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					UPDATE ON
District Health and Welfare System (DH&WS) Development in the

NORTHERN PROVINCE
Issue No.1 September 1998
The purpose of this newsletter is to inform health workers in the Northern Province about developments in the district. It has been produced by the Provincial Health and Welfare department in partnership with the ISDS (Initiative for Sub-district Support), which is a program of the Health Systems Trust.

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Why Do We Need Changes in the Health and Welfare Service Delivery System?
The District Health and Welfare System has been accepted by the Government as the way to bring about quality primary health care and welfare services.

Why is it the best system? Problems with the way health care has been provided: • In the past, health and Welfare services were provided to people who came
to the clinic or out patient department, but no-one knew if these services reached everyone who needed care. Primary Health Care was provided by a number of different departments like local authorities and the provincial health department. Different clinics offered different services on different days. This system was inefficient and treated symptoms, rather than people! We need to integrate our services into a system that reaches everyone who needs care, caters to all their needs and is provided in a way which suits the local conditions. • In our area, big decisions about health care and welfare were made by managers at national or provincial level. These higher level managers appointed and dismissed local staff, decided how money for health and welfare services was spent and they planned how new services would be delivered. This meant that local people had little say in who was appointed or dismissed, how money was spent and how services were delivered. We need to create a system in which health workers, who know about the local needs, have some control over the budget and what it is spent on, and have a say in decision making. • People who received health and welfare services often had no say about the services and how these were delivered. They were not able to say what they were dissatisfied with and why, and were not able to help in planning and implementing the services. We need a system which involves people in improving the services so that these cater to local needs, and in which people can make health care providers aware of any problems they are experiencing in the service. • Like many sections of the civil service, large bureaucracies have developed in health and welfare service management and administration. This means that there is a lot of paper work and meetings. But does this actually improve the quality of services? District health and welfare system aims to move away from administration being the focus to a system where the focus is on actually improving the quality of health and welfare services that is provided to all.

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Districts in the Northern Province

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• The Northern Province is divided into 7 regions to assist with the decentralisation process to districts. There are 25 health and welfare districts in the province. These are shown on the map. The criteria to define the boundaries of these districts was to have rational, manageable service delivery units, with roughly similar population size, and equitable resource distribution. • Most government departments in the Northern Province have agreed that district health and welfare boundaries are rational service delivery units - Ms Rose Mazibuko did all the negotiations in the first quarter of the year 1998.

The Staff Establishment Structure of the District Health and Welfare System in the Northern Province

The provincial health and welfare management has visited the health and welfare departments of other provinces and other neighbouring countries like Botswana. A lot was learnt from seeing how they have set up their districts. Using what was learnt and taking into account the resources which are available, a new structure for the district health and welfare service was outlined. This new structure is shown in the form of an organogram below. This structure means that the following changes will take place: The district management • certain district hospital and regional office management functions be moved to the district office. • a Chief Executive Officer of the district will be appointed. His/ her responsibility will be to ensure that health and welfare services are managed efficiently and effectively. His/ her functions will include the co-ordination of services and the liaison with all role players. The Chief Executive Officer will also be responsible

Chief Executive Officer (Deputy Director Admin) Administration clerk Grade 1

PHC services

Developmental Social Wefare

Social Security Services

Finance and Administrative Services

Human Resource Management

Technical Support and Quality Assurance

District Hospitals

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for all health and welfare functions in the district, including the District Hospitals. • The budget for all district services will be handled by the District Office. The District Office will therefore have more responsibilities. The Regional Office will decrease but it will continue to provide support, supervision and advise when necessary. It is expected that the Regional Office will be done away with in the long term. The District Hospital management • a Chief Executive Officer who does not necessarily need to be a medical doctor. • a Head of the Clinical Section who will be a medical doctor • a Head of Nursing • a Head of Administration

• a computerised staff establishment indicating number of posts was produced • Health workers presently employed by the Department of Health, who were suitable for the different positions, were identified as potential candidates for these posts. They were placed (in pencil) onto the computerised staff establishment. • The post of CEO was advertised internally • A short list was compiled from applications by the provincial management • Interviews of the applicants for the CEO post were conducted in July 1998.

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Piloting Districts in the Northern Province

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Principles:

The Process of District Staffing

The Initiative for Sub-district Support ( ISDS ) a project of the Health Systems Trust, is working in partnership with the National and Provincial Department of Health to pilot implementation of the new system in the Haenertsburg/Tzaneen/Letsitele-Gravelotte (Halegratz) and the Ngwaritsi-MakhuduThamaga-Tubatse-Steelpoort (NMTTS) districts. The purpose of the project is to help improve the quality of district-based primary health care nationally by focusing effor t and expertise in selected pilot sites throughout the country. The purpose of this is to demonstrate how the provision of systematically planned support which uses a bottom-up approach can be an effective mechanism in improving the delivery of health and welfare services. The support strategies include training, building management capacity, developing appropriate management and communication systems, conducting health systems research and supporting information based health and welfare planning.

Staff will be appointed either at Hospital level or Community level. The District CEO has the authority to allow movement of staff within the district but movement between different districts and regions will be considered as a formal transfer and will require the completion of the relevant application forms and approval by the relevant office. The Provincial management decided to pilot the implementation of the staff establishment in the Haenertsburg/Tzaneen/ LetsiteleGravelotte (Halegratz) on the 18th of March 1998. The steps in the process of staffing the Halegratz district were: • a report on the organisation and establishment was submitted to the Director -General of the Province in August 1997 and approved.

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The wide objectives of the ISDS is to act as a support agent to the Department of Health and Welfare by: • deliberately and systematically addressing factors which affect the standard of care at local level • support and strengthen the capacity of both public sector and non-governmental health providers to render effective services • strengthen the capacity of communities to participate in governing and managing health and welfare services. • harnesses technical resources, both local and distant, to support health and welfare systems reform at local level

In the rest of the 24 districts, circulars advertising the post of the District CEO have been sent to various institutions. The closing date for applications was the 30 June 1998 and appointments will be made after interviews have been held. All Regional Offices have the task of filling posts in the districts using the same process that was used in the Halegratz district. The appointment of District management is a big step in the development of districts in the Northern Province because it is the beginning of the implementation process which will improve of the delivery of quality health and welfare services even in the most remote under resourced village of the province.

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Looking Ahead

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Dr. N. Crisp Ms N. Manzini

Important People

Superintendent- General Director Primary Health Care/ DHWS Ms R. Mazibuko Chief-Director Primary Health Care/ DHWS

Any suggestions, question or comment? Please write to: P.O. Box 544 Medunsa 0204 Fax: 012 - 5494951 or Health Systems Trust 504 General building Cnr Smith & Field Streets Durban Fax: 031 - 304 0775

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