FROM POLICY, THROUGH BUDGETS, TO IMPLEMENTATION:
Delivering quality health care services
Authors:
Barbara Klugman, Women’s Health Project, University of the Witwatersrand
Di McIntyre, Health Economics Unit, University of Cape Town
May 2000
For the Women’s Budget Initiative
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Acknowledgements
We would like to thank the following people for participating in the initial workshop:
 Alex van den Heever, Department of Health, Gauteng
 Debbie Budlender, Community Agency for Social Enquiry
 Essina Mabitsela, Department of Health, Northern Province
 Khin San Tint, Women’s Health Project
 Peter Barron, Initiative for Sub-District Support
 Sanjani Varkey, Women’s Health Project
 Sharon Fonn, Women’s Health Project
 Nancy Nyathikazi, national Department of Health
 Maki Pooe, national Department of Welfare
 Suzette Kotze, national Department of Welfare
 Marion Stevens, Women’s Health Project
 Mastoera Sadan, Idasa Budget Information Service
We would like to thank Lucy Gilson for her input regarding the interview schedule
and comments on an earlier draft, Peter Barron and Khin San Tint for comments on
various drafts, Neva Seidman-Makgetla for providing the employment statistics, and
Debbie Budlender for her support and helpful inputs throughout. The authors remain
responsible for any errors and omissions.
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1.1
THE POLICY CONTEXT
INTRODUCTION
1.1.1 What this paper is about
This paper explores the experiences and views of government health officials in
managing the rapid policy change and ongoing restructuring since 1994. It considers
the impact of policies and restructuring on government’s goal to deliver equitable and
high quality health services.
The research for the paper was done as part of the Women’s Budget Initiative (WBI).
The WBI analyses the impact of government budgets on women and men, girls and
boys, and different groups of these. The analysis involves four steps:
 describing the situation of women and men, girls and boys in a particular sector;
 deciding if policy matches that situation;
 seeing if the necessary budget is given to implement gender-sensitive policy; and
 assessing what happens when it is implemented.
The WBI was established in mid-1995. In the first three years the initiative looked at
the budgets of all national - and to a lesser extent provincial - departments. For
example, the second year’s studies included an analysis by Marion Stevens of health
policy and budgets (Stevens, 1997). In the fourth year, the WBI looked, among other
things, at the budgets of five municipalities.
This paper starts to look at the linkages between the different spheres. It focuses, in
particular, on how national, provincial and local relate to each other in the policymaking, budgeting and implementation for new policies.
The paper is divided into three sections.
 The first section provides a brief description of the political and structural context
of health system reform.
 The second section presents the research findings. There are three sub-sections to
this section. The sub-sections match the second, third and fourth steps listed
above: policy decision-making issues; budgeting and financial management
issues; and service delivery or implementation issues.
 The third section of the paper discusses the linkage between broad policy
regarding spheres of government, programming and budgets, and attempts to
provide high quality health services to meet the health needs of different members
of society and to promote social justice in general and gender equality in
particular.
1.1.2 Why should a Women’s Budget Initiative look at general budgeting?
When interviewees were told that this research was being done for the Women’s
Budget Initiative, and that the interviewer was from the Women’s Health Project, they
assumed that we would be discussing reproductive health. However, neither health
policy content generally, nor women-specific policies in particular, are the focus of
this study.
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What is ‘women’s health’?
Many interviewees assumed that a study for the Women’s Budget Initiative must be
concerned with reproduction. Government policy also often equates ‘women’ with
‘mothers’ and ‘reproduction’ (Klugman, 1999). Firstly, girls’ and womens’ needs in
relation to health services begin long before adolescence and end in old age.
Reproductive matters are an important, but not the only, component. Secondly, in
addition to women’s individual needs, women are the main caregivers in society. As
caregivers they come into contact with the health services both when bringing the
sick, whether children or the elderly, to use health services, and in caring for them in
the home. Finally, the vast majority of health workers are women. Their role as
workers is not fully valued because it is seen as ‘women’s work’.
The study takes as given the gender-sensitivity of Department of Health policy since
1994 (See Stevens, 1997; Klugman, 1999 for discussion). It can do this because, in
broad terms, the policies of the Department of Health show a clear commitment to
equity, particularly to meeting the needs of the poor and of the predominant users,
women and children (see Stevens, 1997, for previous WBI analysis of South Africa’s
health policy and budget). This study moves beyond this question, to explore
constraints in moving from policy to implementation. Policy does not have any value
for women users if the services aren’t accessible and of good quality.
There are three important issues which emerge immediately when looking at
implementation of health policy in post-apartheid South Africa.
Firstly, because of the way the Constitution allocates functions, health, in particular,
has to find ways for all three spheres – national, provincial and local – to work
together if implementation is to be effective. Added to this is the health district
concept which, at present, sits somewhere between provincial and local. So one major
strand of the report looks at relationships between spheres.
The second issue is the large number of new policies introduced since 1994. So a
second major strand is how services have been affected by multiple, simultaneous and
rapid changes.
The third challenge is that all this change must be implemented through and in
structures which are top-down and which do not value initiative or problem-solving
from below. These characteristics are gendered to the extent that those ‘below’ are
overwhelmingly women, while men predominate in the top positions. Further, even
when women are in leadership posts, they often follow the established (male) ‘way of
doing business’.
Gender is about relationships, and relationships are about process and power. This
paper looks at how relationships and power, both within the health services and
between service providers and users, must change if the government is to realise its
goals of promoting good health and preventing illness. The study asks who makes
decisions, particularly about financial and other resources, and how such decisions are
made. It asks whether there is transparency in decision-making; whether people at all
levels are valued, and whether their experience and knowledge is taken into account.
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1.1.3 Where this paper fits in with other research
This paper adds to a growing pool of South African research on related issues. Other
research has also looked at how resource allocation decisions are made nationally
(Gilson et al, 1999) and provincially (Brijlal et al, 1997; McIntyre et al,1999).
Research has also investigated the challenges to delivery of specific policies in the
context of health service restructuring (Fonn et al, 1998a; 1998b). Likewise, research
has looked at how policies such as free primary care services (Gilson et al. 1999) and
termination of pregnancy (Stevens, 1998; Klugman, 2000) were developed and
implemented.
This paper confirms some of what was found by those other studies. It adds to
previous research in looking at the relationships between national, provincial and local
government. The interviews tell us that to bring about change, we need to know not
only in which direction we want to move, but also how to get there. In other words,
we need to think about decision-making processes as well as policy (Walt and Gilson
1994; Friedman, 1999; Klugman, 1999).
1.1.4 Methodology
The research began off with a workshop of experts from government and health
research bodies. The workshop and a literature review then informed the development
of the schedules for the interviews which formed the main source of information for
the study. Telephonic interviews were held with officials of provincial, regional,
district and local government in Gauteng, Northern Cape and Northern Province as
well as with a key actor from the national Department of Health, and representatives
of the South African Local Government Association (SALGA). Where requested, the
interview schedule was sent to interviewees beforehand.
Gauteng, Northern Cape and Northern Province were chosen because of their diversity
in terms of population size, infrastructure, access to resources and the way in which
health delivery is organised. The findings from the study may not be representative of
all other provinces, but they do provide some insights, from the implementers
themselves, as to current struggles and challenges.
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The three provinces
 Gauteng is the mining-industrial heart of the country and makes the largest
provincial contribution to South Africa’s economic production. It has the smallest
physical area but the second largest population size, and is thus the most densely
populated province (432 people per km2). Only 3% of the population in Gauteng
live in rural areas. It has a relatively large white population – 23% compared with
national average of 11% - while 70% are African compared with the national
average of 77%. Gauteng has very large African townships adjacent to wealthier
areas, which could mean increased demand for decent services. Gauteng has the
highest per capita expenditure on health services. The provincial health budget
was R931 per person without medical scheme cover in 1999/2000, compared with
the national average of R501. The academic hospital services are also used by
residents of other provinces. If we exclude these services, Gauteng still has by far
the largest level of per capita public health spending.
 Northern Cape has the largest physical area but the smallest population. Its
population density is only 2,3 people per km2. The vast area and sparse population
makes service delivery difficult and relatively costly. It has a large coloured
population (52%) and relatively small African population (33%). This population
composition means that there was moderate service provision during apartheid
through most of the province, with significantly better services in the urban area of
Kimberley. The Northern Cape has below average levels of health spending. The
provincial health budget was R402 per capita in 1999/2000.
 Northern Province was formed from four different ‘homelands’ all of which were
underfunded during apartheid. Its population density (40 per km2) is similar to the
national average (33 per km2). It has the highest level of rural residents. Nearly
nine in every ten (89%) people live in rural areas compared with the national
average of 46%. It also has the highest percentage of African residents, at 97%.
Along with the Eastern Cape, the Northern Province has the highest poverty rate.
The Northern Province has one of the lowest levels of health expenditure in South
Africa. In 1999/2000, the per capita provincial health budget in Northern Province
(R306) was less than a third of the Gauteng per capita health budget (Statistics
South Africa, 1998; McIntyre et al, 1999).
1.2
HEALTH POLICY SINCE 1994
1.2.1 The legacy of apartheid
Until 1993, there were eighteen Departments of Health at the central and regional
government levels. There was the Department of National Health and Population
Development, three ‘own affairs’ Departments of Health for coloured, white and
Indian people, the health departments of the ten former ‘homelands’ for African
people, and the departments of the four former provinces. In addition, half of all local
authorities – approximately 400 in total – were involved in health service delivery.
Public sector health services were fragmented in a variety of ways. Firstly, there was
geographic fragmentation in that there were different types of facilities and different
policies in the various provincial and ‘homeland’ health departments. Secondly, there
was fragmentation along racial lines. Until the late 1980s, there were separate
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hospitals for different race groups. Finally, there was fragmentation between curative
and preventive health care. The provincial and ‘own affairs’ health departments were
responsible for curative care, while local government was responsible for preventive
care. The result was a serious lack of coordination in the development of health
service infrastructure, inefficient duplication of services and lack of integrated
primary health care service provision. Integrated, comprehensive care was provided in
former ‘homelands’, but inadequately and with very limited resources.
The health system was also biased towards hospital-based, doctor-centred curative
care. In 1992/93, 81% of total public sector health care expenditure was allocated to
hospitals. Academic and other tertiary hospitals alone accounted for 44% of the total,
while only 11% was spent on non-hospital primary care services (McIntyre et al.
1995). In addition, there were large inequities in access to health services between
geographic areas and socio-economic groups.
1.2.2 New health policies
The White Paper on Health proposed a major reorientation of the South African health
sector. A key policy aim was to reduce the disparities and to increase access to
improved services. The White Paper specifically states that ‘emphasis should be
placed on reaching the poor, the under-served, the aged, women and children, who
are among the most vulnerable’ (Department of Health, 1997:13). In line with this
commitment, high priority was given to maternal, child and woman’s health
(MCWH).
A related aspect of the new policy was to achieve universal access to an essential
package of primary health care services. The White Paper also says that government
will promote ‘a caring ethos’. Means for achieving this include working with health
workers and users to define a Charter of Community and Patients’ Rights, and
rewarding health workers for ‘compassionate and caring service’ (Department of
Health 1997:Ch 4.3). This aspect is now being linked to a general campaign within the
civil service called Batho Pele – People First. Building health worker morale and
positive attitudes to clients, whether men, women or adolescents, is critical when
dealing with health problems that are intimate and frequently caused by gender
inequality, such as unwanted pregnancy or HIV.
The White Paper’s objectives also include the development of health promotion
activities – both provision of information and empowerment of individuals and
communities to protect and promote their own health. This is important in relation to
gender. Health problems such as violence or sexually transmitted diseases require
community-based interventions which target women and men of different ages and
actively promote gender equality in order to address the underlying causes. But the
White Paper is not explicit on how many of the commitments can be realised, let
alone how gender inequity can be addressed within them.
1.2.3 Employment patterns among health workers
The White Paper commits government to implement affirmative action within the
health services. Since the change of government, women have been promoted into
many senior positions in government. However, there has been relatively limited
progress within the health sector.
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In March 2000 a total of 218 244 people were employed by the national and provincial
Departments of Health. Overall, women accounted for 74% of these employees. Table
1 indicates that women and black people cluster at the bottom of the hierarchy.
 The 70 000 unskilled employees account for about one in every ten employees.
These workers earn between R1 900 and R2 200 a month. Close on two-thirds
(62%) of these lower-paid workers are women, and over half (55%) are African
women. Only 2% are white men. In the public service as a whole, there are more
or less equal numbers of women and men doing unskilled work. The relatively
high share of women in unskilled work in health is probably because most of these
jobs involve cleaning, cooking and laundry – traditional women’s roles. Unskilled
workers in health face two sector-specific problems. First, they need special skills
for dealing with sick people and contagious waste. While some hospitals provide
training for cleaners, most do not. And there is neither certification nor additional
pay for unskilled employees who acquire this knowledge and skill. Second, there
is no clear career path to link unskilled workers to nursing assistants, who make
up most of the semi-skilled level in health. As a result, many health workers have
stayed on level 2 of the salary scale for decades.
 Women dominate even more among semi-skilled and professional workers. They
account for over three-quarters (77%) of the semi-skilled and unskilled personnel,
and 83% of the professional staff such as nurses. Again, African women account
for over half (55% and 57% respectively) of these employees. The professions
alone account for 36% of all national and provincial health staff, and the semiskilled and skilled account for a further 33%. Nursing is particularly important
because, with teaching, it forms one of the two main professions traditionally open
to women. Nurses earn an average salary of around R4 200 per month. African
nurses earn, on average, ten per cent less than white nurses. These differences
reflect the fact that more Africans are staff nurses, who are less qualified than
professional nurses and therefore start at a lower salary level. They also reflect the
fact that promotions in the public service were historically biased toward whites.
 The proportion of women declines sharply in management. Just over a third (35%)
of middle managers are women, and only 14% of top management. African
women account for 9% and 4% respectively of the two groups. White men,
meanwhile account for 36% of middle managers and a full 65% of top managers.
The latter includes directors and above, who earn over R200 000 a year. The two
management groups account for only 3% of all national and provincial health
staff, but will make most of the decisions discussed in this report.
Table 1: Race and gender in national and provincial health departments
African
Coloured
Indian
White
Women Men
Women
Men
Women Men Women Men
Unskilled
55%
32%
6%
3%
0%
1%
1%
2%
Semi- & skilled
55%
17%
11%
2%
2%
2%
9%
2%
Professions
57%
10%
10%
2%
3%
1%
14%
4%
Middle mngmt
9%
17%
1%
2%
4%
10%
21%
36%
Senior mngmt
4%
10%
1%
2%
1%
9%
8%
65%
Total
54%
19%
9%
2%
2%
2%
9%
4%
Total
100%
100%
100%
100%
100%
100%
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There are no figures available for employment in health departments of local
government. However, previous research has shown that local government employs
proportionately fewer women than men. For example, in 1997 under a quarter of all
local government employees were women, whereas there were more or less equal
numbers of women and men employed in national and provincial government
combined (Budlender, 1999:38).
Table 2 provides information on average salaries for different occupations within the
national and provincial health departments as at March 2000. One weakness of the
table is that the employment figures are for all workers in these occupations across all
national and provincial departments. For the directly health-related categories, most of
the workers will be employed by health departments. For other categories, such as
cleaners, many will be employed by other departments. A second weakness of the
table is that it reflects basic salaries without overtime. Overtime payment is received
predominantly by the higher-paid health workers and will, therefore, make the
differences between occupations even bigger than shown in the table. The table does,
nevertheless, provide useful information on the comparative financial rewards for
different workers.
The first three numeric columns in Table 2 give the percentages which white men,
African women, and all women constitute of total employment in the category across
all government departments. The next column gives total employment in that
category, and the final column shows the average annual salary.
 Cleaners account for 13% of all public service workers and are the lowest paid
workers in the health departments. They earn an average annual salary of R23 500.
Less than 1% of the cleaners are white men, and 59% are African women.
 Medical and dental superintendents are the highest paid category, earning an
average of R127 700 per year. Over two-fifths (41%) of the superintendents are
white men and only 6% are African women.
 The biggest single health-related category consists of professional nurses. Less
than 1% of these workers are white men, only 7% are men, and 73% are African
women. Their average salary, at R56 500, is less than half that of the
superintendents.
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Table 2: Average salaries for occupations in health
Cleaner
Food services worker
Household worker
Laundry worker
Clinical technologist
Emergency care practitioner
Medical technical officer
Chiropodist
Clinical psychologist
Dental technician
Dentist
Dietician
Forensic analyst
Health therapist
Medical orthotist and prosthetist
Medical physicist
Medical technologist
Nutritionist
Orthopaedic shoemaker
Pharmacist
Supplementary diagnostic radiographer
Medical natural scientist
Medical officer
Medical/dental superintendent
Medicine control officer
Optometrist
Specialist
Nursing assistant
Professional nurse
Staff nurse
White
men
0%
1%
0%
0%
25%
9%
4%
47%
24%
65%
38%
1%
42%
1%
54%
59%
8%
0%
42%
21%
1%
24%
37%
41%
21%
38%
59%
1%
0%
0%
African
women
59%
54%
46%
62%
9%
3%
46%
0%
13%
4%
9%
19%
5%
23%
1%
0%
21%
48%
0%
10%
59%
10%
7%
6%
7%
21%
3%
66%
67%
73%
Total
Total
women employ
67% 57930
71% 11605
88% 13330
74%
4293
60%
261
10%
1814
66%
285
40%
15
66%
287
22%
68
33%
560
94%
269
49%
153
84%
3840
10%
165
19%
32
64%
1393
87%
31
0%
36
59%
1396
60%
138
61%
169
33%
8194
22%
232
57%
28
38%
24
23%
4455
91% 28913
93% 53351
94% 22016
Average
salary
23500
25100
26800
25500
54100
38500
39000
51900
61200
66400
101100
58700
86200
56200
56800
91700
65500
77100
50800
69800
42300
96700
88400
127700
104700
26200
98100
33500
56500
41600
The figures above reflect the institutionalisation of white power under apartheid. They
also reflect the institutionalisation of men’s decision-making, even in an area such as
health which employs mostly women and serves mostly women and children. This is
the workplace and health system culture into which new policies are being introduced.
Before and since the White Paper, there have been a number of specific policies which
address women’s reproductive health needs or which have other clear gender
implications. For example, in April 1994 President Mandela announced that there
would be free health care for all expectant and lactating mothers and for children
under six. In the context of women’s lesser access to income, this policy is directly
redistributive towards women and children. In 1996 the Termination of Pregnancy
Act was passed, providing – in law if not yet adequately in practice – for much greater
freedom of choice in respect of abortion. More recently, a cervical screening policy
has been approved which promises ten-yearly checkups for women from age 30. At
the practical, administrative level, the Department of Health has approved the idea of
women’s health cards. It has also launched a system of confidential enquiries into
maternal death, ensuring that every pregnancy-related death in hospitals is
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investigated, and drawing on these findings to improve service quality (Department of
Health 1998).
1.2.4 Restructuring the public health sector
Restructuring aims to transform the previous fragmented system into a comprehensive
and integrated one. The 18 health departments have been streamlined into one
national Department of Health and nine provincial health departments. This process
was not simple. The appointment of senior health department managers was only
completed some 18 months after the April 1994 elections (Tollman and Rispel, 1995).
Further, transformation has happened alongside the introduction of new policies. This
research illustrates the many ways in which these simultaneous processes have
complicated each other.
The Constitution allocates health functions between national, provincial and local
government. National government is primarily responsible for policy development and
overall health sector coordination. The provinces have the greatest service provision
responsibilities. These include all hospital services and some, mainly curative,
primary care services. In many provinces, health regions have been created and some
service management responsibilities decentralised to this level. The regions are seen
as an interim structure until health districts (see below) have been successfully
developed.
The exact responsibility of local government remains unclear. The Constitution states
that local government is responsible for ‘municipal health services’ but does not
define these. Only in mid-2000 was there some agreement that municipal health
services should be interpreted as integrated and comprehensive primary care services.
The attempt to provide integrated services is affected by the history of service
provision in the country. The historical separation of preventive and curative services
is one impediment. This is exacerbated by the entirely separate provision of some
services, such as ‘family planning’, from other primary care services.
The debate about definitions was complicated by the historically uneven provision of
health services by local government. In larger cities and towns, particularly in the
metropolitan areas, municipalities had an extensive network of clinics providing
preventive health services. The clinics often operated side-by-side with separate
provincial clinics which provided curative services. The majority of small town and
rural municipalities meanwhile provided minimal health services. In former
‘homeland’ areas, there was no local government health service provision. Instead,
integrated, but poorly resourced, primary health care services were provided by the
homeland authorities.
Today most municipalities continue to be largely responsible for preventive and
promotive primary care services. However, there is a gradual shift towards all primary
care facilities – whether provincial or local – providing comprehensive, integrated
primary care services. The historical patterns are, however, reflected in a bias among
our interviewees in that we do not have local government representatives in areas
where local government is not responsible for any health service delivery at present.
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The creation of a District Health System (DHS) was proposed in the African National
Congress’ National Health Plan. The White Paper on Health sees health districts as
the ‘major locus of implementation’ (Department of Health 1997:12). It is proposed
that districts will be responsible for non-specialist hospitals and comprehensive
primary care services.
Regions and districts – each province is different
There has been uneven progress towards the development of districts in the different
provinces.
 In Gauteng there is a clear distinction between regional offices and districts.
Regions in Gauteng operate as extensions of the provincial sphere.
 In Northern Province there is no clear distinction between regions and districts.
The province is waiting for demarcation of local government boundaries to be
finalised.
 Northern Cape has regions rather than districts because of the large distances and
small population.
There are two important obstacles to the implementation of a DHS. Firstly, there are
problems with demarcation of district boundaries. National guidelines suggested that
the district boundaries should preferably match those of local government, and the
administrative boundaries of other sectors. Matching boundaries are important if there
is to be effective inter-sectoral collaboration. Some provinces such as the Eastern
Cape and Mpumalanga have already gone ahead with health district boundary
demarcation, although these will require revision to account for changes in local
government. Others are leaving the final decisions until local government boundaries
and structures are finalised in mid-2000.
The second big obstacle to DHS development is the continuing debate about
governance. All recent policy documents say that district health services must be
accountable to local government rather than provincial. However, provinces are
allowed to develop the governance mechanisms that they regard as appropriate. For
example, if they think that local government does not have the capacity to provide
health services, provinces could provide them. This has resulted in different
governance options in different provinces. Very recently, it has been decided that local
governments in the metropolitan areas will assume responsibility for all primary care
services as soon as possible.
Handing over power is also never easy. Power and Robbins describe the challenge
facing provincial health department managers as follows: ‘Having been charged with
overall responsibility, and having painstakingly gathered the reins of overall control
into the provincial fist, the next step … [is] to give a lot of it away again to the
regions and districts (and in many areas, local authorities)’ (1996: 35). Nevertheless,
there is a firm commitment to the establishment of a DHS.
1.2.5Budgeting processes
Overall government spending limits are determined through the medium-term fiscal
framework. The framework is based on estimated growth rates of gross domestic
product (GDP), and the budget deficit and other targets set in the Growth,
Employment and Redistribution Strategy (GEAR) strategy. The fiscal framework
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covers the vast majority of government revenue, apart from the small amount of ‘own
revenue’ generated by local government. A ‘top-slice’ is removed from this global
budget to cover debt-servicing costs, standing appropriations (such as the International
Monetary Fund subscription) and a contingency reserve. Funds remaining after the
‘top-slice’ are then allocated to the three spheres of government – national, provincial
and local – in what is called the ‘vertical division’. This division is based on the
service and other responsibilities which each sphere has.
The total provincial allocation is then divided between the nine provinces through the
‘horizontal division’. A formula which estimates the relative need in each province for
specific services (including health, education and social welfare) is used for the
horizontal division. The formula previously gave an extra weighting to women,
children and old people in its health component because these groups tend to need
health services more. For the 1999/2000 budget, the Department of Finance removed
this weighting, making the formula less gender-sensitive. The health component now
consists only of the proportion of the population which is not covered by medical aid
schemes plus a small allowance for those who are members of medical schemes.
The Department of Finance used a horizontal division formula for the local
government sphere for the first time in the 2000/01 budget cycle. The local
government formula is based on estimated expenditure needed to deliver basic
services to poor residents who cannot pay for services themselves. The formula is
adjusted for ‘own revenue’ generated by local government. Provinces have very
limited revenue-raising powers, but some of the wealthier urban municipalities are
able to generate considerable revenue through turnover and payroll levies, property
taxes, sales of electricity and water, and other sources. At present, the basic services
included in the local government formula are electricity, water, sanitation and refuse
removal. Provision of health services by local government is not taken into account
when calculating either the vertical or horizontal divisions for local government.
The national Department of Health and all other national spending agencies negotiate
with the Department of State Expenditure for their share of the total allocation to
national government. Similarly, provincial Departments of Health and other
departments negotiate with their treasuries for a share of the provincial resources.
Total provincial resources are made up of the allocations from the vertical and
horizontal divisions, together with a small amount – usually less than 5% - of
provincially generated revenue.
In addition, provincial health departments also receive funds from the national
Department of Health in the form of conditional grants. Conditional grants are a
mechanism of ‘protecting’ (‘ring-fencing’) funding for specific activities that are
regarded as priorities. The funds are given on condition that they are used only for the
purpose specified. The health sector has conditional grants for:
 Central hospitals: This grant is only given to Gauteng, Western Cape, KwaZuluNatal and Free State to cover the costs of tertiary and referral services used by
residents of other provinces.
 Health professionals’ training and research: All provinces receive a grant, but the
largest shares go to Gauteng, Western Cape, KwaZulu-Natal and Free State.
13




Redistribution of specialised health services: These grants are for the development
of specialised services in provinces that currently do not have them.
The Primary School Nutrition Programme (PSNP): All provinces receive this
grant. The largest shares going to the Eastern Cape, KwaZulu-Natal and Northern
Province.
Hospital rehabilitation and construction: This grant helps provinces improve their
hospital services.
Durban and Umtata hospitals: This grant goes to KwaZulu-Natal and Eastern Cape
respectively.
Because health services are not included in the vertical and horizontal divisions for
local government, municipal health departments are funded through allocations from
local government ‘own revenue’ and subsidies from provincial health departments.
Many municipalities do not provide health services and thus receive no subsidy from
the province. These tend to be smaller municipalities which also have very little ‘own
revenue’. Among municipalities that do provide health services, subsidy payments
vary significantly. Subsidies to large urban municipalities tend to be higher in
absolute terms because these municipalities have relatively extensive health services.
However, subsidies as a percentage of total health expenditure tend to be higher in
small towns because their ability to generate ‘own revenue’ is lower.
2
RESEARCH FINDINGS
2.1 DECIDING ON POLICY
This section considers two different types of policy. Firstly, three are the policies
related to the restructuring of health services described above. Secondly, there are
policies related to specific ‘programmes’, such TB or termination of pregnancy
(TOP).
The national Department of Health coordinates the health sector reform strategy
relating to health financing, establishment of districts, management of hospital
transformation and so on. The national Department also develops policy on specific
health problems such as mental health, mother/child health, nutrition and
communicable diseases. At provincial level too, there are units who are responsible
for implementation of specific health policies. The people staffing these units are
referred to as ‘programme officers’.
As noted above, the White Paper states a commitment to integration and provision of
comprehensive services at primary care level. Integration cannot happen properly if
specific health problems are treated as vertical programmes. Instead, these policies are
all meant to be implemented by the same service providers at clinic level. As will be
seen below, this can and does lead to tension.
14
2.1.1 Roles in national policy making
KEY ISSUES
 There are clear initiatives to involve provinces and regions in decision-making
 Some new national appointees had little experience in policy making within
government
 There is an overwhelming quantity of new policy for officials to implement
All of those responsible for programming or district development at provincial level
say that national asks for their input, which they give. A provincial programme
manager explained that the provincial programme managers meet with national on a
quarterly basis, send in their inputs, and that national then develops the policy: ‘They
don’t do it without the province.’. The provincial managers, in turn, try to involve
regional levels in providing such input. However, some of those interviewed at
regional level said that this does not happen adequately. They said that this explains
why national and provincial policies are not always implementable: ‘It’s totally top
down.’
To complicate matters, the changes in government personnel after the 1994 elections
meant that many of the new appointees to the national Department of Health had
relatively limited policy making experience. In the interim some of the provinces
moved ahead on their own. A more experienced provincial informant noted, however,
that ‘national has now caught up and our role does have to change. We should … be
feeding into their processes.’
There are a wide range of new policies. Some relate to structure – the integration of
different authorities, the move towards a district health system, and some to finances –
free health care, social health insurance, and mechanisms for financial management.
Others relate to specific health programmes where there have been major policy shifts.
These include everything from sexually transmitted diseases to TB. All the informants
spoke of the impact and confusion created by this plethora of policies. Many felt there
should be greater clarity about priorities rather than what a provincial interviewee
termed ‘this shopping list approach to policy’.
On top of health-specific policies, staff must deal with a range of internal institutional
issues. A provincial official explained that there are: ‘the [Employment] Equity bill
and the new Labour Relations Act. We’re bombarded with all this legislation in a very
short space of time. To assimilate and implement it is quite difficult… and you’re not
a legal person… All of a sudden you have to do something differently and you’re not
quite geared for it.’
15
2.1.2 Regional and district involvement in provincial policy making
KEY ISSUES
 The roles and responsibilities of programme management and line management
sometimes create contradictions
 There is often no time for consultation when time-frames are set for policy
implementation
One problem that was repeatedly raised was the division between programmes
(responsible for specific components such as communicable diseases or mother and
child health) and line management (responsible for overall health service delivery).
Where provincial programme officers are prescriptive as to when and by whom
policies should be implemented, it can create tensions at regional or district level,
where there may not be the skills, human resources and management capacity in place.
This applies even when the programme officer provides the necessary funds. A
number of interviewees argued that it would be better if there were fewer programme
officers. Others said it was a transitional problem and, with time, people were learning
to work together.
Another issue is that consultation takes time. Provinces often want to rework national
policy to make it provincially relevant. If they attempt to incorporate participation
from regions, it ‘takes quite a long time’. In other cases, policy doesn’t require
reworking, but there are other time pressures. One provincial manager described how
the Hib vaccine1 came with a ‘D-date’ – it had to be introduced on the first of July.
This meant that every region had to have training in a short space of time. In another
province, a regional manager complained that ‘They just tell us that ‘this is the policy
from national and you have to implement it’ – like that Hib for children… It’s twice
the price. When we heard about it, it was in June and implemented in July, so we
didn’t even have time to argue about the whole issue.’ The reference to price alludes
to financial resources. These are discussed in more detail below.
2.1.3 Local involvement in national, provincial and district policy making
KEY ISSUES
 Most people agree that local authorities should be represented in national
decision-making, but there are logistical difficulties.
 Local authorities tend to be represented at national level only in relation to
financing or restructuring policy issues, but not in relation to policy on clinical
issues.
 Provincial-local relations usually reflect lack of communication, mistrust and little
joint planning despite their interdependence for the delivery of PHC services.
Most informants acknowledged that local authorities need representation in policymaking at national level. There are logistical factors which make real representation
difficult. The first relates to the fact that local boundaries have not yet been finalised.
Hib – Haemophilus influenzae type b – is a newly introduced vaccine to address a
bacterium which is the second most important cause of pneumonia and meningitis in
children under five.
1
16
The second relates to lack of capacity of some local authorities. The third is the way in
which local authorities are organised. Formally, the mechanisms for representation are
in place. However, as a provincial representative noted, ‘Intention is one thing but
implementing that is another. For instance in Minmec now officially we’ve got
positions for local councillors but what’s happening is that how SALGA is structured
is, it’s a national association of provincial associations, but the provincial
associations are made up of individual councils. So it’s hard for provincial
associations to represent individual councils.’
Those who have participated in the policy process since the change of government
report substantial improvements, ‘Having worked in local government all my life, I’ve
seen a very dynamic swing from national planning to bottom up planning… Certainly
no decision will be accepted if there hasn’t been a SALGA input. National have
realised you have to have local government input.’ Those who are not directly
involved are more critical. One reported that he himself gave input to national level,
but that he often had to take the initiative as papers for comment were not always
passed on.
In addition, there are gaps as to the kinds of policy issues on which there is formal
representation of local government at national level. Representation tends to focus on
major restructuring or financing issues, rather than issues of programming. This can
be a source of tension. A researcher observes that ‘some of the more nitty-gritty stuff,
like programme implementation, should involve all three spheres. You will be told
that it is being done like that, but it’s not being done enough’.
Looking at province and local, in some areas, the policy-making and planning
relationship seems to be good. A local government informant reported: ‘We’re very
much involved from local level because of this technical team with regional directors
and heads of health services…[It is] a political decision but as a technical group we
provide the information.’
However, as with national policy, there are logistical problems. Firstly, not all local
authorities can be represented directly. For at least one local informant, it appeared
that, because of the number of local authorities, ‘mostly when they make decisions
they make it on their own.’ Others observed, more optimistically, that after the
demarcation there would be fewer local authorities. They said that this would ease, if
not remove, this problem.
The current difficulties are reflected in frequent expressions of frustration from local
officials. The following is typical: ‘I don’t think that from the national or provincial
side they’re aware of what is going on at grassroots level. They’re sitting with all
these bills and acts and policies that we try to apply. But sometimes we’re not able to.
We don’t have the human resources and financial resources.’
The same informant gave the policy on psychiatric services as an example. He pointed
to deficiencies in both infrastructure and capacity. He said that he had told his
colleagues ‘to discuss it with the province, rather than people saying we won’t do it.’
But he also noted that it was not always appropriate to blame the province, as local
officials were ‘also clinging to old things. People have a lot of resistance to change’.
17
There were several other instances which pointed to differing perceptions of a single
situation. For example, the manager of a historically white local authority said that the
neighbouring historically black township desperately needed a clinic. He said the
province refused to subsidise a clinic in the township, yet had built a health centre
only 500 metres away from a hospital. The same informant said that the provision of
different services by different authorities causes confusion for communities. He said
he was also not able to respond directly to community requests for services, since the
resources lay with province and there was inadequate cooperation. Yet a regional
informant in the same region said that province and local were planning together well:
‘We sit around the table and see whether the department will afford (what the council
asks for)’.
While there are clearly ongoing difficulties with relationships, a local authority
official reported that things were improving: ‘The days of territorial aggression are
gone [in] most of the provinces. It exists on both sides but I’ve served on these
committees … since ‘94 and before and I’ve seen a major shift in the relationships
which has been very exciting.’
2.1.4 Operating in the interim
KEY ISSUES
 The interim state of local government makes the daily process of decisionmaking difficult.
 There is often ‘dual accountability’ where local management is responsible to
both local councils and province because of provincial subsidies.
 There is slow but increasing recognition by management in other spheres of local
authorities as equal partners.
 Racial tensions continue to colour some of the relationships.
‘We have new structures with old legislation. The Health Act of 1977 is
still in force. The constitution makes reference to … ‘municipal health
services’ which is not defined… There appears to be national agreement
that local government must be in the foundation of service delivery
including the district health system… but in some areas it’ll take years to
get that capacity’ (Local government official).
Interim arrangements still apply in two broad areas. One relates to the designation of
districts, the mechanisms of decision-making for districts, and the relationship
between districts and local authorities. The second relates to the division of
responsibility for delivery of primary care services between local authorities and
provinces. In some cases, such as the Northern Cape, which have traditionally
provided most of the funds to local authorities, the province has decided to take over
local authority services. However, in most provinces, where there are long-standing,
functional local health services, these are continuing. In these cases there are,
nevertheless, still tensions around subsidies and around decision-making.
The situation is one of ongoing negotiation, tension and uncertainty. Provincial
informants spoke about how different employers in the local sphere create dual
18
accountabilities, confusion and lack of parity in conditions of service. A regional
manager described the tension of knowing that services will ultimately be run at local
level, but seeing that there is little capacity – or even willingness – at present to do so:
‘We almost completely run the local authority services anyway. They more or less
wash their hands of them. We’ve given them money for running cost,s but sometimes
they’ll refuse to buy cleaning material and that kind of thing, saying they’ve run out of
money’ A local official meanwhile stressed the need for joint planning, but said this
was impossible, despite ongoing meetings, when demarcation had not been finalised.
Managers of urban councils, largely historically white, generally have more
confidence in their capacity to manage delivery, but acknowledge that provinces will
probably retain responsibility for the meantime in rural areas: ‘[Urban] municipalities
are in a better position at this point in time – they are on top of things. The rural
areas are where the province is busy.’
Sometimes the barriers to collaboration are a direct result of the apartheid divides.
Few interviewees were explicit on this issue, but it is clear that in many areas there is
distrust across race lines. Some of this is based on real experience, and some on the
assumption that white officials will not want to participate in the new dispensation. A
white local authority official described the problem thus: ‘ Transformation is taking
place, but not as fast as the political bodies would want it to take place…A new
government has a lot of people they don’t want there and can’t get rid of them… I
want the job to get done and I get blocked because of suspicion that I have a hidden
agenda.’
An aggravating factor is that many (mainly white) senior officials operate in an
‘acting’ capacity for long periods of time while other candidates are sought.
Meanwhile these acting officials are expected to implement new policies without the
necessary trust and authority.
2.1.5 Involvement of politicians
KEY ISSUES
 Politicians are beginning to recognise that policy must be realistic
 Some officials complain that politicians’ personal priorities do not match equity
imperatives
 Local authority managers seem to have closer links with councillors than
provincial or regional managers do with MECs.
Health officials said that politicians had in the past failed to consider the financial
implications of new policies. As in many other areas, however, they said there had
been an improvement. A local authority official explained: ‘The paw-paw hit the fan
with free PHC service, and politicians are beginning to realise that they can’t make
broad policy decisions without realising the financing implications… People are
cautious now about making rash decisions.’
But officials noted that politicians sometimes don’t adopt budget-related proposals
which might be politically unpopular, and that this constrains their ability to control
expenditure. A regional manager cited the example of a 5 000-person town with a
19
hospital but where ‘no politician is prepared to close the hospital. So we’re told to
fiddle around the edges when those big political things are decided.’ Another
interviewee reported a case where politicians ‘for their own political reasons’ will not
close a regional office for which there are no funds.
Both provincial and local spheres of government have formalised systems whereby
officials give input to, and gain guidance from, politicians. Those responsible for
managing health in the local government sphere seem to have closer and more
responsive relationships with politicians. One described the relationship as follows:
‘Any new policy or new thing I have to implement I always go to council, give the
details, advise them on all those things. Normally they take note and approve.’ This
informant also noted that, before reporting to council, he liaised closely with province.
In the provincial sphere the most senior officials engage with the Health MEC, but the
rest appear to feel rather distant from the politicians. Regional managers, likewise said
they do not have formalised ongoing interaction with politicians. Instead there are
once-off interactions. They said the result was that politicians criticised them ‘ for the
smallest thing.’ They also complained about inconsistent cooperation from local
politicians: ‘If the local politicians want something, then the councillors are keen to
work with us. But if they decide it’s a boring issue, we don’t see them in our meeting.
But when the pawpaw hits the fan, then they run straight to the MEC.’
Some efforts are being made to overcome these difficulties. One local level official
described the Gauteng District Health Systems Committee which includes all the
heads of health services of local government and the five regional directors at
provincial level. This is a technical support body to politicians who sit on the Interim
Provincial Health Authority, which is chaired by the MEC for health and has 22 local
government politicians. The official said that the mechanism is helping all spheres
cope with the transition. The situation contrasts starkly with another province where a
regional manager noted: ‘There is a meeting between MECs and local government
people but we’ve never attended that meeting although we were promised we should,
and they look at plans.’
2.2
BUDGETS AND FINANCIAL RESOURCES
Question: Do you know how much money you can spend this year?
Answer: ‘They know but I don’t know’ (Clinic Sister)
‘If something new comes in, someone has to work out what they cut’
(Provincial finance manager)
The bulk of public sector health care expenditure occurs within the provincial sphere.
This section therefore focuses first on provincial health departments and, in particular,
the challenges facing health district and regional managers. Thereafter the section
looks at the interaction between provincial and local government health departments
around financial resources. Finally, donor funding and funding of NGOs are briefly
reviewed.
20
2.2.1 Budget decision-making processes
KEY ISSUES
 Budget decision-making is still highly centralised
 Financial information systems remain weak in some provinces
 There is inadequate understanding of resource allocation and budget decision
making processes at lower levels
 There is limited integration of planning and budgeting
 There is wider involvement in the budgeting process within local governments
The Primary Health Care (PHC) approach suggests that detailed health service
planning, and decisions about how resources are to be used, should be decentralised as
far as possible. This should ensure that locally identified needs can be met optimally.
Within the South African health system, it means that the district office (or the
regional office where districts have not been established) should be responsible for
planning and budgeting for health services.
At the same time, plans and budgets developed at a decentralised level need to be
balanced with the goal of equitable distribution of health care resources between and
within provinces. Previous research has shown the enormous inequities in the
distribution of health care expenditure between health districts and regions (Brijlal et
al., 1997; McIntyre et al., 1999). Some provinces have developed needs-based
formulae to assist in determining equitable health district or region budgets. These
formulae are usually based on the size of the population in each district or region.
They may also include other indicators of relative need for health services such as the
age and gender composition of the population and relative poverty levels (McIntyre et
al., 1999).
Equity is not only about the distribution of funds geographically. It is also about the
nature of services provided. Despite government’s commitment to increasing access at
primary care level, most of the money still goes to hospitals, and particularly to
academic and other specialist hospitals. In response to this, government is currently
developing and costing a PHC package. This package will provide a norm for the
quantity and quality of primary care health services that each province should provide.
The package specifies the type of services that should be provided, a target utilisation
rate and quality standards that should be applied. The package is intended to promote
more uniform provision of high quality services across provinces. However,
provincial health departments will still have to find ways of securing adequate
resources to fund this package.
All three provinces are undertaking major reforms in their budgeting and financial
systems. One financial manager described both the goals and difficulties: ‘In the
past… one person sat in a room and did it. Now … the high levels are decided by the
Health Department management i.e. the allocations by programme and subprogramme. Then there is a process of discussion and further consultation about
more detailed allocation within that… It doesn’t work smoothly at the moment
because the departmental structures themselves are such that they don’t have
adequate support for responding…But I think that what we’re doing now is to make
the bigger decisions around a table – a budget committee has been set up with chairs
21
of sectoral committees… They’d go away and prioritise the individual entities within
them.’
At present budget information usually does not penetrate beyond senior management.
Many interviewees described their frustrations with this situation. A provincial
director complained that she knows neither how much the directorate is allocated, nor
how much has been spent: ‘Every year we sit down, plan and budget. Then present it.
Then they’ll tell you it’ll be discussed by senior management but you’re never told
‘yes you can spend x much money or more’… We just work and spend and as long as
it’s within my signing powers, I sign. As long as I’m sure it’s not corruption. But I
don’t know how much my directorate as a whole has spent from April 1999 until
now.’
The financial manager from the same province explained that it had not at first been
possible to budget accurately because there was no historical data on spending: ‘In the
past at head office level they wouldn’t necessarily have had their budgets revealed to
them because it was all centralised, primarily because expenditures weren’t tracked
at a directorate and chief directorate level… If you don’t know what they were
spending in the past, it’s impossible to budget.’ The financial manager explained that
it was only in the 1999/2000 financial year that there had been real budgeting based on
expenditure for programmes.
The lengthy process of improving financial management systems is one part of the
problem. Another relates to the decision-making process itself in a situation of tight
resources. A provincial manager argued as follows: ‘I know there’s no money (but) we
should be included in the decisions of the budgets at provincial level.’
There are efforts in most provinces to promote decentralised budgeting. Regions (and
districts where they exist) are requested to prepare their own plans and budgets and
submit them to provinces. There is, however, a perception at region and district level
that local plans and budgets are not given adequate consideration. A district manager
reported as follows: ‘We do plan and give it to them and it comes back being a
different thing altogether …We’re asked to budget and send figures, and then it gets
cut.’
In some provinces provincial changes to the budgets submitted by lower levels may
occur because the province is aiming at greater equity between districts or regions. If
this is the case, it seems that the province level has not communicated adequately
about equity-based resource allocation procedures.
Previous research has indicated that one reason that provincial level staff do not base
allocations on locally developed budgets is because they are regarded as ‘completely
unrealistic’ (McIntyre et al., 1999). On the one hand, the preparation of ‘unrealistic’
budgets may be due to ‘budget gaming’ whereby district or regional staff deliberately
inflate budgets in the knowledge that they will be cut. They hope that, after the cut,
they will then get an amount closer to what they actually need. One district
interviewee suggested this practice when he said that ‘sometimes we exaggerate what
we need.’ Another problem is that districts or regions are sometimes not fully
informed about overall budget constraints (McIntyre et al., 1999). Where guideline
22
allocations are provided, the purpose is not always properly explained or understood.
A regional official complained: ‘We end up having a sort of an amount we should
budget within. You are made to feel that you are contributing but at the end you are
told not to exceed here.’
Another area of conflict arises because of the institutional confusion - described above
- between regional structures and programmes. One regional manager reported: ‘We
do strategic planning together with the vertical programmes and we tell them what
our needs are, and they identify more needs. But they don’t come back and tell us
what they’re going to do to meet those needs, nor what it will cost. Or they don’t
budget from their budget – they expect all the money to come from the region.’
One way of promoting greater realism is to integrate planning and budgeting. A
detailed district or regional plan identifies health service priorities and evaluates what
can feasibly be achieved within the coming year and in the medium-term. If this
planning occurs within the context of a guideline budget allocation, realism can be
enhanced. Numerous interviewees referred to the current lack of integration of
planning and budgeting processes. Thus, a provincial official explained that they are
‘developing five year plans which is linked to deliverables but we haven’t aligned it to
the MTEF [medium term expenditure framework] … the two processes aren’t tied
together’. Another provincial interviewee noted that ‘there isn’t a language of
dialogue between you [planners/operational managers] and the budget. We haven’t
bridged that interface. We don’t talk the same language’
Again, however, there are some positive reports. A provincial official described a
collaborative process for budgeting at regional level as follows: ‘I do [district
budgeting] together with community matrons responsible for each district… In the
initial budgeting when we’re all seated together there – we have the cake there and
we’re cutting it. The matrons are motivating what they need. They come to the
meeting prepared. Then sometimes if there’s shortage somewhere we have to
prioritise, negotiate with the other ones on what can wait until the next year’.
Within the local government sphere, long-established local authorities described
formalised and effective systems of budgeting and financial management. Where,
however, they relied on subsidies from the province, the unreliability of the subsidy
payments was said to undermine local government systems.
2.2.2 Financial management capacity issues
KEY ISSUES
 There are still capacity constraints, despite ongoing attention to this issue
 Financial management training has been initiated but capacity development will
take considerable time and energy
 Provincial managers do not want to decentralise responsibility too rapidly, but
regions and districts are eager to assume responsibility
 Financial management capacity is better developed at local government level
than within many provinces
23
Most informants agree that devolution of budgeting and financial management is
desirable because, as a provincial financial manager expressed it, ‘when it happens
centrally you can’t take into account any subtlety’. However, this presumes capacity,
which by and large is still not there. Interviewees cited the lack of skilled personnel
and adequate information systems as key obstacles to successful decentralised
budgeting. Despite attention being focused on this issue since at least 1997, there
appears to be limited progress. One possible interim solution is to redistribute certain
managerial staff from head offices. However, a frustrated regional manager observed:
‘They’ve done decentralisation hard here in the Northern Cape… We do all that and
not one person has been decentralised from Kimberley.’
Capacity is about lack of systems and lack of downward accountability as much as
about lack of skills. Thus many lower level interviewees talked about the difficulties
of keeping to budget in the absence of financial information: ‘In the middle of the
year we find we don’t have that amount of money anymore, so we can’t continue our
plans… They don’t … correspond with us. We just see in the reports what has been
spent. And when we do inquiries we hear ‘No, they took away some money from here
or there.’’
In some provinces, systems for financial monitoring appear to be operating at least
within the provincial sphere. Officials spoke about how these systems have improved
both their ability to plan, and their sense of control over their work. Thus one official
in the Northern Province explained: ‘Each time you spend on any activity you’re able
to check expenditure against budget. Every programme can tell very easily without
having to go to finance people.’ Another confirmed that ‘every month [I get] a
printout to show what I’ve spent on travelling, workshops etc.’
Provincial level officials clearly have concerns about decentralising too rapidly. One
interviewee noted: ‘There’s enormous risks when you decentralise because they may
make mistakes and leave the department in jeopardy.’ The interviewee went on to
suggest that it was not only capacity, but that lower level officials may not ‘fully feel
accountable for what you delegate to them.’ However, district and regional managers
are eager to take more management responsibility, including planning, budgeting and
expenditure control. A regional manager in the Northern Province suggested: ‘Let
each cost centre have authority to manage budgets and if anything goes wrong, let
that cost centre be held responsible.’.
In some provinces, regions and districts have been given ‘responsibility’ for
budgeting, but are not given authority for making decisions which impact significantly
on resource use. For example, one regional level manager reports that, after asking for
security, the province contracted with a private company without involving the
regional office in the negotiations: ‘Now we’ve got to pay huge amounts for a security
service which we didn’t budget for.’
Within local authorities there seem to be stronger systems in place than within regions
and districts. One official described how ‘I’m monitored in terms of performance and
output and delivery in terms of an integrated developmental plan and thirdly an
internal and external audit, and council … We’re monitored quarterly against the
budget… If I want to start cervical screening programmes in informal settlements …,
24
I’d have to go to council and also show them which budgetary provision I would draw
on, or find savings from another line item’ . This manager noted that she and her
financial staff have been trained to operate cost centre budgeting: ‘Meeting with
managers yesterday, they know what it costs to repair taps, to fix a window etc. and
they can make an informed decision about what to do.’
Training is happening in other spheres as well. One financial manager used a medical
analogy to describe the importance of training reaching all levels: ‘As you get the
blood flowing in the system –information at every level, the right administrative
personnel at every level, you have a system that can respond… If a region can’t track
it’s own expenditure, you can’t expect from them.’ But this official went on to
acknowledge that many of the province’s financial problems were at a higher level,
and that these had had to be dealt with before the training of others could commence.
2.2.3 Resource constraints
KEY ISSUES
 Resource constraints make restructuring and policy implementation very difficult
 Unexpected budget cuts and expenditure embargoes cause uncertainty about
resource availability
 There is greater stability where local government health budgets are funded from
own revenue
Budgeting for new policies while ensuring the continued provision of existing primary
care services is particularly difficult in a context of static – or in some provinces,
declining – real health budgets. It is particularly difficult in areas that were historically
under-resourced (particularly in the former homeland areas). In these areas, although
health services were provided previously, they need to be expanded and their quality
improved.
Managers at all levels concur that resources for health service provision are extremely
constrained. A district manager described the shortage of funds as ‘a common
disease.’ The high proportion of fixed costs in most health budgets adds to the
frustration. In the words of one regional manager: ‘80% of our money is tied in
salaries. Another 10% is pharmaceutical services and sundries. So it doesn’t work
when they say how much have you budgeted for TB programmes… Why are they
bothering about the 6% of the budget we have some manoeuvrability about and not
asking about the 94%?’
However, there is a growing awareness that resource constraints will not ease in the
foreseeable future and that more can often be achieved with existing resources if there
is better prioritisation. Further, when asked if shortage of funds is the biggest barrier
to implementation of quality services, almost every interviewee cited health worker
attitudes or staff morale as more important than financial resource constraints.
Nevertheless, many informants did not see the shortage of funds as excusing arbitrary
cuts in the middle, or near the end, of the financial year. Further, some programme
managers said that they have sometimes been instructed not to spend except on
essentials, even though budgets were not officially cut. These experiences not only
25
limit managers’ ability to implement plans, they may also create mistrust of, and
apathy towards, budgeting processes. Clearly the cuts and spending embargoes have
profound effects on service delivery. A regional manager described how expenditure
can be frozen for months: ‘If something runs out, you can’t replace it. Oxygen
cylinders. It’s crazy.’ This same manager observed that budget cuts only seem to
affect service delivery while national and provincial level management structures
remain unscathed. Activities such as health promotion, community outreach and staff
training appear to be particularly ‘soft targets’ in coping with unexpected budget cuts.
In addition to budget cuts, some informants spoke of the difficulty in accessing
budgeted funds. A provincial official said: ‘You get the budget approved but
sometimes must struggle for it to be paid’. Those with more experience of government
systems seem to be better placed to overcome this problem: ‘You do access money but
it’s tedious. Many signatures. You have to start early.’
Local government interviewees indicated that budgets allocated to them are relatively
secure from arbitrary cuts. When asked about cuts, one local government health
manager explained that ‘Council doesn’t function that way’. Interviewees nevertheless
indicated that subsidies from provincial health departments introduced insecurity into
their health budgets. In at least one case, while the province is consciously cutting
subsidies, they are expecting the local authority to continue the service without
discussion as to whether this is feasible.
2.2.4 Provincial–local government interactions: resource control issues
KEY ISSUES
 Provincial-local government financial interactions involve much conflict and little
transparency
 Local government health services appear increasingly vulnerable due to reducing
provincial subsidies and, in some cases, declining budget allocations from own
revenue
 Some local government officials favour direct financing of health services from
the national Department of Finance
The interaction between provincial and local government health departments around
financial resources is usually far from smooth. There is a clear lack of communication
about their respective budgets even though both local and provincial managers
indicate that the lack of transparency is an impediment to rational planning for
integrated service delivery. From the provincial side, interviewees indicated that
contributions to health services from local government own revenue are ‘a state
secret’. Yet without this information, they argue that they cannot ensure equitable
allocation of primary care resources between health districts and regions.
On the other hand, local government managers are not provided with information on
expenditure at provincial facilities within the boundaries of their local government.
Local authority managers also talked about the lack of transparency as to how subsidy
decisions are made: ‘No-one knows how the subsidy works - what’s the amount,
what’s the percentage… 10 or 15 years ago you’d know what percent.’ This
interviewee suggested that the province itself ‘doesn’t know, can’t tell you’. Further,
26
he said that there is no process to facilitate communication: ‘There was a time when
they sent us a form to help them budget so we would say what we would need. But
that’s come to a standstill.’ Another local interviewee said that in their area subsidies
stopped in 1995, but no reasons were provided: ‘We’ve written letters, seen the guys,
talked to them. The last reason that we’ve got is that they’re still in the administration
process and when it’s finalised they’ll see to the subsidies.’
Provincial managers generally favour continued subsidisation of local government
health services through the provincial health department route. However, they want
routine information on local government own revenue contributions, and improved
accountability for expenditure funded through provincial subsidies. At present, some
feel that local governments are ‘doing whatever they want to do with the budget
[subsidy]. This is not being controlled by provincial government’. The national
Department of Health is developing guidelines for ‘service agreements’ between
provincial and local departmentsl. Several provincial manager agree that ‘the service
agreements will be useful – we’ll sign them and that will oblige people [local
governments] to provide certain services.’
Some local managers – particularly in wealthier councils, are not eager to have their
activities monitored by provincial managers. They argued that they are primarily
accountable to their local councils: ‘Province provide 17% of my total health budget
so I can’t be monitored by another authority who provides a small proportion of my
budget’.
Local government health managers find themselves under pressure from all sides. On
the one hand, provincial health departments feel that insufficient revenue is being
allocated by local governments for health services. In addition, provinces appear to be
gradually reducing subsidies in anticipation of a unified system where local
government is controlled by the third sphere and the province pays only for provincial
programmes. Meanwhile, the continuing confusion over functions has been used by
some local councils to cut their own revenue health allocations. As one local official
explained: ‘Departmental heads think provinces should just take over and pay. But
we’re working at community level and will lose that contact if we go to province. We
think the municipality should pay more but the department heads don’t like this.
Politicians don’t seem that aware of this issue.’
Some local government health managers feel that the solution lies not in the
establishment of service agreements, but in direct financing of local government
health services from the national Department of Finance level. They argue that health
services should in future be taken into account in the vertical and horizontal revenue
divisions. Such an arrangement would require increased collaboration between
provinces and local government, yet without one of the parties controlling (at least
partially) the purse strings for the other party’s services. A local government official
argued: ‘It’s imperative that local council services work and you can’t work when
someone else is pulling the purse strings.’ This interviewee feels that there is a ‘firm
understanding’ of this argument within national government.
27
2.2.5 Donor funding
KEY ISSUES
 Donor funding is not coordinated
In most cases, donor funds appear to be negotiated at national level, and then provided
to provinces for specific purposes. For example a provincial interviewee described
how she was given support for certain aspects of the implementation of the Choice on
Termination of Pregnancy Act. In other cases a province or local authority might
approach donors directly. For example, one province described how with the
Integrated Management of Childhood Disease training, they sent the donor a proposal
and conducted the training ‘and they just sent a cheque.’ Similarly, a local authority
informant reported: ‘We’re moving ahead with proposals for capital projects to take
to donors… I put through a proposal to the regional office but also directly to the
Norwegian embassy and all the embassies to ask if they’re interested and could fund
part or whole’. It is not clear in this last instance whether the proposal was successful.
Donor funding can be a source of tension between programmes and line functions. A
regional manager complained: ‘We as regions don’t get donor money but the support
services do get donor money and we don’t know what the amounts are and what for…
That’s another secret… We are not involved in discussions with donors.’
2.2.6 Donor and government financial support to NGOs
KEY ISSUES
 Provincial subsidisation of NGO services is gradually increasing
 The relations between provinces and NGOs are becoming more formalised.
In all provinces there are donor-funded activities undertaken by NGOs, universitybased groups or consultants, where the outside group has approached both the
province and the donor. The province is asked to support the group’s doing the work
within the public health services. The donor is asked to fund their costs and perhaps
some of the costs to the province. Much of this work is done with the idea that
effective interventions piloted in one place could then be undertaken elsewhere. In
some situations, the province does not manage the funds or even the programmes
directly, but rather agrees on the broad principles. As one provincial programme
manager explained: ‘We work closely with the NGOs. They appoint their own
directors and supervisors… We’ve agreed with them in the first place on how money
should be spent’.
In some cases the provinces subsidise NGOs to provide a service even where there are
no external donors. One provincial programme manager said that some care is taken
in selecting and monitoring NGOs: ‘We want an NGO that is organised, that has skill
in that aspect and will be able to deliver… Then we attend what they do, watching
them because we’re subsidising them so we must monitor and evaluate them and get
monthly reports and yearly reports from them.’ This informant reported that local
councils are involved in the selection and monitoring because it is there that the NGOs
are operating. A provincial finance manager spoke about management of funds given
28
to NGOs on tender: ‘There are meant to be service standards with each contract.
Contracting hasn’t been brilliant within the province but it’s moved a lot more in that
direction.’
2.3 SERVICE DELIVERY AND IMPLEMENTATION
This section considers the implications of policy-making and budgets for
implementation. A number of interviewees point out that many of the barriers to
implementation lie outside the health services. For example, the policy that every
woman should give birth at a health centre may be obstructed by poor infrastructure.
A programme manager described how, for example, after two weeks rain’ it’s muddy
so there’s no transport so people deliver at home. Ambulances can’t cross the river.’
The present research focuses on barriers within the responsibility of departments of
health within all spheres.
Many of the communication problems identified in relation to policies and budget
apply equally in the process of delivery and monitoring. A provincial official
complained: ‘When someone has an idea in September in the national department, it
doesn’t seem that unreasonable to expect an answer in October but the request will
only get to the region in mid-October… We see plans as an unfortunate thing that
managers ask for… [So] everything is always a surprise and a crisis.’
2.3.1 Budgeting for policy implementation
KEY ISSUES
 Policy developers often don’t consider budget and operational constraints
 Interim funding helps only in the short-term
 There is increased awareness of the need to plan and cost new policies
 Policy implementation may be thwarted by lower levels of management
 Costing of a basic PHC package is intended to facilitate better prioritisation
Many interviewees noted decision-makers’ failure to consider the resource
implications of new policies. A provincial official said: ‘Our policies are pie in the
sky rather than real… We started off saying things would be delivered because they
were the right things and people were entitled. But entitlement without resources
doesn’t get you anywhere.’ A financial officer noted that, constitutionally ‘the
province has the right to refuse if money doesn’t come – because it’s an unfunded
mandate’. However, no interviewee reported any instances of blatant refusal to
implement a policy.
Instead, those below and even at provincial level report the practical difficulties of
implementing policies that may sound good. For example, one regional manager said
that the ‘policy says two ambulance men always have to be on an ambulance, and
every ambulanceman has to have a course on drowning – so I refused because I don’t
have a river! Also there’s no way I’ll ever have two men. We can just afford one’. The
same interviewee referred to the policy that no nurse may take X-rays ‘but we have no
money for radiographers.’ Another regional manager referred to a policy directive
that rape victims should receive AZT: ‘We asked ‘where does the money come from
for AZT?’ We just have to provide it because someone has approved the policy… We
didn’t have any chance to give our view on the issues.’
29
Similar issues were raised by local government informants. For them the fact that they
are accountable to a different authority exacerbates the tensions. Several local
authority interviewees noted that province often fails to consider its funding
responsibility in respect of new policy and that local authorities therefore carry an
untenable burden. One interviewee observed that this burden comes on top of now
having to provide a full range of services for previously under-served black
townships: ‘Local government nationally is starting to run into a brick wall having
inherited large areas with enormous debts and cultures of non-payment and trying to
put money into disadvantaged areas. So in most areas local government can’t
continue accepting unfunded mandates.’ Again there was the suggestion that some
councils had simply decided simply to refuse to implement.
Where policies are introduced in the middle of the financial year, national or
provincial government sometimes pays the bill and provides materials for the
remainder of that year but expects the implementing level to cover the costs in the
following year’s budget. For example, a provincial programme officer described how
for TOP she provided equipment and long gloves for all regions; for cervical
screening she provided vaginal specula and sterilisers; for immunisation she ordered
cooler boxes ‘for a start. Then from then it’s from their budget.’
Similarly, when the women’s health cards were introduced, national government
provided the first supplies to the provinces and provinces supplied the regions and
hospitals, but regions and hospitals were asked to budget for this the following year.
Provinces found that some regions have done so and others have not. One provincial
manager attributed this to poor financial management and lack of experience. She
argued that ‘they have been workshopped’ but clearly workshops are not enough. A
local authority manager complained: ‘We’re rearing to go but… the [women’s health]
card is supposed to come from national level but there isn’t a guarantee that the card
will be available so we’re scared to implement.’ He said that with the TB register they
had implemented but two months later had run out of cards: ‘It becomes very
demoralising because we get the flack from the patients.’
Several interviewees suggested that the understanding of policy makers is improving.
They said there is increasing recognition that the amount of money available is
unlikely to increase dramatically from year to year, and that what is needed is clearer
prioritisation. One provincial manager noted that ‘amongst people developing policy
… they now do [recognise] that it has to have a price tag attached, that it’s about
choices. The idea that we’re going to have to make choices is a painful one … It
hasn’t been politically acceptable to say choices are needed.’
Some spoke about how they had, practically, made the choices. Thus a manager in the
Northern Province described how, with the introduction of the syndromic approach to
STD management: ‘We didn’t motivate for extra money, but to transfer money from
other sections in the same PHC budget. Just juggling around. Sometimes we had to
give up something. Like we used to have promotional materials like T-shirts and now
we have to use cheaper materials.’
30
In some cases, regional levels have not budgeted for implementation of national and
provincial policy even a number of years after implementation. The decision-makers
in these regions have seemingly prioritised other expenditures. For example, one
programme manager said the health services repeatedly ran out of the necessary
equipment for TOP and then approached the province for funds from its contingency
budget. The programme officer favoured decentralisation of services but felt
disempowered by her lack of influence over the decision-making process: ‘I have to
say ‘please, please do this or that’…But then the regions will raise their own
constraints and will do it at their own pace.’
Gender issues in decentralisation
Decentralisation presumes that decision-makers at lower levels will be guided by the
interests of users. However, health priorities have been defined over centuries by a
predominantly male profession. It is therefore not surprising that despite national and
provincial policy to provide termination of pregnancy services, below provincial level
this happens only in one province at one clinic. Yet a recent enquiry into maternal
deaths found that unsafe abortion remains a key problem (Department of Health,
1998) and suggests that service managers should give priority to decentralised
delivery of TOP services.
In recognition of the ongoing problems caused by introduction of many policies
without increasing funds, the national level, with the involvement of provinces, is
costing a basic PHC package.
2.3.2 Programme priorities and service delivery
KEY ISSUES
 New policies are being brought in when the basic requirements for delivery are
not in place
 Programme managers are often caught between national and implementation
levels
 Separate programmes lead to training overload and duplication
 Donor funding can undercut attempts at integration
 Implementation is influenced by the extent of managers’ commitment and
capacity for innovation
A theme which emerged repeatedly from interviewees responsible for regional or
district delivery was that the pace of change was too fast. Interviewees complained
that new policies, coming through programme officers, are being brought in when the
basic requirements for delivery are not in place. An official responsible for districts
complained: ‘Often we’re not doing basic things right yet and programmatic things
are more fancy and we can’t afford it or haven’t got resources including ongoing
support’. Much of the frustration was directed at programme officers.
The method of work for programme officers differs between provinces. All provinces
have programme officers at provincial level. However, in Gauteng, there are
frequently also programme officers at regional level. These people are the first point
of communication for the provincial officer. Elsewhere there are no programme
31
people at regional level, or people in regional offices double up. For example, one
person may be responsible both for clinic supervision and AIDS programming.
The basic procedure is the same in all provinces. The national develops policy which
the provinces must then implement. On receiving the policies, provinces modify the
guidelines to suit the situation. They then workshop the modified guidelines and
protocols with officials from all levels. Additional training is provided where
necessary. The lower levels are than meant to implement while province is responsible
for monitoring. There are at least two difficulties with this process. Firstly, all the
separate programmes wanting the same group of people to deliver their programmes,
while the service deliverers concerned are striving to integrate services. Secondly,
there is confusion about the rights and responsibilities of programme officials relative
to those in service delivery.
The result is frustration on all sides. In terms of the first issue, a regional manager
reported: ‘We spend two days every month [at provincial level] and they line up
programme people to speak to us – you go in with one wheelbarrow of problems and
you leave with two. There’s no time to talk with each other or talking about how we
solve problems.’
In relation to the second issue, a senior provincial manager commented on the way in
which many provincial programme officers understand and perform their role: ’People
need to understand that it’s not enough to be right. You have to come with evidence
and we’re not used to evidence…We’re going to need at a policy level… people with
skills rather than beliefs. At a local level, once the choices have been made, people
need to co-ordinate a job of work rather than seeing themselves as advocates.’ The
manager said that the current approach resulted in overlap of roles. A provincial
programme manager herself recognised this difficulty and its roots in previous
practices: ‘The province tends to keep hands on which is wrong, but with time they let
go. Nutrition is a district function, but it’s still run by province… But we’re working
on it. It’s the way some of these programmes from the previous government came in.’
The fact that programme officers carry responsibility for policy guidelines, but have
no control over implementation creates substantial tensions: ‘You have to achieve
things through others - you facilitate but you don’t have the power to say this should
happen on this day’. Likewise from the other side, in the words of one regional
manager: ‘There’s a tendency of programme managers to interfere with operational
issues which drives us berserk.’ Another regional manager noted that, ‘They’re totally
unclear on what their role is and national demands things and they’re in the middle
and terrified to phone us because we don’t give them what they need.’
The provincial programme managers described one of their roles as monitoring. They
do this through visits to sites or calling meetings. The language in which they describe
this differs. One programme manager said: ‘We have a checklist and go out in the
region and look at certain things to see if they’re done properly.’ Another
programme manager focused more on the fact that she must offer support:
‘Involvement is very important, and giving people information is very important. You
don’t just say ‘there’s a policy to implement’. They must tell you how they are going
to implement – get input from them because the areas are not the same.’
32
Some districts described provincial programme managers as supportive. Others
argued that they never see the programme managers in the field, unless it’s when they
bring important visitors, particularly from national. They said that programme
managers often have to respond to demands for information from national level and
this made them less responsive to districts’ needs.
Some local council interviewees expressed confusion about the role of programme
officers. They raised concerns both about programme officers’ competence and their
understanding of local conditions. One used TB as an example: ‘Our own
municipality has done some fundamental work on TB yet we get instructions from
province on how we must implement our programmes. In terms of expertise our staff
member could teach the province on how to implement a programme so it’s a waste of
a resource.’ Another local council manager noted that ‘the provincial co-ordinator is
often not au fait with local programmes. We’ve a lot of programmes going on that the
provincial co-ordinator is not aware of… Money is given to NGOs by a provincial coordinator for AIDS – that provincial co-ordinator has no idea what that NGO is
about. A politician who knows that NGO, if they’ve paid their rates and taxes – that’s
the person who’ll know if they’re suitable or not to get HIV/AIDS money.’ This
informant stressed that she felt there was a role for programme officers, but that it
should be confined to monitoring rather than decision-making.
The desire of programme officers to deliver on their job descriptions places pressure
on the regional, district or local managers and their staff: ‘If you have competing
advocates at provincial department, you get paralysed. High level managers all of
whom want their bit because of its importance.’ One of the ways in which the pressure
manifests is that each programme officer wants to ensure that clinic level staff are
trained in relation to the policies for which they are responsible.
Many interviewees recognised that the training can be useful. A local manager
reported: ‘I send my staff because we haven’t got a training contingent in our
authority… They’re doing a good job.’ However, a provincial manager acknowledged
that the training is uncoordinated. She reported that one region said its staff were
spending 40% of their time in training course: ‘We’re now discussing if we can’t give
people guidelines, - do they need to be trained on everything?’ From the regional
side, a manager reported: ‘We’re starting to decide [on training] more and more at a
regional level but the reality of what happens is that the provincial office sends you a
fax saying that next week there’s training on burns, please send someone. Then that
there’s an HIV summit and the Minister wants someone to attend…Everyone’s trained
up to their eyeballs.’
In addition to overload, there are financial constraints. For example, a regional
manager spoke about the costs of S&T (subsistence and travel) for staff attending
training courses.
The lack of training co-ordination was raised repeatedly by both provincial and lower
level officials. Northern Province officials reported that they had a Human Resource
Development unit that was meant to coordinate all training, but that they were not
using this resource. Gauteng, on the other hand, reported that it has begun to address
33
the problem. Instead of having different directorates training separately, with resultant
depletion of service delivery, they are trying to develop generic and integrated training
courses. One example is a ten-day integrated reproductive health course which
includes STD, contraception, HIV/AIDS, TOP, violence against women and gender
issues training.
When there are donor funds or a national conditional grant involved, integration and
coordination across programmes and between levels can be even more difficult. A
number of provincial managers mentioned examples, such the Integrated Management
of Childhood Illnesses. In this case, the Unicef and WHO approach involves training
which should be run by districts, but at the moment remains at provincial level and is
not integrated. Termination of pregnancy training was also mentioned as a donorfunded and NGO-run initiative which has not been integrated into planning or training
at regional level.
The impact of new policy is felt beyond the clinic level. In cases where policies
require referral, the ability of higher tiers of the system to cope comes into question. A
regional manager raised this in relation to cervical screening: ‘I said okay, so if I
implement it routinely, what are the follow up services? They said there can be five
people a week …at the hospital. I said ‘when you improve that, I’ll implement cervical
screening.’’
New policies, money and delivery: DOTS
One of the new policies which was frequently mentioned was DOTS: Direct Observed
Treatment Short-course strategy for tuberculosis.
A local authority person reported: ‘We’re doing 50 a week but can’t do a full
investigation or break the cycle because of staff shortage… We could train people
with matric but we’re not allowed to employ people… People who do DOTS work
want money. SANTA is saying they’ll give T-shirts and lunch packs but this is not
enough… They haven’t got jobs. It’s all money related.’ Other interviewees spoke of
similar money constraints. One suggested paying the DOTS supervisor for every
person cured or treatment completed. Another described the ‘children who
volunteered’ as ‘hungry and unemployed.’ A local authority clinic had stopped doing
DOTS ‘because of shortage of manpower because I’m alone since this millennium.’
Sometimes the money obstacle has been overcome. One region described how they
planned training sessions but had to cancel at the last minute when Santa, the
proposed trainers, phoned to say that the province was reconsidering its contract with
them. The region was understandably upset as such an experience ‘upsets the
community, they lose their confidence in you.’ Nevertheless, the region persevered and
is now using local government councillors instead: ‘They’re paid and keen to be reelected. What better way to prove you’re concerned about your community that to be
seen to be helping the sick?’ .
34
2.3.3 Local primary health care services
KEY ISSUES
 There are big differences between and within provinces in respect of functional
integration at clinic level
 In most provinces, local authority clinics are subsidised by province. In some
cases location of provincial staff within clinics causes tensions over authority and
accountability
 Provision of PHC services by province and local authority can confuse users
The intention of the government is to provide integrated and comprehensive care at
primary level. One aspect of integration is that service users must be able to get all
their service needs met in one place at one time. This is a critical gender issue, since
the vast majority of service users are women, and many of them need not only
reproductive and other services for themselves, but also services for their children.
Having all services available on one day saves women time and the money required
for transport to clinics. It also prevents their losing money from wages or selfemployment. Having one provider meet a range of needs means that they are more
likely to provide quality services, and have an understanding of a woman’s health
needs as a whole, rather than one provider seeing a woman solely in terms of her
contraceptive needs, and another in relation to a health problem.
Integrated services are not always available even in the big cities
When the National Association of Democratic Lawyers (NADEL) looked at women’s
access to health care services, they found three clinics in Cape Town which each had
very different levels of integration (Govender, 1999:16-7):
 The Western Cape province established the Michael Mapongwana Community
Health Centre in Khayelitsha in 1996. Because it was created so recently, it
provides a full package of preventive and curative primary health care services.
However, the Maternity Obstetrics Unit is the only section that is open 24 hours a
day.
 The Khayelitsha Clinic is run by the Tygerberg municipality. It shares a building
with the Khayelitsha Community Health Centre and Maternity Obstetrics Unit
which is run by the province. The clinic provides child health services, TB
curative services, and family planning. It is open only during working hours.
 Manenberg Clinic falls under Cape Town municipality. It provides preventative
and curative primary health care services, but does not have a full range of
services. For example, the Clinic offers postnatal services, but not antenatal. The
clinic is open only during working hours.
One of the factors working against integration is that some services are provided by
province and others by local authorities. A nurse at clinic level running a local
authority service spoke about the problems that arise: ‘I do preventive. The
[provincial] health centre does curative… I transfer people there – just 100 yards
from where I’m working…We used to take maternity but there’s a problem because of
financial problems so we refer to the health centre for delivery… I first send them to
the health centre for booking, then they come back to me for general examination,
observations and everything. Then when due they go to the health centre for delivery’.
35
Regarding sexually transmitted diseases, the sister said, ‘I do see patients and
defaulters, then I send them back to the health centres to be seen by doctors… Minor
STDs I do treat here. If I fail then I send to the health centre.’
Provinces and local authorities have developed different solutions in attempting to
provide comprehensive care. Some reported that there are few problems and good cooperation. For example, a Northern Province local government official reported that
there is ‘very good relationship. We liaise a lot… Any time they want to do anything,
they consult with that.’ The regional office concerned reported that a few local
authorities were not yet offering health services, but that the province was
supplementing in all areas because the existing services were not adequate: ‘We are
still in separate clinics but we meet, discuss, talk. We involve them in in-service
training, in all the changes. We give them the health policies, whatever… It’s going
well.’ On the other hand, the same regional manager noted resistance to actual
integration: ‘We did try but we found that there was resistance from their side.’
One local authority manager described particularly far-reaching efforts at integration.
The district has a health team which includes facility managers and which meets
monthly to discuss implementation and share resources. Overall there are 20
provincial and 57 local government services, but the province employs 77% of the
staff. The manager was proud to report that they had ‘come a long way. We don’t have
a dichotomy of local government working in their own paradigm and province
working in their own paradigm… In the past province only provided curative and
local government your preventive/promotive. Now we’ve taken on curative in 56% of
our facilities and province have taken on some preventive services and we also have a
skills mix… We also run joint training programmes… When we drew up this action
plan people focused on the issues… so people forgot about who has what conditions
of service.’
Other informants described a range of difficulties which undermine integrated
services provision. A provincial programme manager described the problem related to
local and provincial staff having their own reporting structures, ‘So you can’t force
them to do things if their seniors don’t see it as a priority… There are areas… where
the clinics are working together… but you’re still separate. You still account to
whoever you account to… so you still encounter questions like ‘whose budget is it’?’
A regional manager said the situation had improved but that there were still tensions
because the local authority staff had been given supervisory posts and subsidised
vehicles and tended to blame provincial staff when there were any problems. Many
interviewees also described how incomplete integration of provincial and local staff
caused tensions or ‘head butting’ between employees. Several referred to the fact that
local salaries and conditions of work were often better. These issues are discussed in
more detail below.
2.3.4 Reliance on other government departments
KEY ISSUES
 Reliance on other sectors for basic services can be inefficient
36
Implementation is sometimes hindered by the division of responsibilities between
sectors. Transport provides a good example.
Some places have found good working solutions for transport. One region said that
they had taken over all their transport needs: ‘We run the whole ambulance fleet, all
the mobile services, everything. We took over running the vehicles from the
department of transport. They‘ve done decentralisation hard here.’ In another
province, transport remains in the hands of the Transport Department. One informant
said that there is a well-coordinated system between the two departments which has
also decreased theft of vehicles. However, in the same province a regional manager
said that when vehicles were sent to Transport for repairs, ‘they take long to come
back.’
Some local authorities described their transport management systems as working well,
despite not being managed directly by health. A local authority manager reported that
the ‘ admin person takes responsibility for the vehicles. I tell her I need 10 vehicles
for World AIDS Day, for example. It works faster than the provincial side.’ But a
nurse in charge of a local clinic had a different experience. She said, ‘I don’t have a
vehicle – we share with the municipality… Sometimes they don’t turn up. Sometimes
they come late and patients have gone.’
Transport is not the only area where delivery is dependent on the political priorities or
practical capacity of other departments. As one regional manager noted, ‘Water in our
clinics involves another department… We do meet with them to discuss getting water
into the clinics. This involves a lot of departments and things are not as fast as that –
it’s a stumbling block.’
2.3.5 Shortage of funds or shortage of staff?
KEY ISSUES
 Shortage of funds is not seen as the biggest barrier to implementation of quality
services
 The pressures of ongoing restructuring together with new policies affects the
delivery of quality services
 Resource shortages are most often expressed in relation to staff workload, but
this is often a problem of poor organisation
 Institutional culture undermines local level initiative and problem solving
 Planning and priority setting can help to stretch resources
Very few informants said that funds were the biggest barrier to the implementation of
quality services. The following comment encapsulates the more common response:
‘We are moving too slowly for expectations and much too fast for the capacity of the
system to sustain it… Our staff are reeling. I personally think one of the major errors
we committed… we focused too much on restructuring and transition and not enough
on service.’ Several interviewees pointed out that it was not only health that was
restructuring. A district manager explained: ‘Districts involve not only health and
welfare, but all departments, to have a ‘supermarket’ – agriculture, health, welfare
all there… So that’s the problem, not money.’
37
Further, while most interviewees said that funds were not the biggest problem, they
were clear that more funds would allow better services. As one local manager
reported: ‘We’re not doing what we’d like to do – for example we’re servicing
informal settlements on a weekly basis. That’s not ideal… Also increased waiting time
of patients in facilities’.
The most commonly raised issue in relation to funding shortages was staff workload.
As a provincial official expressed it: ‘Shortage of funds is shortage of staff. If you
don’t have enough manpower [sic] then you don’t get everything done the way it
should.’ Others spoke about demands on staff time in relation to training for and
implementing policies such as free health care, screening of all patients for STDs or
community-based systems for implementing DOTS. A clinic supervisor noted that
these ’additional services lowered the morale because a lot of work has to be done .’
Demands on time vary in different areas. In many areas clinics are busy in the
mornings, but staff have no work to do in the afternoons. In others the workload is
substantial throughout the day. A Northern Cape interviewee said that while in
Bloemfontein there are 35 people to see per professional nurse, ‘in our province they
have to see 42 per professional nurse but they’re actually seeing between 50 and 55
per day at the moment – we don’t have enough funds to appoint more people’.
Research reveals that staff find it easier to assume that the problem is staff time than
to analyse how they are spending their time, and whether clinics are organised to make
the best use of time and other resources. Khin San Tint of the Women’s Health
Project is currently assisting regional and clinic staff in integrating services. She says:
‘Time flow studies show very clearly that there’s no shortage of staff but the
utilisation and performance is not according to the standards… In Northern Province
there are some very populated districts where you’ll see people are overloaded – one
to 90 or one to 60. But in most sites they’re under-utilised.’ Rather than overload, the
problem is management and organisational capacity, ‘the ability of people to find
alternative ways of doing things.’ Tint notes that the problem results from the
hierarchical structure: ‘People feel their supervisors don’t allow them to take
initiative. It’s very rigid the way people perform their jobs.’
Government interviewees also pointed to poor organisation, duplication and
ineffective functioning. For example, a Northern Province official described how both
the departments of health and welfare are working on poverty and nutrition. The
budgeted funds come from separate ‘votes’ and they are not able to transfer activities
between votes so as to streamline nutrition-related activities. The official said that
there is no time to think about and find solutions to such problems, and build a shared
vision ‘because we also feel we have to account for a mechanical kind of quantitative
productivity on a day to day basis… We actually could be achieving much more if we
could organise our time much better and know who would be addressing those
demands.’
2.3.6 Health worker morale and attitudes
38
KEY ISSUES
 Health worker attitudes were repeatedly cited as the biggest problem
undermining the delivery of quality PHC
 Poor attitudes are frequently ascribed to low health worker morale
 Initiatives are underway to address this problem but successful interventions are
not being institutionalised
The majority of interviewees cited health worker attitudes as the biggest problem
undermining the ability to deliver quality PHC services. A regional manager reported
on complaints from the public: ‘If you’re working in an office of PHC like me you get
all these people coming in with their complaints and most of the things are attitudes
of the workers.’ A provincial official reported particular instances of poor treatment,
such as a youth being chased away from a family planning clinic and routine poor
treatment at antenatal clients.
An official from another province described an experiment which proved the
importance of staff attitudes: ‘There was a clinic which was always full and another
maybe seven kilometres from it which was not busy. But patients came from the empty
one to the busy one. We took one nurse from the busy clinic and put her in the quiet
clinic and that clinic within a short time was busy. So we could see this was an
attitudes thing.’ Others had similar stories. A local government official told of a PHC
nurse assigned to work alone in a mobile clinic. The nurse saw 70 to 80 patients a day.
‘She has community health workers she has recruited from the community. She’s sent
them for HIV counselling training and other training and they work with her and
support her in her service… She has patients sitting on the grass to see her, who give
her support, for example telling her days not to come because of weather or political
tension.’
The word ‘attitude’ suggests that the responsibility lies with the nurses. Other
interviewees argued that the problem was health worker morale rather than attitude.
For example, a clinic supervisor said that implementing new policies could be
difficulty because ‘people are not very happy about change all the time - people fear
change.’
The definition of the problem clearly depends on one’s position. A clinic supervisor
said she thought the relationship between health workers and clients was ‘healthy. But
you should ask what’s the relationship from clients – it varies from individual to
individual. Nurses know they should react positively with whatever they get from
clients’. Clearly this informant saw users rather than nurses as the problem. However,
a local authority manager who was proud of his own staff’s attitudes, said: ‘I don’t
have any problems. But we usually get complaints when people come from outside.
We ask why don’t you go to your own clinic and they say it’s because people don’t
treat them well and don’t have enough stock so they’d rather come here.’
Some interviewees argued that there are concrete reasons why nurses find their
position difficult. These reasons cause low morale which, in turn, causes poor
relationships with users. Other interviewees were less sympathetic. A regional
manager complained: ‘There’s a moral apathy in the country at the moment. A sense
of entitlement - why should I work for what I get?’
39
Other, more specific, causes of poor morale mentioned were the following:
Transparency in the restructuring process
As part of restructuring, some provinces are cutting posts. A provincial official
explained: ‘We’ve got lots of supernumeraries, inherited old staff. And new staff came
in so our salary budgets are much more than the money used for service delivery’.
Some staff are left wondering when it will be their turn. A provincial official’s
comments reflected her sense of devaluation: ‘They mustn’t just cut and say we don’t
want you old people. We all have experience… They have been too much in a hurry to
cut out the old ones without making sure the new ones have experience and skill.’
A provincial programme manager acknowledged that part of the problem lay with the
lack of communication, and that this resulted in uncertainty and rumours: ‘You get
corridor gossip that this or that directorate is going to go. If someone would come
and tell people that there’s no hidden agenda and spell it out upfront.’ Similarly, a
local authority manager noted: ‘Morale is very low. There’s lots of uncertainty…
Province wants to take over the service and reorganise it and then put it back to local
level. This has created a lot of mistrust and confusion.’
Some of those who argued that health worker morale is the primary problem felt that
there has been progress and morale is ‘picking up’. They said that uncertainty and fear
was understandable given a new government and many changes. But, as a provincial
manager explained, with time, ‘because of the training, capacity building, you see a
light getting bigger and bigger in the tunnel until your morale is better.’
Salaries and conditions of service
Salaries were mentioned by a number of interviewees as a problem – particularly the
salary differentials between local and provincial health workers. The increase in
public sector salaries has ameliorated this problem to some extent and some, such as
this local government manager, argue that it is overstated: ‘In Durban a huge clinic
had been functioning for 18 months with all staff under the same roof. It appeared to
work far better than senior people thought… Sometimes we don’t give staff enough
credit.’
Nevertheless, our interviews also revealed ongoing unhappiness. A clinic sister was
frank about her fears: ‘I’m afraid of the new policy. At present I’m from a government
[provincial] hospital. …When I came back to the municipality they took my pension
for a year. …When I think of going back to government again it will be a problem for
my pension.’ Similarly, a local government manager spoke about a R3 000 difference
in monthly pay between a nurse working in Ennerdale and one working in Soweto,
with further differences in uniform and other costs. The manager said that they were
unable to achieve parity ‘because unions come to the bargaining council’.
Some respondents identified low salaries, rather than differentials, as the barrier. A
provincial official said: ‘Now there’s a shortage of trained nurses. They are taking
packages. They go outside the country to Saudi Arabia, to England… Hard working
people are not getting any incentive and a person will say ‘I’m 20 years but there’s no
promotion, no extra money, no night duty allowance.’’ A regional manager from the
40
same province noted that nurses are drawn to the private sector where salaries are
more attractive.
Pace of change and workload
In some cases, low morale was ascribed to workload in the context of political change,
with resultant burnout. Change was said to be particularly difficult for older staff who
had been operating in a particular way for decades. Their unhappiness demoralised
younger staff ‘ who have innovative ideas and find the older group don’t want to
change.’
Lack of support for nurses
Some interviewees suggested that staff had little sense of being valued or appreciated,
whether by their seniors or the public. As one regional manager explained: ‘Our
people are overworked. Next thing the MEC wants a 24-hour service for Batho Pele
and people feel they can’t cope with that as well. The public are demanding. They
don’t come back and say thank you for the service. Nursing staff also have human
rights. The public expect too much.’
There do not appear to be any fully institutionalised efforts to address health worker
morale. In one province informants spoke of the implementation of Batho Pele as an
enhancement of a ‘why’s’ programme that had been running to promote quality
services. However, at regional level, officials were not really aware of this initiative.
An intervention mentioned by all provinces is the Health Workers for Change
(HWFC) series of workshops (Fonn and Xaba, 1995). This is a change-management
methodology which draws out three skills – identifying health system problems;
identifying the causes and impact of gender inequality on the health system, health
workers and clients; and learning to solve problems collectively. HWFC was
developed in South Africa by the Women’s Health Project, and has been shown here
and elsewhere to have a positive effect on health worker morale and attitudes as well
as on health system functioning.
The efficacy of the programme was acknowledge by interviewees. A provincial
manager reported that where staff had undergone HWFC training, they ‘feel that
they’re contributing something despite that they may not be getting the necessary
support which they need from the province.’ Nevertheless, in no cases is the method
being used systematically or province-wide. Another donor-funded NGO initiative in
the Northern Province, called the Community Responsiveness Project, is successfully
training people on how to be responsive and to link with councillors, traditional
leaders and other community members. Here too, there are no plans for
institutionalisation.
A number of other steps were mentioned. In Gauteng there is the Khanyisa award to
reward the best unit and individual. At district level Gauteng has annual research
conferences which encourage interest in work and reportedly generate some
excitement. A manager in Northern Cape Province said that they try to bring in
community participation and ‘being nice to clients’ as an ‘ongoing chant’. Local
authority informants spoke of similar initiatives to encourage interest in work and
good relationships.
41
2.3.7 Where is health promotion?
KEY ISSUES
 Health promotion and community outreach are first to be dropped when there are
resource shortages
 Clinical services always get priority over outreach
 Health promotion requires managers to move away from the medical paradigm in
which they are trained
The White Paper is very clear about moving from a curative to a preventative
approach. The Paper emphasises health promotion as an important part of this.
However, community outreach appears to be low on the agenda. It is not necessarily
considered central to the job of health providers, and is amongst the first things to go
when funds are short. Thus a provincial manager said that ‘to even think about
community-based activities from the health budget is difficult… in terms of essential
provision when we have to cut, such programmes would be the first to cut from, even
if there has been approval… We survive on donor funding to be able to provide such
services. There’s also a budget from national… but the magnitude of the problem…
makes the budget approved by national insufficient.’
A few interviewees argued that the neglect reflected not simply fund shortages, but a
deeper failure to move away from the traditional medical model of health. One
provincial manager said: ‘Health promotion isn’t health education… I think we miss
the opportunity of impacting in a great way on the health of the people and using our
budget effectively by not really understanding.’
However, few interviewees took this broader approach. For example, when asked to
what extent AIDS is given priority, or about implementation of a DOTS approach to
TB, lack of staff capacity to do outreach was repeatedly mentioned. On the question of
responsibility for building community understanding on STDs, one local authority
clinic supervisor noted that ‘It is our business but there’s a staff shortage so we can
only focus on those who come into the clinic and give talks, but with the added
workload it’s a problem.’
A local authority official described how they manage the local ATTIC on behalf of the
province. The province is meant to provide a 100% subsidy, but seldom pays it. The
ATTIC office is responsible for the entire province, but has only two staff. If they are
out of the office, there is no-one in the office to help people who come for
information. With the ongoing lack of subsidy, the local authority has now cut the
travel allowance ‘so that he can’t go around and do proper training any more.’ A
clinic sister in a provincial facility gave the example of clinics giving women drugs to
treat their partners for STDs, without ever seeing the partners. She said that they do
not have capacity for the community outreach required to build people’s willingness
to attend a clinic on the request of their partners. In addition, many husbands are
migrant workers, and cannot access the clinic since it is closed on weekends. The
current strategy presumes that women will be able to talk to their partners about STDs
and that, should they broach the subject, their partners won’t assault them or accuse
them of promiscuity.
42
Policy-makers are aware of the neglect of health promotion and are attempting to
include it in the PHC package currently being costed. However, ‘in workshopping the
package many nurses (in particular) said that they would not have time to do much of
this.’ This response reinforces the fact that money alone will not resolve the problem.
Further, exact costing is difficult if not impossible. As a provincial manager
explained: ‘It’s difficult to cost it because some PHC services are not health-specific
in the medical sense of the definition of health… In the minds of many people when
you talk about health services you’re talking about tablets and institutions…
However, there may be programmes that are necessary to intervene at the levels
below those of addressing the symptoms.’
3 CONCLUSIONS
The interviews quoted above give a feel for the experience of health officials who are
involved at different points of the policy-making and implementation process. A
report based on people’s experiences can be seen as biased because each person’s own
interests will influence what they say. But that is one of the important things that this
research can teach us. The way institutions work will affect delivery, and that is part
of what this study looks at. But, on top of that, institutions are made up of people and
relationships. How those people understand the process of change will influence the
way in which policies are made, implemented or ignored. The quality of relationships
within institutions will likewise directly affect implementation
The fear of job losses also influences people’s perceptions. Many people in both
provincial and local government posts are worried about what will happen to them
when integrated districts get off the ground, especially if their employer changes.
Those in larger urban municipalities are currently relatively well paid and secure and
fear that this will change. Those in smaller municipalities fear being taken over by
province, demoted or even retrenched.
This section summarises some of the lessons we can learn from the interviewees.

A strong message from these interviews is that there is ‘transformation
overload’. Many informants feel that ‘change has been too big, too huge, too fast,
too wide’. A key issue is the difficulty of balancing the overall restructuring and
transformation processes with the need to implement rapidly a wide array of new
policies.

Many people report that policy-makers often fail to consider the resource
requirements for implementation. These resources may take the form of money,
skills, facilities or management.

Most people in regions, districts and local government feel disempowered when it
comes to national or provincial policy making and implementing the policies.
All but the most senior provincial officials feel disempowered in relation to
decisions about budgets.

For the most part people seem to be excluded for structural and logistical
reasons, rather than because those at the top want to maintain their power and
43
control. Changes here must fight against long-standing bureaucratic rules and
ways of working.

Transformation will not happen if it is seen as simply a technical change, which
focuses only on systems and structures. Systems and structures are made up of
people, and these people need to change the ways in which they think, act and
interact. The interviews show there are still fairly widespread problems of lack of
communication and mistrust.

Health worker morale and attitudes are a significant impediment to quality
health services. The front-line staff who provide all the new services need to feel
cared for and supported. They need to feel that they can influence decisions in
some way. Only then will they feel inclined to address the needs of those they
serve in a caring way.

Another major obstacle to improved health service delivery is the lack of a
coherent human resource strategy. This contributes to shortages of certain
categories of staff, uncoordinated training programs and associated inability to
redistribute staff between types of health facilities and geographic areas. One of
the results is morale problems because of excessive workload in certain facilities.

Some health services are faced with absolute financial (and other) resource
constraints. Provinces which are largely rural and incorporate the former
homelands have health expenditure levels which are well below the national
average. The implementation of new policies in these provinces is particularly
difficult. Some local government health services face increasing uncertainties
over resource availability, particularly where they are heavily dependent on
provincial subsidies.

However, many interviewees – and the politicians who were not interviewed – are
quicker to talk about the extra resources that are needed, and slower to talk about
what can be cut. There is not enough acknowledgment that the size of the cake is
relatively fixed, and that to get more for one purpose or area there needs to be less
spent on something else. Even where there is recognition of resource constraints, it
has proved extremely difficult to reallocate resources from hospitals, particularly
the more specialist hospitals, to fund improved primary care services. It has also
been difficult to reorganise local level services so as to deliver better quality
services more efficiently.

Resource allocation and budgeting processes are still highly centralised. This is
partly due to lack of financial management capacity at lower levels. But the
financial management systems exacerbate the problem because they do not usually
provide the necessary information.

Many health managers do not have a good understanding of budget-making
principles. Regional, district and health programme managers do not understand
the purpose of guideline allocations. They do not always have a good
understanding of the equity considerations which determine, firstly, how much
they get and, secondly, which should influence how they distribute what they get.
44

Officials are often told that they must make decisions about budgets which, in fact,
can only be changed at the margins because of all the fixed costs. The enormity
of considering the whole budget makes the task more complicated. A more
sensible approach may be to tell officials which part of the budget can feasibly be
changed. This would cut down on the size of their task, and make their decisions
less easy to ignore.

Figure 1 summarises what could be a better way of making decisions about
budgets, from an equity perspective. It suggests, that guideline allocations from
the province would be based on equity targets derived from a needs-based
formula. These could then be modified after consideration of locally developed
plans and budgets.
4
Figure 1: Suggested resource allocation decision-making process
ACTION
Provincial level
1. Determine guideline allocations to regions based on
comparison of needs-based formula targets with
current expenditure, and inform regions.
3. Negotiate with regions, based on needs-based
formula targets (equity objective) and regional plans
and budgets.
4. Make final allocation decision, and inform regions.
Provincial
1
2
3
Region
4
5
Regional level
2. Undertake detailed planning and budgeting within
context of guideline allocation. Present these to
province.
3. Negotiate with province for adequate allocation to
implement plans.
5. Finalise regional plan and budget based on allocation.

Most interviewees are committed to the idea of a district health system, based in
local government. Good cooperation between local government and provincial
health departments seems to occur mainly where local government has well
established health services funded largely through own revenue, i.e. where they are
not heavily dependant on provincial subsidies.

The issue of control over resources is a major impediment to a ‘partnership’
approach. There is great uncertainty in local governments about provincial
subsidies and how the decisions about them are made. There are also multiple, and
in some cases conflicting, lines of accountability for local government health
departments due to multiple funding sources.

There is an ongoing tension between restructuring for integrated delivery of
services at primary level on the one hand, and introduction of new programmes
45
on the other. The system of integrated regional budgeting, for example, does not
fit easily with having separate programmes which require designated funds for
specific activities.

Clinical services always get priority over health promotion and community
participation. At times the reason is given as funding shortages – not having
enough staff to move into communities. But it also reflects the overall orientation
of the health system.
4.1 CONCLUDING COMMENTS
The entire health system is engaged in a process of fundamental restructuring. There
are, inevitably, difficulties. Some of these are being recognised and addressed as
lessons are learnt.
The areas of policy change and implementation which are structural and relatively
technical, such as financial planning or restructuring into districts, appear to receive
greater recognition than the ‘softer’ questions. The latter include health worker buy-in
to the change process, health worker responsiveness to clients, and capacity for health
promotion. These areas need serious consideration if we want equity in the provision
of high quality services to women, men, adolescents and children.
Many, if not all, of the observations and recommendations above are incorporated in
the Health Sector Strategic Framework for 1999-2004 produced by the national
Department of Health in 1999. This document includes the following in the
Department’s ten-point plan:
 ‘Legislative reform;
 Improving quality of care;
 Speeding up delivery of an essential package of services through the district health
system;
 Decreasing morbidity and mortality rates through strategic interventions;
 Improving resource mobilisation and the management of resources without
neglecting the attainment of equity in resource allocation;
 Improving human resource development and management;
 Improving communication and consultation within the health system and between
the health system and the communities we serve; and
 Strengthening cooperation with our partners internationally.’ (Department of
Health, 1999:12).
The challenge now for the national, provincial and local departments of health is to
implement this plan taking into consideration the difficulties experienced in
implementing previous policy proposals.
5
5.1
PART 4: REFERENCES AND ANNEXES
REFERENCES
Brijlal V, Gilson L, Makan B, McIntyre D (1997). District financing in support of
equity: Tender Contract to provide technical assistance to provinces with obtaining
equity in district financing. Report submitted to the national Department of Health.
46
Johannesburg: Centre for Health Policy, University of the Witwatersrand and Health
Economics Unit, University of Cape Town.
Budlender D (1999). ‘Women and the Local Government Budget’ in D Budlender
(ed). The Fourth Women’s Budget. Cape Town: Idasa.
Department of Health (1997). White Paper for the Transformation of the Health
System in South Africa. Pretoria: Government Printer.
Department of Health (1998). Saving Mothers: Report on Confidential Enquiries into
Maternal Deaths in South Africa 1998. Pretoria: Department of Health.
Department of Health (1999). Health Sector Strategic Framework 1999–2004.
Pretoria, Department of Health.
Fonn S and Xaba M (1995). Health Workers for Change: a Manual to Improve
Quality of Care, Geneva: UNDP/World Bank/World Health Organization Special
Program for Research and Training in Tropical Diseases and Women’s Health Project.
Fonn S, Xaba M, Tint KS, Conco D, Varkey SJ (1998a). Maternal health services in
South Africa: During the 10th anniversary of the WHO ‘Safe Motherhood’ initiative,
South African Medical Journal, 88: 697-702.
Fonn S, Xaba M, Tint KS, Conco D, Varkey SJ (1998b). Reproductive health services
from rhetoric to implementation: South African experience, Reproductive Health
Matters, 6(11): 22-32.
Friedman M (1999) ‘Effecting equality: translating commitment into policy and
practice’. Agenda: Translating Commitment into Policy and Practice? Special
Education:2-17.
Gilson L, Doherty J, McIntyre D, Thomas S, Brijlal V, Bowa C & Mbatsha S (1999)
The Dynamics of Policy Change: Health Care Financing in South Africa, 1994-99.
Monograph No. 66, Johannesburg, Centre for Health Policy, University of
Witwatersrand/ Cape Town, Health Economics Unit, University of Cape Town.
Govender P (1999) Women’s access to health care services in the Western Cape.
Research Report No 5. Cape Town: National Association of Democratic Lawyers.
Klugman B (1999). Mainstreaming gender equality in health policy, Agenda:
Translating Commitment into Policy and Practice?, Special Edition: 48-70.
Klugman B (2000). Empowering women through the policy process: the making of
health policy in South Africa. In Presser H and Sen G (eds.) Women's Empowerment
and Demographic Processes: Moving Beyond.Cairo, Oxford University Press,
forthcoming.
McIntyre D, Bloom G, Doherty J, Brijlal P (1995). Health expenditure and finance in
South Africa. Durban: Health Systems Trust and World Bank.
47
McIntyre D, Thomas S, Mbatsha S, Baba L (1999). Equity in public sector health care
financing and expenditure in South Africa. In: Ntuli A (ed.). South African Health
Review 1999. Durban: Health Systems Trust.
Power D and Robbins D (1996). Organisation and Management: Public Sector. In:
Health Systems Trust (1996). South African Health Review, 1996. Durban: Health
Systems Trust and the Henry J. Kaiser Family Foundation.
Statistics South Africa (1998). The people of South Africa. Population Census, 1996.
Census in Brief. Report No. 1: 03-01-11 [1996]. Pretoria: Statistics South Africa.
Stevens M (1997) ‘Health’ in D Budlender (ed) The Second Women’s Budget. Cape
Town: Institute for Democracy in South Africa:286-313.
Stevens, M (1998) Factors impacting on the development of a pregnancy termination
Bill. Masters of Management, Faculty of Management, University of the
Witwatersrand.
Tollman S, Rispel L (1995). Organisation, planning and management. In: Health
Systems Trust (1995). South African Health Review, 1995. Durban: Health Systems
Trust and the Henry J. Kaiser Family Foundation.
Walt G and Gilson L (1994) ‘Reforming the health sector: the central role of policy
analysis’ in Health Policy and Planning 9(4): 353-370.
5.2
ANNEX 1: PEOPLE INTERVIEWED
Seokemong Absalom, Clinic supervisor, Galeshewe, Northern Cape
Nafiesa Akharwaray, Deputy Director Financial management, Northern Cape
Mr AJ Britz, Acting Chief: Health Services, Kimberley Local Council, Northern Cape
Mr Buchanan, Acting Manager of Environmental Health Services, Kimberley Local
Council, Northern Cape
Elias Chokoe, Acting head of health care services, Chief Pharmacist, Moletji Matlala
District, Northern Province
Baski Desai, Specialist Post in Chief Directorate District Health Services, Gauteng
Yvonne Holden, Sister in charge of Kuruman clinic, Northern Cape
Mariana Loots, Assistant Director Diamond Fields Region, Northern Cape
Marian Loveday, Regional health manager, Northern Cape
Essina Mabitsela, Deputy Director Mother, child, women’s health, reproductive health
and genetics, Northern Province
Carvie Madikane, Deputy Director Maternal child and women’s health, Northern
Cape
Hlamalali Nellie Manzini, Regional Director, Central Region, Northern Province
Carol Marshall, Chief Director Strategic Development, Gauteng
Natalie Mayet, Executive Officer for Commmunity Health, South Local Council,
Gauteng
Rose Mazibuko, Chief Director PHC, Northern Province
48
Dr Mjekevu, Head of Department for Health, Kempton Park Tembisa Metropolitan
Local Council, Gauteng and representative of SALGA to national department of
health District Health System Task Team.
Greg Munroe, Executive Director, Community Services, South peninsula
municipality, Western Cape and SALGA representative on National Department
of Health Provincial Health Restructuring Committee
Lydia Ndhliwayo, sister, Messina local authority clinic, Northern Province
M J Netshilindi, Deputy director PHC, Northern Region, Northern Province
Yogan Pillay, past Director: Policy Analysis and Planning Unit, National Department
of Health; now Deputy Director: National Expansion, the Equity Project
Phillip Rousseau, Chief Health Services, Messina Transitional Local Council,
Northern Province
Mmipe Saasa-Modise, Director Mother, child health and nutrition, Gauteng
Doreen Senokoane, Deputy Director Reproductive health, Gauteng
Johan Swanepoel, Head of Community Health Services, Pietersburg Transitional
Local Council, Northern Province
Alex van den Heever, Financial manager, Gauteng
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