March 20001

ISBN – 1-919839-15-1

Author:

Jillian Nicholson

Text advisors and content editors:

Beth Englebrecht, David McCoy, Antoinette Ntuli

Illustrator:

Ian Lusted

Design and layout:

Jessica Nicholson

Every attempt has been made to ensure that the information published here

is accurate. However no responsibility is accepted for any loss or damage

that may arise out of the reliance of any person upon any of the information

in this book.

This publication was supported with a grants from the Henry J.

Kaiser Family Foundation (USA) and the Rockefeller Foundation.

Published by

The Health Systems Trust

401 Maritime House

Salmon Grove

Durban 4001

Tel: 031- 3072954

Fax 031 – 3040775

Email: hst@healthlink.org.za

Also available on the internet:http://www.hst.org.za

Bringing health closer to people has long been a goal for us in South Africa. Putting this idea

into practice means that health care should be provided by local government, the sphere of

government closest to people. The demarcation of the municipal boundaries, and the local

government elections in the year 2000, signaled a critical step towards achieving this goal.

This book provides information about the process of transformation of local government and

what the devolution of health care to local government is likely to mean for the provision of

health services. It has been written with health workers and legislators in mind, although it is

likely to be of use to a wider audience including local government councillors and NGOs

among others.

Legislators have a critical role in overseeing policy implementation and this book will

contribute to equipping them to monitor the decentralisation of health care services.

As with every major change, it is inevitable that some uncertainty is created. The process of

transformation is not yet complete. There are still many areas that remain unclear and many

decisions that need to be taken. This book provides a useful interim guide that helps to

answer some of the numerous concerns and questions that are frequently being asked about

what is happening.

Dr. Abe Nkomo

Chair of the National Assembly Portfolio Committee on Health

What is local government and why is it important to the health system? . . . . . . . . . . . . . . . .1Phases in the transformation of local government . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2Two important features of the new system of local government . . . . . . . . . . . . . . . . . . . . . . .6

1. Local government will be developmental . . . . . . . . . . . . . . . . . . . . . . . . . . . . .62. Local government will have more power: changing from tiers to spheres . . . . . . . .7

The new municipalities: boundaries and categories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9Wall-to-wall municipalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9Cross-border municipalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10Three categories of municipality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

Powers and functions of these new municipalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14Prioritising for development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14What about the health services? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15Financing local government . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

Working together: the relationship between local, provincial and national governments . . . . .19The role of provincial governments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19Co-operation between municipalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20

Summary: the essential points of this section . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

Changing the approach to health care in South Africa . . . . . . . . . . . . . . . . . . . . . . . . . . .24The Primary Health Care approach to health . . . . . . . . . . . . . . . . . . . . . . . . . . .26The District Health System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28

Local government and the District Health System: issues to be finalised . . . . . . . . . . . . . . . .301. A legal framework for the health system . . . . . . . . . . . . . . . . . . . . . . . . . . . . .322. How will health districts be aligned with new municipal boundaries? . . . . . . . . .323. How will health districts be managed and controlled? . . . . . . . . . . . . . . . . . . .354. How will health service be delivered? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .365. The transferring of health workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .386. Funding for the new municipalities and health districts . . . . . . . . . . . . . . . . . . .40

Ensuring equitable redistribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42Summary: the essential points of this section . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44

T he system of government in this country is goingt h rough important changes. With the finalisation ofnew municipal boundaries and the passage of the

Municipal Systems and Municipal Stru c t u res Acts, localgovernment is set to play a far more significant role than ithas in the past. These changes mean that new managements t ru c t u res will have to be established, new functions takenon board and new lines of communication set up.

This section gives some background to the development oflocal government in the country and explains the changestaking place and the new system that is being set up.

Local government is the level of government that is closest to people. It

a ffects how people live, work, raise families and spend their spare time.

S t rong local government can help to improve basic services and facilities

and build equity. It is there f o re very important for communities and

their organisations to be involved in matters of local government.

Since 1993, when an Interim Constitution was adopted for South Africa,

local government has been going through a process of transformation.

This transitional phase ended with local government elections on 5

December 2000.

1

Some of the reasons why it is important to be clear about the new local

government system are:

❂ The national government has made a policy decision to have strong

local government in South Africa that will be responsible, among

many other things, for delivering municipal health services.

❂ The changes in local government directly affect the proper

functioning of the District Health System.

❂ Legislators will be making decisions about local government that will

have important implications for health delivery.

The apartheid system repressed the social, economic and political lives

of South Africans. Most people lacked the basic necessities which

government should provide – housing, health care, water, sanitation

and electricity, for example. Black people were excluded from national

and provincial government and black municipalities had no power and

no democratic base. They were administrative agents of the white

provincial governments with no powers of governance of their own.

2

What is the difference between local government and a municipality?

In this book the term ‘local government’ is used to describe the whole system of gov-e rnment at the local level. We talk about national, provincial and local govern m e n t .

The word ‘municipality’ is used to refer to a specific area of land, the residents andcommunities within it, its governing council and the staff employed by the council.There are three different kinds of municipalities. These are described on page 12.

As you can see in the diagram, there was a top-down approach to

governance. Local government was the lowest tier of government.

National Government

Provincial Government

Local Government

3

The struggle for democratic rights at the local government level

intensified in the 1980s, with organised mass action against the

apartheid city stru c t u res. Communities and their org a n i s a t i o n s

demanded improved services and opportunities and a much gre a t e r

say in their local affairs. This led to the formation of local negotiating

f o rums with re p resentatives from civic associations, community and

residents’ associations, trade unions and political parties. By 1993 a

National Local Government Negotiating Forum had been formed to co-

o rdinate the local forums and guide the transformation process.

The 1993 Interim Constitution entrenched this right to transform local

governance though negotiations with communities.

There are three phases to this process:

❂ The Pre-Interim Phase: this was between 1993 and 1996 when the

new Constitution was passed and the first local government elections

were held.

❂ The Interim Phase: this was between 1996 and the second local

government elections in December 2000.

❂ The final stage, which has now been reached, when a new local

government system starts to operate.

During the Pre-Interim phase the local forums were formally

recognised. They were given responsibility for setting up transitional

local government structures based on the principles of non-racism,

democracy, and accountability. A number of different types of councils

were established to replace the old apartheid structures. This included

metropolitan transitional councils, local transitional councils,

transitional representative councils, transitional rural and district

councils. There were also some remaining areas that did not fall into

any of these categories.

4

In 1996, people were elected onto these councils in the country’s first

democratic local government elections.

Between 1996 and December 2000, the transformation process

continued. Although many of the old racial barriers were removed, the

new boundaries of the interim local governments still reflected a racial

divide. The old white towns had Transitional Local Councils. The

surrounding townships and rural areas had Transitional Representative

Councils. So the system was still fragmented, with too many different

types of local structures.

There were huge inequalities and backlogs in the provision of services.

Many of the new councils did not have the capacity to manage their

funds and some became bankcrupt and ineffective. Both these problems

continue today.

In the final stages of transformation, the Municipal Demarcation Board

was set up. Its job was to re-draw all the local government areas and to

develop a system that would be sustainable, effective and efficient.

1980 – mass action against apartheid cities 1993 – formation of local negotiating

forums and National Local Government Negotiating Forum transitional local

government structures set up 1996 – first democratic local government

elections final stages of transformation Municipal Demarcation Board

establishes new municipal boundaries throughout the country December 2000 –

second democratic local government elections the end of the transitional stage.

5

South Africa’s new local government system differs in fundamental

ways from the old apartheid system and also from the transitional

system that ended in December 2000. It is a new and exciting form of

local government that gives substantially more power to municipalities

and their residents.

A culture of public participation in the affairs of local government is

encouraged. This is what people in the 1980s were fighting for.

Two central features of the new local government system are:

The Constitution states that local government in South Africa must be

developmental. This means local governments must work with their

communities to improve economic and social conditions and to

overcome inequality. Equitable redistribution is central to the system. To

do this, more resources must be directed to the areas that have the least

resources.

In terms of the constitution, the objectives of local government are to:

❂ provide democratic and accountable government for local

communities;

❂ ensure the provision of services to communities in a sustainable

manner;

❂ promote social and economic development;

❂ promote a safe and healthy environment;

❂ encourage the involvement of communities and community

organisations in the matters of local government.

6

This is a big change from the past, where local government was mainly

concerned with providing services to white communities and with

matters such as traffic regulation, issuing licences and looking after

parks and recreation.

Talking about ‘tiers’ and ‘spheres’ may seem like playing with words, but

in fact the words are used to describe two very diff e rent systems. As you

saw on page 4 the tier system is a top-down approach. Local government

is the lowest level and the national government is all-powerful. The

Constitution has specifically chosen to use the word ‘spheres’, to describe

the national, provincial and local governments in the country. A s p h e re is

a round shape. It does not have a top or a bottom.

The diagram (right) and the picture on the

next page show three spheres. You can see that

one is not above the other and that at some

points all spheres are linked to each other.

They represent the system that has now been

set in place in South Africa, where national,

provincial and local governments function

within a framework of co-operation. This is

sometimes called a decentralised system. You

can read more about this on page 16.

7

LocalGovernment

NationalGovernment

ProvincialGovernment

8

Local governments are no longer just the agents of the provincial

governments. They now have the power to make and carry out laws,

raise taxes and govern themselves in all matters that have been

allocated to them by the Constitution. They include municipal health

services. However, these still need to be much more clearly defined.

Although it is useful to see each sphere of government with its own

areas of responsibility and authority, ultimately all spheres of

government have joint and shared responsibility for ensuring that the

basic services of the population are met. Therefore, it is important that

the three spheres of

government work towards

a common vision of

equitable, effective and

efficient delivery.

South Africa now has new municipal boundaries and new types of

municipalities, with new powers and duties.

The Municipal Demarcation Board was given the responsibility of

dividing the country into new municipalities. Every bit of land in South

Africa is now part of a municipality, including all farming areas and are a s

which fall under traditional leaders. We have wall-to-wall municipalities.

9

In order to make sure that each new municipality could provide

developmental local government, the Board combined a number of

areas that had previously been separate. Some rural and urban areas

were combined to form one municipality; towns were sometimes

combined with other towns and sometimes an urban area was extended

to include an informal area close by.

The number of municipalities has been reduced substantially, from 834

to 285.

When it set the new boundaries the Demarcation Board looked at a

number of different factors in each area. For example, it looked at the

size of the population, employment and employment opportunities, the

incomes of people, water supply and whether it would be financially

possible for an area to provide the services that a local government has

to provide. It looked at the existing health boundaries and the way that

health services were co-ordinated.

The Board was supposed to take into account everyday factors such as

how the health services in the area were run, where children attended

school, traffic flows and even newspaper deliveries!

A c ro s s - b o rder municipality is a municipality that lies across the bord e r s

of two provinces. There are six of these cro s s - b o rder municipalities.

T h e re has been some confusion about which province is responsible for

these. Here are some points to help clear up the confusion:

❂ Both provinces concerned must agree to the existence of the cross-

border municipality. If they do not agree to it, then it will be de-

established and the Demarcation Board must make new boundaries

that do not cross into another province.

10

❂ In the case of a cross-border municipality, the Member of the

Executive Council (MEC) for local government in both provinces

must decide how the provinces are going to carry out their executive

responsibilities towards this municipality. There are a number of

options for this. They can share these responsibilities or they can

delegate them to agencies to carry out.

❂ An agreement must also be reached about how the laws of the

provinces will apply to that municipality. It is possible for an

agreement to be reached where the laws of only one province will

apply to the cross-border municipality.

11

The Constitution provides for three categories of municipality. Each has

different powers and functions.

There are six metropolitan areas in the country – Cape Town, Durban,

East Rand, Johannesburg, Pretoria and Port Elizabeth-Uitenhage. These

are large urban areas incorporating one major city and a number of

smaller towns. The entire area is divided into wards. Voters elect

councillors onto a Metro Council that has authority for all local

government matters in its area.

A Category B municipality is a single local municipality. Voters in a

Category B area elect councillors onto a Local Council. This Local

Council may also decide to divide its area into wards. All local

municipalities also fall under a district municipality and share some

authority with the district municipality (see below). There are 232 of

these Category B municipalities

Category C municipalities have authority in an area that includes more

than one Local Council. The category will have a District Council that

will consist of some councillors voted directly onto it and some who

re p resent the local councils within the district. Inside some Category C

municipalities there will be some areas that do not have a Local Council.

These are called District Management A reas. Residents of these areas do

not have a local council of their own but fall directly under the District

Council.

The diagram on the next page shows the new municipal boundaries for

the Western Cape. It is divided into local municipalities, district

12

management areas and district municipalities, with one metropolitan

area.

You can see from the map that district councils consist of a number of

local councils, with some district management area.

All these municipalities have been legally established and their new

boundaries, categories and names have been published in the

Government Gazette.

District Municipality

Local Municipality

CapeTown

Metropolitan area

District Management area

Local Municipality

13

All categories of municipalities must have the legal power and

authority to govern their areas effectively. They will be able to make

and carry out laws to promote developmental local government and

will be responsible for the administration of their area.

Section 156 (5) of the Constitution says:

‘a municipality has the right to exercise any power concerning a matter

reasonably necessary for, or incidental to, the effective performance of its

functions.’

All municipal councils have to draw up

development plans for their areas. These are

called Integrated Development Plans

(IDPs). Amongst other things, these plans

must say how councils are going to provide

necessary services, what they are going to

prioritise and how they are going to make use of

their resources.

Councils have to make difficult choices when

they develop these plans. They have to say

where the money will come for the IDP. The

IDP also has to say which department or

14

programme will be responsible for delivering all

the services. These are important issues for

health services.

As far as health care is concerned,

there are some very broad

guidelines for local government but

little clarity on the details:

❂ The Constitution says that

municipal health services are the

responsibility of local government.

❂ The Municipal Structures Act

together with its Amendment Act

says municipal health services are

the responsibility of metropolitan

and district municipalities, not local

municipalities.

❂ The Constitution also says that health

services generally are one of the matters

that can be handed over from a national or

provincial government to a municipality if the municipality has the

capacity to take over this responsibility.

As you can see, this is not very helpful. There is no clear definition of

either health services or municipal health services so there is no clarity

about what health services local government will be responsible for.

Some provinces and local governments think that ‘municipal health

services’ should mean all primary health care services. Others argue for

a narrower definition.

15

There is some speculation that ‘municipal health services’ only mean

environmental issues affecting health, such as the supply of clean water

and sanitation.

Decisions still have to be made through negotiation and agreement.

A critical issue related to this, is funding. Municipal health services will

be funded by the national government. Exactly how this will happen

still has to be decided. Any additional functions will have to be

financed from the provincial departments of health.

16

What do you think about decentralisation?

As you have seen, the new system of local government aims to give more powers and responsi-bilities to local government. This is a decentralised system. There are disadvantages andadvantages to decentralisation in relation to health care.

The advantages are:

❂ Decisions about health care and health management are made at local level which is closerto the people affected these decisions.

❂ Decisions are more likely to be appropriate for the needs of the people in an area than ifthey were made at national level.

❂ There is the possibility of better community participation in the health issues of their area.

❂ There will be greater accountability on the part of local authorities because the people of thearea have elected Councillors.

Some of the possible disadvantages which people raise are:

❂ Decentralisation can weaken the national Department of Health and lead to a lack of co-ordination between the various levels of a health system.

Many of the municipalities in South Africa have been in a serious

financial crisis. Some of the reasons for this are:

❂ They have had to finance the huge backlogs in services in poor areas

that were neglected by the apartheid government.

❂ Lots of people do not pay rates and service charges.

❂ There has been poor financial management in some municipalities.

❂ Combining the old apartheid municipalities into a more efficient local

government system has been very expensive.

Municipalities are now faced with still more costs due to the increase of

their responsibilities and functions. In many instances, it is unclear how

these functions will be financed, but they do have the power to decide

how they can raise more money to fulfil their responsibilities.

Municipalities try to finance some of their day to day expenditure from

their own revenue sources. They raise money from property rates,

charges on services and taxes.

❂ Unless funds and resources are distributed equitably, a decentralised system could lead togreater inequities in health and health care between municipalities.

❂ The interests of everyone may not be properly represented if powerful factions control deci-sion-making and resources at a local level.

❂ Decentralisation may result in different working conditions and in unequal pay for the samework in different municipalities, leading to a form of fragmentation.

❂ Decentralisation can lead to job insecurity, confusion and a loss of morale amongst staff.

17

18

H o w e v e r, most municipalities, particularly in the rural areas, do not

have a large enough tax base to bring in enough finance to cover all their

needs and also receive grants from national and provincial governments.

In some areas such as the former Transkei where the overall majority of

the population live in poverty, local government will have little chance

of raising their own revenue and will continue to be dependent on

national revenues.

In order to work towards equity, poorer municipalities should receive a

larger portion of these funds.

19

In order to govern effectively, local government needs to have a voice in

the provincial and national governments where laws are made, and

where budgets are passed.

Each province has a Local Government Association that re p resents all the

municipalities in the province. Representatives from these pro v i n c i a l

associations form a national association – the South African Local

Government Association (SALGA). These bodies can promote co-

operation between municipalities, between local government and the

p rovincial government and between local government and the national

government. They are represented on the National Council of Provinces

and at national level on the Local Government MINMEC which is a

national committee dealing with all matters affecting local government.

The members of MINMEC are the Minister for Provincial and Local

Government Affairs, the nine provincial Members of the Executive

Council for local government and Salga.

Provincial governments play an important role in supporting local

government. Some of the ways that they do this are:

❂ To provide strategic and policy direction.

❂ They help with the overall development of local government in the

p rovince and making sure that the development plans of the munici-

palities are viable in terms of the development of the whole

p ro v i n c e .

❂ They help build capacity, particularly in the poorer municipalities.

❂ They establish forums and processes so that local government can be

included in the decisions that affect it.

20

❂ They monitor municipalities to ensure that they fulfil their functions

as set out in the Constitution.

❂ They monitor the financial state of municipalities.

❂ They intervene, if necessary, in the affairs of a municipality.

Municipalities can gain a lot by building relationships with each other

and co-operating in the delivery of services. For example, they can:

❂ Share staff and technology – this could help health services in for

example the procurement of drugs.

The essential points of this section

✓ The new system of local government increases the powers, responsibil-ities and accountability of municipalities.

✓ There are now wall-to-wall municipalities throughout the country.

✓ There are three categories of municipality: a metropolitan municipality,a district municipality and a local municipality.

✓ Several local municipalities will be part of one district municipality.

✓ Local government is constitutionally responsible for municipal healthservices, but as yet there is no precise definition of the functions of themunicipal health services.

✓ Some municipalities will not be able to increase their responsibilitiesfor health unless they have assistance from their provinces or thenational government.

✓ Decisions still have to be made regarding exactly what health serviceseach municipality will provide.

❂ Undertake joint investment projects such as for tourism.

❂ S h a re the cost of things such as bulk services (for example, sanita-

tion projects or sharing infrastru c t u re such as dams), consultants

and equipment.

❂ Provide services for each other. For instance if a local council cannot

remove solid waste in its area, the district council could take over this

responsibility.

21

22

A new approach to health has been established forthe country, based on the principles of thePrimary Health Care approach and the District

Health System. It would be very satisfying if we couldtake this approach and the new local government systemand fit them together like the pieces of a puzzle. But thisstage has not yet been reached. Important decisions haveto be made before the puzzle fits together completely.

This is a difficult time for people involved in both healthand local government. Health workers are frustratedbecause health systems that were put in place after 1994are once again changing. Lack of clarity is also a frustrat-ing factor. Local government staff and councillors areunder great pressure as they take on more and moreresponsibilities. Provincial and national legislators willplay a critical role in making new laws, policy decisionsand in monitoring and supporting the new system.

This section gives a brief explanation of the newapproach to health. It then deals with the restructuringthat has taken place in the health system and with whatwe do and do not know about how local government isgoing to work together with health authorities to providea cohesive, integrated health system.

23

24

The apartheid health system was one of the most unequal, fragmented

and wasteful in the world. Fourteen different health departments

administered health and duplicated services on a racial basis. There

were ten bantustan health departments, three ‘own affairs’ health

departments for the white, coloured and Indian population and one

general affairs department. There were also provincial health

departments as well as 382 local authorities that were responsible for

some health issues. Hospitals were segregated until 1990 and even

when this fell away, they were still controlled by racially segregated

health departments.

The old government adopted a medicalised approach to health. This

emphasised curing disease rather than preventing it. It focussed on

hospital-based medicine and the use of advanced technology. The

health system was also very fragmented. For example, services that

helped prevent disease, such as immunisations, were separated from

services for treating disease.

The problems inherited from the apartheid system were enormous, but

in the years since 1994 major strides have been taken to meet the

challenge to overcome them.

Restructuring the health sector has the following aims:

❂ To unify the fragmented health services at all levels into a compre-

hensive and integrated national health system. A district health sys-

tem is seen as the best way to achieve this.

❂ To reduce inequalities in health service delivery.

❂ To mobilise all partners, including the private sector, non-govern-

mental organisations and communities in support of an integrated

National Health System.

These aims are supported by the South African Constitution that states

that everyone in the country has the right to:

‘access to health care services, including reproductive health care.’

( Section 27)

and that children have a right to:

‘basic nutrition, shelter, basic health care services and social service.’

(Section 28)

In addition, everyone has the right to an environment which is:

‘not harmful to health or well-being.’ (Section 24)

25

26

The Primary Health Care approach emphasises general health care

rather than curative health care.

The approach is based on the following principles:

❂ Resources must be distributed equitably. This does not mean that all

areas must be given the same resources. It means that those areas that

have the least resources should be given the most assistance.

❂ Communities should be involved in the planning, provision and

monitoring of their health service. This allows for different needs to

be met in different communities.

❂ A greater emphasis should be placed on services that help prevent

disease and promote good quality health. There is a shift away from

curative services.

❂ Technology must be appropriate to the level of health care. For

example, this would mean ensuring that all clinics have fridges that

work for the storage of vaccines before equipping them with high-

tech medicine facilities.

❂ There should be a multi-sectoral approach to health. In the Primary

Health Care approach, the provision of nutrition, education, clean

water and shelter become central to health care delivery. So, for

example the Departments of Water Affairs and Education are impor-

tant role-players within the health system.

Is there a difference between primary level health services and thePrimary Health Care approach?

Yes. There is an important difference.

Primary level health services refer to basic health care services provided at the lowest level of thehealth system, usually by clinics, community health centres and district hospitals. Examples ofthese services are basic child and maternity care, family planning and school health services.

Other levels of the health service are the secondary and tertiary levels. These tend to providemore specialised services through regional or academic hospitals.

The Primary Health Care approach however is not related to a particular level of the health sys-tem. Its principles apply to the entire health system and all levels of service. This means taking amore developmental approach to health, where communities could be partners in health care;resources and finances would shift away from high-tech, tertiary hospitals to primary level servic-es and specialist doctors would play a more supportive role to nurses working in clinics. Thiswould be a critical move towards health equity.

27

28

The Primary Health Care approach requires a different system of health

delivery to the one used in the past. The District Health System is this

new vehicle for delivery. It is a system organised around areas and their

populations. The country is divided up into health districts and health

is planned, organised and managed at this district level. This is different

to the system that was in place before 1996, where planning took place

at national level and delivery at provincial or local level.

For this system to work eff e c t i v e l y, it is important to get the size of a

district right. It should be large enough to contain the full range of

district health services, including a district hospital, but small enough

to allow efficient service delivery and community involvement.

Ideally a health district should have a population of between 50 000

and 500 000. Some districts will there f o re cover a much bigger are a

than others.

The point of having health districts is to allow communities to interact

with the people who manage health and to allow health workers to

interact with people in other sectors that affect health, such as Water

Affairs. Government health workers can also work together with non-

government workers and with private health workers.

In each health district:

❂ Primary health care must be delivered to all the people in the area.

❂ T h e re must be one health authority responsible for primary health care ,

including community-based services, clinics and district hospitals. A t

p resent primary health care in South Africa is delivered by diff e re n t

p roviders, at diff e rent times and in diff e rent places.

❂ Decisions about health care for a dis-

trict should be made by that district’s

health authority and health council,

and not at a higher level of the health

department.

❂ Communities should have a real say

over their own health care.

Before the new municipal boundaries

were set, 180 of these health districts

were demarcated throughout South

Africa, and interim District

Management Teams were appointed to

run most of them.

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30

The District Health System and the new local government system

have been developing separately and at diff e rent paces. The district

health system began to be implemented much earlier than the new

local government system and so it is quite far ahead in terms of

p ro g re s s .

However, the transformation of local government has now caught up

with the developments within the health care system. An important

step forward was the demarcation of municipal boundaries.

The next step was the local government election. Now the

overall vision of a decentralised health care system with

local government playing a prominent role, through a

district health system, can start to be realised.

There are two fundamental challenges to the health sector:

❂ Firstly, the boundaries of the 180 health districts must be

changed to come into alignment with the new municipal-

ity boundaries.

❂ Secondly, this is to be accompanied by a process of

devolution whereby local governments are expected to

take on some of the provinces’ responsibilities for the

delivery of health care. Exactly how this will happen

must still be decided.

At the moment there are many problems and issues of

concern. Many processes are incomplete and many

decisions are still to be taken at provincial and local level.

Some of the main issues that require finalisation are:

1. A legal framework for the health system.

2. How will health districts be aligned with new municipal boundaries?

3. How will health districts be managed and controlled?

4. How will health services be delivered?

5. The transferring of health workers.

6. Funding for the new municipalities and health districts.

These issues are discussed on the following pages.

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Since 1994 much of the responsibility for health

has been in the hands of the provincial health

departments who have taken the lead in trans-

forming health.

Some provinces have drawn

up their own legislation,

setting out how their health

districts should be governed and

a d m i n i s t e red. They have based this

legislation on a national policy

paper - the White Paper for the

Transformation of Health Care in

South Africa. However they have had no

national laws to guide them. The current Health Act of 1977 is very

outdated and a new National Health Bill is still being drafted.

This lack of legislation has been and remains a problem for an

integrated health system.

In many instances the health district boundaries that were set up after

1996 are different from the boundaries of the new municipalities.

Now that the new municipal boundaries have been set, health districts

will have to fall into line with these. Each province will have to decide

on the best way to do this. Provinces will have to bear in mind that the

size of a health district and the number of people in it, are important

factors in an effective district.

This is not going to be easy. Look at the map. It shows the health districts

of the Western Cape. If you compare it to the earlier map on page 13

showing the three types of municipalities in the Western Cape, you can

see that, excluding the metropolitan area of Cape Town, there are five

district municipalities and twenty-four local municipalities or district

management areas. But there were thirteen health districts demarcated.

District Council boundaries

Health District boundaries

Central Karoo

Klein Karoo

Vredendal

Malmesbury

Vredenburg

Paarl/Stellenbosch

Ceres/Tulbagh/Wolseley

Worcester/Robertson/Montagu

Mossel Bay/Langeberg

Bredasdorp/Swellendam

Caledon/HermanusGrabouw

George Knysna/Plettenberg Bay

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34

There are a number of options for aligning health district boundaries:

❂ New health districts could be formed which have the same boundaries

as the district municipalities. This would mean a big increase in the

size and population in each health district and make the health district

too large to co-ordinate primary health care services eff e c t i v e l y.

❂ The existing health districts could be kept as sub-districts with new

health districts in line with the district municipalities.

❂ New health districts or sub-districts could be formed which have the

same boundaries as the local municipalities. This would increase the

number of health districts.

Each province has different problems and will make different choices.

The conversation below shows the kinds of problems that these changes

are causing health workers.

There may be some provincial differences in health administration and

governance, but the following health structures are already in place in

some provinces:

❂ A provincial health authority consisting of the MEC for health and

other government representatives.

❂ District health managers and district health management teams,

appointed by provincial governments to run the districts. At the

moment they are provincial employees but this will change as local

government takes over more responsibility for health.

To make things more complicated, it is possible that once the new councils

a re established, they may refer the governance of the health district to a

District Health A u t h o r i t y. The constitution of the District Health

Authorities and the details of how they will be run is not yet known. The

diagram below shows the likely organisation of a health district.

35

Provincial MEC for health

District or Metro Health Council

District Health Authority

District health manager and management team

All people, health workers and health organisations in the district

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Do not confuse the delivery of services with overall authority for the

district health service. Delivery is about what services are provided and

how they are provided. At the moment there is very little clarity on

who will be responsible for delivery of primary health in the country.

The Municipal Structures Act says that the metropolitan areas, and the

district municipalities, are responsible for delivering municipal health

services. However, at the moment there is no legal definition for these

services.

A Primary Health Care Package has been developed which suggests a

range of services that should be available to every community. But we

cannot assume that municipal health services are the same as the

primary health care package. It is likely that the amount of resources

available in a municipality will probably be the factor that decides what

services can be offered and how much of each service will be delivered.

The MEC for local government in each province has the right to adjust

the responsibilities of a municipality if it does not have the capacity to

deliver the services.

Until these decisions are finalised there will be a lot of uncertainty for

health workers.

A municipality has a number of options for how to deliver the health

services that it is responsible for:

❂ It can build capacity within the municipality for the delivery of its

services.

❂ It can enter into partnerships with the private sector to provide some

of it services.

❂ It can enter into a partnership with a neighbouring municipality to

provide some services.

❂ It can enter into partnerships with non-governmental organisations.

❂ It can sell off some of its re s o u rces for the private sector to ru n

instead.

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38

District hospitals form an important and integral part of the district

health system. They are crucial for providing administrative and

technical support to primary health care services, and for providing basic

hospital services. Some provinces want to maintain control of the district

hospitals and not pass them over to local government. They argue that

district clinics and community health centres will be more effective if a

hospital is not at the center of a district health system. This is more likely

to be true in urban areas, but in rural areas district hospitals usually play

an important role in supporting primary health care.

Most provinces still have to make decisions about this.

It is likely that about 50 000 health workers will be transferred from one

employer to another. There are three main changes that will impact on

staff transfers are:

❂ The new municipal boundaries will mean that some people will find

themselves working for a new municipality.

❂ With additional responsibilities being shifted to local government,

some people who have previously worked for a provincial depart-

ment will now work for a local government.

❂ In services such as health, it is also possible that some workers, who

have previously worked for a local municipality, will now have to

work for the district municipality.

Without going into too much detail the law says that employees may be

transferred under the following conditions:

❂ The employee must agree to the transfer.

❂ The municipality to which the employee is being transferred must

agree to the transfer.

❂ The conditions of service of the municipality to which the employee

is being transferred will apply to the employee. However, these con-

ditions of service cannot be less favourable that the conditions under

which the employee was previously employed.

There is a lot of uncertainty around the details of this last point. Some

people working for a province may be receiving higher salaries than

people doing similar work for a local government. If these people move

to local government and keep their same salaries – as they are entitled

to do - then there will not be equal pay for equal work.

It is likely that the transfer of staff will be a phased-in process and will

depend on the capacity of each metropolitan or district municipality.

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40

The funding of these new responsibilities is a critical issue. One of the

biggest questions still hanging over municipalities and health

authorities is how their new functions will be funded. And one of the

biggest challenges facing the national and provincial governments is

how to make sure that local government receives the financial support

to enable them to carry out their responsibilities.

It is not just the funding that local government requires, but the

capacity to handle the billions of rands that is needed to support the

district health system.

At present the bulk of funding for primary level services comes from

the national tax revenue and is allocated to the provinces as part of the

large provincial block grant. In some urban areas, especially in the

metropolitan areas, a significant amount of funding for health services

comes from revenue raised through rates and service fees.

There are a number of options for the transfer of funds to local

government:

❂ Municipalities could get a block grant from the province to deliver

services as they decide.

❂ Municipalities could get funding from the province for specific

services.

❂ Funding could by-pass provincial governments and come directly

from the national budget.

As yet there has been no decision on this matter.

Finally, it is critical that a framework is established for co-operation and

accountability between the three spheres of government. It is clear from

some of the issues mentioned above that this has not yet been put in

place and that until it is, the success of the District Health System will

be at risk.

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The changes taking place in local government are meant to improve

service delivery, especially to more vulnerable groups. Some people are

worried that the new system will lead to greater inequality in health

services.

Although there has been some improvement in the redistribution of

re s o u rces since 1994, some provinces remain much better

re s o u rced than others. Sometimes inequity is even gre a t e r

within provinces than it is between provinces. Within the

s p h e re of local government some municipalities will have

d i fficulty in raising funds because the majority of their

population live in poverty and payment for rates and

services is very low. These are areas that are alre a d y

comparatively under re s o u rced, and in which serious

backlogs exist. Added to this, financial management is

often poor and can hamper equitable

redistribution.

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So it is possible that greater decentralisation will result in increased

inequity. It will be important for national and provincial government to

monitor spending on health across municipalities and find ways of re-

distributing resources in favour of the poorest municipalities.

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The essential points of this section

✓ The new health system in the country is based on the Primary HealthCare approach. The District Health System delivers this approach.

✓ The boundaries of health districts must be aligned with either theCategory A or C municipal boundaries. A number of critical decisionshave to be taken before the whole system falls into place. In manyinstances the provinces will take these decisions together with the localgovernments concerned.

✓ There are a number of options open to municipalities regarding thedelivery of services. These include entering into partnerships with theprivate sector, with other municipalities or with non-governmentalorganisations.

✓ The conditions under which health workers will be transferred arecomplicated. A process for this has still to be negotiated in manyprovinces.

✓ Local governments that take on new responsibilities for delivering serv-ices will require extra funds from government. How this will be donehas not been decided.

✓ The principle of equity must be put high on the agenda in this newdecentralised system.