1. SOUTH AFRICAN EXPERIENCE, IMPLEMENTATION OF DISTRICT HEALTH SYSTEM CAMBRIDGE INTERNATIONAL HEALTH LEADERSHIP PROGRAMME, 21 – 28 APRIL 2004

2. ABOUT SOUTH AFRICA POPULATION SIZE: 45 Million 9 provinces, and 9 provincial departments of health, each with health minister Public sector dependent population: 82% Area (square km): 1 219 090 Population density (people per sq km): 34.4 GDP on Health: 7,4%

3. DISTRICT HEALTH SYSTEM (DHS) AND PRIMARY HEALTH CARE (PHC) 1.DESCRIPTION OF POLICY: Provision of primary health care through health districts which are co – terminous with boundaries of municipalities. 2.OBJECTIVES Provision of comprehensive primary health care package through the DHS. Development of district health plan that is part of Integrated development plan of the municipality.

4. OBJECTIVES CONTINUED Management of effective non – hospital PHC as close to the community as possible, to ensure local accountability. Joint funding from municipalities (local govt) and provincial health department. A single health budget with clear budget lines/components.

5. IMPLEMENTATION District management teams put in place consisting at least of District manager, & managers for Community Health Services and for Administration. Put district hospital under control of district manager, to ensure that it becomes part of DHS, and supports clinics and health centers. Governance structures put in place - clinic committees and district health forums. Classification of each district as cost centers for good financial management.

6. WHAT WENT WELL Reduction of burden on hospitals – community awareness about role of non – hospital/PHC. Community participation, through governance structures became more pronounced. Financial accountability improved resulting from creation of cost centers. A health information system that supports DHS successfully implemented. Clinics and health centers benefited from support provided by district hospitals.

7. WHAT CREATED DIFFICULTIES The policy on DHS was not supported by passing of supporting national legislation. Resulting in inconsistencies - each province introducing own legislation. Disparate approaches btw provincial health departments and municipal government - functional integration has not been fully achieved. Appropriately costed funding of PHC has not been fully achieved. District Health Expenditure reviews have been recently introduced.

8. LESSONS LEARNT? Where policy is not supported by a legislative framework, this creates implementation difficulties. Communication of policy is as important as policy development itself – impacts on effectiveness of implementation. Management capacity to implement policy is integral to success. Costing of policy initiatives should precede or at least accompany implementation.

9. END – THANK YOU.