The District Health System (DHS) is a management framework for the integrated delivery of primary health care services. The DHS is an instrument of transformation in that it is key to overcoming the fragmentation of the past and the inequities that existed even within limited geographic areas. Its transformative role also lies in facilitating decentralisation, as the DHS is a local structure and it shifts management and accountability for primary care services much closer to communities.
The strategy for primary health care in the period immediately after the first democratic election focused on the expansion of a network of facilities in a context where there were large areas where the local population had never had easy access to a clinic or hospital. In the current phase, objectives relate more to the range of activities carried out by clinics, the suitability of their personnel for the tasks expected, the adequacy of infrastructure and supply systems and the links to the community.
Five year objectives
Key objectives for 2001/2
Development of districts
The Health Minmec decided in early 2001 that health districts should be redefined to coincide with the newly demarcated municipal areas. This decision was consistent with the policy that health districts and municipal boundaries should at all times coincide.
The development necessitated major reorganisation during 2001/2, as the earlier 174 health districts were reshaped and consolidated into 53 new districts. This task was largely completed by the end of the financial year, although there are still some problems with the organisation of services in district councils that straddle provincial boundaries. Most provinces have also identified health sub-districts, consisting of one or more local municipalities within a district or metro council area.
The scene is now set for each health district to develop a comprehensive health plan and budget. This will facilitate much greater accountability to local communities. While it may take a year or two to clarify the respective budgetary contributions of the province and the municipality to the health district, once this is done - and once the 2001 Census results are available - a very clear picture will emerge of per capita health spending. This will be a powerful weapon in the battle for health care equity.
During the year under review, Provincial Health Authorities and Provincial Health Advisory Committees were established in five provinces. They comprise provincial and local government representatives and play an important role in facilitating co-operative governance.
Improving primary care
The defined package of comprehensive primary care services, finalised in 2000, was launched during the year. The national and provincial health departments are committed to ensuring that the range of services is available in all districts and that the relevant norms and standards are met by March 2004.
To achieve this goal in the poorest districts, most funding made available by the European Union for district development for the period 2001 to 2003 has been directed to the 13 nodes of the ISRDP. A contract to support implementation of the service package in these areas was awarded to the Health Systems Trust in October 2001. By March 2002 HST had appointed a facilitator for each node and formal launches of the package had occurred in several nodes.
Nine out of 13 district councils for the ISRDP nodes agreed to treat implementation of the PHC package as an "anchor" project for the node. This local government buy-in is critically important and should lead to plans for the PHC package being incorporated into the Integrated Development Plans for the relevant areas.
In addition, to assist provinces to implement the package outside the development nodes, information was collected to establish the gap between the requirements of the package and what is currently provided. The package itself has been costed and work has begun on developing district health plans and budgets.
The PHC Clinic Survey focused particularly on the personnel available to implement the service package and quantified the gap in various areas. This is reported more fully on page 73.
District Health Information System
In order to assist the planning of primary care services, the District Health Information System - which uses standard software - is in place in all provinces. At the end of the period under review 95% of primary care facilities were recording and reporting basic information. Some facilities were reporting more comprehensive information and the objective is to have all facilities at "level 3" reporting by December 2002.
Special support was provided to the 13 rural development nodes to ensure the development of sound information systems there. Once more the EU was the funder and the expertise was provided by a consortium comprising the Universities of Natal and the Western Cape and HST.