1. City of Cape Town DIRECTORATE: CITY HEALTH Primary Health Care Presented by: Dr Ivan Bromfield Executive Director: City Health

2. Content Context in the metro Some selected outcomes Mandate City Resources Challenges Discussion on Way Forward

3. EIGHT

4. Context in Metro There are two authorities responsible for PHC i.e. City Health and Metro District Health Services (PGWC) Have agreed on cooperative management structures i.e. a District Executive (DEX) and eight Integrated Sub-district Management Teams (ISDMTs) Have developed: Joint District Health Plan - Includes a District Health Expenditure Review (DHER) and the setting of joint priorities, programmes and targets. Signed Service Level Agreement dealing with current funding arrangement for clinic services. Provincial Act on the establishment of a District Health Council – still to get operational date proclaimed Established Metro Health Forum (community structure) but the framework in which it should operate has yet to be approved by the Provincial Health Council.

5. Infant Mortality Rate Babies dying < 1 yr of age, out of 1,000 live births

6. Cape Town: % of births to women <18yrs 2007-2009

7. Cape Town Metro: STIs-New, 2004-2010

8. Male Condom distribution, 2004-2010 (millions) This looks good, but…

9. Male Condom distribution, 2004-2010 (millions) We set stretch targets: 2 condomsX52 weeks=104 condoms/male >15yrs/year

10. TB Case-finding and New Smear+ Cure Rate

11. Get tested & HCT campaigns

12. How do we get it right? Decentralized management – 8 Sub-Districts Flat structure (few managerial levels) Integrated approach: personal & environmental health fall under same SD Manager maximise collaboration (not separate divisions) Management systems and processes geared for service delivery on the ground. Lean middle management with a strong sense of purpose and skills in project & change management. Flexibility, innovation and creativity encouraged. Lots of horizontal networks and communication opportunities for adoption and transfer of innovation Culture of using information for action: structured quarterly Plan-Do- Review meetings Extensive feedback and staff recognition (award ceremonies) Investment in partnerships: Academia, researchers, NGOs/NPOs

13. Mandate Our Mandate Constitution LG competencies of Municipal Health Services (MHS), Air Pollution, Business Licensing & Noise Pollution Health Act Personal Primary Health care (PPHC) – dealt with in terms of a signed SLA with Provincial Government Health Department – continue to improve cooperation and SLA Other legislation By-laws Environmental Health By-law Air Pollution Control By-law (was adopted by Council in 31 March 2010 and was gazetted in August 2010) Health Responsibility of 3 spheres of Government

14. Organisational Aspect Eight sub-districts " City Health is responsible for public health in the City of Cape Town. Our services are delivered on the WHO District Health System (DHS) model which means that we have divided the City into 8 subdistricts (service delivery areas) i.e. Southern, Western, Northern, Eastern, Khayelitsha, Mitchells Plain, Klipfontein and Tygerberg. Across the City there are: 93 clinics, 18 satellite clinics and 6 mobile clinics (NB: clinic services delivered in partnership with PGWC metro district health services who run 47 Community Health Centres) Approximately 104 Environmental Health Practitioners delivering a decentralised service to the 8 sub-districts. Air Quality Management Unit - responsible for 7 monitoring stations spread across the City (Bothasig, City Hall, Drill Hall, Goodwood, Khayelitsha, Molteno Reservoir, Killarney.) This service is done in partnership with Scientific Services who have a monitoring station at Athlone."

15. City Health Resources 2009/2010 Financial Year OPEX: R 666,723,341 – Spend 98.5% CAPEX: R 26,313,979 – Spend 97.2% STAFF: – 1,438

16. Increasing Burden of Disease and patient numbers with no additional resources (staffing & opex) Increasing costs of pharmaceuticals and laboratory tests above parameter budget increases Uncertainty over governance of PHC (clinic services) Current issues Relationship strain Staff burn out. Challenges

17. PHC at Sub-District Level Tertiary & specialized hospitals District Hospitals: More serious medical conditions Increased admissions Increased costs: both to services & patients MDHS Community Health Centres: Doctor intensive, more complex Misuse of scarce staff resources: nurse clinical skills underutilized Fragmentation & duplication Increased service costs Poor efficiency & effectiveness City PHC Facilities Providing variable packages of care with serious omissions Nurse-based, without daily doctor support – reduces the package Patient delays due to difficulty in accessing PHC services Clinical deterioration, unnecessary increased morbidity & mortality Staff stress, anxiety, fatigue, absenteeism & attrition Smaller and easier to manage Public confusion, Dissatisfacti on, lack of trust Public by- passing the PHC system Worsening community health status Resources not where they are most needed & difficult to shift them Two authorities more costly and doesn't facilitate seamless service provision No political will to resolve the situation Healthy City for All vision not fulfilled MDGs will not be met

18. PROBLEMS TO ADDRESS Resources shortage to be resolved Assessment of staff shortages at the various CoCT sites Within resource constraints, prioritization of 1-2 problems per sub-district to be addressed every year Exclusion from strategic positioning Strategic planning discussion /sessions to be implemented at CoCT Develop a focussed plan of action Health Care 2020 to acknowledge and include the presence of CoCT, until such time that it ceases to provide PHC. Organizational culture Develop assertiveness Withdraw from toxic relationship with MDHS sub- structures Negotiate harmonization of services with MDHS Each authority to be responsible for own improvement plans and accountable for own performance results At PDR, HCT meetings, etc each authority to be questioned separately for own performance in relation to targets Resolve the funding strategy problems CoCT financial contribution from rates and taxes to be increased PGWC criteria for disbursing funds between the 2 authorities to be made available Or funding to come directly from National to CoCT Update of total transfer payments to CoCT

19. Principles in favour of Local Government Providing PHC PHC approach demands that communities be meaningfully involved in controlling its own health services. LG is the democratically elected local representatives of the community. Multi-disciplinary and intersectoral approach - Will lose link with hard engineering services (Water, Sanitation, Solid Waste) City currently renders a very effective clinic services component of the PHC package City currently contributes to the provision of clinic services from rates. If clinic services were to be under the authority of PGWC they would have to identify additional funding to cover this gap as this income from rates would be lost to clinic services. The reality is that the fundamental issue revolves around funding. If LG could obtain funding directly from National to make up the funding gap, the City would then still be in a position to contribute additional funds over and above this towards PHC from rates.

20. We need to understand what local government should be doing as guided by the principles of the Constitution, the Systems Act and the Structures Act. It is a sphere of government in its own right which must provide basic services and be developmental in nature. The matter should be looked at from a developmental service delivery aspect based on the needs of the community – NOT just a unfunded mandate perspective. Based on what local governments objectives are as outlined in the Constitution and the two Acts we should be asking: What should we be doing for PHC? What is our role in cross cutting matters? Who should be responsible for funding of PHC? Approach to Way Forward

21. Way Forward There is general agreement that health services in the country should be based on the Primary Health Care (PHC) approach, and that public health services should be organised in terms of the DHS model. Municipal health services (MHS) is defined in the Act and a high court decision in April 2008 concluded that the definition is, capable of a construction that incorporates such primary health care services as municipalities provided before the Act came into force. The relevant MEC must assign such health services to a municipality in his or her province in terms of section 156(4) of the Constitution i.e. if that matter would most effectively be administered locally and the municipality has the capacity to administer it. From the above it is clear that the legislation allows for the City of Cape Town to render PHC in its broader sense as opposed to the narrow environmental health interpretation of MHS.

22. Conclusion There must be active engagement with those metros who indicate a willingness to offer PHC services involving all three spheres of government.

23. Thank You