Chapter 19

The Role of Donor Agencies and Non- Governmental Organisations

In its efforts to ensure the implementation of the RDP, South Africa is undergoing a process of profound transformation at all levels of Government and society. With the establishment of a democratic Government, international donor agencies are approaching the Department of Health in increasing numbers to offer aid in support of health services. Whilst international assistance is welcome and appreciated, it is the responsibility of the South African Government to ensure that the economy develops in such a manner that it can meet all the country's needs within its own means and resources.

International assistance should be used to support the process of transforming society, and to meet the health priorities of the country. Such assistance should not be seen as a substitute for investment in the country, but as an intervention that will facilitate such investment. The areas of support to which donor assistance will be channelled will be by agreement between the Government of South Africa and the donor(s) concerned.

19.1 POLICY GUIDELINES FOR DONORS IN THE HEALTH FIELD

International experience with regard to donor activities, especially in developing countries, indicates that without sound policy guidelines, various problems may be encountered, such as:

1. fragmented and uncoordinated external financing of health services, leading to the implementation of conflicting health policies;
2. donations not necessarily addressing priority issues in the recipient country, thus diverting emphasis from real health needs;
3. conditions attached to donations having a negative impact on the economy and health services of the recipient country;
4. capital projects being undertaken, without ensuring that Government has the necessary resources to fund the recurrent costs;
5. donor programmes which fail to appreciate the importance of the multisectoral dimensions of health;
6. donations of equipment creating problems with appropriate utilisation and maintenance as a result of lack of skills, expertise and/or parts; and
7. donor assistance failing to strengthen the recipient nation's capacity to manage public policy and administration.

Assistance has, in some instances, undermined the recipient governments' policies to such an extent that these nations are wholly dependent on foreign assistance for service delivery.

The aim of developing policy guidelines for donors is to ensure that donations dedicated to health in South Africa are managed in such a way that they optimise the benefits to local health services.

19.1.1 Principles and guidelines

(a) All donations should be supportive of the RDP health priorities and those of the Department of Health.

(b) Donor contributions should be used to support integrated programmes that meet the people's needs in a coherent manner, as opposed to the uncoordinated vertical projects of the past. These contributions should help to develop sound health policies and create an enabling environment in which they will be realised, as well as giving rise to health systems reform.

(c) Conditions attached to donations should -

• be acceptable to both the donor agency and Government-,
• be in accordance with broad Government policies-
• assist and support the sound planning and management of health services;
• be aimed at making an impact on the health services;
• promote intersectoral collaboration and co-ordination; and
• develop South Africa's capacity (at the national, provincial and/or local levels).

(d) The principles that must be advanced by all donor projects or programmes include:

(i) Sustainability
Donations which have recurrent cost implications for Government must be evaluated, to ensure that the required financial resources are available to sustain such programmes or projects.

(ii) Equity
Donations must address -

• the shift to primary health care-,
• inequalities between provinces, as well as unequal development within provinces;
• under-served areas, especially rural areas; and
• the needs of specific groups in society, such as women and children.

(iii) Accessibility

Donations should be directed at making health services accessible to all South Africans, irrespective of race, gender, income status or geographic location.

(iv) Efficiency

Donations should promote the efficiency of the health services through different mechanisms, e.g. training programmes for health workers, establishment of sound information systems, technical support initiatives and strengthening community involvement and participation in health services delivery.

(v) Acceptability

Donations should not only be acceptable to Government structures, but also to the communities for whom such donations are intended.

(e) In view of the multidimensional nature of health, intersectoral collaboration among health, education, agriculture, housing, water provision and sanitation and other relevant Government department must be fostered by donations. Donations should be flexible enough to allow for the inclusion of those sectors which are major contributors to health.

(f) Donations should be in accordance with South Africa's priority health needs. Prospective donors and the South African Government must agree on the areas to which donations will be directed.

(g) Donations should promote and encourage self-reliance and the development of communities, and not foster dependency.

(h) The sustainability of donor support must be ensured in the short, medium and long term.

19.1.2 Categories of donations

(a) Financial donations

1. The acceptance of funds donated by external agencies must be in keeping with South Africa's fiscal policy and financial legislation.
2. Subject to the general guidelines, the donation of funds should be focused initially on bridging finance for the reconstruction and rationalisation of the health services.
3. Funding of recurrent expenditure for predetermined periods should focus initially on priority areas, as identified in the Government document titled "The Health Priorities of the Reconstruction and Development Programme" and other government policies.

(b) Donations of technical expertise

1. The Department will solicit and accept contributions of a technical nature from the donor community. This will only occur if there is a local shortage of such skills, or if such contributions are geared to enhancing local skills.
2. Costs related to the provision of international expertise will be supported by the donor agency(ies), upon review and agreement with the Department.

(c) Other donations

1. Donations of equipment will be subject to the following principles:
• appropriateness of and need for the particular equipment in South Africa; and
• adequate and readily available support structures, including -
• expertise, potential for training and availability of suitable health personnel;
• an adequate maintenance service, including the availability of service personnel and parts at a reasonable price; and
• -the necessary infrastructure, such as electrical power supply, adequate roads and telecommunications.
2. Donations of equipment which would replace existing equipment generally should take preference over the provision of new equipment, as the latter would result in an increase of recurrent costs.
3. Donations involving capital projects should facilitate job creation, capacity-building and community development, with particular emphasis on disadvantaged communities. In assessing such projects, one of the fundamental factors is their sustainability in the medium to long term.

19.1.3 Co-ordination

All offers of assistance to the Department of Health should be coordinated at the national level. This applies to both bilateral and multilateral agencies (UN agencies like UNICEF, the WHO, etc.). The provinces will be responsible for the co-ordination of offers of aid made to them, or to specific local communities. The national Department should be informed of all offers accepted. This will not only ensure equity between the provinces, but also that all offers are in keeping with Government priorities and needs.

9.2 RELATIONS BETWEEN THE DEPARTMENT OF HEALTH AND NON- GOVERNMENTAL ORGANISATIONS

The Department of Health, as a national authority, has the responsibility to determine the country's health priorities and policies. The Department is also ultimately responsible for the delivery of services to South Africa's people.

19.2.1 Community participation

Community participation is one of the key principles of the Department. This aspect is clearly enunciated in the RDP, which states that......" apart from the strategic role of government in the RDP, mass participation in its elaboration and implementation is essential". NGOs, as part of civil society are, therefore, expected to contribute to the attainment of national priorities and programmes.

The Government and its departments are not responsible for the funding of NGOs. Such funding is a matter between donors and the NGOs concerned. Where the Department of Health commissions an NGO(s) to execute some of its programmes, the Department will be responsible for mobilising the financial resources for such a programme. It will sign a contract with the donor(s) concerned, and will be responsible for expenditure accounting.

Overall, the Department feels that NGOs can play a positive role. The Department of Health will thus, at all times, nurture relationships that impact positively on its national objectives.

19.2.2 Guidelines for the funding of NGOs by the Department of Health

1. The NGO concerned should address national and/or provincial priorities.
2. It must be non-racial and non-sexist.
3. It should be non-profit-making.
4. It must be accountable in terms of its -
1. mission, i.e. serving the interests of the community;
2. organisational structure; and
3. finances.
5. Preferred NGOs for funding are those which extend the Government's scope of activities. Examples include hospice care, advocacy organisations and certain forms of training.
6. In the production of media messages, close attention should be given to content, literacy and language.
7. The NGO concerned must adhere to the RDP's principles, namely -
1. integration and sustainability;
2. nation-building;
3. peace and security;
4. linking of reconstruction to development; and
5. democratisation of the country.
8. It must be a legally constituted body and, therefore, in law, a legal entity.
9. It should be duly constituted, have a functioning committee and be managed by a management committee.
10. It should have a potential or demonstrable capacity and proven track record for executing the proposed project.
11. The project should be evaluated against the criteria for the national health budget for the financial year concerned.
12. The NGO concerned should be able to provide evidence of its financial stability, together with a summary of its current financial situation. (Where applicable, audited balance sheets should be supplied). It should have no history of financial mismanagement.
13. It is preferable that an NGO request funding for a specific project, with defined outputs. This is easier to evaluate than the provision of global funding that provides for its continued functioning.
14. Other bodies involved in the provision of funding to the NGO, or those which have been approached, must be declared. The NGO concerned must demonstrate its ability to obtain external funds, as Government rarely subsidises a project in its entirety.

International Health

Since the advent of a democratic government, the country has become an active and strategically relevant member of the international community. This also applies to South Africa's international health relations.

The primary responsibilities of Government include the following:

• leadership in the development of international health relations;
• guidance in setting priorities for development assistance utilisation;
• management to ensure the effective utilisation of these resources; and
• an effective fink between the South African health sector and the international community.

The Department of Health will be a strong advocate for health improvements to be recognised as a developmental priority within South Africa and the international community.

20.1 AN EFFECTIVE MECHANISM FOR INTERNATIONAL HEALTH LIAISON WELL BE ESTABLISHED AND AWARENESS OF INTERNATIONAL ISSUES AND OPPORTUNITIES CREATED

The Department of Health has a central role to play in coordinating, developing and managing South Africa's international health relations and providing support to the broader health sector in this field. A Directorate for International Health Liaison (IHL) was, therefore, established in 1994.

20.1.1 Implementation strategies

(a) Function and position of the International Health Liaison Directorate

This Directorate will be the focal point for the co-ordination and management of all international health and donor activities. It will be strategically positioned within the organisational structure to bring knowledge, skills and experience to bear on departmental policies. It will also participate in all international relations-related activities of the Department. An effective service will be provided to Government decision-makers, the international community and other clients.

(b) Health Attache Programme

The international health objectives of the Department of Health will be supported through the Health Attache Programme.

The Department will fulfil its obligations towards health and development in the international environment, and seek to maximise its contribution to the focus, content and direction of international policy. Using its international networks, opportunities for health development in South Africa will be maximised. For this purpose, health attaches will be deployed in several key positions.

Mechanisms will be developed to accommodate attaches between placements, to ensure the retention and optimal utilisation of their acquired skills within the public sector.

(c) Consultation mechanisms and services

The Department of Health must have the capacity to consult with, and for, other Government departments, the provinces, service, academic and research institutions, and the private sector on international health affairs.

(d) Increasing awareness of international health issues and opportunities

Government, the provincial health departments and the health sector at large will be kept informed of current developments in international health, their influence on South Africa and potential opportunities arising.

The performance of this task requires an effective information and communication system. This will necessitate not only improved communication and co-ordination of activities within and between the national and provincial departments of health, but also dissemination of relevant information through all available communication channels.

(e) Provincial health departments

In many respects, it is the provinces and districts which will benefit most from opportunities realised through the NIL and the acquisition of donor assistance. Close co-ordination is required, if the mobilisation of resources is to match needs and the IHL Programme is to identify resources capable of fulfilling these requirements. The provinces also have to be kept informed about their responsibilities under international treaties and resolutions. A strategy will be developed to improve communication with provincial authorities.

(f) Intersectoral collaboration

Collaboration with other departments is essential for effective IHL. An interdepartmental international affairs liaison committee will be established.

(i) Department of Foreign Affairs

The implementation of international health policy will have a bearing on international relations, which is the responsibility of the Department of Foreign Affairs (DFA). Close co-ordination on health and development issues is crucial for a coherent approach to foreign governments and international agencies. It will be ensured that all bilateral agreements on development co-operation with other countries reflect health sector requirements. The Health Attache Programme adds value to the work of the DFA in foreign health missions, but co-ordination of effort and agreement on responsibilities is essential.

Response to humanitarian situations of conflict, famine and natural disaster require liaison with the DFA for both policy formulation and intervention, and with the South African Medical Services.

(ii) Department of Welfare and Population Development

By definition, the overlap in responsibility for social affairs with the Department of Welfare and Population Development - particularly with respect to disabled, elderly, mentally and chronically ill persons - necessitates the synchronisation of international efforts toward people-centred social development.

(iii) Department of Arts, Culture, Science and Technology

Due to a shared responsibility for health sciences, close collaboration on international resources, meetings and committees is necessary with the Department of Arts, Culture, Science and Technology (DACST). The absence of science advisors or attaches abroad has, in some instances, resulted in health attaches' bearing responsibility for these functions on behalf of the DACST. Continued dialogue is required to direct the Department's efforts and responsibilities in this regard, and ensure they are in harmony with the objectives of the DACST's international programme.

(iv) Reconstruction and Development Programme

Donor assistance requires collaboration with the authority responsible for the RDP, whereas programme implementation requires co-ordination with the Department of Finance.

(v) Other departments

Numerous other departments are affected by factors failing within the scope of international health. The strategy for marketing health services and products will be developed in close conjunction with e.g. the Department of Trade and Industry.

(vi) Marketing strategy for South African health services and products

Expansion of the client base and customer orientation will improve service and increase the likelihood of effective exploitation of the Programme's opportunities.

A strategic partnership will be established with appropriate Government departments and industry. This will be done to explore mechanisms for utilising the strategic contacts of the Department in support of international market expansion.

(vii) Research and development capacity

Research and development capacity will be developed in IHL to refine policies, mount rapid and efficient responses to new opportunities and develop projects. This will require the use of nongovernmental and parastatal institutions for health and development. The Directorate must offer an advisory and consultancy service in these instances.

Consistent with the diversion of resources for capacity development in previously underfunded institutions, the Department will establish a research database and development units in Government, non- governmental and private institutions capable of responding to project development and implementation.

(viii) Employment of South Africans in the international health community

A system will be established for the identification, promotion, selection and recruitment of South Africans to serve on international expert advisory committees of the UN and other agencies. A policy for the placement of our nationals in international agencies must ensure that precious human resources are not lost to the international community.

20.2 INTERNATIONAL HEALTH RELATIONS SHOULD SERVE THE INTERESTS OF SOUTH AFRICANS, AND CONTRIBUTE TO THE ADVANCEMENT OF GLOBAL HEALTH GOALS

This objective will be achieved through focusing the Department's liaison activities on advancing the public health interests of developing countries in the international public health community, promoting good governance in international organisations, developing strategic international alliances, contacts and agreements, and promoting the South African health sector's international interests.

20.2.1 Implementation strategies

(a) Promoting the public health interests of developing countries

The Department of Health will promote developing countries' public health interests by -

1. actively raising awareness of developing countries' particular health needs in the international community through active bilateral and multilateral diplomacy;
2. influencing United Nations Agencies' agendas with health-related concerns through participation in and membership of governing bodies;
3. ensuring that emerging public health issues -are brought to the attention of international organisations, and through developing joint initiatives; and
4. promoting the inclusion of South African experts in advisory and technical committees of international agencies.

(b) Promotion of good governance within the World Health Organisation, UNAIDS and other international health organisations

The Department of Health has the primary responsibility for conducting government relations with certain international organisations. It will fulfil its obligation as a responsible member state by ensuring that all aspects of this relationship advance good governance in these organisations. In pursuit of this goal, the Department will use diplomacy and participation in governing bodies to promote -

1. responsible, accountable and transparent management practices; and
2. principle-based employment practices that will take into account representation of gender, race and people with disabilities.

(c) Development of strategic international alliances, contacts and agreements

To ensure optimal advantages from international relations, mutually beneficial bilateral agreements relating to co-operation on health issues will be developed. This will be in accordance with foreign policy guidelines. A proactive approach will be followed in establishing and maintaining strategic contacts with:

1. all United Nations Agencies involved with health or related activities including: WHO, UNICEF, FAO, UNESCO, UNFPA, ILO, the World Bank, UNFPA, IAEA, UNDCP, UNDP, UNEP and other relevant UN headquarters programmes;
2. the European Union;
3. the Commonwealth;
4. regional organisations, with particular emphasis on organisations in the African region, and those representing developing countries; and
5. relevant bilateral development agencies and foundations.

(d) Promotion of the international interests of the South African health sector

Collaboration with the broader health sector (private, provincial and academic) will be undertaken to ensure that their interests are promoted internationally. This will include:

1. Support through consultancy and information services on international issues; and
2. direct support from the IHL Directorate and health attaches.

(e) Representation of government at international meetings

The interests of the health sector will be promoted by the participation of Government delegations at international meetings where issues relevant to health are on the agenda.

(f) International obligations

Health-related obligations resulting from South Africa's membership of international organisations, bilateral agreements or international conventions will be identified and incorporated with health policies and strategies. Implementation of such obligations will be monitored on a regular basis.

20.3 DEVELOPMENT CO-OPERATION AND DONOR ASSISTANCE SHOULD SUPPORT HEALTH REFORM

International resources will be utilised in support of health and development. As the long-term sustainability of such resources (technical and financial) cannot be guaranteed due to declining development assistance, such offers of support will be carefully managed to ensure compatibility with national priorities and programmes, and ensure the long-term sustainability of projects.

International resources will also be utilised to fast-track programme development and promote intersectoral collaboration.

20.3.1 Implementation strategies

(a) Identification of international resources for health and development

The Department will network with foreign governments and international agencies to identity opportunities for health and development within RDP health priorities. For this purpose, it will use its own international networks and liaise closely with representatives of these governments in South Africa.

(b) Mobilisation of resources

The Department encourages donors to provide programme support in a way which strengthens systems. Interventions should increase capacity to collect and analyse health and related data, monitor trends and evaluate the impact of interventions. They should assist policy development and planning for health, as well as development of the necessary human resources to fulfil the above objectives and deliver PHC services at the district level.

Because of concerns about sustainability and recur-rent costs, there is a preference for horizontal programmes which are integrated with the Department's objectives for health. This will facilitate improved co-ordination and make for smoother programme management. Donors can, thus, relate to priority areas and be confident that their investments are fully congruent with the most pressing needs of the Department. Certain activities of the Department readily lend themselves to technical or budgetary support. Conversely, a multiplicity of projects are a burden, and this form of assistance is best directed to NGO's or other publicly funded institutions.

Instruments of support include support for research and evaluation, technical assistance and direct budgetary support.

The IHL Directorate will advise on project development for donor support including design, preparation of business plans, budgets, operationalisation and implementation.

(c) Co-ordination

Whilst all managers in the Department (national and provincial) should explore the use of international resources, co-ordination of these activities is essential for their rational use and South Africa's relations with foreign governments and agencies. Nationally, the Chairperson of the Departmental Donor Committee bears overall responsibility for all donor affairs. The focal point of first contact, however, is the IHL Directorate.

(d) Universities, NGO'S, research-based and other institutions

International resources will be directed to universities, NGOs, research-based bodies and other institutions. There will be particular emphasis on strengthening capacity amongst historically Black and under-resourced institutions.

20.4 INTERNATIONAL LIAISON ACTIVITIES SHOULD SUPPORT REGIONAL HEALTH SECTOR CO-OPERATION IN SOUTHERN AFRICA

Given the agreement between SADC Health Ministers on the need for and terms of reference of a health sector, the most urgent needs are mobilisation of all potentially available resources within member states and the acquisition of resources from the international community. This will support capacity development for regional health initiatives and programme development.

The development of health programmes will be consistent with the need for greater regional co-operation in health, within the framework of the resolutions adopted by the Health Ministers focusing on -

• communicable disease control;
• human resource development and management;
• regional health information and communication systems;
• procurement and distribution of pharmaceuticals;
• harmonisation of legislation on public health, pharmaceuticals, environmental health and food; and
• health research relevant to SADC issues.

20.4.1 Implementation strategies

(a) Establishment of an active liaison capacity for co-operation with SADC countries

A health attache post in the IHL Directorate will be dedicated to this objective. This will provide the South African health sector with an implementation capacity for developing activities in the context of SADC health sector co-operation.

(b) Mobilisation of resources

International liaison activities of the Department in general, and of health attaches in particular, will be utilised to identify and mobilise resources (technical and financial) for SADC health sector projects.

20.5 SOUTH AFRICAN PARTICIPATION IN INTERNATIONAL HEALTH SCIENCE DEVELOPMENT SHOULD BE ENCOURAGED

In matters affecting health science policy and intergovernmental agreements, there is shared interest and responsibility, and a need for co-operation with the Department of Arts, Culture, Science and Technology. The Department will work with universities and other institutions for health science research actively to encourage international agencies, organisations, foundations and trusts to support "essential national health research" in South Africa.

20.5.1 Implementation strategies

(a) Increasing funding for health research in South Africa

Efforts will be directed toward international resources for research programme support, capacity development, and identification and activation of international scholarships and fellowships.

(b) Increasing access to international research programmes

Numerous international research programmes have the capacity for third country participation. Knowledge about these opportunities will be disseminated throughout the research community.

In some instances, entry to these programmes require government-to- government agreements, where close collaboration with the Department of Arts, Culture, Science and Technology and the Department of Foreign Affairs is required.

(c) Promoting South African expertise

Promoting the participation of South African experts and scientists in international scientific, technical and advisory committees will be utilised for this purpose. The programme will raise awareness of South Africa's strengths across the range of health science research activities.

(d) Facilitating contact with the international research community

Opportunities identified during liaison activities will be brought to the attention of the research community. Active assistance can be provided to the research community, on request.

(e) Initiating and developing collaborative research projects

Based on experience and knowledge of the content, work programmes, networks and application procedures of international research programmes, the Programme will, in certain circumstances, initiate, advise and develop collaborative research projects with partners in research-based institutions.

Year 2000 Health Goals, Objectives and Indicators for South Africa

The mission of the Department of Health is to provide leadership and guidance to the National Health System in its efforts to promote and monitor the health of all South Africans, and provide caring and effective services through a primary health care approach.

This chapter, compiled by the National Health Information System Committee, presents the health goals, objectives, strategies and indicators based on the RDP's priorities, the recommendations of the health committees convened by the Minister of Health, and provincial goals, objectives and indicators. The goals and objectives presented here are not the product of one organisation only, but of many individuals and organisations. They represent high priority national goals and objectives for the year 2000, unless otherwise indicated. Provincial and district health authorities will have additional goals and objectives, based on local health conditions.

The goals contained here offer a vision of improved health status, and are based on several principles. These include the need to provide comprehensive and integrated services at all levels of health service delivery, and a commitment to primary health care principles. Some objectives in this chapter have specific, measurable outcomes, based on recommendations submitted to the Department of Health. These are not final outcomes, but should initiate discussion to achieve consensus on measurable outcomes.

For many of the objectives, additional information is required to determine baseline data and develop specific outcomes. Outcomes listed in this document may be modified, based on information collected in future years. Improvements to the National Health Information System will require addressing deficiencies in vital statistics, health facility records, and existing surveillance systems. The development of new surveys and data collection systems will be required to supplement existing information.

The legacy of apartheid has created marked differences in health status, based on race. The creation of a healthier South Africa depends on narrowing the difference in mortality and morbidity, and improving access to comprehensive health services for all population groups.

Outcomes for these population groups, as well as South Africans as a whole, will be developed.

Although not specified here, it is understood that data will be collected for variables that will facilitate health promotion and disease prevention and control.

Although health priority areas are listed separately, many are related to one another. In particular, many health objectives from maternal, reproductive and women's health, child health and nutrition are complementary.

The Department of Health acknowledges the importance of a national consultative process involving the health and other sectors to achieve these objectives and improve the health status of all South Africans.

21.1 Organising, planning and financing health services

Problem Statement: Health services are fragmented and unevenly distributed, resulting in inefficiency and ineffectiveness . In particular, many people in rural and peri-urban areas have inadequate access to health care services.

21.2 Maternal, reproductive and women's health

Problem Statement: Women often do not have access to comprehensive health services, including antenatal, delivery, postnatal and reproductive health services.

21.3 Child health

Problem Statement: There is poor access to quality preventive health care services, resulting in significant mortality and morbidity.

21.4 Adolescent health

Problem Statement: There is a need to increase access to health care services for adolescents, with the emphasis on reducing substance abuse, depression, teenage pregnancies and sexually transmitted diseases.

21.5 Care of older persons

Problem Statement: There is a need to improve knowledge of the health status of the elderly and their access to health services.

21.6 Nutrition

Problem Statement: There is a need to eliminate micronutrient disorders and monitor mortality related to disease of lifestyle.
[Note that nutrition objectives related to children are listed under child health]

21.7 Oral health

Problem Statement: Oral diseases are common in South Africa, and there has been an insufficient focus on preventive strategies.

21.8 Environmental health

Problem Statement: The prevalence of environmental health-related risks are important causes of mortality and morbidity. In certain geographic areas, environmental health services coverage is inadequate. The majority of South Africans have no access to basic housing and amenities.

21.9 Occupational health

Problem Statement: Occupational mortality, morbidity and disability are a major problem in South Africa. There is a need to place greater emphasis on prevention.

21.10 Emergency health services

Problem Statement: There are inadequate emergency health services, especially in rural and peri-urban areas. Emergency health standards and training for emergency health personnel are required.

21.11 Human resource development

Problem Statement: There is a need to improve the distribution of health personnel and provide training programmes and reorientation towards integrated health services, especially primary health care.

21.12 Substance abuse

Problem Statement: Substance abuse, including tobacco, is an important and increasing cause of mortality and morbidity. There is also a need to increase access to prevention and treatment programmes.

21.13 Mental health

Problem Statement: Mental health services are often inaccessible, and are not integrated with primary health care services. There is a need to improve knowledge and treatment of mental disorders.

21.14 Disability

Problem Statement: Ineffective legislation, lack of policy and inadequate health care programmes deprive people with disabilities of opportunities to function independently in the community of their own choice.

21.15 Sexually transmitted diseases (STDs) and HIV/AIDS

Problem Statement: The prevalence of STDs and HIV is a critical health and social problem which requires increased emphasis on prevention and treatment.

21.16 Chronic diseases

Problem Statement: Selected Chronic diseases (Cancer, hypertension, smoking-related diseases, diabetes, tuberculosis, and malaria,) are important causes of mortality and morbidity. Increased emphasis should be placed on prevention, early detection and treatment. [Note that objectives relating to immunisation are listed under child and maternal, women's and reproductive health]

21.17 Technology policies

Problem Statement: There is a need to guide the purchase and distribution of health technologies.

21.18 Drug policy

Problem Statement: There is an inefficient and inadequate drug distribution system which results in poor access to and availability of essential drugs.

21.19 Health information system

Problem Statement: Health information is uncoordinated, fragmented and poorly utilised.

21.20 Health research

Problem Statement: Research is fragmented, uncoordinated and there is no essential research strategy. Research has not been used to develop the health system. fragmented and uncoordinated.

Glossary

Child (under 5) Mortality Rate
The number of deaths among children before the age of 5 years per 1000 live births.

Maternal Mortality Rate (MMR)
The number of female deaths that occur as a result of complications of pregnancy and child birth per 100000 live births.

Infant Mortality Rate (IMR)
The number of deaths among children before the age of one year per 1000 live births.

Neonatal Mortality Rate
The number of deaths before one month of age per 1000 live births.

Perinatal Mortality Rate
The number of stillbirths and early neonatal deaths per 1000 live and still births.

Comprehensive
The fullest possible range of, for example, primary health services; the provision of preventive, promotive, curative and rehabilitative care by a health care facility or authority.

Decentralisation
The process of shifting responsibility, authority and accountability for planning, management and allocation (and raising) of resources to those who are implementing policy at the lowest level; the transfer of appropriate authority from central government to provinces, regional offices, district health authorities, local governments and/or nongovernmental organisations.

Delegation
The process of shifting authority and responsibility for specific issues and defined functions to other administrative structures or individuals; responsibility remains with the delegating authority

Devolution
The creation or strengthening of sub-national levels of government (such as local authorities) that arc substantially independent of the national level with respect to a defined set of functions; normally there is geographic responsibility for a range of services and the power to raise revenue; accountability is usually to the electorate.

District Council Area
An area which is managed by a district council; may be larger than a health region; may contain a Transitional Rural Council and Transitional Local Councils.

District Health Authority
Governance structure which is responsible for ensuring the delivery of all primary health care in a health district.

District hospital
First level non-specialist hospital to which patients from clinics or health centres may be referred.

Economies of scale
Achieving the correct scale of operations so that the unit cost of each production or purchase is reduced to a minimum, e.g. it may be cheaper for a provincial department of health to purchase medicines than for a district health authority.

Effectiveness
The best possible outcome or result.

Efficiency
The attainment of the best outcome or result at the lowest possible cost.

Ensure
To make happen; to co-ordinate.

Equity
The universal provision of services on the basis of need rather than any other criterion.

Governance
The processes used by governing structures to make and implement laws and provide services.

Health district
Geographic area that is small enough to allow maximal involvement of the community so that local health needs are met, but also large enough to effect economies of scale.

Health region
Geographic area into which a province is divided and within which secondary hospital services are available within the health districts that fall within its boundaries.

Local authority
Administrative structure that is responsible for the provision of services within a local government.

Local government
Third tier of government; most suitable for a village, rural setting, town or city.

National Health Service
Health services provided by a country for all Its citizens.

National Health System
The organisation of a country's health service (including services provided by central government, provincial government, local government, NGOs/CBOs and the private sector).

Prevention
Ensuring that diseases or illnesses do not occur.

Primary Health Care approach
The underlying philosophy for the provision of health care services that is based on the Alma Ata Declaration, i.e. comprehensive care that includes curative, preventive, promotive and rehabilitative care within the context of, amongst others, community participation and intersectoral collaboration.

Public sector
Services provided by and through government structures (national or provincial departments of health or local government), for the benefit of all citizens.

Quality assurance
A management system designed to ensure the provision of services that are of the highest possible standard.

Rationalise
A process whereby resources are used most effectively and efficiently; often used to mean, especially in the civil service, a cutting back or reduction of resources.

Regional hospital
Usually a secondary hospital to which patients are referred from the district hospital (i.e. a hospital which serves many districts and at which more specialised services are available).

Revenue
Monies earned; income; usually refers to income earned by a government or authority, e.g. from taxes, or from user fees collected by a hospital.

Wellness approach
An approach to the provision of services that places the emphasis on creating all the conditions (i.e not just health services) that enable people to become, and remain, healthy and that contribute to the well-being of all.

Academic Health Complex
Functional unit consisting of one or more faculties and/or departments of health sciences and associated health care facilities at the primary, secondary and tertiary levels.

Hospital
Level 1
Patients requiring treatment which may be adequately and appropriately provided at the first level of referral (e.g. a community hospital) by a generalist with access to basic diagnostic and therapeutic facilities.

Level 2
Hospitals providing specialist services at the provincial level. Such hospital would be equipped with an intensive care unit.

Level 3
Patients requiring the expertise and care associated with the specialities, sub-specialities and less common specialities (such as cardiology, endocrinology, oncology, plastic and trauma surgery, neonatology, sophisticated paediatrics and specialised imaging), or requiring access to scarce, expensive and specialised therapeutic and diagnostic equipment found only at a central or tertiary hospital (the third level of referral)
Level 4
(or national) facilities providing quaternary health care (such as liver transplantation and heart transplants).