Municipal Health Services The Local Government Perspective Eastern Cape Example
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Municipal Health ServicesThe Local Government PerspectiveEastern Cape Example
SALGAConsultative Meeting on Municipal and Primary Health
Care (Discovery Auditorium, Sandton)08 April 2011
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Background
Legislative framework Constitution (Act 108, 1996)– Schedule 4B Local Government: Municipal Structures Act
(Act 117, 1998) – S84(i) National Health Act (61 of 2003) – Definitions &
S32(1) MINMEC decision – MHS and who should
render DORA Bill, 2006 – MHS – “Basic Service”
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Introduction
SALGA requested the Eastern Cape to present on
our experience with the devolution of MHS
Eastern Cape one of the poorest provinces
The province consists currently of one Metro
(NMMM) and 6 District Municipalities
One aspirant metro (Buffalo City)
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Governance arrangements
ECDoH facilitated and coordinated the Provincial Environmental Health Devolution Task Team (PEHDTT) - 2003 Chairperson of PEHDTT– alternated between ECDoH and LG. Consisted of Metro, DM and ECDoH environmental health
management Working Committees established to collect data
Also established District EH Devolution Task Teams at each DM and Metro Consisted of Local Government and Provincial EHPs Union representatives (Local Government & Government) Directors / Managers to whom EHPs report Politicians (Ad hoc feedback) Reported to District Management Team (ECDoH); Top
Management and Standing Committee and PEHDTT. ECDoH – reported to PHAC and PHC and subsequently to Parliament
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Initial process
PEHDTT’s Working Committees collected data necessary
for the devolution of MHS e.g. Staff information; available
equipment.
Invited DWA – Share best practice with integration of
water function to the WSAs
Invited Unions (Government) and the Bargaining Council
to inform them and to get direction – S197 of LRA -
Medical Aid and Pension fund issues.
Regular PEHDTT meetings from 2003 till 2006 –
Aeroplane
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Challenges
No further substantial progress with ECDoH – irregular meetings
Numerous national due dates were set for devolution (2004 then 2006 and the latest was April 2010) which resulted in: Provincial colleagues resigning – prolonged devolution
process. JGDM – 45% Provincial EHPs resigned in 18 months ADM – 5 Provincial EHPs resigned in one month
Provincial EHPs not benefiting from car allowances etc. >90% EHPs are without transport
Lack of establishment cost for provincial staff Provincial staff mostly without transport and equipment
Lack of an exit strategy from DoH such as DWAs.
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Challenges (Cont. 1)
LG cannot populate organisational structures – wait for provincial staff
Shortage of EHPs at LG, services that are not properly structured and little to no growth opportunity for EHPs at DMs leads to frustration from LG’s own staff - JGDM 83% EHP staff turnover in past 5 years
Environmental health not regarded as priority Support from authorities Governments strategic monitoring of basic services – “Turn
Around Strategy” – LGTAS – did not reflect on MHS – weekly monitoring (R 1; R 2; New conservancy).
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Challenges (Cont. 2)
Ratio of EHP per population (SA - 1:15 000) (WHO – 1:10 000) – Attitude of Management – can never have the ideal situation.
(Community Service EHPs – National Programme) – No transport, office accommodation, some accommodated without skilled EH support
Sustainable funding beyond 3 year funding from ECDoH (2009/10)– National Treasury model (MHS not income generator)
Equitable Share (Basic Services) not ring-fenced for EH – R2m only received R200k internally.
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Results
After 2006 lack of progress through ECDoH, we resorted to SALGA EC
Meetings with MEC for Health and LGTA National surveys on the progress with the devolution of
MHS – 2006 and DBSA, 2007 – Presented at national forums – give momentum.
Interaction with National Treasury – costing Department Housing, Local Government and Traditional
Affairs made funding available - S78 municipal capacity assessments (R280 – R300k)
Follow up PEHDTT – Workshops (Nov 2009) Service Level Agreement ECDoH – funding – 3 years at 100% (2006/07 till 2008/09) Funding and transfer of staff not synchronised
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Results (Cont.)
Presentations to SALGA EC resulted in buy-in SALGA EC – MHS Working Group established
Elevate to SALGA National SALGBC – 2010 - Working Group
Special Resolution submitted to April 2010 Local Government Summit
Appointment of permanent National Environmental Health Director Interaction at national level between DoH; COGTA and National
Treasury Functional integration initiatives between LG and ECDoH to use
provincial staff locally. ECDoH – negotiated with individual DMs for transfer A few DMs in advanced stage to receive provincial EHPs by 1 July
2011.
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Recommendations
Develop a proper devolution framework and monitor its implementation.
COGTA should be more strategic – Municipal Turn Around Strategy (LGTAS) – focus on “basic services” but it does not reflect MHS
Do such surveys on a regular basis also for MHS – include legal requirements such as S78 capacity reports; budgets, inclusion of MHS in IDP, ornanisational structures and vacancy rates; progress with devolution and integration of MHS at DMs and Metros, etc.
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Recommendations (Cont.)
Use and understanding of terminology which negatively affects Environmental Health / Municipal Health Services Health Services Environmental management
Facilitate a proper national costing study for MHS – National Treasury challenges our figures.
Clarify the use and preparedness of LG for accepting and managing Community Service EHPs.
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“Usana olungakhaliyo lufela embele kweni”
CLAIM YOUR SPACE!!!!
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Support for Municipal Health Services from National and Provincial Structures
InstitutionGood % Average % Poor %
EC Nat EC Nat EC Nat
NDoH 0 0 17 24 83 68
PDoH 33 24 17 44 50 29
DPLG 17 9 33 18 50 65
SALGA 0 3 17 21 83 53
SAIEH 0 3 67 32 17 59
Unions 17 24 17 24 33 34
Source: National devolution progress surveys - January and July 2006 and DBSA survey, 2007
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Eastern Cape Province in relation to South Africa
MUNICIPALITIES Metropolitan = 6
District = 46
Local = 229
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National EH Indicators – George, October 2004
Monitoring the Impact of MHS Policy Implementation January 2005
Financing EHS in SA May 2004
MINMEC Decision 21 August 2003
National Summit Polokwane May 2004
2 year transitional period
SALGA: Workshop on MHS March 2005, JHB
Draft National Environmental Health Policy October 2004
DBSA Development Dialogue on MHS, Midrand , March 06
9 October 2002 Cabinet decision
1 July 2004 Implementation
date
1 July 2005 First Municipalities
taking over functions
Developments with regard to the interpretation and implementation of MHS in South Africa since the Cabinet decision that EHS will be MHS and the function of Metropolitan and District Municipalities from 1 July 2004.
National Framework for the Devolution of EHS in SA – Implementation Strategy, March 2004
FFC Submission: Financing PHC and EHS in SA August 2004
SAIEH Conference – Municipal Health Services Feb 2006
MHS Conference, East London 28-30 November 2006
Time Line
Seminar on Implementing MHS, July 2006, Pretoria
DBSA Research, Delivery of MHS by DMs in SA, July 07
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JOE GQABI DISTRICT MUNICIPALITY
Municipal Health Services March 2008
41%
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Progress with the devolution/consolidation of MHS (New or extended service – Municipal Systems Act)
VariablesEastern Cape %
National %
Section 78 assessment undertaken 100 60
Approved S. 78 report 83 23
DMs Service Level Agreement with LMs 67 13
MHS part of Integrated Dev. Plan 83 60
MHS budgeted for 2006/07 100 27
Integrated Multi year budget approved 100 21
DMs take transfer of staff from LMs 40 27
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Sewerage pump station
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Sewerage Balance Drain – Engineering solution - >10 years
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New Sewerage Pumps – 6 months after transfer of LM EHPs to DM
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Sewerage spills in communities
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Sewerage spills monitored weekly by EHPs
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Broken sewerage connections – Who cares?
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Politicians, Engineers and communities want structures.
MHS/EHS concerned with operations not causing a health hazard
to communities to prevent illnesses from occurring – sometimes
conflicting – substandard facilities.
Damage to infrastructure - maintenance
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Housing development: Quality of Workmanship
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Condition at landfill site – lack of control and management
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Infrastructure damaged due to a badly managed landfill site
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Local municipal workers offloading waste in non demarcated area on landfill site
MHS monitors and compliance enforce as part of pollution control and waste management
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each year at least 3 million children under the age of 5 die due to environmental related illnesses
90% of Acute Respiratory Infections world wide
80-90% of Diarrheal cases -contaminated water and inadequate sanitation.
90% of malaria cases are attributed by environmental factors
Millennium Development Goals??
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After 6 years of continued monitoring by EHPs – improved sewerage system – only clean for 2 months – Honey sucker services terminated – EHPs frustrated – what is my role and purpose?
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Current cost of MHS – 2009/10
Expenditure Income Balance
Alfred Nzo DM 12,176,334 5,659,000 -6,517,334
Amatole DM 22,818,963 14,069,196 -8,749,767
Cacadu 11,402,877 4,741,000 -6,661,877
Chris Hani DM 23,818,521 11,400,000 -12,418,521
OR Tambo 19,749,963 20,779,000 1,029,037
Joe Gqabi DM 10,225,788 5,208,487 -5,017,301
NMMetro 29,162,483 13,726,000 -15,436,483
Buffalo City (Metro) 22,767,107 10,674,804 -12,092,303
152,122,037 86,257,487 -65,864,550
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Future funding implications Eastern Cape - Shortfall
2009/10 2010/11 2011/12 2012/13
Expenditure 152,122,037 166,573,630 182,398,125 199,725,947
Income 86,257,487 86,257,487 86,257,487 86,257,487
Shortfall -65,864,550 -80,316,143 -96,140,638 -113,468,460
Per Capita Cost R23.58
Per Capita Income R13.37
Balance -R10.21
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Equitable Share Allocation for MHS - Prediction to Reach R13/head
R -
R 2.00
R 4.00
R 6.00
R 8.00
R 10.00
R 12.00
R 14.0020
06/0
7
2008
/09
2009
/10
2010
/11
2011
/12
2012
/13
2013
/14
2014
/15
2015
/16
2016
/17
2017
/18
2018
/19
Financial Years
Per C
apita
R -
R 10.00
R 20.00
R 30.00
R 40.00
R 50.00
R 60.00
Per H
ouse
hold
Per Capita Cost NDoH Equitable Share per Household
5 – Yrs - DoH
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Per Capita and Household Income and Expenditure for 2009/10 – MHS
0102030405060708090
100110120130
Income Cost Equitable Share
Per Capita and Household Income and Expenditure: MHS - 2009/10
Per Capita Per Household NDoH Target
NDoH – proposal – HST costing study