DEPARTMENT OF HEALTH

WHITE PAPER FOR THE TRANSFORMATION OF THE HEALTH SYSTEM IN SOUTH AFRICA

The White Paper for the TRANSFORMATION OF THE HEALTH SYSTEM IN SOUTH AFRICA is hereby published by the Ministry of Health. The object of the White Paper is to present to the people of South Africa a set of policy objectives and principles upon which the Unified National Health System of South Africa will be based. In addition to these objectives, this document presents various implementation strategies designed to meet the basic needs of all our people, given the limited resources available.

PREFACE

We have set ourselves the task of developing a unified health system capable of delivering quality health care to all our citizens efficiently and in a caring environment.

The strategic approach guiding us in this endeavour is that of Comprehensive Primary Health Care. We believe this accords with the health objectives spelt out in the Reconstruction and Development Programme, the vehicle for socioeconomic transformation in our country.

We advance a wide range of policies that will fundamentally transform our health care delivery system. Some significant steps have already been taken in this direction but a lot still needs to be done. We intend to decentralise management of health services, with emphasis on the district health system- increase access to services by making primary health care available to all our citizens; ensure the availability of safe, good quality essential drugs in health facilities; and rationalise health financing through budget reprioritisation. Furthermore, the development of a National Health Information System will facilitate health planning and management, and strengthen disease prevention and health promotion in areas such as HIV/AIDS, STDs and maternal, child and women's health. The Integrated Nutrition Programme will focus more on sustainable food security for the needy.

As part of this process of health reform, I appointed various ministerial task teams and committees with wide representation. Their recommendations have been further consolidated by the Department of Health and inform the key policies articulated in this White Paper. A detailed policy document outlining our National Drug Policy was released in February 1995. It is a critical component of our review of our health services and should thus be read with this White Paper. A detailed policy on health insurance will be published and will thus complement the White Paper.

On behalf of our Government, I am very pleased to present to the people of South Africa a set of policy objectives and principles upon which the unified national health system of South Africa will be based. In addition to these objectives, this document presents various implementation strategies designed to meet the basic needs of all our people, given the limited resources available. These strategies are based on the belief that the task at hand requires the pooling of both our public and private resources.

I would like to acknowledge and thank all those who have participated in the consultation process undertaken, for dedicating their time and energy to this all important task. Unfortunately, they are too numerous to be listed.

It is my sincere hope that this document will inspire all of us to work in unison towards the improvement of the health of our nation and ensure a brighter future for our children. May this effort inspire all of us, rich or poor, urban or rural to take individual and collective responsibility for our health.

DR NKOSAZANA C. DLAMINI ZUMA
MINISTER OF HEALTH

CONTENTS

Preface
Abbreviations

CHAPTER 1:
Mission, goals and objectives of the health sector

CHAPTER 2:
Reorganising the health service

CHAPTER 3:
Financial and physical resources

CHAPTER 4:
Developing human resources for health

CHAPTER 5:
Essential national health research

CHAPTER 6:
Health information

CHAPTER 7:
Nutrition

CHAPTER 8:
Maternal, child and women's health

CHAPTER 9:
HIV/AIDS and sexually transmitted diseases

CHAPTER 10:
Communicable diseases

CHAPTER 11:
Environmental health

CHAPTER 12:
Mental health and substance abuse

CHAPTER 13:
Oral health

CHAPTER 14:
Occupational health

CHAPTER 15:
Academic health service complexes

CHAPTER 16:
National health laboratory services

CHAPTER 17:
The role of hospitals

CHAPTER 18:
Health promotion and communication

CHAPTER 19:
The role of donor agencies and non-governmental organisations

CHAPTER 20:
International Health

CHAPTER 21:
Year 2000 health goals, objectives and indicators for South Africa

Glossary

Abbreviations used

AHSC Academic Health Service Complex
AIDS Acquired Immune Deficiency Syndrome
GDP Gross Domestic Product
GNP Gross National Product
RDP Reconstruction and Development Programme
NGOs Non-governmental Organisations
NHS National Health System
DHS District Health System
STDs Sexual Transmitted Diseases
HIV Human Immune Deficiency Virus
NHIS National Health Information System
WHO World Health Organisation
UNICEF United Nations Childrens Fund
UNDP United Nations Development Programme
UNFPA United Nations Fund for Population Activities
PHC Primary Health Care
MCWH Maternal, Child and Women's Health
CHC Community Health Centre
PHCN Primary Health Care Nurse
NITER National Increment for Teaching, Education and Research
PCTs Primary Care Teams
EDL Essential Drugs List
GNU Government of National Unity
NDP National Drug Policy
LBW Low Birthweight Babies
PEM Protein-energy Malnutrition
PSNP Primary School Nutrition Programme
NNSDP National Nutrition and Social Development Programme
FLAG Food Legislation Advisory Group
GMP Growth Monitoring and Promotion
PEP Peri-natal Education Programme
DEPAM Education Programme for Advanced Midwives
NACOSA National AIDS Convention of South Africa
NAPWA National Association of People Living with HIV/AIDS
CBOs Community-based Organisations
EHOs Environmental Health Officers
NAHSC National Academic Health Service Council
NHLS National Health Laboratory Services
ENHR Essential National Health Research

Chapter 1

Mission, Goals and Objectives of the Health Sector

South Africa has a population of over 40 million, 73% of whom are women and children.Although classified as a middle-income country and spending 8,5% of GDP on health care. South Africa exhibits major disparities and inequalities. This is the result of former apartheid policies which ensured racial, gender and provincial disparities.

The majority of the population of South Africa has inadequate access to basic services including health, clean water and basic sanitation. Statistics for 1994 suggest that between 35% and 55% of the population live in poverty. Fifty three percent of the population live in rural areas the vast majority of whom are poor (seventy-five per cent of the poor live in rural areas).

Women and children are amongst the most vulnerable groups in South Africa. Sixty-one per cent of children in South Africa live in poverty, and women are also disproportionately represented among the poor.

It is estimated that the Infant Mortality Rate (IMR), Under-five Mortality Rate (U5MR) and Maternal Mortality Rate (MMR) are much higher than expected of a country with South Africa's level of income. Existing disparities amongst the various race groups are well documented.

The Government has developed a framework for socioeconomic development in its Reconstruction and Development Programme (RDP), in which it has set out broad principles and strategies for development in all key areas and sectors in order to effectively address the various problems facing the majority of the people of South Africa.

The task of improving the health of South Africa's population is not that of the health sector alone. The RDP sets the framework whereby the health of all South Africans must reflect the wealth of the country and lays the foundation for a process of democratising the State and society that will foster the empowerment of all citizens and promote gender equality.

The second major thrust of the RDP concerns building the economy. Poverty is widely recognised as a major determinant of the health status of individuals, households and communities, and gains in health will only be possible if the RDP's attack on poverty through economic development succeeds.

The third component of the RDP is the development of human resources. Equipping individuals with the necessary knowledge to care for themselves will be a major step towards improving their health. No factor can be shown to be more important for a family's health than the educational status of women. Therefore the RDP's specific emphasis on women in the planning and implementation of human resource development is critical to the improvement of health.

Finally, within the RDP's focus on meeting basic needs, the development and improvement of housing and services like water and sanitation, the environment, nutrition and health care represents its most direct attack on ill health. It follows that trends in health status during and following the implementation of the RDP will be amongst the most important indicators of the success of the entire programme. The Department of Health aims to ensure that the health sector succeeds in fulfilling this vital role in ensuring progress.

Details of the proposed health sector strategies are set out below. They are based on a common vision which reflects the principles of the RDP:

1. The health sector must play its part in promoting equity by developing a single, unified health system.
2. The health system will focus on districts as the major locus of implementation, and emphasise the primary health care (PHC) approach.
3. The three spheres of government, NGOs and the private sector will unite in the promotion of common goals.
4. The national, provincial and district levels will play distinct and complementary roles.
5. An integrated package of essential PHC services will be available to the entire population at the first point of contact.

The health sector's mission, goals, objectives and implementation strategies are articulated in this and subsequent chapters.

1.1 HEALTH SECTOR MISSION, GOALS AND OBJECTIVES

In order to realise the above mission, it is envisaged that the National Health System (NHS) will incorporate all stakeholders, i.e. the Government sector, NGOs (including religious and grassroots organisations), the private sector and, especially, the communities.

It is essential to obtain the active participation and involvement of all sectors of South African society in health and health-related activities. All sections of the community, all members of households and families and all individuals should be actively involved, in order to achieve the health consciousness and commitment necessary for the attainment of goals set at the various levels. The people of South Africa have to realise that, without their active participation and involvement, little progress can be made in improving their health status.

Health teams and workers at all levels should develop a caring ethos and commit themselves to the improvement of the health status of their communities. They should not only be responsible for the patients who attend their health facilities, but also have a sense of responsibility towards the majority of the population in their catchment areas.

Every effort should be made to ensure the improvement in the quality of services at all levels. An essential package of primary health care interventions will be made universally accessible. Emphasis should be placed on reaching the poor, the under-served, the aged, women and children, who are amongst the most vulnerable.

In addition, the management of services should be decentralised and focus on improving the district health system. District teams will have to be established and trained to enhance their capacity for planning, implementation, supervision, monitoring and evaluation of health activities. Mechanisms should be developed to enhance intersectoral collaboration at the national, provincial, district and community levels.

Restructuring the health sector has the following aims:

1. To unify the fragmented health services at all levels into a comprehensive and integrated NHS;
2. to reduce disparities and inequities in health service delivery and increase access to improved and integrated services, based on primary health care principles-,
3. to give priority to maternal, child and women's health (MCWH); and
4. to mobilise all partners, including the private sector, NGOs and communities in support of an integrated NHS.

1.1.2 Goals and objectives

(a) To unify fragmented health services at all levels into a comprehensive and integrated NHS:

1. reorganise the Department of Health, so that it can fulfill its designated functions;
2. integrate the activities of the public and private health sectors, including NGOs and traditional healers, in a way which maximises the effectiveness and efficiency of all available health care resources; and
3. reorganise the health care system based on primary health care services, with effective referral systems at the primary, secondary and tertiary care levels.

(b) To promote equity, accessibility and utilisation of health services:

1. increase access to integrated health care services for all South Africans, focusing on the rural, peri-urban and urban poor and the aged, with an emphasis on vulnerable groups;
2. establish health care financing policies to promote greater equity between people living in rural and urban areas, and between people served by the public and private health sectors; and
3. distribute health personnel throughout the country in an equitable manner.

(c) To extend the availability and ensure the appropriateness of health services:

1. establish a district health system in which all communities are covered by a basic health unit which offers an essential package of care;
2. ensure a functioning referral system at the primary, secondary and tertiary levels;
3. improve access to comprehensive health services;
4. ensure the universal availability of high quality, low cost essential drugs; and
5. ensure that every South African develops his or her potential fully, with the support of community-based nutrition promotion activities.

(d) To develop health promotion activities:

1. promote a healthy environment;
2. improve the psychological well-being of people and communities;
3. ensure access to health-related information, community support and health services for adolescents;
4. reduce alcohol and other drug abuse, with particular emphasis on tobacco, glue, cocaine, Mandrax, heroin and marijuana,
5. promote healthy behaviour to prevent sexually transmitted diseases (STDs) and HIV transmission;
6. prevent the transmission of communicable diseases such as tuberculosis, and the development of hypertension and diabetes;
7. (help the disabled to become independent and reach their potential for achieving a socially and economically productive life; and
8. reduce the incidence of intentional and unintentional injuries.

(e) To develop the human resources available to the health sector:

1. promote the optimal use of the skills, experience and expertise of all health personnel;
2. develop education and training programmes aimed at recruiting and developing personnel who are competent to respond appropriately to the health needs of the people they serve;
3. ensure that the composition of human resources in the health sector reflects the demographic pattern of the general population-,
4. promote a new culture of democratic management in the health sector; and
5. ensure a caring and compassionate health sector.

(f) To foster community participation across the health sector:

1. involve communities in various aspects of the planning and provision of health services;
2. establish mechanisms to improve public accountability and promote dialogue and feedback between the public and health providers; and
3. encourage communities to take greater responsibility for their own health promotion and care.

(g) To improve health sector planning and the monitoring of health status and services:

1. develop a national health information system that will: facilitate the measurement and monitoring of the health status of the South African population; enable the evaluation of the delivery of health services; and support effective management at all levels of the health service;
2. ensure that those responsible for the health status of South Africa's population are kept up to date with the information generated; (iii) monitor the health impact of the implementation of the RDP, including the development of a nutritional surveillance mechanism, and
3. building capacity at the provincial, district, local and community levels to develop plans based on priority issues and ensure appropriate and cost-effective interventions.

Reorganising the Health Service: Priority for Primary Health Care

Changes dictated by the South African Constitution include the devolution of certain responsibilities for health services to the provincial and municipal levels. To give effect to this mandate, it is essential that, inter alia, a district health system (DHS), in which responsibility for service delivery is entrusted to the district level, be established as soon as possible.

Restructuring the organisation of the health services, therefore, requires that distinct functions be assigned to the national department, the provinces and the districts/municipalities. These are listed below. Furthermore, it requires that the new structures be staffed by skilled people, to ensure efficiency and effectiveness in management and administration. Private sector health services will also have a major role to play in the National Health System (NHS).

2.1 DEPARTMENT OF HEALTH

2.1.1 Functions of the national department

The Department of Health has a responsibility to -

1. Provide leadership in the formulation of health policy and legislation, including the development of a NHS;
2. provide leadership in quality assurance, including the formulation of norms and standards;
3. build the capacity of the provincial health departments and municipalities, to enable them to ensure the provision of effective health services;
4. ensure equity in the allocation of resources to the provinces and municipalities and their appropriate utilisation;
5. provide leadership in planning for and the strategic management of the resources available for health care;
6. provide services which cannot be cost-effectively delivered elsewhere;
7. develop coordinated information systems and monitor the progress made in the achievement of national health goals-
8. provide appropriate regulation of the public and private health sectors, and regulate health-related activities in other sectors;
9. support the provinces and municipalities in ensuring access to cost-effective and appropriate health commodities; and
10. liaise with national health departments in other countries and international agencies.

2.1.2 Organisational structure of the national department

A new organisation structure for the Department of Health has been established.

A specific goal has been set that the Department of

Health will be representative, i.e. its staffing pattern will reflect the national demographic structure.

(a) POLICY CO-ORDINATING UNIT

Responsible for defining, coordinating, integrating, synthesising, reviewing and monitoring fundamental strategic health policy matters and key institutional relationships within the NHS.

(b) INTERNATIONAL HEALTH LIAISON: DIRECTORATE

Responsible for formulating policy proposals and mobilising financial, material and human resources for the upliftment of South Africa's people by promoting national and international co-operation in the implementation of the RDP.

(c) POLICY AND PLANNING BRANCH

Responsible for developing strategic health policy, formulating operational and technical policy, allocating health resources, coordinating research and developing a national health information system.

(i) National Health Systems : Chief Directorate

Responsible for ensuring the development of a functional NHS at all three levels of government, with effective co-ordination amongst all role-players including the public, private and voluntary sectors; responsible, at the national level, for facilitating and monitoring the development of the District Health System.

- Health Promotion and Communication : Directorate

Responsible for coordinating and supporting health promotion initiatives and, in collaboration with the provinces, developing clear and transparent criteria for establishing national health promotion priorities, including training and capacity-building; ensuring that all decisions, policies and laws emanating from other organs of state are health-promoting, and that opportunities for health promotion are maximised in all settings and in relation to all topics; developing effective channels for the communication of and liaison on health policy, and ensuring that health policies are marketed through the launching of campaigns, using print and audiovisual media to create awareness and stimulate public debate.

- Systems Development, Legislation and Policy Co-ordination Directorate

Responsible for ensuring the development of a coordinated NHS and facilitating and monitoring the development of the District Health System; that departmental policies are coordinated, consistent and coherent, that national health legislation is drafted, as and when required.

(ii) Hospital and Academic Health Service Complexes : Chief Directorate

The Chief Directorate has three main responsibilities:

- Hospital Development : Sub-directorate

Responsible for ensuring that hospitals use resources efficiently, that their services are coordinated and that they support PHC services. This unit will also be expanded to take on responsibility for coordinating and controlling the budgets of academic central hospitals.

- AHSC Development : Sub-directorate

Responsible for ensuring that the policy developed for academic health centres (AHSCs) enables them to remain an integral part of the NHS; that the training provided is in accordance with a national human resource policy and appropriate to the needs of South Africa.

(iii) Operational and Technical Policy: Chief Directorate

Responsible for developing policies, norms and standards for the health services in consultation with the relevant examining and statutory bodies and interested stakeholders.

- Health Services : Directorate

Responsible for developing norms and standards for basic packages of health services, their delivery and the quality of care and developing systems and methodologies for quality assurance and the maintenance of good quality care.

- Environmental Health : Directorate

Responsible for developing policies, norms and standards for environmental health; ensuring that basic environmental needs are met and that environmental factors inimical to health are minimised- developing an environmental surveillance and evaluation system to monitor the effectiveness of environmental interventions.

- Food Control : Directorate

Responsible for developing standards for food hygiene, additives, labelling and identification; and ensuring food safety through regulation and public education, as well as the ratification of and participation in international standards.

- Oral Health : Directorate

Responsible for developing policies, norms and standards for oral health services aimed at the effective distribution and utilisation of resources, training and orientation of appropriate professionals and the adoption of public health interventions.

(iv) Health Resource Planning: Chief Directorate

Responsible for planning the optimal utilisation of health care resources.

- Health Finance and Economics : Directorate

Responsible for the planning of national health care finances, ensuring that the national health budget is restructured to support RDP priorities (and other governmental priorities), and monitoring and evaluating public and private health expenditure.

- Human Resource Planning: Directorate

Responsible for developing a national human resource audit, policies, plans and strategies for implementation: to ensure the availability, equitable redistribution and appropriate mix of human resources.

- Health Facilities : Directorate

Responsible for developing a comprehensive plan for the distribution of health facilities in the public and private sector that ensures equity in underserved areas.

(v) Health Information, Evaluation and Research : Chief Directorate

Responsible for developing and maintaining a national health information system, evaluating health programmes rendering epidemiological support and coordinating health research.

- National Health Information System : Directorate

Responsible for developing (and maintaining) a health information system that begins at the local level and feeds into the district, provincial and national levels.

- Health Systems Research Epidemiology : Directorate

Responsible for public health surveillance, epidemiology and ensuring the use of health systems research in planning, evaluation and management of the health services.

Responsible for developing a national research and funding strategy, and facilitating and coordinating an essential national health research programme.

(c) REGULATION, SERVICES AND PROGRAMMES BRANCH

Responsible for: regulating health matters and the procurement of supplies and services; rendering support services at the national and departmental levels; establishing health programmes and promoting occupational health.

(i) Registration, Regulation and Procurement : Chief Directorate

Responsible for promoting the registration, regulation and procurement of health supplies and services.

- Medicines Administration : Directorate

Responsible for the regulation of medicines and related substances and the development of effective medicine supply systems.

- Health Technology : Directorate

Responsible for the evaluation, regulation and registration of health technology.

- Medical Schemes, Supplies and Pharmaceutical Services: Directorate

Responsible for promoting the sound management of medical schemes and pharmaceutical services, including the procurement of medical supplies.

(ii) National Programmes : Chief Directorate

Responsible for the management of national health programmes in accordance with the objectives of the RDP.

- Maternal, Child and Women's Health Services : Directorate

Responsible for developing an effective and equitable health care system, with priority for mothers and children; managing the maternal, child and women's health programmes, including the prevention and management of genetic disorders.

- Nutrition: Directorate

Responsible for developing policies, strategies and guidelines for a national integrated nutrition programme.

- Communicable Disease Control : Directorate

Responsible for promoting the control of communicable diseases.

- HIV/AIDS and Sexually Transmitted Diseases (STDs): Directorate

Responsible for coordinating the national effort to prevent the spread of HIV/AIDS and STDs.

- Chronic Diseases, Disabilities and Gerontology : Directorate

Responsible for developing strategies and guidelines for the prevention of chronic diseases and the prevention and management of disabilities.

- Mental Health and Substance Abuse : Directorate

Responsible for developing national policies and norms for the prevention and control of mental illness and substance abuse.

(iii) National Services : Chief Directorate

Responsible for rendering national services that cannot be rendered at the provincial and district levels, and promoting priority health programmes.

- National Health Laboratory Services : Directorate

Responsible for facilitating the co-ordination and accreditation of health laboratory services and promoting effective public and private sector collaboration.

- National Disaster Services and Medical Advice : Sub-directorate

Responsible for promoting the prevention of, preparedness for and response to major disasters, and advising other State departments on health and medical matters.

- National Forensic Chemistry Laboratories : Sub-directorate

Responsible for delivering an effective chemical laboratory service at the national level in support of forensic medicine and law enforcement, through regulatory control of chemical substances injurious to health.

- Vaccine Unit : Sub-directorate

Responsible for the manufacture and supply of vaccines and biologicals.

- National Institute for Virology : Directorate

Mandated to function as a national resource centre of excellence for viral diseases.

(iv) Occupational Health : Chief Directorate

Responsible for the promotion and surveillance of the health of people at work.

The Directorates: Occupational Medicine and Pathological Services and the Sub-directorate: Occupational Hygiene and Toxicology constitute the -

- National Centre for Occupational Health

Responsible for supporting occupational health at all levels, promoting occupational health services and fulfilling statutory obligations in terms of the Occupational Diseases in Mines and Works Act, 1973, as amended and the -

- Medical Bureau for Occupational Diseases

Responsible for discharging duties in terms of, and administering the Occupational Diseases in Mines and Works Act, 1973, as amended (as above).

(v) Departmental Support Services : Chief Directorate

Responsible for establishing and maintaining an effective internal support service for the Department of Health. - Financial Management Services : Directorate

Responsible for providing financial advice and ensuring that expenditures incurred are in accordance with the various programme descriptions; rendering and maintaining information technology services within the Department; and advising the Department on the procedures to be followed to obtain goods and services.

- Administration : Directorate

Responsible for rendering personnel administration, auxiliary and administrative support services to the Department.

- Legal Services : Sub-directorate

Responsible for drafting legislation, preparing contracts and other legal documents and providing general legal advice and services.

- Special Programmes : Sub-directorate

Responsible for the development of programmes for the achievement of a more representative Department, and monitoring the implementation thereof

2.2 PROVINCIAL HEALTH DEPARTMENTS

2.2.1 Role and functions of the provincial health departments

The mission of a provincial health department, as mandated by the Constitution of South Africa within the framework of national policies, strategies and guidelines, is to promote and monitor the health of the people in the province, and develop and support a caring and effective provincial health system, through the establishment of a province-wide district health system (DHS) based on the principles of primary health care (PHC).

During the period of transition required for the establishment of a DHS, the provincial authorities (in addition to the functions listed below) will perform functions that will be devolved to the newly-established districts at a later stage During this critical process, sub-provincial structures such as health regions may be established to assist in carrying out these functions.

The functions of the provincial health authorities will include, ensuring -

1. the provision of regional and specialised hospital services, as well as academic health services, where relevant;
2. appropriate human resource management and development;
3. the rendering and co-ordination of medical emergency services (including ambulance services);
4. the rendering of medico-legal services;
5. the rendering of health services to those detained, arrested or charged-
6. the planning and management of a provincial health information system,
7. quality control of all health services and facilities;
8. the screening of applications for licensing and the inspection of private health facilities,
9. the formulation and implementation of provincial health policies, norms, standards and legislation,
10. interprovincial and intersectoral co-ordination and collaboration;
11. co-ordination of the funding and financial management (the budgetary process) of district health services,
12. the provision of technical and logistical support to health districts;
13. the rendering of specific provincial service programmes, e.g. tuberculosis programmes,
14. the provision of non-personal health services;
15. the provision and maintenance of equipment, vehicles and health care facilities;
16. effective consultation on health matters at the community level-
17. the provision of occupational health services;
18. research on, and the planning, co-ordination, monitoring and evaluation of the health services rendered in the province; and
19. that functions delegated by the national level are carried out.

2.3 THE DISTRICT HEALTH SYSTEM

2.3.1 Principles, long-term goals and role of the District Health System

(a) Principles

A national committee established to develop a DHS, comprising representatives of the national and provincial health departments, has agreed unanimously that there are twelve principles with which planners must comply in the development of the DHS. These are :

1. overcoming fragmentation
2. equity
3. comprehensive services
4. effectiveness
5. efficiency
6. quality
7. access to services
8. local accountability
9. community participation
10. decentralisation
11. (developmental and intersectoral approach
12. sustainability

(b) Long-term goals and role of the district

The goal outlined in the RDP is to have a single NHS, based on a district health system that facilitates health promotion, provides universal access to essential health care and allows for the rational planning and appropriate use of resources, including the optimal utilisation of the private health sector resources.

The country will be divided into geographically coherent, functional health districts. In each health district, a team will be responsible for the planning and management of all local health services for a defined population. The team will arrange for the delivery of a comprehensive package of PHC and district hospital services within national and provincial policies and guidelines. In time, all district level staff should be employed on the same salary scales and under the same terms and conditions of employment that apply to public sector health personnel throughout the country.

In view of the variety of conditions that exist among and within the provinces, it is unlikely that a single system of governance can be implemented throughout the country. Therefore, three governance options are suggested:

1. The provincial option, i.e. the province is responsible for all district health services through the district health manager. (This option can be exercised where there is insufficient independent capacity and infrastructure at the local level.)
2. The statutory district health authority option, i.e. the province, through legislation, creates a district health authority for each health district. (This option can be exercised in instances where no single local authority has the capacity to render comprehensive services.)
3. The local government option, i.e. a local authority is responsible for all district health services. (This option can be exercised if a local authority, whose boundaries are the same as that of a health district, has the capacity to render comprehensive services.)

2.3.2 Implementation strategies

1. Each province will be subdivided into a number of functional health districts.
2. The district will serve both as a provider and purchaser of health services, and select the appropriate strategy on the basis of equity, efficiency and assessment of local conditions.
3. Peri-urban, farming and rural areas will fall within the same health district as the towns with which they have the closest economic and social links. The fragmentation and inequity created by the past practice of separating peri-urban and rural health services from the adjacent municipal health services must be eradicated.
4. There will be parity in salaries and conditions of service for all public sector health personnel throughout the country, which include appropriate incentives to encourage people to work in underserved areas. This is essential in order to rationalise services, overcome fragmentation and promote equity, particularly between metropolitan, urban and rural areas.
5. Financing mechanisms or formulae will be devised, to ensure that district level health services are financed in an equitable and sustainable manner.

The establishment of the DHS is at the core of the entire health strategy , and its rapid implementation, therefore, is of the highest priority.

2.3.3 Functions of a health district

This level of the health care system should be responsible for the overall management and control of its health budget, and the provision and/or purchase of a full range of comprehensive primary health care services within its area of jurisdiction. Effective referral networks and systems will be ensured through co-operation with the other health districts. All services will be rendered in collaboration with other governmental, non- governmental and private structures.

Functions at this level are as follows:

(a) Health care

1. Ensuring health promotion services-,
2. providing for collaboration with other sectors of Government and NGOs in promoting health and ensuring the rendering of health services in the health district"
3. providing for community participation in health promotion and health service provision;
4. ensuring the availability of a full range of PHC and other relevant health services in communities, clinics, community health centres, district hospitals and other facilities;
5. ensuring primary environmental health services, the promotion and maintenance of environmental hygiene; the prevention of water pollution; enforcement of environmental health legislation, i.e. regarding sanitation, housing, smoke, noise, fitter, food hygiene and occupational hygiene, and the identification and control of local health hazards.
6. rendering essential medico-legal services; and
7. ensuring services to those arrested and charged, in collaboration with the relevant authorities.

Note: this package will be subject to the outcome of negotiations between the province and a municipality in terms of the constitutional right of municipalities to render municipal health services.

(b) Administrative, financial and support services

1. Ensuring the provision of support services essential to the rendering of health services, including: the accommodation for staff, where necessary; appropriate facilities for the rendering of maternal and mental health services, essential medicines, essential diagnostic services, transport; and the maintenance of equipment, facilities and other assets-
2. establishing and managing the health district's budget in accordance with national and provincial policies and guidelines, and purchasing services as appropriate, and
3. ensuring the promulgation of health by-laws.

(c) Planning and human resources

1. Monitoring and evaluating health and health service provision,
2. gathering, analysing and managing health information at the district level;
3. providing for appropriate human resource development- and
4. ensuring the performance of any other health function or duty assigned to the health district.

2.4 INTEGRATING THE PUBLIC AND PRIVATE HEALTH SECTORS

(a) Integration of private practitioners

Private health practitioners should be integrated with the public sector with regard to the provision and management of services. The central thrust being to enhance the capacity of the NHS to deliver affordable quality health care to all citizens of South Africa.

(b) Implementation strategies

1. The policy should apply to all private practitioners including private midwives, general medical and dental practitioners, specialist obstetricians and gynaecologists, paediatricians and private pharmacists.
2. Services delivered by occupational health practitioners, and prison and military health authorities, should be subject to the same principles.
3. In the delivery of a comprehensive and integrated maternal, child and women's health (MCWM) service, an MCWH management team will oversee both public and private sector delivery at each organisational level.
4. Private practitioners will be required to meet national training standards in relation to the services rendered at each level of care.
5. Private practitioners will be encouraged to assist in the development of and follow standardised clinical management protocols.
6. Both the public and private sectors will be required to provide information to the National Health Information and Audit Systems.
7. To avoid duplication of expensive equipment within certain geographic areas, all equipment should be purchased through a system of control, be used optimally by both the public and private sectors, and be properly maintained.
8. Provincial health departments and health districts will be responsible for purchasing services from the private health sector and accredited providers, where required.

(c) Role of non-governmental organisations

Non-governmental organisations (NGOs) should continue to play an important role in the delivery and management of health services.

2.5 INVOLVING THE COMMUNITY

2.5.1 All South Africans should be equipped with the information and the means for identifying behavioural change conducive to improvement in their health

Much of the progress made in improving the health status of individuals depends on the existence of healthy environments and lifestyles. It is crucial to involve individuals, families and communities in this process.

(a) Implementation strategies

1. The national health service should take advantage of all available opportunities to provide individuals, communities and the public at large with relevant information on healthy behaviour.
2. The Department of Health should work in close collaboration with all social groups, especially women's and youth groups, to support the acceptance of and response to messages related to healthy behaviour.
3. The Department of Health should promote and support legislation and policies for creating an environment that is conducive to healthy behaviour.
4. The Department of Health should seek to establish close collaboration with the media to facilitate the wide dissemination of health-related information and positive role-models.
5. The Ministry of Health should work in close collaboration with the Ministry of Education and other social ministries, to provide them with the technical support required to develop their potential in health promotion fully.
6. Clinic, health centre, hospital and community health committees should be provided with the required technical support and motivation to become advocates of positive behavioural change in the communities they represent.
7. The Minister of Health should mobilise political leaders at all levels to lend their support to health promotion efforts.

2.5.2 People should be afforded the opportunity of participating actively in various aspects of the planning and provision of health services

In accordance with the democratisation of South African society, mechanisms for the participation of the people in the National Health System will be established at all levels.

(a) Implementation strategies

1. Clinic, health centre and hospital and community health committees should be established to permit service users to participate in the planning and provision of services in health facilities.
2. Each community should know which CHC is responsible for providing it with the essential PHC package; therefore, the catchment area of each CHC must be clearly defined and known to all partners.
3. The essential PHC package should be negotiated between the providers and the communities, to ensure that priorities perceived by the communities are addressed and that the communities have a clear understanding of their entitlements.
4. The communities should elect the individuals who will represent them with regard to health matters.
5. The roles and powers of elected representatives should be clarified.
6. Simple community-based information systems should be established by communities with the support of the health staff, to provide the information needed for the identification of priorities, the monitoring of progress made towards locally-established objectives and decisions on actions to be taken.
7. Representatives of the communities should play a pivotal role in identifying underserved groups, and establish strategies to reach them in partnership with the primary health team.
8. Women should be enabled and supported in playing a major role in local health committees.

2.5.3 The Department of Health should provide the public with regular updates on progress, results and emerging issues related to its work, and should ensure that people participate in the development of national policy

The NHS is undergoing major changes which are bound to raise questions and create anxieties. Therefore, to facilitate the process, promote consensus and engender support, consultation must be extensive, the rationale behind changes clearly explained and regular updates on progress made widely disseminated to the public.

(a) Implementation strategies

1. Periodic national health summits should be established as a mechanism for public participation, make policy recommendations and identify new areas requiring attention.
2. Similarly, provincial and district health summits should be held to review the progress made and plan improvements to the system, as well as structure local inputs to the national summits.
3. National, provincial and district annual reports should be compiled and disseminated to the public.
4. The national, provincial and district health authorities should develop a mechanism for responding timeously to enquiries raised by the public.
5. The Minister of Health should provide parliamentarians and other political representatives with the information they require to respond adequately to questions raised by their constituencies.
6. Officials of the Department of Health should seek opportunities to present and explain issues of concern to the public.
7. The NHS should make use of appropriate mechanisms to measure the level of consumer satisfaction with the services provided, and disseminate the results.

2.6 PRIMARY HEALTH CARE

2.6.1 The priority of the National Health System

The new South African health system adopts the PHC approach because this approach is the most effective and cost effective means of improving the population's health. The approach involves a health system led by PHC services, which are at the base of an integrated district health system.

2.6.2 Definition of the PHC package

The PHC package will comprise the services listed below. The provision of these services will be promoted and evaluated by district health teams and relevant support personnel. The actual scope of the package of services will be determined by the available resources and will be implemented on a sustained and incremental basis over a 10 year period.

Table 3.2 PHC services to be provided through the district health system

* These services are likely to be provided at the district level, but may be in part or completely funded from sources other than the health vote.

2.6.4 Public-private mix at the district level

District Health Authorities will supervise and allocate budgets to public providers and, where appropriate in the case of personal ambulatory care, purchase services from accredited private providers. There will thus be an opportunity for the ultimate emergence of some form of provider competition, especially in densely populated areas of the country. These arrangements will encourage improved governance, both at the district and provider levels.

Because of potential problems envisaged with the too rapid introduction of accredited private providers, public facilities will remain the dominant PHC providers funded by the government for the next few years. Accredited private providers will be introduced gradually, particularly in currently under-served areas. Priority will be given to sessional work by private providers in public facilities. In accordance with the principle of devolution of authority to the district level, DHAs will themselves make decisions regarding the appropriate public-private provider mix in their districts at different points in time.

Where full and/or part-time practitioners are in short supply, private practitioners' services will be used through referral contracts, and patients will be referred to a general practitioner by a PHC nurse in the public The overall effect of these reforms will be to facilitate the emergence of flexible and creative arrangements between DHAs and local practitioners and to maximise private doctors' contributions to the public health system.