building relationships with each other and co-operating in the delivery of services. For example, they can: Share staff and technology this could help health services in for example the procurement of drugs. 20

26 Undertake joint investment projects such as for tourism. S h a re the cost of things such as bulk services (for example, sanitation projects or sharing infrastru c t u re such as dams), consultants and equipment. Provide services for each other. For instance if a local council cannot remove solid waste in its area, the district council could take over this responsibility. The essential points of this section The new system of local government increases the powers, responsibilities and accountability of municipalities. There are now wall-to-wall municipalities throughout the country. There are three categories of municipality: a metropolitan municipality, a district municipality and a local municipality. Several local municipalities will be part of one district municipality. Local government is constitutionally responsible for municipal health services, but as yet there is no precise definition of the functions of the municipal health services. Some municipalities will not be able to increase their responsibilities for health unless they have assistance from their provinces or the national government. Decisions still have to be made regarding exactly what health services each municipality will provide. 21

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28 Anew approach to health has been established for the country, based on the principles of the Primary Health Care approach and the District Health System. It would be very satisfying if we could take this approach and the new local government system and fit them together like the pieces of a puzzle. But this stage has not yet been reached. Important decisions have to be made before the puzzle fits together completely. This is a difficult time for people involved in both health and local government. Health workers are frustrated because health systems that were put in place after 1994 are once again changing. Lack of clarity is also a frustrating factor. Local government staff and councillors are under great pressure as they take on more and more responsibilities. Provincial and national legislators will play a critical role in making new laws, policy decisions and in monitoring and supporting the new system. This section gives a brief explanation of the new approach to health. It then deals with the restructuring that has taken place in the health system and with what we do and do not know about how local government is going to work together with health authorities to provide a cohesive, integrated health system. 23

29 The apartheid health system was one of the most unequal, fragmented and wasteful in the world. Fourteen different health departments administered health and duplicated services on a racial basis. There were ten bantustan health departments, three own affairs health departments for the white, coloured and Indian population and one general affairs department. There were also provincial health departments as well as 382 local authorities that were responsible for some health issues. Hospitals were segregated until 1990 and even when this fell away, they were still controlled by racially segregated health departments. 24

30 The old government adopted a medicalised approach to health. This emphasised curing disease rather than preventing it. It focussed on hospital-based medicine and the use of advanced technology. The health system was also very fragmented. For example, services that helped prevent disease, such as immunisations, were separated from services for treating disease. The problems inherited from the apartheid system were enormous, but in the years since 1994 major strides have been taken to meet the challenge to overcome them. Restructuring the health sector has the following aims: To unify the fragmented health services at all levels into a comprehensive and integrated national health system. A district health system is seen as the best way to achieve this. To reduce inequalities in health service delivery. To mobilise all partners, including the private sector, non-governmental organisations and communities in support of an integrated National Health System. These aims are supported by the South African Constitution that states that everyone in the country has the right to: access to health care services, including reproductive health care. ( Section 27) and that children have a right to: basic nutrition, shelter, basic health care services and social service. (Section 28) In addition, everyone has the right to an environment which is: not harmful to health or well-being. (Section 24) 25

31 The Primary Health Care approach emphasises general health care rather than curative health care. The approach is based on the following principles: Resources must be distributed equitably. This does not mean that all areas must be given the same resources. It means that those areas that have the least resources should be given the most assistance. Communities should be involved in the planning, provision and monitoring of their health service. This allows for different needs to be met in different communities. A greater emphasis should be placed on services that help prevent disease and promote good quality health. There is a shift away from curative services. Technology must be appropriate to the level of health care. For example, this would mean ensuring that all clinics have fridges that work for the storage of vaccines before equipping them with hightech medicine facilities. There should be a multi-sectoral approach to health. In the Primary Health Care approach, the provision of nutrition, education, clean water and shelter become central to health care delivery. So, for example the Departments of Water Affairs and Education are important role-players within the health system. 26

32 Is there a difference between primary level health services and the Primary Health Care approach? Yes. There is an important difference. Primary level health services refer to basic health care services provided at the lowest level of the health system, usually by clinics, community health centres and district hospitals. Examples of these services are basic child and maternity care, family planning and school health services. Other levels of the health service are the secondary and tertiary levels. These tend to provide more specialised services through regional or academic hospitals. The Primary Health Care approach however is not related to a particular level of the health system. Its principles apply to the entire health system and all levels of service. This means taking a more developmental approach to health, where communities could be partners in health care; resources and finances would shift away from high-tech, tertiary hospitals to primary level services and specialist doctors would play a more supportive role to nurses working in clinics. This would be a critical move towards health equity. 27

33 The Primary Health Care approach requires a different system of health delivery to the one used in the past. The District Health System is this new vehicle for delivery. It is a system organised around areas and their populations. The country is divided up into health districts and health is planned, organised and managed at this district level. This is different to the system that was in place before 1996, where planning took place at national level and delivery at provincial or local level. For this system to work eff e c t i v e l y, it is important to get the size of a district right. It should be large enough to contain the full range of district health services, including a district hospital, but small enough 28

34 to allow efficient service delivery and community involvement. Ideally a health district should have a population of between and Some districts will there f o re cover a much bigger are a than others. The point of having health districts is to allow communities to interact with the people who manage health and to allow health workers to interact with people in other sectors that affect health, such as Water Affairs. Government health workers can also work together with nongovernment workers and with private health workers. In each health district: Primary health care must be delivered to all the people in the area. T h e re must be one health authority responsible for primary health care, including community-based services, clinics and district hospitals. A t p resent primary health care in South Africa is delivered by diff e re n t p roviders, at diff e rent times and in diff e rent places. Decisions about health care for a district should be made by that district s health authority and health council, and not at a higher level of the health department. Communities should have a real say over their own health care. Before the new municipal boundaries were set, 180 of these health districts were demarcated throughout South Africa, and interim District Management Teams were appointed to run most of them. 29

35 The District Health System and the new local government system have been developing separately and at diff e rent paces. The district health system began to be implemented much earlier than the new local government system and so it is quite far ahead in terms of p ro g re s s. However, the transformation of local government has now caught up with the developments within the health care system. An important step forward was the demarcation of municipal boundaries. The next step was the local government election. Now the overall vision of a decentralised health care system with local government playing a prominent role, through a district health system, can start to be realised. There are two fundamental challenges to the health sector: Firstly, the boundaries of the 180 health districts must be changed to come into alignment with the new municipality boundaries. Secondly, this is to be accompanied by a process of devolution whereby local governments are expected to take on some of the provinces responsibilities for the delivery of health care. Exactly how this will happen must still be decided. At the moment there are many problems and issues of concern. Many processes are incomplete and many decisions are still to be taken at provincial and local level. Some of the main issues that require finalisation are: 30

36 1. A legal framework for the health system. 2. How will health districts be aligned with new municipal boundaries? 3. How will health districts be managed and controlled? 4. How will health services be delivered? 5. The transferring of health workers. 6. Funding for the new municipalities and health districts. These issues are discussed on the following pages. 31

37 Since 1994 much of the responsibility for health has been in the hands of the provincial health departments who have taken the lead in transforming health. Some provinces have drawn up their own legislation, setting out how their health districts should be governed and a d m i n i s t e red. They have based this legislation on a national policy paper - the White Paper for the Transformation of Health Care in South Africa. However they have had no national laws to guide them. The current Health Act of 1977 is very outdated and a new National Health Bill is still being drafted. This lack of legislation has been and remains a problem for an integrated health system. In many instances the health district boundaries that were set up after 1996 are different from the boundaries of the new municipalities. 32

38 Now that the new municipal boundaries have been set, health districts will have to fall into line with these. Each province will have to decide on the best way to do this. Provinces will have to bear in mind that the size of a health district and the number of people in it, are important factors in an effective district. This is not going to be easy. Look at the map. It shows the health districts of the Western Cape. If you compare it to the earlier map on page 13 showing the three types of municipalities in the Western Cape, you can see that, excluding the metropolitan area of Cape Town, there are five district municipalities and twenty-four local municipalities or district management areas. But there were thirteen health districts demarcated. District Council boundaries Health District boundaries Vredendal Malmesbury Vredenburg Ceres/ Tulbagh/ Wolseley Central Karoo Paarl/ Stellenbosch Caledon/ Hermanus Grabouw Worcester/ Robertson/ Montagu Bredasdorp/ Swellendam Mossel Bay/ Langeberg Klein Karoo George Knysna/ Plettenberg Bay 33

39 There are a number of options for aligning health district boundaries: New health districts could be formed which have the same boundaries as the district municipalities. This would mean a big increase in the size and population in each health district and make the health district too large to co-ordinate primary health care services eff e c t i v e l y. The existing health districts could be kept as sub-districts with new health districts in line with the district municipalities. New health districts or sub-districts could be formed which have the same boundaries as the local municipalities. This would increase the number of health districts. Each province has different problems and will make different choices. The conversation below shows the kinds of problems that these changes are causing health workers. 34

40 There may be some provincial differences in health administration and governance, but the following health structures are already in place in some provinces: A provincial health authority consisting of the MEC for health and other government representatives. District health managers and district health management teams, appointed by provincial governments to run the districts. At the moment they are provincial employees but this will change as local government takes over more responsibility for health. To make things more complicated, it is possible that once the new councils a re established, they may refer the governance of the health district to a District Health A u t h o r i t y. The constitution of the District Health Authorities and the details of how they will be run is not yet known. The diagram below shows the likely organisation of a health district. Provincial MEC for health District or Metro Health Council District Health Authority District health manager and management team All people, health workers and health organisations in the district 35

41 Do not confuse the delivery of services with overall authority for the district health service. Delivery is about what services are provided and how they are provided. At the moment there is very little clarity on who will be responsible for delivery of primary health in the country. The Municipal Structures Act says that the metropolitan areas, and the district municipalities, are responsible for delivering municipal health services. However, at the moment there is no legal definition for these services. A Primary Health Care Package has been developed which suggests a range of services that should be available to every community. But we cannot assume that municipal health services are the same as the primary health care package. It is likely that the amount of resources available in a municipality will probably be the factor that decides what services can be offered and how much of each service will be delivered. The MEC for local government in each province has the right to adjust the responsibilities of a municipality if it does not have the capacity to deliver the services. Until these decisions are finalised there will be a lot of uncertainty for health workers. 36

42 A municipality has a number of options for how to deliver the health services that it is responsible for: It can build capacity within the municipality for the delivery of its services. It can enter into partnerships with the private sector to provide some of it services. It can enter into a partnership with a neighbouring municipality to provide some services. It can enter into partnerships with non-governmental organisations. It can sell off some of its re s o u rces for the private sector to ru n instead. 37

43 District hospitals form an important and integral part of the district health system. They are crucial for providing administrative and technical support to primary health care services, and for providing basic hospital services. Some provinces want to maintain control of the district hospitals and not pass them over to local government. They argue that district clinics and community health centres will be more effective if a hospital is not at the center of a district health system. This is more likely to be true in urban areas, but in rural areas district hospitals usually play an important role in supporting primary health care. Most provinces still have to make decisions about this. It is likely that about health workers will be transferred from one employer to another. There are three main changes that will impact on staff transfers are: The new municipal boundaries will mean that some people will find themselves working for a new municipality. With additional responsibilities being shifted to local government, some people who have previously worked for a provincial department will now work for a local government. In services such as health, it is also possible that some workers, who have previously worked for a local municipality, will now have to work for the district municipality. Without going into too much detail the law says that employees may be transferred under the following conditions: The employee must agree to the transfer. The municipality to which the employee is being transferred must agree to the transfer. 38

44 The conditions of service of the municipality to which the employee is being transferred will apply to the employee. However, these conditions of service cannot be less favourable that the conditions under which the employee was previously employed. There is a lot of uncertainty around the details of this last point. Some people working for a province may be receiving higher salaries than people doing similar work for a local government. If these people move to local government and keep their same salaries as they are entitled to do - then there will not be equal pay for equal work. It is likely that the transfer of staff will be a phased-in process and will depend on the capacity of each metropolitan or district municipality. 39

45 The funding of these new responsibilities is a critical issue. One of the biggest questions still hanging over municipalities and health authorities is how their new functions will be funded. And one of the biggest challenges facing the national and provincial governments is how to make sure that local government receives the financial support to enable them to carry out their responsibilities. It is not just the funding that local government requires, but the capacity to handle the billions of rands that is needed to support the district health system. At present the bulk of funding for primary level services comes from the national tax revenue and is allocated to the provinces as part of the large provincial block grant. In some urban areas, especially in the metropolitan areas, a significant amount of funding for health services comes from revenue raised through rates and service fees. There are a number of options for the transfer of funds to local government: Municipalities could get a block grant from the province to deliver services as they decide. Municipalities could get funding from the province for specific services. Funding could by-pass provincial governments and come directly from the national budget. As yet there has been no decision on this matter. 40

46 Finally, it is critical that a framework is established for co-operation and accountability between the three spheres of government. It is clear from some of the issues mentioned above that this has not yet been put in place and that until it is, the success of the District Health System will be at risk. 41

47 The changes taking place in local government are meant to improve service delivery, especially to more vulnerable groups. Some people are worried that the new system will lead to greater inequality in health services. Although there has been some improvement in the redistribution of re s o u rces since 1994, some provinces remain much better re s o u rced than others. Sometimes inequity is even gre a t e r within provinces than it is between provinces. Within the s p h e re of local government some municipalities will have d i fficulty in raising funds because the majority of their population live in poverty and payment for rates and services is very low. These are areas that are alre a d y comparatively under re s o u rced, and in which serious backlogs exist. Added to this, financial management is often poor and can hamper equitable redistribution. 42

48 So it is possible that greater decentralisation will result in increased inequity. It will be important for national and provincial government to monitor spending on health across municipalities and find ways of redistributing resources in favour of the poorest municipalities. 43

49 The essential points of this section The new health system in the country is based on the Primary Health Care approach. The District Health System delivers this approach. The boundaries of health districts must be aligned with either the Category A or C municipal boundaries. A number of critical decisions have to be taken before the whole system falls into place. In many instances the provinces will take these decisions together with the local governments concerned. There are a number of options open to municipalities regarding the delivery of services. These include entering into partnerships with the private sector, with other municipalities or with non-governmental organisations. The conditions under which health workers will be transferred are complicated. A process for this has still to be negotiated in many provinces. Local governments that take on new responsibilities for delivering services will require extra funds from government. How this will be done has not been decided. The principle of equity must be put high on the agenda in this new decentralised system. 44

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