IMPLEMENTING THE MUNICIPAL HEALTH SERVICES (MHS) POLICY IN SOUTH AFRICA

1. IMPLEMENTING THE MUNICIPAL HEALTH SERVICES (MHS) POLICY IN SOUTH AFRICA “District Health in South Africa” Conference : 5th & 6th August 2004 Ross A. Haynes Researcher Health Systems Trust

2. THE PRESENTATION WHAT IS MHS? decisions!! MHS IS !!?? the what IMPLEMENTING MHS the how This work forms part of a DANIDA-funded project impacts

3. the original possibilities (definitions) Primary Health Care services minimal “midi” maximal MHS? WHERE DOES IT COME FROM? • a Constitutional phenomena - powers and functions of municipalities • [section 156 (1)(a) Part B of Schedule 4] • previous health activities at municipalities- mainly local (B’s) and metro (A’s) municipalities - clinics (p&p) and environmental health services • - focused on the urban areas (provs served non-urban) • - included “own” funds

4. SOME IMPORTANT DECISIONS • MINISTER OF PROVINCIAL AND LOCAL GOVERNMENT • MHS devolution set for 1st July 2004 • A and C municipalities responsible • C’s may delegate to B municipalities • Health MinMEC >> NAT. HLTH BILL (Aug 2003) • MHS is a “list of environmental health services”

5. THE PRESENTATION WHAT IS MHS? decisions!! MHS IS !!?? the what IMPLEMENTING MHS the how impacts

6. MHS is ………. • a “list of environmental health services” .. • a “list of environmental health services” .. • devolved to District and Metro municipalities .. • as from 1st July 2004 .. • which can be delegated to Local municipalities (i.e. agency basis) • Consider this in the light of • the new environmental health policy and • LGs position for intersectoral collaboration

7. “list of (9) environmental health services” • water quality monitoring • food control • waste management • health surveillance of premises • surveillance and prevention of communicable diseases, (excluding immunisations) • vector control • environmental pollution control • disposal of the dead • chemical safety EH services retained as Provincial responsibilities • port health • control of hazardous substances • malaria control Other EH services delivered by municipalities ??

8. THE PRESENTATION WHAT IS MHS? decisions!! the what MHS IS !!?? what IMPLEMENTING MHS the how impacts

9. MHS MHS Some barriers Implementing MHS … (the what) 1st July2004 Provincial structures District / Metro Municipalities Local Municipalities 1. Devolving the function ? Funding ? Staff transfers ? Equipment ? Agreements (SLA, MoU) Why District level? • legislative environment • funding • policies / tools

10. THE PRESENTATION WHAT IS MHS? decisions!! MHS IS !!?? the what the how IMPLEMENTING MHS how impacts

11. >> Report: Financing EHS in South Africa [www.hst.org.za] Implementing MHS … (the how) • no unfunded mandates! Treasury!! • what do the services cost? >>> • how many EHPs/support staff are required? >>> • smoothing out the inequities RESOURCES MONITORING & EVALUATION CO-ORDINATION & POLICY DEVELOPMENT • are there monitoring tools and an EHIS system in place? • MHS - a LG competency (DPLG) but ….. NDoH responsible for the health of the population (provinces?)

12. How many EHPs are required? - Current numbers TABLE: EHPs post establishment in South Africa

13. FIGURE: Inter-provincial comparison of population size per Environmental Health Practitioner (filled posts) 1/15 000 How many EHPs/support staff are required? - Coverage 36 437 Community members / EHP

14. Eastern Cape Province population EHP posts (filled) Population / EHP PROV LG TOTAL Nelson Mandela Metro 1 005 776 4 54 58 17 341 DC10 Cacadu 388 184 0 17 17 22 834 DC12 Amatole 1 664 251 16 21 37 44 980 DC13 Chris Hani 749 979 7 14 21 35 713 DC14 Ukhahlamba 341 321 1 9 10 34 132 DC15 OR Tambo 1 676 480 21 0 21 79 832 DC44 Alfred Nzo 550 400 11 0 11 50 036 Total/Average 6 376 391 60 115 175 36 437 How many EHPs/support staff are required? – Intra-provincial coverage Table: Coverage of EHP’s, per Metro and District Municipality, in the Eastern Cape Province X

15. Personnel costs Operational costs Total costs Per capita costs Actual 1/15000 Eastern Cape 31 020 4.86 11.82 Free State 22 945 8.48 9.68 Gauteng 108 307 11.53 17.96 KwaZulu Natal 73 532 7.80 14.01 Limpopo 26 509 5.43 9.50 Mpumalanga 22 811 6.56 12.46 Northern Cape 10 456 11.61 13.40 North West 15 208 4.95 9.22 Western Cape 82 261 18.18 17.35 What do the services cost? - 1 TABLE: EHS delivery costs (in R000s) in the country – for 2002/03 (provinces) and 2001/02 (LG) Actual NATIONAL 312 765 80 284 393 048 8.78 10.76 National population (44,819,733) x 1/15 000 per capita cost (R10.76) = R482,26 mill.

16. R13.00 (national figure) R10.76 (@1/15 000) R8.78 (actual per capita) What do the services cost? - 2 FIGURE: Inter-provincial comparison of per capita cost (in Rands) of delivering Environmental Health Services, for 2002/03 (provinces) and 2001/02 (Local Government) Costing based on EHPs only. Cost of delivery actually higher with support staff.

17. THE PRESENTATION WHAT IS MHS? decisions!! MHS IS !!?? the what IMPLEMENTING MHS the how impacts impacts

18. Implications - actual and potential • insecurity and demotivation • lack of clarity - on LG budgeting processes - transfers and secondments - current status quo arrangements • potential fragmentation • enhanced intersectoral coordination • urban / rural differences in MH services • training of future EHPs

19. Implications - actual and potential • MHS – a Constitutional disaster or golden opportunity ? • stemming the flow • preventative and promotive“high % diseases by environmental factors” • developmental EHS / MHS • intersectoral co-operation • LG’s accountability to the people

20. IMPLEMENTING THE MUNICIPAL HEALTH SERVICES (MHS) POLICY IN SOUTH AFRICA “Strong leadership, the necessary political will and a high level of professionalism can ensure effective implementation of the MHS policy leading to improved health status of the community.”

21. THANK YOU …. delightful for being a wonderful audience attentive ???