RHD Prelude Chapter - Health Systems Trust

UNDERSTANDING THE IMPACT
OF DECENTRALISATION ON
REPRODUCTIVE HEALTH
SERVICES IN AFRICA
(RHD)
South Africa Report
Wendy Hall and Jaine Roberts

UNDERSTANDING THE IMPACT
OF DECENTRALISATION ON
REPRODUCTIVE HEALTH SERVICES IN AFRICA
(RHD)
Contract: C4-CT-2002-10028
SOUTH AFRICA REPORT
November 2006
WENDY HALL and JAINE ROBERTS
Published by Health Systems Trust
ISBN: 1-919839-57-7
401 Maritime House Tel: 27 – 031 – 307 2954
Salmon Grove Fax: 27 – 031 – 304 0775
Victoria Embankment
Email: hst@hst.org.za
Durban, 4001
Web: http://www.hst.org.za
Citation: Hall, W. and Roberts, J. (2006) Understanding the Impact of Decentralisation on
Reproductive Health Services in Africa: South Africa Report. Durban, Health Systems Trust.
The information contained in this publication may be freely distributed and reproduced as
long as the source is acknowledged, and it is used for non-commercial purposes.

Contents
Figures and Tables
Abbreviations and Acronyms
Acknowledgements
Executive Summary
Chapter 1: Introduction
1.1 The Research
1.2 Decentralisation and reproductive health in South Africa
1.3 Methodology
1.4 Constraints
1.5 Structure of the report
Chapter 2: Context of Decentralisation and Reproductive Health
Services in South Africa
2.1 Introduction
2.2 National
2.2.1 Economic
2.2.2 Political
2.2.3 Social
2.2.4 Health Care System
2.3 Provincial
2.3.1 Economic
2.3.2 Political
2.3.3 Social
2.3.4 Health Care System
2.4. Local
2.4.1 Klerksdorp
Economic
Political
Social
Health Care System
2.4.2 Mafikeng
Economic
Political
Social
Health Care System
2.4.3 Ganyesa
Economic
Political
Social
Health Care System
05
11
14
15
25
25
26
28
30
30
32
32
32
40
48
50
57
66
02

03
Chapter 3:
Health Systems Decentralisation in South Africa
Chapter 4: Reproductive Health Services in South Africa
4.1 Introduction
4.2 National
4.3 Provincial
4.4 Local
4.4.1 District A
4.4.2 District B
4.4.3 District C
Chapter 5: Districts – Context, Decentralisation, Intermediate
Processes and Reproductive Health Services
5.1 Introduction
5.2 District A
5.3 District B
5.4 District C
Chapter 6: Service Organisation and Delivery
6.1 Introduction
6.2 Prioritising
6.3 Targeting
6.4 Service Packages
6.5 Standards
6.6 Contracting
Chapter 7: Finances
7.1 Introduction
7.2 Health District Funding
7.3 Health District Budgeting
7.4 Health District Expenditure
Chapter 8: Human Resources
8.1 Introduction
8.2 Public service arrangements and conditions of service
8.3 Jobs
8.4 Hiring and firing
8.5 Supervision
8.6 Training
8.7 Performance management
8.8 Staff attitudes
8.9 Professional relations
78
97
97
99
106
108
111
126
141
170
170
171
173
175
182
182
182
183
183
185
185
188
188
200
202
207
216
216
220
224
224
225
228
239
239
248

Chapter 9: Planning, Monitoring and Evaluation
9.1 Introduction
9.2 Planning processes
9.3 Information systems
9.4 Monitoring and evaluation
Chapter 10: Governance
10.1 Introduction
10.2 District governance structures and processes
10.3 Community involvement
10.4 Intersectoral collaboration
10.5 Public – private relations
Chapter 11: Logistics and Referral
11.1 Introduction
11.2 Drug supplies
11.3 Transport and ambulances
11.4 Laboratory services
11.5 Infrastructure and maintenance
11.6 Referral system
Chapter 12: Discussion and Conclusions
12.1 National provincial context
12.2 Local context
12.3 Dispersions and linkages
12.4 Human Resource Management
12.5 Finance
12.6 Logistics
12.7 Capacity
12.8 Governance
12.9 Conclusion
Appendix:
Table Analysis of Policy and Legislation for
Decentralisation and Reproductive Health Services
251
251
252
255
259
262
262
262
273
285
288
289
289
289
297
300
304
309
319
319
320
321
323
324
325
325
326
327
328
04

x
List of Figures
05
Figure 2.1
(a) (b) (c):
Sections of National Department of Health Organogramme – to show relationship
between District Health System and Reproductive Health Services (pg 75, 76)
Figure 2.2: North West Province Population Pyramid – 2001 Census (pg 43)
Figure 2.3: North West Province - Population by Racial Group - 1996 and 2001 Census
(pg 44)
Figure 2.4: North West Provincial Department of Health Organogramme (pg 45)
Figure 2.5: North West Province - Relationship between management systems in Health
Districts (pg 77)
Figure 2.6: North West Province - Health District Generic Organogramme (pg 49)
Figure 2.7: Klerksdorp Local Municipality - percentage households per income bracket in
Rands - 1996 and 2001 Census (pg 51)
Figure 2.8: Klerksdorp Health District Population Pyramid - 2001 Census (pg 53)
Figure 2.9: Klerksdorp Health District - Population by Home Language - 1996 and 2001
Census (pg 54)
Figure 2.10: Klerksdorp Health District - Population by Racial Group - 1996 and 2001 Census
(pg 55)
Figure 2.11: Klerksdorp Health District - CHC and clinic nursing staff working days - 2000
to 2003 (pg 58)
Figure 2.12: Mafikeng Local Municipality - Percentage households per income bracket in
Rands - 1996 and 2001 (pg 59)
Figure 2.13: Mafikeng Health District - Population Pyramid - 2001 Census (pg 61)
Figure 2.14: Mafikeng Health District - Population by Racial Group – 1996 and 2001 Census
(pg 62)
Figure 2.15: Mafikeng Health District - Population by Home Language – 1996 and 2001
Census (pg 63)
Figure 2.16: Mafikeng Health District - CHC and clinic nursing staff working days - 2000 to
2003 (pg 66)
Figure 2.17: Ganyesa Health District (Kagisano and Molopo Municipalities) - Percentage
households per income bracket - 1996 and 2001 Census (pg 67)
Figure 2.18: Ganyesa Health District Population Pyramid - 2001 Census (pg 69)
Figure 2.19: Ganyesa Health District - Population by Racial Group - 1996 and 2001 Census
(pg 70)
Figure 2.20: Ganyesa Health District - Population by Home Language - 1996 and 2001 Census
(pg 70)
Figure 2.21: Ganyesa Health District - CHC and clinic nursing staff working days - 2000 to
2003 (pg 73)

Figure 4.1: Generic Health District Organogramme (pg 111)
Figure 4.2: Klerksdorp Health District - Use of Contraceptives: 2000 to 2003 (pg 114)
Figure 4.3: Klerksdorp Health District - Ante-natal clinic attendances - 2000 to 2003
(pg 115)
Figure 4.4: Klerksdorp District Live Births in Hospital and Clinic; and percentage deliveries
in clinics - 2000 to 2003 (pg 115)
Figure 4.5: Klerksdorp Hospital - Percentage deliveries referred to hospital from Klerksdorp
Clinics and from outside Klerksdorp Health District - 2000 to 2003 (pg 116)
Figure 4.6: Klerksdorp Health District - Clinic births, referrals to hospital and referral rate
- 2000 to 2003 (pg 117)
Figure 4.7: Klerksdorp Health District - total deliveries and teenage pregnancy rate - 2000
to 2003 (pg 118)
Figure 4.8: Klerksdorp Health District - Number of sexually transmitted infections at PHC
clinics - 2000 to 2003 (pg 119)
Figure 4.9: Klerksdorp Health District - Maternal Mortality Ratio, Peri-natal Mortality Rate
and Neonatal Mortality Rate - 1996, 2000 to 2003 (pg 120)
Figure 4.10: Mafikeng Health District - Use of Contraceptives - 2000 to 2003 (pg 128)
Figure 4.11: Mafikeng Health District - Antenatal clinic attendances - 2000 to 2003 (pg 129)
Figure 4.12: Mafikeng Health District - Live Births in Hospital and Clinics and percentage
deliveries in clinics - 2000 to 2003 (pg 130)
Figure 4.13: Mafikeng Health District - Clinic births, referrals in labour and referral rate -
2000 to 2003 (pg 131)
Figure 4.14: Mafikeng Health District - Teenage pregnancy rate - 2000 to 2003 (pg 133)
Figure 4.15: Mafikeng Health District and Mafikeng Hospital - Live births and still birth rate
- 2000 to 2003 (pg 133)
Figure 4.16: Mafikeng Health District - Sexually Transmitted Infections at clinics, CHC and
mobiles - 2000 to 2003 (pg 134)
Figure 4.17: Mafikeng Health District - Maternal Mortality Ratio, Peri-natal Mortality Rate
and Neonatal Mortality Rate - 1996, 2000 to 2003 (pg 135)
Figure 4.18: Ganyesa Health District - Use of Contraceptives - 2000 to 2003 (pg 142)
Figure 4.19: Ganyesa Health District - ANC first and repeat visits - 2000 to 2003 (pg 143)
Figure 4.20: Ganyesa Health District - Total Births in Ganyesa Hospital and District CHCs
and clinics - 2000 to 2003 (pg 143)
Figure 4.21: Ganyesa Health District - Total number of births and teenage pregnancy rate -
2000 to 2003 (pg 144)
Figure 4.22: Ganyesa Health District - Total births and still birth rate - 2000 to 2003 (pg 145)
Figure 4.23: Ganyesa Health District - Clinic deliveries, referrals during labour and percent
referrals - 2000 to 2003 (pg 146)
Figure 4.24: Ganyesa Health District - Sexually transmitted infections - 2000 to 2003 (pg 146)
Figure 4.25: Ganyesa Health District - Institutional Maternal Mortality Ratio, Peri-natal
Mortality Rate and Neonatal Mortality Rate - 1996, 2000 to 2003 (pg 148)
Figure 4.26: North West Province - Percentage Population per Age Group - from 2001 Census
(pg 155)
06

Figure 4.27: Public Institutional (Hospitals and Clinics) Maternal Mortality Ratio - Ganyesa,
Mafikeng and Klerksdorp Health Districts and North West Province - 1996, 2000
to 2003 (pg 156)
Figure 4.28: Public Institution Peri-natal Mortality Rate - Ganyesa, Mafikeng and Klerksdorp
Health Districts - 2000 to 2003 (pg 157)
Figure 4.29: Public Institution Neonatal Mortality Rate - Ganyesa, Mafikeng and Klerksdorp
Health Districts - 1996, 2000 to 2003 (pg 158)
Figure 4.30: Number of Termination of Pregnancies per Province - February 1997 to January
2003 (pg 163)
Figure 4.31: Number of Public Facilities Designated for TOPS and Providing TOPS per
Province, 2003 (pg 164)
Figure 4.32: Mafikeng Health District - Requests for TOP and number of TOPs done (pg 167)
07
Figure 7.1: Primary Health Care Expenditure and Rand per capita per province - 2002 to
2003 (pg 192)
Figure 7.2: Primary Health Care Expenditure and Rand per capita per province - Budget
2003 to 2004 (pg 193)
Figure 7.3: National Trends in Health Expenditure on Health Programmes - 1999 to 2000
and 2005 to 2006 (pg 193)
Figure 7.4: National Trends in Health Expenditure as percentage of total expenditure - 1999
to 2000 and 2005 to 2006 (pg 194)
Figure 7.5: North West Province - Health Expenditure by Programme - 1999 to 2000 and
2005 to 2006 (pg 195)
Figure 7.6: North West Province - Percentage Budget per Programme - 1999 to 2000 and
2005 to 2006 (pg 195)
Figure 7.7: Total (R million) and Rand per capita Public Sector Health Financing (non
medical scheme members, real 1999/00 prices) (pg 196)
Figure 7.8: National Health Total and per Capita Expenditure - 1998 to 1999 and 2005 to
2006 (pg 198)
Figure 7.9: Representation of Funding Flows relating to PHC (pg 201)
Figure 7.10: Funding for Reproductive Health Services in South African Public Health Sector
(pg 215)
Figure 7.11: North West Province - Inequities in distribution of district health service budgets
- 1997 to 1998 (pg 203)
Figure 7.12: National Health Expenditure and budget forecast in selected PHC elements -
1999 to 2000 and 2005 to 2006 (pg 208)
Figure 7.13: Total National PHC Health Expenditure and budget forecast, and Rand per
capita - 1999 to 2000 and 2005 to 2006 (pg 208)
Figure 7.14: North West Province - Total PHC Expenditure and PHC Expenditure per capita
- 1999 to 2000 and 2005 to 2006 (pg 209)
Figure 7.15: Ganyesa, Mafikeng and Klerksdorp Districts Health DHER - Expenditure per
line item - 2003 to 2004 (pg 212)
Figure 7.16: Ganyesa, Mafikeng and Klerksdorp Health Districts DHER - Percentage
expenditure per line item - 2003 to 2004 (pg 213)

Figure 7.17: Klerksdorp, Mafikeng and Ganyesa Health Districts - Expenditure per capita
and Expenditure per visit - 2003 to 2004 (pg 213)
Figure 7.18: Klerksdorp, Mafikeng and Ganyesa Health Districts - Population and Visits per
Year - 2003 to 2004 (pg 214)
Figure 8.1:
Figure 8.2:
Figure 8.3:
Figure 9.1:
Total umber of personnel in North West Department of Health and South Africa
- 2002 (pg 217)
North West Province Department of Health - Vacancies and unfunded post rates
- November 2003 (pg 220)
North West Province Department of Health - Posts, funded, unfunded and
vacancies - November 2003 (pg 220)
Data and Information Flow from Local level to National Level – North West
Province (pg 261)
Figure 10.1: Relationship between Health Governance Structures and Local Government
Structures – North West Province (pg 264)
Figure 10.2: North West Province – Health Governance Relationships (From North West
Health Bill – 2002) (pg 288)
Figure 11.1: Drug Distribution – North West Province (pg 291)
Figure 11.2: Referral Systems – North West Province (pg 310)
Figure 12.1: Pattern of Analysis (pg 319)
08

x
List of Tables
Table 1.1: Research Questions. Methods and Techniques for Data Collection (pg 29)
09
Table 2.1: North West and South Africa Political Representation in National Assembly and
Political Representation in North West Legislature - 2004 (pg 42)
Table 2.2: Population of North West Province according to Age Groups – 2001 Census
(pg 43)
Table 2.3: Klerksdorp Local Municipality – Political representation in North West Legislature
(2004) and Klerksdorp Local Municipal Council (2000) (pg 52)
Table 2.4: Population of Klerksdorp Local Municipality according to Age Groups - 2001
Census (pg 53)
Table 2.5: Klerksdorp Health District - Health Areas: Number of CHCs and Clinics according
to Hours of Opening (pg 55)
Table 2.6: Klerksdorp Health District: Facilities per 100 000 head of population (pg 56)
Table 2.7: Klerksdorp Health District: Health Professionals per 100 000 population
(pg 57)
Table 2.8: Mafikeng Local Municipality - Political representation in North West Legislature
(2004) and Mafikeng Municipal Council (2000) (pg 60)
Table 2.9: Population of Mafikeng Local Municipality according to Age Groups - 2001
Census (pg 61)
Table 2.10: Mafikeng Health District - Health Areas: Number of CHCs and Clinics per area
according to Hours of Opening (pg 64)
Table 2.11: Mafikeng Health District - Facilities per 100 000 head of population - 2001
Census (pg 64)
Table 2.12: Mafikeng Health District - Health Professionals per 100 000 head of population
- 2001 Census (pg 65)
Table 2.13: Kagisano and Molopo Local Municipalities - Political representation in North
West Provincial Legislature (2004) and Local Municipalities (2000) (pg 67)
Table 2.14: Ganyesa Health District - Population according to Age Groups - 2001 Census
(pg 68)
Table 2.15: Ganyesa Health District - Health Areas: Number of CHCs and Clinics according
to Hours of Opening (pg 68)
Table 2.16: Ganyesa Health District - Facilities per 100 000 head of population - 2001
Census (pg 72)
Table 2.17: Ganyesa Health District - Health Professionals per 100 000 head of population
- 2001 Census (pg 73)
Table 2.18: Summary Comparative Table of Three Study Sites in North West Province
(pg 74)

Table 3.1:
Policy, Legislation and other significant events for decentralisation and reproductive
health (pg 82)
Table 4.1: Klerksdorp Health District - Reproductive Health Indicators - 2000 to 2003
(pg 119)
Table 4.2: Mafikeng Health District - Reproductive Health Indicators - 2000 to 2003
(pg 136)
Table 4.3: Ganyesa Health District - Reproductive Health Indicators - 2000 to 2003
(pg 148)
Table 7.1:
Comparative Health Expenditure per Line Item - Klerksdorp, Mafikeng and
Ganyesa Health Districts - 2003 to 2004 (pg 211)
Table 8.1: Total number of personnel in provincial health departments - South Africa and
North West Province - 2002 (pg 217)
Table 8.2: North West Province, Department of Health - Total, funded and vacant posts -
November 2003 (pg 219)
Table 9.1: Strategic Health Plans: National and North West Province (pg 251)
10

x
Abbreviations and Acronyms
11
AD
ADAdmin
ADCHS
AIDS
ANC
ANC
AWB
CD
CEO
CHC
CHC
CHW
COSATU
CPA
CPMS
CTOPA
DDG
DENOSA
DG
DHA
DHER
DHIS
DHS
DIO
DoH
DOT
DPLG
DPSA
DSE
DWAF
EDL
EMS
EN
EXCO
FFC
FP
GAYCO
Assistant Director
Assistant Director Administration
Assistant Director Community Health Services
Acquired Immunodeficiency Syndrome
African National Congress
Ante natal Care
Afrikaner Weerstandsbeweging
Chief Director
Chief Executive Officer
Community Health Centre
Community Health Committee
Community Health Worker
Congress of South African Trade Unions
Cape Provincial Administration
Certified Professional Midwives
Choice on Termination of Pregnancy Act
Deputy Director General
Democratic Nurses Organisation of South Africa
Director General
District Health Authority
District Health Expenditure Review
District Health Information System
District Health System
District Information Officer
Department of Health
Directly Observed Treatment
Department of Provincial and Local Government
Department of Public Service and Administration
Department of State Expenditure
Department of Water Affairs and Forestry,
Essential Drug List
Emergency Medical Services
Enrolled Nurse
Executive Committee
Financial and Fiscal Commission
Family Planning
Ganyesa Youth Committee

GDP Gross Domestic Product
GEAR Growth, Employment and Redistribution
GNU Government of National Unity
HBC Home Based Care
HIO Hospital Information Officer
HIV Human Immunodeficiency Virus
HOSPERSA Health and Other Service Personnel Trade Union of South Africa
HR Human Resources
HRM Human Resource Management
ICDP International Conference on Population Development
IDP Integrated Development Plan
IMF International Monetary Fund
IUD Inter-uterine Device
MCC Medicines Control Council
MCWH Maternal, Child and Women’s Health
MEC Member of the Executive Committee
MHA Municipal Health Authority
MHS Municipal Health Services
MinMEC Committee, chaired by the National Minister of Health, of the nine
provincial MEC’s for Health.
MMC Member of the Municipal Council
MMC Member of the Mayoral Committee
MMR Maternal Mortality Ratio
MTEF Medium-Term Expenditure Framework
NA National Assembly
NA Nursing Assistant
NAFCI National Adolescent Friendly Clinic Initiative
NEHAWU National Education, Health and Allied Workers Union
NCOP National Council of Provinces
NDHSC National District Health Systems Committee
NDoF National Department of Finance
NDoH National Department of Health
NDP National Drug Policy
NGO Non Governmental Organisation
NHA National Health Act
NHA National Health Accounts
NHIS National Health Insurance System
NHISSA National Health Information System of South Africa
NHLS National Health Laboratory Services
NHS National Health System
NNMR Neonatal Mortality rate
NPHCFS National Primary Health Care Facilities Survey
12

13
NT
NW
PC
PCC
PDoH
PDDLG
PDP
PFMA
PHA
PHC
PHMC
PHRC
PHSA
PMDS
PMTCT
PN
PNMR
PPASA
PPI
PPWD
PWD
QSR N6
RDP
RHRU
RHS
RSC
SACP
SAHR
SALGA
SLA
SAMA
SRHS
STD
STI
TB
National Treasury
North West
Portfolio Committee
President’s Coordinating Council
Provincial Department of Health
Provincial Department of Development, Local Government and
Housing
Population and Development Programme
Public Finance Management Act
Provincial Health Authority
Primary Health Care
Provincial Health Management Committee
Provincial Health Restructuring Committee
Public Health Services Authority
Performance Management and Development System
Prevention of Mother –to- Child Transmission of HIV
Professional Nurse
Peri-natal Mortality Rate
Planned Parenthood Association of South Africa
Public-Private Initiative
Provincial Public Works Department
Public Works Department
Package used for Data Analysis
Reconstruction and Development Programme
Reproductive Health Research Unit
Reproductive Health Services
Regional Services Council
South African Communist Party
South African Health Review
South African Local Government Association
Service Level Agreement
South African Medical Association
Sexual and Reproductive Health Services
Sexually Transmitted Disease
Sexually Transmitted Infection
Tuberculosis
TBA Traditional Birth Attendant
TOP Termination of Pregnancy
TPA Transvaal Provincial Administration
UCDP United Christian Democratic Party
UNFPA United Nations Population Fund
VCT Voluntary Counseling and Testing
VIP Ventilated Improved Pit Latrine

x
Acknowledgements
The Understanding the Impact of Decentralisation on Reproductive Health Services in Africa
(RHD) research project was funded by the European Commission.
Our appreciation and gratitude is extended to the following for their support and assistance in
making the RHD research in South Africa possible. We thank:
- The National Department of Health for permission to do the research and for interviews;
- The North West Provincial Department of Health for permission and support in
undertaking the research, and for the extensive interview time made available;
- The District Management teams for their assistance and interviews;
- The many health personnel interviewed who gave so generously of their time;
- The University of the North West, School of Nursing. for research assistance;
- The Madibeng Community Development Centre for their assistance with focus groups;
- The Nuffield Centre for International Health and Development for their management
and coordination of the project, Understanding the Impact of Decentralisation on
Reproductive Health Services in Africa (RHD);
- Charles Collins, Nancy Gerein and Susannah Mayhew of the Nuffield Centre for
International Health and Development for their support, insights and critical review of
the South African research.
14

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Executive Summary
The provision of appropriate reproductive health care remains one of the main health care
challenges in developing countries. The development of the delivery of reproductive health
services is continually confronted by challenges from a changing environment, an important
element of which is health sector reform, in particular decentralisation, which is being undertaken
by most governments in Africa. The general objective of this research is to make health sector
decentralisation more effective in the development of appropriate reproductive health services.
The general research question is: How does decentralisation affect reproductive health services?
The overall research project compares different forms of decentralisation in two anglophone
(South Africa and Uganda) and two francophone (Burkina Faso and Mali) countries in Africa
to assess the impact of decentralisation on, and importance for, the development of reproductive
health services.
This report is one of the deliverables of the European Union funded research project, led by The
Nuffield Centre for International Health and Development (Contract: CA4-CT-2002-10028),
“Understanding the Impact of Decentralisation on Reproductive Health Services in Africa”
(RHD) and reports on the findings of the research in South Africa. The findings of this research
have been used for the comparative study of the two anglophone countries (South Africa and
Uganda) and for the comparison of the anglophone and francophone countries. The final product
of the research project are the guidelines for policy makers which have been published by
Nuffield Centre for International Health and Development.
15
Analysis of the research data
In understanding the impact of decentralisation on health sector reforms cognisance is taken of
the context in which the reforms and decentralisation is taking place. This involves a review of:
1. The broad historical changes
The processes leading up to the democratic elections of 1994 and the end of apartheid
policies in South Africa impacted on the rate and manner in which reforms were introduced.
The Constitution of the Republic of South Africa of 1996 entrenched the rights of the
population to health care, in particular reproductive health care.
2. The policy process
The policy process through which decentralisation and sexual and reproductive health
policies were formulated and implemented, and the impact these have on the relationship
between decentralisation and health sector reforms, is reviewed. The policy process for
both decentralisation and sexual and reproductive health are analysed in terms of:
• Policy rationale and content
• Policy understanding
• Policy linking
• Policy implementation
3. The system of decentralisation and sexual and reproductive health
These structures have an impact on the decentralisation / sexual and reproductive health
relation.
The broad pattern of analysis used in this research is shown in figure no. 1:
The research in South Africa was carried out in 2003 and 2004.

Figure 1: Pattern of Analysis
Broad Historical Change and Policies
Policy Process
• Policy rationale and content
• Policy understanding
• Policy linking
• Policy implementation
System of
Decentralisation
and SRHS
Impact of decentralisation SRHS interrelation
The Research in South Africa
The Constitution of the Republic of South Africa, 1996, establishes three spheres of government
– national, provincial and local. South Africa is divided into nine provinces as the second sphere
of government and can, therefore, be regarded as a “quasi-federal state” of nine provinces. The
political, socio-economic and historical context in each of the nine provinces varies. The impact,
therefore, on service delivery of implementation of national policies, such as decentralisation,
and health reform polices, such as those for reproductive health, varies between provinces. It
was agreed to limit the research to one province, namely North West Province. Within the North
West Province three health districts were selected as case studies – Klerksdorp (urban) in the
Southern Region, Mafikeng (semi-urban) in the Central Region and Ganyesa (rural) in the
Bophirima Region.
16
Chapter 1
Chapter 1 introduces the research process used and the broad context in which policy changes
have been introduced in South Africa since the first democratic elections of 1994. The 1996
Constitution of South Africa is the foundation on which policies are developed in the country.
The Constitution envisages services to be delivered at a local level by municipalities.
The socio-political, economic and historical context of these municipal areas, however, varies
across the country. The implementation and functioning of decentralisation policy varies as well
and different impacts on health services and reproductive health services in particular are noted.
The impact varies according to the form of decentralisation and/or the level to which decentralisation
occurs. Other community factors or factors within the health services, such as management style
and personalities, also impact on the quality of health services in a particular province or
municipal area within the province.
If political and health sector reforms are to positively support reproductive health services it is
important for policy makers and managers to understand the circumstances and context in
which these policies are implemented. The principle of “one shoe fits all” may not apply. The
differences between municipal areas needs to be accommodated in implementation of policy.

There is little understanding of how decentralisation and health sector reforms are impacting
on health service delivery in South Africa. The current research seeks to understand some of
the factors within decentralisation that are impacting on reproductive health services.
Chapter 2
Chapter 2 introduces the context of decentralisation and reproductive health services in South
Africa. Since 1994 South Africa has been through a process of transformation of government,
policies and legislation affecting all sectors of government. The effectiveness of this transformation
is dependent, in part, on the context in which the policies are implemented. The impact on
reproductive health services of implementing health policies within the over all transformation
of government, such as decentralisation, is likewise dependent on the context in which this is
happening. The context can not be limited to the present, but is dependent on the past and
how the changes are moved into the future. It is further dependent on globalisation which is
impacting on South Africa during this process of internal transformation. South Africa is
influenced by international trends in policy and funding and these are reflected in policy
development. Furthermore, the context varies between and within the nine provinces, the six
metropolitan municipalities, the 47 district municipalities and the local municipalities.
17
The importance of early policies, such as The Reconstruction and Development Programme
(RDP) and subsequent changes brought in by the Growth, Employment and Redistribution
(GEAR) policy are highlighted. In particular the move from a macro-economic policy of “growth
through redistribution” of the RDP to the cost efficient, with strong fiscal controls, policy of
GEAR is a challenge for health sector reforms that are guided by social outreach and expansion
of services.
There are three spheres of government. The constitution defines the responsibilities and functions
of each sphere. Each sphere of government has elected political representation. There are,
therefore, three political lines through which community members are represented at national,
provincial and local government levels.
• The National Sphere is responsible for policy development, for the overall coordination
of services in the country, and for the equitable distribution of resources, particularly
financial resources.
• There are nine provinces defined in the Constitution. Each province is semi-autonomous.
A number of functions is devolved from the national level to the provincial level.
Provincial governments are responsible for monitoring and evaluating the implementation
of national policy. National policies, however, can be adapted to suit the particular
needs of the province. Each province is an amalgamation of two or more previous
administrations from the apartheid era.
• The Constitution recognises local government as a third sphere of government. This
has enhanced the status of local government, in particular the role of municipalities as
the level for delivery of services. Local Government is responsible for providing basic
services, such as water, sanitation and electricity and is the level of implementation of
policy. Health policies envisage local government to be the level at which the district
health system, as the vehicle for health service delivery, is established. Finances are
provided by the National Treasury through the Equitable Share and from locally raised
rates and tax revenue.
The three spheres of government work together as a cooperative government.
The National Department of Health (NDoH) is responsible for policy development. Decentralisation
of health services and development of the District Health System (DHS) at municipal level is

the responsibility of National Chief Director for District Development. Reproductive health
policies are the responsibility of National Chief Directorate for Maternal Health, Child health,
Genetics and Nutrition. There is fragmentation within and between these Chief Directorates
with at times poor communication between, and even within, these directorates. A number of
programmes are managed vertically e.g. HIV/AIDS and nutrition, with conditional grants for
funding from the national treasury. Not all role players and stake holders are involved in policy
development.
At the provincial level in North West Province the African National Congress (ANC) dominates
political representation. There are, however, some strong opposition parties in some municipalities
which contributes to a less cohesive political context.
The Provincial Department of Health (PDoH) has a similar structure to the national structure.
The provincial department is responsible for implementation, monitoring and evaluation of
national policies. Fragmentation and lack of communication within the department was evident
from some of the informants interviewed.
Three health districts were used as study sites at the local level. These represented an urban, a
semi-urban and a rural area of the province. Each site is noted to have different socio-political
and historical backgrounds which seem to account for the differences in the ability of districts
to manage the services.
There is a complex management system at health district level. These include:
• Health District Management Team – responsible for community outreach services,
mobile clinics, fixed clinics, community health centres and some community hospital
services. The Health District Manager reports to the Regional Director.
• District Hospital Management – responsible for District (level 1) hospital services.
The District Hospital Manager reports directly to Regional Director.
• Regional and Provincial Hospital Management – providing first level hospital care
in health districts where there is no district hospital. The Hospital Chief Executive
Officer reports directly to Chief Director: Health Service Delivery in the Provincial
Head Office.
• Emergency Medical Services (EMS) – responsible for ambulance services and referral
of patients between levels of care. EMS has provincial, regional and district management
structures separate to the all other structures and reports to the Chief Director: Strategic
Health Plans in the Provincial Head Office.
• Laboratory Services – part of the National Health Laboratory Services (NHLS),
based in the district or provincial hospital to provide quality laboratory services to all
health services in the district. The NHLS is a parastatal and has a centralised structure
extending from national to hospital level.
• Local Government Health Services – responsible for some Primary Health Care (PHC)
services in some metropolitan, district and local municipalities. These services are
managed through separate structures within each municipality.
18
Managing these systems requires time and energy from all managers. Formal and informal lines
of communication have developed. The complexity is most notable in the urban district which
has a long history of local authority involvement in health care delivery. Health workers are
employed under different conditions of service and paid on a different salary scale. Amalgamation
of the provincial and municipal health services is a challenge; this can impact negatively on
service delivery.

The three health districts are notably different. The researchers believe that these contextual
differences between the districts are important for understanding the impact of decentralisation
on reproductive health services in North West Province.
Chapter 3
Chapter 3 discusses health systems decentralisation in South Africa. Reference is made to the
role of foundation documents, such as the RDP, the Freedom Charter, the Constitution of South
Africa, the ANC Health Plan of 1994 and The White Paper for the Transformation of Health
Services of 1997 as guides for health sector reforms.
The department of health was one of the first government sectors to start the process of developing
policies for decentralisation of health services to local level. It has, however, taken ten years for
these policies to be entrenched in a National Health Act. Legislation for establishing local
government as the third sphere of government was required before health decentralisation
legislation could be finalised.
Health services in South Africa are based on a primary health care approach through the district
health system. Establishing the DHS, however, has not been easy and each province has determined
their processes for implementation.
The North West Provincial Department of Health, not withstanding these delays, has made
significant strides towards a decentralised district health system.
19
Chapter 4
This chapter introduces the development of health policies in South Africa and reviews the
development of reproductive health polices and services. After 1994 health services in South
Africa moved from a fragmented system of fourteen (14) health departments into one national
department of health, within one national health system. Reproductive health did not previously
have a comprehensive and coordinated policy and there was no coordination between the different
health authorities, and programmes were run vertically with little integration at service delivery
level.
The right to reproductive health is now entrenched in national legislation and policies. Details
of these policies are included in the Appendix.
Services for reproductive health have generally improved since 1994. There are more clinics
providing 24 hour services and these clinics are better equipped. There are standard protocols
for referral to hospital when required. This expansion of services is often equated with the
process of decentralisation but is probably independent of it. Decentralisation of PHC services,
however, would probably be more difficult if the expansion of services had not occurred. Although
there has been no specific major investment in reproductive health there are signs that it is given
special attention.
Reproductive health policies focus on equity of services and on the most vulnerable and
disadvantaged, such as women and children in rural areas. The stated goals of the policies are
in line with International Conference on Population Development (ICPD) principles of 1994,
although these are not identified as such. The policies further state that services are to be delivered
through an integrated approach as part of the district health system, supported by a vertical
management system.

Although planning within the National Department of Health is done at the cluster level of
Maternal Health, Women’s Health, Child Health and Nutrition, reproductive health programmes
are not fully integrated. Prevention of Mother-to-Child Transmission (PMTCT), for example,
started as a research programme within the HIV/AIDS Directorate. The need to integrate
directorates within the Department of Health is acknowledged and restructuring was being
planned at the time of the research.
At the provincial level in North West Province reproductive health is the responsibility of several
directorates and sub-directorates under the Chief Directorate: Strategic Health Programmes. The
services, however, are delivered as part of the integrated PHC approach. The sub-directorates
collaborate with each other as many of the services overlap and impact on each other.
Communication from the provincial programme managers to the health district, the level of
implementation, is officially via the regional offices. However, many provincial managers
communicate directly with their counterparts in the districts. The programmes are seen to be
managed vertically, but the health district is expected to implement them all in an integrated
fashion; nurses are trained to deliver integrated services. Reproductive health services can be
compromised within such integrated service delivery.
There is a standard PHC Service Package 1 developed by the National Department of Health
and required to be delivered in health districts. Reproductive health services are included in this
package. The availability, access and uptake of reproductive services varies between districts.
The research points to some of these differences as experienced in the three study sites –
Klerksdorp (urban), Mafikeng (semi-urban) and Ganyesa (rural). The experiences of health
workers, patients and other stakeholders are different in each site. Quantitative data that has
been gathered, however, has not shown marked differences in health outcomes, except an apparent
overall improvement in the rural district. The data available has to be analysed and understood
within the context of each district. For example, maternal mortality ratio appears to be highest
where there are the best resources, staffing levels, and history of good health services; the urban
district. These resources, however, are supporting the least resourced district included in the
study, the rural district, with a history of poorer health services. It is only through knowledge
of the context of each district that these apparent anomalies can be explained and understood.
20
Chapter 5
Chapter 5 looks at each of the three study sites in North West Province in terms of how
decentralisation has an impact on the intermediate processes and reproductive health services.
Particular attention is paid to the impact of the district context on the intermediate processes and
reproductive health services. Does decentralisation have a different impact on reproductive health
services in the three districts, and, if so, why? Table 5.1 summarises the information on the three
districts.
The most rural district, Ganyesa, shows the most improvement in reproductive health indicators.
The district and the local municipality are usually referred to as having the least capacity to
manage services, including health services. The improvement in indicators may not be due to
decentralisation, but could be attributed to a lower starting point and the almost total neglect
of the area under the previous government. The same policies are implemented in the semiurban
district, Mafikeng. The indicators, however, in this district show a decline in health
outcomes.
Klerksdorp district faces many challenges of bringing together different health services –
provincial and local government. Local government is required to change focus in health services
1 Department of Health: A Comprehensive Primary Health Care Service Package for South Africa: September 2001.

from a health promotion and preventative service to one that incorporates the full PHC package.
Coordination of the services managed by the different spheres of government presents particular
challenges. Despite these challenges there is a positive attitude regarding improvement of
services.
21
Chapter 6
Chapter 6 reviews service organisation and delivery.
Prioritising of services is mainly set by the national department of health, although provinces
do have official autonomy to decide for themselves. The health districts generally follow the
provincial priorities, although in some areas these may differ.
Targeting of services is set by provincial and/or the local level and is to some extent dependent
on local need. There are times, however, when provincial or even national priorities take
precedence in a district.
“A Comprehensive Primary Health Care Service Package for South Africa” 2 was published
in September 2001. The Package defines services in terms of level of care and approach. It
includes priority area services to be provided at community level, mobile clinics, fixed clinics
and community health centres. A suggested referral system from primary level to a district
hospital is included.
Norms and standards for PHC services are included in the package published by the National
Department of Health. 3 The document covers clinic and community based services. Reproductive
health norms are included.
Government policy supports the involvement of the private sector in service delivery through
contracting processes, such as service level agreements and private-public partnerships, among
others. Contracting, however, in the health services is not a prime means of service delivery.
Patient care is seen as a core function of the Department of Health and is therefore provided
internally.
Chapter 7
Chapter 7 describes financing of health services. The budgeting process in government has
changed since 1994. National Treasury is responsible for distribution of public funds. In 1997,
fiscal federalism and the Medium-term Expenditure Framework (MTEF) were introduced. Fiscal
federalism comprises global allocation to provinces according to the Equitable Share. The
provinces then divide their allocation to provincial sector departments.
There are, in addition, conditional grants allocated by National Treasury to each province; for
health these are for HIV/AIDS, hospital revitalisation, nutrition and training.
Decentralisation, by definition, entails moving decision space to the lowest most appropriate
level. Establishing a decentralised health system requires decentralising financial management
and budgeting to the health district level. Currently financial control remains centralised
to the national government sphere, with some decentralisation to the provinces. There is, however,
little further decentralisation below this level. Health districts are involved in the budgeting
process, but these budgets are finalised at the provincial level.
Funding, budgeting and expenditure in health services are complex systems. Health is a social
service with demand to expand services and provide access to an increasing number of people
2 Deptartment of Health; A comprehensive Primary Health Care Package for South Africa; 2001.
3 Department of Health: The Primary Health Care Package for South Africa: A Set of Norms and Standards. September 2001.

each year. The macro-economic trends in South Africa are cost containment and efficiency driven
by GEAR and other policies.
There are limited sources of funding for reproductive health services. The services are dependent
on funding from the National Treasury which filters down to the health district, the level of
implementation, via several routes. Funding for reproductive health services is not protected.
All funding for these services is included in funding for all PHC services. National policy is
implemented vertically whereas funding is horizontal and integrated. Some HIV/AIDS programme
funding is through vertical conditional grants to health districts.
Local government has a different budget cycle to the provincial and national governments. The
local government health services are budgeted for from general municipal funds with some
subsidies from the Provincial Department of Health usually to cover salaries of health staff the
subsidies may also cover drugs and special HIV/AIDS programmes. The Provincial Department
of Health retains some control over local government health services; this ensures compliance
with provincial and national norms and standards.
Chapter 8
In Chapter 8 human resource management and development is discussed.
Personnel are the most significant resource for health services. In 2002/03 the personnel share
of total health expenditure in South Africa was 58.1% or R19 320 million. 4 There is, however,
variation between and within provinces. The District Health Expenditure Reviews, for example,
for 2003/04 for the three study sites in the North West Province included in this project showed
between 67% and 77% of the total expenditure was on personnel.
An overall shortage of health personnel is noted at all levels of the health system. The greatest
shortage is noted in the more rural areas which have a less hospitable working environment.
Recruitment and retention of staff is a major challenge.
Differences in conditions of service between municipal and provincial employed health workers
are a block to integration of services in districts where there is a strong municipal health service.
This impacts on provision of 24 hour services at community health centres and clinics, in
particular. There are moves towards developing a single public service that will include municipal
employees.
Human resource issues of recruitment, job descriptions, training and supervision are described
in the three health districts. Health workers have different experiences. One thing in common,
however, is feeling of being over worked due to staff shortages and an increasing work load.
This can negatively impact on reproductive health services.
Community members interviewed during the research gave interesting, and at times divergent,
perspectives of the services and of the health care providers.
22
Chapter 9
Chapter 9 looks at the planning, monitoring and evaluation of health services. Reproductive
health services are included in the general planning cycle and within broad objectives for service
delivery.
Planning, monitoring and evaluating of health services are an essential, although complex,
process. A top-down approach appears to still dominate. The national Ten Point Strategic Plan
4 Republic of South Africa. National Treasury. Intergovernmental Fiscal Review 2003. page 78

for 2004 to 2009 emphasises primary health care and strengthening governance structures (and
presumably community participation). Reproductive health services are not mentioned separately.
The National Health Act of 2003, Chapter 5, establishes a district health system for South Africa.
For this to be a reality, horizontal and vertical gaps in the systems need to be bridged. Planning
processes for the vertical programmes at national and provincial levels require co-ordination;
the voice of the communities served by the health services need to be heard and noted in the
planning process.
Chapter 10
Chapter 10 reviews the formal governance structures for health and local government, their roles
and functioning; community involvement in health; inter-sectoral collaboration and public –
private relationships within the health system.
A duplication of structures at a local level (established under different spheres of government
and different legislation) is noted. This appears to lead to confusion and possible delays in
implementing resolutions or bringing problems to the notice of authorities. Some health governance
structures overcome this by following two lines of reporting – to the provincial department and
to the local municipality. The relationship between these different structures is illustrated in
Figure 10.1.
The functioning of governance structures varies between the health districts. There appears to
be greater community cohesiveness in the most rural district and greater involvement of the
community in these structures.
23
Chapter 11
Chapter 11 addresses logistics and the referral system. The essential support services include
drug supplies, transport (other than ambulance services), laboratory services, infrastructure and
maintenance, and ambulance services.
Policy and legislation for drug management is centralised to the National DoH. Procurement
and distribution is a provincial responsibility. PHC facilities are supplied by hospitals which are
part of different institutional management systems. Drug supply to clinics is better than it was
previously in North West. Although some drugs may be out of stock, contraceptives and condoms
are well supplied. Management of drugs is a concern because of shortage of trained staff.
Transport for service delivery is difficult. There is shortage of vehicles and their allocation is
centrally controlled within the Department of Transport. Community members have difficulty
accessing services due to a lack of community transport systems.
Laboratory services are outsourced to a parastatal, the National Health Laboratory Services.
Problems are particularly noted in the rural areas where it is not possible to provide a 24 hour
laboratory service. Patients may require referral 300kms to the nearest hospital with full laboratory
services.
The management of ambulance services is centralised to the provincial level. This gives rise to
frustration at the local level and point of service delivery. Lengthy delays in accessing transport
for emergency patients, including pregnant women requiring referral from a clinic to hospital
for higher level care, are experienced.

Building and maintenance of infrastructure is the responsibility of the Provincial Department
of Works. Management of the relationship can be difficult and there can be long delays in
receiving responses.
Chapter 12
The final chapter explores some of the key issues that have emerged from the research in South
Africa. The two comparative reports (the two country comparative report of South Africa and
Uganda; and the four country comparative report of South Africa, Uganda, Mali and Burkina
Faso) further draw out issues for consideration.
Decentralisation is complex. It is not possible to separate the impact of this process from other
parallel policy changes, such as development of reproductive health policies and their
implementation. The context in which this is being introduced impacts on the ability of the local
level to respond to the demands of a decentralised system. This in turn seems to impact on the
implementation of reproductive health policies and the outcomes for reproductive health in each
district.
The findings of the RHD research, however, do illustrate the complexity of the evolving systems
for health services. There is some insight into factors requiring consideration before and during
implementation if there is to be a positive outcome from policy changes. Many of these issues
will be further developed in the comparative reports of the four countries involved in the RHD
research.
24

Chapter 1
Introduction
1.1 The Research 1
General Objective of the Research
The provision of appropriate reproductive health care remains one of the major health systems’
challenges in developing countries. The development of reproductive health service delivery
is continually confronted by challenges from a changing environment an important element of
which is health sector reform, particularly decentralisation, being undertaken by most governments
in Africa.
The general objective of this research is to investigate how health sector decentralisation can
be made more effective in the development of appropriate reproductive health services. The
general research question is: How does decentralisation affect reproductive health services?
The project compares different forms of decentralisation in two anglophone (South Africa and
Uganda) and francophone (Burkina Faso and Mali) African countries to assess their impact on
and importance for the development of reproductive health services.
Specific scientific and technical objectives are to:
25
1. identify and explain the key features and changes in reproductive health policies and
services in Burkina Faso, Mali, South Africa and Uganda;
2. identify and explain the key features and changes in decentralised health systems in
Burkina Faso, Mali, South Africa and Uganda;
3. document, assess and explain the extent to which the key features and changes in
reproductive health policies and services noted in objective (1) are affected by the
features and changes in decentralisation noted in objective (2);
4. identify those characteristics of decentralised health systems that are beneficial/ not
beneficial/ neutral to reproductive health policies and to interpret the specific context
of these features in the study countries;
5. conduct a comparative analysis of francophone and anglophone systems / experiences
within this field;
6. identify lessons for policy-makers within and between the different health systems
analysed;
7. develop national and international guidelines / recommendations which can inform
national reproductive health and health sector reform policy makers and multilateral /
bilateral agencies;
8. build the research capacity of partner research institutions in Africa;
9. promote co-operative and collaborative links between African and European institutions
involved in the research; and
10. disseminate findings to a national and international audience including European and
African academics, policy makers and health specialists.
1 Nuffield Institute for Health, University of Leeds, UK. Research Proposal Document.

1.2 Decentralisation and reproductive health in South Africa
Decentralisation of government to the level closest to the people is an accepted government
reform process in many developing and emerging nations. This principle is now entrenched in
policy and legislation in democratic, post-apartheid South Africa. There are three spheres of
government (national, provincial and local) detailed in the Constitution and other legislation.
Local government is designated as the level of service implementation, with provincial and
national spheres playing roles of policy development, legislative, support, and monitoring and
evaluation. The structures and functions of these spheres of government are described in Chapter
2 of this report.
Chapter 7 of the Constitution of Republic of South Africa (1996) outlines the functions of local
government. Section 156 (1) states:
A municipality has executive authority in respect of, and has the right to administer
(a) the local government matters listed in Part B of Schedule 4 and Part B of Schedule
5; and
(b) any other matter assigned to it by national or provincial legislation.
All government sectors, such as water, education, health and welfare, are further encouraged
to decentralise management of other functions to local government, as required in terms of
Section 156(4) of the Constitution,
The national government and provincial governments must assign to a municipality,
by agreement and subject to any conditions, the administration of a matter listed in
Part A of Schedule 4 or Part A of Schedule 5 which necessarily relates to local
government, if
(a) that matter would most effectively be administered locally; and
(b) the municipality has the capacity to administer it.
26
There is, therefore, a political drive to decentralise service delivery to local government and
within government sectors to decentralise management.
Decentralised management is not entirely new to South Africa as some government functions
were decentralised within the apartheid system. The historical changes and guiding principles
and policies in the transition from apartheid to democratic government are described in
Chapter 2.
A central health policy in South Africa is that primary health care is to be delivered through a
district health system (DHS) that is municipally based. This is legislated in Chapter 5 of the
National Health Act (NHA) of 2003.
Section 32 of the NHA outlines the health responsibilities of metropolitan and district municipalities,
in agreement with Section 156 of the Constitution:
(1) Every metropolitan and district municipality must ensure that appropriate municipal
health services are effectively and equitably provided in their respective areas.
(2) The relevant member of the Executive Council must assign such health services to a
municipality in his or her province as are contemplated in section 156(4) of the
Constitution.

(3) An agreement contemplated in section 156(4) of the Constitution is known as a service
level agreement and must provide for-
(a) the services to be rendered by the municipality;
(b) the resources that the relevant member of the Executive Council must make
available;
(c) performance standards which must be used to monitor services rendered by the
municipality; and
(d) conditions under which the agreement may be terminated.
Health services are expected to be delivered within the provisions of the Constitution and NHA.
This includes the full basket of primary health care services outlined in Chapter 6 section 4.
Reproductive health is part of this basket of services and is described in Chapter 4.
The right to health and, in particular, reproductive health is enshrined in the Bill of Rights,
Chapter 2 of the Constitution. Section 27 states:
(1) Everyone has the right to have access to
(a) health care services, including reproductive health care;
(b) sufficient food and water; and
(c) social security, including, if they are unable to support themselves and their
dependants, appropriate social assistance.
27
(2) The state must take reasonable legislative and other measures, within its available
resources, to achieve the progressive realisation of each of these rights.
Provision and improvement of reproductive health services is focused on within the Department
of Health. New policies, based on the principles of the International Conference on Population
Development (ICPD) of 1994, have been developed and are being implemented. The focus is
on gender rights and empowerment of women through education, accessibility to services and
the right of women to make their own reproductive choices. The new legislation and policies
are outlined in Annexure 1 and include:
• Choice of Termination of Pregnancy, 1996.
• Maternal, Child and Women’s Health Draft policy document, 1995.
• Notification of Maternal Deaths, 1997.
• Policy Guidelines for Youth and Adolescence Health, 2001.
• Guidelines for Maternity Care in South Africa, 2002 (2 nd edition).
• National Contraception Policy and Guidelines, 2002.
• National Guidelines for Cervical Cancer Screening Programmes.
• HIV/AIDS and STD Strategic Plan for South Africa, 2000 to 2005.
• Operational Plan for Comprehensive HIV and Aids Care, Management and Treatment
for South Africa, November 2003.
Implementing these policies requires support from wider health sector change as well as political
and economic reforms, to ensure improvement in reproductive health services and improved
health status.
In South Africa there is wide diversity of race, culture, economic and social standing as well
as historical experiences. The political and health sector reforms contemplated in policy and

legislation are designed to unify this diversity as a developmental democratic society. As stated
in the Constitution and NHA, the metropolitan and district municipalities are envisaged as the
level for decentralisation of health services. Provinces have discretion to decentralise to a lower
level, the local municipality. The North West (NW) Province, at the time of this research,
envisaged the local municipality as the level for decentralisation of health services and the DHS.
The socio-political, economic and historical context of these municipal areas, however, varies
across the country. The implementation and functioning of decentralisation policy may vary as
well and have different impacts on health services and reproductive health services in particular.
The impact may vary according to the form of decentralisation and/or the level to which
decentralisation occurs. There may be other community factors, or factors with in the health
services, such as management style and personalities, which impact on the quality of health
services in a particular province or municipal area within the province.
If political and health sector reforms are to positively support reproductive health services it is
important for policy makers and managers to understand the circumstances and context in which
these policies are implemented. The principle of “one shoe fits all” may not apply. The differences
between municipal areas need to be accommodated in implementation of policy.
There is little understanding of how decentralisation and health sector reforms are impacting
on health service delivery in South Africa. The current research seeks to understand some of
the factors within decentralisation, and other policies, that are impacting on reproductive health
services. The information will be used to inform policy makers and implementers, to help build
on positive factors and to help address constraints identified. The findings will also be used to
inform the international health community.
1.3 Methodology
Both qualitative and quantitative research methods were used. The qualitative approach followed
on from the research questions which recognised the need to explain social reality through the
interpretations of individuals and groups in different social contexts. Quantitative data was
included to give strength to policy advocacy and change activities which were an important
consideration for this project. Several aspects of the research questions could be answered
through quantitative data – in particular the state of reproductive health and services.
The research was applied in the sense that it provided an improved understanding of the way
in which two hitherto un-linked areas of policy making – reproductive health and decentralisation
- can interact for the mutual benefit of both. The findings provide a practical guide as to how
and what linkages can be made between the two policy areas and related to other areas, such
as privatisation and gender issues. The research aimed at facilitating dialogue between the
respective networks of actors, each of whom were involved as stakeholders in the research.
The research was conducted through multi-disciplinary and multi-institutional collaboration.
Each partner had important and complementary skills to offer.
A comparative approach was developed in the research. There is potential for cross-learning in
respect of how different anglophone and francophone African countries address reproductive
health care under different models of decentralisation. The incorporation of four countries
increases understanding and generalisability. There are different models of intersectoral
collaboration, community participation, and funding mechanisms in each of the study countries
that relate to both reproductive health and decentralisation. The research documented and assessed
these factors.
28

Research Techniques
Qualitative and quantitative research techniques were developed according to the nature of the
research question, as set out below.
Table 1.1: Research Questions, Methods and Techniques for Data Collection
29
Research Questions
1. What are the key features of
and changes in reproductive
health policies and services in
the four study countries?
2. What are the key features of
and changes in decentralised
health systems in the four study
countries?
3. To what extent are the key
features for reproductive health
policy affected by the key
features of decentralisation in
each study country?
4. Which features of
decentralisation are most
beneficial/ neutral/ not
beneficial to reproductive
health services and what are
the specific contexts of these
features?
5. To what extent can lessons be
learned across the different
health system?
6. What guidelines can inform
reproductive health service and
decentralisation national and
international policy-makers?
Research Methods and Techniques for Data Collection
Documentary analysis of international and African
literature; Political mapping and stakeholder analysis;
Interviews; Service check-lists; Quantitative
questionnaires
Documentary analysis; Interviews; In-country case
studies; Quantitative data collection on funding and
management issues
Documentary analysis; Semi-structured interviews; Incountry
case studies; Observation; Focus group
discussions; Political mapping and stakeholder analysis;
Quantitative data collection on health impacts and
service outcomes
Comparative analysis using; Group discussion analysis;
Case-orientated analysis;
Cross-case analysis; Variable-orientated analysis;
Matrices
Documentary analysis of country case studies and
comparative reports; Group discussion analysis
Documentary analysis of country case studies and
comparative reports; Group discussion analysis
Data Analysis
Quantitative data was analysed using a statistical package. Qualitative data was coded manually.
A statistical programme, QSR N6, was used for storage and further manipulation of the data.
Selection of research sites
The research was applied in three purposely selected health districts to fulfil the criteria of the
over all project as outlined above. South Africa has nine, semi-autonomous provinces. In

consultation with the National Department of Health (NDoH), the NW Province was selected
for the study. The three study sites were:
Klerksdorp Health District in Southern District Municipality – Urban;
Mafikeng Health District in Central District Municipality – Semi-urban; and
Ganyesa Health District in Bophirima District Municipality – Rural.
1.4 Constraints
The general methodology used in the project is described above.
The project was well supported by the health authorities at national, provincial and the district
levels. The researchers, however, were faced with a number of constraints in accessing all
information and data required. These included:
• Accessing Municipal health managers and councilors.
• Accessing some Provincial hospitals.
• Questionnaire returns on training of nursing staff was poor in all districts.
• Disparities in data available at district level and from the District Health Information
System.
• Paucity of data available from years prior to introduction of decentralisation for
quantitative comparative purposes.
• Accessing Emergency Medical Services, National Health Laboratory Services and other
sectors for triangulation of data.
• Institutional diversity within each health district.
30
1.5 Structure of the report
This report refers to research findings from the South African case studies. The structure of the
report is designed to lead the reader logically through decentralisation policy in general and
decentralisation policy in health in particular.
Chapter 2: Context of decentralisation and reproductive health services in South Africa
This chapter describes the economic, political and social context at the national and NW Provincial
spheres of government, and the three health districts involved in the study. The health care
system at each level is described.
Chapter 3: Health Systems Decentralisation in South Africa
This chapter provides a general description and analysis of the historical development of health
systems decentralisation, and the present structure and stakeholder positions. It includes detail
on general decentralisation and health management decentralisation from a national, provincial
and a district perspective.
Chapter 4: Reproductive Health Services in South Africa
This chapter describes the development of reproductive health services in South Africa. The
current policies and implementation of reproductive health services is included. Details of
reproductive health services, including data analysis, for each study site is given.

Chapter 5: Districts – Context, Decentralisation, Intermediate Processes and Reproductive
Health Services.
This chapter links the information in the previous chapters for each study site, and, in particular,
reviews the impact of the different contexts of the three sites on reproductive health services
in those sites. It also links these issues with the information in the chapters 6 to 11.
Chapters 6 to 11
These chapters deal with the identified intermediate processes with specific focus on the
relationship between decentralisation and reproductive health services.
Chapter 6: Service Organisation and Delivery
This chapter discusses prioritising, targeting, service packages, standards and contracting of
services in South Africa and NW Province.
Chapter 7: Finances
This chapter looks at funding, budgeting and expenditure in the districts. An overview of national
and provincial funding and budgeting is included.
Chapter 8: Human Resources
This chapter reviews human resource management in respect of conditions of services, job
descriptions, hiring and firing, supervision, training, performance management, staff attitudes
and professional relationships. The focus is not only on reproductive health services, but more
general human resource issues are also included.
31
Chapter 9: Planning, Monitoring and Evaluation
The processes of planning, monitoring and evaluating service delivery are reviewed. A description
of the current DHIS is included.
Chapter 10: Governance
This chapter reviews the governance structures, formal and informal, that exist in the districts.
The discussion includes assessing at community involvement, intersectoral collaboration and
public-private relations in the districts.
Chapter 11: Logistics and Referral
Chapter 11 discusses some of the support systems for health services. These include drug supplies,
transport systems, laboratory services, infrastructure and maintenance, and the referral and
ambulance systems.
Chapter 12: Issues and Conclusions
This chapter brings together and discusses the main issues identified through the research.

Chapter 2
Context of Decentralisation and Reproductive
Health Services in South Africa
2.1 Introduction
Since 1994 South Africa has been through a process of transformation of policies and legislation
affecting all sectors of government. The effectiveness of this transformation is partly dependent,
on the context in which policies are implemented. The impact of implementing health policies
on reproductive health services, in the context of government transformation policies such as
decentralisation, is likely to be influenced by current events. The context is influenced by both
the past and the present; and is dependent on how the changes are moved into the future. It is
further dependent on globalisation which is impacting on South Africa during this process of
internal transformation. South Africa’s policy development is influenced by international trends
in funding policies.
The Constitution of South Africa established a three sphere government system. Chapter 3,
specifically Section 40, of the Constitution describes how these three spheres are to relate to
each other:
(1) In the Republic, government is constituted as national, provincial and local spheres
of government which are distinctive, interdependent and interrelated.
Geographically the country has been divided into nine provinces. The provinces are the second
sphere of government; and the country can be regarded as a “quasi-federal state” of nine
provinces. The context within these nine provinces vary and therefore the impact on service
delivery of national policies may differ between provinces.
32
The local sphere of government consists of six metropolitan and 47 district municipalities within
the nine provinces. The municipal boundaries are demarcated in terms of the Local Government
Demarcation Act, No. 27 of 1998. The district municipalities are further subdivided into local
municipalities. The number of local municipalities per district varies between two and five. The
context of these municipal areas differs and thus the impact of policy implementation can differ.
This chapter describes the economic, political and social contexts at national, provincial and
local spheres of government. At the provincial level the focus is on the NW Province where the
research was conducted. Three local municipalities in the NW Province, namely Klerksdorp,
Mafikeng and Ganyesa, are described as case studies. These three municipalities represent the
contexts in which policies for decentralisation and reproductive health are being implemented
in South Africa. Details of the health care system at each level and in the three local municipalities
are discussed. The historical background and development of policies related to decentralisation
for health services under the post apartheid government is described in Chapter 3.
2.2 National Context
National Government is responsible for the overall rule of law, policies and legislation in South
Africa. Transformation of government organs since 1994 has been guided by a number of
fundamental documents of the African National Congress (ANC). A synopsis of these documents
is included in the Appendix. Some of these policy documents are expanded upon below.

2.2.1 National Economic
Reconstruction and Development Programme
The economic policy in post- apartheid South Africa was initially outlined in the Reconstruction
and Development Programme (RDP) of 1994. Although at the core of the RDP was a macroeconomic
policy of “growth through redistribution” (redistribution acting as the catalyst for
growth) and was the principle guideline for over-coming the legacies of apartheid, reduction
in state expenditure does feature in the RDP chapter on the economy. Advocating expansion of
social infrastructure in certain sections, while advocating cuts in public spending in others,
clearly revealed the internal contradictions in the RDP document. Pillay and Bond (1995) note,
while the RDP document was developing, that the health budget was “targeted for explicit cuts”
but that this was later “modified” so that health would gain increases over the forthcoming years.
Pillay and Bond elaborate on the different ideological strands running through the RDP, which
make “it a document open to multiple (and often conflicting) interpretations.” 1 These ideological
‘strands’ include, firstly, maintenance of limits on state expenditure, promoting international
competitiveness and establishing an independent Reserve Bank.
33
At the time of development of the RDP, Tito Mboweni, the then deputy head of the ANC’s
economic planning department and currently Governor of the Reserve Bank, stated that ANC
policies “would after 1990 emerge from an interplay of inputs from the ANC’s organisational
structures; the policy departments; the positions of allies of the ANC (in particular Congress
of South African Trade Unions (COSATU); the experiences of developing countries; the lobbying
efforts of capital, the media, western governments, and independent commentators; and policy
research work of the International Monetary Fund (IMF) and World Bank.” 2 Marais has described
the “ideological barrage” and “plethora of research projects launched by the IMF and World
Bank” as “incessant.” 3
The RDP chapter on the economy also talks of “fiscal discipline” in reducing government
expenditures as a percentage of GDP. The IMF’s Key Issues in the South African Economy
document “warned against excessive expenditures on education, health, training and complementary
infrastructure.” 4 The second ideological strand in the RDP, as noted by Pillay and Bond,
“affirms the hegemonic role of markets in ordering of much of South African society, such that
the state operates primarily to lubricate the market and to correct its imperfections.” 5
However, the third ideological strand in the RDP reflected the input and “demands of the labour
and social movements that authored most of the document” and includes “a very strong
commitment to making basic goods affordable to all.” 6 Within this third ideological current of
the RDP there was a warning against IMF and World Bank programmes. Yet “the possibility
of the third, more radical current of the RDP becoming dominant dimmed further as World Bank
and other neoliberal programmes were adopted in the land and housing sectors, as education
reform experienced budget cuts and heavy ideological opposition, and as various efforts to
challenge corporate power were effectively thwarted.” 7
1 Pillay, Y.G. and Bond P. (1995) Health and Social Policies in the New South Africa, Int. J of the Health Services, Vol 25,
No 4, 727-748 (p 732).
2 Cited in Marais, Hein. (1998) South Africa. Limits to Change. The Political Economy of Transformation. University of Cape
Town Press, Cape Town. (p.76).
3 Marais, Hein. (1998) South Africa. Limits to Change. The Political Economy of Transformation. University of Cape Town
Press, Cape Town. (p.150 and 151).
4 Ibid (p.153).
5 Pillay, Y.G. and Bond P. (1995) Health and Social Policies in the New South Africa, Int. J of the Health Services, Vol. 25,
No 4, 727-748 (p 733).
6 Ibid.
7 Pillay, Y.G. and Bond P. (1995) Health and Social Policies in the New South Africa, Int. J of the Health Services, Vol. 25,
No 4, 727-748 (p.735).

The RDP White Paper was released in September 1994. In the White Paper the macro-economic
shifts were more pronounced in strengthening the emphasis on fiscal discipline, making explicit
a policy of export-led growth, lessening the original RDP document’s emphasis on basic
needs, further stressing reductions in public spending, and emphasising privatisation and the
expansion of the private sector. The contradictory strands of macro-economic conservatism in
the original RDP policy document were more explicitly revealed in the RDP White Paper with
the tightly controlled macro-economic balance taking precedence over redistribution.
Growth, Employment and Redistribution (GEAR) Policy
A currency crisis occurred in February 1996 with the Rand losing 25% of its value. Government
stressed that South Africa was in a precarious international position and that there was a need
to regain international confidence, and for South Africa to adapt to the New International
Economic Order. The RDP office was shut down in April 1996 and its functions transferred to
the offices of the Finance Minister and the Deputy President.
The GEAR policy was then released in June 1996, embracing the “Washington Consensus”, and
asserting that the policy was “non-negotiable”. It is claimed that the Tripartite Alliance partners,
COSATU and the South African Communist Party (SACP), were not fully consulted beforehand
and were only shown the section headings and not the full document. The response from
government to opposition to GEAR, from various quarters, was that it was not negotiable. 8
GEAR provided for the standard neo-liberal economic solutions of economic deregulation, a
dramatic reduction in the deficit, keeping inflation in single digit figures, trade liberalisation
in the form of lower tariffs, lower corporate taxes as well as tax reductions to encourage foreign
direct investment, an export orientated development strategy, increased labour market flexibility,
the relaxation of exchange controls, and the restructuring and privatisation of state assets. In
GEAR, fiscal policy became not merely ‘disciplined’ but ‘austere’. Most surprisingly, Government
proceeded to lift tariffs at a faster rate than was even recommended by the World Bank and IMF.
34
From as early as 1996, the principles of the free market have prevailed with severe implications
for delivery on the government’s social programmes; line ministries experienced the consequences
of GEAR’s fiscal constraints. The economic policy of the RDP’s “growth through redistribution”
was finally, and fully, abandoned in adopting economic liberalisation. Marais maintains that the
‘basic needs’ concept survived merely as a rhetorical device aimed at massaging political tensions
within the tripartite alliance.” 9
There was a shift from a social out reach policy to a cost efficient with strong fiscal controls.
This is similar to the conflict that Collins writes of in describing two broad approaches for health
sector reforms – the social development approach, as a vital principle of PHC particularly in
development of intersectoral coordination and community participation; and a market approach,
which sees decentralisation as a support for privatisation an ingredient of quasi-markets in the
public sector, a means to the breaking-up large public sector bureaucracies, and as a way in
which the advantages of small enterprise management may be incorporated in the public sector. 10
Is it possible to fulfil the social and health development required in South Africa within the
changing financial context?
The funding, budgeting and expenditure for health services is discussed in Chapter 7. The impact
of national fiscal changes on health services in general and reproductive health in particular is
also discussed.
8 Gumede, W.M. (2005) Thabo Mbeki And The Battle For The Soul Of The ANC. Zebra Press, Cape Town
9 Marais, Hein. (1998) South Africa. Limits to Change. The Political Economy of Transformation. University of Cape Town
Press, Cape Town. (p.189).
10 Collins C; Ten Key Issues for Developing Health Sector Devolution; HST Seminar; 16 Jan 2001; Durban.

2.2.2 National Political Context
The first democratic elections were held in South Africa in 1994 and the restructuring of
government began. The ANC dominates the party political scene nationally and in most provinces.
There is, however, active opposition politics in play.
Many new policies were developed and new legislation passed affecting services in public and
private sectors. The new government moved from a fragmented, inequitable system to a democratic
and developmental system. The restructuring of the public sector places emphasis on decentralisation
of services to be close to the community and the point of delivery. Communities were encouraged
to participate in the process. The three spheres of government places national government as
setting policy; provincial government as monitoring and evaluating policy implementation; and
local government as the sphere involved in implementation of policy.
The Constitution of the Republic of South Africa was signed into law in 1996 (Act 108 of 1996).
This has guided the establishment of a system of three spheres of government; namely, national,
provincial and local government. These three spheres work together in a “consultative and cooperative”
manner as outlined in Chapter 3 of Constitution. 11 The Intergovernmental Relations
Framework Bill to promote and facilitate intergovernmental relationships was published for
public comment in 2004.
National Government
The National sphere is responsible for policy development, the overall coordination of services
in the country, and the equitable distribution of resources, particularly financial resources.
35
Parliament is the legislative authority of South Africa and has the power to make laws for the
country in accordance with the Constitution. It consists of the National Assembly (NA) and the
National Council of Provinces (NCOP). Parliamentary sittings are open to the public.
The NA has between 350 and 400 members elected through a system of proportional representation.
Members of parliament do not, therefore, represent a particular constituency. The NA represents
the people in South Africa to ensure democratic governance as required by the Constitution.
The majority party elects their leader, who is also the President of the country. The NA provides
a national forum for public consideration of issues, passes legislation, and scrutinises and oversees
executive action.
The NCOP represents the interests of the provinces in the national sphere of government.
Each province has six permanent members and four special delegates on the NCOP. The
NCOP is mandated by the provinces to make decisions on behalf of the provinces.
Bills are introduced into the NA for debate and are then passed to the NCOP for consideration.
The NCOP can reject a Bill or pass it back to the NA with amendments for further consideration.
Both houses must pass a Bill before it is signed in to Law by the President.
The NA and the NCOP are divided into committees who are responsible for the bulk of the work
of Parliament. The NA has a Portfolio Committee (PC) for each government department. The
Health PC discusses, suggests changes or can reject any legislation related to health. The NCOP
has nine Select Committees each responsible for dealing with a number of departments and
issues, in a similar role to the PCs.
The PCs are required to consult the public on proposed legislation. Public hearings are held at
which individuals or organisations can make representations on proposed legislation.
11 National Government of South Africa (1996) Constitution of the Republic of South Africa, Act 108 of 1996, Chapter 3.

The committees are required to hold government to account for the work they are doing,
and to hold hearings on the budget and expenditure each year. The Health Portfolio
Committee holds hearings on provincial and the national departments of health budgets.
The system of government is designed to make provision for public participation at the highest
level of government.
Provincial Government
Each of the nine provinces defined in the Constitution, is semi-autonomous. A number of
functions are devolved from the national level to the provincial level. Finances come from the
National Treasury. The provincial government is responsible for monitoring and evaluating the
implementation of national policy. National policies, however, can be adapted to suit the particular
needs of the province. Each province is an amalgamation of two or more previous administrations
from the apartheid era.
Each of the nine provinces has its own legislature consisting of between 30 and 80 members
as determined in terms of a formula set out in national legislation. The members are elected in
terms of proportional representation. As with the National Assembly, there is no constituency
based representation in the provincial legislature. The Executive Council of a province consists
of a Premier and a number of members. The Premier is appointed by the National President.
The Provincial Legislature may adopt a Constitution for that province, provided two-thirds of
the members agree. The Provincial Constitution must, however, correspond with the National
Constitution. According to the Constitution, provinces have some legislative and executive
powers concurrently with the national sphere of government. These powers can be exercised
to the extent that provinces have the administrative capacity to assume effective responsibilities.
Health services are one of these responsibilities. The provinces may pass their own Provincial
Health Act, which must correspond with the NHA.
36
Provinces have exclusive competency over some health functions, including ambulance services.
A number of intergovernmental forums and committees meet regularly to facilitate co-operative
governance and intergovernmental relations. These include:
• The President’s Coordinating Council (PCC) – consists of the National President, the
National Minister for Provincial and Local Government and the premiers of the nine
provinces. The PCC meets to discuss issues of national, provincial and local importance.
• The MinMECs – consists of the national line-function ministers meeting with the
respective provincial government counterparts.
• Ministerial clusters – consists of provincial director generals meeting with the Forum
of South Africa Directors General.
• Other intergovernmental forums.
Local Government
The Constitution recognises local government as a third sphere of government. This has enhanced
the status of local government, in particular the role of municipalities as the level for delivery
of services. Local Government is responsible for providing basic services, such as water, sanitation
and electricity and is the level of policy implementation thus decentralising services and
encouraging community participation. Finances are provided by the National Treasury through
the Equitable Share and from locally raised rates and tax revenue.

The South African Local Government Association (SALGA) is formally recognised through the
Organised Local Government Act, 1997 (Act No. 52 of 1997) and is mandated to represent the
interests of organised local government in the country's intergovernmental relations system.
37
Three categories of municipalities are provided for in the Constitution. These are A or metropolitan,
B or local, and C or district municipalities. The roles and functions of these levels of local
government are laid out in the Constitution and in local government legislation. 12, 13, 14
Municipalities were demarcated by the Demarcation Board in 2000. 15 There are six metropolitan
municipalities and 47 district municipalities. These 53 municipalities cover the entire country.
Within each district municipality are two to five local municipalities, with a total of 231 local
municipalities in the country. The district municipalities are mainly responsible for capacity
building and provision of bulk services, such as water and electricity, and Municipal Health
Services (MHS). The local municipalities are the implementers, but do not have any legislated
health role. The district municipality can, however, decentralise on an agency basis any function
to a local municipality if the district municipality does not have the capacity to perform that
function.
Local government elections are held every five years, but not at the same time as those for
national and provincial spheres. Voting for local government is on a Ward system within each
local and metropolitan municipality. Representation in the municipal council is according to
majority vote within the Ward. The mayor is elected from the ranks of the majority party in the
council and mayoral committees established in terms of local government legislation. District
municipal councils are composed of representatives from the local municipalities from within
the district municipality.
Political representation at community level
Each sphere of government has elected political representation, as described above. There are,
therefore, three political lines through which community members are represented at national,
provincial and local government.
2.2.3 National Social Context
Since 1994 there has been a complete social re-alignment in South Africa. The country has
moved from a racially divided society to one that recognises every one to be equal before the
law. Racial restrictions have been removed and this has influenced migration of black population
into better suburbs previously reserved for Whites only. Apartheid, however, has left a legacy
of poorly resourced areas, particularly in the rural areas and developing ‘informal’ settlements
near the urban areas, and well resourced areas of the previously white population. New black
elites have emerged with this development.
Schools, hospitals and social services are open to all races. A programme of affirmative action
was introduced to assist in identifying previously disadvantaged people to progress to middle
and upper management levels within public and private sectors. Specific management training
courses are available to assist. Progress has been made towards correcting the imbalances of
the past and an increasing number of blacks and females are now found in senior management
positions.
South Africa has been described as “the rainbow nation” because of the racial, cultural and
language diversity. This diversity adds to the complexity of the context within which transformation
12 Constitution of the Republic of South Africa 1996 (Act 108 of 1996), Chapter 7. ,
13 Local Government Municipal Structures Act, No 117 of 1998. ,
14 Local Government Municipal Systems Act, No 32 of 2000.
15 Local Government Demarcation Act, No 27 of 1998.

of government organs and health services in particularly are taking place. It also helps to explain
the differences in the impact of policies on services delivery that is noted in the three case studies
used in this research.
2.2.4 National Health Care System
The National Department of Health (NDoH) is responsible for health policy development and
legislation and is responsible for monitoring the implementation of policies by the Provincial
Departments of Health (PDoH).
The following section describes the structure and systems in the NDoH, in particular in relation
to decentralisation, the DHS and reproductive health services (RHS).
Structure of National Department of Health
Decision making structures for health include:
• The Health MinMEC; chaired by the National Minister for Health and comprising the
Member of the Executive Committee (MEC) for Health from each province.
• The Provincial Health Restructuring Committee (PHRC); chaired by the Director
General of the National Department of Health and comprising the Provincial Heads of
Department of Health in the nine provinces as well as local government representation.
• The National District Health System Committee (NDHSC); chaired by the National
Chief Director for District Development and responsible for district health development,
decentralisation and DHS. The NDHSC has representation from each province and
from local government.
38
Sections of the NDoH organogramme is shown in Figures 2.1a, Figure 2.1b and Figure 2.1c on
pages 75 and 76, to illustrate the relationship between the departments with core responsibility
for decentralisation, DHS and reproductive health.
At present there are two Deputy Director Generals (DDGs) in the department. The Chief
Directorate for District and DHS Development are under the same DDG (Strategic Health
Planning) as are elements of reproductive health. There is no single directorate for reproductive
health. This function is split between the chief directorate of Maternal, Child and Women’s
Health (MCWH) and the HIV/AIDS Chief Directorate. These three chief directorates form
separate clusters for budgeting, management and monitoring. The official contact point between
the three is through the Chief Directors who are part of the extended management team of the
department.
There are plans to change this structure to increase the number of DDGs with a smaller span
of control so as to increase their effectiveness. Human resources will be the responsibility of
one of the new DDGs.
Senior management in the NDoH, comprising all chief directors and above, meet biweekly. The
purpose of these meetings is to assess departmental priorities and planning. Each meeting ends
with a discussion on HIV/AIDS issues and priorities. Coordination, however, between the
directorates and sub-directorates can be difficult and each is perceived to be working in isolation
to the others or as vertical programmes. This perception was evident at all levels of the health
care system.
The District and Development Chief Directorate is very small and lacking in capacity. It consists
of the Chief Director, a Director and one Deputy Director.

“Look, to be honest, at the national department at the moment, I am only acting in this
position while TW is in the EC, – there is me, there is BA, there is an Assistant Director
whose capacity is very poor – and that is it! …… Of course we have brought in some
additional expertise, some technical assistance……. But in the national department – that’s
it! And this is only part of my responsibility. The rest of my time is in strategic planning.”
The provincial counterparts are also small.
(National Health Chief Director: Strategic Planning)
The Chief Directorate for Maternal Health, Child Health, Genetics and Nutrition has undergone
changes since its inception in 1994. It started as a maternal, child and women’s health unit
looking at the issues of children, pregnant and lactating women and other women’s health issues.
It was later changed to have separate directorates for children and youth and another for women’s
health and genetics. HIV/AIDS is under a separate chief directorate, within its own cluster for
budgeting and planning. The split came at the time when HIV/AIDS was highly politicised.
HIV/AIDS, although recognised as a part of reproductive health, often operates separately. Each
cluster, under a chief director, plans as a unit; this means that HIV/AIDS and STI plan in a
separate cluster to the rest of reproductive health.
The PMTCT programme started within the HIV/AIDS directorate and was a research project.
This was incorporated into policy and operational plans of the cluster, with little initial input
from the maternal and women’s health cluster. This has changed to a certain extent and the two
clusters are reportedly working together, as described by a member of the HIV/AIDS directorate.
39
“Yes, we try as much as possible to co-ordinate. If we talk about training …… we have
recently developed a training manual for PMTCT of which MCWH was an integral part.
They contributed a huge section which was incorporated into the manual. So we work
together quite a lot.”
(NDoH HIV/AIDS Directorate)
A different perception of the situation, however, comes from the maternal and women’s health
cluster. Although MCWH are invited to attend meetings of the HIV/ADS cluster, decisions are
made without them being part of the decision making process, as explained by the Director for
Mother and Child Health:
“It is a struggle with reproductive health when we look at the sexually transmitted infections
including HIV and AIDS because of the political background and the history in the country.
It (HIV/AIDS) got so much attention and a lot of funding and support from donors … that
give directly. They end up pushing and running with the programmatic issues where the
reproductive health unit like the women’s health get invited to just come along, but not be
directly involved.”
(National Health Director – Mother and Child Health)
According to policy and the National Health Act of 2003 all reproductive health programmes
are to be delivered through the DHS. There has, however, been little consultation between the
two sections of district development and reproductive health programmes, as described by the
Chief Director: Strategic Planning:

“Let me start with the national department…… The first strategy to work more closely with
the programmes was for the systems people to move into the same building …… The (Chief
Director), when he took over, thought that was the key. It makes sense. But if you ask me
if it has made any difference as to how closely we work with the programmes, the answer
unfortunately is “No”. But what we are doing, and this is now very much strategic planning,
we are using the planning process to try and get people to work more closely together.”
He further explained:
(National Health Chief Director- Strategic Planning)
“So we are doing it via the planning process, we are doing it via a meeting process and
of course we are doing it via networks of personal contacts. But having said all that there
are still problems in the way that we interact.”
(National Health Chief Director- Strategic Planning)
Despite all efforts to date, coordination of programmes within DHS development remains a
challenge:
“…… left to their own devices each programme does its own thing. There is really no
coordination.”
(National Health Chief Director- Strategic Planning)
Human resources management has been considered as a weakness and not meeting the needs
of district development, as explained by a Chief Director in the NDoH:
40
“We recognised early on that our best managers should be at the local level, but the best
paid jobs are not at the local level. So our human resource strategy didn’t meet our district
development strategy. And we still find that today.”
(National Health Chief Director: Strategic Planning)
A Deputy Director General (DDG) for human resources will be appointed as part of restructuring
of the NDoH. Development of technical staff is mainly the responsibility of the relevant sections.
2.3 Provincial Context – North West Province
As mentioned previously the nine provinces, in South Africa act as in “quasi-federal” system
and are semi-autonomous. Each province is different in political, social, historical background
and capacity to deliver services. The provincial governments can develop their own policies and
legislation best suited to the needs of their communities. These, however, are required to be in
line with national policies and legislation.
This study was undertaken in NW Province and therefore discussion of provincial structures,
systems and processes for decentralisation and health services will be confined to this province.
In 1994 NW Province was formed through amalgamating the western part of the previous
Transvaal, the north western part of the Cape Province and the ‘homeland’ Bophuthatswana.
The province covers 114 343 sq kms, and has a population of 3 669 350 (2001 census). It has

een demarcated into four district municipalities (Central, Southern, Bojanala and Bophirima
District Municipalities) within which are 22 local municipalities. Cross-boundary areas are
shared with two provinces, namely Gauteng (City of Tswane) and Northern Cape (Kalahari-
Kgalagadi District Municipality and Taung-Hartswater Local Municipality). There are no
Metropolitan Municipalities in North West Province. North West Province borders four other
provinces to the east and south – Limpopo, Gauteng, Free State and Northern Cape – and has
an international boundary with Botswana to the north and west. The capital is Mafikeng in the
Central District Municipality which is close to the Botswana border
The topography of the province is rolling hills in the east, changing to flat semi-desert toward
the west and north where the province borders on the Kalahari Desert. In the east and south are
the main industrial and mining areas. The central part of the province comprises fertile commercial
farmland used for growing maize and grazing cattle. The north of NW province is the previous
Bophuthatswana ‘homeland’ where majority of the people are involved in subsistence farming.
In the west, the land is dry and semi arid.
Map of North West Province
BOTSWANA
Lobatse
Gabarone
PILANESBERG
NATIONAL PARK
Pilanesberg
Sun City
WATERBERG
Limpopo Province
Warmbaths/
Bela Bela
BORAKALALO
NATIONAL PARK
41
McCarthy’s
Rest
Tosca
Ganyesa
North West
Vryburg
Mafikeng
Zeerust
Lichtenburg
Rustenburg
Derby
Hartebeesfontein Potchefstroom
Klerksdorp
Orkney
Brits
Parys
Pretoria
Krugersdorp
Johannesbur
Soweto
Gauteng
Vereeniging
Kuruman
Bothaville
Kroonstad
Northern Cape
Warrenton
Free State
Welkom
2.3.1 North West Province Economic
The main commercial activities in the NW Province are mining (platinum and gold) and farming
(maize and cattle).
2.3.2 North West Province Political
The ANC has held political power in the province since1999 when they won with 79% of the
votes. The United Christian Democratic Party (UCDP) with 9.5% of votes in 1999, is the only
other political party with significant influence. The UCDP was the only significant political
party in the former homeland of Bophuthatswana. Its power-base is concentrated around Mafikeng.

There was political turmoil in the area during the run up to the first democratic elections in 1994.
Ventersdorp, which lies about 100 kms east of Mafikeng, is the home of the ultra right wing
Afrikaanse Weerstandsbeweging (AWB) Political and racial tensions ran high with resistance
to change shown from and between the UCDP and AWB. It may be argued that many issues
between the groups have been resolved. Evidence and experiences on the ground, however,
suggest that the history of these conflicts, particularly in Mafikeng area, may have an impact
on service delivery. This is explored later in this report.
The 2004 elections representation in the North West shows slight change to above. (See Table
2.1 below).
Table 2.1: North West and South Africa Political Representation in National Assembly
and Political Representation in North West Legislature - 2004
Sphere of
Government
African National
Congress
United Christian
Democratic Party
Democratic
Alliance
Other
Votes
% Votes % Votes % %
National Assembly
- North West
Province
representation per
political party
1 083 254 82
86 476 7 72 444 5 6
National Assembly
- total
representation per
political party
10 880 915 70
117 792 1 1 931 201 12 17
42
North West
Provincial
Legislation -
representation per
political party
1 048 089 82
110 233 9 64 925 12 4
Source: Independent Electoral Commission at www.elections.org.za
The NW Province is politically dominated by the ANC. It is, however, the only province with
significant representation from the UCDP in the National Assembly. In the 2004 election 73%
of the UCDP support in South Africa was from the NW Province.
Although decentralisation is a national policy, the process may be influenced by provincial
politics; and who is appointed into key posts, such as the MEC for Health. The MEC for health
in NW Province has completed two terms and was replaced following the April 2004
elections. Although the new MEC for Health is from the ruling party, there is uncertainty as
to how the process may change in future, as expressed by one senior provincial manager:
“And next years (2004) elections are going to impact because our MEC’s term of office
stops, …… so there is going to be a new MEC and we know how things works when political
heads change; there is a lot of other changes coming.”
(PDoH Chief Director- Health Services)

2.3.3 North West Province Social
The population of NW Province in 2001 according to age groups is shown in Table 2.2 and in
the population pyramid Figure 2.2. Thirty-one percent of the population was under 15 years of
age while only 5% was over 65 years old.
Table 2.2: Population of North West Province according to age groups - 2001 census
Years
No. of Persons in 2001
% of Total
0 - 4 361 686
10
5 - 14 786 519
21
15 - 34 1 332 800
36
35 - 64 1 004 973
27
Over 65 183 371
5
TOTAL 3 669 349
100
Source: Municipal Demarcation Board at www.demarcation.org.za
Figure 2.2: North West Province Population Pyramid - 2001 Census
43
Over 65
35 - 64
YEARS
15 - 34
5 - 14
0 - 4
-8000000 -6000000 -4000000 -2000000 0 2000000 4000000 6000000 8000000
Females
Males
Source: Municipal Demarcation Board at www.demarcation.org.za
Africans (black) represented 91% of the population in the NW Province in 2001 (Figure 2.3).
They live in the rural areas towards the western side of the province and industrial areas
near Klerksdorp and Rustenburg, the main areas of employment. Sestwana is the predominate
language. The white population, predominately Afrikaans speaking, mostly live in the
urban areas in the south and east and on commercial farms across the province.

Figure 2.3: North West Province - Population by Racial Group
- 1996 and 2001 Census
Less than 0.5%
2%
7%
KEY
Black - 3 358 450
White - 244 035
Coloured - 56 959
Indian - 9 906
91%
Source: Municipal Demarcation Board at www.demarcation.org.za
2.3.4 Provincial Health Care System – North West Province
In 1994 the NW Provincial Department of Health was established by joining previous departments
which were managed by different ‘governments’ and provided different services, with different
funding mechanisms and systems. They were centralised systems with different cultural ethos.
These were:
• The Transvaal Provincial Administration (TPA) health services which, although in
regions, were centrally controlled with hospi-centric services and focused mainly on
the white population. Limited range of PHC services (promotive and preventative health
services, such as immunisation, contraception and nutrition) were mainly delivered by
the local authorities and town councils, with little outreach to the community.
• The Cape Provincial Administration (CPA) – northern area; had similar structures to
the TPA.
• The Bophuthatswana government health services, which provided additional PHC
services to above, (such as treatment of minor ailments, antenatal care, TB treatment)
and general services through hospi-centric health wards, with only a few technical
decisions being decentralised. The services were for the African (black) population of
Bophuthatswana.
44
Internally there were major cultural, social and economic problems to overcome in bringing
these three health departments together because of the previous centralisation of services,
he different administrative systems and the different ethnic groups. A Strategic Management
Team comprising representatives from each previous administration oversaw the
process and in 1997 the integration of services into a unified provincial health service began.
The executive authority of the health department is invested in the MEC for Health. This is an
appointment, usually for one, or a maximum of two, five-year terms. The Head of Department
is a Deputy Director General (DDG) who is responsible for the administration of the department.
Figure 2.4 shows part of the head office organogramme. This demonstrates the relationship
between the directorates responsible for decentralisation and DHS development and the
reproductive health programmes. (See Appendix 2 for the complete NW PDoH organogramme)

The NW Province is divided into four health service delivery regions - Central, Southern,
Bojamola and Bophirima. The boundaries of these regions are coterminous with the boundaries
of the district municipalities of the same names. The services in each region are headed by a
Regional Director with a small Regional Management Team. Each region is sub-divided into
Health districts whose boundaries are coterminous with the local municipalities within the district
municipality. The Health District (i.e. Local Municipality) is the level to which the NW Province
plans to decentralise health services and establish a DHS. 16
Figure 2.4: North West Provincial Department of Health Organogramme - 2003
Head of Dept
DDG
Strategic Planning
Director
Health Service
Delivery CD
Corporate Services
CD
Health Programmes
CD
Finance
CD
Health Care
Services Director
Regional
Director x 4
CEO Hospital
Complexes x 3
PHC
Programmes
Communicable
Diseases
45
District Develop
DHS
MCWH
HIV/AIDS
District Hospital
Services
Source: NW PDoH, 2003
The establishment of the DHS and decentralisation of health services is the responsibility of the
Chief Director- Health Service Delivery. District Development and District Hospital Services
are sub-directorates within the Directorate-Health Care Services.
The director post for DHS has been vacant since 2000. A Deputy Director in the PDoH expressed
the impact of this:
“……but there was a weakness on the departmental side because the post of the director
has been vacant since 2000. It was only filled in June this year (2003). …… it was affecting
the whole DHS agenda which should be dominating every programme. So that was a major,
major, major weakness…… I attended NDHSC meeting as assistant director and I had to
push and struggle. I didn’t have support…… even my new Chief Director is not up to
scratch, with due respect, with DHS issues. …… there isn’t much debate; people don’t take
decentralisation debate seriously and yet it affects how we relate to other people and how
it relates to our own work. …… So who was pushing the decentralisation or logistical
systems agenda in the department?
(PDoH -Deputy Director)
16 North West Health Bill, 2001

Within each health district there is a full staff complement for all health and support services.
Hospitals are not part of the health districts and have their own separate management.
Where there is a lack of capacity within a hospital, expertise is shared with the district office.
The separation of hospitals from the district is a fairly recent decision and has meant
appointment of additional management personnel within the system. This was explained by the
Regional Director in Bophirima in describing management in the district level.
“But mind you we have our district hospital managers, general managers that have been
appointed; we have the full complement in this region. We have now appointed support
staff, because the district and the hospital were linked in one before, we have separated
them with the view to this delegation…… we have been appointing state accountants to take
the responsibility of financial management and that, and hospital information officers have
been appointed in some of our hospitals.”
(Regional Director)
In the PDoH, health programmes, which include all reproductive health services, are the
responsibility of the Chief Directorate- Strategic Health Programmes. There is no single
reproductive health programme. It is a shared responsibility across a number of sub-directorates
within the four directorates that are part of the Chief Directorate- Strategic Health Programmes.
The NW Province is divided into four regions, whose boundaries are each coterminous with a
district municipality. The provincial regional directors are on the Provincial DoH head office
staff establishment and are the main link between the PDoH and the health districts.
The regional director for the Bophirima Region is jointly appointed by the Bophirima District
Municipality, although paid by the province. The other three regional directors were
appointed in consultation with local government. This is part of the preparation for decentralisation
of PHC services to local government. Likewise, local municipalities are consulted in the
appointment of all health district managers, although they are not joint appointees.
46
The functions of the regional director are to:
• support the health districts, monitor services and address equity issues between health
districts;
• support and monitor the district hospital services within their region;
• liaise with other health support services, such as emergency medical services and
laboratory services;
• use their delegated powers in finance, personnel and other management areas;
• liaise, negotiate and coordinate with local government health services in the district
and local municipalities; and
• prepare for decentralisation of health services to local government.
(Extract from Personal Performance Agreement – Regional Director)
The regional offices have a small complement of staff that has regional responsibilities for
training, specialist support (pharmaceuticals, pediatrics, obstetrics and gynaecology, forensic
medicine) and other functions.
In the health districts, the level at which the DHS is being developed for delivery of PHC, the
services are provided through separate management systems:

• Health District Management Team – responsible for community outreach services,
mobile clinics, fixed clinics, community health centres and some community hospital
services. The Health District Manager reports to the Regional Director.
• District Hospital Management – responsible for district (level 1) hospital services.
The District Hospital Manager reports directly to Regional Director.
• Regional and Provincial Hospital Management – providing first level hospital care
in health districts where there is no district hospital. The Hospital Chief Executive
Officer reports directly to Chief Director- Health Service Delivery in Provincial Head
Office.
• Emergency Medical Services (EMS) – responsible for ambulance services and referral
of patients between levels of care. EMS has provincial, regional and district management
structures separate to the other structures and reports to the Chief Director -
Strategic Health Plans in the Provincial Head Office.
• Laboratory Services – part of the National Health Laboratory Services (NHLS), based
in the district or provincial hospital to provide quality laboratory services to all health
services in the district. The NHLS is a parastatal and has centralised structure extending
from national to hospital level.
• Local Government Health Services – responsible for some PHC services in some
metro, district and local municipalities. These services are managed through separate
structures within each municipality.
47
These structures and their relationship to each are illustrated in Figure 2.5 on page 77 at the end
of Chapter 2.

2.4. North West Local Level
The local sphere of government is the level of implementation of basic services and any other
services delegated from the national or provincial sphere.
Section 152, Chapter 7, of the Constitution of the Republic of South Africa 17 outlines the objects
of local government as:
(a) to provide democratic and accountable government for local communities;
(b) to ensure the provision of services to communities in a sustainable manner;
(c) to promote social and economic development;
(d) to promote a safe and healthy environment; and
(e) to encourage the involvement of communities and community organisations in the
matters of local government.
In addition it says:
A municipality must strive, within its financial and administrative capacity, to achieve the
objects set out in subsection (1).
And Section 156, on powers and functions of municipalities it says:
(1) A municipality has executive authority in respect of, and has the right to administer
(a) the local government matters listed in Part B of Schedule 4 and Part B of Schedule 5;
and
(b) any other matter assigned to it by national or provincial legislation.
48
Local government legislation, such as the Municipal Structures Act No 117 of 1998 and the
Municipal Systems Act No 32 of 2000, provide details on the functioning of local government.
Constitutionally, local government is responsible for ‘MHS’. 18 These have now been defined
in the NHA, 2003 19 as elements of environmental health. The balance of PHC, therefore, remains
the responsibility of the provincial sphere of government. The long term vision, however, is for
all PHC services to be delegated, or assigned, to local government through Service Level
Agreements.
Within each metro, district and local municipality PHC health services are provided by provincial
and MHS. In the NW Province these services have been functionally integrated since 1997 and
employees of both spheres are represented on the Health District Management Team.
This section will firstly, briefly outline the generic structures for health in a health district in
the NW Province, and secondly, provide a detailed description of the three study sites used in
the research.
17 Constitution of Republic of South Africa, 1996.
18 Constitution of Republic of South Africa, 1996 – Schedule 4, Part B
19 National Health Act No 61 2003 (Act 61 of 2003).

Health District Management
The organogramme below (Figure 2.6) shows the generic structure of the health district
management team. Each district varies according to local need and staffing numbers. In Ganyesa,
the rural health district, some area managers have responsibility for a particular health programme
as well; in Klerksdorp, the urban health district, the municipal employed health manager and
facility managers are part of the management team, although they report to the municipal
structures as their line managers. There is no single person appointed in any health district to
be in charge of reproductive health. As at national and provincial levels, the responsibility is
shared among a number of officials, all of whom report to the Assistant Director- Community
Health Services (ADCHS).
Figure 2.6: North West Province - Health District Generic Organogramme
Regional Director
Health District Level
Health District Manager
AD Administration
AD Community
Health Services
49
Finances
Programme Manager
MCWH, Com Dis
Human Resources
Health Area Managers
Other support
services
CHC, Clinics, Mobiles
Source: NW PDoH, 2003
Health services in districts are delivered through Health Areas, each managed by an appointed
Health Area Manager who is in charge of the community health centres, clinics, mobiles and
other services in their areas. Facility managers take responsibility for the services within their
facility, including contributing to the budgeting process. Facility managers report to the area
managers who assists them in solving problems. Patients requiring higher level of care are
referred, by ambulance or private transport, to the district hospital. The district hospital is under
a separate management structure. In some health districts there is no district hospital. These
services are then supplied by a regional or provincial hospital that is located within the health
district.
Services are rendered as a comprehensive, integrated service, often referred to as a ‘supermarket’,
one-stop approach. This means that all services are available at all times that the clinic is open.
The opening times of clinics vary. As far as possible there is a community health centre (CHC)
within each health area that provides 24 hour service, including maternity care. Problem cases
are referred from the CHC to a hospital.

There are varying numbers of mobile clinics operating from the CHCs. These mobile clinics
provide a weekly, fortnightly or monthly service to more remote areas of the district. Fixed
clinics in the Health Area operate 8, 12 or 24 hours per day, depending on staffing and local
need. Problem cases are referred either to the CHC or directly to the hospital. There is a plan
to increase coverage through establishing 2-roomed clinics run by a single professional nurse
in remote areas. Voluntary health workers, community health workers and NGOs work with the
health services to extend care into the community.
An important component of the health services within each district are the governance
structures established in terms of the North West Health and Social Welfare Governance Structures
Act of 1997. The functioning and impact of these structures varies between districts and even
between facilities. These structures and their function are discussed in Chapter 10.
Local Government Health Structures
The organogramme for local MHS depends on the size of the local municipality and the extent
of their involvement in health. Prior to 1994 some local authorities rendered PHC services on
an agency basis for the National Department of Health, who built clinics on municipal owned
land, equipped them and handed them to the local authority to run. The services, including
medicines, were funded by the national government through special grants.
Where there is a significant municipal PHC service the Municipal Health Manager is responsible
for all municipal clinics and reports to the Municipal Manager. The combined health district
management team includes the Municipal Health Manager and the provincially appointed Health
District Manager.
Provincial and local government spheres have different conditions of employment and structure
of posts. Provincial conditions of service are set centrally by the national government; each local
municipality in the province determines these for themselves. This is likely to change when a
single public service is finalised and the conditions of service at national, provincial and local
spheres are standardised. This is discussed further in Chapters 4 and 8.
50
2.4.1 Klerksdorp Health District, Southern Region (District
Municipality) – urban
Klerksdorp Health District is coterminous with Klerksdorp Local Municipality and is one of
four health districts in the Southern Health District or Region in the NW Province.
Klerksdorp is approximately 200 kilometres (kms) west of Johannesburg, and about
10 kms from the Vaal River. The topography is mostly flat. The Klerksdorp Local Municipality
comprises 4 previous local authorities – Klerksdorp, Orkney, Stilfontein and Hartebeesfontein
– and the commercial farmland between them and is frequently referred to as KOSH. 20 It borders
on the Free State Province to the south. Klerksdorp, the second largest urban area in the province,
was founded as a gold mining town and mining remains the main industry in the area.
The previous local authorities all provided some health services, mainly environmental health
services with a few clinics providing family planning and preventative and promotive health
services. This has changed. The municipal clinics have been integrated with the provincial
services and now provide a comprehensive primary health care (PHC) service. Additional staff
for these expanded services is provided by the province. Health services to the farming areas
are mostly provided through mobile clinics that visit these areas on a weekly or monthly basis.
These are mostly run and managed by the provincial health services.
20 There are additional commercial farming areas.

The private sector provides significant health services in Klerksdorp, being an urban area there
are more people with private medical aid. The mining sector provides some services for their
employees, but not for the families, who are therefore dependent on the state for services.
Demand for services from the public health sector is increasing due to the mines now contracting
out functions that were previously done in house thereby having less directly employed workers.
The mines do not provide medical care to these contractees, who are therefore also dependent
on the state.
The Regional/District Director has her office in the district and is appointed by the province.
The Regional/District Director’s roles are to coordinate and monitor the health services in the
Southern District Municipality. The Regional Office is small and consists of the Regional Director
with administrative support staff.
51
2.4.1.1 Klerksdorp Economic
According to the 2001 national census, the total work force in Klerksdorp Local Municipality
was 159 898 of which 95 871 (60%) are employed, 64 027 (40%) are unemployed and a further
90 267 are recorded as being ‘economically inactive.’ 21 The 1996 census does not record the
number of ‘economically inactive’; but of the total workforce of 156 763 the number of employed
(113 499 – 72%) was higher and the unemployed (43 264 – 28%) lower. The total population
of the district increased from 335 237 in 1999 to 359 202 in 2001, an increase of 7%. 22
The main source of employment is the mining or quarrying industry. Between 1996 and
2001 the numbers employed dropped from 48 285 to 30 340, a decrease of 37%. Many of the
mine workers are migrant labourers from other provinces, such as the Eastern Cape.
These figures indicate a rising population, but decreasing employment and industrial activity.
In 1996 the number of households with no income was 7 968 (11%); this increased to 22 185
(20%) in 2001 – an increase of 14 217 households. There are fewer households with an income
of over R9 600 per annum. This is shown in Figure 2.7.
Figure 2.7: Klerksdorp Local Municipality - percentage households per income
bracket in Rands - 1996 and 2001
35.0
30.0
Percent Households
25.0
20.0
15.0
10.0
5.0
0.0
None
1 - 4
800
4 801 -
9 600
9 601 -
19 200
19 2001 -
38 400
38 401 -
76 800
76 801 -
153 600
15 601 -
307 200
307 201 -
614 400
614 401 -
1 228 800
1 228 801 -
2 457 600
Over
2 457 600
1996 2001
Income Bracket in Rands
Source: Municipal Demarcation Board at www.demarcation.org.za
21 The term ‘economically inactive’ is not defined in the information provided by Municipal Demarcation Board.
22 2001 Census – taken from Municipal Demarcation Board website: http://www.demarcation.org.za/

2.4.1.2 Klerksdorp Health District Political
Prior to the 1994 democratic elections Klerksdorp fell entirely within the Republic of South
Africa. The white community was generally conservative and supportive of the government.
Klerksdorp was divided on racial lines, with ‘Whites’ and Africans (‘blacks’) living in separate
parts of the city.
The December 2000 local government elections consolidated four local authorities and the
commercial farm land in between them into the Klerksdorp Local Municipality. The previous
local authorities brought with them experience in local government. The municipality has a
Mayor and Mayoral Committee to run the affairs of the municipality. There is an appointed
Health Manager who is part of the district management team.
Political party representation in Klerksdorp in the North West Provincial Legislative Assembly
and the political representation in the Klerksdorp Local Municipal Council are shown in the
table 2.3 below. The council and local politics are dominated by the ANC, with some support
for the Democratic Alliance. There is small representation by the UCDP and small support for
the right wing Freedom Front Plus Party.
Table 2.3: Klerksdorp Local Municipality - Political representation in North West
Legislature (2004) and Klerksdorp Local Municipal Council (2000)
Sphere of
Government
African
National
Congress
Votes
United
Christian
Democratic
Party
Democratic
Alliance
Freedom
Front
Other
% Votes % Votes % Votes % %
52
Provincial
Legislative
Assembly - 2004
101 121 78
1 653 1 15 428 12 3 607 3 5
Klerksdorp Local
Municipality - 2000
112 775 74 1 451 1 30 379 20 - 0 5
Source: Independent Electoral Commission at www.elections.org.za
The Klerksdorp Municipal Council has 22 members from the ANC, 7 from the Democratic
Alliance and one Independent.
2.4.1.3 Klerksdorp Health District Social
In the 2001 census the total population of Klerksdorp Local Municipality was 359 202 of whom
175 593 (49%) were female. Population in 1996 was 335 237 (an increase in 2001 of 7.1%)

Over 65
Figure 2.8: Klerksdorp Health District Population Pyramid - 2001 Census
35 - 64
YEARS
15 - 34
5 - 14
0 - 4
-8000000 -6000000 -4000000 -2000000 0 2000000 4000000 6000000 8000000
Females
Males
Source: Municipal Demarcation Board at www.demarcation.org.za
Data from the 2001 census shows that 26.5% of the population was under 15 years and 37%
was between 15 and 34 years and 4.2% was over 65 years.
Table 2.4: Population of Klerksdorp Local Municipality according to age groups
- 2001 Census
53
Years
No. of Persons in 2001
% of Total
0 - 4 31 602
8.80
5 - 14 63 730
17.74
15 - 34 132 898
37.00
35 - 64 115 889
32.26
Over 65 15 083
4.20
TOTAL 359 202
100
Source: Municipal Demarcation Board at www.demarcation.org.za
Other data from the 2001 and 1999 census includes:
• 31.6% of over 20 year olds had some or no primary schooling (36.6 % in 1996); 21.9%
had completed Grade 12 (14.2% in 1996) and 6.0% had higher education (4.7% in
1996).
• Children and adolescents between 5 and 24 years – 31.1% were not at any education
centre, 3.0% were at pre-school, 63.3% were at school and 2.6% were attending higher
education institutions. There were no details from 1996 census.
The above data shows that more young people are receiving basic education. In 2001, though,
nearly one third of youth and young adults were out of school.
• Light sources – electricity 81.1% (68.2% in 1996); paraffin 2.6% (3.0% in 1996);
candles 16.1% (28.6% in 1996).

• Water source – in dwelling 27.6% (54.4% in 1996); in yard 55.6% (32.3% in 1996);
community stand 6.4% (10.2% in 1996).
• Sanitation – flush 66.9% (62.3% in 1996); VIP 0.7% (nil in 1996); pit latrine 2.0%
(5.2% in 1996); bucket 23.7% (26.9% in 1996); none 5.5% (5.6% in 1996).
• Refuse removal – municipal weekly 86.5% (84.6% in 1996); communal dump 0.7%
(2.0% in 1996); own dump 6.6% (6.9% in 1996); no disposal 4.2% (3.6% in 1996).
Figure 2.9: Klerksdorp Health District - Population by home language
- 1996 and 2001 census
%
18
3
0.5
KEY
Persons 2001 1996
Afrikaans 66 311 62 082
English 9 957 9 046
IsiNdebele 517 211
17
2
1
20
IsiXhosa 61 234 60 612
IsiZulu 6 742 6 102
Sepedi 1 995 1 566
Sesotho 73 297 65 987
Setswana 128 627 114 431
54
35
1
0.5
2
1
Siswati 2 124 2 363
Tshivenda 508 309
Xitsonga 5 955 8 534
Other 1 935 1 426
Source: Municipal Demarcation Board at www.demarcation.org.za
Basic infrastructure for water and sanitation and refuse removal shows some improvement.
The 2001 national census shows that 79% of the population in Klerksdorp are Africans (blacks),
18% are White and 3% are Coloured.
The Africans (black group), although dominated by Setswana, includes a significant number of
Xhosa, Sesotho and other ethnic indigenous groups. The Whites and Coloureds are predominately
Afrikaans speaking.
Klerksdorp was formally in the Transvaal Province and includes no areas of previous ‘homeland.’
The majority of Africans probably moved to Klerksdorp as part of the migrant labour system,
in particular the Xhosa, Sesotho and Zulus. Many Africans (blacks) did not have permanent
homes in the area and did not have access to land until after the 1994 elections.

3%
0%
Figure 2.10: Klerksdorp Health District - Population by Racial Group
- 1996 and 2001 census
18%
KEY
Persons 2001 1996
Black 283 848 263 934
Coloured 10 005 8 726
Indian 1 332 1 521
79%
White 64 017 59 205
TOTAL 359 202 335 237
Source: Municipal Demarcation Board at www.demarcation.org.za
Table 2.5: Klerksdorp Health District - Health Areas: Number of CHCs and
Clinics according to Hours of Opening
Area
CHC - 24hour
Clinics Mobiles TOTAL
55
Klerksdorp 1
6
4
11
Stilfontein 1
3
2
6
Orkney 1
2
3
6
Hartebeesfontein 1
3
1
5
TOTAL 4
14
10
28
Source: Klerksdorp District Management Team
Prior to 1994 the whites dominated the commercial, mining and industrial sector in Klerksdorp
and employed many migrant workers, particularly on the mines. The town was separated into
White, Coloured, Indian and Africans residential areas, with the ‘white’ areas having the most
developed infrastructures and services.
The community in Klerksdorp is more reflective of the multi cultural nature of South Africa.
The community as a whole is less influenced by traditional systems than the more rural areas.
2.4.1.4 Klerksdorp District Health Care System
The present health services in Klerksdorp are provided through integration of a number of
previous health authorities – the Western Transvaal and local authorities. There are no previous
‘homeland’ health services in the district.

The province and the local municipality jointly manage the health services in Klerksdorp.
Historically the previous local authorities ran many of the clinics. The services have been
expanded within these clinics, the additional staff being employed and paid for by the province.
A close working relationship has developed between the two spheres of government, despite
the different conditions of service for personnel between the local and provincial governments.
Services are managed through four health areas known as Klerksdorp, Orkney, Stilfontein and
Hartebeesfontein, the four local authorities that form, with some agricultural areas between
them, the Klerksdorp Local Municipality.
PHC services are delivered through community health centres (CHCs), fixed clinics, satellite
clinics and mobile clinics. Klerksdorp Municipality plays a significant role in provision of
PHC services and works closely with the provincial services. The provincial department of
health provides all hospital services in the district through one hospital complex – Klerksdorp-
Tshepong Provincial Hospital. The Tshepong section provides district hospital (level 1)
health care and the Klerksdorp section regional (level 2) and some tertiary (level 3) health care.
The CEO of the complex reports directly to the Provincial Chief Director- Health Services.
In Klerksdorp Health District there are four CHCs and 14 clinics. See Table 2.5. Thirteen of
these facilities are managed by the MHS and the rest by the provincial health services.
There are, however, health workers from both health authorities working in all clinics.
Table 2.6: Klerksdorp Health District: Facilities per
100 000 head of population
Facility
CHC
Fixed Clinics
Mobile Clinics
Hospitals
No. per 100 000 population
1.1
3.90
2.78
0.28
56
Source: Klerksdorp District Management Team
Table 2.6 shows the number of facilities in the district per 100 000 head of population in 2001.
Data from the Regional Quarterly Report, July to Sept 2003, show that 85% of population lives
within 4kms of a PHC facility.
There are a number of private and mining hospitals in the district. There is some coordination
developing between the public and private sector. Negotiations are underway to use some private
beds in a mining hospital for state patients.
Availability of Hospital Beds – Public Sector
Tshepong section of Klerksdorp Hospital complex provides district level health care. The hospital
provides:
• First level care for the health district.
• Coordinates drug supplies to all clinics and community health centres in the district.

• Provides laboratory services through the NHLS based on the premises.
• Provides doctors to visit clinics and community health services.
The provincial hospital has a decentralised management system – the CEO reports directly to
the provincial Chief Director, who is also the Regional Director. The hospital provides secondary
and tertiary level care for the whole region, and, in addition, is the referral centre for other
districts in the province, such as Bophirima.
The District manager has no jurisdiction in the hospital, but has established a good working
relationship with the hospital CEO and managers. District and clinic staff attend monthly
Maternal Mortality and Peri-natal Mortality meetings convened by the hospital. The hospital
provides specialist antenatal care, termination of pregnancy services and other services. A number
of patients by-pass the clinics and deliver at the hospital. This is discussed in Chapter 5.
Health Professionals
There are a number of vacant health worker posts in the district. These are listed in Table 2.7
and related to the population in 2001 for ratio of public service health professionals per
100 000 head of population.
Table 2.7: Klerksdorp Health District: Health Professionals per 100 000 population
Prof Group
Place
No.
Appointed
Vacancy
Posts
Vacancy
Rate in %
Population
Ratio
57
Medical Officers
District
Klerksdorp Hospital
Total
4
40
44
1
16
-
20
29
- 12.25
Specialists
District
Klerksdorp Hospital
Total
0
12
12
0
8
-
0
20
- 3.34
Prof Nurses
District
Klerksdorp Hospital
Total
68
302
370
23
24
-
25
7.40
- 103.01
Source: Klerksdorp District Management Team
In Klerksdorp District there is an increase in the number of professional nurse days worked in
the CHCs and clinics. (See Figure 2.11) This is in line with the changing services delivered
through the clinics following the functional integration of provincial and local government
services. Prior to 1994 these clinics provided promotive and preventative services only, which
required less staff. All clinics now provide comprehensive health services that require expertise
of professional nurses. The total number of patients attending these clinics has increased with
the opening of services to all race groups.
2.4.2 Mafikeng Health District, Central Region (District Municipality)
– semi-urban
Mafikeng Health District is one of five districts within the Central Region of the NW Province.
The boundaries are coterminous with those of the Mafikeng Local Municipality. The Central
Region boundaries are coterminous with those of the Central District Municipality.

Figure 2.11: Klerksdorp Health District - CHC and Clinic nursing
staff working days - 2001 to 2003
Number work days
20,000
15,000
10,000
5,000
0
2000
2001 2002 2003
year
PN work days PHC
EN work days PHC
NA work days PHC
Source: North West District Health Information System
The district is identified as a “semi-urban” health district. It comprises the town of Mafikeng
and surrounding commercial farms and “tribal” areas of the previous Bophuthatswana ‘Homeland’.
It borders onto Botswana to the north and the other districts of the district municipality to the
south, east and west.
The area is generally flat, savannah country with a comparatively low annual rainfall, but fertile
soils and is a rich maize producing area. There are also cattle farms in the area.
58
During the apartheid era, Mmabatho which is about 5 kms from the centre of Mafikeng town
was purposely built as the capital of the Bophuthatswana ‘Homeland.’ The apartheid laws
separated the community by race – Whites lived in Mafikeng and Africans in Mmabatho. The
Whites included central government officials seconded to work with the Bophuthatswana
government and commuted daily to work in Mmabatho. There was little, if any, social mixing
between the two groups. At the height of political tensions in the area prior to 1994
Mmabatho residents were not allowed into Mafikeng at night due to a nightly curfew. 23
The two towns are now part of the same municipal council, Mafikeng Local Municipality, and
there is free movement between the two centres.
Mmabatho was the centre of political power for the Bophuthatswana government. Mafikeng
and surrounding farm areas were dominated by white right wingers from the Conservative Party
and other right wing parties. During the early transition phase towards democracy the area was
a ‘hot-bed’ of political activity.
The town of Mafikeng is the seat of the NW Provincial government. It is a commercial centre
with some industry. The public service is the main employer. However, a number of the public
servants have homes elsewhere in the province or neighbouring provinces, in particular Gauteng.
It is also a university and educational centre. There is a military camp outside the town.
The town is growing. It is served by an airport which at present is used mainly by private charter
flights, but in the past has had commercial flights to and from Johannesburg. These are expected
to be re-introduced.
23 DoH official; Personal communication , 2004.

There are informal settlements on the edge of the town, in marked contrast to other parts of town
where there are large, expensive homes presumably mainly for government and civil service
officials.
All public health services are managed by the PDoH. The Mafikeng Local Municipality runs
one small clinic for their employees and families. With the large number of government employees,
most of whom have access to private medical aid, there are significant private sector services.
Military staff and families are catered for through South African Medical Services.
The NW Provincial Department of Health and the Central Regional Office are located in
Mafikeng.
59
2.4.2.1 Mafikeng Economic
The total population of Mafikeng Local Municipality increased from 242 193 in 1996 to 259
478 in 2001; an increase of 7.1%. In 2001, out of total workforce of 93 509, about half - 47 448
were employed (47697 in 1996; a drop of 0.5%) and 46 061 were unemployed (37 316 in 1996;
a rise of 23%) with a further 71 453 recorded as ‘economically inactive’. The ‘economically
inactive’ were not included in the 1996 census.
The main employment is in the community/social/personnel sector (36% in 1996 and 37% in
2001); private households (15% in 1996 and 13% in 2001) and retail/wholesale (12% in 1996
and 14% in 2001).
Figure 2.12 shows the fall in annual income per household between 1996 and 2001. The
percentage of households with no income increased from 17% to 28% in the 5 year period.
There are also a lower percentage of households with over R9 600 per annum.
Figure 2.12: Mafikeng Local Municipality - percentage households per income
bracket in Rands - 1996 and 2001
30.0
Percent Households
25.0
20.0
15.0
10.0
5.0
0.0
None
1 -
4 800
4 801 -
9 600
9 601 -
19 200
19 201 -
38 400
38 401 -
76 800
76 801 -
153 600
15 601 -
307 200
307 201 -
614 400
614 401 -
1 228 800
1 228 801 -
2 457 600
Over
2 457 600
1996 2001
Income Bracket in Rands
Source: Municipal Demarcation Board at www.demarcation.org.za

Mafikeng is the seat of the provincial government; the public service is a major employer. There
is little formal industry. The town, however, is a commercial farming centre and a rail link to
Botswana and other sub-Saharan countries. The University of the NW Mafikeng Campus, is
situated in this town.
2.4.2.2 Mafikeng Health District Political
The Mafikeng Local Municipality was established in 2000, according to the Municipal
Demarcation Act. Provincial Legislative Assembly representation in Mafikeng is dominated by
the ANC, with 30% supporting the UCDP, the party that governed Bophuthatswana.
Table 2.8: Mafikeng Local Municipality - Political representation in North West
Legislature (2004) and Mafikeng Local Municipal Council (2000)
Sphere of
Government
African
National
Congress
United
Christian
Democratic
Party
Democratic
Alliance
Freedom
Front
Other
Votes
% Votes % Votes % Votes % %
Provincial
Legislative
Assembly - 2004
56 515 66
26 226 30 999 1 184 0 3
Mafikeng Local
Municipality - 2000
46 472 54 37 169 43 2 119 2 - 0 1
60
Source: Independent Electoral Commission and Municipal Demarcation Board
In the December 2000 local government elections the Mafikeng Local Municipal had 54% ANC
and 43% UCDP. See Table 2.7.
The municipal council has 19 ANC Councillors and 9 UCDP Councillors.
History shows that some party members of UCDP opposed some of the post 1994 changes and
Mafikeng was an area of some political upheavals.
Mafikeng Local Municipality is in the Central District Municipality, which is a new structure.
Neither municipality provides health services, nor has appointed a Health Manager. Each does,
however, have a Member of the Municipal Council (MMC) responsible for social services,
including health.
2.4.2.3 Mafikeng Health District Social
The total population of Mafikeng Local Municipality was 259 480 (2001 Census) of whom 138
872 (51.59%) were female. The population in 1996 census was 242 193, an increase in 2001
of 17 647 (7.3%).
Data from the 2001 census shows that 32.5% of the population was less than 15 years; 37.8%
between 15 and 34 years. 4.2% were over 65 years.
23 DoH official; Personal communication , 2004.

Table 2.9: Population of Mafikeng Local Municipality according to age groups
- 2001 census
Years
No. of Persons in 2001
% of Total
0 - 4 26 376
10.16
5 - 14 58 153
22.41
15 - 34 98 078
37.80
35 - 64 66 023
25.44
Over 65 10 850
4.18
TOTAL 259 480
100
Source: Municipal Demarcation Board at www.demarcation.org.za
Over 65
Figure 2.13: Mafikeng Health District Population Pyramid - 2001 Census
35 - 64
61
YEARS
15 - 34
5 - 14
0 - 4
-8000000 -6000000 -4000000 -2000000 0 2000000 4000000 6000000 8000000
Females
Males
Source: Municipal Demarcation Board at www.demarcation.org.za
Other data from the 2001 and 1999 census shows that:
• 36.1% of over 20 year olds have some or no primary schooling (38.9% in 1996); 22.3%
have completed Grade 12 (17.5% in 1996) and 8.5% have higher education (6.5% in
1996).
• Children and adolescents between 5 and 24 years – 28.8% were not attending any
educational institution, 3.5% were at pre-school, 63.1% were at school and 4.4% were
attending higher education institutions. There were no details from 1996 census.
The general level of education is improving in Mafikeng municipality with 8.5% having tertiary
education. This possibly relates to the presence of the University in the town and the civil-service
nature of employment. There were 29% of youth and adolescents not attending any educational
institution.

• Light sources – electricity 71.0% (22.5% in 1996); paraffin 3.6% (11.7% in 1996);
candles 24.0% (46.8% in 1996).
• Water source – in dwelling 23.5% (32.4% in 1996); in yard 21.7% (15.2% in 1996);
community stand 11.2% (17.2% in 1996); borehole 22.6% (24.8% in 1996).
• Sanitation – flush 27.0% (25.5% in 1996); VIP 18.4% (nil in 1996); pit latrine 46.3%
(71.0% in 1996); none 4.6% (3.0% in 1996).
• Refuse removal – municipal weekly 25.6% (22.5% in 1996); communal dump 3.8%
(2.3% in 1996); own dump 63.5% (68.5% in 1996); no disposal 6.2% (5.5% in 1996).
Water, sanitation and refuse removal infrastructure shows some improvement between 1996 and
2001.
The 2001 national census shows that 95% of the population of Mafikeng was African (black).
See Figure 2.14.
Figure 2.14: Mafikeng Health District - Population by Racial Group
- 1996 and 2001 census
2% 1% 2%
KEY
Persons 2001 1996
Black 247 634 230 969
Coloured 5 458 4 565
95%
Indian 1 858 1 332
White 4 528 4 149
TOTAL 259 478 242 193
62
Source: Municipal Demarcation Board at www.demarcation.org.za
The dominant home language of the Africans was Setswana (83%) followed by Afrikaans 3%,
English 2% and a few other indigenous groups, such as Sesotho, Xhosa and Zulu. (Figure 2.15)
The town of Mafikeng is a mixture of middle and upper class suburbs, with informal settlements
on the outskirts. Further from the town are tribal areas which were previously part of
Bophuthatswana. These areas adhere to some traditional value systems, including of the presence
of a paramount chief in the area.
2.4.2.4 Mafikeng Health District Health Care System
The health services in Mafikeng Health District were previously predominately run by the
Bophuthatswana Health Department. There were no significant health services run by the
Transvaal Provincial Administration, except some mobile clinics in the farming areas.
The Mafikeng Health District has been affected by a realignment process to change boundaries
to being coterminous with those of Mafikeng Local Municipality. The district management team

0.5%
Figure 2.15: Mafikeng Health District - Population by Home Language
- 1996 and 2001 census
%
3
2
0.5
6
1
4
KEY
Persons 2001 1996
Afrikaans 7 599 6 583
English 5 582 4 167
IsiNdebele 619 173
IsiXhosa 14 483 13 206
IsiZulu 3 254 2 377
Sepedi 1 084 656
83
Sesotho 10 194 7 842
Setswana 212 655 203 213
Siswati 567 136
Tshivenda 174 82
Xitsonga 481 244
Other 2 787 2 209
63
Source: Municipal Demarcation Board at www.demarcation.org.za
has been responsible for the services in Makgobistadt, which is in Setlakgobi Local Municipality.
A new health district is being established in Setlakgobi and these services are being transferred
to the new district. Similarly, a neighbouring health district, Delerayville, managed the services
around Gelukspan Hospital in the south of the Mafikeng Local Municipality. These are being
transferred to the Mafikeng Health District. At the time of the study these transfers had not been
finalised. Annual reports for 2001/2002 and 2002/2003 therefore include the services in
Makgobistadt and not those around Gelukspan Hospital.
The services within the boundaries of Mafikeng Local Municipality are described here as this
is the level of government to which such services could be decentralised in the future.
The Mafikeng Health District is sub-divided into five Health Areas. Each area is managed by
a Health Area Manager. Each area management team sets their own goals and objectives, based
on the over all plan for the health district, which in turn bases its plan on provincial guidelines.
The Health Area Managers are all based in the district office in Mafikeng and supervise their
areas from these offices. Two have subsidised cars, but others rely on pool transport. In each
area there is one Community Health Centre and a varying number of clinics. There is one mobile
clinic.
Table 2.10 lists the number of primary level facilities in the district and hours of opening. The
five 24 hour facilities are community health centres.
Table 2.8 shows number of health facilities per 100 000 head of population in Mafikeng.

Table 2.10: Mafikeng Health District - Health Areas: Number of CHCs and
Clinics per area according to Hours of Opening
Area
24hour
10hr x 7 days 8hr x 5 days Mobiles TOTAL
Modimela 1
0
3
1
5
Montshioa 1
0
6
1
8
Ramatlabama 1
0
3
1
5
Unit 9 2
1
3
0
6
Gelukspan
TOTAL
-
5
-
1
2
17
1
4
3
27
Source: Mafikeng Health District Management Team: November 2003
Table 2.11: Mafikeng Health District - Facilities per
100 000 head of population - 2001 Census
Facility
CHC
Fixed Clinics
Mobile Clinics
Hospitals
No. per 100 000 population
1.93
6.94
1.54
0.77
64
Source: Mafikeng Health District Management Team: November 2003
Population is taken as the 2001 census figure of 259 478.
Data from the Regional Quarterly Report, July to Sept 2003, show that 60% of population is
within 4kms of a PHC facility.
Other health facilities in the district include:
• Victoria Hospital – private facility
• Mafikeng Municipal Clinic – small clinic run by the local municipality for municipal
staff.
• Operation Blanket – an NGO promoting cervical smears and offering training and
support for HIV/AIDS related Home Based Care.
Availability of Hospital Beds – Public Sector
There is one district hospital in the district, Gelukspan Hospital, which is about 60 kms from
Mafikeng. As mentioned above, this hospital has recently been transferred to the Mafikeng
Health District. As with all district hospitals in the province it is managed separately to the

district services, with the Hospital Manager reporting directly to the Regional Director, as does
the health district manager. This hospital is in the south of the district and is situated far from
the majority of the population. Plans to change the hospital to a community health centre are
being discussed. The hospital provides drugs, laboratory and other services to neighbouring
clinics.
Mafikeng Provincial Hospital, in Mafikeng itself, is a hospital that provides first level care
for the Mafikeng Health District. This has a separate management structure which reports
directly to the Chief Director- Health Services in the provincial office – the same person to
whom the regional director reports. District services provided by this hospital include:
• Accepting all referrals from clinics with the required letter of referral.
• Gateway Clinic at the entrance to the hospital is responsibility of the district.
• Provision and distribution of drugs to all clinics.
• Laboratory services.
• Medical officer coverage to the clinics.
Health Professionals
There are a number of vacant health worker posts in the district. 24 These are listed in
Table 2.12 and related to the population in 2001 for ratio of public service health professionals
per 10 000 head of population.
65
Table 2.12: Mafikeng Health District Health Professionals per 100 000 population
- 2001 Census
Prof Group
Place
No.
Appointed
Vacancy
Posts
Vacancy
Rate in %
Population
Ratio
Medical Officers
Mafikeng District
Gelukspan Hospital
Mafikeng Hospital
Total
5
4
35
44
0
4
7
-
0
50
17
- 1.70
Specialists
Mafikeng District
Gelukspan Hospital
Mafikeng Hospital
Total
0
0
7
7
0
0
5
-
0
0
42
- 0.27
Prof Nurses
Mafikeng District
Gelukspan Hospital
Mafikeng Hospital
Total
102
75
146
323
0
1
16
-
0
1.30
10
- 12.45
Source: North West PDoH Chief Director: Health Services
Figure 2.11 shows that in Mafikeng CHCs and clinics the numbers of professional nurses (PNs)
and nursing assistants (NAs) days have remained static. There is a marked decrease in the number
of enrolled nurses (EN) working in the clinics in support of the other nursing staff. The fall in
nursing assistant days may be related to these nurses taking opportunity to improve their
qualification through bridging courses. The net result is that their work load is now done by the
remaining categories of nurses which increases their workload.
24 Provincial Chief Director: Health Services

Figure 2.16: Mafikeng Health District - CHC and Clinic nursing
staff working days - 2000 to 2003
16 000
14 000
Number work days
12 000
10 000
8 000
6 000
4 000
2 000
0
2000
2001 2002 2003
year
PN work days PHC
EN work days PHC
NA work days PHC
Source: North West District Health Information System
2.4.3 Ganyesa Health District, Bophirima Region (District
Municipality) – rural
Ganyesa Health District is in the Bophirima District Municipality in the north west of NW
Province. It is a deep rural area, semi-desert, bordering on the Kalahari Desert and Botswana.
The area is flat and sparsely populated apart from the villages in which people live.
All health services are rendered by the PDoH. Ganyesa Health District boundaries are coterminous
with the Kagisana and Molopo Local Municipalities. These local municipalities are new structures,
established in December 2000, and which have no experience with running health services. Part
of the district was a Regional Services Council under the apartheid government, which did run
some health services, mainly mobile services to farms.
Data from Kagisano and Molopo Local Municipalities are combined to cover data for the
Ganyesa Health District.
66
2.4.3.1 Ganyesa Health District Economic
The total population of Kagisano and Molopo Local Municipalities has increased from 106 271
in 1996 to 108 074 in 2001; an increase of 1.7%. The 2001 census records that of a total work
force of 21 556, only 13 054 (61%) are employed, 8 502 (39%) are unemployed and a further
38 392 are recorded as ‘economically inactive’. In 1996 the total workforce was 25 976, of
whom 13 154 (51%) were employed and 12 822 (49%) were unemployed. The number of
‘economically inactive’ is not recorded. There is an apparent out migration of the labour force
with a result that higher percentage of available labour is employed.

Most employed people are in unskilled work. Skilled employees are in government services,
such as teachers, health workers or employed by the local municipality. There is little formal
employment outside the government related departments; most people are reliant on subsistence
living, social grants and migrant labour in commercial farms in the east of the district. In the
far north of the area, mostly within Molopo Local Municipality, there are old asbestos mines
which possibly in the past attracted families to move to the area.
The percentage of households with no annual income has increased from 23% to 31% between
1996 and 2001. This percentage represents an absolute increase in numbers from 4 901 to 8 545,
this is about 3 644 households. See Figure 2.17.
Figure 2.17: Ganyesa Health District (Kopano and Molopo Municipalities):
percentage households per income bracket in Rands - 1996 and 2001
35.0
30.0
Percent Households
25.0
20.0
15.0
10.0
5.0
67
0.0
None
1 -
4 800
4 801 -
9 600
9 601 -
19 200
19 201 -
38 400
38 401 -
76 800
76 801 -
153 600
15 601 -
307 200
307 201 -
614 400
614 401 -
1 228 800
1 228 801 -
2 457 600
Over
2 457 600
1996 2001
Income Bracket in Rands
Source: Municipal Demarcation Board at www.demarcation.org.za
2.4.3.2 Ganyesa Health District Political
Ganyesa Health District presently includes two local municipalities, namely Kagisano and
Molopo.
Kagisano and Molopo Local Municipalities are new structures created through the Municipal
Demarcation Act in 2000. Councillors are elected by the community and a Mayor appointed by
the Councillors. The Council is dominated politically by the ANC.
The Kagisano Municipal Council employs a Municipal Manager and other officials, but has not
appointed a Health Manager. This role is taken by the provincially employed Health District
Manager, who also attends all Council meetings. There is a close working relationship between
the provincial health services and the Council.
Traditional leadership is strong within the municipality. Traditional leaders have been incorporated
into the council and the health governance structures.

Political representation in the health district is shown in Table 2.13 below. In 2004 there was
80% vote for the ANC and 16% for UCDP for the provincial legislature. For the local municipal
elections in 2000 the ANC vote was 62% and UCDP 36%. The UCDP support possibly comes
from the rural areas supportive of the previous Bophuthatswana government.
Table 2.13: Kagisano and Molopo Local Municipalities - Political representation
in North West Legislature (2004) and Local Municipalities (2000)
Sphere of
Government
African
National
Congress
United
Christian
Democratic
Party
Democratic
Alliance
Freedom
Front
Other
Votes
% Votes % Votes % Votes % %
Provincial
Legislative
Assembly - 2004
28 640 80
5 552 16 566 2 157 0 2
Kagisano &
Molopo Local
Municipalities -
2004
18 686 62 11 006 36 756 2 - 0 0
Source: Independent Electoral Commission and Municipal Demarcation Board, 2000
The Kagisano Local Municipality has eight ANC and one UCDP councillors. Molopo Local
Municipality has three ANC and one Democratic Alliance councillors.
68
2.4.3.3 Ganyesa Health District Social
The total population of Kagisano Local Municipality is 96 385 (2001 Census) of whom 51 163
(53%) are female. Population in 1996 was 92 866.
Table 2.14: Ganyesa Health District - Population according to age groups
- 2001 census
Years
No. of Persons in 2001
% of Total
0 - 4 13 905
12.9
5 - 14 29 222
27.0
15 - 34 35 454
32.80
35 - 64 24 102
22.30
Over 65 5 389
5.0
TOTAL 108 072
100
Source: Municipal Demarcation Board at www.demarcation.org.za

The Molopo Local Municipality had a total population of 11 789 people at the 2001 census; a
decrease of approximately 2 000 from the previous census in 1996.
A high percentage of the population in Ganyesa Health District was under 15years (39.9%) with
a further 32.8% between 15 and 34 years. Only 5.0% were over 65 years.
Over 65
Figure 2.18: Ganyesa Health District - Population Pyramid - 2001 Census
35 - 64
Years
15 - 34
5 - 14
0 - 4
-20 000 -15 000 -10 000 - 5 000 0 5 000 10 000 15 000 20 000
Females
Males
Source: Municipal Demarcation Board at www.demarcation.org.za
69
Other data from the 2001 and 1996 census shows that:
• 66.4% of over 20 year olds had some or no primary schooling (68.0% in 1996); 8.6%
had completed Grade 12 (5.6% in 1996) and 3.1% had higher education (2.2% in 1996)
• Children and adolescents between 5 and 24 years – 34.4% were not at any educational
instutions, 2.6% were at pre-school, 62.9% were at school and 0.2% was attending
higher education institutions. There were no details from 1996 census.
Two-thirds of the population over 20 years had little or no formal education and could be
considered functionally illiterate. Only 3.1% had higher education; although higher than in 1996
it is still remains low. More than one-third of children and young adults were not attending any
educational institution.
• Light sources – electricity 67.2% (1.05% in 1996); paraffin 3.8% (16.1% in 1996);
candles 28.2% (68.3% in 1996).
• Water source – in dwelling 4.3% (6.2% in 1996); in yard 14.6% (12.0% in 1996);
community stand 23.3% (37.3% in 1996); borehole 22.4% (29.4% in 1996).
• Sanitation – flush 2.3% (5.0% in 1996); VIP 28.4% (nil in 1996); pit latrine 40.7%
(72.5% in 1996); none 24.5% (22.0% in 1996).
• Refuse removal – municipal weekly 1.3% (0.5% in 1996); communal dump 2.6% (4.6%
in 1996); own dump 84.8% (85.2% in 1996); no disposal 11.1% (9.5% in 1996).
Infrastructure developments show great strides in expansion of the electricity grid into the rural
areas, but little improvement in water, sanitation and refuse removal.
The 2001 national census showed that 96% of the population were Africans (black), 2% were
White and 2% were Coloured. (See Figure 2.19)

Figure 2.19: Ganyesa Health District - Population by Racial Group
- 1996 and 2001 Census
2% 0% 2%
KEY
Persons 2001 1996
Black 104 253 102 252
Coloured 1 655 1 578
Indian 26 37
96%
White 2 140 2 108
TOTAL 108 074 106 271
Source: Municipal Demarcation Board at www.demarcation.org.za
In 2001 93% of the population home language was Setswana, with 3% Afrikaans, 3% other and
1% other black languages. (See Figure 2.20)
0.5
Figure 2.20: Ganyesa Health District - Population by Home Language
- 1996 and 2001 Census
%
3
2
0.5
6
1
4
KEY
Persons 2001 1996
Afrikaans 3 248 3 578
English 266 162
IsiNdebele 218 32
IsiXhosa 248 107
IsiZulu 205 29
Sepedi 368 131
70
93
Sesotho 276 120
Setswana 99 909 98 183
Siswati 150 7
Tshivenda 35 31
Xitsonga 24 18
Other 2 948 3 283
Other (black) 1 524 475
Source: Municipal Demarcation Board at www.demarcation.org.za

The community is mostly Setswana. Except for a small section of the eastern border, the district
has for many years been under the traditional Setswana leadership. There is cohesion in the
community. Local government was established after the election in 2001and is an entirely new
structure. Traditional leadership is part of the local council and they work closely together.
71
2.4.3.4 Ganyesa Health District Health Care System
All health services in Ganyesa are managed by provincial health services. There are no private
or municipal clinics. Private services, however, are provided by a few general practitioners
resident in the area, some of whom provide part-time services to the public sector.
The Health District Manager is a joint appointment with the Kagisano Local Municipality, but
is paid by province and reports to the Regional Director and the Municipal Manager. A close
working relationship has developed between the provincial district team and the local municipality
officials and politicians, although the local municipality currently has no PHC health care
function.
The Health District is divided into three Health Areas – Ganyesa, Tlakgameng and Morokweng.
The district management is also responsible for management of health services in the neighbouring
Molopo Local Municipality, a very sparsely populated, semi-desert area, with a total population
of approximately 12 000.
Each Health Area is managed by a Health Area Manager, who is based in the district office in
Ganyesa. Some area managers have dual roles in the district; for example, the MCWH coordinator
is also responsible for one area. The number of clinics in each area varies, as do their opening
hours. See Table 2.15.
Table 2.15: Ganyesa Health District - Health Areas: Number of CHCs and Clinics
per Area according to Hours of Opening
Area
24hour
10hr x 7 days 8hr x 5 days Mobiles TOTAL
Ganyesa 1
4
0
1
6
Tlakgameng 2
3
0
1
6
Morokweng 3
4
0
2
9
TOTAL 6
11
0
4
21
Source: Ganyesa Health District Management Team: November 2003
Table 2.16 shows number of health facilities per 100 000 head of population in Ganyesa.
Population is taken as the 2001 census figure of 96 384 (Kagisano Local Municipality only).
The Regional Quarterly Report for July to Sept 2003 shows that 36% of population is within 4
kms of a PHC facility.
The Regional Office for the Bophirima Health District is in Vryburg, 70 kms from Ganyesa.
The Regional Director holds a joint appointment with Bophirima District Municipality. He works
two days per week for the district municipality and three days per week for the Province. A close
working relationship has been established, more so than in the other regions in the province.

Table 2.16: Ganyesa Health District Facilities per
100 000 head of population - 2001 Census
Facility
No. per 100 000 population
CHC
Fixed Clinics
Mobile Clinics
Hospitals
6.23
11.41
4.15
1.04
Source: Ganyesa District Management Team, November 2003
The Regional Office is small. There is the Regional Director with administrative support, PHC
trainer for the region and a few regional specialists – pharmacist, forensic, paediatrics. Some
district appointees carry a regional function as well; for example, the MCWH coordinator in
Kalagadi Health District is used regionally and considered to be member of the provincial “team”
referred to by the provincial reproductive health co-ordinator in her interview.
Availability of Hospital Beds – Public Sector
The district hospital is under a separate management system that reports to the Regional Director.
However, the hospital does not have a full complement of staff and therefore uses some support
services in the district; for example, personnel and transport. However, this is likely to change
once the hospital has a full complement of staff appointed.
A relatively new (built in 1996) and well maintained 60 beds hospital situated about 5 kms
outside Ganyesa village is the only referral centre for all clinics and CHCs in the district.
The referral hospital is Klerksdorp Provincial Hospital, about 300 kms away. Referrals are made
on a regular basis via a small bus; emergencies are transferred by the EMS. Two ambulances
are based at the hospital, but the EMS service is centrally controlled from the province. These
two ambulances are required to service the whole district as well as attend to emergency transfers.
Services provided by the hospital include:
• Referral centre – high-risk maternity, TOP etc. There were no TOP services during
2003 because the professional nurse providing the service was on study leave doing
Advanced Midwifery. TOP patients were referred to Vryburg – 70 kms away.
• Drugs and other supplies for clinics – distributed through the hospital pharmacy.
• Laboratory services – these are part of the NHLS. No laboratory services are available
after hours. Patients, therefore, are referred to Klerksdorp for monitoring (for example
eclamptics, diabetics).
• Doctors – there were three doctors (one South African and two Cuban) in 2003 for
whole district. They were based at the hospital, but provide limited services to the
district, with few visits to the clinics.
72
Health Professionals
As in other districts there are a number of vacant and frozen health professional posts in the
Ganyesa Health District. 25 These are shown in Table 2.17. Population used for health worker
to population ratio is the 2001 census figure of 108 074.
25 Provincial Chief Director, Health Services, 2003.

Table 2.17: Ganyesa Health District - Health Professionals per 100 000 head of
population - 2001 Census
Prof Group
Place
No.
Appointed
Vacancy
Posts
Vacancy
Rate in %
Population
Ratio
Medical Officers
Ganyesa District
Ganyesa Hospital
Total
0
2
2
2
1
3
100
33
- 0.19
Specialists
Ganyesa District
Ganyesa Hospital
Total
0
0
0
0
0
-
0
0
- 0
Prof Nurses
Ganyesa District
Ganyesa Hospital
Total
66
14
80
8
6
-
11
30
- 7.40
Source: North West PDoH Chief Director: Health Services
73
Figure 2.21 shows that in Ganyesa there is a slight fall in the number of days for each category
of nursing staff, with an increase in professional nursing and nursing assistant days in 2003. The
continued fall in EN working days is possibly due to nurses attending bridging courses, as in
Mafikeng. With the increase demand for services this data tends to support the impression of
clinics being under staffed.
Figure 2.21: Ganyesa Health District - CHC and Clinic nursing
staff working days - 2000 to 2003
Number work days
10 000
8 000
6 000
4 000
2 000
PN work days PHC
EN work days PHC
NA work days PHC
0
2000
2001 2002 2003
year
Source: North West District Health Information System
2.5 Conclusion
Chapter 2 has provided an overview of the national, provincial and local context in which
decentralisation and health services are being implemented. An overview of health care system
at each level is given.
The three health districts are notably different. These differences will be referred to in subsequent
chapters. The researchers believe that these contextual differences between the districts are
important for understanding the impact of decentralisation on reproductive health services in
the NW Province. Table 2.18 below compares the three health districts described in detail above:

Table 2.18: Summary Comparative Table of Three Study Sites in North West Province
Klerksdorp
Mafikeng
Ganyesa
REGION
Southern
Region/District
Municipality
Central
Region/District
Municipality
Bophirima
Region/District
Municipality
Type
Urban Semi-urban Rural
Demographics: (2001 census)
Population
Area
Population density
Male : Female Ratio
% population under 15yrs
Over 20yrs old with little or no
education
Unemployment rate
Not economically active
Households with no income
Health status indicators
359 202
3 624 sq. kms.
100 per sq. km.
51 : 49
26.5
36.6 %
25.6%
36.1%
19.8%
259 478
3 800 sq. kms.
68 per sq. km.
48 : 52
32.6
38.9 %
27.9%
43.3%
27.6%
96 385
14 857 sq. kms.
6 per sq. km.
47 : 53
40.5
68.0 %
15.5%
66.4%
34.5%
74
Crude birth rate
Neonatal death rate
Maternal death rate
17.2 /1000 head
48.8 /1000 live births
408 /100 000 live births
15.6 /1000 head
19 /1000 live births
356 /100 000 live births
14.6 /1000 head
11 /1000 live births
627 /100 000 live births
Public health services
Authority
District health
management team
Provincial & Municipal
Combined provincial
and municipal
Mostly provincial, 1
small municipal clinic
Provincial only
Provincial only
Provincial only
District health facilities
Community health centres
Clinics
Mobile clinics
4
14
10
4
18
4
6
11
4
Hospitals
No district hospital
1 Provincial hospital
1 district hospital to be
downgraded to CHC
1 Provincial hospital
1 district hospital

Figure 2.1a: National Department of Health – Organisational Structure - March 2003
National Minister of Health
Director General for Health
Deputy Minister of Health
Strategic Planning
Internal Audit
Deputy Director General
Health Service Delivery
Chief Financial Officer
Deputy Director General
Strategic Health Programmes
Subordinates Subordinates Subordinates
Source: National Dept of Health, website
75
Figure 2.1c: National Department of Health – Organisational Structure - March 2003
Director General
DDG Health Services Delivery
Non Personal Health Services
Hospital Services Human Resources Others
• Communications
• Legal services
• Disease prevention
• Health and Welfare
Subordinates Subordinates Subordinates Subordinates
Source: National Dept of Health, website

Figure 2.1b: National Department of Health - Organisational Structure – March 2003
Director General
DDG Health Services Delivery
Mental Health and
Substance Abuse
Gender Desk
International Health Liaison
District & Development
District Health Services
Maternal, Child
and Women’s
Pharmaceutical
Planning and
HIV/AIDS
and TB
Medicines
Regulatory Affairs
Health Monitoring
and Evaluation
76
Subordinates
Subordinates
Subordinates
Subordinates
Subordinates
Source: National Dept of Health, website

Figure 2.5: North West Province - Relationship between management systems in Health Districts
Provincial Department
of Health
Provincial Public Works
Department
National Health Laboratory
Services
Regional Director
Regional EMS
District Hospital Manager & Team
First Level hospital care
Emergency services
Drugs and supplies to clinics
Emergency
Medical Services
77
District Manager & Team
Health Areas
Community Health Centres
Laboratory
Services
Public Works
Clinics
Mobiles
Community
KEY
Line Management
Co-ordination
PT Referral
Drug Supplies

3.1 Historical Background
Chapter 3
Health Systems Decentralisation in South Africa
South Africa, under the National Party’s Apartheid or ‘Separate Development’ policies from
1948 to 1994, was a country divided along racial and ethnic lines into the Republic of South
Africa with four provinces for Whites, and a number of supposedly ‘independent or ‘selfgoverning’
‘homelands’ such as Transkei, Ciskei, Bophuthatswana, Venda, Qwa-Qwa, Lebowa
and KwaZulu for the respective Africans (black) ethnic groups. Prior to 1948, the Gluckman
Commission 1 had proposed a national health service responsive to the needs of the whole
population. The Gluckman Report was rejected and put aside in the following years, and an
increasingly divided and inequitable health systems developed.
The ‘homelands’ were essentially ‘dumping grounds’ for the different Africans (black) ethnic
groups, depriving them of South African citizenship and replacing it with citizenship of one of
the ‘Bantu homelands’. These ‘homelands’ were not economically independent or sustainable,
and were ‘funded’ by the white regime, having delegated powers in the disbursement of
funds. In the early 1980s a limited franchise was granted to the ‘Indian’ and ‘Coloured’
population groups through a tripartite system; the House of Assembly representing Whites, the
House of Delegates for ‘Indians’ and the House of Representatives for ‘Coloureds’.
78
Public expenditure was inequitably distributed in favour of the White minority. The four provinces
within (white) South Africa had some de-concentration of authority but power was centralised
within the national government. Government consisted of three levels – National, Provincial
and Local – with concentration at national level. Pillay and Bond (1995) have noted, however,
in the context of the current provincial federalism where “provincial health ministries now have,
within the broad policy guidelines set by the central Department of Health, the freedom to
determine health policy and plan and implement health services” that this is “not a substantial
change from the past, since the four white-controlled provinces during the apartheid era (as well
as the impoverished African homelands) always maintained responsibility for and control over
hospital and clinic services. Ironically, precisely this devolution is most often blamed for the
structural crisis in health service delivery since the 1940s.” 2
Before 1994 local government consisted of numerous Local Authorities who were responsible
for local level services for which they could raise local revenue through rates and taxes. Regional
Services Councils were established to cover services in rural areas.
Two foundational documents developed prior to the 1994 democratic elections and which formed
the basis for much of the legislation and policy in the post-apartheid era were The Freedom
Charter of the ANC and the Reconstruction and Development Programme (RDP).
The Freedom Charter of the ANC
The Freedom Charter has been described by Marais (1998) as forming “an ideological bedrock
and key hegemonic instrument for the ANC. Idealistic and emotively phrased, it bore close
resemblance to the French Declaration of the Rights of Man.” 3 However, it was “not a policy
1 Gluckman H et.al (1944) Report on the National Health Services Commission, 1942 – 44; Union of South Africa.
2 Pillay, Y.G. and Bond, P. (1995) Health and Social Policies in the New South Africa, Int. J of the Health Services, Vol 25,
No 4, 727-748 (p 731).
3 Marais, Hein. (1998) South Africa. Limits to Change. The Political Economy of Transformation. University of Cape Town
Press, Cape Town (p. 74).

document and its specific points steadily became detached from concrete moorings as time
passed……… Its formulation of post-apartheid policy was inexplicit, functioning not as
road signs for transformation but as flagstones for mobilisation and organisation.” 4
Marais describes the development of ANC’s economic policy as “a short-walk to orthodoxy.” 5
On his release from Victor Verster prison, Mandela affirmed the Freedom Charter’s call for
nationalisation of “the mines, banks and monopoly industry.” Four years later, on May Day
1994, Mandela stated that there was not a single reference to nationalisation in the ANC’s
economic policies. As Marais aptly describes it, what had happened was that the ANC’s “economic
thinking was launched on a roller coaster ride – buffeted by threats, cajoling, ridicule and
injunctions from business organisations, banks, Western governments, activists, trade unions,
foreign lending institutions, economists and consultants. The first target for attack was the ANC’s
alleged penchant for nationalisation, which it soon dropped……. Nationalisation was a
red herring, though. Its resonance in popular discourse stemmed less from its literal prescription
than from its symbolic power; encoded in that instrument was the overriding commitment to
redistribute resources and opportunity in favour of the majority.” 6
However, with the adoption, during the negotiations process, of a Government of National Unity
(GNU) until 1999, majority rule was postponed. Marais concludes that “the ANC’s historical
privileging of the political over the economic allowed for the possibility of a settlement based
on significant restructuring of the political sphere, and broad continuity in the economic sphere.” 7
Redistributing resources was then, ostensibly, to be achieved through the RDP.
The Reconstruction and Development Programme (RDP)
The RDP was adopted as official ANC policy before the 1994 elections. It, seemingly, laid the
basis for developmental democracy with services being decentralised to the lowest appropriate
level, and with community participation playing a key role. The RDP programme focused on
the key areas of meeting basic needs, developing human resources, building the economy
and democratising the state. Health was considered a “basic need.” Certain key sections of the
RDP relating to a National Health System (NHS) and reproductive health are cited below: 8
79
The priorities of the RDP were to meet the basic needs of “jobs, land, housing, water, electricity,
telecommunications, transport, a clean and healthy environment, nutrition, health care, and social
welfare.” 9 Webster and Adler (1999) have noted that, while the RDP was developing as a policy
document, “a set of local and international pressures were profoundly changing economic
thinking in the ANC. From the 1950s, the ANC was publicly committed to a state-interventionist
redistributive strategy, as articulated in its central policy document, the Freedom Charter” and
that this “developmentalist position had by the late 1980s and early 1990s come under substantial
pressure. If Mandela had entered prison at a time when nationalisation was an article of faith,
he was released into a world where monetarism and its obsession with inflation and the reduction
in state expenditure had become the new orthodoxy.” 10
4 Ibid (p. 74).
5 Ibid (p. 146).
6 Ibid (p. 146).
7 Marais, Hein. (1998) South Africa. Limits to Change. The Political Economy of Transformation. University of Cape Town
Press, Cape Town (p.85).
8 African National Congress (1994) The Reconstruction and Development Program: A policy Framework. Umanyano Publications,
Johannesburg. (p. 42-47).
9 Ibid (p. 7).
10 Webster, E. and Adler, G. (1999) Towards A Class Compromise in South Africa’s “Double Transition”: Bargained Liberalization
and the Consolidation of Democracy. Politics and Society, Vol, 27, No 3, pp 347-385 (p. 364).

80
Reconstruction and Development Programme
2.12. HEALTH CARE
2.12.5. National Health System (NHS).
2.12.5.1. One of the first priorities is to draw all the different role players and services
into the NHS. This must include both public and private providers of goods
and services and must be organised at national, provincial, district and
community levels.
2.12.5.3. Communities must be encouraged to participate actively in the planning,
managing, delivery, monitoring and evaluation of the health services in their
areas.
2.12.5.8. The whole NHS must be driven by the Primary Health Care (PHC) approach.
2.12.6.1. Health care for all children under six years of age, and for all homeless
children, must immediately be provided free at government clinics and health
centres.
2.12.6.2. There must be a programme to improve maternal and child health through
access to quality antenatal, delivery and postnatal services for all women.
This must include better transport facilities and in-service training programmes
for midwives and for traditional birth attendants. Targets must include 90
percent of pregnant women receiving antenatal care and 75 percent of
deliveries being supervised and carried out under hygienic conditions within
two years. By 1999, 90 percent of deliveries should be supervised. These
services must be free at government facilities by the third year of the RDP.
In addition, there should be established the right to six months paid maternity
leave and 10 days paternity leave.
2.12.6.4. One important aspect of people being able to take control of their lives is
their capacity to control their own fertility. The government must ensure that
appropriate information and services are available to enable all people to
do this. Reproductive rights must be guaranteed and reproductive health
services must promote people’s right to privacy and dignity. Every woman
must have the right to choose whether or not to have an early termination
of pregnancy according to her own individual beliefs. Reproductive rights
must include education, counselling and confidentiality.
It is clear that the RDP fell short of a socialised National Health Programme. However, the
RDP was clear on a policy of PHC based on a District Health System model, and this, and the
rejection of cost recovery, has been maintained. The short-lived RDP office did initially fund
the provision of free public health care services for pregnant women and children under six of
years of age. In fact, the only ‘promises’ of the entire RDP document to materialise and survive
have been the provision of free PHC, and legislatively guaranteed reproductive rights.

3.2 National Policy development
The Constitution provides for a decentralised system of government in which local government
is responsible for delivery of services, and the national and provincial spheres have a supportive
and monitoring role. The structures, functions and powers of provincial government are laid out
in the Constitution of the Republic of South Africa, Chapter 6, Section 104:
“(1)The legislative authority of a province is vested in its provincial legislature, and confers
on the provincial legislature the power
(a) to pass a constitution for its province or to amend any constitution passed by it
in terms of sections 142 and 143;
(b) to pass legislation for its province with regard to
(i) any matter within a functional area listed in Schedule 4;
(ii) any matter within a functional area listed in Schedule 5;
(iii) any matter outside those functional areas, and that is expressly assigned to
the province by national legislation; and
(iv) any matter for which a provision of the Constitution envisages the enactment of provincial
legislation; and
(c) to assign any of its legislative powers to a Municipal Council in that province.” 11
Decentralisation in the country is the joint responsibility of Department of Provincial and Local
Government (DPLG) and the different sectors at national and provincial levels. In the NDoH
overall responsibility for implementing decentralisation policies and setting up a functional DHS
rests with the Chief Directorate, District and Development. However, the nine provinces in
South Africa have their own unique requirements and each plans their own decentralisation
process. Each province has a Provincial Health Advisory Committee, with representation from
health and local government. The functioning of these committees, according to a Chief Director
in the NDoH, varies, as does the capacity of the provincial departments of health to manage the
process. This has resulted in the process proceeding at different paces across the country and
with some provinces decentralising many functions to local government and others opting to
keep many functions centralised in the provincial office. Each province does, however, have
the constitutional right to re-centralise any function that the local government level has failed
to manage.
81
The policies and legislation related to decentralisation and reproductive health is
summarised in Appendix 4. Table 3.1 lists these policies in chronological order, categorised
according to General National, General Health, Reproductive Health and NW Province.
11 The Constitution of the Republic of South Africa, Act 108 of 1996. Section 104.

Table 3.1:
Policies, Legislation and other significant events for decentralisation and reproductive
health
Year
International
National
Health
1993
1994
ICDP Cairo
1st National Democratic Elections
ANC Health Plan
Reconstruction and Development Plan.
1995
Beijing Conference
White Paper on Transformation of the
Public Service
1996
Constitution of South Africa - No. 108
of 1996
1997 White Paper on Transforming Service White Paper on
Delivery
Transformation of Health
(Batho Pele White Paper)
1998
White Paper on Transformation of local
government.
L/G Demarcation Act - No. 27 of 1998
The Municipal Structures Act 1998 (Act
No. 177 of 1998)
82
1999
2 nd National Democratic Elections
Growth, Employment and Redistribution
(GEAR)
Public Finance Management Act - No.1
of 1999
Health Sector Strategic
Framework 1999 to 2004
(Ten Point Plan)
2000 L/G Municipal Systems Act - No. 32 of
2000
Local Government Elections
National Health Laboratory
Services Act No. 37 of 2000
2001
2002
The District Health System:
Proposal for Terminology Jan
2002
The District Health System -
Proposed Way Forward:
Discussion Document for the
PHRC - May 2002
2003 National Health Act - No. 61
of 2003
2004 3rd National Provincial Elections Strategic Priorities for the
National Health System,
2004 - 2009

Repro Health
North West
Free Services for pregnant women and
children under 6 years
Mother, Child and Women’s Health draft
policy
Choice on Termination of Pregnancy Act -
No. 92 of 1996
North West Health, Developmental Social
Welfare and Hospital Governance Institutions
Act - No. 2 of 1997
North West, Devolution of Powers to Local
Government Act - No. 6 of 1998
With amendment - No. 10 of 1998
First Savings Mothers
Report
83
HIV/AIDS Strategic Plan
2000 to 2005
Saving mothers policy and guidelines
Adolescent Health Policy
North West Health Bill
Guidelines for Maternity Cases
National Conception Policy and Guidelines

Of note is that policy for decentralisation of health services and establishing a DHS in South
Africa were on the table early in the transformation process. It has, however, taken 10 years for
these policies to be entrenched in a National Health Act. Legislation for establishing local
government as the third sphere of government was required before health decentralisation
legislation could be finalised. (It is noted that delays in passing a National Health Act were not
only been related to difficulties with decentralisation and DHS, but to other sections of the Act
as well, such as certificate of need for practitioners.)
National Level Policy
National government is the driving force behind decentralisation and moving decision making
powers to the local level. The objectives of this were included in early documents and polices
of the ANC. A Director in DPLG emphasised the central role of National Treasury and DPLG:
“… national government, but primarily National Treasury and Department of Provincial
and Local Government was responsible for giving policy direction in this regard.”
(Director – DPLG)
It has, however, at times been controversial, more from a political than a technical perspective,
as described by the Deputy Director responsible for decentralisation and DHS in the NW
Provincial Department of Health:
84
“So I think for power mongers, the debate on decentralisation is indeed controversial
because it is saying, as you decentralise from national or central to provinces, from
provinces to district, from district to locals, you know, there are major, major power
shifts and those who want to influence what is happening in local politics will definitely
want not to lose some influence on local politics being national people……
But the debate, depending on the history of a country and its cultures and other
things, the debate on decentralisation in my opinion will remain controversial.”
(Provincial Deputy Director – DHS)
The international push is for decentralisation of government functions, requiring the centre to
relinquish power and control. In implementing a decentralised policy a tension develops between
the national (centre) and the local (peripheral) levels. Central control may be better for the
country as a whole for uniformity of policy development, for monitoring implementation, and
for the equitable distribution of resources. Local control is better for the constituents of the
country as the local needs can be better addressed. In transformation of government towards a
decentralised and developmental democracy, as envisaged in the Constitution of South Africa,
a tension can develop between the spheres of government. This was described by a DPLG
director as “the biggest danger” in South Africa:
“And that is the biggest danger of decentralisation is losing that connection between what
national government thinks is important for the country and what municipalities think are
important for their constituents.”
(Director – DPLG)
There is, however, a tendency for the centre to hold on to power, and reluctance to decentralise
where there is no certainty of capacity to manage at the local level. As explained by a Director

in the Department of Provincial and Local Government (DPLG) the process is slow and capacity
needs to be developed in all three spheres of government:
“I think the provincial levels, my personal viewpoint – have always been a little weak, and
then if you look at the provinces and if you look at the way they manage their budgets and
you look at the way they spend their budgets, they are always underspending. … I think
there is need very strongly for provinces to take on this whole aspect because provincial
governments role in decentralisation is largely on monitoring and supervision support. …
I think a lot of capacitation needs to be done on the provincial level in order for them to
be able to actually take on the proper role as things are decentralised down to lower levels
of government. I don’t think they are completely able to actually handle it. There is still a
lot of hand holding from the national government. There is still a lot of oversight at national
level.
At local level you’ve got very different capacity again so it’s very hard to make a blanket
statement. Some municipalities are definitely ready and some municipalities are definitely
not ready. But again, national government through this phased way of doing things is trying
to capacitate municipalities in a phased fashion. So, for example, with regard to the division
of powers and functions, we started off with water and sanitation in July last year. … DPLG
is again consolidated capacity building initiatives within the department and over time the
capacity building initiative across the different sectors have been consolidated. … Then the
next step would be looking at the health function, the next step would be looking at the
electricity issue. … It’s again an approach of capacitating these parties …”
(Director – DPLG)
85
Department of Local Government and Provincial Administration (DPLG)
Vision
The vision of the DPLG is to:
• Have an effective and integrated system of government consisting of three spheres
working together to achieve sustainable development and service delivery.
Mission
The mission of the DPLG is to:
• Develop and promote systems and structures of effective governance, particularly at the
local sphere; and
• Develop and promote a system of integrated government between the spheres of government
Mandate
The primary mandate of the Department is to:
• Develop and monitor the implementation of national policy and legislation seeking to
transform and strengthen instructions of governance to fulfil their developmental role;
• Develop, promote and monitor mechanisms, systems and structures to enable integrated
service delivery within government; and
• Promote sustainable development by providing support to provincial and local governments.
Source: DPLG website: www/dplg.co.za, 2003

Department of Provincial and Local Government
The Department of Provincial and Local Government (DPLG) has a key role to play in
decentralisation. The DPLG is responsible for establishing, monitoring and evaluating provincial
and local government. The department works with all government sectors in implementing
policies such as housing, water supply and other basic services. This includes decentralisation
of some functions. They are also responsible for promotion of intergovernmental relationships
to ensure that the spheres work together as required in legislation.
The DPLG strongly supports decentralisation of services to local government as prescribed in
the Constitution. A proper legislative framework is required, as expressed by a DPLG director:
“So, there definitely is at DPLG, a very strong movement towards wanting to decentralise
down to the local level,… to have the proper legislative framework in which to manage it.”
(Director - DPLG)
Research has played a central role in decision making, although there is no overall coordinated
framework for decentralisation, as explained by the Director - DPLG :
86
“… It’s been research. It wasn’t a conscious research initiative to say is decentralisation
good or bad …. It was in the context of current ongoing reforms… around the structure of
local government. … Looking at the structure and institutions of local government and
looking at the relations between local and provincial and national government as the
Municipal Structure Act (and) the Municipal Systems Act came about, as the Property Rates
Bill started being conceptualised. … to look at all those individual reforms in the context
of a … larger inter-governmental framework. … There is no firm fiscal framework on the
table. The Financial and Fiscal Commission (FFC) is certainly in favour of decentralisation.
So there has been a research component which has been putting pressure on government,
or on parliamentarians, by saying this is the way we think it should be going. And national
government to a large extent has accepted that advice”
(Director - DPLG)
Each government sector, however, is working independently of each other and at a different
pace. Some sectors are choosing to decentralise many functions, such as the Department of
Water Affairs and Forestry (DWAF), while others, such as electricity, have chosen to keep
services centralised. This was again explained by the DPLG director:
“After 1994, the newly elected government was saying, “yes, decentralisation is a good
idea”. But … to allow that to happen is taking a lot more time. You are seeing a reversal
to some extent in terms of some of the decisions about decentralisation e.g. with electricity
restructuring. … that’s one classic example … national government say “we don’t think
decentralising electricity distribution down to the local level is going to be best thing for
the country in terms of equity.” And therefore, in order to achieve equity they want to
establish very large regional electricity distributors.…. with water, they are going the other
direction … they want to decentralise down to local level.”
(Director - DPLG)
The Department of Health (DoH) was one of the earlier sectors to start a decentralisation process
of health management through establishing health regions and health districts in each province.

The Head of Department of Health in one province emphasised the early role of health sector
and the prominence of the ANC Health Plan in determining national policies. The driving force
was from outside of the country:
“… the health sector is driven by what we would have called progressive reform agendas,
lobbies, and forces. It is a movement that has gone worldwide driven outside SA but also
inside SA and clearly the ANC is part of that kind of political movement that had the
particular philosophy that dovetailed in. And if you recall the two main policy documents
on which the ANC fought the first election were the RDP and the ANC Health Plan. They
were the two significant policy documents. There wasn’t much else. There was a lot of
rhetoric around other things but they were the two key documents largely because the health
sector was probably the more mobilised and the more active and the more of the kind of
‘intelligentsia’ element in it, and it was a cog in that sort of machine, certainly a major
player.”
(Provincial Head of Dept. of Health)
The progress that health was making towards reforms and decentralisation of health management
was disrupted by the municipal demarcation process of 2000. Health regions and health districts
were required to be realigned to be coterminous with the local government boundaries. National
and provincial governments had started a process of transformation before the local government
sphere was established. It was only December 2000 that there was meaningful engagement
within the health sector with local government, as explained by National Director for DHS:
“Post 1994 it was national departments and provincial departments that were transformed.
Local government was in an interim phase until the [local government] elections took place
in December 2000. … So it’s really only after December 2000 with the formal new local
government structures and systems that we could start engaging meaningfully. Luckily some
of the people remained behind, but there were a lot of new people that needed to be
convinced, re-oriented, etc.”
(National Dept. of Health- Director for DHS)
87
Municipal health services (MHS), according to the Constitution, are a local government
responsibility. The constitution, however, does not define MHS. DPLG and NDoH worked
closely together to finalise the definition of MHS and to determine which level of local government
MHS would be devolved to. MHS has now been defined as part of environmental health 12 and
not the whole basket of primary health care (PHC) services as originally envisaged in the ANC
Health Plan. This means that most of PHC remains a provincial responsibility. This decision
was influenced by the need to ensure a seamless referral system between levels of health care
and to facilitate the equitable distribution of resources.
There has been some controversy between departments, such as DPLG, National Treasury and
NDoH, as to what should be decentralised and to which level. DPLG and National Treasury,
for example, favoured decentralisation of MHS to the local municipalities, whereas NDoH
favoured the district municipalities and metros. A political, not technical, decision was required
for MHS to be located with the district municipality. The DPLG director attempted to clarify
the issues and reasoning:
12 National Health Act - No. 61 of 2003.

“Definitely, at least that is the way to go; to go down to the lowest level possible at which
you can achieve the best economies of scale. So, it would vary from service to service
because for some services, you know the lowest level possible is the local municipality. For
some services, the best level possible might be at the district municipality level. Health
seems to think that with regard to the delivery of health services, especially certain basic
packages that can more effectively be performed at a district level rather than at a local
level.”
(Director – DPLG)
The NDoH was in favour of different definitions of MHS for different categories of municipalities.
This would mean the metros could retain more PHC functions. It is not, however, legislatively
possible to have different definitions of MHS. PHC services (except for the elements of
environmental health services included in MHS), therefore, constitutionally remain the responsibility
of provincial government.
National Treasury
The National Treasury has a central role to play in national, provincial and local government.
Chapter 7: Budgeting and Finances discusses their role with focus on health services and are
not discussed further in this chapter.
88
3.3 North West Province Decentralisation
The Constitution of South Africa lists services that are devolved to provincial and local
government. 13 The Constitution requires provincial government to assign additional functions
to:
“a municipality, by agreement and subject to any conditions, the administration of a matter
listed in Part A of Schedule 4 or Part A of Schedule 5 which necessarily relates to local
government, if
(a) that matter would most effectively be administered locally; and
(b) the municipality has the capacity to administer it.” 14
A mixed form of decentralisation is envisaged in South Africa, but with an emphasis for functions
to be moved to the lowest level possible. The NW Province favours decentralisation and has
developed policies and legislation in support of the process.
North West Provincial Plans for Decentralisation
The Department of Developmental Local Government and Housing (DLGH) in the NW
Province is responsible for decentralisation. Each sector in the province is responsible for
developing plans for decentralisation that are in line with the provincial plans and the North
West Devolution of Powers Act of 1998 (Act 6 of 1998), with its amendment, Act 10 of 1998.
A Decentralisation Task Team (The Provincial Inter-government Forum) was established in 1996
by the MEC for Developmental Local Government and Housing. All government departments,
as well as organised local government, SALGA in the NW Province are represented at this
forum. The committee is tasked with developing a comprehensive framework for decentralisation.
The main goal is to ensure that local government is empowered to accept decentralisation of
some provincial functions, and to maintain a balance between the two spheres of government.
13 Constitution of South Africa 1996. Schedules 4 and 5.
14 Constitution of South Africa 1996, Section 156 (4).

A step wise process of decentralised functions across the whole province has been proposed and
accepted by most departments. The NW PDoH, however, prefers to decentralise all health
functions to a defined geographical area, such as a District Municipality, as a pilot. Once this
has been accomplished in one district the process would be rolled out to other districts in the
province. 15
Sectors have different views on what and how much to decentralise. This was well described
by a senior official in the North West Provincial Department of Developmental Local Government
and Housing, as departments “cherry-picking” because of fear of loosing control and power:
“It [decentralisation] is supported within the province but if you engage individual
departments they are ‘cherry-picking’ in terms of what it is they should devolve and so on.
… I think it is understandable because at the same time it's going to touch on the role of
the province and the entire governance system of South Africa. If I am the department of
public works and I agree that 80% of the functions of the department should go to
municipalities, I remain with 20% and that in itself in terms of the fiscal relations and
Division of Revenue Act, it means the larger portion of what used to come to me from
national as an allocation will go to that municipality. So… it tempers on their role and
competencies. … it should not be discussed in isolation from other spheres… the role of
national, the role of province, the role of municipalities. It must be discussed within that
context and I am sure if we can clarify that, people will let loose at some point.”
(Chief Director- Dept. of Developmental Local Government and Housing)
He further emphasised the importance of a provincial, coordinated plan for decentralisation in
order to avoid sectors either dumping functions on local government without the resources or
withholding other functions which would be better run by local government.
89
There has been intersectoral consultation on decentralisation, but NW PDoH has found that the
departments are not in agreement on issues related to decentralisation. This was expressed by
a regional health director:
“We are not going the same route, and that has been the concern as we consult with these
people. There has been concern from a member of SALGA North West that the decentralisation
must be a package that includes all to go that route. … other departments are regionalising…
But there seems to be no intention of taking the service to local municipalities.”
(Regional Director for Health)
and the Deputy Director for DHS in the North West PDoH:
“We have a Provincial Steering Committee on Decentralisation and I think some do share
our view. … our view is informed by what we have done. To decentralise to category B’s
is informed by the relative capacity that we have built over the years. … we have trained
people, we have established systems and our boundaries are coterminous with local
government; we are serving the same population … And those who don’t share it when we
examine their critique of our own view it's basically the issue of capacity.”
(Provincial Deputy Director)
15 Matlawe E, (Chief Director, Developmental Local Government, North West Province). Decentralisation/Devolution of Functions
to Municipalities: A Case for the North West. Paper shared at interview. Undated.

3.4 Health Decentralisation Policy
Health policies in South Africa are based on ANC policy documents such as the RDP and the
ANC Health Plan. The Constitution of South Africa of 1996 states in Section 156(4):
“The national government and provincial governments must assign to a municipality, by
agreement and subject to any conditions, the administration of a matter listed in Part A of
Schedule 4 or Part A of Schedule 5 which necessarily relates to local government, if
(a) that matter would most effectively be administered locally; and
(b) the municipality has the capacity to administer it.”
Part A of Schedule 4 includes “Health Services” and Part A of Schedule 5 includes “Ambulances”.
The White Paper on Transformation of Health of 1997 and the National Health Act of 2003
support decentralisation of health services to local government. This principle is generally
accepted, although some may argue that services can equally well be delivered from the provincial
level, as mentioned by the chief director in NDoH.
“You are more likely to be able to manage the equity issue if you have the province providing
the funding and providing the service than if you have local government.”
(NDoH chief Director: Strategic Planning)
90
Policy development has been influenced by a number of factors. The Chief Director for Strategic
Planning in NDoH mentioned the experiences of health activists; tours of countries such as the
Philippines; Alma Ata Declaration; World Health Organization; and experience and research in
South Africa.
Early policy development was coordinated by the Health Systems Development Unit which was
funded by the European Union. There was, however, no involvement of reproductive health and
other health programme stakeholders in these processes.
The government is committed to a process of consultation before committing itself to any new
policy or legislation and there has been wide consultation on the policy of decentralisation. The
same is true for health policy. Consultation included:
• other clusters and directorates within the NDoH;
• those external to the department such as DPLG, National Treasury, academic institutions,
NGOs, SALGA and other organisations; and
• international partners.
The process of consultation started before 1994. Provincial Strategic Management Teams set
up to oversee the transformation of health services in each province played a prominent role in
this. Local Government was involved in the debates, but only at a later stage. The whole policy
was then debated in parliament on 1995 and formally adopted in 1996. An attempt at wide
consultation was made, as indicated by the national chief director:
“To the extent that our democracy does work or doesn’t work certainly there was an attempt
to use the organs of debate. So I think it was fairly widely consulted.”
(Chief Director- NDoH,)

A Provincial Head of Department of Health feels that lack of consultation has not been a problem,
but the lack of enabling legislation. He said:
“It didn’t move because there were certain issues, a lack of enabling legislation or certain
key things, but there was no lack of consultation. We as South Africans can consult, we
can have workshops, and we can kill a thing with involvement. … Deliberations with the
DPLG have mainly been around division of powers between spheres of government, the
definition of MHS and which level of local government will be responsible for MHS.”
(Provincial Head of Dept. of Health)
The consultation process helps to identify the complexities, the realities and the difficulties in
introducing change. It is seen as a means of bringing people on board and facilitating changes.
The NDoH consults with the PDoH management through a number of standing committees.
These include MinMEC, PHRC and the National District Health System Committee (NDHSC);
all meet regularly. These meetings are forums for sharing between the provinces.
Some caution is expressed in noting some of the dangers of decentralisation. Lack of capacity
throughout the system is often cited as the major problem. The need, however, for a seamless
referral system and equitable distribution of resources is considered by some to be more important
than insufficient capacity, and is considered a reason not to decentralise all PHC services from
provincial to local government. This was explained by a Chief Director in the NDoH.
“Initially the issue was capacity for local government to render the full basket of services.
The new reason now is not so much capacity but maintaining a seamless service and that
would be easier to maintain a seamless service if you have one provider. And the concern
that we are going to split primary health care from the hospitals and so therefore would
not be able to manage the referral system …. And the second issue that is raised is particularly
around equity. You are more likely to be able to manage the equity issue if you have
the province providing the funding and providing the service than if you have local
government. So it has moved now from an issue of capacity to those two issues.”
(NDoH Chief Director- Strategic Planning)
91
Policy implementation
Policy content for decentralisation and the DHS is informed by a number of documents. (see
Appendix 4). There have been ongoing discussions between stakeholders at the political and
intersectoral level to finalise what and how this process will be taken forward. DPLG, who are
responsible for establishing local government and the relationship between the spheres of
government, expressed concern at the lack of positive decisions as to what the NDoH want to
decentralise, to what level and by when. A lack of strong leadership with good knowledge and
experience of the decentralisation process within the NDoH is seen as a weakness. 16
In August 2004 the NHA (No. 61 of 2003) was signed into law by the National President. It is
expected that this Act will increase the impetus for implementing a DHS in South Africa.
In terms of Local Government legislation and the NH Act of 2003, MHS, which is defined as
some elements of environmental health, is the responsibility of local government and was
devolved to district municipalities on 1st July 2004. The vision, however, remains for the whole
PHC basket of services to be decentralised to the district or local municipality level. 17
16 Personal communication 2003 – Chief Directors and DDG in DPLG (interviews not recorded).
17 National Dept. of Health: The District Health System - Proposed Way Forward: Discussion Document for the PHRC; May
2002.

The process of establishing health districts was started soon after the 1994 election and provinces
were established. With the support and direction of the NDoH each province was divided into
regions with an appointed manager and team. The core function of these regions was to establish
health districts within the region, and once established, for the previous regional offices to be
closed. The provinces had varying success with this process. The re-demarcation of municipalities
in 2000 interrupted the process because the health district boundaries were not coterminous with
the municipal boundaries. A restructuring of the health districts was required. According to
NDoH policy a “health district” is coterminous with a district municipality or a metropolitan
area. 18
There are, therefore, 53 Health Districts in South Africa (47 District Municipalities and
6 Metropolitan Areas) that cover the whole country. This is the level, according to the NHA
of 2003, to which MHS is devolved and the level to provinces may decentralise other
PHC health services. Some provinces have further sub-divided the Health Districts into
Health Districts, coterminous with one or more local municipality boundaries. This then is the
level to which these provinces, such as the NW Province, plan to decentralise PHC services.
Each province has progressed at different rates according to their own plan of action. The NW
Province, for example, is considered to have done well, partly because they appointed early on
district health managers with delegated authority and powers to proceed with the process of
developing health districts.
In the view of a head of a provincial department of health, a stable local environment is a
prerequisite for successful decentralisation. If an organisation is in chaos then decentralisation
will fail. He explained:
92
“In management terms it is kind of a dogma…… decentralisation etc, is the current dogma.
One prominent politician said to me… ‘if you decentralise chaos you get worse chaos’…
Decentralisation is not a panacea to good organisational discipline and in fact it’s
better to first get your organisation disciplined and sort out your fundamentals and then
decentralise on that. Decentralisation it not the solution it’s an action, it’s a mechanism;
it’s a strategy which promotes the better functionality of the organisation and a greater
responsiveness … to needs and pressures. … if you think you can just take a disorganised,
chaotic organisation and decentralise, you don’t do that. In fact in times of hardship
(and) fiscal discipline, we centralise, you pull everything back again; it’s a response.”
(Provincial Head of Dept. of Health)
The director for DHS believes a structured approach to implementation is also important as is
capacity:
“We must allow them [local government] to settle in, build the necessary capacity etc, etc.
and then for us to have a more structured decentralisation and shift from provinces to
municipalities.”
(Director- NDoH)
The need for an organised, structured approach was also shared by other stakeholders:
“Let local government get … their own house in order. And instead of a piecemeal fashion
as we’ve planned it at the moment … let’s wait and put all the systems and structures in
18 National Dept. of Health, Policy document, “The District Health System: Proposal on Terminology”, dated 16 January 2002.

place. The way the district health system is supposed to function up to and including district
hospitals, let them hand over the whole package ….”
(Provincial Head of Dept. of Health)
The process has been slower than anticipated. It is difficult to change the past; there are difficulties
accepting change.
“The structures in government have been difficult to change and bureaucracy is a large
inert thing. We sit on top here and anybody a little way down can just strangle anything
that comes down, so unless you get into the organ down there, you find it very difficult.”
(Provincial Head of Dept. of Health)
The general agreement was that decentralisation is a process, and needs to proceed slowly and
according to a well formulated plan. Lack of capacity at the local government level to take on
additional functions is often cited as a reason for waiting. One Regional Director, however,
working with local level health teams, suggests that this is not true because staff, and therefore
capacity, will be transferred with the functions as they are decentralised. To address the capacity
problems DPLG have initiated training programmes within their department and across the
sectors.
Funding flows for functions decentralised to local government has not been finalised. This is
another barrier to progress. Functions cannot be decentralised without adequate funding:
“Funding arrangements haven’t been sorted out to ensure that if a municipality has been
given a responsibility, it does have the funding to follow it.”
(Director- DPLG)
93
Adequate preparation of the local level is essential for decentralisation to be successful; building
capacity and ensuring adequate funding, as has been mentioned, as well as the need to move
slowly to ensure that the lower levels of the system are adequately prepared.
North West Department of Health – Plans for Decentralisation
Decentralisation of health services in the NW Province are not happening in isolation. As
mentioned previously, the province is developing a provincial framework within which all
sectors are expected to develop their own plans for decentralisation.
In addition, decentralisation is seen both as a management process of empowering district
management teams and as a political move between spheres of government. The Chief Director
for Health Service in the NW Province expressed this view and explained that the process has
started in the province:
“…I think decentralisation is used in two ways, one is and maybe they mean the same in
the end but one is to give local managers more powers. The other one is to move services
from a provincial to a local authority level and I mean we are busy now with decentralising
primary health care to local authorities in the Bophirima region and we are working on a
plan to do it across the province by June, July next year, so between March and June it
should be decentralised all over.”
(Provincial Chief Director- Health Services)

The MEC for Health in the NW Province has been in office since 1994. He has been a
driving force behind decentralising government services, in particular health, to local
government and has built an administrative team of similar minded people to support this. His
term as MEC, however, was not extended after the 2004 national and provincial elections and
the impact or possible changes of a new MEC was not known at the time of the research.
The MEC’s vision is for the local municipalities to be responsible for health services, with the
district municipalities performing a monitoring role. As a pilot, Service Level Agreements have
been drafted for the delegation of all PHC services, minus district hospitals, to local municipalities
in the Bophirima District Municipality. These were signed in March 2004. A rural district
municipality was chosen as a pilot because there are no significant local Municipal Health
Services and the process was expected to be comparatively easy.
There is, however, some doubt within the NW Province Department of Developmental Local
Government and Housing, who is responsible for overseeing the establishment of local government
in the province, including decentralisation, whether it is correct for services to be decentralised
direct to local municipalities. There is also some concern in starting with the most rural district
as a pilot site, as explained by the chief director in that department:
94
“Not unless they take it as a pilot of some sort. Because you have in some municipalities
that are really struggling. For instance in the Bophirima District it would really make sense
to put it at the level of the districts. You may isolate 1 or 2 municipalities that have capacity
to really engage them with the function. But just going there wholesale with some local
municipalities, I have got some doubts about it.”
(Provincial Chief Director- DDLGH)
The North West Provincial DoH strongly supports the national policy of decentralising health
services and establishing a DHS. The MEC for health is very clear on this and has, since he
came into office in 1994, pushed for decentralisation to the lowest level of management as
possible. The first director for health in the province supported these views and was ultimately
promoted to Deputy Director General (DDG) of the department. However, more recently the
MEC noted a move to recentralise management and for the DDG to be involved in district level
appointment of clerks. The DDG was removed and a new appointment made. 19 It appears that
this was done to ensure a coherent vision is maintained at all levels of the department.
The North West Provincial Health Bill established a Provincial Health Authority (PHA) which
includes representation from the departments of Health and Developmental Local Government.
This structure, however, is not fully operational, although the two MECs had a close working
relationship. It is uncertain as to the future of the PHA as the National Health Act establishes a
National Health Council, and the provinces are expected to have a similar structure, a Provincial
Health Council. A regional director believes that decentralisation of health would be more easily
achieved if this structure was fully functional and there was improved communication of decisions
made at the provincial level. She said:
“… if we can get our provincial health planning, which actually indicates that we need to
have a PHA - provincial health authority, which should be chaired by the two MEC’s. …
what is also very difficult for us is the fact that most of the decisions are not in writing and
this also ties in with communication; the way you hear about the decisions is just ‘by the
way’. So if things could be more formalised from a recognised forum or strategic structure…”
(Regional Health Manager Director)
19 from notes from MEC interview of 22 October 2003

The NW Province was initially a leader in the country with developing the DHS even without
systems in support of the process. A Chief Director from the NDoH complimented the NW
Province for the progress they have made:
“We haven’t created the systems, or the capacity to have significant decentralisation of
responsibility and authority. Now…, some provinces are doing better than others. The North
West, I think they have done well, because they did that first. They were the first province
to appoint district managers. And they had a weak provincial office. The managers – I think
they were quite lucky with whom they appointed – they just went on and did things.”
(Chief Director- NDoH)
Soon after the NW Province and the North West PDoH was established in 1994, the province
was divided into regions and health districts; managers were appointed and processes for
establishing a DHS were put in place. From the start the PDoH, led by the MEC for Health,
planned to decentralise all PHC services, including district hospitals to local municipalities.
However, these plans have been modified in accordance with national policy, as this has changed.
The process whereby PHC services can be decentralised to local government has changed.
Delegation through Service Level Agreements has been proposed instead of full devolution or
assignment. 20
Four regions in the province have been established as part of the strategy for decentralisation.
The appointed regional managers are part of the PDoH head office establishment, but are placed
at the regional level to oversee implementation of decentralisation within the region or district
municipality.
“I should not see myself separately, because I am part of head office. It’s just a decentralisation
strategy, to make sure that when people need things they get to them at a local level. And
I am on the head office structure rather than the regional structure.”
(Regional Health Director)
95
The regional directors are delegated some management authority for finance and personnel and
are actively involved in drawing up the budget for health districts and the regions. This is part
of the strategy of decentralising health management and establishing the district health system.
The regional directors, although line managed by the Chief Director for Health Service Delivery,
are required to co-ordinate with the other three chief directorates in the province.
“… my job is also made quite difficult because I coordinate. … Now the difference between
us as regional directors and other directors in head office… the four chief directorates
would deal with all their functions and that is why our role is more co-ordination and
decentralisation of management.”
(Regional Health Director)
Delegation of financial and personnel functions to either the regional directors or to the district
managers are being phased in according to local capacity and preparedness to take on the
delegation. There is a proviso that such delegations can be retracted if necessary.
20 National Health Act - no 10 of 2003.

3.5 Conclusion
This chapter provides a brief overview of the processes towards decentralisation in South Africa.
Special reference is made to the NW Province and the provincial approach to decentralisation
of services.
The process is complex and dependent on multitude of factors. The vision, as contained in
the constitution of South Africa is for all government departs to decentralise their functions to
local government where ever capacity and resources is available. Decentralisation of health
services started soon after the new government of 1994 came into office. Delays in establishing
the local sphere of government, however, has delayed the process for health service delivery.
The NW PDoH, not withstanding these delays, has made significant strides towards a decentralised
district health system. These will be discussed in subsequent chapters of this report.
96

Chapter 4
Reproductive Health Services in South Africa
4.1 Introduction
This chapter introduces the development of health policies in general and in particular reviews
the reproductive health polices and services development in South Africa.
During apartheid, South Africa had fourteen (14) different Departments of Health, each responsible
for its own area of jurisdiction and development of processes. Hospitals, focusing on curative
services, fell under the national government, the four White controlled provincial administrations
and the ‘homeland’ governments. Local Authorities were responsible for preventative and
promotive health services through a system of clinics which included some mobile clinics serving
some rural communities. All these services were stratified according to race, and there was little
expenditure on basic health needs and Primary Health Care (PHC).
The ‘homelands’ developed their own health systems based on Health Wards which were similar
to a District Health System (DHS). However, the services within these Health Wards were hospicentric
with inclusion of fixed and mobile clinics within defined geographical areas, and some
community outreach programmes. The clinic services were largely run by professional nurses
with support from hospital-based doctors, and were run along PHC-type lines.
Some powers and authority were delegated or de-concentrated to the Medical Superintendents
of hospitals but this authority was limited to the areas of financial and personnel management.
‘Hiring and firing’ remained the responsibility of the centralised ‘homeland’ government, although
recommendations were made by the hospital management team. The ‘homelands’ were underfunded
per capita compared to White governed areas, and there was little coordination between
services.
Reproductive health programmes did not have a comprehensive and coordinated policy.
Additionally, there was no coordination between the different health authorities. Programmes
were run vertically with little integration at service delivery level. Family Planning (FP) services
were developed in the 1970s as a vertical programme and focused on increasing White fertility
rates while reducing fertility rates amongst all other groups. While the 1980s saw international
trends integrating family planning services into the broader maternal and child health care
programmes, the South African government continued to promote a vertical programme for FP.
This vertical reproductive health programme became part of the Population and Development
Programme (PDP) which was designed to support overall population development through
education, PHC and economic development. The PDP did not apply in the ‘homelands’, nor
was it accepted by the majority of the population. Other reproductive health programmes, such
as safe motherhood and management of sexually transmitted infections (STIs) remained part
of the hospi-centric and curative services, except in the ‘homelands’ where the services were
integrated at a clinic level.
By 1994 the public health sector served 80 percent of the population yet received only 50 percent
of the total health budget, while the private sector, serving 20 percent of the population consumed
the balance. The private sector was served by nearly 70 percent of all registered medical
practitioners. The cost of private health insurance increased 12-fold, as opposed to the consumer
price index which increased four-fold, from 1982 to 1993, making it increasingly unaffordable
even to the richest twenty percent of the population. 1
97
1 Pillay, Y.G. and Bond P. (1995) Health and Social Policies in the New South Africa, Int. J of the Health Services, Vol. 25,
No 4, 727-748 (p 727).

As Pillay and Bond have described, “the health system, like all other official institutions in
South African society, is the product of material processes related to the country’s economic and
social development, and has also been profoundly shaped by racist, sexist, and market ideologies.”
2 They further state, “there is no dispute that under apartheid, health care services were fragmented,
inadequate, ineffective, poorly distributed, and inefficiently delivered. There are many indicators
that document the disaster of apartheid health policy, and all available health status indicators
bear out huge discrepancies.” 3
The effectiveness of these services was particularly seen in the availability of contraceptives.
The fertility rate in South Africa dropped from 4.5 to 2.9 between 1978 and 2001. 4 The population
growth rate was 1.5 between 1995 and 2000 and predicted to be 0.8 between 2000 and 2005. 5
Maternal mortality ratio (MMR) and other indicators, however, have not decreased. MMR in
1999 was 230 maternal deaths per 100 000 live births and in 2002 it was 340 maternal deaths
per 100 000 live births. 6
In the ‘homelands’ all reproductive health services were part of the PHC services provided
through clinics and hospital within a health ward. The health ward system was similar to the
DHS providing health services within a defined geographical area to a defined population. The
services, however, were hospi-centric with the hospital management team being responsible for
first level hospital, clinic and community health services.
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The right to reproductive health is now entrenched in National Legislation and policies which
include:
• Reconstruction and Development Programme – 1994.
• African National Congress Health Plan – 1994.
• Maternal, Child and Women’s Health; Draft Policy Document – 1995.
• The Constitution of the Republic of South Africa – 1996.
• Choice on Termination of Pregnancy Act – 1996.
• White Paper for the Transformation of Health Services in South Africa – 1997.
• Notification of Maternal Deaths – 1997.
• Health Sector Strategic Framework – 1999 to 2004.
• Policy Guidelines for Adolescent and Youth Health – 2001.
• Guidelines for Maternity Care in South Africa – 2002.
• National Contraception Policy and Guidelines – 2002.
• Strategic Priorities for the National Health System – 2004 to 2009.
• National Health Act – 2003.
• Patients Rights Charter.
A Patients’ Rights Charter which includes right to privacy, treatment, respect, information and
to be treated with dignity is in place from the national level and is displayed in all clinics. This
charter is expected to be adhered to.
Reproductive health services have generally improved since 1994. There are more clinics
providing 24 hour services and these clinics are better equipped. There are standard protocols
for referral to hospital when required. This expansion of services is often equated with the
2 Pillay, Y.G. and Bond P. (1995) Health and Social Policies in the New South Africa, Int. J of the Health Services, Vol. 25,
No 4, 727-748 (p 728).
3 Pillay, Y.G. and Bond P. (1995) Health and Social Policies in the New South Africa, Int. J of the Health Services, Vol. 25,
No 4, 727-748 (p 728).
4 World Health Reports - 1999 and 2002.
5 United Nations Population Fund (UNFPA) Reports – 1999 and 2002.
6 United Nations Population Fund (UNFPA) Reports – 1999 and 2002.

process of decentralisation, but is probably independent of it. Decentralisation of PHC service,
however, would probably be more difficult if the expansion of services had not occurred. Soon
after 1994, for example, capital was made available for building, refurbishing and equipping
clinics and hospitals throughout the country.
“In North West, a third of the facilities were built within the past ten years, of which 22%
were established during the latter half of this period.” 7
Although there has been no specific major investment in reproductive health services there are
signs that it is given special attention, as described by one district manager:
“No I would say no (to special focus on reproductive health)…. We just look at the whole
service that we have to render. … it (reproductive health services) accounts for a major
part of our clientele. So even though there is no specific focus on it, if you were to go into
the figures you would find that we are disproportionately spending more on it. … we measure
maternal death, neonatal death and so on. … So there is pressure on us as management
and as providers to make sure that we handle reproductive health correctly. …”
(District Health Manager)
4.2 National Reproductive Health Services
The NDoH drafts and develops policy and then provides the PDoH with support in implementation.
The two spheres of government work together in identifying the resources required, with the
national level playing a supportive role to the provinces. The NDoH officials do not have a
mandate to directly contact the health districts or districts which are the levels of service delivery.
The NDoH officials rely on the provincial officials to be invited to visit the service delivery
levels. This problem is illustrative of the effect of the quasi-federalism in South Africa, as
described in Chapter 2, and the power of the provincial sphere of government.
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“Not direct (to district level). It causes a bit of a problem … We have to go through the
province and the province takes us. Although we are now going into some health districts,
but we have to be very careful how we interact and how we even feedback what we find
there.”
(Chief Director- NDoH)
“But because provinces have their own semi-autonomy we can’t give total direction. We
have to negotiate in order to work together in a sort of cooperative governance. We take
decisions together and try and move together.”
(Director Maternal Health - NDoH)
Provincial reproductive programme managers are included in discussion on policy and
implementation strategies. The NDoH provides a framework within which each province must
work according to the needs of their province and offers support when required. However, the
provincial experience of support from the national level is varied, as explained by the NW
Province Director for HIV/AIDS programme:
7 The National Primary Health Care survey – 2003. North West Province p15.

“Yes in a way they (the NDoH) are supportive, the only thing they are slow, very slow and
sometimes they are not capacitated enough to be able to handle the provincial governance
and differences.”
(Provincial Director HIV/AIDS- NW Province DoH)
Reproductive health policy development and implementation in South Africa
In 1995, the NDoH published a draft policy document for Maternal, Child and Women’s Health
(MCWH). This draft policy document is based on the RDP and ANC Health Plan. The focus
of the policy is on equity of services and on the most vulnerable and disadvantaged, such as
women and children in rural areas. The stated goals of the policy are in line with International
Conference on Population Development (ICPD) principles of 1994, although these are not
identified as such. The policy states, for example:
• To achieve optimal reproductive and sexual health (mental, physical and social) for
all women and men across the life-span of individuals.
• To raise the status of women, their safety, health and quality of life.
The policy further states that services are to be delivered through an integrated approach as part
of the DHS, supported by a vertical management system.
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“Health services for mothers, children and women will be delivered as part an integrated
comprehensive health system (horizontal approach) and supported by an organisation and
management structure which is vertical in emphasis, but linked to the rest of the service
administration at each political level.”
As already mentioned, women’s reproductive health and rights are given high priority in other
policy documents, such as the RDP, the ANC Health Plan, the Constitution of South Africa and
the White Paper on the Transformation of the Health Services in South Africa. HIV/AIDS
programmes, however, appear to be prioritised above other reproductive health programmes.
Although planning within the department is done at the cluster level of Maternal Health, Women’s
Health, Child health and Nutrition, reproductive health programmes are not fully integrated.
The HIV/AIDS and STI programmes are separately funded and largely perceived to run
independently of other programmes. Reproductive health is considered to be part of the whole
package of primary health care and is fully integrated into the “supermarket approach”. Integrating
the vertically managed programmes involved in reproductive health is a challenge at all levels,
from policy formulation, implementation and service delivery. The PMTCT programme, for
example, was started as a research project within the HIV/AIDS directorate at NDoH without
involving the maternal and women’s health directorate. This has been corrected and the two
directorates join for all meetings on PMTCT. The difficulties experienced with coordination
were expressed by two national managers from each directorate – HIV/AIDS and Maternal
Health:
“I’m not against it (integration), but the actual practicality of it is quite difficult. We try
as much as possible to integrate even here at national level, but because there are so many
competing priorities it makes it very difficult. An area I may consider to be important for
us to integrate with MCWH, for instance, may not necessarily happen that way because of
competing priorities. … But it is an excellent approach.”
(Deputy Director- National HIV/AIDS Directorate)

“…for instance HIV/AIDS would be driving and running with the PMTCT programme
which is a maternal and child issue, … it fell under a lot of pressure from the politicians
and the funders and the approach it took was more of a research, … without
saying that we have got maternal health units out there that are doing antenatal care.
This is where you locate PMTCT. …. Now you have to look at integrating it into antenatal
care and the maternal health units … So it is a struggle now and not a pleasant one.”
(Director Maternal Health- NDoH)
Other departments or directorates of importance in support of reproductive health policies and
services are mental health (in handling sexual abuse and violence against women), chronic
diseases (for breast and cervical cancer), human resource development (for training) and hospital
services. Linkages have also been formed outside of the department with other government
sectors, such as Justice, Arts and Culture, Education and with Non Governmental Organisations
(NGOs).
Numerous priorities faced the new government in 1994, many of which, such as cervical cancer
screening, could not be addressed immediately. Priority was given to addressing maternal
mortality and addressing the problem of unsafe or “back-street” abortions. Two of the earliest
policies and legislation enacted for reproductive health were the Choice on Termination of
Pregnancy Act of 1996 and Notification of Maternal Deaths in 1997.
“It comes back to the fact that we have made maternal survival (a priority). Olive Shisana
did one thing as DG: she single mindedly drove through the need to register births and
deaths and maternal deaths and that is the key and she knew that …”
(Provincial Head of Dept. of Health)
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Policies for safe motherhood, monitoring of pregnancy and maternal care are based on the
findings from the Saving Mothers Reports and Saving Babies Reports published by the National
Department of Health between 1999 and 2004. The development of policies for improved
maternal care are influenced by the development of the United Nations Millennium Development
Goals, and international monitoring of progress.
The ICPD principles, although not specifically mentioned in many policies, are incorporated
in many new policies for reproductive health services. South Africa is a signatory to these
ICPD principles and those developed at subsequent conferences, such as the Beijing Conference
in 1995. The emphasis is on women’s rights and freedom to make decisions such as when
to have or not to have children. Promotion of these values in the midst of a patriarchal society
is a challenge, as noted by a NW Province Deputy Director for Reproductive Health:
“They [traditional leaders] are supportive of no-violence against woman, that they are very
vocal about. But the rights in the sense of rights of a woman have equal rights with a man
they are not so open about it.”
(Provincial Reproductive Health Deputy Director)
This is experienced particularly with provisions under the Choice of Termination of Pregnancy
Act (CTOP) and female sterilisation. A husband’s consent is not required. This is a major
change from tradition and can lead to confrontation between communities and the health
services, or within families. The NW Province Deputy Director for MCWH shared an experience
in a community meeting illustrative of the challenges in bringing about changes:

“… people are becoming much more vocal about their rights and if they are not explicitly
entrenched in a policy, the health workers will not know precisely what to do. … there was
this Imbizo [Community Meeting]. This man stood up to complain to the Minister of Health
‘… here is my wife who had a sterilisation without my permission. … you just sterilised her
and gave her a paper!’ … he is missing an issue that this woman has a right to do a
sterilisation without calling the husband and the husband is not aware and perhaps the
woman is afraid of him. She doesn’t tell him the truth and then blames the health facility.
… she feels that if she tells him the truth it would be disrespectful (to her husband) … (she
would) rather be safe and blame somebody else.”
(Provincial MCWH Directorate)
The House of Traditional Leaders is assisting in addressing these difficulties. A consultation
process between traditional and other community leaders, such as local government councilors,
is in place. (See chapter 10: Governance)
Leadership from the National Minister of Health is important. Her participation in international
and national debates and past experiences within health and other sectors are seen by one senior
NDoH official as being important in formulation of policy. The current National Minister of
Health is a medical practitioner and was previously the Deputy Minister of Justice. She is seen
as a leader in the debates on equity and gender rights.
Interviewees agreed that there are a number of influential factors behind reproductive health
policy development and implementation. These include:
102
• NGOs (Human Rights Commission; Reproductive Rights Alliance, Aids Law Project).
• Gender Commission.
• Youth Commission.
• Donors and funders of research and programmes, particularly in relation to HIV/AIDS
projects. Funders have their own agendas and can influence priorities.
• Political issues, particularly in HIV/AIDS programmes. The development of the
comprehensive HIV/AIDS strategy and the role out of antiretroviral treatment has, in
part, been due to pressure from a Constitutional Court ruling on the right to access to
treatment for the thousands who suffer from AIDS. The number of PMTCT sites
increased in six months from 200 to several thousands.
• International pressure for South Africa to conform to international agreements following
the 1994 democratic elections. South Africa became a signatory to the conventions
passed at ICPD and other conferences.
• Internal research, such as that presented to the HIV/AIDS Consultative Forum for South
African Scientists in August 2002. The recommendations influenced policy for HIV/AIDS
and the ongoing research agenda for the programme.
• Results of international research are adapted for local implementation.
• Cultural issues. The empowerment of women is seen as undermining the traditional
patriarchal society of the majority of the population in the country.
A process of consultation with stakeholders does take place in development of policy. It appears,
however, to be confined to the national level and to include some provincial representatives,
academics, some NGOs and local and international consultants. Community members and health
workers are not generally consulted on policy and legislation. They can, however, be part of the

process of developing green and white papers and draft bills by submitting comments to the
Health Portfolio Committee. The debates can be lengthy and can delay the enactment of legislation,
such as with the National Health Act of 2003.
Other bills have been fast tracked through parliament with little or no consultation with
stakeholders, such as the service providers. This was the case with the introduction of free health
services for pregnant women and children under 6 years of age. Although accepted as a part of
the RDP, inadequate preparation and planning at the local level for the implementation of the
policy led to a chaotic situation as the demand for services initially exceeded supply, as explained
by a chief director in the NDoH:
“For instance if you look at the free health care for pregnant women and so on, there was
quite a lot of … resentment particularly amongst the health workers that this service is now
being provided to everyone. Suddenly people are flooding the clinics because money is no
longer that much of an issue. And we said we wish we had been better prepared or better
informed about what was going to happen.”
(Chief Director- NDoH)
As a member of the HIV/AIDS directorate explained, this directorate has a specific process for
consultation with as many stakeholders as possible:
“Within HIV/AIDS, what normally happens … is that the HIV/AIDS Directorate will sit
down and draft the policy guidelines. … they ensure they distribute them to the experts
(including civil society) around the country for their comment. Once they have that kind
of input, they call a formal workshop where they discuss in more detail with these experts,
plus provincial people and even sometimes district managers. That process informs the
final policy guidelines. But it still has to go through the department channels again … senior
management committees, … PHRC, … MINMEC, and then it’s finally adopted. Then it
goes to Cabinet, and it’s all systems go”
(Deputy Director - HIV/AIDS Directorate)
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Compromises have been reached between the stakeholders, according to a National Director for
Women’s Health:
“… yes – some compromise with a lot of bargaining. Because we as government must focus
on democratic processes and allow all the views to come in all the time. So people get a
lot of opportunity to bargain … even in parliament.”
(National Director Women’s Health )
The ability to implement reproductive health policies varies between provinces – this is closely
related to capacity, resources and availability of specialists and specialist run services. As
explained by one national manager in reproductive health, Gauteng is known to be well-resourced
with many specialists, whereas Northern Cape and Mpumalanga each have only one specialist
obstetrician in the public service within these provinces. In 2003 Gauteng had 19.7 medical
specialists in the public sector per 100 000 population. The figures for NW, Mpumalanga and
Northern Cape Provinces were 1.5, 0.7 and 2.7 respectively. 8
8 Day C, Halleberg C. Health Indicators. In: Ijumba P, Day C, Ntuli A, editors, South African Health Review 2003/04. Durban.
Health Systems Trust.

Preparation of the local level to accept and to implement a new policy is seen as essential. This
was expressed by the National DoH- Reproductive Health Director who accepts that preparation
was not optimal and there is always something that is overlooked:
“I think had we been well prepared, we would have anticipated some of these and the fact
that some of these things caught us unawares – the problem is that we were not that well
prepared.” … “Well, you can never have anyone who is adequately prepared. There is
always something that you find along the road.”
(Reproductive Health Director - NDoH)
The difficulty of accepting change, without proper preparation and adequate human resources
is appreciated by the HIV/AIDS directorate:
“It’s always very difficult for people to readily accept to implement such a service, especially
when they have not been prepared in advance. Again it boils down to the issue of human
resources.”
(Deputy Director - National HIV/AIDS Directorate)
And a head of department of health in another province was adamant that decentralisation and
new policies will fail if there is inadequate preparation:
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“Against (decentralisation), if you don’t prepare people properly, if you don’t train them,
if the system is very rigid then the system will just fail. So I think what is important is
preparation.”
(Provincial Head of Department of Health)
A process of advocacy is required. The introduction of free health services for pregnant women
and children under 6 years and later extended to free PHC services for all caused great confusion
because of lack of preparation.
The local level was not well prepared for the introduction of post exposure prophylaxis (PEP)
for rape and sexual assault. The policy to add antiretroviral drugs to the package was announced
one day by the Cabinet and the health services were expected to provide it the following day.
However, in this case there was also a delay in implementing the original policy, as explained
by a national health manager:
“But when one looks at the other side of the coin, with the PEP programme for instance,
the only new thing there was the provision of ARV. The Sexual Assault Package of Care
was supposed to have been long in place since 1999 when that Bill was passed.”
(Deputy Director National HIV/AIDS Directorate)
Other problems with inadequate preparation of the local level to implement changes in policy
were identified by interviewees as:
• Lack of local capacity.
• Lack of number of staff at national level to oversee the process.

• Autonomy of the provinces to appoint staff; who may not full understand their
responsibility and roles.
• Compromised training due to integration of services for delivery, such as Family
Planning.
• Lack of commitment from the provinces to allocate resources to implementing a new
policy, such as the HIV/AIDS policy. It is difficult to push from the national level,
although there appears to be less resistance from the provincial level than from the
district level.
From the national perspective there has been better preparation where someone had previously
worked at the national level and gained a broad overview of the changes and then moved to the
provincial level to be involved in implementation. This was shared by the National Chief Director
for MWCH:
“They (provinces) appoint whoever they think is appropriate for that position without really
fully understanding the kind of responsibilities they need to take into the job. Some of the
people, I think, that have done well are people who may have started for instance at national
level, saw the overall picture, saw the kind of skills that are necessary and then moved to
the provinces.”
(Chief Director MCWH- NDoH)
As mentioned, reproductive health services form part of the primary health care package. A
comprehensively trained professional nurse is expected to manage the whole range of services
and be responsive to a number of vertical programmes. National health management believes
technical staff are in favour of integration of the services.
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“If they could they would like to have it integrated but the problem there was of management
of the process – that you have to deal with.”
(Director Women’s Health- NDoH)
In practice priorities have focused on increasing access to services, equity and the most vulnerable
groups, particularly in the underserved areas. Preparation for implementation varies between
provinces, and is usually related to availability of resources and capacity at service delivery
level.
A policy once developed is launched by the NDoH in conjunction with the PDoHs. This entails
publicising and distributing the policy before developing guidelines and protocols for
implementation.
Most stakeholders and informants interviewed consider decentralisation of reproductive
health services to be good. One NDoH manager, however, expressed the opinion that the
preventive and promotive aspects of reproductive health would be better managed centrally:
“I think the preventive services … their responsibilities should be re-centralised because
out there it’s the immediate things that attract attention and therefore suck in resources…
if you have somebody central that is now responsible for making sure that those programmes
are going on and those programmes will go on irrespective of anything else that happens.”
(Chief Director MCWH- NDoH)

Purchase of contraceptives should remain centralised for reasons of economy of scale and
protecting the availability of the service. If decentralised, a district or local municipality may
be persuaded to divert funds to purchase antibiotics that are needed for immediate urgent use;
following the thinking that contraceptives are not life saving and the patient can return next
week.
“They’d rather buy penicillin than to buy Depo Provera because they come with pneumonia
in the morning, they are going to die tomorrow. Whereas somebody comes in, they are
supposed to have their injection today; they can still come back next week.”
(Chief Director- NDoH)
Apart from adequate preparation of the local level, a number of other lessons have been learnt
in the process of developing and implementing new policies. These are:
• the role of civil society
• the role of academics and research; and
• the need to strengthen collaboration between stakeholders.
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Close collaboration has been developed between health, justice and police in developing and
implementing management of sexual and domestic violence against women and children. In the
nutrition programmes there is collaboration with the Department of Agriculture. HIV/AIDS
collaboration is wide with social services, education, academic institutions, private sector and
NGOs playing a role. National, Provincial and District AIDS Councils, comprising a cross
section of government, private sector and civil society, are included in the strategic plans for
managing HIV/AIDS. The functioning, however, of these structures varies considerably.
NGO may be funded by or through the NDoH and are assisted and supported in preparation of
their business plans. Collaboration with NGOs is more for training of nurses and advocacy for
women’s rights rather than provision of services, except for voluntary counseling and testing
(VCT). A framework for cooperation and coordinating services provided by the NGO sector so
as to ensure they are in line with each other has been developed. The provincial office gives
permission for NGOs to operate at a local level.
Perceptions of the NDoH are generally that services are better under a decentralised system of
management. These perceptions include:
• Access to services has improved.
• Vertical programmes are being integrated at a local level; for example, family planning
which had previously been vertical through the PDP is now part of the PHC package.
4.3 Provincial Reproductive Health Services – North West Province
In NW Province reproductive health is the responsibility of several directorates and subdirectorates
under the Chief Directorate: Strategic Health Programmes. The services, however,
are delivered as part of the integrated PHC approach. The sub-directorates collaborate with each
other as many of the services overlap and impact on each other. (See Chapter 2)
“… so we collaborate with them and coordinate things together, we meet on a monthly
basis with all the reproductive health managers, just like PMTCT, it's driven from reproductive

health and from us and also when we talk about the CTOPs and the maternal death, family
planning, fertility rates and we do the analyses we realise that health services is one, it's
just that for easy manipulation and working you will have to compartmentalise it, but in
actual fact it's one.”
(Provincial Director for HIV/AIDS)
The programme extends to the district level. The Provincial MCWH Director incorporates
representatives from the district level in her reproductive health team. This widens the skills
base of the team, especially for training.
Communication from the provincial programme managers to the health district, the level of
implementation, is officially via the regional offices. However, many provincial managers
communicate directly with their counterparts in the districts. The programmes are seen to be
managed vertically, but the health district is expected to implement them all in an integrated
fashion; nurses are trained to deliver integrated services. The difficulties involved are acknowledged,
particularly with the increase in number of patients and the shortage of staff.
The PDoH reproductive health managers are consulted as part of policy development process
of NDoH. The provincial department’s responsibility is to then develop guidelines, with support
from the NDoH, for implementation of the policy at the district and hospital level, according
to the requirements of the community.
New policies are ‘launched’ in the province and the district level is consulted before implementation,
as explained by the provincial MCWH Coordinator.
“There has been a lot of consultation because we have just noticed that it becomes a useless
feat to take a box of (policy documents) … to deposit them all over. You’ll find them like
that (in the box). But if they understand it has been a process that … there will be a phase
where you are going to launch. And when we launch, we implement and when you implement
these are issues to address and this is how to deal with the policies. So you will find them
out of boxes in use.”
(Provincial Women and Child Health Coordinator)
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A standard process for implementing a new policy is followed. Workshops are held across the
province to introduce the policy, how it can be used in the different clinics and how it will benefit
the community. Sustainability is addressed through ongoing budgeting for and training on the
policy.
Thorough preparation of the people who will be implementing the policies is essential. This has
not always been optimal and is an area for improvement.
“I always think that what we should have done differently is to prepare the providers,
you know, capacitate the provider very well before we take the service out to the people.”
(Provincial Reproductive Health Manager)
Changes made to policies, such as for contraception or youth policies, are not usually piloted.
New policies, however, are piloted to determine their cost effectiveness before introducing them
across the province. The PMTCT programme, for example, was piloted and subsequently rolled
out to additional sites.

The new policies from national, based on ICPD principles, have brought changes, such as more
counseling and opportunities for the patients to make informed choices. An example of this is
the greater choice available for contraception:
“… you know we came from an era, we talked family planning; we now talk reproductive
health.”
(Provincial Reproductive Health Manager)
The move towards a more rights based approach to reproductive health is seen as positive in
North West Province, although there are clashes with some traditional beliefs and the prevailing
patriarchal culture.
Research on the impact or effectiveness of new policies is done by the NDoH, and not by the
PDoH. This was expressed by provincial managers in MCWH and seen as a weakness in the
department:
“… there has been some research on the Use of Contraception, and the youth one.… No,
no, - national (DoH); we (PDoH) haven’t done any research.”
(Provincial Women and Child Health Coordinator)
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“In the North West, in the reproductive health services there is no, I don’t want to tell lies,
it's zero. I would rate it zero.”
(Provincial Reproductive Health Manager)
All new policies from NDoH have been implemented in NW Province. However, not all are
being monitored by the provincial programme managers and there is uncertainty as to whether
all districts are complying with the new policies, as shared by the provincial MCWH Coordinator:
“I would assume that it (emergency contraception) should be (available) because we have
made it a point that the stores have it, so that the clinics can access it. So as to availability
I cannot assure you, now. … But it is available like any other drug that is in the stores that
…. It's something that one needs to monitor.”
(Provincial Women and Child Health Coordinator)
The 2003 National Facility Survey reports:
“Four out of five facilities nationally (80%) compared to three out of five facilities in North
West (63%) provided emergency contraception.” 9
Monitoring of the policies can be difficult due to weaknesses in the information system. There
is a DHIS which is not fully implemented in all districts and districts, mainly due to lack of
capacity. The DHIS is discussed in Chapter 9.3.
4.4 Local Level Reproductive Health Services
There is a standard PHC Service Package 10 developed by the NDoH and required to be delivered
in health districts or district. Reproductive health services are included in this package. The
9 The National Primary Health Care Facilities Survey 2003 North West: page 17
10 Department of Health: A Comprehensive Primary Health Care Service Package for South Africa: September 2001.

availability, access and uptake of reproductive services vary between districts, as described
below.
According to the PHC Service Package (see Chapter 6.4) reproductive health services are
available at all mobile and fixed clinics and all community health centres (CHC), with linkage
to the District Hospital Package of Services. The reproductive services of the PHC package
include:
• Antenatal care – including screening for syphilis infection, PAP smears and counseling
for VCT and inclusion in the PMTCT programme is necessary.
• Post natal care.
• Maternal health – uncomplicated deliveries in clinics and community health centres.
• Counseling and referral (if necessary) for termination of pregnancy.
• Counseling and referral (if necessary) for voluntary testing for HIV infection.
• Screening for cervical cancer.
• Contraceptives.
• Diagnosis and treatment of sexually transmitted infections.
The level of care within each category at mobiles, clinics and CHC is defined in the Package.
All services are expected to be available within each health district on a 24 hour basis; at clinics,
CHC and/or district hospitals. Some of the services allocated to CHC in the Package are likely
to remain with the district hospitals due to the CHCs not being fully operational.
All services are offered in an integrated fashion. Nursing staff have generally adjusted to these
changes. Fast queues are used for patients requiring one service or repeat medication so that
they do not have to wait as long. This was explained by the Central Region Director:
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“Each clinic provides that kind of health service … there has been changes… family planning
clinics are part of mother and child services in the clinic – there are no separate days for
family planning as previously. … we have also created fast lines, so that the person who
is coming for (repeat) family planning does not queue for long time …”
(Regional Health Director)
The integrated service means that a patient is seen by one nurse who attends to all his/her
requirements, as explained by a district MCWH coordinator.
“… when a mother has brought her child for immunisation … we don’t concentrate on only
the child; when the mother comes we also ask if there is anything that she would like us
to attend to concerning her … she goes out having had information … having had her
contraceptives…”
(Health District MCWH Coordinator)
HIV/AIDS programmes are integrated at the service level, although managed vertically from
the national and provincial levels (as described previously).
“… the HIV programme is integrated into the primary health services … like prevention
of mother to child transmission of HIV/AIDS it is provided in all primary health care
facilities. … so a client gets a comprehensive care package. And the other STI services like

voluntary counseling and testing we get people in the family planning clinics and pregnant
women … and all the other people who come to the clinics.”
(Health District HIV/AIDS coordinator)
Some clinics do still have special return days for antenatal care (ANC) clients. This facilitates
taking blood specimens for transport to the laboratory at the hospital. Transport, in some
places, is only available on a weekly basis and it is preferable to draw bloods on the scheduled
transport day rather than store in a refrigerator for any length of time. (See Chapter 11)
The practical difficulties of integrating the services are acknowledged, even at the national level,
as expressed by the National Chief Director for MCWH:
“… the practicality of service integration is a difficult one. … it is difficult to have this one
super-nurse who will have all the time to go through every integrated approach. … So they
sort of have to separate to the extent that they have separate settings in the facility and they
run separate clinics.”
(Chief Director, MCWH NDoH)
In health districts where local government and provincial clinic services operate, the services
have been functionally integrated. The staff members, however, are paid and line-managed by
the different government structures.
110
Management protocols are supplied to each facility for use for managing reproductive health
services. Many of these protocols originate from the national department of health, with few
changes at the provincial level. Some provincial reproductive health managers have been involved
in developing the protocols and policies.
Cervical screening can not be offered at all clinics due to a lack of resources. In November 2003,
there was a programme to target cervical cancer screening of women. Staff were specially trained
and the team moved between districts and between facilities within the district. Although this
was a once off campaign, it is hoped that it will be integrated into the PHC services at all clinics.
The motivation for the campaign originated from the national level. Similar campaigns are
arranged for other health projects during the year, usually coinciding with nationally determined
days or months.
The generic district organogramme below shows reproductive health management at district
level. (See Chapter 2.4 for further details)

Figure 4.1: Generic Health District Organogramme
Regional Director
Health District Manager
AD Administration
AD Community Health Services
Finances
Programme Managers MCWH,
Community Districts
Human Resources
Health Area Managers
Other support services
CHC, Clinics, Mobiles
Source: NW DoH, 2003
Data for graphs in the following sections are taken from the DHIS and Hospital Information
System which is still being developed. (See Chapter 9.3 for further details of DHIS)
111
4.4.1 Klerksdorp Health District, Southern Region (District
Municipality)
Services available in the districts
Reproductive health services are available throughout the Klerksdorp district in community
health centres, clinics and via mobile services. One Youth Centre has recently been opened in
Joubertina, the largest residential township in Klerksdorp. Referrals to hospital are to Klerksdorp
Provincial Hospital Complex. This complex is an amalgamation of two hospitals – Klerksdorp,
in the City of Klerksdorp, and Tshepong, situated in Joubertina.
Services are integrated into the PHC package and are officially available at all times that the
facility is open. There is community demand for there to be 24 hour services available in all
areas of the district. This has been problematic because of the integration of the provincial and
municipal services which are part of different spheres of government and offer different conditions
of service to their staff. The confusion and difficulties in providing this 24 hour service was
expressed by provincial and local government employees:
The request for these services is acknowledged by the district manager:
“The key issues that are brought forth by governance structures for instance are extension
of services, like a 24 hour service. It is very clear throughout that people want 24 hour
service.”
(Regional Health Director)

The ADCHS, who has resided and worked in the area for many years, explained further:
“Why am I saying this is, is because as we know especially for Klerksdorp district the
department of health is in two. It is the local municipality or local authority and the province.
So out of the 14 clinics in Klerksdorp, only 2 are provincial clinics, the rest are, local
municipality and in those clinics we are having 2 sets of employees. That is now those
employed by province and those employed by local authority and doing the same work but
not getting the same salary.”
(District ADCHS)
She went on to explain:
“…you first have to have a meeting with the councillors from the local municipality get
their feeling so which is one can say it’s politically at times. If it’s not in their favour they
might have a resistance in taking over. I can make for example the extension of hours where
we wanted our clinics to work beyond 4 or 5 o-clock to go off at 7 o-clock or even open
on during weekends. We struggled from 1996 up to now. We are still struggling. There are
those clinics which we are still having problem to extend the hours, but as I say the community
I don’t see it as, it won’t be a problem, because they would like to have the services.”
(District ADCHS)
112
The municipal health manager explained the problem from the municipal perspective and the
longer hours required to be worked by their staff:
“The only things that give them a problem is at the moment they are talking, if we work 7
to 7 we must get transport to take us home, we must have doctors on call, such things. We
spoke to the province to say that they must make sure that they will be doctors on call,
which is what normally happens anyway. But changing hours, because ultimately we want
all these facilities to start delivering so that is the other thing that still has to be negotiated
through the bargaining council to say what now?”
(Local Municipality Health Manager)
Health workers in the clinics from each respective employing authority, however, work well
together on a day to day basis. Twelve of the fourteen clinics in the district are owned and
managed by the municipal health services and the additional help from provincially employed
nurses is appreciated, as explained by one Facility Manager:
“… now we have got nurses from the province who has been appointed to our clinic. It's
going to be okay now, but there is this thing of, you know, the teething problems of having
to get used to one another. They did not know the set up at the clinic.”
(District Facility Managers Discussion Group)
Contraceptive services / Family planning
Contraceptive services are available in most health facilities in Klerksdorp. The ADCHS
elaborated:

“I would say each and every clinic, with the exception of one clinic; all of the other 13
clinics are rendering family planning. And family planning is rendered every day, anytime
of the day. So it’s not say today is family planning you don’t come today come tomorrow
for that, it is done everyday.”
(District ADCHS)
The one method not readily available is insertion of an inter-uterine device (IUD). The reasons
are possibly a combination of staff not being trained in insertion of these devices and the
community being poorly motivated to use them. The devices, however, are available and are
given to patients on request to be inserted by a private practitioner, as explained:
“I wouldn’t say its (IUD) not provided, it’s only that it’s either nurses are reluctant to do
it or our communities are not well motivated with the IUD. But … our private doctors
request the IUD devices from us because people are going to them. The nurses are trained
on IUD insertion. So why can’t they do it at the clinic? Is it because they don’t have time?
Or they are reluctant? If you are going to insert an IUD you need to have time to do full
examination. So, I can’t blame the clients because if they don’t, why do they go to doctors,
if they can use the clinic?”
(District ADCHS)
The female condom is new and recently introduced in the district and from one pilot site the
programme has been extended. By the end of October 2003 a total of 1 400 female condoms
had been distributed. The ADCHS again:
“It’s coming up, we started with the pilot in one clinic, and we have extended the pilot for
end of October. We distributed 1 400 female condoms.”
(District ADCHS)
113
Patients requesting sterilisation during the antenatal period are usually referred to the Klerksdorp
Provincial Hospital for delivery so that the procedure can be done 24 hours after delivery.
Figure 4.2 shows that between 2000 and 2003 there has been a decline in the number of
contraceptive acceptors, particularly of oral contraceptive pills.

Figure 4.2: Klerksdorp Health District - Use of Contraceptives: 2000 to 2003
Number of injections
60 000
50 000
40 000
30 000
20 000
10 000
57 000
56 000
55 000
54 000
53 000
52 000
51 000
50 000
Number of oral pill cycles
0
2000
2001 2002 2003
year
49 000
Medroxyprogesterone
Norethisterone
Oral Pill Cycle
Source: North West District Information System
The contraceptive services are appreciated and considered good by some community members,
as expressed in the community discussion groups:
114
“Family planning, they do give it to the women at the clinic. And if you want contraception,
they ask you what kind of contraception do you want? depo, pills... It is you that has to tell
them… they show you and give you all necessary information you want to know… more
especially with young girls who start to be adolescents.”
(District Community Discussion Group)
“For family planning I can say it (staff-patient relationship) is good.”
(District Community Discussion Group)
“With my younger sister, I go with her and introduce her to the nurses and they will sit
down with her and talk to her, why she wants to do this and what to do. And the nurses
advice us not to rush things, with contraceptives, because she is still young.”
(District Community Discussion Group)
Safe motherhood
Antenatal services are provided at all CHCs, clinics and mobiles. High risk antenatal patients
are referred to the hospital for specialist and doctor care. Figure 4.3 indicates a decrease in the
number of patients attending antenatal care in the district between 2000 and 2003.

Figure 4.3: Klerksdorp Health District - Antenatal clinic
attendances - 2000 to 2003
25 000
20 000
Number
15 000
10 000
5 000
0
2000
ANC 1st visit
2001 2002 2003
year
ANC follow-up visit
Source: North West District Information System
Prior to 1994 all maternity cases were referred to hospital for delivery. After 1994 with the
integration of health services and focus on PHC services at all CHCs and clinics, national and
provincial policies are that uncomplicated deliveries are done in CHCs and clinics. Only high
risk patients should be delivered in hospital. Figure 4.4 below indicates that the majority of
deliveries are still being done in the hospital, although the percentage of live births in the clinics
has increased from 2% in 2000 to 8% in 2003.
115
Figure 4.4: Klerksdorp Health District Live Births in Hospital and Clinic;
and percentage deliveries in clinics - 2000 to 2003
7 000
9.0%
Number of live births
6 000
5 000
4 000
3 000
2 000
1 000
8.0%
7.0%
6.0%
5.0%
4.0%
3.0%
2.0%
1.0%
Percentage of Live Births in
clinics
0
2000
2001 2002 2003
year
0.0%
Clinics
Hospital
% clinic births
Source: North West District Information System

The Klerksdorp Provincial Hospital is the referral centre for other districts and patients come
from as far as Ganyesa for specialist care, or even for caesarean section. The total births in the
district are not a true reflection of population growth in Klerksdorp as they include patients
referred from outside of the district.
Figure 4.5 shows that the percentage of deliveries at Klerksdorp Hospital that are referred from
outside the district is decreasing.
Figure 4.5: Klerksdorp Hospital - Percentage deliveries referred to hospital from
Klerksdorp Clinics and from outside Klerksdorp Health District
- 2000 to 2003
70
60
Percent of deliveries
50
40
30
20
10
116
0
2000
2001 2002 2003
year
% hospital deliveries referred from within district
% deliveries referred to hospital from outside district
Source: North West District Information System
A constraint to extending services in the clinics to include deliveries was noted by the district
pharmacist. There is no concomitant increase in budget to cover the purchase of additional drugs,
intravenous fluids and other surgical sundries required. More personnel are required; of concern
is the increased responsibility with increased storage of drugs without a dedicated pharmacy
assistant or nurse to control these. She explained:
“I think there is a need for more personnel. The clinics are understaffed, greatly understaffed
if you take Joubertina Clinic; it’s the biggest clinic in Klerksdorp. They are starting a
maternity unit they do not have enough money to buy enough vaco-litres, Ringers Lactate,
for the pregnant women when they deliver. They have this new unit, they’ve got 4 personnel
extra, but they still can not put a specific person in charge of the pharmacy department.
… No one can take that responsibility because there is not enough staff to do the work that
should be done, primary health care. …there is a big staff shortage and I think that makes
the sisters incompetent to handle all the responsibilities that go with the work.”
(District Pharmacist)

Figure 4.6 shows that the total number of women in labour attending the clinics is increasing
and the percentage referrals in decreasing. This indicates that access to maternal services at
CHCs and clinics is improving in Klerksdorp, despite the constraints and difficulties.
Figure 4.6: Klerksdorp Health District - Clinic Births, referrals
to hospital and referral rate - 2000 to 2003
600
Number
500
400
300
200
100
Referrals %
0
2000
Live birth
80
70
60
50
40
30
20
10
0
2001 2002 2003
year
Refer during labour by clinics % referrals clinics to hospital
Source: North West District Information System
The district ADCHS explained how the role out of maternity services to clinics is progressing
and the changes that have occurred over the past few years:
117
“All along all cases, antenatal cases used to go to the hospital. … the community health
centre only started functioning on the 6th of November as a community health centre. It’s
now completely build and they are now rendering maternity service. But they use to be
referred to the Klerksdorp Hospital, maternity ward. So all the clinics around will refer
their patients, especially those in Joubertina, because the community health centre is in
Joubertina. (Others) can refer still to the hospital. …And then Orkney, the community health
centre is being extended, but they refer their deliveries to Klerksdorp maternity ward.
Stilfontein, we do have a community health centre, all other clinics refer to that clinic, and
then Hartebeesfontein we do have a community health centre, it’s only two clinics there of
course they refer to there. So from these community health centres they do normal deliveries.
All the other deliveries, complicated deliveries, are referred to the Klerksdorp Hospital.”
(District ADCHS)
The hospital staff, however, do feel the excess load of work, although decreasing, coming from
outside the district, and that local clinics are not fully functioning for uncomplicated deliveries.
This was expressed by the Klerksdorp Medical Manager:
“Joubertina has the structure. But there is still like - you know their staffing is a problem
there and I don’t think they are fully functional the way that we would like it to be. So
patients do come here. … Our main areas are the actual high risk ante-natal ward, the
labour ward which is basically level 1 and level 2 and obviously because of that a high
caesarean section rate because patients are from the Bophirima region because they have
a huge problem of getting caesarean sections done - lack of doctors, nurses, that sort of
thing….”
(Hospital Medical Manager)

Teenage pregnancy rate, as in all districts in the province, is of concern. Figure 4.7 shows
minimal change in the rate between 2000 and 2003.
Figure 4.7: Klerksdorp Health District - total deliveries and teenage pregnancy
rate - 2000 to 2003
7 000
18
Number of deliveries
6 000
5 000
4 000
3 000
2 000
1 000
16
14
12
10
8
6
4
2
% teenage pregnancies
0
2000
2001 2002 2003
year
0
Total deliveries
% teenage pregnancies
118
Source: North West District Information System
Klerksdorp is an urban, industrialised area and, as mentioned previously, a number of people
are likely to have private medical aid coverage and use the private sector. The above figures do
not include deliveries in the private sector and therefore can not be taken as a true reflection of
the whole district.
The need for special services for youth and adolescents was expressed by facility managers.
There is presently one Youth Centre in Joubertina, in Klerksdorp, for the whole district; more
centres are required to offer full coverage. A facility manager explained the need for these special
services:
“Formerly we used to have everybody coming to clinics for family planning and STIs, but
now they have discovered that young people really don’t want to come for that, for them
falling pregnant and getting infected with HIV. When they (adolescents) come to the clinic
they are afraid to speak to us, or they are ashamed or they are a bit shy and they may meet
their elder sisters or their mothers. It could be best if they have a place of their own where
they get the family planning methods and also where it would be suitable and convenient
for them to get health education, family planning, STI and HIV, teenage pregnancies and
all that in an environment that is youth friendly … they would go and relax and talk about
their problems and you will find that in our statistics you don’t have young people or
teenagers, most of them go to that centre.”
(District Facility Managers Discussion Group)

HIV/AIDS/STI
Services for HIV/AIDS and STIs are integrated into PHC services and are rendered at all health
facilities in the Klerksdorp district. Figure 4.8 shows that between 2000 and 2003 there was a
slight increase in the number of new cases of STIs treated and a slight decrease in male patients
with urethral discharge. There has been a decrease in the number of contact slips issued to
patients and in the number of contacts treated. More patients have been counseled for HIV
testing.
Figure 4.8: Klerksdorp Health District - Number of sexually transmitted infections
at PHC clinics - 2000 to 2003
16 000
14 000
Number of patients
12 000
10 000
8 000
6 000
4 000
2 000
0
2000
2001 2002 2003
year
119
STI treated - new
MUS treated - new
STI slip issued
STI partner treated
HIV/AIDS pre-test
Source: North West District Information System
Table 4.1: Klerksdorp Health District - Reproductive Health Indicators - 2000 to 2003
MMR
PNMR
NNMR
2000
578
71
42
2001
454
58
33
2002
414
60
29
2003
563
74
30
MMR = Maternal Mortality Ratio = Maternal deaths to 100 000 live births
PNMR = Perinatal Mortality Ratio = Perinatal deaths to 1 000 births
NNMR = Neonatal Mortality Ratio = Neonatal deaths to 1 000 births
Source: DHIS - Institutional rates only

Other reproductive health indictors
Other reproductive health indicators are shown in Table 4.1 and Figure 4.9.
In 1996 the MMR was 45 and NNMR was 22. 11 These calculations were made from best
information available at that time.
Figure 4.9 shows that there has been little change in these three indicators between 2000 and
2003. The MMR is higher than the national figure as reported in the UNFPA reports of 1999
and 2002.
Figure 4.9: Klerksdorp Health District - Maternal Mortality Ratio, Perinatal
Mortality Rate and Neonatal Mortality Rate - 1996, 2000 to 2003
80
700
120
PNMR and NNMR -
deaths per 1 000 live births
70
60
50
40
30
20
10
600
500
400
300
200
100
MMR and NNMR -
deaths per 100 000 live births
0
1996
2000 2001 2002
year
2003
0
PNMR
NNMR
MMR
Source: North West District Health Information System
Services for termination of pregnancy are discussed at the end of this chapter.
Availability of reproductive health services in Klerksdorp Health District
Reproductive health services, as listed in the PHC Service Package, are available at all community
health services, most clinics and on the mobile services in the Klerksdorp health district. For
after hour’s services patients attend a community health centre or the hospital.
As noted previously, not all reproductive health services are available throughout the district as
a 24 hour service. The services are integrated into the general PHC services, and should be
available throughout opening hours at each facility. The Klerksdorp District Manager explained
some of the difficulties:
“As far as district level it will be possible to sort of integrate them, but it is quite a challenge
to do that really. Because I've said previously you know for each and every programme
manager his or her programme is the most important one you know, and to manage these
things here at district level is more than a challenge.”
(Health District Manager)
11 Health and Welfare in North West Province - Implications for planning. 1996.

Reality, however, does not always meet expectations. With extended hours of service and the
overall shortage of staff there are occasions a clinic can not provide the full PHC basket of
services, as explained by the ADCHS for the district.
“The other issue is the one of extended hours. You find that some clinics you thought people
around there will be happy to have clinics open till seven, but they will tell you it’s useless
to go there because the sister won’t be able to attend to my child; because she can’t do
suturing;, she can’t do … or if a maternity, she is not qualified.”
(District ADCHS)
Clinics do not always open at the advertised time of opening and even at times close early, as
noted by a community member in a discussion group:
“The clinic is supposed to be open at 7h00 a.m., but they open at 9h00 and the health
workers will find us waiting!”
(Community Discussion Group)
Despite health system offering an integrated service, some clinic staff turn patients away because
they have come on the wrong day, as expressed in another community discussion group:
“We are not satisfied with the opening hours of the clinic. You find that there is a day set
aside for pregnant women but you don't know, so you have to go back and come the following
day. … They usually place a notice but now it’s no longer there, and old people or old
community residents know these things but for a person who doesn't know, it’s a problem
and you can find that they came from a long distance. Those nurses will not talk to you
nicely; they just yell at you saying “Can't you see that its Pregnancy Day, please just go”!
(Community Youth Discussion Group)
121
Similar incidences have been observed by other health officials visiting the clinics. The District
Pharmacist is based in Klerksdorp Provincial Hospital with responsibility to distribute and
monitor supplies to, and use of, drugs in the clinics. She was outspoken on the standard of health
care in the public sector:
“Now while the other sisters doing the minor ailments and the chronic, they must see the
second and third visits. What happens in one of the clinics, she just said that, “now only
first visits, thank you.” How can you say that you have a supermarket approach and Batho
Pele, People First when there is a person sitting like this and say, “No, I cannot help you
I’m not doing second visits today.” How can you say that? How can you come to work at
8h30, take a tea break at 10 and continue it up to lunch and then say, “No I’m on lunch.
Sorry I’ll only be available at 3h00” and at 4h00 the clinic closes. How can you do that?”
(District Pharmacist)
Community members are concerned about the issue of staff shortages and availability of services,
and appear to want to help in finding solutions, as expressed by two community members in
discussion groups:

“… increase nursing staff and at the same time try to see whether problems are really
caused by the shortage of nurses or not. … If we talk about increasing staff, the department
will tell you about the budget.”
(Community Discussion Group)
“The government should make sure they retain the current staff, perhaps satisfy them with
more benefits because some nurses are leaving the clinics.”
(Community Discussion Group)
When services are not available from the clinics, patients attend Klerksdorp Provincial Hospital
for PHC services. This places an additional burden on the hospital budget, for which they do
not receive any compensation. The Klerksdorp Hospital Medical Manager expressed his view
on this:
“We are asked to give a level of care without providing the resources for that level of care.
You know for example, medical outpatients they say they have got so many doctors, we can
handle 100 patients but if 150 patients come we are not allowed to turn them back. Now
how do we provide the same level of care when we have 50% more patients coming in?
And if you must sit there and if the patient complains because he had to wait now another
one hour or more, you know, we should just do that. We do that but you know the blame
is still on us and not on the patients.”
(Hospital Medical Manager)
122
As noted, the problem of staff shortages in Klerksdorp is exacerbated by having two employing
authorities with different conditions of service. The local municipality is constrained in employing
additional nurses, even if there is a vacant post, by the provincial department of health. The
municipal health manager in Klerksdorp explained:
“… it's more provincial personnel than municipal. Our local MEC imposed a moratorium
on the filling of vacant posts on the 5th November 1995…. If I've got a vacancy I must then
write a letter to province and say please, I've got this vacancy, first of all can I fill it? And
they say yes or no. if they say, yes, I can only fill it on my budget for a matter of 2 or 3
months contractual on the nursing services system. I can't employ anybody on a permanent
basis.”
(Municipality Health Manager)
Even provincial posts when advertised are difficult to fill, as explained by the ADCHS:
“…. there is a lot of the nursing staff that are leaving our department … if we advertise the
posts we don’t get all the applicants. Say for instance when we advertise for 20 posts we
don’t receive all that applicants; we only get maybe 10.”
(District AD Administration)
Geographical Accessibility of reproductive health services in Klerksdorp
Klerksdorp Health District is a comparatively small geographical area. All clinics are within 25
kms of Klerksdorp centre, with good infrastructure for access by road. Additionally, communities

have good telephone communication. Services have been extended with two new clinics being
built and new mobile points opened up. The services are closer to the people as explained by
the MCWH Coordinator:
“Yes, they are very much closer to the people, even the mobile. In the same townships there
are clinics and then in some areas, the clients are staying far from the clinics but you see
mobiles … staying next to the community. So now the services are very nearer to the people.”
(Health District MCWH Coordinator)
There are some areas, such as the informal settlements which are not well provided for, even
with a mobile service. The district ADCHS explained:
“We’ve got 5 from the province that are doing the rural area and we’ve got a 5 from the
local municipality doing the areas around the municipality area. For those extensions or
areas which are far from the clinic, which don’t have a clinic mobile within the township,
you find that the clinic is more than 10 km from them - in the squatter areas.”
(District ADCHS)
Despite the expansion of services there are communities who have difficulty accessing services.
This was a point of discussion in the community groups:
“With some clinics one uses a taxi, with other clinics one walks. They try to place clinics
where people are, but it is often not the case. At Kuma the mobile clinic comes once a week
on Monday’s only, all the other days of the week a patient has to use a taxi or hire a car
to the nearest clinic and it costs money to do that and most people do not work 12 … Most
of the time people have to spend money to travel to reach the health services and mothers
give birth on the streets.”
(Community Discussion Group)
123
Access to hospitals is also a problem; some people are in walking distance while others are able
to use a taxi. Community members said they would like to see hospitals closer to the community:
“It actually depends (easy to get to hospital); there are people who travel long distances
and there are those who can just take a walk. … It is better that these hospitals are placed
in our location where people are. It doesn’t make any sense to place hospitals in cities.”
(Community Discussion Group)
In emergency situation the ambulance service can be problematic because of delays in response
and, for maternity cases, the need to double up with trauma cases to get to hospital. This is an
area of real concern for the community as several said in the discussion groups:
“We can wait for ambulances but at the end it won’t pitch up, the woman will give birth…”
(Community Discussion Group)
“Another point will be, you call on the ambulance when it comes it will be full of stabbed
patients and you will be included there also.” 13
(Community Discussion Group)
12 Are not employed
13 The Emergency Health Services are discussed in Chapter 11

Financial Accessibility to reproductive health services in Klerksdorp
All PHC services at clinics are free. Fees are payable at hospitals, according to a means assessment.
There is, however, a cost for transport, although a member of the district management team
believes this is less a problem than in the past.
“So they (the services) are next to the people, they are accessible. People don’t spend money
to go to the hospital or to the clinic, so they are very nearer to the clients. Unlike previously
they had to travel long distances or take a taxi. Sometimes they don’t have money to go to
the hospital, but now its better.”
(District MCWH Coordinator)
A community member expressed a different point of view. There are still many people who
cannot afford transport to a health facility:
“I can take you now with a car and show you around the places where the clinics are
needed. There are people who are not working, so where will he get R3.00 to pay for a taxi
to a clinic or hospital? The only alternative is to go by feet.”
(Community Discussion Group)
124
As noted, not all clinics can provide all services on a 24 hour basis. Delays in opening a 24 hour
service in Joubertina means those patients have to travel to another health facility, this is difficult
especially at night. There are times when, for example, there is no midwife on duty and a
maternity case is transferred to hospital. This concern was shared by a community member as
well as a concern of not being informed for the delays in opening the maternity ward:
No (clinics are not always able to deliver babies). …You get a transfer to the hospital. …
It is not safe because you waste money for traveling and it’s during the night you can spend
almost R100 from home to clinic… .It’s almost a year now, there is big clinic over there
and it has maternity ward but it’s not working up until now since January. We don’t know
what is causing the delay. We now have to go to the city.”
(Community Discussion Group)
There is a fee for admission to hospital, or for attending the hospital without a referral letter
from a clinic or other health facility. However, if you do not have any funds the hospital
management can assist, although the patient would be expected to pay later:
“If you are at the hospital and you don’t have money, they can assist you but you will have
to pay later.”
(Community Discussion Group)
Attitudes to the services
Health managers and workers in the district are generally positive about the services they offer.
They believe that the services have improved and that the community have accepted their role
of participating in the services. The participation is seen to be having a positive impact.

“And the community since they are involved they can come forward and say my neighbour
is one, two, three. They can come and report to you about that.”
(District ADCHS)
The community is more involved with patient care after discharge from the hospital. Initially
there was reluctance on the part of community members and NGOs to take responsibility for
care of people when discharged from hospital. A process of orientation of clinic staff and NGOs
was required and this community role in health care is more acceptable to the community.
“No, they accept it (community participation), … anything which is introduced people tend
to have a fear, … we started the issue of hospital referring down to the clinics, and then
the clinics will identify an NGO which will render a home based care. In the beginning it
was as if now being a nurse why should I refer to an NGO the patient to be cared for? But
when we sat down and looked at issues then it is understood and it is now working very
smoothly.”
(District Assistant Director)
Community members are encouraged to be involved with the services through volunteering,
although some want financial incentives for this work, as noted by an Assistant Director in the
district.
“For some (volunteering) it’s love of it, because you find those who don’t even care whether,
they get R250; others you’ll see that when that R250 the cheques are not yet on certain
time, where we say, they’ll be here, you find it really frustrating. And next time you don’t
find it or they don’t even do any activities at their…, but others they just continue. So I’ll
say the love of it.”
(District Assistant Director)
125
Community members have mixed reactions to the changes in health services. Some believe that
they are worse off while others are supportive of the changes and the efforts of the new government.
“To be honest, since the previous government changed to a new democracy and with regard
to the health related matters... there is nothing we can say ‘yes that has changed’ or what?
Things seem to be getting worse!”
(Community Discussion Group)
“I can comment in this way: After 1994, I saw some changes related to the way the patients
are treated at the clinic and the hospital. Just like the government policy, it’s ensuring that
its people are taken care of in the right manner. There is nothing bad that I can say that
the previous government did; nor did it bring the problems in our current situation. The
constitution is clear and is working nicely for us. The only problem is lack of policy
implementation at the local government level. The policy is very, very good but at the local
level that’s where most of the communities suffer and that’s why most of us blame the
government.”
(Community Discussion Group)

A lack of privacy in the clinic is noted:
“I went to the clinic to see one of the sisters and women came to consult: they just did that
in front of me. So the thing is that there is no privacy.”
(Community Discussion Group)
And for some the services are worse than previously when patients had to pay for them:
“They (reproductive health services) were good during those times when our parents were
paying for the services… They used to give people attention and help that they needed at
the clinic, now since decentralisation is in place everybody is doing what she wants. …
Ambulances used to come when we needed their help but now they will tell you about
distance and kilometres that they will be traveling to come to your place, I think they are
bad.”
(Community Discussion Group)
The problems with the attitude of health workers to community members and other problems
is a two way thing – community is also has a responsibility, as expressed by the health manager
of the Klerksdorp Municipality.
126
“But they killed me yesterday about the attitude of the nurses towards the community. They
said we are rude and I had a Bhato Pele issue here the day before yesterday about the same
thing. But on the other hand I received a letter from a member of the community congratulating
us. He said he went to one of our clinics … for two weeks, consecutive weeks, not introducing
himself, he just sat there and you know, was just there. And he said thank you, he wanted
to pay a compliment to the staff about their attitude towards the community. And then his
last paragraph he said, he thinks that the community should also pay respect to the staff.
So it’s visa versa. So we do get problems.”
(Municipal Health Manager)
4.4.2 Mafikeng Health District, Central Region
(District Municipality)
Services available in the districts
Reproductive health services in Mafikeng are available through mobile clinics, fixed clinics and
community health centres. Most referrals from the clinics are to the Mafikeng Provincial Hospital
as the Gelukspan District Hospital which is situated far from the majority of population in the
district.
An overall improvement in reproductive health services was noted by the regional director:
“If I look at the, what I call Maternal Child and Women’s Health programmes within
the facilities, if I look at the number of facilities where we have, 24 hour maternity
services and if I look at the equipment that have in the past 5 years been purchased for
specifically maternity units in the clinics and where we have very small clinics that render
24 hour maternity services, I think reproductive health has definitely benefited.”
(Regional Director for Health Services)

This was supported by the Health District Manager.
“I think they are, because they have closer to people. And because one of the indicators
you have noted today was how many people are within 4kms radius of a clinic. Ya, we trying
to measure that so these services should be at least within 4km radius, basically that in the
first of this decentralisation that we are trying to get there.”
(Health District Manager)
The increase in the number of health facilities, as noted elsewhere in this report, are not due
to decentralisation, but to the nationally driven programme for upgrading and building
new clinics. The extension of the services, however, is supportive of decentralisation.
The services are integrated in all the community facilities and are all available during the normal
working hours of the facility, as explained by a facility manager:
“But then truly speaking it – at least family planning and reproductive health can happen
any time of day – that is an advantage. It is not like before when we used to allocate a
certain day for family planning… .and when they have to come, they have to wait for another
day, or for that day.”
(District Facility Managers Discussion Group)
A youth centre has been opened in one part of Mafikeng. Although well used by the local youth,
it is not accessible to all youth in the district, as noted by the Mafikeng ADCHS:
“It is not very accessible. I am saying this, because although it is central, the youth from
the furthest villages the youth are not able to use the centre because of the distance. Distance
is a big problem and there is no flexible transport for them.”
(District – ADCHS)
127
Contraceptive services / Family planning
Contraceptive advice and services are integrated as part of all PHC services, including during
post natal and ante natal visits:
“Family planning is integrated into other services like in postnatal, after delivery we
normally encourage them.”
(District Facility Mangers Discussion Group)
Services provided include:
• Injectables – Noristerate and Depo Provera.
• Oral contraceptives pills.
• Barrier methods – male and female condoms.
Intrauterine devices cannot be inserted in the clinics, due to lack of trained staff. These clients
are referred to the hospital, as explained by the MCWH Coordinator as the one method not
available:

“Yes, like the intrauterine device. We don’t have people trained on that.”
(District MCWH Coordinator)
Figure 4.10 shows a decrease in uptake of injectable contraceptives in the district between 2000
and 2003. The use of oral contraceptives increased in 2001 and 2002, but decreased in 2003.
Figure 4.10: Mafikeng Health District - Use of Contraceptives
- 2000 to 2003
Number of injections
60 000
50 000
40 000
30 000
20 000
10 000
57 000
56 000
55 000
54 000
53 000
52 000
51 000
50 000
Number of oral pill cycles
0
2000
2001 2002 2003
year
49 000
128
Medroxyprogesterone
Norethisterone
Oral Pill Cycle
Source: North West District Health Information System
The MCWH Coordinator for the district expressed concern for the standard of contraceptive
services in the district. She believes that under the old system it was better.
“I am really motivating about family planning because you know you realise that before
any method can be prescribed the women has to be examined from head to toe. We don’t
have that quality. We used to have family planning cards with everything written there,
varicose veins, you name them, lumps. We don’t have such cards. You find just a piece of
paper on which a method is prescribed and when the client goes they just throw it away.
So we cannot follow the clients properly. We wouldn’t even know how long has this client
been on this pill. When was she diagnosed? Or had a pap smear? You know, I’m really
not happy.”
(District MCWH Coordinator)
The district management proposed developing cards for individual patients in their district, but
were prevented from doing so by the PDoH as any such cards should be standardised across the
province.
“…perhaps if we were to design our own record, I think that would be much better rather
than wait for the province to design a card or what ever, find a tender so that they can print
that and so on. I wouldn’t say today was better when it was a vertical programme. … We

suggested that, but we were told that we have to be standardised …. There was that women’
health card, you know that one we used to fold. We don’t know what happened to it…”
(District MCWH Coordinator)
The Mafikeng Provincial Hospital does have a Reproductive Health Unit which is also responsible
for termination of pregnancies. This unit offers a full range of contraceptives and other reproductive
health services. Data from this unit was not available through the hospital information system
and it is not known if this data is included in the above figures.
Safe motherhood
Ante-natal care is mainly provided in the clinics and community health centres. The Mafikeng
Provincial Hospital provides a service for high risk maternity cases referred from the clinics.
Gelukspan District Hospital, situated about 60 kms from the town of Mafikeng is far from the
concentration of population and is therefore only used by clinics close to that hospital. Mafikeng
Provincial Hospital provides the main district level hospital care in Mafikeng District.
Figure 4.11 shows a constant number of first time visits for antenatal care, but a decrease in the
number of follow-up visits. These figures do not include hospital attendances.
Figure 4.11: Mafikeng Health District - Antenatal clinic attendances
- 2000 to 2003
25 000
20 000
129
Number
15 000
10 000
5 000
0
2000
ANC 1st visit
2001 2002 2003
year
ANC follow-up visit
Source: North West District Health Information System
The remoteness of some communities makes it difficult for all pregnant women to attend antenatal
care. This is noted by the hospital midwives who have a number of patients coming to the
hospital without having had any ante-natal care:
“Ya we’ve got a number of clinics but you know our villages, for some of them the clinics
are quite remote (for attending ANC)… No transport sometimes - those are some of the
problems they are telling us.”
(Maternity Matrons- Regional Hospital )

The total number of deliveries in the district has increased between 2000 and 2003. In the clinics,
however, there has been a decrease in total number and percentage of total deliveries in the
district. See Figure 4.12.
Figure 4.12: Mafikeng Health District - Live Births in Hospital
and Clinics and percentage deliveries in clinics - 2000 to 2003
4 500
40
Number of live births
4 000
3 500
3 000
2 500
2 000
1 500
1 000
500
35
30
25
20
15
10
5
Percentage of Live Births in clinics
130
0
2000
2001 2002 2003
year
0
Clinics
Hospital
% clinic births
Source: North West District Health Information System
There are some home deliveries, but according to the ADCHS in the district, these have reduced
in number.
“Yes, we start by just saying Safe Pregnancy. That is where we start educating women
about safe pregnancy, safe practices during pregnancy and then delivery., we have a very,
very, very small number of home deliveries. … it has reduced dramatically. You know
again for a very valid reason, … there are those villages without clinics, and then during
the night they would not be having money to hire transport to the nearest clinic or hospital.
… it is not by choice, necessarily.”
(District ADCHS)
As in the other districts lack of transport is a problem in accessing services, particularly at night,
where there is no 24 hour service available. A facility manager has a different opinion to the
ADCHS and believes that a number of women deliver at home, without a trained midwife,
because of the lack of transport:

“Yes, a 24-hour service (is needed). The people are there and they haven’t got money to
get transport to the health centre or to the hospital as necessary. Most of them deliver at
home because of no transport.”
(District Facility Managers Discussion Group)
Some hospital outside the district may refer deliveries to Mafikeng Provincial Hospital. These
figures, however, are not reflected accurately in the hospital information system.
“Another thing I was going to say, apart from the clinics, the neighbouring district hospitals
they refer most of their problems here. Even caesarean sections sometimes, they refer
patients to be done caesareans here.”
(Maternity Matrons- Regional Hospitals)
The increase percentage of deliveries in hospitals is supported by the increase in referral rate
from clinic to hospital. See Figure 4.13. These referrals can be related to lack of midwives in
the clinics, as stated by the Mafikeng Hospital Maternity Matrons.
“Sometimes you find a patient is being here (at the hospital) from the clinic the reason being
no midwife, there are such things.”
(Maternity Matrons- Regional Hospital)
Figure 4.13: Mafikeng Health District - Clinic Births, referred
in labour and referral rate - 2000 to 2003
131
1 800
60
Number of patients
1 600
1 400
1 200
1 000
800
50
40
30
Referrals %
600
20
400
200
10
0
2000
2001 2002 2003
year
0
Live birth
Refer during labour by clinics
% referrals clinics to hospital
Source: North West District Heath Information System

The increase in number of referrals to the hospital places an increased workload on the hospital
maternity staff, who are themselves short staffed. This was explained by the hospital midwives:
“They’ll be referring to us being only two in the labour ward. Then when somebody has
gone for Caesar then you’ll be left alone and you’ll be delivering one, two, three women
at the same time. So we are also short staffed, we are really, although we are just trying
but we are really short staffed. … It’s getting worse. When I joined the old mission we were
32 sisters. 32 sisters then and then it was just a small unit, a unit of midwives… We are
now 18 for the whole unit.”
(Hospital Midwives)
The increasing number of women in labour being referred to the hospital may be related to the
shortage of midwives in the clinics. At times there are clinics with only a nursing assistant on
duty. If she is able, although not trained, she may conduct a delivery. Otherwise the patient is
referred to hospital. This was explained by the MCWH Coordinator in the district:
“… shortage of manpower where you find that some of the clinics are run by assistant
nurses. So that when a difficult maternity case comes, it becomes a problem. Fortunately
we had never had maternal deaths due to maybe problem related to administrative problems…
you find that (deliveries done by nurse without midwifery training) because maybe
that particular nurse somehow knows how to conduct a delivery, she does it.”
(District MCWH Coordinator)
132
The high number of teenage pregnancies is of concern in the Mafikeng District. From the
information available the teenage pregnancy rate has, however, remained constant between 8%
and 10%. See Figure 4.14. One explanation offered for this lower teenage pregnancy rate than
in other districts is the use of the private sector for which figures are not included on the DHIS:
“But you will find that mostly their parents have medical aid so they attend to private
doctors and deliver at private hospitals and so on.”
(Health District MCWH Coordinator)
The need for Youth Centres and safe places for teenagers and adolescents to access care was
noted by facility managers and the district manager, who said:
“…in our situation, what I realise is that the barrier to adolescent for not using the services
effectively is that they don’t like to go with adults and there is no special provision made
for them. But, what we have in place for now is that we have a youth centre in …so we
normally refer them to the centre……although there may not be that much access. If it were
possible that a provision is made for them where they can be given an attention as a youth,
different from adults, then they would use them.”
(District Facility Managers Discussion Group)

Figure 4.14: Mafikeng Health District - Teenage Pregnancy Rate
- 2000 to 2003
6 000
12
Number of deliveries
5 000
4 000
3 000
2 000
1 000
10
8
6
4
2
% teenage pregnancies
0
2000
2001 2002 2003
year
0
Total deliveries
% teenage pregnancies
Source: North West District Health Information System
“We have a problem with teenager pregnancy and by virtue of the age the risk comes in
and also then it becomes a social impact as well because then that person does not work,
doesn’t go to school, what ever the case may be. … They are still young, they know too
much and they are rebellious, so they have to be treated separately and you have to have
trained people to deal with them effectively.”
(District Health Manager)
133
Figure 4.15: Mafikeng Health District and Mafikeng Hospital - Live births and
still birth rate - 2000 to 2003
Number of births
6 000
5 000
4 000
3 000
2 000
1 000
4.5
4.0
3.5
3.0
2.5
2.0
1.5
1.0
0.5
% still births
0
2000
2001 2002 2003
year
0.0
Live birth
Still birth rate
Source: North West District Health Information System

The still birth rate has remained between 3% and 4% between 2000 and 2003.
HIV/AIDS/STIs
Services for HIV/AIDS and treatment of sexually transmitted infections are available at all health
facilities in the Mafikeng Health District.
Figure 4.16 shows that between 2000 and 2003 there has been little change in the number of
STI cases treated at the district health facilities.
PHC services, although integrated at point of service delivery, remain, vertically managed at the
district management level, as expressed by the district HIV/AIDS/STIs Coordinator:
“In the district we have 8 programmes. Mother and child health services are one of them
that are solely doing on family planning and what have you. I am only coming into the
picture where I have to on STI’s actually; but I am sort of complementing each programme.
We don’t work in isolation.”
(HIV/AIDS/STIs Coordinator)
Figure 4.16: Mafikeng Health District - Sexually transmitted infections
at clinics, CHC and Mobiles - 2000 to 2003
12 000
10 000
134
Number of patients
8 000
6 000
4 000
2 000
0
2000
2001 2002 2003
year
STI treated - new
MUS treated - new
STI slip issued
STI partner treated
Source: North West District Information System
Voluntary counseling and testing (VCT) for HIV infection is offered at all health facilities in
the district. This service has been extended to ‘non-medical’ sites, such as the University of
Mafikeng campus and NGOs who have employed nurses. The HIV/AIDS Coordinator plans to
target private practitioners to become VCT sites. This process will not be easy, but it will increase
access to the service, as she explained:
“But I was even talking to the provincial coordinator, how are we going to do this? Because
with us VCT is for free, and those people (private practitioners) are going to charge. And

with counseling they can charge because with counseling you spend a lot of time, 45 minutes
in counseling… the test they don’t have to charge.”
(HIV/AIDS/STIs Coordinator)
Other reproductive health indictors
The MMR has increased between 2000 and 2003; from 175 to 294 maternal deaths per 100 000
live births. The other indicators have also increased. In 1996, taken from the best data available
at that time, the MMR was 198 deaths per 100 000 live births and the NNMR was 16 deaths
per 1000 live births. 14
See Table 4.2 and figure 4.17
Figure 4.17: Mafikeng Health District - Maternal Mortality Ratio, Perinatal
Mortality Rate and Neonatal Mortality Rate - 1996, 2000 to 2003
100
350
PNMR and NNMR -
deaths per 1 000 live births
90
80
70
60
50
40
30
300
250
200
150
100
MMR and NNMR -
deaths per 100 000 live births
135
20
10
50
0
1996
2000 2001 2002
year
2003
0
PNMR
NNMR
MMR
Source: North West District Health Information System
Availability of Reproductive Health Services in Mafikeng Health District
Reproductive health services, as listed in the PHC Service Package, are available at all community
health services, most clinics and on the mobile services in the health district. After hours patients
attend a community health centre or the hospital.
The lack of services in some clinics is acknowledged by facility managers.
“We do not have everything. For example in the satellite clinic we do not offer 24hours
service, we don’t deliver and we don’t offer termination of pregnancy in the rural areas;
14 Health and Welfare in North West Province - Implications for planning. 1996.

we refer them to the hospital. We motivate at antenatal visits that they should go to the
clinic for delivery, but most time we do not deliver because of the structure or the staff
shortage, because sometimes you find that there is only a nursing assistant without a
professional nurse for 8 hours.”
(District Facility Managers Discussion Group)
Table 4.2: Mafikeng Health District - Reproductive Health Indicators
- 2002 to 2003
MMR
PNMR
NNMR
2000
175
46
13
2001
164
59
23
2002
300
87
28
2003
294
55
20
MMR = Maternal Mortality Ratio = Maternal deaths to 100 000 live births
PNMR = Perinatal Mortality Ratio = Perinatal deaths to 1 000 births
NNMR = Neonatal Mortality Ratio = Neonatal deaths to 1 000 births
136
Source: DHIS - Institutional rates only
One of the main difficulties in Mafikeng Health District in providing adequate services,
24 hours a day in all clinics is the shortage of professional nurses and midwives. Managers
find that when a professional nurse is appointed in a rural clinic she very soon requests a
transfer to an urban area as explained by the MCWH Coordinator in the district.
“But it is a problem in this area, shortage of manpower. Even if we can appoint people they
will agree to go and work on that side; but immediately she is on the system, she asks for
transfer.”
(District MCWH Coordinator)
Facility managers are more concerned about the shortage of nurses in the clinic than doctor
support from the hospital, which they think is sufficient. There is a problem, however, with
communication between the hospital and clinics when the doctor is not available.
“We do have medical support, there are doctors who come twice a week. That is enough.
We can’t fault that. It is with nursing… We haven’t got a phone; if they don’t come they
can’t let us know. And sometimes if they don’t come we stay there with patients, sometimes
with patients that needed referral.”
(Facility Managers Discussion Group)
The shortage of staff at the clinic was noted with concern by two members of the district
management team. The shortage is a barrier to adequate programme review.

“You find that when you have to go for clinic supervision we find that there is a lot clients
there, there are too few nurses on duty, the others maybe working on night duty or a person
is booked off sick and then you begin to say what is going to happen when I have to sit
down try to inspect different areas in the clinic, try and fill up the in-depth programme
review form? Am I not going to take up a lot of this individual’s time? That creates a lot
of problems.”
(District HIV/AIDS Coordinator)
Staff shortage also disrupts supervision visits, even when these are welcomed by the nurses, as
found by the HIV/AIDS Coordinator:
“In a way I would say they value that (supervision) but at times you’ll find that they are
so busy and short staff so when you come in you get a negative response. But it is encouraging
on their part when we visit them, to discuss a problem with them, to assist them, especially
when the clinic is full and getting involved as well with the queue to clear the clinic and
then thereafter you can start to attend to issues of supervision.”
(District MCWH Coordinator)
The shortage of staff leads to demotivation , as expressed by clinic midwives in Mafikeng:
“The cornerstone of demotivation stems up from the fact that there is drastic shortage of
staff.”
(Clinic Midwives Discussion Group)
The midwives further said that management do not listen to them or try to address their problems:
137
“There are so many things that the registered nurse is doing – prescribing that side,
dispensing at the same time, packing the dispensary, counting at the same time… you are
always under pressure… And the other thing is the security is not good… We have addressed
these issues several times to the management.”
(Clinic Midwives Discussion Group)
The hospitals experience staff shortages. As stated above, the total number of midwives working
in the maternity unit has decreased. Many have left the service. Those remaining in the service
feel frustrated, as expressed by the hospital midwives:
“They (midwives) have left, but not for overseas, but for other reasons. Either they have
deviated from nursing; they went to other departments, like human resource; and then
others, college and so forth. …and other provinces as well, because really conditions here
are really terrible, especially in the midwifery section. On night duty you will be two in the
labour ward and at times you are so busy, two (midwives) with one nursing assistance you
are only three on duty…”
(Hospital Midwives)
Health Forum members acknowledge the shortage of staff. Volunteerism for community members
to assist in the clinics, and even hospitals and district offices, is quite common throughout NW

Province. There are, however, problems with this system as at times the volunteers resent
not receiving any incentive as care-givers as they did in the past, not even for travel.
“The very serious problem is that of shortage of clinic staff and cleaners. We’ve been
volunteering for a long time… Last month, we received our first incentive since 1999 of
about R500. Like others who are traveling we need money for transport.”
(District Health Forum)
Geographical Accessibility to reproductive health services in Mafikeng Health District
Mafikeng Health District covers a large geographic area with higher concentration of the
population around Mafikeng and Mmabatho near the western border of the municipality. Health
facilities are, therefore, concentrated in the west, with few in the other areas. The eastern side
of the district is commercial farmland. Health services to these areas, and other remote areas,
are delivered by weekly, fortnightly or monthly mobile clinic services. Services are generally
accessible for those living in the town, but not for those in the more remote areas of the district.
The furthest clinic from the district office in Mafikeng is 127 kms. The services there are not
as good as those in the town, as noted by the MCWH Programme Manager:
“…you will find that things are happening around here, urban and peri-urban areas.
But when you travel up to one, - for instance the furthest clinic is 127 Km - you find that
things are not really as they are here, so those far away areas are at a disadvantage.”
(District MCWH Coordinator)
138
Services are not readily accessible for youth. There is only one Youth Centre in the district,
which is in a suburb of Mafikeng. It is difficult for rural youth to access. This has been noted
previously and commented on several times by the ADCHS in the district:
“Yes, we will need to have more funds. Maybe to establish 2 more centres in those more
far areas. Then we will say in our district, we are now covered and know that our youth
have got the centres.”
(District ADCHS)
The lack of transport is noted for emergency transfers to hospital. Long delays are experienced
before the ambulance service arrives. This can compromise the health of a woman in labour and
professional staff resort to using their own vehicles to transfer a patient. Many comments were
made by facility managers and community members. Facility managers at times resort to using
their own transport to take a patient from the clinic to hospital:
“We end up using our own transport seeing that we are going to prevent ending up with
a corpse. Like last time I was on night duty and I was the only midwife, this woman was
brought into the centre bleeding so profusely; I took my own transport after two hours
waiting for the ambulance.”
(Facility Managers Discussion Group)
“We are quite used to it. I can say like once in three months a staff member has to take a
patient.”
(Facility Managers Discussion Group)

Community members do not have their own transport to assist with taking patients to hospital
and can only rely on the ambulances, which frequently take a long time to arrive:
“Totally not, our clinics at rural and urban areas open at eight and closes at five, most of
the time in rural areas we [care givers] don’t have transport to transport patients or
ambulances. If you call an ambulance they will say all ambulances are out, gone to the
village and even tells you about kilometres.”
(Adult Community Discussion Group )
“Most of the people living in the rural areas have problems with transport even the ambulance
are not coming to their places because of the poor roads…”
(Adult Community Discussion Group )
Financial Accessibility to reproductive health services in Mafikeng Health District
Primary health services are free at the clinics and community health centres in Mafikeng. There
is, however, a fee for admission to hospital. As with the other districts the greatest cost to a
patient is transport from home to the health facility. Ambulances services are slow to respond
to calls and there are areas in the district to which they will not travel because of road structures.
Hiring private transport is very expensive, particularly from the more remote areas of the district.
“The services are free at the clinic but at the hospital you pay and you only pay for the
transport.”
(Community Discussion Group)
139
Attitudes to the reproductive health services
Facility managers expressed mixed feelings about the change in services. The workload in the
clinics has increased, with more patients coming for services, while the number of staff has not
increased. The changes in services have, however, brought an apparent increase in maternal and
infant mortality. (See Figure 4.15) this is possibly attributable to the increase in the number of
women re accessing the services. Women and babies previously died in the community and these
deaths were not notified to the facilities. A facility manager also blamed the increase in workload
to decentralisation as all patients are required to go via a clinic and not directly to hospital.
“The change we have seen (with decentralisation), it has increased the maternal and infant
mortality. Because mostly they were just delivering there and there were no notifications
if there were any deaths. And then bringing the services towards the people it has increased
that. … What I can say is that this decentralisation has caused us – problems. Now, people
don’t go straight to the hospital, even if they are in labour. The have to go via the clinic.
So – you can see that all these pregnant women they will come to one clinic. They will come
to deliver there, unless there is a problem so that we can refer. But – what about the staff?
They didn’t come with the job. They were not increased. At the end of the day that workload
ends up on one person, or on two persons. The hospital will only take in the emergency
cases.”
(Facility Managers Discussion Group )

In reality there are probably many reasons for the increased work load and some facility managers
appreciate the improved access to services that has come with the changes. Community members
are more aware of the services and even claim ownership of them, as expressed two facility
managers:
“Decentralisation, I think it makes people … be more aware of the services that are in the
government and in the clinics. So I think it opens up. People are coming in. they are no
longer staying home. They are using the facilities better. … I can see it as increased
ownership by the community. It seems that most who can access the services are able to
use them.”
(Facility Managers Discussion Group)
“Yes, for example in the rural areas most of the people are staying very far. So bringing
the services towards them has actual cut down the kilometres that they have to walk. And
the other thing, there are mobile clinics they visit all the places.”
(Facility Managers Discussion Group)
There appears to be some problem in attitudes between health workers and the community. The
health workers and facility managers feel that the community is often demanding on them and
demanding of the patients’ rights as expressed in the Patients’ Rights Charter and Batho Pele
policy. 15 Facility managers explained their feelings:
140
“Yes, we adhere to the Patients’ Rights Charter and patients are aware about that we try
by all means to go by this – privacy, confidentiality.”
(District Facility Managers Discussion Group )
“Yes they are, they (the community) are demanding. We as nurses don’t have any rights,
we are just workers; we have to please them, that’s what we are told. So we just have to –
if they say this - even if we are taking a tea or lunch break, if they say, ‘are you going to
work?’ you just have to stand up and work. Those patient’s rights are imposed on us and
we are suffering.”
(District Facility Managers Discussion Group )
“To me there is no problem with the patients’ rights as long as they can be emphasised
together with our rights.”
(District Facility Managers Discussion Group)
The community, on the other hand, sometimes view the health workers as unsympathetic and
not providing a good service. They feel that the services are not meeting all their needs. The
health forum is not functioning as it should. For some the services were better in the past. There
were several comments from community members expressing dissatisfaction, as follows:
“We walk long distances in the village and find that some are very sick and you [caregivers]
will call an ambulance and the emergency services they will tell you that the ambulance
is not there. But in the 80’s there was an ambulance and the community were paying two
rand. The clinic opens for 24 hrs but you’ll find that there is no medication.”
(Community Discussion Group )
15 See Table of Policies and legislation

“The health forums are there but they are not structured. The committee has to consist of
12 members but now we are left with three; that is the chairperson, me [caregiver] as
assistant chairperson and an old lady of seventy two years. She is old and cannot perform
all the duties effectively. Others have stepped down because they [the district] are not
prepared to pay them as they are volunteers. We, as youth, don’t have any working experience,
we don’t benefit and the only benefit that we get is information.”
(Community Discussion Group)
“The clinic opens at eight, but they don’t start immediately and their closing time
depends on them [nurses], instead they return people home and say the clinic is closed.”
(Community Discussion Group)
4.4.3 Ganyesa Health District, Bophirima Region (District
Municipality)
Services available in the districts
Reproductive health Services are provided at all mobile clinics, fixed clinics, community health
centres 16 with referral to Ganyesa District Hospital for those services not available. The services
are officially integrated at the point of delivery. Management from the district level,
however, remains vertical. This was referred to as such by the ADCHS in the district.
“…. who is in charge of this management of this programme (PMTCT)? ANSWER: The
HIV Coordinator. QUESTION: And who is in charge of the reproductive health programmes?
ANSWER: The mother and child health programme.”
(District ADCHS)
141
For convenience, and often due to staff shortages, some specific services are only offered on
one day a week in some clinics in Ganyesa, as explained by a facility manager and local area
manager.
“It is an integrated service, but for the sake of collecting PAP smears and because of
shortage of staff, those that come for ANC for the first time we’ll book them for Fridays,
for the sake of collecting the PAP smears and the beginners.”
(District Local Area Manager)
“So since this supermarket system has started it improved a lot, even though we are not
fully participating with it.”
(District Facility Manager)
A Youth Centre has recently opened in the town of Ganyesa and provides services for youth and
adolescents, including reproductive health services. It is, however, situated far from many youth
in the district and can be used by a limited number of youth. Some of the services and programmes
are, however, taken to the schools as well.
16 In Ganyesa some Community Health Centres are referred to as “Community Hospitals” – these names were used prior to
the amalgamation of services and are still commonly used by some community members and others.

Contraceptive services / Family planning
Contraceptive services readily available at all health facilities in Ganyesa District are:
• Oral contraceptive pills.
• Injectables – Noristherate and Depo provera.
• Barrier methods – male condoms and, in some, facilities female condoms.
Intra-uterine device insertion is not available at clinics or CHCs because of lack of trained nurses
in the procedure. Any patient requesting this as a method is referred to Ganyesa Hospital.
Figure 4.18 shows the number of contraceptive injections given in the district facilities and the
number of oral pill cycles dispensed. After an increase in 2001 of the number of patients for all
three methods, there has been steady decrease in uptake.
Figure 4.18: Ganyesa Health District - Use of Contraceptives
- 2000 to 2003
18 000
30 000
142
Number of injections
16 000
14 000
12 000
10 000
8 000
6 000
4 000
2 000
25 000
20 000
15 000
10 000
5 000
Number of oral pill cycles
0
2000
2001 2002 2003
year
0
Medroxyprogesterone
Norethisterone
Oral Pill Cycle
Source: North West District Health Information System
Services for family planning are available at all times and the community feel free to attend for
the services, as explained by members of the Ganyesa Health Forum:
“Family planning, they are doing it on daily basis, one can come at whatever time. … In
the then government, it was then only on Thursdays. But since there are the changes, since
‘94, it is done on a daily basis. One may come at whatever time. And they are given
everything: injection, pill, loop, all those things. … Yeah, and you can even come after
hours. Last week I was here roundabout 6 o’clock. People came here for birth planning
and they helped them, they never complain. And before they used to complain: ‘why do you
come at this time?’”
(District Health Forum)

Ganyesa Hospital does not offer contraceptive services, except for intra-uterine device insertion
when referred from the clinics.
Safe motherhood
The clinics and CHCs offer ante-natal care. Figure 4.19 shows that between 2000 and 2003 there
was an increase in attendance in 2001, and a slight decline in 2002 and 2003. High risk antenatal
patients are referred to the hospital to be seen and managed by a doctor. No figures of the
number of such referrals were available.
Figure 4.19: Ganyesa Health District - ANC first and repeat visits
- 2000 to 2003
12 000
10 000
Number
8 000
6 000
4 000
2 000
0
2000
2001 2002 2003
year
143
ANC 1st visit
ANC follow-up visit
Source: North West District Health Information System
There are no on site tests for syphilis at clinics. These are therefore sent to the laboratory at
the hospital and results returned to the clinics.
Figure 4.20: Ganyesa Health District - Total Births in Ganyesa
Hospital and District CHCs and clinics - 2000 to 2003
Number of deliveries
2 000
1 800
1 600
1 400
1 200
1 000
800
600
400
200
0
2000
2001 2002 2003
year
Hospitals
CHCs & Clinics
Source: North West District Health Information System

The number of deliveries at the clinics has increased with a decrease rate of referral to hospital.
(See Figure 4.20)
Figure 4.21: Ganyesa Health District - Total number of births and teenage
pregnancy rate - 2000 to 2003
2 000
16
Number of births
1 800
1 600
1 400
1 200
1 000
0
2000
2001 2002 2003
year
– 14
– 12
– 10
8
– 6
– 4
– 2
0
% teenage pregnancies
Total deliveries
% teenage pregnancies
Source: North West District Health Information System
144
The teenage pregnancy rate has declined from 14% to 9% between 2000 and 2003. (See Figure
4.21)
The mother and child health coordinator in Ganyesa believes that there is a positive trend among
the youth and adolescents. They are more aware of the rights, but still need user-friendly services
for themselves. She explained:
“The youth at least now, they are aware of their rights and they want a service of a specific
quality so at least you can see that they are becoming aware they are becoming interested.”
(District Mother and Child Health Coordinator)
“… specially the youth, maybe they don’t need a contraceptive, they need education and
then they decide but because of [inaudible] they just come here for an FP method and then
you’ll ask maybe specific questions and then you choose the method; but we need a service
that will be user-friendly that will accommodate the youth but loveLife is coming so they
will be able to do that.”
(District Mother and Child Health Coordinator)
Some health workers and some community members surmise that one reason for the high teenage
pregnancy rate is the social grant offered to all children less than seven years (now being extended
to 14 years).
“I think it is getting higher because of the grant … they are going to get – and they don’t
use it for the baby, they use it for other things.”
(District NGO Representative)

“… our school is just next to the post office, where people who are going for the children’s
grant get their grant. So on that day, most children absent themselves from school.”
(District Governance Structure Group Discussion)
“… , what I have realised now is that the young children are being helped with the money,
so I think that is one of the cause of the teenage pregnancy …”
(District Health Facility Manager)
There is, however, no proof of this being so and no adolescent interviewed admitted to
purposely becoming pregnant to access the grant. In addition the statistics available indicate a
decrease in teenage pregnancy and not the increase reported in the discussion groups.
The still birth rate in the district remains about the same of 3 to 4%. (See Figure 4.22)
Figure 4.22: Ganyesa Health District - Total births and still birth rate
- 2000 to 2003
2 000
5.0
1 800
4.0
Number of births
1 600
1 400
1 200
3.0
2.0
1.0
% still births
145
1 000
2000
2001 2002 2003
year
0.0
Live birth
Still birth rate
Source: North West District Health Information System
Total live births in the hospital increased in 2001, but decreased to about half in 2002 and a
slight rise in 2003. The referral rate from clinics to hospital of patients in labour has decreased.
(See Figure 4.23)
HIV/AIDS/STIs
Treatment of sexually transmitted infections is available at all clinic and community health
centres in Ganyesa Health District.
Figure 4.24 shows that the number of cases of sexually transmitted infections decreased in
Ganyesa between 2000 and 2003.

Figure 4.23: Ganyesa Health District - Clinic deliveries, referrals
during labour and percent referrals - 2000 to 2003
1 400
30
1 200
– 25
Number of patients
1 000
800
600
400
– 20
– 15
– 10
Referrals %
200
– 5
0
2000
2001 2002 2003
year
0
Live birth
Refer during labour by clinics
% referrals clinics to hospital
Source: North West District Heath Information System
146
Figure 4.24: Ganyesa Health District - Number of sexually transmitted infections
- 2000 to 2003
8 000
7 000
Number of patients
6 000
5 000
4 000
3 000
2 000
1 000
0
2000
2001 2002 2003
year
STI treated - new
MUS treated - new
STI slip issued
STI partner treated
Source: North West District Health Information System

“Yes, a 24-hour service (is needed). The people are there and they haven’t got money to
get transport to the health centre or to the hospital as necessary. Most of them deliver at
home because of no transport.”
(District Facility Managers Discussion Group)
Some hospital outside the district may refer deliveries to Mafikeng Provincial Hospital. These
figures, however, are not reflected accurately in the hospital information system.
“Another thing I was going to say, apart from the clinics, the neighbouring district hospitals
they refer most of their problems here. Even caesarean sections sometimes, they refer
patients to be done caesareans here.”
(Maternity Matrons- Regional Hospitals)
The increase percentage of deliveries in hospitals is supported by the increase in referral rate
from clinic to hospital. See Figure 4.23. These referrals can be related to lack of midwives in
the clinics, as stated by the Mafikeng Hospital Maternity Matrons.
“Sometimes you find a patient is being here (at the hospital) from the clinic the reason being
no midwife, there are such things.”
(Maternity Matrons- Regional Hospital)
Community members feel freer to attend for treatment than previously. A health forum member
said:
147
“Yes, because before people were not feeling free to come to the clinic when they were
having these STI’s. So, these days they are coming to the clinic and they are given treatment
immediately. But the only problem is with the males, their partners. Females do come, but
males, it is a problem, they don’t come.”
(District Health Forum)
VCT is offered at clinics, but blood for testing is sent to the laboratory at the hospital.
Other reproductive health indictors
Table 4.3 and Figure 4.25 show that between 2000 and 2003 the maternal mortality ratio is rising
while the perinatal and neonatal mortalities were falling. In 1996, from the best information
available at that time, the MMR was 145 deaths per 100 000 live births and the NNMR was 6
deaths per 1000 live births. 17
Availability of reproductive health services
Reproductive health services, as listed in the PHC Service Package, are not available at all health
facilities in Ganyesa. Some of the difficulties were explained by the district manager and facility
managers. Shortage of midwives in some clinics means that deliveries can not be done in those
facilities:
17 Health and Welfare in North West Province - Implications for planning, 1996.

Table 4.3: Ganyesa Health District - Reproductive Health Indicators
- 2002 to 2003
MMR
PNMR
NNMR
2000
129.1
41
4
2001
173
48
7
2002
382.2
27
3
2003
304.9
17
0
MMR = Maternal Mortality Ratio = Maternal deaths to 100 000 live births
PNMR = Perinatal Mortality Ratio = Perinatal deaths to 1 000 births
NNMR = Neonatal Mortality Ratio = Neonatal deaths to 1 000 births
Source: DHIS - Institutional rates only
Figure 4.25: Ganyesa Health District - Maternal Mortality Ratio, Perinatal
Mortality Rate and Neonatal Mortality Rate - 1996, 2000 to 2003
148
PNMR and NNMR -
deaths per 1 000 live births
60
50
40
30
20
10
0
1996
2000 2001 2002
year
2003
450
– 400
– 350
300
– 250
– 200
150
– 100
– 50
0
MMR and NNMR -
deaths per 100 000 live births
PNMR
NNMR
MMR
Source: North West District Health Information System
“It (the service package) is according to the province; although it can be according to what
we have. … We can add or take away because of not having these midwives there and then
that clinic would not be having the total service package as outlined. … There is a clinic
that … there is no midwife … we would not have delivery services at that clinic or would
have them at a very small scale because now it will be open from 8 until 5.”
(District Health Manager)
The mobile clinic services can be irregular and a facility manager requests employers on the
farms to assist by bringing their workers to the facility for services:

“No, there is a mobile unit but it's not stationed at Piet Plessis. But they do come and do
the farms but that is very, very irregular and then you find the people phoning to the hospital,
they want to know from us when is the mobile clinic coming again because all the ladies
who are going to be pregnant again. Then we just ask them please make an effort and bring
them in from the farms to the hospital so we can give them their injection or their pills
because the mobile unit is being very irregular.”
(District Facility Manager)
One of the main reasons for this is the lack of health workers – professional nurses and doctors.
It is difficult to replace those who leave, retire or die, as explained by the district manager:
“… it's just over a period of time we are unable to replace staff. If say 5 nurses out of 20
have left and maybe 2 die and three leave due to transfer, especially when they get married
and they leave the area, it is always more difficult for us to replace them. …we have funds,
we advertise the post in the newspaper … we are unable to recruit people from the bigger
cities or towns because they don’t want to come and stay in a rural area, due to poor
infrastructure.”
(District Health Manager)
The shortage of staff is a major problem in Ganyesa and the entire Bophirima Region (District),
and was identified by managers, front line health workers, the municipal manager and the
community. The regional director was looking at ways of attracting local general practitioners
to work part-time for the state:
“I think we are a district that is hard hit in terms of the availability of the health professionals,
the nurses and doctors. The Chief Director has challenged us and I am toiling and thinking
around that of engaging private practitioners, GPs here, in sessional services in our hospitals
… then the few that we have must go to the clinics. Yes, we have problems where we get
maternal death.”
(Regional Health Director)
149
The Kagisano Local Municipal Manager was disturbed by the lack of applicants to advertised
posts:
“I was disturbed when Mr … (the district manager) told me that they advertise the positions
for the professional nurse they couldn’t get even a single one.”
(Local Municipal Manager)
The difficulty in retaining staff in a rural area was shared by the ADCHS:
“You know there is one thing that I wanted to bring to your attention, is the district; the
nature of the district makes it very difficult for us to retain staff. The whole time people
come and the turn over rate is very high. So we do not know what will happen that will
attract people to come and work here…. I think what should happen is the people must be
given incentives, you know, some sort of rural allowance.”
(District ADCHS)

The delay experienced by patients in receiving treatment was of concern to a facility manager:
“They queue for a long time in the clinic so we explain to them that the reason for long stay
in the clinics is that there is shortage of staff. We can not help you in time.”
(District Facility Manager)
A clinic midwife expressed her feelings of being required to do the work of five people:
“You find that one person does the work that is supposed to be done maybe by five people.
So the problem of shortage of staff.”
(Clinic Midwife)
The staff who stay are generally those whose homes are in the area, as expressed by two health
workers:
“You see this is a rural area they don’t like being here. They’ll just go it’s only us who are
having the homes here.”
(District Facility Manager)
150
“I’m working here because, my house is here and my parents are near. I think that is the
only thing that is keeping me here.”
(Clinic Midwife)
The hospital was also short staffed and unable to manage all referrals. The shortage of doctors
was of particular concern because maternity patients requiring caesarean section were being
referred to Klerksdorp Hospital, approximately 300 kms away. A community service doctor was
not allocated to work in Ganyesa. These concerns were expressed by the hospital manager and
maternity matron:
“At the moment we don’t have a community (doctor) but they do come when they are
available, they do send them.”
(District Hospital Manager)
“… the last 4 or 5 weeks, we were not able to do Caesarean Sections anytime a patient
needs it. So we end up referring the patients to Klerksdorp, so it’s another three hours. So
sometimes a Caesar is three hours away from hospital.”
(District Hospital Maternity Matron)
Health forum members expressed concern for the need to refer patients to Klerksdorp. A member
would prefer the referral hospital to be closer, such as in Vryburg:
“Because we feel that from here people are referred to the local hospital, from the local
hospital, people are transferred to Klerksdorp. And Klerksdorp is too far. They are transported
by the health vehicles. But it is too far. If it is an emergency, what will happen along the
way? I don’t know how many kilo’s it is 300 and something, or 400 and something, from

here to Klerksdorp? So if at least the nearest referral hospital can be Vryburg. Then we
can feel that it is decentralised. It is too far for us.”
(District Health Forum)
As with the clinics, vacant posts in the hospital are difficult to fill and many professional nurse
posts remain vacant, despite advertising. Nurses prefer the urban areas:
“Right now we have six professional nurse posts, but it’s not filled. We advertised, but noone
wants to come and work here. It’s very far … If you advertise six posts on the
same paper that Klerksdorp Hospital advertised 13 posts and Potchefstroom advertised
10 posts and …advertised 12 posts – where are the professional nurses going to?”
(District Hospital Maternity Matron)
The shortage of health workers in facilities to run the services was repeatedly identified by all
community members; however, none were able to offer any easy solution:
“You see we have got a serious shortage of senior resources people who work in our
structures. There are not enough nurses. Also we are running short of doctors. We have
only 3 in our hospital – we should have contracted more.”
(District Health Forum)
“You can see them in this building; you will find one sister the whole day.”
(District Health Forum)
151
Patients requiring referral from clinics to Ganyesa Hospital or to a hospital outside the district
include patients needing:
• Contraception – sterilisation or insertion of intra-uterine devices.
• Termination of pregnancy. Initial counseling can be done at the clinic and the patient
referred to Ganyesa Hospital. The service, however, is not always available at the
hospital as there is only one trained professional nurse on the staff. The patient is then
referred to Vryburgh or even to Klerksdorp.
• Extra care because they are high risk maternity cases.
• Infertility investigation.
The referrals are usually for consultation with a doctor, specialised tests or referral to a specialist
outside the district, as explained by the ADCHS for Ganyesa:
“…if somebody has a problem here or in the clinic with fertility or such things, we refer
them to the hospital and then the doctors they do whatever tests they have to do there and
to be referred if they cannot assist at the hospital.”
(District ADCHS)
“… you know some people stay very far away, there isn’t even an ambulance to carry the
woman from her home to the nearest clinic; so people go there on their own. And then when
they arrive at the clinic, if there are no problems then the women will deliver in the clinic.

But if there are problems she can be referred to the hospital here and, if the hospital experiences
problems, then they refer them to Klerksdorp hospital.”
(District ADCHS)
Geographical accessibility to reproductive health services in Ganyesa Health District
Ganyesa district is a large, deep rural area and is sparsely populated. Infrastructure, such as
roads, public transport systems, buildings and communication are poor in many areas. Access
to services is difficult because of the terrain and distances to be traveled. The recommended
norm is for everyone to live within easy walking distance of a clinic or health facility. This is
not always cost effective in sparsely populated areas such as Ganyesa.
The lack of transport, public and from the health department, were the major problems mentioned.
This was recognised by the ADCHS:
“… the situation of the district itself makes it very difficult, it poses difficulties because they
stay very far from the clinic, and sometimes there is no transport to carry them in time to
the hospital.”
(District ADCHS)
152
Communities have demanded more clinics, but these can not always be granted. The expense
of hiring private transport in an emergency in the face of the high unemployment and poverty
of the area decreases the accessibility to the services. This is acknowledged by the district
manager:
“…unemployment, poverty, I’m sure it’s pushing people to say we need a clinic. Whereas
if the community was in walking distance then there is no demand for that.”
(District Health Manager)
And shared by a member of the Ganyesa Health Forum:
“They have to hire transport to the clinic. Maybe the emergency services, transport, they
are not there. Some are not even able to contact them. So these are the problems that the
community experiences.”
(District Health Forum)
Mobile clinics are used to reach some of the more isolated villages for weekly or monthly visits.
These mobile services, however, are sometimes irregular in which means that patients are not
attended to and will then have to travel to a clinic or CHC. A Facility Manager explained the
mobiles cover vast areas:
“I think they are about ten (mobile points), I‘m not sure of but they are many, they go as
far as 80 kilos from the clinic, so there are many points. They cover a big area, so we are
actually covering a big area.”
(District Facility Manager)

The planned two-room clinics may alleviate the problem, but the problem of staff recruitment
and retention in isolated places will probably remain.
There is no reliable public transport system in the district, and even though there is an ambulance
service in the district it is not always available. Local solutions to the problems are found as
noted by a Facility Manager:
“They were complaining of transport but the transport issues has been cleared up because
we are having ambulances, though sometimes they are broken, there is no transport. But
we normally devise some means so that a person is taken from home to the clinic.”
(District Facility Manager)
The situation of poor infrastructure, long distances between the community and facilities and
poor transport impacts on the ability of the health services to render good reproductive health
services, particularly safe motherhood. Women in labour are delayed in reaching a clinic or
hospital; many women deliver at home without the presence of a trained midwife and, coupled
with the shortage of staff in the hospital, high risk maternity patients are at times transferred
to Klerksdorp. Maternal and foetal morbidity and mortality is likely to be higher under these
circumstances. A Facility Manager explained that the delay in transport meant that patients arrive
in advanced labour:
“… a residential area quite far from the hospital, they [the community] have to hire a
bakkie and, and they come in when almost fully dilated.”
(District Facility Manager)
153
The ADCH in Ganyesa acknowledged that a number of deliveries happen at home, even without
a traditional birth attendant present:
“Yes, there are a number of home deliveries. … We don’t have traditional birth attendance….”
(District ADCHS)
The Ganyesa Hospital maternity matron was particularly concerned about the delays in patients
accessing the hospital from remote areas. She is left with a distressed mother, “holding the baby”
as they wait for an ambulance to move her to the next hospital:
“Ya, but the most thing that affect the people this side and impacts on safe deliveries is the
transport and the distances between facilities. That one is really disadvantaging the people
in the end. For example the patient at Heuningvlei – you know where Heuningvlei is? It is
very far. And the roads are so bad – it is not even tarred. So you can imagine an eclamptic
woman who comes all the way from Heuningvlei, already has … and when you try to get
an ambulance here, the ambulance is already on the way or half coming back from
Klerksdorp. So you are stuck with that woman for the next 4 hours. … We end up with,
really complications, that maybe because of - if the transport was available, if the distance
was a little bit shortened between the facilities maybe they wouldn’t have complicated to
that stage.”
(District Hospital Maternity Matron)

Financial Accessibility to reproductive health services in Ganyesa Health District
Primary health care and reproductive health services, in line with national policy, are free. A
charge is made for a patient admitted to hospital or who by-passes a clinic and go direct to
hospital. However, travel from home to the health facility is not free, unless an ambulance has
been called. A Facility Manager explained:
“They don’t pay for ambulance; they only pay R11 at the hospital. But if they go by
themselves I think they double the amount. But the principle is that they have to come to
the clinic then be referred. They shouldn’t just go by themselves…. They don’t pay, but the
ambulance is stationed at the hospital, so they call it from the hospital. From the hospital
they go to the village and bring the patient to the clinic, they don’t pay.”
(District Facility Manager)
The problem worsens when a patient has been transferred out of the district, such as to Klerksdorp.
They may be recalled for a follow-up visit which can become expensive for the patient, as
explained by the district manager:
“Then there is one with a van and that person charges them R200 that night and that person
will not be healed totally, maybe that person will fall sick again, just some ten days thereafter,
another R200 and they don’t have it. So there are complex issues.”
(District Health Manager)
154
It is also expensive to visit a relative who has been transferred to Klerksdorp and difficult for
them to get information on the condition of their relative. Members of the Health Forum were
emphatic about this:
“It is a problem. Everybody mentions the problem of transport; it is unaffordable to travel
all the way to Klerksdorp.”
(District Health Forum)
Although the service is slow at the clinics because of the shortage of staff, most people use the
clinics in preference to a private doctor because the services are free and are appreciated by
community members.
Attitudes to the reproductive health services in Ganyesa Health District
The main demotivating factor for the staff is the shortage of staff and therefore work overload.
Generally they feel that services are better and that they are treated better by their employer,
the PDoH. There is more scope to practice their skills. This was expressed by a clinic midwife:
“I think most of the services were decentralised to the clinics, unlike before where we would
get everything at a central point. But after this decentralisation even the services we are
able to attend to our vision. The only service that we still having a problem are the maternity
patient could not have a doctor and ….we refer them to the state hospital. Otherwise other
services since after decentralisation are available.”
(Clinic Midwife)

This view was not universally held in the district and another midwife felt that the supermarket
approach is failing because of the staff and other shortages:
“I was just saying how this system of supermarket that we are working in the clinics, it
seems to be failing. As you can look at it, it is as if things were not properly planned. What
makes it fail; first it is shortage of staff. We don’t have a doctor around. There are no
vehicles here to transport patients when we are having patients… so people have to stay
for a long time… even the accommodation concerning the supermarket - it is a problem
because you’ll be having a small consulting room where you won’t be able to attend to the
patient as a whole, given all the resources in the consulting room.”
(Clinic Midwife)
4.4.4 Comparison of the three districts:
This section compares the quantitative data gathered on reproductive health from the three
districts. The researcher had difficulty in accessing accurate, complete data from the districts
during the field work. At the time the DHIS was being upgraded and information officers were
being trained. In 2004 the researcher accessed North West DHIS for data that had been collected,
collated and cleaned by the national and provincial information teams. DHIS is discussed in
Chapter 9.3. The section concludes with a general summary of reproductive health services
available in North West Province.
Figure 4.26 shows that of the three study districts, Ganyesa District has the highest percentage
of teenagers and young people. Klerksdorp district has the lowest percentage teenagers and the
highest elderly (over 65 years).
155
Figure 4.26: North West Province - Percentage population per Age Group
- 2001 Census
40%
35%
30%
Percent of Total
25%
20%
15%
10%
5%
0%
0 to 4
5 to 14 15 to 34 35 to 64
year
Over 65
Klerksdorp
Mafikeng
Ganyesa
North West Total
Source: Municipal Demarcation Board at www.demarcation.org.za

Figure 2.25 compares the maternal mortality ratios in the three districts. The maternal mortality
ratio is highest in Klerksdorp District. This is possibly due to Klerksdorp being a referral centre
for the southern and western part of the North West Province, including Ganyesa which has the
lowest maternal mortality ratio of the three districts. There are, however, a higher number of
home deliveries in Ganyesa where access to services is more difficult and some maternal deaths
may go unreported.
Figure 4.27: Public Institutional (Hospitals and Clinics) Maternal Mortality Ratio
- Ganyesa, Mafikeng and Klerksdorp Health Districts and North
West Province - 1996, 2000 to 2003
700
156
Maternal deaths per 100 000 births
600
500
400
300
200
100
0
1996
Klerksdorp
2000 2001 2002
year
Mafikeng
Ganyesa
2003
North West
Source: North West Provincial District and Hospital Information Systems
Figure 4.28 compares the perinatal mortality rates in the three districts and with NW Province
average. A similar pattern to the maternal mortality ratio described above.
Figure 4.29 compares the neonatal mortality rates for the three districts and NW Province. The
pattern is the same, with Klerksdorp the highest and Ganyesa the lowest.
General summary of services
Contraceptives / Family planning services:
• Methods offered are injectables, barrier (in some places female condom as well as male
condoms), and oral contraception. The most common method used is injectables.
• Insertion of intra-uterine devices is only available at hospitals or in the private sector.
• No services are offered in the community. Community health workers, however, are
able to advise on family planning.
• Youth Centres are being built in each health district to provide services specific to
adolescents and youth, including contraception.
• Services are integrated into ante- and post-natal services.
• Emergency contraceptives are available.
• Female and male sterilisation services are available at the hospitals on request.

Figure 4.28: Public Institution Perinatal Mortality Rate - Ganyesa, Mafikeng
and Klerksdorp Health Districts - 2000 to 2003
100
Perinatal deaths per 1 000 births
90
80
70
60
50
40
30
20
10
0
2000 2001 2002
year
2003
Klerksdorp
Mafikeng
Ganyesa
North West
157
Source: North West Provincial District and Hospital Information Systems
Safe Motherhood
This is also known as “Safe Pregnancy”. Services provided cover from ante-natal care, to delivery
and to post-natal care. Services include:
• Education of women about pregnancy.
• Antenatal care (ANC) – at all mobiles, clinics and community health centres. Hospitals
generally provide ANC services for high risk patients that have been referred from the
district services.
• Deliveries are done at all 24 hour service centres and during normal working hours at
some other clinics. Alternatively women are referred to a local hospital.
• Very few deliveries are done at home. This generally only happens when transport is
unavailable, such as in rural areas or at night.
• Caesarean sections are done at all district hospitals. Where there is a shortage of doctors
with the necessary skills, such as in some rural hospitals, patients may be transferred
long distances (up to 300 kms) for a caesarean section.
• Infertility problems are referred to hospitals for management.
• More specialised examinations, such as sonar, are only available at hospitals. Dopplers
are used at the clinics to assess foetal hearts.
High risk maternity cases are managed at hospitals. A number of low-risk pregnant women when
in labour by-pass the clinic system to deliver at hospital. The hospitals are managed separately

Figure 4.29: Public Institution Neonatal Mortality Rate - Ganyesa, Mafikeng and
Klerksdorp Health Districts - 1996, 2000 to 2003
Neonatal deaths per 1 000 births
45
40
35
30
25
20
15
10
5
0
1996
2000 2001 2002
year
2003
Ganyesa
Mafikeng
Klerksdorp
North West
158
Source: North West Provincial District Health Information Systems
to the district responsible for the clinic services. Meetings are held between the hospital and
district management teams to address these and other problems.
Deliveries are not possible at some clinics due to the shortage of professional midwives. Patients
are therefore advised to go to the next clinic or community health centre when in labour.
PMTCT programmes are provided at hospitals and many of the clinics. Where trained staff are
not available patients are referred to hospital. The programme is coordinated by the HIV/AIDS
Coordinator in the district.
Services given are according to provincial policies and guidelines, and protocols for safe
motherhood. These include: regular check up; bloods for haemoglobin, syphilis and blood group;
iron supplementation; treatment of any infections such as STI and advice on nutrition. Districts
and regions do not develop their own packages for ANC.
Traditional birth attendants are found in some rural areas. They work with the clinic staff in
providing maternal care, particularly antenatal care.
HIV/AIDS/STIs
Condoms are available at all health facilities and are provided through dispensers in shops,
schools and meeting places in the community. Services for treatment of STIs and for HIV are
integrated into other services, such as family planning and safe motherhood. STIs are treated
according to national policy protocols using the syndromic approach.
VCT is available at all clinics. The counselors include nursing staff and lay people from the
community, but available resources are insufficient to cope with the demand. Not all clinics,

however, are able to test for HIV and thus the patient, after counseling, is referred to another
clinic or hospital. Counseling for HIV is offered by some NGOs in non-medical sites, such as
the University in Mafikeng. The provincial health services support these NGOs, both financially
and with information. Adolescents and sex workers have been identified as target groups for
VCT by the provincial HIV/AIDS directorate. Projects for these groups are organised and run
in each health district. Information on HIV/AIDS is readily available in all government buildings,
on bill-boards and other advertising space.
Other service providers in the districts
In each health district there are other providers of health services, including for reproductive
health. These are:
• Private sector – provides full services, including FP, safe motherhood, treatment of
STIs and TOP to:
- private medical aid patients, and
- private (out of pocket) patients
- Industry – mines offer services to employees, but not to all their families who must
then access care through the public sector.
- Defence Force – provide services to members and their families.
All these services are found more in the urban areas where there is industry and a number of
public servants. In rural areas there are private general practitioners providing general health
services. Some of these doctors work part time for the state in a hospital or community health
centre. These services have little integration with the public health sector and do not normally
provide statistics to be included in the district data and information.
There is some cooperation between the private sector and the public sector in certain areas. For
example the public sector clinics are not able to insert intrauterine devices (IUD) due to lack
of staff, time or expertise. The clinics, therefore, supply an IUD to a client for insertion by a
private doctor thereby saving the patient the cost of the device.
159
Staffing of services
Professional nurses form the ‘back-bone’ of staffing for reproductive health services in the
districts and the hospitals. They are responsible for ANC clients and only refer to a doctor when
a potential problem is identified. There is, however, an overall shortage of professional nurses
in North West Province and there are times when a clinic has a nursing assistant in charge. All
maternity cases then require referral to another clinic or hospital. A rapid turn over of staff
aggravates the shortage. Continuity of care is therefore poor as patients do not see the same
nurse on subsequent visits. In the hospitals and some community health centres there are advanced
midwives who are able to do more advanced procedures, such as a ventouse.
In recent years there has been a shift in power relationship between doctors and nurses. The
doctor is no longer assumed to be the leader of the team and nurses are taking more of a lead
in planning PHC services in the district.
Doctors are employed by hospitals and visit the clinics as arranged between the district and the
hospital. There is a shortage, however, of experienced doctors in the hospitals and visits are
often allocated to junior doctors, such as the community service doctors, who have little
understanding of PHC and the role of the clinics in the health system. Such visits are often
irregular and for a limited time only. A rotation system operates such that a doctor may be

allocated to clinic duties for three months only, where after there is a change. There is reliance
on foreign trained doctors, such as those from Cuba, who are employed through a government
to government contract by the NDoH. The training and experience of these foreign graduates
does not always fit with the needs of the South African health service. In service training is then
required.
At the regional level there are a few regional specialists, such as for obstetrics and gynaecology,
paediatrics and forensic medicine. Their role is overseeing and coordinating the services of their
specialty within the whole region (district) and to support training. Private practitioners are
employed on a sessional basis in hospitals to assist with relieving the shortage of doctors. Other
ways of filling the gaps through partnerships with the private sector are being explored.
Access to services
Access to all health services have improved in the last 10 years. There are many reasons for
this. An active programme of clinic and hospital building and refurbishing in the mid 1990’s
ensured that more clinics and services were available, particularly in rural areas. Intensive
training programmes for nurses and other health workers has increased capacity for nurses to
treat more conditions.
160
Clinics and health centres are staying open for extended hours creating an opportunity for those
who are employed to have easier access. In North West Province the intention is to have at least
one 24-hour service health facility available in each health area within a district. Lack of physical
infrastructure and human resources is delaying achieving this goal. The different conditions
of service between provincial and local government employees have caused problems with
extension of opening times of some clinics where the two work together. Conditions of employment
for provincial services requires nurses to be available to provide 24 hour services through
working at night and over weekends and public holidays; municipal services require nurses to
work an eight hour day, five days a week only. The provincially employed nurses are not
prepared to carry the burden of all night and weekend duties while the municipally employed
nurses claim that it is not part of their conditions of service to work at night or weekends.
The deep rural areas, including farms, are reached by the mobile health services that travel to
each visiting point weekly, fortnightly or monthly.
The provision of all services on every day of the week through the “supermarket approach”
helps with access. A patient is less likely to be turned away from an ANC clinic and asked to
return on another day. She will be attended to and an initial examination done. However, the
experiences of some community members indicate that this is not fully operational at all clinics.
Health workers note that even where there are good services available, and accessible to the
community, that some women do not attend ANC. The reasons for this are not clear.
Outreach services into the community have made such things as Home Based Care accessible
to many home-bound chronically ill patients. These programmes are mainly run by NGOs with
support and guidance from health workers.
Despite efforts to make all services accessible to the whole community there are some services,
such as termination of pregnancy, for which there is poor access. The Act requires services to
be available, but they are not available due to shortage of staff prepared to be involved on ethical
and religious grounds. There are a limited number of designated facilities available and staff
require training. There is also antipathy in some communities towards termination of pregnancy
as being culturally unacceptable, particularly where a patriarchal society dominates.

Service uptake
It is difficult to quantify the increase in service uptake in the last 10 years. Data and information
is not readily available. The DHIS is improving and in time there will be better records.
Subjective and anecdotal impressions from health workers, managers and the community are
that more people are accessing the services than previously. Possible reasons are: -
• Increase in number of facilities available
• Free services at primary level facilities.
• Improved motivation and education of the community on health issues.
• Increased “ownership” of the services by the community.
• Integration of services at clinics and the “super-market approach.”
• Extended opening hours of clinics.
• Decentralising of some decisions and services to the local level.
The establishment of Youth Centres in health districts and offering reproductive health services
and life skill programmes for youth are seen as a means to better reach adolescents who are a
designated target group in the province.
Increased attendance has been noted:
• by males – seeking condoms, treatment of STIs and generally taking a greater interest
in reproductive health issues;
• at ANC clinics;
• number of births under supervision;
• requests for VCT; and
• in numbers joining PMTCT programme.
161
Uptake of termination of pregnancy remains comparatively low. The reason are complex and
include stigma and inaccessible services, lack of staff willing to be trained, cultural, religious,
moral and patriarchal issues.
There is low return for male STI contacts who partners are given a contact slip to be treated.
There is concern about the high teenage pregnancy rate. Contraceptives and condoms are freely
available at clinics and youth centres, but approximately 15% of all pregnant women are under
18 years old; with some of these having their second or third child.
Adolescent services
Adolescents are a target group for the whole NW Province. They form a high percentage of the
population, particularly in rural areas – approximately 40% of the population is under 15 years
of age in Ganyesa (rural); 32% in Mafikeng (semi-urban) and 26% in Klerksdorp (urban).
Youth Centres are being established with the assistance of the Planned Parenthood Association
of South Africa (PPASA). The centres are staffed by departmental staff and have various
programmes run by PPASA and loveLife. 18 One of their strategies is to improve access to
health services for adolescents. This is being done in conjunction with the public health
services and is known as the National Adolescent Friendly Clinic Initiative (NAFCI).
The Youth Centres, though, are situated in the main towns and are not easily accessible to youth
living in rural areas or on the other side of the town. Transport is difficult and these centres can
only cater for youth living in the vicinity of the youth centre. There is an identified need to
increase the number of youth centres so that they can be made more accessible to greater numbers.
18 loveLife is a national NGO that focuses on reducing HIV infection in youth through education and life skills development.

Other clinics do not provide separate facilities or services for youth, although some clinic sisters
may organise special youth clubs and work closely with schools in the area in educating youth
on sexual matters. Youth Clubs in the areas around clinics may invite the nurses to address them,
as well as organisations such as loveLife.
The Youth Centres were initially started by PPASA. After one year the province took over the
running of them and they have now been taken over by the health district which is required to
staff and fund the services. Additional funds are required for this service.
The teenage pregnancy rate is high in all districts with approximately 15 % of all maternity cases
being under 18 years of age. The figures, however, from the DHIS may be inaccurate because
a number of women deliver in the private sector or in other districts. The child support grant
of R160 per month is thought by some people to be one of the reasons why teenagers want to
have a baby. There was no collaboration for this from teenagers.
The clinics can be a barrier to adolescents needing access to reproductive health care. The girls
do not like being seen at the clinic by older relatives and the boys would prefer to access the
clinics after hours, but the services are not always available at those times. Adolescents attending
the clinic at times experience a judgemental attitude from nursing staff when they request
contraception. However, if they come with a parent or other adult the staff attitude is different
and they are treated with respect.
162
There are a number of NGOs focused on youth in each district. These are sometimes formed
and run by youth themselves, without funding. They work with the DoH structures on education
programmes, particularly in regard to HIV/AIDS, but on other health issues as well. Due to lack
of finance to be able to pay people who join or to offer employment only a few youth are reached
by many of these NGO’s, such as GAYCO in Ganyesa.
The PDoH works closely with the Provincial Department of Education on education programmes
within schools in all districts. HIV/AIDS is often the focus of these programmes, but
other issues, such as general sexual and reproductive health, are covered. However, there are
some youth who feel they are over “lectured” on some issues at school and would prefer to
attend the Youth Centre for information or be given something to read for themselves.
Termination of Pregnancy
One of the ‘promises’ of the RDP which survived is the right to reproductive choice. Pillay and
Bond comment that the RDP served as “crucial link to other social programs….the RDP allowed
activists and policy advisors from outside the field of health to make inputs into health policy.
This was particularly important, for example, when ANC women leaders promoted reproductive
rights as a non-negotiable component of the RDP, which gave the Health Department a firm
mandate to insert this clause in its policy notwithstanding substantial opposition by men (and
some traditional women) in rural areas who were opposed to abortion.” 19 The Choice on
Termination of Pregnancy Act (CTOP) was passed in 1996. High levels of unsafe abortion, with
consequent high mortality and morbidity rates, made legislative reform an imperative, the new
Act made provision for termination of pregnancy up to twenty (20) weeks on request. Special
conditions do apply to those pregnancies of more twenty (20) weeks gestation. For minors,
parental permission is not required although consultation and counseling is recommended.
The realities of whether TOP services are available and accessible as a ‘basic right’ is explored
here in some detail in order to reveal how the limitations on public expenditure, and thus on
resources and implementation of policy, results in limited provision of a constitutionally guaranteed
right. The reality within the public health sector of constitutionally guaranteed reproductive
19 Pillay, Y.G. and Bond P. (1995) Health and Social Policies in the New South Africa, Int. J of the Health Services, Vol 25,
No 4, 727-748 (p.735).

ights is that these rights have materialised for only limited numbers of women. The existence
of legalisation is never a sufficient indicator of the availability of services and this is most clearly
revealed when assessing provision of TOP services.
Budgeting for termination of pregnancy services is problematic. There is no single budget for
reproductive health, and the budget for TOP services is spread through other programmes such
as the comprehensive PHC package and through hospital budgets. According on one senior
provincial manager, TOP is not considered a core function of reproductive health. Some health
workers see CTOP as a politically driven programme that attracts more attention than other
reproductive health programmes. This is contrary to the views of many others who believe there
are insufficient resources for the CTOP.
Although the Choice on Termination of Pregnancy Act, 1996 aimed to make services available
to all women, particularly those from previously disadvantaged and rural areas, through providing
terminations of pregnancy services up to 12 weeks gestational age at primary health care clinics
or community health centres, the overwhelming majority of TOPs are being done in hospital
settings. TOPs although are listed as part of the PHC package, to be carried out by doctors or
nurses who have received the required training, but are only found at the primary level in rare
instances. In 2000, 99% of the public sector facilities designated to provide TOPs were hospitals,
and nearly half of these were located in Gauteng and Western Cape. 20 These two provinces have
the highest levels of urbanisation, and the lowest levels of poverty; Gauteng comprises 20% of
the population and produces 34% of the GDP, and Western Cape comprises 10% of the population
and produces 15% of the GDP. 21
Until the amendments to the CTOP Act were passed in 2004, centralised control over the
designation of facilities permitted to render TOP services remained in Clause 3 of the CTOP
Act:
163
Figure 4.30: Number of Termination of Pregnancies per Province - February 1997
to January 2003
Number of TOPS
120 000
100 000
80 000
60 000
40 000
20 000
0
106 109
23 083 228 296 35 117
36 956
13 8333 15 398
11 757
3 910
EC FS GP KZN LP MP NW NC WC
EC: Eastern Cape | FS: Free State | GP: Gauteng | LP: Limpopo | MP: Mpumalanga
| NW: North West | NC: Northern Cape | WC: Western Cape
20 Varkey, S.J. (2000) Abortion Services in South Africa:Available Yet Not Accessible to All; International Family.
Planning Perspectives, Vol.26:2, P. 87.
21 Stats SA, Census 2001.
22 Choice on Termination of Pregnancy Act of 92 of 1996.

The surgical termination of a pregnancy may take place only at a facility designated by the
Minister by notice in the Gazette for that purpose under subsection (2). 22
Provincial Departments of Health are required to report back to the NDoH on progress made
in implementation.
Problems in uneven access, with large areas having no access at all, have been experienced.
Furthermore, due to a range of factors, not all those facilities designated by the Minister of
Health are rendering the service. The first graph illustrates the uneven spread, through the nine
provinces, of TOPs performed in the public sector over a five year period. The second graph
illustrates the high number of officially designated public facilities which are currently not
providing the service.
Public facilities in Gauteng, the most urbanised province, performed close to 40% of all TOPs
countrywide during the five year period shown. (this percentage, however, has declined from
Gauteng’s 60% of the total performed between enactment of the legislation and 2000.) 23
KwaZulu-Natal, the most populous province with the highest number of women, performed
only 12.8% of the total TOPs over the five year period reflected in this graph.
Figure 4.31: Numbers of Public Facilities Designated for TOPs and Providing
TOPs, per Province 2003
70
164
Number of Facilities
60
50
40
30
20
10
0
EC FS GP KZN LP MP NW NC WC
| EC: Eastern Cape | FS: Free State | GP: Gauteng | LP: Limpopo | MP: Mpumalanga
| NW: North West | NC: Northern Cape | WC: Western Cape |
No. of facilities providing TOPs
No. of facilities designated to provide TOPs
Over 69% of the designated facilities in KwaZulu-Natal are not offering TOPs.; the province
has only 17 functioning public facilities for TOPs. Almost half the women in KwaZulu-Natal
have given birth to a child by the age of 19. 24 It is also the province with the highest prevalence
of HIV.
23 Penn-Kekana, L. (2000) Report on the Public Hearings - ON the Implementation of the Choice of Termination of Pregnancy
Act 1996, National Portfolio Committee on Health.
24 Mazur,R. (1995) Population structure, fertility and childhood mortality in South Africa: lessons to be learned from analysis
of the poverty survey, medical Research Council Working Paper.
25 Marais, Hein. (1998) South Africa. Limits to Change. The Political Economy of Transformation. University of Cape Town
Press, Cape Town. (p.92).
26 Ndebele, T.A. (2003) Accessibility to Pregnancy Termination Services in Durban, KwaZulu-Natal. Paper presented to the
Reproductive Health Research Priorities Conference, Johannesburg.
27 Issues in Current Service Provision. Implementation of the new South African Abortion Law: a six month overview from
hospital reports. Reproductive Health Matters 1998:6:145-58. Reproductive Rights Alliance. Barometer: Towards ensuring
access to reproductive choice 1998;2 (1).

The reality is that TOP services are not readily available. There are groups, such as traditional
and religious groups and many health workers, who are opposed to the implementation of the
CTOP Act. Noteworthy, in the context of improving women’s access to reproductive health
services and expanding their choices, is the fact that the powers of traditional leaders have been
protected, “lending politicised ethnicity a menacing lease of life whilst also threatening to
diminish and delay democratisation in rural areas.” 25 There also appears to be a shortage of
health personnel willing to be involved, as well as unwillingness on the part of management to
support staff training.
A 2003 descriptive study examining accessibility to TOP services, and identifying factors that
hinder access, in two urban regional hospitals in KwaZulu-Natal, concluded that TOP services
were inaccessible to women who seek the service in the province of KwaZulu-Natal. 26 Health
care providers at most public hospitals and clinics in KwaZulu-Natal have refused to provide
TOPs. 27
It would appear that facility managers are applying their personal beliefs to the entire facility;
research has found that “abortion providers ranked the problem of management resistance to
making abortion services available in their facilities as the greatest obstacle to implementing
this policy.” 28 There are reports of hospital administrators using various tactics to avoid providing
services – making operating theatres unavailable; refusing to nominate staff for TOP training;
claiming to be understaffed and unable to release anyone to provide TOP services. 29
Another tactic, that of claiming that ‘the community’ does not want TOPs, was revealed in a
written submission, from the Medical Superintendent of a KwaZulu-Natal rural district hospital,
to the National Portfolio Health Committee’s public hearings on implementation of the CTOP.
The report on the hearings describes this:
“He stated that he was not prepared to be involved in any way in providing terminations
of pregnancy. He had communicated with community leaders and clinic health
committees in his region and they all agreed with his position. Furthermore he suggested
that the fact that very few rural women were accessing services was more a reflection of
the fact that rural women didn’t want to access the services than lack of services. 30
165
In 2000, a national study found that the incidence of incomplete abortions was not statistically
significant between 1994 and 2000; the incidence rate was 375 in 1994 and 362 in 2000. 31 The
study concluded that there was a reduction in morbidity from unsafe abortions, largely due to
a significant reduction in the proportion of cases with signs of infection on admission, but that
the modest size of the effect of the legalisation of TOP reflected the inadequacy of services in
many areas.
A second study focused specifically on why women are still having unsafe, illegal abortions in
Gauteng where there is relatively substantial service provision. Fifty five percent (55%) of the
women did not use legal services because they did not know about the law, 17% feared ‘rude
staff’, 15% did not know of a facility providing TOP services, 7% feared breach of confidentiality,
4% found the waiting list to be too long and 2% were unable to access care because their
pregnancy was too advanced. 32 Among those women who knew of the law, the most important
deterrent to using legal services was fear of staff hostility. Several women reported having been
28 McIntyre, D. and Klugman B. (2003) The Human Face of Decentralisation and Integration of Health Services: Experience
from South Africa. Reproductive Health matters, 11(21)108-109.
29 Hord, C.E and Xaba, M. (2001) Abortion Law Reform In South Africa: report of a study tour May 13 – 19 2001, IPAS.
30 Penn-Kekana, L. (2000) Report on the Public Hearings on the Implementation of the Choice on Termination of Pregnancy
Act 1996; National Portfolio Health Committee. p131.
31, 32, 33 Department of Health, South Africa (2002) An Evaluation of the Implementation of the Choice on Termination of
pregnancy Act.

to a clinic for help and had either not been told about the Act or had not been effectively referred
to a facility which provided TOPs. The study concluded that the health sector plays “a substantial
role in induced abortions occurring outside designated facilities” as “among those who knew
of their entitlement, perceptions of the quality of care of services was the most substantial barrier
to their use” 33 .
Amendments to the 1996 CTOP Act
As a result of research, evaluation and debates, changes to the CTOP legislation have occurred
since 1996. The findings of the Confidential Reports on Maternal Deaths do influence policy
development for safe motherhood.
To streamline the TOP legislation, proposed changes to legislation and implementation strategies
were introduced via a draft Bill to amend the CTOP Act of 1996. This was tabled in Parliament
in November 2003. One amendment has introduced a degree of decentralisation for implementation
of the Act. This amendment decentralises authority for the designation of TOP facilities
from the National Minister of Health to the Provincial Ministers of Health. (MECs) The
amendment empowers provincial MECs to approve facilities where TOP services can be provided.
Previously, Section 3 of the Act was one of the pivotal centralising provisions in that TOP
services could only take place at facilities designated by the National Minister of Health.
Most significant of the amendments is that all public and private facilities offering 24-hour
maternity services will be able to provide TOPs of up to 12 weeks gestational age without the
permission of the provincial MEC. These amendments to the CTOP Act will be advantageous
and improve the geographical spread of functional facilities.
166
Further significant amendments allow registered nurses who have undergone the prescribed
training, rather than only medical practitioners and registered midwives who have been trained,
to perform TOP services. This will increase the potential number of health professionals,
supportive of women’s right to reproductive choice, who are eligible for training in TOPs, and
who are thereafter available for service provision. However, services will not improve without
substantial increases in targeted health sector expenditure.
One suggestion, made by a rural district Maternal, Child and Woman’s Health Coordinator, was
that training in TOPs be part of nurses’ basic training so that all nurses are trained:
“So that’s my main concern about that so I was thinking that maybe if this training could
be incorporated in the basic training so that everybody would be forced to do it.”
(District MCWH Coordinator)
However, no health workers are ‘forced’ to provide TOP services; the Act clearly gives choice
to health workers as to whether they are prepared to be part of TOP services or not.
There has been resistance to the amendments. This was noted by one NDoH informant who
commented on opposition from the South African Society of Gynaecologists who saw TOP
services as the preserve of doctors:
“…. we came from a very male, white dominated kind of service. … the South African
Society of Gynaecologists basically said it is a mistake to allow nurses to terminate
pregnancies. … this was the preserve of the doctor or gynaecologist, and that of course
translated to mainly male and white and nurse translates to female and black. … Two years
down the line we endorsed the things and then they had this magnanimity of them coming
and saying that they had objected then, now they see, and are actually recommending, that

it should not be restricted to midwives and really any professional nurse who is trained
should be able to do it.”
(National DoH Chief Director - Maternal, Child and Women’s Health)
TOP Services in North West Province
In NW Province, CTOP services are currently available in 12 district hospitals and in 2 provincial
hospitals. Recently, as a pilot, the service has been decentralised to community health centres
in one region of the province.
Women who request a termination are counseled at a clinic, and then referred to the nearest
hospital. This adds to the work load of hospitals and can be a financial barrier for many clients
in accessing the service as they must transport themselves to and from the hospital.
A number of terminations are done in the private sector, but it is difficult to obtain figures for
these because the procedure is generally recorded as a diagnostic curettage or incomplete abortion;
often in order that private medical aid schemes will then pay the private hospital fees; private
insurers do not cover TOPs. In the public sector the service is free of charge.
TOP is a one-day service, and uses manual vacuum aspiration for pregnancies under 12 weeks.
At one provincial hospital (Mafikeng) terminations are done in the Reproductive Unit, where
patients are counseled beforehand. The unit has only one trained nurse (a male) and the service
is not available when he is on leave. Other hospitals experience similar problems when trained
staff go on leave. In a rural hospital (Ganyesa), where there is only one trained nurse, the service
closed for a year while this nurse attended an advanced midwifery training programme outside
the district. Women requesting terminations during this year were referred to a hospital in the
next health district, approximately 60 kms away.
167
Figure 4.32: Mafikeng Health District - Requests for TOP and number of TOPs
done - 2000 to 2003
1 200
Number of TOPS
1 000
800
600
400
200
0
2000 2001 2002 2003
year
TOP performed - hospital
Request for Tops - clinic
Source: North West Province: District Health Information System
There is a varying demand for the services. The single service provider in Mafikeng may do 10
to 12 terminations per day. Some clinics reported that they have only 2 or 3 requests per month;
these are then referred to hospitals. A number of women voluntarily go to other districts, or

even other provinces, as they fear possible repercussions from family and friends if it is known
that they have had a TOP.
The TOP service provider at a hospital believes it is preferable to keep the service centralised
to a hospital. It is easier for a woman to come and go unnoticed compared to attending a clinic
when the clinic is in the community in which she lives. Women can be ostracised by family and
friends as the right to request TOP is not widely accepted in all communities. It was the opinion
of this health worker that once there is more general acceptance of the right of women to choose,
then the procedure could more easily be decentralised to clinics.
There has been an increase in uptake of the service, although many women appear to go directly
to hospitals with only a few being referred from the primary level. This can be seen in the
following figure which shows TOPs provided directly at hospital level in Mafikeng and those
referred via clinics between 2000 and 2003.
Some midwives and other health workers expressed strong views and frustrations about the
CTOP services. The frustrations arise from knowing that contraceptives are widely available for
all women, the belief that young people use TOP as a means of contraception and, possibly,
their own opposition to abortion on request. Concern was expressed that some women may use
termination as a form of contraception:
168
“I think there was a big negative perception about contraceptive services under the old
system but then we went over to a new regime and I think there is big silence about
contraceptive services and that is a concern. I think termination of pregnancy has become
a contraceptive because if you go and look at the statistics in the hospitals the person who
came for a first termination often comes for a second or a third one whilst there is the
necessary preventative measures in place that could be used. I think it’s a neglected area.”
(Provincial Chief Director)
“Yes – they are even abusing them (their rights). … I think they are well aware that they
have to come for the family planning, they have to take whatever but one would come and
say, ‘you know I did not take my pill, so I missed about two to three months, I want to abort,
I have the right.’ So, really, it irritates because everything is humanly available for them
and they know and there are so many points, as we have been saying, at least the government
has made so many opportunities for them.”
(District Midwives Discussion Group)
“They (teenagers) are not using contraception and not using condoms. They are using TOP
as a method.”
(District Hospital Midwives Discussion Group)
Concern in relation to a clash between traditional values and termination of pregnancy was
expressed:
“When the choice on termination of pregnancy act was introduced we explained to our
traditional healers because in our society abortion is not socially acceptable and then when
you have had that even if it's an inevitable one, you have to undergo a cleansing ritual… they
wanted us to refer clients for the cleansing ritual so you think that it's a women’s choice and
we cannot divulge such information so they were saying that is why there is so much drought
because these women who underwent an abortion did not undergo a cleansing ritual.”
(District MCWH Coordinator)

“And even the introduction of CTOPs, although it seems a taboo because of our culture,
but for those civilised people, it is assisting them.”
(District Midwives Discussion Group)
Clinic nurses generally accept that the Act is in place and if a woman or adolescent requests a
termination of pregnancy they will refer her to the nearest facility offering the service:
“Yes, (the referral does work well) because we have an Act to guide us. If the child wants
TOP we don’t have queries, we just send her, irrespective of her age.”
(District MCWH Coordinator)
One key informant identified problems in the initial implementation of the programme as the
failure to adequately equip and prepare the health workers, and described how this was improved:
“When we started we just started with the Act being there and the nurses having to do this
and in the meantime we didn’t have trained nurses. We didn’t even have, or we looked at
what the providers need relating to providing the service - that is psychological needs or
physical needs or whatever. … we had a lot of resistance and we started doing values
clarification, Health Workers for Change … Then I saw a change. The providers accepting
the services, talking about the service … and training them for pre and post abortion,
contraceptive counseling … then there was a change.”
(Provincial Reproductive Health Coordinator)
The responses of adolescents, when asked if they would ever consider termination of an
unwanted pregnancy, varied. This is illustrated by the following six statements from a group of
adolescent girls. Their statements also reveal some ignorance of the legislation as parental consent
is not required for minors, and TOP cannot be done as late as six months gestation.
169
“I will terminate that pregnancy. … I am not ready to be a mother. I expect my parents to
do a lot for me and if I have a baby they are going to do nothing for me. They will be doing
for my child. I am still a child; I need my parents’ love. So if I had a child, who is going
to give that parental love? No- one.”
“Termination of pregnancy is a sin.”
“Sometimes your boyfriend’s family will force you to do it and you have to go to the hospital
to do it or at the private clinic.”
“To go and terminate pregnancy maybe in the hospital you have to bring your parents so
that she could give their consent to terminate your pregnancy.”
“To give an example about my ex- friend; she terminated her pregnancy and she was excited
to do it and telling every body about it. She even told us that it was a boy. By the time she
terminated that pregnancy it was about six months, and that shows that she was heavily
pregnant.”
“Even back street is dangerous. What if things got complicated and I die? Who is going
to tell my parents what happened? By then I will be dead.”

Chapter 5
Districts - Context, Decentralisation, Intermediate
Processes and Reproductive Health Services
170
5.1 Introduction
Policy and legislation in South Africa is centralised to the National sphere of government. The
political thrust in the post-apartheid era is for a decentralised, developmental, democratic
government as enshrined in the Constitution of 1996. Chapter 3 of this report describes the
development of decentralisation policy and plans for national implementation. In the NW Province
a number of functions have been, or are planned to be, devolved to the provincial or local
government sphere. National government, however, retains control of many financial and
budgeting processes, and human resource management, within the provincial sphere of government.
Local government, through the Constitution and local government legislation, appears to have
greater autonomy for raising finance, budgeting and human resources management than the
provincial sphere. There is still, however, central control of direct funding from national treasury
to municipalities, and a proposed bringing together of human resources into a single civil service
for all spheres and levels of government.
Policy and legislation for health sector reforms are the responsibility of the National Department
of Health (NDoH), although other stakeholders are consulted during the development of these
policies. National health policy focuses on the development of a National Health System (NHS),
which incorporates primary health care (PHC) delivered through a district health system (DHS)
that is municipally-based. Local government has the constitutional responsibility for municipal
health services (MHS), which are defined in the National Health Act of 2003 as part of
environmental health services. The balance of PHC is a provincial responsibility. Establishing
a DHS that is municipally-based is complex. Essentially, management of provincial health
services are de-concentrated to health districts or districts whose boundaries are coterminous
with metro, district or local municipal boundaries. Some provincial departments of health
propose to delegate PHC services, except district hospital services, to local government: NW
Province is piloting delegation of PHC in one district municipality (Bophirima) and continues
a de-concentration of the management in the other district municipalities. The health care
structures and systems are described in Chapter 2.
Reproductive health policies, as with the above health policies, are developed centrally by the
NDoH. Other stakeholders are consulted, including some provincial representatives. The policies
are passed vertically to the PDoH, who are responsible for their implementation in the districts
and/or districts as part of the integrated package for PHC. These policies are based on the
principles of the International Conference for Population Development of 1994 (ICPD). These
principles, in broad terms, include female education, gender equality, and female choice in
reproduction, among others. These policies and reproductive health services are discussed in
Chapter 4.
A number of intermediate processes are required to implement these policies. These include
service organisation and delivery (Chapter 6), finances (Chapter 7), human resources (Chapter
8), planning, monitoring and evaluation (Chapter 9), governance (Chapter 10) and logistics and
referrals (Chapter 11).

The three sets of policies for political decentralisation, establishing decentralised health
management and reproductive health services, are applied equally across each province in the
country. The implementation and impact of these, however, is at the local level, within the defined
boundaries of municipalities and health districts or districts. Each province and each district
within the provinces are different and have different contexts – historical, contemporary
political/social/economic dynamics, development and ‘capacity’ to engage with change. The
context of each of the three study sites is described in Chapter 2.
This chapter looks at each of the three study sites in NW Province in terms of how decentralisation
has an impact on the intermediate processes and reproductive health services. Particular attention
is paid to the impact of the district context on the intermediate processes and reproductive health
services. Does decentralisation have a different impact on reproductive health services in the
three districts, and, if so, why? Table 5.1 summarises the information on the three districts.
5.2 Klerksdorp Health District
Klerksdorp is a mining, industrial and commercial centre in the south of NW Province. The
district includes some commercial farms, mainly White owned. There are no previous ‘homeland’
areas.
Prior to 1994, the area was part of the Transvaal, a conservative, predominately Afrikaans
community that largely supported the National Party and other right-wing parties of the apartheid
government. Blacks had no right to ownership of land; Coloured and Indians were accommodated
in separate townships outside of the city. Africans (blacks) working on the mines were largely
migrant workers from the ‘homeland’ areas of Transkei, Ciskei, KwaZulu and from Lesotho.
Klerksdorp was a socially and economically divided community with different levels of service
for each racial group.
Klerksdorp is the second largest industrial and mining area in NW Province. (Rustenburg to the
north east of the province, the centre of platinum mining, is larger). The mines remain the main
source of employment. This mine employment, however, reduced between 1996 and 2001 by
37% (Chapter 2.4.1). There are probably many reasons for this, including a move towards
outsourcing some functions to contractors. The mines are not responsible for health care of these
contractees; nor do they provide health care for their own employees’ dependents. 1 These workers
seek health care through the public sector.
The residential areas in Klerksdorp remain partially racially divided in that the cost of moving
from the ‘townships’ to the ‘suburbs’ is high and only affordable for higher income groups.
The census data shows an increase in population of 7.1% between 1996 and 2001 with an
increase in the number of households with no annual income of 14 217. (Chapter 2.4.1)
The ANC dominates the political arena, with support for opposition parties, such as the Democratic
Alliance in the Klerksdorp Municipal Council and the Freedom Front Plus in the provincial
legislature. (Chapter 2.4.1) Local government governance structures (such as ward committees)
are in place and are consulted by local councilors on wide range of issues, including health. 2
There are also health governance structures – the Health Forum – which interacts with the health
district management team, including commenting on financial issues and being part of the
appointment procedure of staff. The health forum in Klerksdorp is active and interested in
improvement in health services.
Klerksdorp has a history of strong local government prior to 1994. The council was responsible
for some primary level care, particularly for prevention (immunisations) and promotive health,
171
1 Klerksdorp Health Districts Manager
2 Klerksdorp MMC for Health and Klerksdorp LM Health Manager

including family planning. These services were provided through a system of clinics, managed
and maintained by the council although built by the old Transvaal Provincial Administration. 3
There were also a few provincially run clinics in the same areas, but these were managed
separately to the municipal clinics. The scope of services provided by these clinics has widened
to include the full (or majority of) package of PHC services as per national policy. The provincial
and local government services have been functionally integrated, as a possible first step towards
decentralisation of PHC services to local government. There are now provincial and local
government employed health workers working in the same facility – but working under different
conditions of service. (Chapter 2.4.1) Decentralisation of PHC services in Klerksdorp are
imminent – the province is to pilot the process in Bophirima first and then possibly role out to
other district municipalities. Confusion remains as to the future of staff – whether the status quo
will remain; whether all will be transferred to provincial or to local government employment;
or whether the proposed single civil service will materialise.
The local council in Klerksdorp is strong. The Member of the Mayoral Committee (MMC) for
Health is knowledgeable on health issues and decentralisation policy. There is an appointed
health manager who has worked and lived in the area for many years. There is a good working
relationship between the services, but uncertainty was expressed by both managers as to the
future and as to which sphere will take full responsibility for the health services. 4
172
The health district has a provincially appointed district manager and consists predominately of
provincial employees. The local government health manager and facility managers form part
of the combined, extended management team. Relationships are reported to be generally ‘good’,
but difficult at times with tensions particularly related to human resources. The municipality is,
according to the constitution, an independent and autonomous sphere of government. In reality,
however, for health services, the municipality is controlled by the provincial sphere in that
funding comes through the province (see Chapter 7 and 2.4.1). The municipality is limited in
appointing health workers, whereas province can appoint and promote staff as they require.
Of particular concern in the district is the provision of 24 hour services at the clinics. Community
members, through the Health Forum, have requested 24 hour services. The differences in
conditions of services between provincial and local government has delayed the services being
open 24 hours in Joubertina, the largest township (see Chapter 2.4.1). Friction has developed
between the community and health workers as community members have no understanding
of these problems. The MEC for health in the province is unable to resolve the problem
because the clinic is managed by a different sphere of government. The complexity of relationships
is difficult to manage and takes much of the energy and time of managers.
In addition, the diversity of institutions responsible for health services and support services
within the district – such as PHC, district and other hospitals, laboratory, emergency services,
transport – adds to the tensions and complexity. Delays in finalising policies and then in passing
legislation have added to the problems. Some of the institutions have become entrenched, even
in the financing and planning policies and structures. The PHC services are managed by the
district health management team; the provincial hospital provides district level hospital facilities
but is under a separate management team. Frictions do arise between nursing staff in the clinics
and the hospital – these are resolved as far as possible through bilateral meetings. According
to policy more uncomplicated deliveries should be done at the primary level than in hospital;
the move towards this, however, is slow.
There is a strong private sector for health services, mainly used by those with access to private
medical aid schemes. There is little cooperation between the public and private sector, and data
is not shared.
3 Klerksdorp Health District Manager
4 Klerksdorp Health District Manager and Klerksdorp LM Health Manager

It is in this mix of complex issues, interacting and impacting on each other and changing over
time that the intermediate processes for health service delivery must operate so that quality
reproductive health services are delivered.
The researcher was aware of certain tensions, particularly between the provincial and municipal
employees and to lesser extent between district and hospital services. Their relationships are
cordial and cooperative. However, there was also a feeling of grappling with the issues and a
determination to make things work and to see service delivery improve. These tensions did not
prevent the district management team opening doors for the researcher to meet municipal
managers and councilors and to access the hospital. Relationship with the governance structures
was noted to be open and good with honest sharing and enthusiasm on all sides.
The trends in reproductive health (as described in chapter 4.4.1) reveal:
Access to services
• Increased with increased number of clinics, but not everyone can access 24 hour services.
• One youth centre opened in Joubertina for whole district.
Contraception
• Decreased uptake between 2000 and 2003.
Safe motherhood
• Declining ante-natal attendances.
• Increased percentage of deliveries being done in clinics – but still only 8% of total.
• Decrease in referrals from outside the district.
• Decreased number of patients referred in labour from clinic to hospital.
• Teenage pregnancy rate is static.
• Institutional perinatal mortality rate shows slight decrease; no decrease in maternal
mortality ratio or neonatal mortality rate.
173
HIV/AIDS
• Number of STI cases treated is static.
• Increasing number of HIV pre-testing counseling.
5.3 Mafikeng Health District
Mafikeng (which includes Mmabatho) is on the north west border of NW Province, close to the
border with Botswana. The town serves as a railhead between Botswana and South Africa, a
commercial centre for surrounding commercial farms and the seat of the provincial legislature
and administrative head offices for the provincial public sectors.
During the apartheid era the town of Mafikeng was in South Africa and the town of Mmabatho
was the capital of Bophuthatswana. There was a racial divide between the two centres – Whites
living in Mafikeng and Africans (black) in Mmabatho. White civil servants, seconded to work
in Bophuthatswana, lived in Mafikeng and commuted the 5 to 10 kms daily to work. At night,
African (black) civil servants and other residents in Mmabatho were not permitted to enter
Mafikeng.
Political tension developed during the period leading up to the 1994 democratic elections.
This was partly reluctance of the party in power in Bophuthatswana, the United Christian

Democratic Party (UCDP) lead by Lucas Mangope, to relinquish their power and partly the
right-wing Afrikaner Weerstandsbeweging (AWB) resistance to the new government. After the
1994 election the two towns were amalgamated into one, known as Mafikeng.
Political tensions are continuing. The ANC is the majority party in the provincial legislature, but
there is small, but significant, support (9%) for the UCDP. This support is strongest in Mafikeng
where 30% of the votes were for the UCDP. In the 2000 local government elections, 43% of votes
were for the UCDP, who have nine of the 28 municipal council seats. (See chapter 2.4.2)
Mafikeng is surrounded by some tribal areas where traditional values are strong. The residents
are mostly subsistence farmers. There is a paramount chief in the area who is considered one
of the leaders in the community. 5 There are also commercial farming areas to the east of the
town, mostly owned by more conservative Afrikaans families many of whom have been resident
in the area for many years.
Africans (black) make up 95% of the population, predominately Setswana (83%). The White
population is dominated by Afrikaners. English is the accepted language for business and in
government. Mafikeng is thus a mixed population, urban and rural, and racially, influenced by
western society as well as traditional norms, and with groups with conflicting interests, politically
and socially.
174
The total population of the district increased 7.3% between 1996 and 2001. There has been a
small decrease in number of people in employment, but a large increase in the unemployed. The
number of households without any annual income has increased from 17% to 28% of all
households. Education levels are generally higher than the other districts – this could be in part
due to the nature of employment and the presence of the Mafikeng Campus of the University
of the North West in the town.
It is difficult to interpret economic figures. A proportion of public servants working in Mafikeng
do not have their permanent homes in the town. 6 The live in other towns or in other provinces,
particularly Gauteng and commute to Mafikeng.
Public health services in Mafikeng are managed entirely by the provincial services. Local
government has one small clinic to serve their own staff. There is, therefore, no tension between
health workers in the different spheres of government, as in Klerksdorp. It is, however, difficult
for the health district management team to liaise with the local councilors and there appears to
be little sharing between the spheres of government.
Governance structures for health and local government co-exist. The health forum, though, is
weak and consists of three people – one in over 70 years, one care-giver and one member who
represents the health forum on the hospital board but who ‘never reports back’. The local
government health portfolio committee appears unaware of health policy, in particularly in
relation to decentralisation of services from provincial to local government. 7 The extent to which
traditional leadership, although acknowledged as important, is incorporated into governance
structures was not clear.
As elsewhere, institutional diversity has developed for health service delivery within the
health district. Tensions at times exist between these institutions, such as the clinics and PHC
services having to refer high risk cases to the provincial hospital. A common complaint at all
levels of the services is a lack of skilled personnel to handle the work load.
The context and complexity in Mafikeng is different to Klerksdorp; while policies for
decentralisation, health sector reform and reproductive health are the same. The circumstance
in which these policies are implemented is different.
5 Member of District Health Management Team
6 Provincial Director for HIV/AIDS - personal communication, 2003.
7 Meeting with Health Portfolio Committee - not recorded

The researcher was constantly aware of the tensions between role players. It was impossible for
the district manager to access the local or district municipal officials or councilors and he used
‘back-door’ means of gaining information. The regional director had a more direct connection
with the district municipal officials. The researcher noted a rift between the district and the
hospital and had to make her own plans to gain access to the staff and information. The researcher
noted the relationship with community was not good. The health forum appears ineffectual.
The trends in reproductive health (as described in Chapter 4.4.2) reveal:
Access to health care
• Increased access through increased number of facilities and hours of opening.
Contraceptives
• Decreased in uptake of contraceptives between 2000 and 2003.
Safe motherhood
• First antenatal care visits are static in number; repeat visits are decreasing.
• The percentage of deliveries happening at the primary level in the clinics and community
health centres is decreasing.
• There is an increased referral rate of women in labour from clinics to hospital.
• Teenage pregnancy rate remains at about 8%.
• Institutional maternal mortality ratio increased in 2002 and remained constant in 2003;
perinatal mortality rate and neonatal mortality rate show an initial increase and then
decrease in 2003.
HIV/AIDS
• There is little change in the number of patients treated with STIs.
175
5.4 Ganyesa Health District
Ganyesa health district is a deep rural area in the far north west of the province, close to the
Kalahari Desert.
Prior to 1994, most of the area was within the boundaries of Bophuthatswana ‘homeland’, with
some areas in the east and north as part of the Transvaal. In chapter 4.4.3 mention is made of
the community being homogenous, with 93% of the total population in 2001 being Setswana.
The area is largely tribal owned where traditional values are strong. Traditional leadership is
important and respected, and has been incorporated into governance structures for health and
local government.
There is little formal employment in the area, apart from government services, such as health
and education, and the farms in the east of the area. There is a high dependency on social grants
and remittances of salaries from outside the area. A high, and increasing, number of households
have no formal annual income. The number of households with no income has increased by 3
644 households between 1996 and 2001; this is 31% of all households.
Infrastructure development in the area, particularly expansion of the electricity grid, has been
good between 1996 and 2001. There are still many homes, however, without water and proper
sanitation.

The total number of people recorded as employed has decreased, but the total workforce has
also decreased. The net result indicates that a higher percentage of the total workforce is employed.
The total population in the district has increased by only 1.7%. The decrease in workforce size
could, in part, be due to out-migration.
Politically the area is dominated by the ANC, but with reasonable support for the UCDP in the
provincial legislature (16%) and in the local municipalities (36%).
Within Ganyesa there is, as in the other districts, institutional diversity. The working relationship
between the district hospital and the district appears good, with the two institutions sharing some
administrative support services. The relationship between the hospital staff and clinic staff for
maternal care appears good; a long serving doctor has in the past worked closely with the clinics
on the referral system, but less so currently because of the separation of the district PHC services
and the district hospital.
In 2001, 40% of the population was under 15 years of age; 32.6% of the population over 20
years of age had no or limited primary school education. In 1996 the figures were 42.6% and
30.4% respectively.
Despite the low development, low economic status of the community and high level of illiteracy,
the researcher was aware of a cohesion between all role players in health in general, and
reproductive health in particular. No tension was evident between role players. There was an
easy working relationship between the health district manager and the local municipal mayor
and manager. A good relationship was evident with hospital management and community,
including traditional leaders.
176
The trends in reproductive health (as described in Chapter 4.4.3) reveal:
Access to health care
• Increased access through increased number of facilities and hours of opening. But
remains difficult because of the long distances between homes and health facilities and
lack of public transport, particularly at night.
Contraceptives
• An initial increased uptake was seen between 2000 and 2001; this dropped in 2003 to
below that of 2000.
Safe motherhood
• Ante-natal care attendance shows an increase between 2000 and 2001 with a decreasing
in 2002 and 2003 to below the 2000 level.
• The number of deliveries at the clinics has increased with a decrease rate of referral
to hospital.
• The teenage pregnancy rate has declined from 14% to 8% between 2000 and 2003.
HIV/AIDS
• There was an increase in the number of STIs treated between 2000 and 2001; in 2002
and 2003 these number have decreased.
The maternal mortality ratio shows an increase between 2000 and 2003; the perinatal mortality
rate and neonatal mortality rate have both decreased over the same period. These figures are
based on health facilities deliveries data only.

5.5 Conclusion
The most rural district, Ganyesa, shows the most improvement in reproductive health indicators.
The district and the local municipality are usually referred to as having the least capacity to
manage services, including health services. The improvement in indicators could be attributed
to a lower starting point and the almost total neglect of the area under the previous government.
Equal attention, however, is currently given to the Mafikeng area with the same policies being
implemented. Yet indicators in this district are declining.
Klerksdorp district faces many challenges of bringing together different health services –
provincial and local government. Local government is required to change focus in health services
from a promotive and preventative service to one that incorporates the full PHC package. This
has changed again with the passing of the National Health Act with MHS now being defined
as elements of environmental health. In this district there is a feel of moving forward.
177

Summary Table of Districts - Context, Decentralisation, Intermediate Processes and
Reproductive Health Services in South Africa
Klerksdorp Health
District
Mafikeng Health
District
Ganyesa Health
District
Region
Southern Region/Dist
Municipality
Central Region/Dist
Municipality
Bophirima Region/Dist
Municipality
(includes Kagisano &
Molopo LM)
Type Urban
Semi-urban Rural
Demographics:
(1999 census)
bv
Population
335 237
242 193
106 271
Area
3 624 sq kms
3 800 sq kms
27 445 sq kms
Population Density
92.5 per sq km
63.7 per sq km
3.9 per sq km
Male : Female Ratio
52 : 48
47 : 53
47 : 53
% Pop. under 15yrs
26.9%
35.5%
42.6%
Over 20yrs with little or
no education
22.3%
20.0%
30.4%
No. employed
113 499 (72.4%)
47 697 (56.1%)
13 154 (51%)
178
No. unemployed
No. not economically
active
43 264 (27.6%)
Not recorded
37 316 (43.9%)
Not recorded
12 822 (49%)
Not recorded
Households with no
income
7 968 (11.5%)
8 226 (16.9%)
4 901 (23%)
Demographics:
(2001 census)
Population
359 202
259 478
108 074
Area
3 624 sq kms
3 800 sq kms
27 445 sq kms
Population Density
100 per sq km
68 per sq km
3.9 per sq km
Male : Female Ratio
51 : 49
48 : 52
47 : 53
% Pop. under 15yrs
26.5%
32.6%
40.0%
Over 20yrs with little or
no education
20%
20.1%
32.6%
No. employed
95 871 (59.9%)
47 488 (50.7%)
13 054 (61%)
No. unemployed
64 027 (40.1%)
46 061 (49.3%)
8 502 (39%)
No. not economically
active
90 267
71 453
38 392
Households with no
income
22 185 (19.8%)
18 638 (27.6%)
8 545 (31%)

Klerksdorp Health
District
Mafikeng Health
District
Ganyesa Health
District
Region
Southern Region/Dist
Municipality
Central Region/Dist
Municipality
Bophirima Region/Dist
Municipality
(includes Kagisano &
Molopo LM)
Type Urban
Semi-urban Rural
Geography
South of the province,
near border with Free
State and near Orange
Rivier.
Flat, fertile area - maize
and cattle farming.
Reasonable rainfall.
North west of the
province - on
international boundary
with Botswana.
Dry and hot - but
commercial farms in east
- maize, sunflower, cattle.
Flat savannah country.
Far north west of
province.
Dry, arid area - Molopo
on edge of Kalahari
Desert.
Dry and very hot.
Some commercial
ranching in east of area.
Predominantly
subsistence farming and
tribal-authorities.
Historical Background
Part of Western
Transvaal.
No homelands.
Conservative - supportive
of National Party and
right-wing parties under
apartheid.
Split between Cape
Province and
Bophuthatswana (Bop)
Homeland.
Conservative White
Community - AWB.
Mmabathi - capital of
Bop.
Strictly racially divided
- whites in Mafikeng;
blacks in Mmabatho.
Was political centre for
Bophuthatswana.
Mostly part of Bop. with
farms on east as part of
Western Transvaal/Cape
Province.
179
Economic
Mining, commercial and
farming centre.
Administrative and
commercial centre.
Tribal areas.
Rail head between SA
and Botswana.
Tribal land plus some
commercial farms.
Political Support
Provincial Legislature
ANC = 78%
ACDP = 1%
DA = 12%
FF = 3%
Others = 6%
ANC = 66%
ACDP = 30%
DA = 1%
FF = 0%
Others = 3%
ANC = 80%
ACDP = 16%
DA = 2%
FF = 0%
Others = 2%
Local Municipality
ANC = 74%
ACDP = 1%
DA = 20%
FF = 0%
Others = 5%
ANC = 54%
ACDP = 43%
DA = 2%
FF = 0%
Others = 1%
ANC = 62%
ACDP = 36%
DA = 2%
FF = 0%
Others = 0%

Klerksdorp Health
District
Mafikeng Health
District
Ganyesa Health
District
Region
Southern Region/Dist
Municipality
Central Region/Dist
Municipality
Bophirima Region/Dist
Municipality
(includes Kagisano &
Molopo LM)
Type Urban
Semi-urban Rural
Social
Predominately Setswana,
but with Xhosa, Zulu,
Tswana - migrant labour
for mines.
Racially divided
community in the past -
suburbs etc now open -
possibly more social
class division.
White community -
predominately Afrikaans.
Predominantly
(Setswana - 83%)
Mixed social.
Civil service town - not
all permanent residents
in the area.
Rural areas - tribal
alignment.
Cohesive community -
95%.
Setswana.
Few white farmers.
Long history of tribal
rule.
180
Experience with local
government
Long history of local
government in
Klerksdorp and other
small towns in the
municipal area.
Well established system
and structures - including
some for health services.
Some local authority in
Mafikeng in the past -
limited experience
generally.
No experience in the
area.
Structures and systems
for local government all
new.
Current local
government
structures and cooperation
between
spheres - in
relation to health
services
Established local council
with appointed mayor
and mayoral committee
- MMC for Health
appointed; well informed
on health and
decentralisation.
Well established
administration; health
manager and health
services functioning.
Works closely with
provincial health
authorities.
Consulted in provincial
appointments
New structures and
systems in place.
Mayoral committee -
MMC for Health
appointed; poorly
informed on health
policies and
decentralisation.
Administration - appears
to not be well
established.
Poor liaison with
provincial health
authorities.
New structures and
systems in place.
Mayoral committee -
MMC for Social cluster.
No health manager
appointed.
Provincially appointed
district manager
considered to be the
municipal health
manager.
Close working
relationship between
local government and
provincial health
authorities.
Part of appointment
process for provincial
appointees for health.
Public Health Services Provincial & municipal Mostly provincial - one
small municipal clinic
Provincial only
District health
management team
Combined provincial &
municipal - but headed
by provincial appointee
Provincial only
Provincial only

Klerksdorp Health
District
Mafikeng Health
District
Ganyesa Health
District
Region
Southern Region/Dist
Municipality
Central Region/Dist
Municipality
Bophirima Region/Dist
Municipality
(includes Kagisano &
Molopo LM)
Type Urban
Semi-urban Rural
Reproductive Health
Trends
Contraceptive uptake
Decrease uptake between
2000 and 2003.
Decrease uptake between
2000 and 2003.
An initial uptake was
seen between 2000 and
2001; this dropped in
2003 to below that of
2000
Safe motherhood
Increase % of deliveries
being done in clinics -
but still only 8% of total.
Decrease in referrals
from outside the district.
Decrease number of
patients referred in labour
from clinic to hospital.
Teenage pregnancy rate
is static.
Institutional perinatal
mortality rate shows
slight decrease; no
decrease in maternal
mortality ratio or
neonatal mortality rates.
First antenatal care visit
are static in number;
repeat visits are
decreasing.
There is decreasing % of
deliveries happening at
the primary level in the
clinics and community
health centres.
There is increased
referral rate of women in
labour from clinics to
hospital.
Teenage pregnancy rate
remains at about 8%.
Antenatal care
attendances show an
increase between 2000
and 2001and then
decreasing in 2002 and
2003 to below the 2000
level.
The number of deliveries
at the clinics has
increased with a decrease
rate of referral to
hospital.
The teenage pregnancy
rate has declined from
14% to 9% between 2000
and 2003.
181
HIV/AIDS
Number of STI cases
treated is static.
Increasing number of
HIV pre-testing
counseling.
There is little change in
the number of patients
treated with STIs.
There was an increase in
the number of STIs
treated between 2000 and
2001; in 2002 and 2003
these numbers have
decreased.
Health Status
Indicators
Crude birth rate
17.2 per 1000 head of
population.
15.6 per 1000 head of
population.
14.6 per 1000 head of
population.
Neonatal mortality rate
(NNMR)
4.8 per 1000 live births.
19.0 per 1000 live births.
11 per 1000 live births.
Maternal mortality rate
(MMR)
408 per 100 000 live
births.
356 per 100 000 live
births.
627 per 100 000 live
births.
(institutional based)
MMR and PNMR have
risen and the NNMR
show a slight drop
between 2000 and 2003.
MMR, NNMR and
PNMR after an initial
rise in 2002 show a slight
decrease in 2003.
MMR shows an increase
between 2000 and 2003;
the PNMR and NNMR
have decreased over the
same period.

6.1 Introduction
Structure and organisation of the health system at national, provincial levels and within each
study district is described and discussed in Chapters 2, 3 and 4. This chapter highlights some
key issues associated with organisation and delivery of health services.
6.2 Prioritising
Chapter 6
Service Organisation and Delivery
Prioritising of services is mainly set by the National Department of Health (NDoH),
although provinces do have official autonomy to decide for themselves. The health districts
generally follow the provincial priorities, although in some areas these may differ.
182
The NDoH set priorities on a five yearly cycle. In 1999 a Ten Point Plan for 1999 to 2004 was
published. The strategic framework for that five year period was based on the following elements:
1. Reorganisation of certain support services.
2. Legislative reform.
3. Improving quality of care.
4. Revitalisation of hospital services.
5. Speeding up delivery of an essential package of services through the district health
system.
6. Decreasing morbidity and mortality rates through strategic interventions.
7. Improving resource mobilization and the management of resources without neglecting
the attainment of equity in resource allocation.
8. Improving health human resource development and management.
9. Improving communication and consultation within the health system and between the
health system and communities we serve.
10. Strengthening cooperation with our partners internationally.
The Ten Point Plan for 2005 to 2009 includes:
1. Improve governance and management of the NHS.
2. Promote healthy lifestyles.
3. Contribute towards human dignity by improving quality of care.
4. Improve management of communicable diseases and non-communicable illnesses.
5. Strengthen primary health care, EMS and hospital service delivery systems.
6. Strengthen support services.
7. Human resource planning and development.
8. Planning, budgeting and monitoring and evaluation.
9. Prepare & implement legislation.
10. Strengthen international relations.

6.3 Targeting
Targeting of services is set by provincial and/or the local level and is to some extent dependent
on local need. There are times, however, when provincial or even national priorities take
precedence in a district.
Youth and adolescents are a national target group. This is particularly in response to the HIV/AIDS
epidemic. Mafikeng district specifically targets sex workers along the transport route to Botswana.
6.4 Service Packages
“A Comprehensive Primary Health Care Service Package for South Africa.” 1 was published in
September 2001. The Package defines services in terms of level of care and approach. It includes
priority area services to be provided at community level, mobile clinics, fixed clinics and
community health centres. A suggested referral system from primary level to a district hospital
is included. Below is a summary of reproductive health services according to level of care
contained in the Package.
1. Community services
• Intersectoral collaboration, such as with Youth Commission, social welfare, traditional
healers and community organisations.
• Marketing IEC materials in community.
• Home-based care (HBC) for AIDS and other chronically ill patients.
2. Mobile and fixed clinic services
• Antenatal and postnatal care.
• Family planning services.
• Treatment of communicable diseases, including sexually transmitted infections.
• Screening for cervical cancer.
• Counseling and referral for termination of pregnancy.
• Voluntary counseling and testing (referred if necessary) for HI virus.
• Daily service available.
183
3. Community Health Centres
• Referral centre for mobile and fixed clinics, plus services for local population.
• Antenatal and postnatal care.
• Termination of pregnancy.
• Normal deliveries – ventouse and forceps available.
• Screening for cervical cancer.
• Adolescent/youth services.
• Voluntary counseling and testing for HI virus.
• 24 hour service.
• Offer support to clinics.
Many of the services suggested for community health centres are provided at district hospital
level because of insufficient health centres that are fully staffed and equipped.
1 Dept. of Health; A Comprehensive Primary Health Care Package for South Africa; 2001.

4. District Hospital
Although not included in the PHC Package of services, the district hospital plays a vital role
in primary level services within the district health service. A Services Package for District
Hospital is being developed. This will link closely to the PHC package.
The district hospital is expected to be a referral centre for the primary level services and provide:
• Caesarean section and other operative service.
• Deliveries of high risk patients.
• Services of community health centres when not available in the health district.
• Support to primary level services in way of medical officer and specialist visits.
Some health districts, or districts, do not have a district hospital. Patients are either referred to
a district hospital outside of the health district or to a regional or provincial hospital if available
in the district.
Experiences with PHC Package
Health districts and regions are expected to provide all appropriate services in the PHC package.
They may also add additional services according to local need and within available resources.
There are times, however, when some services are not available. This is usually related to lack
of staff in the facility, as explained by the district manager in Ganyesa:
184
“We can add or take away because of not having these midwives there and then clinic
would not be having the total service package as outlined, according to the local situation.”
(District Health Manager)
Most districts strive to provide the minimum, but do not adapt the PHC package as
distributed by provincial or national offices. This was confirmed in the three districts:
“No we haven’t … at local level when it comes to norms and standards we get them from
national through the provincial office. And I don’t think we have actually, you know, how
I can put it – adjusted or adapted to suit any local programme.”
(Regional Health Director)
“We haven’t developed specific services package because according to the norms and
standard there is a core package of services in primary health care services. We are using
the national core package.”
(District MCWH Coordinator)
A Deputy Director in the National Department of Health understanding of what is happening
at the service level is that a full comprehensive PHC package is being provided.
“From where I’m sitting, and from what I understand from the provincial reports, that is
what’s happening. If you look at the primary health care setting, the clinic there which
is in most cases run by one or two nurses, it’s really an issue of offering a very comprehensive
package of care. It includes everything from reproductive health to HIV/AIDS to - you
name it. Everything is under one umbrella. From what one gathers from the provincial

eports that seems to be working. Of course people are battling because of the human
resources issue, but it seems to be working well. One can go to one stop and get all the
services.”
(HIV/AIDS Directorate - NDoH)
6.5 Standards
Norms and standards for PHC services are included in the package published by the NDoH. 2
The document covers clinic and community based services. Reproductive health norms are
included.
The document is considered to be a “living” document and changes are made periodically.
Provinces and districts are encouraged to set their own goals, but based on the national norms
and standards.
6.6 Contracting
Government policy supports the involvement of the private sector in service delivery through
contracting processes, such as service level agreements, private-public partnerships, among
others.
A discussion group on Public-Private Interactions (PPI) was included in the Health
Summit in 2001. This placed PPIs on the agenda for health services. The NDoH has developed
guidelines for PPIs which are in line with the National Treasury’s PPPs Guidelines.
The NDoH guidelines for PPIs are used by the provinces, but any such contract must be referred
to NDoH for final agreement. The procedure is long and at the local level managers circumvent
some of the red tape through use of service level agreements, as explained by one regional
director:
185
“Not at this point in time. You know public private partnerships are a difficult thing because
any proposal for a public private partnership must be submitted to the national department.
They have a PPP unit, however we get around that and …we go into service level agreements;
it's not a pure private public partnership.”
(Regional Health Director)
Contracting for support services, such as security, purchase of drugs and surgical sundries and
distribution of pharmaceuticals is centralised almost exclusively to the provincial level. There
is no contracting out for delivery of health services. The Mafikeng District Manager explained:
“Let me safely say no, because a lot the contracts are set at the provincial level and goes
through tender boards and all that kind of thing. There have been in senses like security
we have done some local arrangements … but that is a very touchy subject. Because if
somebody comes and complain you are in trouble and they so it’s better that you leave it
to the tender board to handle that.”
(District Health Manager)
At the local level in NW Province the regional directors and district health managers have
limited discretion with contracting out of services. They are bound by the requirements
of the Public Finance Management Act (PFMA) and have delegated powers as below:
2 Department of Health: The Primary Health Care Package for South Africa: A Set of Norms and Standards. September 2001.

• Up to R7 500 without contract.
• From R7 500 to R30 000 requires to be ratified by a higher official in provincial office.
• From R30 000 to R50 000 required closed regional tender
• Above R50 000 is referred to provincial office for an open tender process.
Contracts for sundries are finalised by the province:
“… the purchasing of pharmaceuticals or clothes or whatever all those contracts are down
at head office.”
(District Health Manager)
The local level is bound by provincial contracts for purchase of many items, which some
managers believe they could purchase more cheaply locally, such as in Klerksdorp:
“I think so yes. I think it will be more cost effective also. You will get a situation now that
an approved tender will charge you more for toilet paper than you can buy at Pick ‘n Pay
or at Checkers, but you have to use the tender, that’s that.”
(District Health Manager)
A district manager may be involved in negotiating a longer term contract, but the contract must
be finalised by the provincial office, as explained in Ganyesa:
186
“Yes - for support services, we are able to through the tender board. If we do it here it will
be on a very small scale. For example we are contracting out the security services… We
go to province, just to finalise the service level agreement and down here, according to the
service level agreement, we will manage that within the facilities here; monitor it and see
if we are getting the correct services from that company.”
(District Health Manager)
Contracting out of services is not generally done at a local level. These contracts, which are
mostly for support services, are negotiated at provincial level through the Tender Board. One
District Health Manager expressed reserve with regard to being involved in such contracts as
they can be very sensitive issues:
“Let me safely say no (to local contracting out)… a lot of the contracts are set at the
provincial level and go through tender boards. … sometimes security services have done
through local arrangements … but the thing is a very touchy subject. Because if somebody
comes and complains you are in trouble and so it’s better that you leave it to the tender
board to handle.”
(District Health Manager)
The local level, however, is responsible for monitoring any contract, initiated by the provincial
office, for services within their area of jurisdiction. The local level, however, does have limited
discretion for local contracts for a limited period of time. This is possible in Klerksdorp, as
explained by the district manager:

“We have two clinics; we don’t have personnel to clean the gardens and whatever. And
then I locally, I call for quotations in the local newspapers and I take a decision so on very
limited day to day issues”
(Health District Manager)
Short term contracts can include specific training programmes by NGOs or other organisations.
For example the Reproductive Health Research Unit (RHRU) has been contracted for training,
particularly on reproductive issues and values clarification around free choice for termination
of pregnancy.
In Klerksdorp Municipality there are a number of mine hospitals that are not fully utilised. The
health district management team are negotiating a contract with the mines for use of their spare
beds for use by the public sector.
“So if you can call that out contracting and outsourcing that is what we are trying to do
now, to get a contract with them, we buy 40 beds from them and they render level one health
care service for us.”
(District Health Manager)
District health managers can, however, contract locally for small, short term projects, such as
cleaning of gardens in Klerksdorp.
“We don’t have personnel to clean the gardens and whatever. And then I locally, I call for
quotations in the local newspapers and I take a decision so on very limited day to day issues,
when you're getting to the purchasing of pharmaceuticals or clothes or whatever all those
contacts are down at head office.”
(District Health Manager)
187
Contracting in the health services is not a prime means of service delivery. Patient care is seen
as a core function of the department of health and is therefore provided internally. A form of
contracting is used for employment of doctors to work part time in hospitals and clinics. This
is a means of addressing the acute shortage of medical personnel. Support services, however,
can be more efficiently run through a contract process, such as for security services and delivery
of goods.
The processes have little specific impact on reproductive health services.

Chapter 7
Finances
7.1 Introduction
Prior to 1994 there was severely inequitable distribution of funding and expenditure for health
services. In the 1992/93 financial year approximately R30 billion was spent on health care; this
equalled 8.5% of Gross Domestic Product (GDP). The private sector, which catered for
approximately 23% of the total population, spent 58.6% of the funds, the public sector spent
38.6%, donors, research and training spent 1.3 and 1.8% respectively.
In 1992/93 approximately 94% of the health budget for the public health sector came from
national revenue collection. Expenditure was concentrated on hospital services; acute hospitals
accounting for 76%, tertiary hospitals 44% and primary health services 11% of the funding. 1
Reproductive health services (RHS) were incorporated into the overall health services and
received no specific funding. The exception was contraceptives, or, as it was widely known,
family planning (FP) services. Contraceptive services were part of a nationally driven, independently
funded, programme of the Department of Health, the Population and Development Programme
(PDP). The programme did not include the ‘homeland’ areas. In these areas all RHS were funded
through the general health budget.
188
The mal-distribution followed the apartheid lines with the South African provinces and
predominately White population benefiting from higher expenditure per capita and distribution
of health resources than the ‘homelands’ and predominately black populations. During the period
of the Tripartite Government in South Africa, Coloureds and Indians received some benefit from
additional funding of services.
In 1994, nine new provinces were established, bringing together the previous South African
provinces and ‘homelands’. However, in 1995/96 great inequities remained between these new
provinces. The predominately urban and better resourced provinces of Gauteng and Western
Cape had a higher per capita expenditure on health of R506 and R564 respectfully while the
predominately rural provinces of Eastern Cape, Mpumalanga and Limpopo had per capita of
R282, R201 and R264 respectively. The national average per capita was R351 and NW Province
per capita was R249.
The National Department of Health (NDoH) set the following challenges for the health sector
to:
• address the mal-distribution of resources between provinces and within provinces;
• improve primary level utilisation levels;
- redistribution of resources between levels of care, improve re-sourcing of primary
level while still maintaining an adequate referral system,
- reduce barriers to primary care access; and
• diversify sources of funding for health care and reduce reliance on general tax revenue. 2
1 McIntyre D. Finance and Expenditure.In Harrison D,editor. South African Health Review 1995. Durban: Health
Systems Trust; 1995.
2 McIntyre D, Thoma S, Mbatsha S, Baba L. Equity in public sector health care financing and expenditure in South Africa. In
Ntuli A, Editor. South African Health Review 1998. Durban: Health Systems Trust; 1998.

Changes in national economic policies, budgeting processes and other national priorities have
impacted on the ability of the Department of Health to address these challenges. Key policies
influencing financing and expenditure for health are the:
• White Paper for Transformation of the Health System in South Africa. This aims to
unify health sector, address inequity, improve access to care, and to focus on a PHC
approach.
• Growth, Employment and Redistribution Macro Economic Strategy (GEAR). This aims
primarily to:
- cut the budget deficit;
- avoid permanent increases in overall tax burdens; and
- reduce consumption expenditure relative to Gross National Product.
• The importance of GEAR is that it sets explicit and stringent targets for reducing the
budget deficit, thus reducing public spending.
• Policies relating to distribution of funds between spheres of government and between
provinces. Proposals made by the Financial and Fiscal Commission (FFC) and Department
of Finance suggested population-based formula as the basis for determining provincial
budgets for 1998/99.
• The Medium-Term Expenditure Framework (MTEF, 1997). This introduces three-year
rolling budgets for all national and provincial departments. It is intended to encourage
departments to evaluate their objectives within realistic budget projections and to enable
government to make strategic policy choices between expanding priorities.
New and innovative ideas for increasing the health budget were needed. A National Health
Insurance System (NHIS) has been proposed, but to date has not been developed further. A
NHIS is designed to ensure universal and non-discriminatory access to quality PHC for all South
Africans. It is seen as a means of promoting access to PHC; developing district based health
services; human resource training and re-distribution; and improved conditions of service.
189
The 1995/96 and 1996/97 financial years saw a real increase of 2.6% in the health budget and
an overall increase in per capita expenditure. Inequity, however, remained between the predominately
urban and predominately rural provinces. 3 During this period the budgeting process for health
was coordinated by the NDoH, with representation from each PDoH, through the Health
Functional Committee. A predetermined formula for allocating funds to provincial health
departments was used. In 1997 changes were made, however, in the national financing process
to the provinces; fiscal federalism was introduced. This supported the provinces in meeting the
constitutional obligations of the South African Constitution passed in 1996. The Financial and
Fiscal Commission (FFC) proposed a formula for global provincial budgets that were based on
population and weighted to allow for rural populations.
The Health Expenditure Review of 1995 highlighted the inter-provincial disparities in funding.
A National Task Group on District Financing for Intra-Provincial Equity was mandated to address
this issue. The MTEF was seen as a means of strengthening PHC and enhancing redistribution
of resources. An increase of 9% per annum for PHC was recommended. This increase, however,
was not intended to compromise hospital services which may receive more referrals because
of the improvement in the primary level services. 4
In 1996, the Growth, Employment and Redistribution (GEAR) macro-economic policy for the
country superseded the RDP. GEAR set ambitious targets for reducing the budget deficit while
3 SAHR - 1996 Chapter
4 SAHR - 1996 Chapter

at the same time not increasing the tax burden. This policy has impacted on health sector reforms,
the expansion of services and attaining inter- and intra-provincial equity of health resources.
GEAR focuses more on efficiency than equity, one of the pillars of health sector reforms.
These macro-economic changes (GEAR, MTEF and provincial global budgeting) have increased
the complexity of the budgeting process for health services. Along with the changes in processes
and policies there has been an overall decrease in finances available from the national fiscus for
the public sector. For health services this is compounded by the increasing number of patients
moving from private sector to public sector health care, particularly for chronic medication. In
1992/93, 23% of the population used private sector health services. This figure has now decreased
to 16%.
The 1997/98 funds were allocated for the first time as a global amount to each province, through
a fiscal federalism. The Budget Council, (comprising the nine MECs of finance, the National
Minister and Deputy Minster of Finance plus officials from Department of Finance and State
Expenditure and the Provincial Treasuries and the FFC as observer) coordinated the process.
In 1997/98 the DoH committed itself to establishing the district health system (DHS), and
defining the norms and standards for the PHC package and hospitals. 5
The National Treasury (NT) plays a central role in decentralisation. It is responsible for distribution
of funds to provincial and local government for provision of services. Treasury monitors the
use of funds according to financial legislation. The treasury is seen by some managers as
retaining control centrally and not being in favour of decentralisation, particularly of non basic
services. Health is not a defined as a “basic service” in the Constitution, although in many
quarters it is considered as such, and is defined as a “basic need” in the RDP document.
190
7.1.1 National and Provincial Processes
Before 1997, the budget process was highly centralised through the Department of State
Expenditure (DSE). The Health Functioning Committee used historical budgeting data in
allocating funds for the provinces and the ‘homelands’ for health services. Provinces and ‘selfgoverning
states’ had little flexibility to change budgets once set by the committee. Between
1994 and 1997 a needs formula based on population size was used for provincial health budgets.
Thereafter, in 1997, fiscal federalism and the MTEF were introduced. Fiscal federalism comprises
global allocation to provinces, who then divide this allocation to provincial sector departments.
The National Department of Finance (NDoF) has retained a centralised role in the budgeting
process because the department is the appointed custodian of GEAR. The MTEF was introduced
to monitor and account for expenditure. The National Cabinet sets broad government priorities
against which the detailed provincial budgets are evaluated. Although there is some devolution
of budgeting to the provinces, central government retains a controlling influence. Overall
constraints on public spending are due to policies within GEAR and the MTEF. Personnel costs
are a major component of government spending. Civil service salaries are negotiated through
central bargaining structures and significantly constrain available resources for service delivery. 6
In 1998/99, a process of ‘horizontal’ and ‘vertical’ allocations between spheres and across spheres
of government was introduced. Guidelines for allocations for national and provincial level
budgets are available. National Cabinet requires Provinces to allocate 85% of their total budgets
to the social sectors i.e. health, education and social welfare. Local government, however, is not
subject to the same control and has a different budgeting process.
5 South African Health Review 1997. Durban: Health Systems Trust; 1997.
6 Di McIntyre, Stephen Thomas, Sandi Mbatsha and Luvuyo Baba. In Crisp N, Ntuli A, editors South African Health Review
1999. Durban: Health Systems Trust; 1999.

Teams for the ‘big five’ sectors; namely health, education, social welfare, justice and defence,
consider all MTEF from provinces relating to their sector. The team comprises representatives
from national and provincial sectors. They set expenditure models for the sector, consider policy
choices, develop norms and standards and make recommendations on conditional grants. Thus
the NDoH has some input into, but little influence over, the provincial health budget process
through the Health MTEF Team. It is, therefore, difficult for the National Minister of Health
to compile a national budget for health, as explained by a Provincial Head of Health:
“… our Health Minister. … faces major challenges in compiling a health budget. She has
very little jurisdiction over the overwhelming majority of funds in the budget. It’s the
provincial MECs who have the power. She doesn’t have the power, other than via policy
directorate, or policy framework but in terms of the constitution the provincial MEC can
actually say ‘I’m not doing it’.”
(Provincial Head of Health)
These budgeting process changes have implications for the health sector. This was noted by the
same provincial head of health department:
“…: until 96/97 … national got all the money. We all went to Pretoria and … Head’s of
Health and the DG worked on formulas to divide the money and address equity. And over
the first 3 years we actually started to move towards equitable distribution. Then they
abolished the Health Functioning Committee. The money was directed from national
treasury to provinces. In each province the health department now makes a bid and therefore
you see a major difference and it has actually got worse in terms of the per capita
allocation in a province like North West or Mpumalanga versus the Western Cape.”
(Provincial Head of Health)
191
Fiscal federalism has shifted expenditure decisions away from the equity focus of the Functional
Committee system to that of the total provincial budgets. There appears to be a lack of concern
within the MTEF for the equitable distribution of health care resources. GEAR and the MTEF
show an overall concern for efficiency rather than equity. The Health MTEF Team, in considering
all provincial health budgets, provides a potential mechanism for putting equity back on the
agenda. Unfortunately, this opportunity does not appear to have been taken in the first round
of the process.
GEAR is, however, supportive of the health sector in that increasing health expenditure is seen
as part of social redistribution. Funding for health services is likely to increase faster than total
government funds, but the increase is unlikely to keep pace with the population growth. Total
funding under GEAR for health was set to increase from 10% to 11% of the national fiscus.
The provincial budget is mainly influenced by size of the global budget for the province, and
conditional health sector grants, awarded. The MTEF budgets are submitted to provincial treasury
by the PDoH and the final MTEF allocations are determined by the provincial treasury and
Executive Committee (EXCO) of the province.
The budgeting process in South Africa has restricted health equity in several ways:
• Decentralisation of budgetary authority to provinces makes decisions around the
provincial health allocations hostage to local politics.
• Focus of conditional grants relates to levels of care and not to equity.

• Budgeting process does not give explicit concern to equity in health sector funding
across provinces.
• Department of Finance inter-provincial resource allocation formula waters down equity
concerns by including components and weightings which favour richer provinces.
As stated by Stephen Thomas et al, “Health sector policy, directed at improving equity, appears
to be at odds with current monetary and fiscal policy. 7 Solutions to equity for health services
cannot be found within the health sector alone.
Provincial variation and inequitable distribution of funding is noted, with little difference seen
between the 2002/03 actual expenditure and 2003/04 budget. (See Diagrams 7.1 and 7.2)
Figure 7.1: Primary Health Care Expenditure and Rand per capita per province -
Budget 2002 to 2003
1 400
– 250
Rand millions
1 200
1 000
800
600
– 200
– 150
– 100
Rand per capita
400
192
200
– 50
0
EC FS GP KZN LP MP NW NC WC
0
EC: Eastern Cape | FS: Free State | GP: Gauteng | LP: Limpopo | MP: Mpumalanga
| NW: North West | NC: Northern Cape | WC: Western Cape
Source: Intergovernmental Fiscal Review, 2003. Republic of South Africa, National Treasury
April 2003
There has been a real or predicted increase in expenditure across all heath programmes nationally.
The percentage allocation, however, for district services has remained constant of the total
national budget, with a decrease for central hospitals and increase for maintenance and expansion
of health facilities. These trends are shown in Figure 7.3 and 7.4.
Trends in health expenditure in the NW Province are shown in Figures 7.5 and 7.6. The trend
is similar to that seen at national level referred to above. There is a general rise in total expenditure
across programmes, in real terms and expected according to the MTEF. The greatest increase
is in district services, although percentage wise of the total provincial health budget this was
expected to drop from 56% to 53 %. There is a slight increase in percentage allocation for
support services, such as administration, emergency services, training and health facility
maintenance.
7 Thomas S, Muirhead D, Doherty J, Muheki C. Public Sector Financing In Ntuli A, Crisp N, Clarke E, Barron P. South African
Health Review 2000. Durban: Health Systems Trust; 2000.

Figure 7.2: Primary Health Care Expenditure and R per capita per province
- Budget 2003 to 2004
1 600
300
1 400
– 250
1 200
Rand millions
1 000
800
600
400
– 200
– 150
– 100
Rand per capita
200
– 50
0
EC FS GP KZN LP MP NW NC WC
0
EC: Eastern Cape | FS: Free State | GP: Gauteng | LP: Limpopo | MP: Mpumalanga
| NW: North West | NC: Northern Cape | WC: Western Cape
Source: Intergovernmental Fiscal Review, 2003. Republic of South Africa, National Treasury
April 2003
Figure 7.3: National Trends in Expenditure on Health Programmes
- 1999 to 2000 to 2005 to 2006
193
18 000
15 000
Rands in millions
12 000
9 000
6 000
3 000
0
Admin
District
Services
EMS
Provincial
Hospitals
Central
Hospitals
Health
Training
Support
Services
Health
Facilities
Other
1999/2000
2000/2001 2001/2002 2002/2003
2003/2004 2004/2005 2005/2006
Source: Intergovernmental Fiscal Review, 2003. Republic of South Africa, National Treasury.
April 2003.

Figure 7.4: National Trends in Health Expenditure as percentage of total expenditure
- 1999 to 2000 and 2005 to 2006
45
40
Percent of total expenditure
35
30
25
20
15
10
5
0
1999/2000
2000/2001 2001/2002 2002/2003 2003/2004 2004/2005 2005/2006
year
Administration
District services
Emergency Services
Provincial Hospitals Central Hospitals Health Training
194
Support Services
Health Facilities
Source: Intergovernmental Fiscal Review, 2003. Republic of South Africa, National Treasury 2003.
The public health sector is heavily dependent on general tax revenue. User fees collected by
hospitals are returned to the provincial treasury and not to the institution. Alternate sources for
funding are still under discussion, such as a Social Health Insurance and retention of revenue
collected within the health sector.
Early in the process of introducing health sector reforms, the importance of quantifying the
sources of funding and the expenditure on health services was recognised. This would have
assisted in tracking movement towards equity and increased access to health services. Initially,
accurate and reliable data was difficult to obtain. Some in-depth studies have now been carried
out and reflect the trends in overall expenditure on all health services and for specific functional
areas, such as PHC, hospital care, HIV/AIDS, nutrition and emergency services. Comparisons
between provinces and within provinces are also being undertaken, and a means of monitoring
change over time is being developed.
The Health Goals, Objectives and Indicators for 2001-2005 of the National Department of Health
include three goals for financing of health services. These are:
• Achieve equity in distribution of resources for service delivery in all provinces.
• Implement Social Health Insurance.
• Increase revenue generated and retained. 8
8 Health Goals, Objectives and Indicators 2001-2005; Pretoria: Dept. of Health. Available from;
http://www.doh/gov/za/docs/misc/indicators.html

Figure 7.5: North West Province - Health Expenditure by Programme
- 1999 to 2000 and 2005 to 2006
16 000
14 000
Rands in millions
12 000
1 000
800
600
400
200
0
Admin
District
Services
EMS
Provincial
Hospitals
Health
Training
Support
Services
Health
Facilities
1999/2000 Actual
2000/2001 Actual 2001/2002 Actual
2002/2003 Est Actual 2003/2004 MTEF 2004/2005 MTEF 2005/2006 MTEF
Source: Intergovernmental Fiscal Review, 2003. Republic of South Africa, National Treasury.
April 2003.
195
Figure 7.6: North West Province - Percentage Budget per Programme
- 1999 to 2000 and 2005 to 2006
70
60
50
Percent of budget
40
30
20
10
0
1999/2000
2000/2001 2001/2002 2002/2003 2003/2004 2004/2005 2005/2006
financial year
Administration
District Services
Emergency Services
Provincial Hospitals Health Training Support Services
Health Facilities
Source: Intergovernmental Fiscal Review, 2003. Republic of South Africa, National Treasury
April 2003.

Other indicators to be monitored are:
• Private medical aid coverage.
• Per capita health expenditure.
• Public sector (uninsured) population.
• Ratio of public to private sector per capita health expenditure. 9
The National Health Accounts 9 project was used to quantify resource availability and distribution
within the health sector during the time of reform implementation. The analysis for the public
health sector included three financial years – 1996/97, 1997/98 and 1998/99. The study reflects
expenditure and therefore actual use of resources and showed two eras of public health financing,
namely:
• Period of substantial growth from 1992/93 to 1997/98.
• Period of falling funding and a reversal of inter-provincial redistribution trends in
1998/99.
Figure 7.7 shows these two eras – the marked increase in total funding and per capital funding
in 1997/98 financial year and the decrease in both total and per capita in 1998/99 financial year.
Figure 7.7: Total (R million) and Rand per capita Public Sector Health Financing
(non medical scheme members, real 1999/00 prices)
33 500
980
196
Total (R million)
33 000
32 500
32 000
31 500
31 000
– 970
– 960
– 950
– 940
Rand per capita
30 500
– 930
30 000
– 920
29 500
1996/1997
1997/1998 1998/1999
financial year
910
Comprehensive Health Financing
per capita Health Financing
Source: Thomas S, Muirheid D et al; Public Sector Financing. South African Health Review 2000;
Health Systems Trust, Durban 2000.
Many of the changes and trends already discussed have contributed to this decrease in funding.
Other key findings of the study were:
• An overall rise in total comprehensive expenditure on health, with an initial increase
per capita but then a decrease.
9 SAHR 2003/04 Chapter 20
10 SAHR 2000 Chapter 5

• Sources of funding were predominately from general taxation – approx 94%; local
authority (not including Provincial contribution) 3% and donor funds less than 1%.
• Reliance on general taxation makes health sector vulnerable and is not a point of strength
for tackling inequities, but is rather a “scramble for scarce resources.”
• Different sources of funding between 1992/93 and 1998/99 shows increase overall;
increase from general taxation; increase from local authority; increase from donor (but
from very low base and therefore not significant.); decrease in household contribution.
Analysis on expenditure on priorities revealed:
• Funding of PHC, including primary level care, public health programmes, such as
nutrition and a proxy for district hospital outpatients, has increased. The figures show
10% growth per year on PHC spending between 1996/97 and 1998/99.
• A swing to PHC is also seen in the clinic upgrading programme, free health care and
other initiatives, plus apparent increase proportion of provincially employed staff who
are now based in non-hospital PHC settings; a national shift from 7.2% to 12.8%
between 1997/98 and 1998/99. (NW Province increased from 15.8% to 18.5%)
The 2003/04 South African Health Review builds on previous research and a number of messages
are discussed. These include:
• It is projected that by 2005/06 there will be an increase in real funding for all health
services of R8.7 billion over a decade earlier.
• Uninsured population grew by almost 7 million between 1995 and 2005 – this will
place additional burden on the public sector.
• A real growth of R3 billion in personnel expenditure has masked a decrease of 19000
filled posts. Personnel expenditure is higher, but there are less health workers.
• The HIV/AIDS epidemic is estimated to be costing around R6 billion per year and the
health sector has been incompletely compensated for this.
• Conditional grants and equitable shares are given for AIDS related expenditure – but
still substantial amount coming from department of health core health funding.
• Health inflation exceeds the general inflation. Therefore increase budget is going to off
set increase wages and high medical inflation and not to improving health service.
• NDoH provides a small part of total health expenditure. In 2003/04 the department has
R8.4 million in their vote, but over 88% is to be transferred to provinces as conditional
grants, leaving R973 million. This includes funds earmarked for the Medical Research
Council (R157 million), condoms (R108m) and forensic mortuaries (R87m).
• Conditional grants have changed over time and are now for:
- National Tertiary Services.
- Health Professionals Training and Development.
- Hospital Revitalisation and other Capital Grants.
- HIV/AIDS.
- Integrated nutrition programme.
- Hospital Management and Quality Improvement.
197
• These conditional grants are included in NDoH budget. Provinces are responsible for
expenditure, but are monitored by the NDoH. The provinces determine their overall

udget requirements, including those for conditional grants. The conditional grant
amount is subtracted from provincial allocation and are not, therefore, additional funds.
• Local government spends approx R2 billion per annum, R800m are transfers from
provinces and R1.2m from their own revenue.
• Health district expenditure for PHC varies from R50 to R389 per capita across the
country. At 2002/03 prices, PHC package costs approx R220 per capita per year.
• A deprivation index has been developed which is shown to be highest where the per
capita expenditure is lowest. 11
Figure 7.8: National Health Total and per Capita Expenditure
- 1998 to 99 and 2005 to 06
40 000
1 000
Rand millions
37 500
35 000
32 500
– 900
– 800
– 700
– 600
Rand per capita
per year
3 000
1989/
1999
1999/
2000
2000/
2001
2001/
2002
2002/
2003
2003/
2004
2004/
2005
2005/
2006
– 500
financial year
198
Total National Expenditure
National Expenditure per Capita
Source: Blecher M. Thomas; Health Care Financing. South African Health Review 2003/04, Durban:
Health Systems Trust; 2004.
The budget for all provincial services is devolved directly to the provinces from National
Treasury. The provincial government is responsible for allocating funds to sectors within the
province. The NDoH has no say in this process and, therefore, can not demand information on
expenditure. This is only possible for the conditional grants. The NDoH does not directly finance
any reproductive health programmes in the provinces. This was explained by two national senior
managers:
“They are not even obliged to inform us how much money they got from National Treasury
or how much of the provincial budget is actually for reproductive health.”
(Chief Director MCWH- NDoH)
The NDoH does not have complete control.
“But because provinces have their own semi-autonomy we can’t give total direction. We
have to negotiate in order to work together in a sort of cooperative governance. We take
decisions together and try and move together.”
(Director Maternal Health -NDoH)
11 Thomas S, Mbatsha S, Muirhead D, Okorafor O, McIntyre D. Gilson L. Primary Health Care Financing and Need across
Health Districts in South Africa. July 2003. Durban: Health Systems Trust; 2003.

7.1.2 Local Government Processes
The local government sphere has undergone major restructuring since 1993. The present municipal
boundaries were established in 2000. The budgeting process for local government is different
to the national and provincial spheres. Approximately two-thirds of municipal activity is self
funded from rates and taxes, sale of utilities (electricity and water) and other levies. Other funds
are provided through the National Treasury Equitable Share and from provincial government
in the form of agency payments or subsidies. The Equitable Share forms a much larger proportion
of municipal funding in rural than in urban municipalities.
District municipalities raise money from businesses through the Regional Services Council
(RSC) Levy. This is a locally determined tax. The National Treasury, however, can impose some
restrictions on the district municipalities in setting the level of this tax. This was explained by
a senior manager in the National Department of Provincial and Local Government (DPLG):
“… Now from the mid 1990s, local government has to get permission from the Minister of
Finance if it wants to increase that RSC levy and that RSC levy has been capped for the
last 8 to 9 years. The minister has approved very limited increases for municipalities. …
it is a local tax, but it’s not a true local tax because you have the minister who has capped
it for the past few years.… that flies in the face of decentralisation because when you are
looking at decentralisation … you are giving local government then the ability to raise
revenues in order to deal with those responsibilities. … with property rates it’s a different
matter, local municipalities raise revenues at a local level, there is no capping. That’s truly
a local tax. But from a taxation point of view national treasury still levies.”
(Director- DPLG)
199
An argument against decentralisation is the potential it has to increase inequity between
municipalities. The better resourced municipalities may have the capacity to raise additional
funds and even offer higher salaries than an under resourced neighbouring municipality. If
treasury continues to transfer money to local government the danger of inequity is lessened, as
explained by a Director in the DPLG:
“So the equity argument you know, might hold water if there are no transfers effective from
national government to local government, as long as national government can continue to
provide transfers down to the lower levels of government then that can be taken care of
through looking at the fiscal equalisation.”
(Director- DPLG)
The Equitable Share formula for the allocation of resources from the National Treasury to
individual municipalities was first introduced in the 1998/ 99 financial year. This comprised
three parts:
• Institutional grant in support of municipalities with low revenue.
• Basic services grant for electricity, water, sanitation and refuse removal.
• Special allocation to previous ‘homeland’ areas, known as the R293 towns.
In addition, some conditional grants were directed to capacity building, restructuring and infrastructure
development.
Health services managed by local government previously focused on preventive and promotive
health, environmental health with very little focus on curative health. Funds for these services

are budgeted for from general municipal funds. In addition, the PDoH provides subsidies for
Municipal Health Services and in some provinces may contract local government to run services,
such as emergency medical services, on an agency basis. Provincial subsidies usually cover
salaries of health staff, but may also cover drugs and special HIV/AIDS programmes.
The Provincial Department of Health retains some control over local government health
services; this ensures compliance with provincial and national norms and standards.
Any analysis of the funding or expenditure on public health services within any health district
must include the local government services. This is particularly important if local government
is to take greater responsibility for health services beyond their constitutional obligation for
Municipal Health Services.
In addition, plans and budgets for all health services in a municipal area, whether nationally,
provincially or locally funded, are required to be incorporated into the Integrated Development
Plans for the municipality. The process is complicated by the different financial years of the
spheres of government – national and provincial financial year runs from 1 April to 31 March;
local government runs from 1 July to 30 June.
200
7.2 Health District Funding
In 2003/04 a new provincial health budget structure was introduced. 12 The aim of this change
was to enhance the planning and monitoring of service delivery. An advantage of the new
structure is the separation of different components of PHC services, hospital services and
emergency services. PHC services include clinics, community health services, community-based
services and HIV/AIDS and nutrition. Health programmes, such as RHS, are not listed separately,
but are included in the overall primary health care services. HIV/AIDS is the one exception.
The format is used by all provinces and it contains measurable objectives and indicators against
which progress can be monitored.
New Provincial Budget Structure as of 2003/04
1. Administration
2. District Health Services
3. Emergency Health Services
4. Provincial Hospital Services
5. Central Hospital Services
6. Health Sciences Training
7. Health Care Support Services (only where centralised)
8. Health Facilities
Funding for DHS, although primarily from the province, comes through several channels.
The institutional diversity seen in delivery of district level health services results in a number
of different funding and budgeting processes. All need to be coordinated. Budgeting is part of
the planning process in which all institutional managements teams are expected to be involved.
Funding also involves all spheres of government with complex funding flows, although the bulk
of funds originate from the National Treasury.
Figure 7.9 below illustrates the funding flow for district level non-hospital PHC services. Funds
for district level health services reach the district via a number of routes and there is no single,
consolidated budget for a health district.
12 Intergovernmental Fiscal Review, 2003. Republic of South Africa, National Treasury. April 2003

Figure 7.9: Representation of Funding Flows relating to PHC 13
Provincial Treasuries
National Treasury
Provincial Departments
Own Revenue
Non-hospital
PHC
District and Metro Municipalities
Local
Apart from funding through different spheres of government – provincial and local, within the
provincial services funding is provided through different institutions. These include:
• Health district funding – community health centres, clinics, mobile services.
• Hospitals – for all hospital services plus funding for drugs and other supplies to
community health centres, clinics, mobile services.
• Emergency Medical Services – own funding system.
• Laboratory services – a national parastatal, operating out of district and provincial
hospitals.
• Maintenance of buildings – through Dept. of Public Works,
201
This division is now fixed in the Provincial budget Structure of 2003/04 referred to previously.
The local health district budget does not separate funding for RHS from other funding. RHS,
therefore, compete for funding with other programmes, such as TB, environmental health, chronic
diseases and support services, such as drugs and other surgical sundries. Some funding for RHS
is provided through the district hospital services, particularly for maternity services, ante natal
care and termination of pregnancies.
Decentralisation, by definition, entails moving decision space to the lowest most appropriate
level. Establishing a decentralised health system requires decentralising financial management
and budgeting to the health district level. Currently financial control remains centralised to the
national government sphere, with some decentralisation to the provinces. There is, however,
little further decentralisation below this level of services. Health districts are involved in the
budgeting process, but these are finalised by the provincial level.
Mention has been made of the differences between provincial and local government financing
flows for health services, financial systems and procurement systems. These differences are seen
as a challenge in the process of decentralisation.
The PDoH funds most health services provided by local government, in particular salaries and
drugs, as explained by the Klerksdorp Health District Manager.
13 From Thomas S, Mbatsha S, Muirhead D, Okorafor O, (2003) Primary Health Care Financing and Need across Health
Districts in South Africa, Health Systems Trust. Available at www.hst.org

“The local government doesn’t [fund any services] because it is subsidised by the province,
so it automatically comes from the budget of the province.”
(Member of Health District Management Team)
The two spheres operate within different financial years The provincial services are from
April to March and local government is from July to June.The provincial services are from
April to March and local government is from July to June. The three month lag is particularly
difficult to manage, as expressed by the Klerksdorp health district manager:
“It is a problem. I mean for example if I allocated funds for a year to them I allocate it
from April to March now they are asking me what about April, May and June? Because
when they compile their budget in June they also have to put in estimate figures for the
whole year until the end of June. I can't commit the province or this office for April,
May and June on that side. So it's hanging somewhere there you know. It's not easy.”
(District Health Manager)
A further difficulty is the different purchasing and payment systems, as explained by a district
administrator in Klerksdorp:
202
“Their system of purchasing is different from ours altogether. They are using chequebooks
when we are using (another) system. So I don’t know what is going to happen about that.
According to my understanding.… we are still going to be paying with our system which
at times is laborious. You have got to fill in many forms before you get what you want.
Unlike they are doing in the municipality where you just put them before the Council and
they pay up and … you buy what you want.”
(Health District Administrative Officer)
Details of the financial systems in local government have not been reviewed.
7.3 Health District Budgeting
Budgeting for health districts is the responsibility of the provinces. The Health Sector MTEF
team submissions suggested increasing resources to district health services from 39% in 1996/97
to 42% by 2000/01 and increasing primary care services (which includes non-hospital primary
care and district hospital outpatient care) from 23% to 26% for the same period. These increases
were budget estimates and may not reflect actual expenditure in the districts. Some provinces
have not been able to achieve the shift of resources as proposed.
The lowest level of health care, including the clinics and health districts and health districts, is
encouraged, as part of the planning process, to be involved in budgeting for their health services.
These are consolidated per district or region for submission to the provincial office for final
allocations and approval. Each province has its own processes. The process and experience of
health workers of these budgeting processes in the NW Province are described below.
Ideally, in a decentralised system, the provincial level resource allocation decision-making should
link with district level planning and budgeting, such that district level planning and budgeting
is taken into consideration when resource allocation decisions are made at provincial level. An
attempt to do this is seen in NW Province. The difficulties of accomplishing this are discussed
in the SAHR of 1999. 14 The lack of reliable data from the district level to apply an equity-
14 Thomas et al. stress the need for redistribution of resources to be done at a realistic pace so as not to destabilise the services.

promoting formula needs to be addressed – many districts are still using historically based
budgeting. They conclude that the problem is lack of capacity at the decentralised district level
to develop reasonable, realistic budgets as well as lack of provincial capacity to collate these.
Their main recommendations are:
• Develop capacity.
• Provide guideline allocations to districts/regions.
• Develop adequate provincial capacity essential in support of the districts
The current budgeting and financing process possibly impacts on RHS. There is, for example,
no “ring-fencing” of funds for these services as they are considered part of the total PHC package.
The flow of funds from the level of National Treasury to RHS delivery within a health district
is depicted in Figure 7.10, at the end of this chapter. The funds pass through four or five divisions
and processes at different levels. Each level supports a management structure and systems to
allocate and then monitor the spending at the lower level.
RHS are spread across a number of functional areas and between levels of care. At primary level
these services are considered to be part of the PHC package. Although the number of deliveries
at clinics is increasing, there are still a significant number carried out at district or even provincial
levels, hospitals and these deliveries are thus funded by secondary or tertiary level funding.
RHS are included in several functional areas in the new budgeting structure; such as PHC,
HIV/AIDS, EMS (for referrals), training, support and administration. There has been an annual
increase in all these areas since 1999/2000 – PHC - 4.4%, HIV/AIDS - 48.2%, EMS - 8.7%,
training - 7.2%, support - 6%. All are higher than total increase of 3.1% for health services. 15
Policies for RHS are focused on human rights, social expansion to reach the majority of people
and on equity and equal access to services. Current financial policies are focused on containing
expenditure and keeping tax low. The two policy directions are not supportive of each other.
There is a tension between the social outreach, equity and expansion of RHS with the national
macroeconomic policy of containing expenditure with a focus on efficiency. Inequitable distribution
of resources between health districts across the NW Province was noted in the 1997/98 budget.
District health services budgeting ranged from 46% above to 131% below the provincial equity
target.
203
Figure 7.11: North West Province: Inequities in distribution of district health service
budgets - 1997 to 98
% deviation from
provincial target
50
0
- 50
- 100
- 150
-16
-31
-98
-131
-8 -7 -3
46
4 8 10 10 16 16 22 30 36 37
Mogwasa
Delareyville
Potchefstroom
Kudumane
Vryburg
Wolmaranstad
Moretele
Ventersdorp
Klerksdorp
Mafikeng
Schweizer
Taung
Zeerust
Brits
Rustenburg
Lichtenburg
Ganyesa
Odi
Source: Blecher M. Thoma S; Health Care Financing. South African Health Review 2003/04, Durban:
Health Systems Trust; 2004.
15 Intergovernmental Fiscal Review, 2003. Republic of South Africa, National Treasury. April 2003

As mentioned previously, funding for provincial health services comes from the global provincial
budget that is allocated to the province by the National Treasury. The health sector competes
with all other government sectors for their “slice of the cake”. Once the provincial budget is
allocated to the department, it is then re-allocated to the health districts. In NW Province this
is done in a participatory way from the lowest level of health care through to the province.
With the decentralisation process, more managers in the district are involved in budgeting and
monitoring of expenditure. The process for budgeting begins at the facility level with involvement
of facility managers and area managers. From these inputs a health district budget is developed.
The district hospitals draw up their budgets separate to the district budgets. Governance structures
and health forums are also involved in the process.
The budgets from the districts and hospitals are consolidated by the regional (district) office into
a regional (district) budget before submission to the provincial department. The budget and line
items are finalised at provincial level. For the 2004/05 budget there has been a departure from
this process. The four regional directors in the NW Province DoH have taken responsibility for
budgeting for district services. The Regional Director for Central Region explained:
204
“…the 2004/2005 budget was the first budget in this department’s history that was compiled
by the four regional directors. We were given an envelope and we were given a leeway …
We shifted funds, we reduced allocations on certain standard items, increased them in
others because we always had an under funding of personnel, always. We always had an
under funding of pharmaceuticals and people had to buy on other standard items and
journalise and whatever, and it never came right. This year we were given a task and we
said right we were going to do it. Now when I say the four regional directors I imply that
we did it together with our management teams.… and I think as far as Programme 2, which
is District Health Services are concerned, I think we have made a major, major shift in the
way that it's being done. No manager can come and say to me, “but province gave me this
budget”. They agreed to it before we took it and finally submitted, every manager agreed
to what was there.”
(Regional Health Director)
At the local level decentralisation of budgeting is generally seen as positive as more people are
involved in the process. This was expressed by a district financial manager:
“…people are actively involved.… in budgeting and cash flow management. … each month
we have a cash flow meeting where they will indicate their needs, and they will be approved,
they are able to follow up what they buy and all that.”
(District Health Finance Officer)
The facility managers are responsible and accountable for their budget. A district manager,
however, indicated that some facility managers have not taken on this responsibility:
“The sister in charge must manage her budget. When it comes to drug management the
same applies, she must manage the drugs, she must know what her budget is and she must
manage accordingly. … I think there is a lack in many cases regarding that.”
(District Health Manager)

The budget for all programmes and services are integrated in the health district. There is no
dedicated budget for RHS. Expenditure is from the facility budget and is difficult to separate
out from other programmes. HIV/AIDS services have in the past had separate funding for
attending workshops or conducting training courses in the district. Health District HIV/AIDS
coordinators have experienced some difficulties with this change. They now source funds from
facility budgets for specific activities such as running awareness days. A district programme
manager expressed frustration in drawing on facilities for finance instead of having her own
budget for the programme:
“For example if I have to travel over to attend a conference somewhere or a workshop if
they have to charge they have to charge against the budget from the primary health care
facility. But I just hope it could be like it used to be before where you have a special budget
which I can access funds from.”
(District HIV/AIDS Coordinator)
The HIV/AIDS Coordinator from the rural district, Ganyesa, experienced similar problems:
“Usually in the past we used to have a budget because of this trainings and campaigns that
we have to conduct. But this year we didn’t have any money although it was budgeted for,
it was not there – it is used for other things. Mostly I access money from the clinics for
other things and workshops so I ask a certain clinic or a certain area manager to help me
with the training, this amount of money for training.”
(District HIV/AIDS Coordinator)
These experiences seem to contradict policy, as viewed by the NDoH. Conditional grants for
HIV/AIDS projects are given by the National HIV/AIDS Directorate, via the PDoH to the health
districts or districts. These grants are monitored by the NDoH through the PDoH. A deputy
director in the NDoH, HIV/AIDS office explained some of the difficulties with this process:
205
“If you look at it now we have quite a lot of money that comes from the national Dept. of
Health to the province for HIV/AIDS programmes in the form of conditional grants. But
those particular programmes are implemented at district level. So we needed to hear, for
instance, does that money filter down to them, are they able to implement these things, how
much interaction is there between them and district?”
(HIV/AIDS Directorate - NDoH)
As part of the programme to strengthen PHC and ‘decongest’ the hospitals, patients are being
referred from hospitals to clinics, or being turned away from hospitals if they do not have referral
notes from a clinic. Financially this is a burden on the district budgets which managers report
have not been increased to accommodate the additional patients. Insufficient funds have been
shifted from hospital to PHC services and a tension has developed between the two levels of
service:
“But the majority of patients who were being seen at the hospital and receiving treatment
are now going to the clinics, but they did not increase the budget in the clinics. So we are
having a higher demand from the community which we cannot afford with our budget.”
(Facility Managers Discussion Group)

The hospitals are also under funded for the services they are expected to provide. The Medical
Manager of the provincial hospital in Klerksdorp said that the department wants first world
medicine, but are not able to provide the resources. The budgeting system, although decentralised
on paper, is still centrally controlled as the province finalises the budget and makes the final
decision on distribution of the funds between line items.
Drugs are a major expense in the health services. Concern is expressed by pharmacists who are
responsible for supply of drugs to clinics that the sister-in-charge is not always aware of how
to order, and of the cost of these drugs. Hospitals supply drugs to clinics and themselves keep
records of all deliveries. Yet very few clinics request details of expenditure each month. A high
over-stock at some clinics is noted with many expired drugs.
Equitable redistribution of resources between health regions and health districts remains a
challenge. There is no provincial plan to address this. According to one Regional Health Director
per capita expenditure per patient varies between districts within NW Province from as little as
R95 to as much as R350. The disparities are related to past inequitable distributions under
apartheid. The need to address the problem is recognised and the regional directors, as explained
by one of then, are more actively involved in the budget process which includes addressing
equity. The four regional directors in the NW Province have been requested to assist with the
process of addressing equity of funding, as explained by one director:
206
“…we have set ourselves the target of producing a resource allocation criteria and plan
so that we ensure … that districts are equitably resourced and financed to render the service
that they are supposed to render. … the 2004/2005 budget was the first budget in this
department’s history that was compiled by the four regional directors. We were given an
envelope (to) come up with four packages … equally … We shifted funds, we reduced
allocations on certain standard items, increased them in others, (such as) personnel …
pharmaceuticals … when I say the four regional directors I imply that we did it together
with our (health district) management teams.”
(Regional Health Director)
This is a change from previous years. Health district and hospital managers, as explained
previously, have complained that their requested budgets are changed by the provincial office.
In the new financial year this could change due to the greater involvement of the regional directors
and the management teams within their regions.
“And the advantage that we have … the corrected version of the budget for next year is
exactly the same as what we had. So managers and every district and hospital manager
and district manager in this province can base his district health plans for next year on an
allocation which he already knows exactly what it is going to be, for personnel for running
expenses, for rentals, etc. etc, etc. Whereas we never knew that up until the end of April
of a financial year and you know our financial year starts on the 1st April.”
(Regional Health Director)
The regional directors believe this is a positive step in the right direction for budgeting and is
more participatory than ever before.
“I think we have made a major, major shift in the way that it's being done and no manager
can come and say to me, but province gave me this budget. They agreed to it before we

took it and finally submitted, every manager agreed to what was there.”
(Regional Health Director)
Another regional director confirmed flexibility in allocation of funds between the institutions
and districts within the region. This is done democratically as far as possible, but a time does
come when the director must take a decision.
“Yes I do (have flexibility); more specifically with the money. Because when I allocate
resources at the beginning of the financial year then I do have fiscal flexibility that I can
say you must have that much, you must have that much. Even though at first I do try to be
democratic but it doesn’t help in most instances.”
(Regional Health Director)
And another stated:
“… from the provincial side of view we need to ensure that there is equity of resources
allocation and also monitoring service delivery and coordination and support. Now that
is a role of the district.”
(Regional Health Director)
The researcher has not had opportunity to verify these changes and moves to equity with the
provincial financial director or other stake-holders. A follow-up and more in-depth review of
the financial flows in NW Province would be useful.
Closely aligned with financial inequity across the province is the inequitable distribution of
professional staff. A provincial chief director expressed his concern when he explained the
differences between two hospitals in different regions:
207
“… if you take for example Potchefstroom hospital (in the Southern Region) and in the
Central Region Mafikeng Hospital; Mafikeng’s total patient daily equivalents is less than
Potchefstroom. Mafikeng renders an average of 103 000 patient daily equivalents per annum
whilst Potchefstroom delivers 123 000; it's nearly 20% more. But the total number of posts
for Potchefstroom hospital is only 14 medical officers whilst Mafikeng is 45 of whom 42
posts are filled. So although Potchefstroom has 100% filling rate or a very low vacancy
rate, it's not like apple comparing with apple.”
(Provincial Chief Director)
To correct this requires funds to be shifted between the hospitals.
7.4 Health District Expenditure
Selected PHC of national expenditure and budget forecast show a real increase in expenditure
on clinics and community health centres (Figure 7.12). There has been a national increase in
per capita expenditure for PHC. (See Figure 7.13)
It is not, however, possible to determine any trend in expenditure on RHS as these are included
in the total PHC package funding.

Figure 7.12: National Health Expenditure and budget forecast in selected PHC
elements - 1999 to 2000 and 2005 to 2006
4 000
3 500
3 000
Rands in millions
2 500
2 000
1 500
1 000
500
0
1999/2000
2000/2001 2001/2002 2002/2003 2003/2004 2004/2005 2005/2006
year
District Management
Clinics
Community Health Centres
Community Based Services
Other Community Services
208
Source: Intergovernmental Fiscal Review, 2003. Republic of South Africa, National Treasury
April 2003
Figure 7.13: Total National PHC Health Expenditure and budget forecast, and
Rand per capita - 1998 to 1999 and 2005 to 2006
8 000
190
7 000
– 180
Rand millions
6 000
5 000
4 000
3 000
– 170
– 160
– 150
– 140
– 130
Rand per capita
2 000
– 120
1 000
– 110
0
1999/
2000
2000/
2001
2001/
2002
2002/
2003
2003/
2004
2004/
2005
2005/
2006
100
financial year
Total
Total Rand per Capita
Source: Intergovernmental Fiscal Review, 2003. Republic of South Africa, National Treasury.
April 2003.

In NW Province there has been a similar overall increase in expenditure on PHC services and
per capita expenditure on PHC as shown in Figure 7.14.
Figure 7.14: North West Province - Total PHC Expenditure and PHC Expenditure
per Capita - 1998 to 1999 and 2005 to 2006
3 500
1 000
3 000
– 900
Rand millions
2 500
2 000
1 500
1 000
– 800
– 700
– 600
Rand per capita
500
– 500
0
1999/
2000
2000/
2001
2001/
2002
2002/
2003
2003/
2004
2004/
2005
2005/
2006
400
financial year
Total
Expenditure per Capita
Source: Intergovernmental Fiscal Review, 2003. Republic of South Africa, National Treasury.
April 2003
209
There is a nationally driven programme for all health districts to carry out comprehensive district
health expenditure reviews (DHER). These aim to develop district level capacity for budgeting
and to be used as part of monitoring tools for obtaining equity.
Responsibility for expenditure, through the Public Financial Management Act (PFMA), is
delegated to a lower level than it previously was. Hospital and Health District Managers
are now responsible for expenditure and can be held accountable for over expenditure. The
budget is allocated to cost centres. In the health district this is to the facility level.
A provincial director for DHS expressed concern as to whether local levels have been adequately
prepared to take on the additional responsibilities.
“… do we have state accountants or the management capacity? … because now the
expenditure process will no longer be monitored here (at provincial level), it will be
monitored at local level. … so that we do not have someone approving something that is
far above his delegated authority? So there are those concerns and the feeling was that
some people are not ready …”
(Provincial Director, DHS)
The chief director for health services in the provincial offices strongly supports pushing ahead
with decentralising financial processes, even if capacity is still lacking. He said:

“At the moment there is a drive for more decentralisation again and it comes specifically
out of our department’s Auditor General’s reports, which were not always positive. The
whole issue about the Public Finance Management Act and adherence to delegations etc
and you must link that to my previous statement in terms of empowered staff. It's not only
empowered staff but it's also about systems and whether systems are in place to support
decentralised management, as well as adherence to necessary statutory requirements
regarding legislation etc. …if you don’t correct the wrong and for us to just centralising
a bit again is not necessarily going to give you the outcome that you want. … I would not
like to go that route… we should correct the wrongs and keep it decentralised.”
(Provincial Chief Director)
The health district managers do have some delegated financial powers, within strict criteria. The
district managers are accountable in terms of the PFMA Act, although final accountability rests
with the Head of Department of Health and MEC for Health in the province. The delegation of
authority was explained by all health managers as being:
210
“… expenditure within the confines of the PFMA and the allocated amounts. Procurement,
I can procurement of equipment within the certain confines that I can procure up to R30
000, but let us say I can procure up to R7 500 without contract, but between R7 500 and
R30 000 I can procure, but I need some ratification but even after I have procured.
Transport, management and allocation I will make decisions as to which car goes where
and when.”
(District Health Manager)
“… we have a regional tender committee. Our delegation is go up to R30 000. In the event
where there is no contract we can buy out up to 30 000. From R30 000 to R50 000 it has
to be closed tender in the region from which the regional tender committee should consider.
But when you look at our range of services that is actually very little money because from
R50 000 upwards the invoices have to go to head office.”
(Regional Health Director)
The health district managers and the regional director essentially have the same delegated powers
for expenditure.
Monthly financial meetings are held. The purpose is to review expenditure to date and make
projections for the rest of the financial year to determine areas of possible under or over
expenditure. The health district or hospital cannot move funds between line items. A motivation
to do this is referred via the regional office to the provincial office. Additional funds are motivated
for from the same committee, with no assurance of these being given. A financial manager
explained:
“Sometimes there are under allocations, in the budget… although we do submit our requests
on a monthly basis …. Sometimes the budget is not loaded as requested…. at the end of 6
months each year we submit our adjustment budget. We indicate to them (provincial office)
so far we have spent this much and we project that for the remaining months we will need
this much. So if we project an over expenditure it would mean that we need more funds but
we don’t always get more funds even if we do need them. So under allocation is a major

problem. Also in procurement, there will be people who are trained in procurement systems
and they don’t come back and implement.”
(Health District Financial Manager)
External auditing of districts and hospitals are done by the provincial office and/or by the Auditor
General’s office. The manager, according to the PFMA, has final responsibility for all expenditure
in the district or hospital. The regional directors offer good support to these managers.
Each health district in the NW Province has done a DHER based on the national guidelines. 16
Klerksdorp, Ganyesa and Mafikeng heath districts did these for the financial year 2003/04. The
data made available to the researcher was incomplete. Table 7.1 summarises available information
per general line item:
Table 7.1: Comparative Health Expenditure per Line Item - Klerksdorp, Mafikeng
and Ganyesa Districts - 2003 to 2004
Personnel
Livestock
& Stores
Other
Total
Klerksdorp Health District
R21 403 452
R 8 416 072
R 3 214 366
R 33 033 890
Mafikeng Health District
R 37 967 026
R 7 816 728
R 3 223 815
R49 007 569
Ganyesa Health District
R 20 237 552
R 2 222 505
R 4 296 309
R 26 756 366
Source: Health District Expenditure reviews - 2003/2004
211
Klerksdorp Health District
Table 7.1 indicates that the total expenditure in Klerksdorp District for 2003/04 was R 33 033
890. Personnel expenditure was R 21 403 452 (65%), livestock and stores R 8 416 072 (25%)
and others R 3 214 366 (10%). These figures do not include expenditure for Klerksdorp Local
Municipality managed health services.
There were an average of 2.1 visits per capita to PHC facilities at average expenditure per visit
of R48.46. 16 Average per capita expenditure for PHC was R 102.56.
Mafikeng Health District
The total expenditure in Mafikeng District for 2003/04 was R 49 007 569. Personnel expenditure
was R 37 967 026 (77%), livestock and stores R 7 816 728 (16%) and others R 3 223 825 (7%).
There was an average of 2.6 visits per capita to PHC facilities at average expenditure per visit
of R70.9.1 18 Average per capita expenditure for PHC was R 187.64.
Ganyesa Health District
Table 7.1 shows that the total expenditure in Ganyesa District for 2003/04 was R 26 756 366.
Personnel expenditure was R 20 377 552 (76%), livestock and stores R 2 222 505 (8%) and
others R 4 296 309 (16%). These figures do not include Ganyesa District Hospital PHC services.
16 Health Expenditure Review Task Team (HERTT), Guidelines for District Health Expenditure Reviews in South Africa. Health
Systems Trust. Durban. June 2001. Health Systems Trust. Durban. Available at http://www.hst.org
17 Southern Region DHER 2003/2004, sourced December 2004.
18 Mafikeng Health District DHER 2003/2004, sourced December 2004

There was an average of 2.9 visits per capita to PHC facilities at average expenditure per visit
of R79.91. 19 Average per capita expenditure for PHC was R 233.45.
Comparison between districts
The expenditure per capita and per visit was highest in the most rural health district, Ganyesa
and least in the most urban district, Klerksdorp. These differences may in part be explained
because of the vast area of Ganyesa with a more disperse population than Klerksdorp.
The number of visits per year per capita is highest in Ganyesa and lowest in Klerksdorp. A large
number of people in Klerksdorp can afford to use a stronger private health situated in Klerksdorp
compared to Ganyesa where the majority of the people are dependent on the public sector for
health care.
Figure 7.15: Ganyesa, Mafikeng and Klerksdorp Health Districts DHER
- Percentage expenditure per line item - 2003 to 2004
40 000 000
35 000 000
212
Expenditure in Rands
30 000 000
25 000 000
20 000 000
15 000 000
10 000 000
5 000 000
0
Personnel Livestock & Stores Other
Klerksdorp
Mafikeng
Ganyesa
Source: Health District DHERs - 2003/2004.
Figure 7.15 shows the line item expenditure in Klerksdorp, Mafikeng and Ganyesa Health
Districts for 2003/04. Mafikeng District has the highest total expenditure.
Figure 7.16 shows the line item expenditure in Klerksdorp, Mafikeng and Ganyesa Health
Districts as a percentage of total expenditure for 2003/04. Mafikeng District has the highest
percentage expenditure on personnel.
19 Ganyesa Health District DHER 2003/2004, sourced December 2004

Figure 7.16: Ganyesa, Mafikeng and Klerksdorp Health Districts DHER
- Percentage expenditure per line item - 2003 to 2004
90
80
70
Percentage
60
50
40
30
20
10
0
Personnel Livestock & Stores Other
Klerksdorp
Mafikeng
Ganyesa
Source: Health District DHERs - 2003/2004
Figure 7.17 shows expenditure per capita and expenditure per PHC visit in Klerksdorp, Mafikeng and
Ganyesa Health Districts for 2003/04. Ganyesa District has the highest expenditure per capita and per
PHC visit.
213
Figure 7.17: Klerksdorp, Mafikeng and Ganyesa Health Districts
– Expenditure per capita and Expenditure per visit - 2003 to 2004
250
200
Rands per capita
150
100
50
0
Ganyesa Mafikeng Klerksdorp
Expenditure per capita
Expenditure per visit
Source: Health District DHERs - 2003/2004

Figure 7.18 shows total district population (2001 census) and average number of PHC visit per
year in Klerksdorp, Mafikeng and Ganyesa Health Districts for 2003/04. Ganyesa District has
the lowest population and the highest PHC visits per year.
Figure 7.18: Klerksdorp, Mafikeng and Ganyesa Health Districts
– Population and Visits per Year - 2003 to 2004
400 000
4.00
Rands per capita
300 000
200 000
100 000
3.00
2.00
1.00
Visits per year
0
Ganyesa Mafikeng Klerksdorp
0.0
Population
Expenditure per visit
Source: Health District DHERs - 2003/2004
214
7.5 Conclusions
Funding, budgeting and expenditure in health services are complex systems. Health is a social
service with demand to expand services and provide access to an increasing number of people
each year. The macro-economic trends in South Africa are cost containment and efficiency driven
of GEAR and other policies.
Thomas’ statement, as quoted previously, is worth repeating:
“Health sector policy, directed at improving equity, appears to be at odds with current
monetary and fiscal policy.” 20
There are limited sources of funding for health services. The services are dependent on funding
from the National Treasury which filters down to the health district, the level of implementation
via several routes (See Figure 7.10).
Funding for RHS is not protected. All funding for these services is included in funding for all
PHC services. National policy is implemented vertically whereas funding is horizontal and
integrated. Some HIV/AIDS programme funding is through vertical conditional grants to health
districts.
There is pressure for the services to do more with less funds; for example, in November 2003
there was a national cervical smear, funded by NDoH. The primary level is now expected to
take over the services without additional funding.
20 Thomas S, Muirhead D, Doherty J, Muheki C (2000); Public Sector Financing in South African Health Review 2000.
Health Systems Trust. Durban. Page 130

Figure 7.10: Funding for Reproductive Health Services in South African
Public Health Sector
National Treasury
Equitable Share
National Department
of Health
Provincial Global
Funding
Local
Government
Conditional Grants
HIV/AIDS
Grants &
Agencies
Own Revenue
Prov DoH
Prov PWD
Other Prov Dept.
Health District/
District
District Hospital
Emergency Medical
Services
215
PHC
CHCs, Clinics & Mobiles
Reproductive Health Services
KEY
Community
First Division
Authors’ own interpretation of divisions of finance from
National Treasury to community level for Reproductive Health
Services
Second Division
Third Division
Fourth Division
Fifth Division

Chapter 8
Human Resources
8.1 Introduction
Personnel are the most significant resource for health services. In 2002/03 the personnel share
of total health expenditure in South Africa was 58.1% or R19 320 million. 1 There is, however,
variation between and within provinces., The District Health Expenditure Reviews (DHER), for
example, for 2003/04 for the three study sites in the NW Province showed that between 67%
and 77% of the total expenditure was on personnel. Refer to Chapter 7 in this report.
Human resources management (HRM) has been considered as a weakness. As part of restructuring
of the NDoH, human resources will in future be headed by a Deputy Director
General. This was shared by a chief director in the department:
“… we have changed it [the organogramme] multiple times. We had 2 branches – we have
now given up on the branch story. We are now going to have a third DDG (Deputy Director
General) for human resources. We are probably going to have a fourth DDG for regulatory
affairs.”
(Chief Director; Strategic Planning- NDoH)
216
The Chief Director for MCWH sees HR as the “Achilles tendon” of the services. Many human
resource issues are left to the units instead of being handled by a dedicated section. He said:
“Human Resources, we had been working with Human Resources. However, I think as
South Africa, that has probably been our Achilles tendon and that’s why the (National)
Department has moved on to now have almost a branch that will be headed by a Deputy
Director General: Human Resource, together with a Chief Director and Directors and so
on because that is really the natural driving force for health service delivery. Up to now
the Human Resource development issues, particularly when it comes to the technical issues,
have often been just left to the various units to carry out and we think that is probably the
right way to go.”
(Chief Director, Maternal, Child and Women’s Health - NDoH.)
Human resources are central to implementation of national health policies, as recognised by a
National Chief Director:
“… there are some provinces that would implement policy quite well and others who struggle
to implement policy. And it’s all about human resources. …”
(Chief Director, Maternal, Child and Women’s Health -NDoH)
The National Treasury, Intergovernmental Fiscal Review for 2003 indicates a decrease in total
number of personnel employed in the health sector between 1998 and 2003. Table 8.1 shows
there has been a decrease in total employees in NW Province of 9.2% between 1998 and 2003.
The national decrease in HR for the same period was 6.8%.
1 Republic of South Africa. National Treasury. Intergovernmental Fiscal Review 2003. page 78

Table 8.1: Total number of Personnel in provincial health departments - South
Africa and North West Province - 2002
North West Province
South Africa
Total
% of
Total
Change % Total Total %
Change
Change Change
1998-1999
16 881
7.4
-
-
228 444
-
-
2000-2001
16 068
7.4
-813
-4.8
216 958
-11 486
-5.0
2001-2002
15 438
7.1
-630
-3.9
217 552
594
0.3
2002-2003
15 623
7.2
185
1.2
216 092
- 1460
-0.7
2003-2004
15 332
7.2
-291
-1.9
212 983
- 3109
-1.4
% change 1998-2003
-
-
-9.2
-
-
6.8
Source: RSA National Treasury: Intergovernmental Fiscal Review 2003
North West DoH
Figure 8.1: Total number of personnel in North West Department of Health and
South Africa - 2002
18 000
290 000
– 270 000
16 000
– 250 000
14 000
– 230 000
12 000
– 210 000
– 190 000
10 000
– 170 000
8 000
150 000
1998/99 2000/01 2001/02 2002/03 2003/04
year
South Africa Total
217
NW Total
SA Total
Source: IGF Review 2003
The decrease in number of employees is possibly in part due to rationalising and amalgamation
of the numerous health departments; but can also be due to attrition of staff and indicate that
there are vacant posts.
The need to increase number of health professionals in public health services, for them to be
allocated equitably and according to needs of services and to improve Human Resources
Management has been a focal strategy for the department for the past 10 years. 2,3 These strategies
are driven centrally and apply to the national and provincial level health workers but not to local
government employed health workers.
2 Strategic Priorities for the National Health System, 2004-2009; National Dept. of Health 2004.
3 National Department of Health Strategic Plan, 2004/05 - 2006/07.

The National Strategic Health Plan for 1999 to 2004, Strategy Number 8 was for “Improving
human resource development and management”. The reported 4 achievements during this period
were:
• A national Health Human Resource Survey in 1999/2000 which formed the basis for
developing the Health Human Resources Strategy in 2001.
• Implementing a medical assistant programme to ensure that patients admitted to district
hospitals, in particular, receive appropriate care. Implementation of community service,
for doctors, dentists and pharmacists and other categories of health professionals. Nurses
joined the programme in January 2005.
• Recruiting and retaining health workers; a rural and scarce skills allowance for a range
of health workers was introduced.
The 2004 to 2009 strategic priorities for human resources include: 5
218
• Implement plan to fast track filling of posts.
• Strengthen human resource management.
• Implement national human resource plan.
• Strengthen implementation of the CHW programme and expand the mid level worker
programme.
• Strengthen programme of action to mainstream gender.
In the public health sector (national and provincial) all levels of the health system have
responsibility for human resource management.
National Responsibility Provincial Responsibility Service Delivery Level -
hospitals and health districts
• Policy and legislation
• Monitoring
• Setting of norms and
standards
• Conditions of service
• Setting salaries and
benefits; special allowances
• Registration of health
professionals
• Education standards
• Appointment of
management level staff –
deputy director and above
• Final dismissal
• Budgeting
• Training – provincially and
in support of local training
• Performance management
• Monitoring
• Appointment up to assistant
director
• Initiate disciplinary actions
• Performance management
• Training – locally
• Budgeting for personnel
• Allocation of staff to health
service delivery duties
In the local government sphere each municipality (district and local) and metro set their own
conditions of service. All municipally employed health workers, however, are required to be
registered with the relevant national health professional board or council. At service delivery
level, in many health districts, health services have been integrated with employees of provincial
and local government spheres working in the same facilities. The differences in conditions of
service, however, can cause tensions.
4 Strategic Priorities for the National Health System, 2004-2009; National Dept. of Health 2004.
5 National Department of Health Strategic Plan, 2004/05 - 2006/07.

HRM in the public sector remains centralised to the national and provincial levels, although
some functions within hiring, in-service training, leave and placement of staff within
facilities have been decentralised to health regions (districts) and health districts.
North West Province
NW Province, as with all other provinces, has a shortage of health personnel. The total number
of posts has been reduced as part of the process of rationalising the services. There remains,
however, a shortage of professional staff such as doctors, nurses and para-medicals. Posts
especially in rural areas remain vacant and are difficult to fill. Some personnel functions have
been decentralised, such as appointments of nurses and some other categories of staff, but this
does not appear to assist at a local level. The Provincial Chief Director, as with many other
managers, believes one of the main problems in the health sector is lack of staff. He said:
“To me decentralisation is not negatively impacting; to me it is about human resources
availability. That’s the main problem and we've lost the staff. … I do think we are making
progress at the moment … on obstetric services in the province …. I think the biggest
problem is staff shortage and having the available professional nurses. I have clinics where
I only have staff nurses and that staff nurse catches the baby, she does everything –
specifically in the rural areas.”
Table 8.2: North West Province, Department of Health - Total funded and vacant
posts- November 2003
Posts
Total
Posts
Funded
Posts
Unfunded
Posts
Total Vacant
Posts
Vacancy
Rate
% Unfunded
219
Medical Officers
391
369
22
80
22
6
Specialists
77
67
10
22
33
13
Professional Nurses
3 793
3 595
198
736
20
5
TOTAL
4 261
4 031
230
838
21
5
Source: Chief Director: Health Service Delivery - North West Department of Health
(Provincial Chief Director, Health Services)
Table 8.2 shows the total number of posts, posts funded and unfunded and number of vacancies
in November 2003. There was an overall vacancy rate of 21% and 5% of posts were unfunded.
Figure 8.2 shows the percentage vacant and unfunded posts in November 2003.
Figure 8.3 shows total number of posts, funded, unfunded and vacant for doctors, specialists,
and professional nurses and total for the province as at November 2003.

Figure 8.2: North West Province, Department of Health - Vacancies and unfunded
posts - November 2003
35
30
Percentage
25
20
15
10
5
0
Medical
Officers
Specialists
Professional
Nurses
TOTAL
Vacancy Rate
Unfunded Posts
Source: Chief Director: Health Service Delivery - North West Dept. of Health, 2003.
220
Figure 8.3: North West Province, Department of Health - posts, funded, unfunded
and vacancies - November 2003
5 000
4 000
Number of Posts
3 000
2 000
1 000
0
Total
Posts
Funded
Posts
Unfunded
Posts
Total Vacant
Posts
Medical Officers
Specialists
Professional Nurses
Total
Source: Chief Director: Health Service Delivery - North West Dept. of Health, 2003.
8.2 Public service arrangements and conditions of service
Local government employees presently have different conditions of employment to national and
provincial government employees. Legally it is not possible for employees to transfer between
spheres of government without loss of benefits accrued.

The Department of Public Service and Administration (DPSA) is responsible for developing a
single public service for the country with conditions of service to apply equally to national,
provincial and local government employees. This is expected to be finalised in 2006 /2007 and
to facilitate the transfer of personnel between spheres of government bringing all health workers
under the same conditions of service. The difficulties involved in creating a single public service
are recognised, but is seen as essential by senior managers in all sectors, as expressed by provincial
and national senior managers:
“… there is a lot of research which is being done on, you know the single public service
and yes, it is a very difficult situation. …DPSA is working very closely with DPLG and with
the Department of Health … to actually make recommendations. DPLG is currently working
on legislation towards a single public service.”
(Director - DPLG)
“…maybe the bargaining will take place in a much broader and a much more national level
when the one public service needs to be formed. It will be the same service conditions
whether we work for a local municipality or for provincial government.”
(Provincial Chief Director, Health Services)
Conditions of service for all public sector employees of the national and provincial spheres of
government are set by the national DPSA. There is active participation by labour unions in the
process through various Bargaining Chambers. Health workers are represented by a number of
general unions, such National Health and Allied Workers Union (NAHAWU) Health and Other
Service Personnel Trade Union of SA (HOSPERSA), or by specialised professional unions, such
as Democratic Nurses Organisation of South Africa (DENOSA) for nurses and the South African
Medical Association (SAMA) for doctors.
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Salaries and benefits, once agreed in the Bargaining Chambers, are applied equally across the
public service. Provincial governments have no authority to change these; nor are they able to
offer additional incentives to attract professional staff.
Municipalities and metros have freedom to set their own conditions of service, which includes
salaries and benefits. There is, therefore, disparity between national and provincial government
spheres and the local government sphere in conditions of service. In addition, the freedom for
municipalities to set their own conditions of service has resulted in wide disparity in salaries
between municipalities. The national Department of Provincial and Local Government is
addressing some of the problems and the DPSA is working, in conjunction with all government
sectors, to establish a single public service that will apply to the three spheres of government.
Retention of well trained and skilled staff is a challenge. Managers in the NW Province, once
trained, move on to perceived better career opportunities, often in another province. This may
be related to the general lack of skills in the country, as well as high emigration rate of health
professionals.
There is a real shortage of all health professionals, especially in rural areas. A rural allowance
is in place for doctors and some scarce nursing skills. In the view of a provincial chief director
this allowance should be extended to all professional nurses in rural settings as their PHC skills
are scarce in these areas.

The shortage of health personnel in South Africa and mechanisms for retention and recruitment
are slow in being implemented. The NW Provincial Chief Director for Health Services expressed
this in several ways. There is a lack of a critical mass of professionals:
“In South Africa we have a severe human resources problem. … we just don’t have that
critical mass of empowered staff left in the clinical field and if we are not going to correct
it we are going to run into problems. There are all these nice strategies, you know recruitment
and retention strategies of scarce resources, rural allowance; but it doesn’t get implemented.”
(Provincial Chief Director, Health Services)
There is disagreement as to what should be designated as a “scarce skill” and the NDoH and
Treasury can not agree on the funding:
“We've made our proposals, now there is a fight between national and treasury whether
nurses should be included or not. A nurse in Ganyesa in our province is a scarce resource,
not even a theatre or a ICU qualified nurse, a trained professional nurse is a scarce resource
… maybe national should not make these decisions on rural allowance issues, it should
become a provincial initiative decentralised, not to a local level that far, but to a provincial
level. This is our situation; we will have to pay; which will allow us to get staff in those
places.”
(Provincial Chief Director, Health Services)
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Any province who takes an initiative is “punished” by national:
“…and the Eastern Cape is in the hot water at the moment … they went and paid a rural
allowance to all categories of staff … and national is very upset about that…”
(Provincial Chief Director, Health Services)
Even when funds are made available from a PDoH, it is not possible to implement these retention
strategies before clearance from National Treasury and NDoH has been obtained.
The different conditions of service between provincial and local government employees are
problematic in career progression, particularly for the latter. For provincially employed
nurses problems are experienced with implementing their basic conditions of service, such as
payment for overtime worked. This was expressed in a focus group with midwives:
“So many people are working more than the hours we are required to work… you are
suppose to be given something for that overtime that you are working. But you find that you
don’t and never know really what is the problem, and you don’t get feedback from human
resource, to say you can’t get this because of that…”
(Health District Midwives Discussion Group)
Other issues that cause concern and demotivation are conditions for vocational and study leave.
It seems to nurses that districts vary in applying the conditions of service, and there is confusion.
Granting and monitoring leave is decentralised to the local level and there may not be uniformity
in interpretation of conditions of service.

In Health Districts, such as Klerksdorp, where there are provincial and local government PHC
services, a process of functional integration has brought the services together. There is no longer
duplication of services, nurses from the two employing spheres work in the same building and
the services are managed by a combined district health management team.
The lack, however, of a single public service and the continued difference in conditions of service
of the two government spheres is problematic. Staff members are uncertain of their future, such
as who will employ them and under what conditions. A regional director explained:
“The different conditions of services, it's a major issue, it is difficult. Although you can say
you can manage it, but you still have this situation of two employees, both professional
nurses working on the same level, but different salaries, different conditions of service, etc.
and I didn’t say we can't manage it, we are doing it thoroughly but it's very difficult, it's
not a smooth ride at all, definitely not.”
(Regional Health Director)
The Regional Director for Health in the Southern District, employed by the provincial government,
strongly believes that, in the interest of service delivery, health workers, managers and the
labour unions need to shift from the old system and embrace the new. She said:
“I would just like to say that local authorities also went through a paradigm shift regarding
the old and the new. I'm afraid that in many cases they haven’t gone through that paradigm
shift. For me it is unacceptable that local authorities and when I say local authorities I'm
referring to the local authorities that I am working with directly, that they still can allow
personnel to debate and even hold them to a certain extent at ransom not to implement a
24 hour service - a service that is needed by the community. It is unthinkable to me and
that is why I say, it seems to me, whether it is supported by unions, whether it is supported
by any other labour organisations, whether it is supported by councilors, I say that my view
is that those people didn’t go through a paradigm shift. They still want to render the services
as pre 1994. At that time it was done like that as an acceptable norm, but it is not any more
the acceptable norm today.”
(Regional Health Director)
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She further described the situation as being “a nightmare!” The community does not understand
the difficulties; their interest is to have a 24 hour clinic service available close to their homes.
The net result is tension between the provincial and local government employees which spills
over into tension between the community and the health services.
Solutions have been proposed, including transfer or secondment of staff between the spheres
of government. Neither of these is currently legally possible. The problems are likely to be
resolved once the single public service is introduced in 2006 /07.
Facility managers and nurses from the two government spheres are generally working well
together. Integration takes time, is painful for staff and requires on going support from management.
It is particularly difficult with disciplinary issues as expressed by a facility manager who is
employed by local government:
“It's a problem because, we are from the local authority it is done this way, and then from
the provinces it is done that way. If you are a manager from the local authority, how do

you say, or how do you control the people from the provinces? Because they have their own
conditions of services.”
(District Facility manager)
These uncertainties and difficulties affect the motivation and morale of staff and can impact
negatively on service delivery. Some of the frustration was expressed by a facility manager in
Klerksdorp:
“So that at the present moment the province wants to take over the primary health care
services, the local authorities also wants to keep them. So for now it is said that they have
borrowed us, those from the local authorities, until July next year when the whole process
will be over. Like I said earlier it has been like that. It was the process of devolution, then
decentralisation, then as it is now there it an assignment and it causes a lot of confusion
and frustration for us. So we are also insecure because we really don’t know where we
belong.”
(District Facility Manager – Municipal Employee)
8.3 Jobs
224
National norms and standards for staffing levels at all levels of the health services and in facilities
have not been finalised. The NDoH has, however, developed tools to assist in determining staffing
levels according to outpatient attendances and range of services offered at clinics and other
health facilities.
Strengthening HRM is a priority for national and provincial departments of health. This is further
discussed in Chapter 6.2.
Job descriptions were not accessed from the district managers. One regional director shared his
job description which is based on the provincial strategic goals and is used for performance
appraisal. Job descriptions are expected to be aligned with the recently introduced performance
management system.
8.4 Hiring and firing
In NW Province, hiring of health workers up to the level of assistant director is decentralised
to the regional and district level. The district managers identify their most urgent need for staff
and can proceed to fill the vacancy without first referring to the provincial offices. In the Western
Cape Province such appointments are centralised and it takes 39 steps to appoint a nurse at a
rural clinic.
The local level is involved through the whole procedure of appointing new staff, such as
nurses. This includes determining criteria and skills required, advertising, short-listing,
interviewing and the final appointment. The regional director confirms the appointment.
Disciplinary procedures are in place, but lack of capacity within the department means that the
procedures are not always followed through. The appeal process, in particular, is very long and
often overruns the stipulated three months. Union representation is essential. The frustration in
the delays in completing the process was expressed by one district manager:

“…where you have poor performances you must have good labour relations management,
and that we do not have okay. …when a person appeals it takes forever. … if you make a
mistake especially for serious offences where you dismissed … (the person) will still work
because the appeal will take too long and it may even take place beyond a stipulated three
months, in which case you go into technicalities … it should actually be settled within 3
months. I have one … its now 7 months and we are still waiting for that appeal.”
(District Health Manager)
With the decentralisation of labour relations functions to the district level the situation is expected
to improve. A labour relations officer is appointed in the district offices.
The code of conduct is set by the provincial office and is expected to be applied equally in all
districts and institutions, as explained by a hospital manager:
“…we are provided with a code of conduct and a disciplinary hearing, if the person does
not abide by the code of conduct. So I have to follow the steps that are provided for in the
misconduct guidelines.”
(District Hospital Manager)
The local government health component is strong in some districts, such as Klerksdorp, but the
provincial sphere dominates because of the financial processes. The PDoH dictates filling of
vacant posts and promotions within the local government component, although they can not
dictate salary levels. Local government posts were frozen by the MEC for Health in the
NW Province as part of a strategy to equalise salaries between the two spheres. Permission must
be granted from the PDoH to fill any vacant posts. PDoH posts are not frozen and can be
advertised and filled by the districts. The Klerksdorp Municipal Health Manager explained:
225
“…it's more provincial personnel and municipalities because our local MEC imposed a
moratorium on the filling of vacant [municipal] posts on the 5th November 1995….if I've
got a vacancy I must then write a letter to province and say please, I've got this vacancy,
first of all can I fill it? And they say yes or no. if they say, yes, I can only fill it on my budget
for a matter of 2 or 3 months contractual on the nursing services system. I can't employ
anybody on a permanent basis….Provincial services are appointing. They advertise quite
frequently. I know it's their second time this year that they’ve advertised and one of our
nurses in Klerksdorp municipality resigned now to go and work for province. That’s the
one problem. The other one is that our personnel can't be promoted because I can't get
permission to appoint them in higher positions. So now they are rendering the service,
assisting us free of charge without any incentive but they are still professional nurses.
Province are employing chief professional nurses for example and now they are working
as chief professional nurses of province are working under the supervision of a professional
nurse of the municipality. So in Afrikaans we say it is ‘deurmekaar’ [mixed up] and it can
only be solved once the devolution or the decentralisation has been completed.”
(Local Municipality Health Manager)
These different service conditions and the fact that a ‘professional nurse’ appointed by the
municipality may be in charge of a clinic and be required to supervise a ‘chief professional
nurse’ appointed by the provincial services can be a cause of dissatisfaction. The challenge is
managing the situation and dealing with the concerns of staff during the transition period so that

services are not compromised. Creating joint appointments for management positions, such as
the regional directors and health district managers and combined interviewing processes, is an
attempt to address some of the problems. These jointly appointed managers, however, are
appointed on provincial conditions of service and the posts are funded by the province.
Doctors are not employed directly by the health district management. Doctors employed by
hospitals in the district visit the clinics as arranged between the district and hospital management.
This arrangement can be problematic as there is a shortage of experienced doctors in the hospitals.
Visits to clinics are often allocated to junior doctors, such as the community service doctors,
who have little understanding of PHC and the role of the clinics in the health system. Such visits
can be irregular and for a limited time only. A rotation system operates such that a doctor may
be allocated to clinic duties for three months only and then thereafter there is a change.
Foreign trained doctors, such as those from Cuba, are employed through government to government
contract by the NDoH and deployed to work in under-served areas. The training and experience
of these foreign graduates does not always fit with the needs of the South African health service.
In service training is then required. This concern was expressed by the chief director, who said:
“The Cuban colleagues, the family physicians, they are not trained in those skills, they
don’t give anaesthesia … family physicians who we appoint under government agreements
are actually trained to the level of our primary health care nurse with a special qualification
in diagnosis and treatment”
(Provincial Chief Director of Health)
226
A few regional specialists, such as for obstetrics and gynaecology, pediatrics and forensic
medicine, are employed Their role is overseeing and coordinating the services of their specialty
within the whole region (district) and to support training. Private practitioners are employed on
a sessional basis in the hospitals to assist with relieving the shortage of doctors. Other ways of
filling the gaps through partnerships with the private sector are being explored. The regional
director in Bophirima said:
“I think the Chief Director has challenged … around engaging private practitioners, GPs
here, in … an agreement of how they can do the sessions. Maybe … the few that we have
must go to the clinics. Yes, we have problems where we get maternal death. …Whilst we
have a gynaecologist who is at the regional who somehow has to visit each and every
hospital… the impact is not as good as if a person was there. He (the regional obstetrician)
goes there once a week… there is no stability or sustainability in district hospitals.”
(Regional Health Director)
8.5 Supervision
There is general agreement that good managers, who are adequately trained and have the required
resources, are required at all levels of the system. This is particularly true in a decentralised
system. A local level manager is expected to take a decision and not have to refer to the provincial
level. Supervision and support from a higher level is equally important, as is the ability to say
“thank you” for work well done. The Head of Department in one province said:

“Human beings respond to that. (….) we are very bad at saying thank you in the public
service”.
(Provincial Head of Dept. of Health)
The style of management encouraged is participatory, with all levels having input into the budget,
purchase of equipment, decisions on training needs and other management functions. District
managers empower their subordinates and facility managers to manage and only have matters
referred to them that can not be addressed at a lower level.
Provincial and regional managers are responsible for ensuring capacity is built in middle and
lower level managers. The health district, hospital and facility managers are closest to service
delivery, and if they are not able to perform the regional and higher managers are equally
responsible. One regional director is very clear on this responsibility:
“… my primary function is to ensure that those managers (district and district hospital)
do have the capacity to manage … I cannot put the blame on them if they don’t perform.
The blame is on me because I need to develop that capacity in them.”
(Regional Health Director)
District health managers and programme managers visit clinics and CHCs on a regular basis
in support of nurses. Clinic Supervisors or Area Managers are part of the District Management
Team and are responsible for overseeing the running of clinics in their area. A Supervisor’s
Manual developed nationally, is being used in evaluating performance of the clinic services.
The participatory management style has improved communication among the facility managers.
There is more regular coming together to share and discuss problems and solutions. A facility
manager in Klerksdorp saw this as part of decentralisation and shared:
227
“I think because of decentralisation we are able to, as managers now, we are able to share
ideas, to share the experiences, to share the things that maybe we didn’t know as different
managers.”
(District Facility Manager Discussion Group)
Members of the district management team believe supervision is generally appreciated by the
facility managers, except when it is not planned or when the clinic is busy. This was expressed
by several managers:
“They don’t like when they are busy with their daily routine that the supervisor comes in.
But otherwise, really, they appreciate it.”
(Member of Management Team - Health District)
Clinic staff like to be informed of visits in advance, but managers feel that it is good to do
unannounced visits as well:
“…if I say to you I’ll be coming to do supervision, obviously you’ll be prepared for me. But
if I go there just want to see, then it’s what they don’t like. They want to be informed. But
I think if I’ve done my formal supervision and there were things which were of negative, I
need to go unannounced to see if really it has improved.”
(Health District ADCHS)

Supervisors find it difficult to carry out their functions when the clinic is busy and short staffed.
Some will apply themselves in assisting with the waiting queue of patients and thereafter do
their supervision tasks. This decreases time available for the supervision and time spent with
the nurses. Other managers, however, expressed the opposite opinion; that facility managers in
fact do not appreciate supervision as it is seen as policing. One MCWH Coordinator said:
“No, they do not value it (supervision). They see it as labeling, as the policing – they haven’t
seen it in a positive way… there is no need to change at all.”
(District Mother and Child Health Coordinator)
Facility managers want support, but find that nurses when promoted to a supervisor soon loose
touch with the realities of the service level. There appears, at times, to be a gap between the
district management team and the facility managers, as expressed by a facility manager in
Mafikeng:
“… at times we need management’s support. There is this problem that nurses when they
become managers immediately they leave the hands on situation they start to fail to
understand the situation at the functional level.”
(District Facility Managers Discussion Group)
228
There is a feeling that some supervisors have favourites and are not open to hearing any criticisms
from others. Nurses feel victimised if they raise any criticism or make any negative comment.
A feeling of being uncared for by management was expressed, especially in Mafikeng:
“The other thing is favouritism that is practiced by some of the supervisors. They would
like to silence you. You must not say anything that they don’t like. Everything you say must
be what they want you to say. If you say something they don’t like, you are victimised. You
are not sent to training for that.”
(District Midwives Discussion Group)
Klerksdorp and Ganyesa districts generally expressed a more positive relationship between
supervisor and supervisee:
“…but I think in our department we don’t get a lot, how can I say, problems with subordinates
and the supervisor. Most of them are getting along with the supervisors.”
(Health District ADCHS)
8.6 Training
Training is provided at all levels of the health system and is a joint responsibility of the programme
managers and human resources division. The former focuses on technical issues and the later
on more generic issues.

National level
The NDoH has a budget for training, mostly for nurses at the delivery level. Some training is
also offered by the Human Resources Directorate for the higher professional levels such as
doctors and specialists. Some of these professionals are trained through government-to-government
contracts. Doctors, for example, are training in Cuba. On completion of their studies they are
contracted to work for the number of years equal to the number of years for which they were
sponsored in their home areas. Other bursaries are available for training in South Africa.
The National Chief Director for MCWH believes some training in reproductive health may be
better managed centrally, such as for termination of pregnancy and contraceptive/family planning.
Centralised specialised training does ensure consistent high standards being maintained, and
decentralisation may result in failures in quality and non standardised training. He explained:
“… now we have an integrated approach to reproductive health. … Now the impact that
it has had is they started losing the support structures that were built around for instance,
family planning. We had training in Johannesburg, in Cape Town, Durban. That was family
planning training units. KwaZulu/Natal still has that. But the other places have lost that.
And with that loss, there is loss of focus. Now the whole issue of for instance, integrating
services has really been that its more sustainable rather than the vertical, but I think that
we recognised too that there is also some loss of efficiency once we do that. We still get a
programme instead of operating at level A you have it operating at level B now, but going
to operate for a longer period of time”.
(Chief Director - NDoH)
For HIV/AIDS the bulk of the training is done by the HIV/AIDS directorate, and very little
training is done by the Human Resources Directorate.
229
North West Provincial Level
The PDoH is responsible for some training. There is, however, confusion, even within the districts,
as to who provides what training. The responsibility is, ultimately, shared between the programmes,
human resources section and the health regions and districts.
Some district managers, for budgetary reasons, support centralised training to assist the districts.
External, private funding is also sought to support training, for example IPAS South Africa,
LoveLife and NAFCI.
Training offered by the provincial PHC directorate includes:
• Home based care – teams are formed in conjunction with Hospice.
• Reproductive health – coordinated by the mother and child programme manager.
• Termination of pregnancy – manual vacuum aspiration, and values clarification workshops.
• PMTCT.
• HIV/AIDS directorate – has specific budget through conditional grants.
• Training that requires liaison with other stakeholders, such as universities, is handled
by the Human Resources Directorate. This includes decentralised training for advanced
midwifery.

Local Level
As much as there is support for centralised training there is also support for decentralisation of
training. This enables the training to reach more people involved in implementing the policies.
A facilitator from the provincial office to do the training in the district could help. The right
people do not always go for training when it is centrally run as selection is not always according
to district priorities.
Local training includes contraception and family planning for nurses, community health workers
and other volunteers; in services training of new appointees, particularly clerical.
The health districts have a training budget to be used as determined within the district. Provision
is made for staff to attend training, such as advanced midwifery, outside of the district. The
Provincial Department of Health can give additional assistance if requested and will also assist
with accessing funds from private donors and NGOs. The decision to release staff for training
is made by the district management team according to local need and ability to release staff from
the service.
Although training needs are generally decided at the local level according to need, the province
does dictate some special training according to their own priorities, such as for the cervical
screening campaign of November 2003.
230
There is a PHC Training Coordinator in each regional office whose role is to oversee and
coordinate training within the region. Coordinators and managers in the health districts may be
requested to assist. The regional management can assist with providing relief nurses for those
attending training courses. Distant learning through such programmes as tele-medicine run by
the Potchefstroom Campus of the University of the North West is extending training possibilities.
The regional office is likely to coordinate this initiative.
Training in the NW Province appears to focus on managers within the newly created institutions,
with possible neglect of facility managers and front line health workers. The groups expressed
different experiences of the training available. Differences are particularly noted between the
three study sites, as discussed below.
Management Training
Health managers at provincial, regional and health district levels are positive about the increase
in training opportunities offered by the health department since 1994. The Chief Director for
Health Services expressed his appreciation for this:
“There has been a tremendous amount of empowerment given to managers. I've been part
of the previous government and part of the present government; I can really experience the
change”
(Provincial Chief Director for Health Services)
A regional director likewise feels that the training has helped with her day to day functions:
“On the job training, I think, the day-to-day functions, it has helped.”
(Regional Health Director)

And a district manager agreed that courses are available at accredited institutions:
“The courses are available. We have quite a number of accredited institutions that are
available to us for further training - finance, human resource management, procurement
and provisioning…”
(Health District Manager)
These managers generally believe they are trained and have the skills and the capacity to manage,
whatever their previous function has been:
“Yes - I think I'm trained. With medical background (nursing) I'm really comfortable with
that because I have been given opportunities to train even before I came here. And the
department does give us opportunities to learn while we are still doing your job. And yes
they give us opportunities to identify your learning gaps, you are able to identify the gaps
where you feel you are not confident enough to do this then you submit your learning gap,
then you can go for training”
(District Hospital Manager)
A high turn over of trained management staff, however, is noted. Mostly they move from rural
to urban areas or to other provinces, as lamented by a Provincial Director:
“The unfortunate thing is managers don’t stay … when a better option comes, the person
goes. You may have a situation whereby all managers were trained and all managers were
pulling but when opportunities come somewhere along the line, two or three people leave.
That affects your entire process.…”
(Provincial Director - District Health Systems)
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Facility Managers’ Training
Some facility managers feel they are not adequately prepared to manage a health facility, such
as a community health centre or clinic. One facility manager expressed her feelings:
“…we are trained nurses … we did our extra curriculum studies really for ourselves …
from our employer we are not given ….management (training). They do organise some
training courses, short courses … but normally we are just like being thrown in a river and
then being told to swim, being inside the river.”
(District Facility Managers’ discussion group)
The role of the nurse has widened with the introduction of the comprehensive PHC approach
at the community health centres and clinics. They are not only responsible for the medical care
of the patients, but the facility managers are accountable for budgets and control of stocks, such
as drugs. Training in drug management is provided by specialist in their field. Shortage of
specialist staff, such as pharmacists, however, does limit the opportunities for this training,
adding to the facility managers’ responsibility without proper preparation. (See Chapter 11.2)

Training for Health Workers
Training opportunities for nurses and front line health workers have increased. This is seen to
have improved the standard of health care by a district ADCHS:
“It has (improved health care), the very example I have talked about is maternal record.
The record keeping improved. You know in maternity when a woman is in labour, the
plotting of labour progress will indicate to you whether you should refer this woman or
keep this woman here.”
(ADCHS - Health District)
With the introduction of the PHC approach and integration of all services into a “supermarket”
approach, the nursing profession takes a greater responsibility for managing the care of patients,
instead of referring everything to a doctor. The training needs of these nurses are very important
and opportunities are provided. Most mangers believe opportunities have increased:
“Previously there wasn’t much training that was done but now there is a lot of training”
(ADCHS - Health District)
“Yes, there were opportunities (previously), but I don’t think as much as what there is now.”
(Facility Manager - Health District)
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One area manager in Ganyesa, however, disagreed:
“No – the strategy is still the same, the policy is still the same, and we have got the same
training policy for the district … Decentralisation hasn’t affected it. …not for the nurses.”
(Area Manager - Health District)
Ongoing in-service training is included as part of supervisory visits to the clinics. Monthly
training sessions are held on identified needs, as explained by the ADCHS in Mafikeng:
“We have a monthly in-service training that is continuous training. We come up with
different topics, so that we would not specifically be addressing reproductive health every
month. Then on job training, is done by the supervisor and the programme for maternal
child and women’s health. … like maybe she is going to see whether protocols are being
adhered to; then and there she will do on-job training.”
(ADCHS - Health District)
District managers believe that training improves motivation of staff in their work, although it
is not purposefully used for this:
“Yes it is, because you know if we have to work without necessary knowledge and skills it's
really demotivating.”
(HIV/AIDS coordinator - Health District)
Managers note, however, that professional nursing staff, once trained, will apply for alternate
jobs in other provinces where working conditions are perceived to be better. This adds to the

staff turn over rate, especially in rural areas. Ongoing training is then required for new staff
joining the service.
Experiences with training
Positive experiences with training offered were expressed by a number of district level people.
It is seen as an opportunity to increase personal knowledge as well as facilitating capacity
building in others, as one district HIV/AIDS coordinator shared:
“And then when there was training going on …I say really I want to attend them. Then after
coming from the particular workshop I will give feedback and implement… one of my
functions is to facilitate and build skills around people within the community as well as the
service providers”.
(HIV/AIDS Coordinator - Health District)
Other categories of staff are now receiving training. General workers are trained in labour
relations and other relevant topics. They are seen to be more empowered through this process.
Front line health workers experience training differently; management styles differ as well as
applying criteria used for selection for training. These differences are discussed in the following
sections.
Experiences in Ganyesa and Klerksdorp
In the rural (Ganyesa) and urban (Klerksdorp) districts experiences were similar for the clinic
nurses. They appear positive and happy with training offered. No major complaints were raised.
The Ganyesa midwife group commented:
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“There are opportunities (for training) – we are sent for workshops, we attend some
courses.”
(District Midwives Discussion Group)
Managers in these two districts have a similar process for selection of topics for training and
trainees to attend. Emphasis is placed on participation of and consultation between the district
management team, area managers and facility managers in identifying gaps for training and
selection of trainees.
The process in Klerksdorp was explained:
“Each clinic - they’ll forward their own needs and say, ‘we would like to have this training.’
And then we look at how many requested the same training and then we prioritise accordingly.
… And then the others you identify them when you are going through your supervisory visits
to the clinics, when you identify that this is lacking in this clinic.”
(ADCHS - Klerksdorp Health District)
Selection of participants for training is done by the facility manager to ensure that everyone has
an opportunity:
“The selection is… say its training for family planning and the trainer will need to have
15 people. Then we say to the clinics identify people whom you think need family planning

training. So the supervisor of that particular facility will identify whoever needs to come
for training…. Their criterion is all the people in that particular clinic are written down
with all the training they’ve attended. … so people who haven’t attended will be the ones.”
(ADCHS - Klerksdorp District)
Those who express and show interest are given opportunity. Selection is done in consultation
with the facility manager:
“Those that are active, those that are showing interest in the specific area, they are chosen.
That is the criteria that are used to pick them out. … I usually contact the sister in charge
of the clinic to ask her who (should attend)… It is discussed at the clinic and then she will
give me the names and I forward them.”
(Mother and Child Health Coordinator - Health District)
Monthly in-service training meetings are arranged. A note of training attended is kept and there
is rotation of staff to attend these monthly meetings.
“We’ve tried to formulate a monthly meeting for all the nurses at the clinics. So they rotate
- today it’s you, the following month it’s me. It works like that so that they all get a chance.
During our meetings we usually organise some in service training for each programme
which we have in the clinic.”
(ADCHS - Health District)
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In Ganyesa nurses are asked to identify their own training needs:
“Yes (training is better since decentralisation) - because people were not asked to say what
are your training needs. But now with the decentralisation we send out notices to say to
everybody, ‘What do you see that you lack in your work field, so that it can improve?’”
(ADCHS - Health District)
A team process is used and includes a union representative as well:
“We do it like this; there are four area managers and there is a union rep. We sit down as
a group, as a team, around November month to see, to identify that this one will stay in my
clinic, this one is to be trained on this, this one has to go for this and I will be part of the
discussion. So we decide as a team.”
(Area Manager - Health District)
A needs analysis is applied:
“Topics for training will differ … we do a needs analysis; that, why do you want to have
a training? What have you identified that made you want to train people? I think the topics
will come from that. That you see that there is a need on this aspect.”
(HIV/AIDS coordinator - Health District)

Additional training sessions are included in the schedule for introducing something new in the
district.
“We take what the people want for training and then maybe if there is something new, like
this new maternity chart that we use, then we would put it on the list to say you will be
training them on this because they don’t know. And we also take what they need to be
trained in”.
(ADCHS - Health District)
Experiences in Mafikeng
In Mafikeng the experiences of the front line workers of the selection of topics and participants
for training was very different. The midwives from the clinics expressed extreme unhappiness
with the present selection processes. It was difficult for them to express their feelings or identify
the source of the problem:
“I can’t pin point it on any certain individual per se, but my general feeling is, I don’t know,
something is not right. I do not know whether it is administration or what, I can’t put my
finger on it, because there are certain courses, you find that you hear there is certain
training and you are not informed. And you will find that some people.., there is concentration
of courses where one individual attend 20, 30 courses and the others are not attending,
that’s my feeling. … I don’t know, something is not right.”
(Mafikeng Midwives Focus Group Discussion)
Another midwife felt that the same person was selected for training whereas she has never been
given an opportunity:
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“I was not even trained on any reproductive health. I'm just waiting there as I was trained
during my formal training, but I was never sent for training on reproductive issues. The
other problem that we are having there are people who are chosen – they will be called for
a task team, they will be called for an interview, be called for whatever, - but now these
people, they are the ones that are concentrated on whatever. If it is reproductive, she is
the one who is going to be called now and again to go to these, but there is nothing that
is infiltrating to the masses, to us now – she is the one.”
(Mafikeng Midwives Focus Group Discussion)
Other complaints included:
• Short notice of courses – the information arriving too late for them to apply.
• Favouritism in selection – the same person attends many courses while others attend
none.
“One person will just go again and again.”
(Mafikeng Midwives Focus Group Discussion)
• Staff from less busy clinics are given preference because it is not possible to be released
from a busy clinic

“…when it is said we need somebody, for example advanced midwifery, to attend the course,
they will take somebody from the clinic where is operating only for 8 hours. …we are
working in a very, very busy clinic we are not given opportunity of attending any courses.
Always you are working…”
(Mafikeng Midwives Focus Group Discussion)
• Limited study leave granted for private study – nurses are requested to use their days
off for writing examinations because of the shortage of staff.
• Inequity between health districts – some districts offer bursaries for study whereas
others do not.
“So when coming to study leave there are issues. The district where I am coming from we
are given government bursaries. So here, there is nothing like that. You have to pay for
yourself. Whereas, I am studying with other people from Magaliesberg, they are paid
bursaries through their administration or whatever hospital for whatever management or
whatever they are doing.”
(Mafikeng Midwives Focus Group Discussion)
• Those who do attend training do not share the information.
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“Some people get it but I don’t know whether the problem is cascading this information.
I don’t know, obtaining information…!”
(Mafikeng Midwives Focus Group Discussion)
• Wrong selection of people to attend a workshop – a district programme manager or
someone who is not interested in the topic is given preference over a clinic nurse who
is interested.
“You know there are sometimes courses that you think you are supposed to attend as the
person at the facility, but when you hear that the assistant director attended, you ask yourself,
because there are nurses who are doing midwifery, a nurse who is delivering who is supposed
to know the basic things. Now when a person who is in this office… or someone who is not
even interested, they are just told that they are needed there.”
(Mafikeng Midwives Focus Group Discussion)
In Mafikeng District the process for selection of topics and trainees appears to be different to
that in Ganyesa and Klerksdorp. The process is less participatory with the facility managers and
the front line health workers and controlled by the district management team. The language and
tone used by stakeholders was more ‘we, the management’ make decisions, rather than a
discussion with the front-line workers or facility managers. A skills assessment was done:
“Yes, skills assessment done – normally through the area managers, we request them to
tell us STI’s, TB, STD, HIV and whatever. I have a list with the training officer of how many
people are left to target on various sessions.”
(HIV/AIDS coordinator - Mafikeng District)

Programme managers work closely with the training officer to ensure the training she wants is
done:
“We work hand in hand with the training officer. Let’s say maybe I have something I would
like a staff member to do, like reproductive guidelines, and then the training officer will
organise everything.”
(Mother and Child Health Coordinator - Mafikeng District)
The district management appears to be the ones setting the priorities:
“We make priorities for training and then at the end of the year we draw a list of training
priorities.”
(ADCHS - Mafikeng District)
Selection of staff for training also appears to be centrally decided:
“As long as it is a professional nurse who deals with the clients, she must be trained.”
(Mother and Child Health Coordinator - Mafikeng District)
“We will (select) depending on the type of training that will be offered. If it is for the
maternity record … we will firstly target the 24hour clinics where they conduct deliveries.
We select trainees where the biggest needs are.”
(ADCHS - Mafikeng District)
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Nurses can attend training outside the district, such as for advanced midwifery. As with the other
districts the number and who attends these trainings is monitored by the district management
team.
“We plan for that in advance. To say, this year how many people can we send for advanced
midwifery? They will apply and then we approve so many. … it is being controlled by us.
If we send 3 midwives to advance midwifery, then how are we going to fill in their gaps,
so we make the decisions ourselves, the planning and everything.”
(ADCHS - Mafikeng District)
Monthly in-service training is organised, as well as on the job training during supervisory visits.
Selection of topics for these sessions appears to be central in the district office and there was
no clear process shared for ensuring that everyone has an opportunity to attend in rotation.
“We have a monthly in-service training that I would say is continuous training that is in
place. We come up with different topics and we would not specifically be addressing
reproductive health every month. Then on job training, is done by the supervisor and the
programme for maternal child and women’s health. During visits to clinics, that is where
she will offer on-job training, like maybe she is going to see whether protocols are being
adhered to, and she will do on-job training.”
(ADCHS - Mafikeng District)

In Mafikeng Provincial Hospital, which is situated within the Mafikeng District but under a
different management structure, the midwives are more positive about the opportunities for
training they have. The process is fair and opportunity is given in turn, as shared in the discussion
group:
“Yes there are [opportunities to train]. What we do we have sort of a list, a programme.
That after this one is this one, as long as you are interested you just apply and then know
that after you, it will be this one and after that one is this one. … you can select because
at the moment we having our own theatre here and then fortunately neonatal, neonatology
plus midwifery – it is combined therefore one would just go and apply for advanced
midwifery.”
(Midwives Discussion Group - Mafikeng Provincial Hospital)
The main complaint expressed by these midwives was the lack of skills of the midwives working
in the CHCs and clinics. This can lead to friction between the two levels of care.
The hospital is under a separate management team to the district. There are, however, coordinating
meetings held between the hospital and the district teams, mainly to discuss the referral system
between the two levels of care. The hospital management has no responsibility for services in
the district.
Reproductive Health Training
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There is no dedicated funding for training in RHS at the local level. Training is incorporated
into general training programme. The provincial reproductive and women’s health sub-directorate,
however, does have limited funding for training and is active in undertaking provincial wide
training for specific purposes, such as termination of pregnancy, values clarification and cervical
cancer screening. 6 The active involvement of the provincial programme managers was confirmed
by two coordinators in Ganyesa:
“It [training in reproductive health] is organised by the coordinator for reproductive
health. …I for one have attended one of those trainings – counseling on termination of
pregnancy and courses like those. … we have a very productive reproductive health unit.”
(HIV/AIDS Coordinator - Health District)
“It's done centrally because the provincial coordinators are organising it. For example if
you have to train people on choice of termination of pregnancy it's not done at district level
or regional level, they do it provincially, all the nurses in the province will be trained.”
(Mother and Child Health Coordinator - Health District)
Candidates attending training from the districts are expected to share what they have learnt with
other nurses in their district through a process of cascading the knowledge to everyone in the
district. This is not always successful done as not everyone shares what they have learnt.
Centralised training at the provincial level is necessary, mainly due to lack of training skills at
the local level. Where this skill is available locally, for example for FP in Klerksdorp, this
resource is shared and the trainer works in other districts as well.
6 During the study period there was a provincial outreach campaign for cervical cancer screening. This was initially driven by
the National Dept. of Health. Funding was supplied partly by the NDoH, the PDoH and from donations. The campaign was
considered a great success but its sustainability was not planned for.

“The only training which we organise here it‘s our family planning, because we do have
a family planning trainer who was trained as a trainer in the past. Fortunately she is with
us here, so she is doing our family planning training for the district. Whereby you find that
other districts are also requesting her services, but it depends whether she is available so
that she can go out to the district to help.”
(District ADCHS)
There are gaps in training for clinic nurses for reproductive health; for example insertion of
intrauterine devises can only be done in hospitals.
Training has a positive impact on level of skills as expressed by a group of hospital midwives.
Many of them have been trained as advanced midwives and are able to handle many more
problem cases than previously. One midwife, who had previously worked in a clinic, believes
that such training would have helped her in the clinic and this training should be extended further.
The Perinatal Education Programme is offered in some districts. This is a modular training
programme over one year at the end of which the nurses receive a certificate. This, with perinatal
mortality meetings, is viewed as positive training.
8.7 Performance management
A Performance Management and Development System (PMDS) has recently been
introduced for staff appraisals. PMDS originates from the NDoH and is gradually being applied
to all health workers. A means of rewarding good performance is under consideration.
The system is not fully functional, but managers generally agree that it is an improvement on
previous systems. It is designed as a monitoring and evaluation tool measured against the agreed
to job description objectives with key performance areas. Managers who understand the new
system see it as a good tool for identifying their own gaps in training. Some nurses and other
workers, however, are generally not clear how the system works and there is confusion.
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The PMDS for personal evaluation is too new to judge its value. Hope was expressed that there
will be a fair system of rewards for good work.
Once fully operational, the PMDS will be used in support of human resource development. This
includes identifying gaps for training and corrective action when an official is not performing.
It will also assist with disciplinary action.
8.8 Staff attitudes
The principles developed at the1994 ICPD Cairo conference have moved the emphasis for health
services, in particular for reproductive health, from a mainly bio-medical model to one which
recognises the rights of people to make choices. This change is captured in South African
legislation and policies. The Bill of Rights, for example, is incorporated into the 1996 Constitution
of South Africa, Chapter 2. The White Paper on Transforming Public Service Delivery of 1997,
also known as the Batho Pele (People First) White Paper, outlines principles for service delivery
within the public sector to which all sectors are expected to adhere. Health legislation (such as
the National Health Act of 2003 and the Choice on Termination of Pregnancy Act of 1996) and
policies (such as the Policy Guidelines for Youth and Adolescence Health of 2001, the National
Contraception Policy and Guidelines of 2002 and the HIV/AIDS and STD Strategic Plan for
South Africa 2000 to 2005) all include emphasis on the rights of access to treatment and
knowledge and to free choice for all women.

With the introduction of the PHC approach through the DHS professional nursing staff are the
main front line providers of health services. Implementing many of these new policies may
require a shift in approach by some health care providers towards patients and issues. Community
members are more aware of their rights as outlined in the legislation and policies and are
increasingly demanding that their rights be respected.
This section accesses health workers’ attitudes to their work and environment, to clients and
patients and to issues, such as youth and adolescents, HIV/AIDS and termination of pregnancy,
in the three study sites. Community members’ responses to staff attitudes are also included.
Attitudes to work and environment
It has been noted elsewhere that there is generally low morale among health workers in South
Africa. One response from the health workers has been an out-migration of all cadres from the
public sector to the private health sector, to other countries, or out of the profession. Mention
has been made to staff retention strategies, mainly centred on additional remuneration for certain
scarce skills and working in ‘inhospitable areas’. There are, however, other issues that need to
be addressed if the morale of staff is to improve, and staff retained within the public sector.
Several stakeholders recognise the difficulty with coping with the many changes experienced
by health workers. A director in the NDoH, responsible for DHS development, expressed concern
about the need to handle the process of change carefully and with proper planning:
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“I think some of the major problems could be that, because it’s a massive process given
the complexities of the South African system, if you don’t manage it properly, and if there’s
no well-designed implementation plan, then you are bound to fail. Because you can’t chop
and change every five minutes. It doesn’t work like that. And with this kind of thing you
also can’t justify chopping and changing every time because of the resources.”
(Director, DHS - NDoH)
The difficulty with change is acknowledged by reproductive health policy makers:
“… we are all human and it’s very easy to slip back into the comfortable mode. Change
is not easy so you may have one committed person but the other people may very quickly
slip back.”
(Chief Director - Maternal and Child Health, NDoH )
And at the provincial level:
“But change is a difficult thing, humans naturally resist change; that’s our state isn’t it?
We are inherently inert.”
(Provincial Head of Health Department)
There have been many changes through restructuring of health services. These have, at times,
occurred rapidly and without due consideration to managing the changes. This has resulted in
the lower level health workers, in particular, feeling demotivated and uncertain as to what is
happening, as expressed by one provincial coordinator:

“At first there was a lot of confusion because with every change you have to manage the
change but as time goes on they could see that when things works everybody is happy but
when they change … everybody complains and the feeling is that why do you change? …
we’re too fast and there …. many things that come at the same time that you become
inefficient and don’t know what you are doing …”
(Provincial Reproductive Health Coordinator)
And also the need to ensure that staff are prepared and empowered for their new roles within a
decentralised system, as expressed by a Provincial Chief Director:
“We must, however, accept that in a country that has gone through so much change as ours
and so much empowerment that the foundation is sound so that the person who must take
the decision has been empowered enough. … you cannot just look at foundation stone of
decentralisation management and accept that the other preconditions will be in place. There
is a challenge to us within the system to ensure that they both are there, that you have
empowered staff who are able to take decentralised management.”
(Provincial Chief Director - Health Services)
Resistance to change is acknowledged by provincial reproductive health managers:
“Change is something that is very difficult. With change we have got a lot of resistance
because people are comfortable in their comfort zones in what is normal, what is routine.
If you come up with changes you are upsetting their comfort zones and you want them to
adopt things that they are not used to. So it has not been easy.”
(Provincial Deputy Director - Reproductive Health)
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With all the changes and difficulties the efforts of the front line health workers are acknowledged
and appreciated at the highest level.
“And I think there’s a very high level of commitment, especially from the people on the
ground. They deal with really, really serious issues which I don’t think some of us as
managers can imagine. And given their own circumstances, being human beings and all
that, I think they do a pretty good job.”
(National Director for DHS development)
The North West Provincial Department of Health, Reproductive Health Unit, has run province
wide workshops using the programme, Health Workers for Change, to assist with the process
of changing attitudes among staff. 7 Some success with the process was reported by the Deputy
Director.
Some changes have come too fast and have been difficult to manage, as expressed by the North
West Provincial Director for HIV/AIDS:
“I think we’re too fast and there are so many things that come at the same time that you
become inefficient and you don’t know what you are doing; that’s a feeling on the ground.”
(Provincial Director - HIV/AIDS)
7 Health Workers for Change

In the three study sites, a general demotivation and low morale was noted in the midwives and
in some facility managers. This was particularly noted in Mafikeng where the midwives appeared
desperate with, and completely disillusioned by, services and their working conditions and
environment. Some of their comments were:
“A major demotivating factor is the overall shortage of staff to cope with the increasing work
load in the clinics… The cornerstone of demotivation stems up from the fact that there is
drastic shortage of staff…. as one professional nurse with an assistant nurse I am supposed
to do the delivery, consultations, suturing, attend to all emergencies that come in the clinic
at night…. From the simple implementation of the basic conditions of employment is a
problem… even if you are working overtime at least you are suppose to be given something
for that overtime, but you find that you don’t and never know really what is the problem. …
There is nothing that can motivate us, to wake up in the morning and come here, to smile to
patients. … I think five years back we were promised that we will be subsidised for uniforms.
Even today we are still buying for ourselves, the uniform……. Prescribing that side, dispensing
at the same time, packing the dispensary, counting at the same time. There are so many things
that the registered nurse is doing. And sometimes you don’t even remember when you are
writing these things. You know that you are always under pressure. … the security is not good;
this community we are working in, the urban area people at night can do as they like…”
(Midwives - Mafikeng District)
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Midwives in the other two districts of Klerksdorp and Ganyesa, although admit to feeling stressed,
did not have as many complaints as the midwives in Mafikeng. In Ganyesa the main problem
seems to be with lack of communication between management and front line health workers,
as well as staff shortages:
“I think our major problem these days is that our working condition is not so … You find
that one person does the work that is supposed to be done maybe by five people. So the
problem is shortage of staff. … What I experience is that we do not have support from the
management. So these policies they come they are showing you … so sometimes you do
that, they don’t do the follow up and checking that we are doing the right thing or what are
we practising.”
(Midwives - Mafikeng District)
Subsequent to the research visit to Ganyesa, the Ganyesa District Management Team conducted
a survey among clinic staff to ascertain the main problems. Top of the list was the gap between
management and clinic staff. A strategy to improve this is in place. 8
In Klerksdorp the demotivating issues are more concerned with the differences in condition of
service between municipal and provincial employed staff and the uncertainty of the future. The
district management team and municipal officials, although it is difficult, appear to be coping
with the challenges:
“They work hard. You see our employees, especially the municipality ones; they are very
demoralised because of the whole process. Because they were so confused … it has been
years since this started. … the municipality workers were traumatised because all the time
they were told this is going to be provincialised. Now they were thinking but the salary
there is lower, some of us if it is provincialised it's possible we going to be retrenched or
whatever, all those frustrations. But we managed to keep them positive and had some
8 Ganyesa Health District Manager – personal communication – Nov 2004

meetings with them to motivate them to let the process unfold because as it unfolds the trade
unions will be involved and those are the people who are elected by you to represent you.
… we must handle it with care. Once it affects them negatively (remember they are the ones
who are rendering this service to our people), if they have that bitterness in them, you
obviously get poor service.”
(Member of the Municipal Council for Health)
As discussed previously the extreme demotivation of the Mafikeng midwives is possibly related
to the management style of the district management or other contextual factors.
Most managers at national, provincial and district level believe that training is a motivating
factor for staff. Addressing the problems listed above are equally important. Some nurses
expressed motivating factors as being enjoyment of their work, a word of gratitude from patients
and management support.
Motivating factors mentioned in Ganyesa were:
“What would motivate me a lot in order that we are willing to work with a happy mind and
happy soul is that at the health area that I work there is a team spirit and if there is a team
spirit … by team spirit we mean working together, we are one family. Everybody is free
with each other if we have a problem we come together and discuss it jointly. Nobody is
left out as we are working with general cleaners and grounds men.”
(District Midwives Focus Group Discussion)
“Myself what motivates me is working with the community and the community that I know
their culture because … you tend to understand them (and) their situations. It’s easy for
you to get solutions to their problems.”
(District Midwives Focus Group Discussion)
243
Staff Attitudes to Clients and Patients
The primary health care approach encapsulates the idea of patient-centred care. This approach
is also emphasised in policy documents referred to previously, in particular the Patients’ Right
Charter and Batho Pele. These principles are well known to community members, who expect
them to be applied. A Regional Director said:
“Our local communities are talking about issues such as health officials not implementing
and not honouring the principles of Batho Pele and the Patients’ Rights Charter.”
(Regional Health Director)
These principles, however, are not universally applied by health workers; this is acknowledged
by some managers as being a problem:
“Because we do have some buzz words in the health department and some of them are
community participations, some are Batho Pele and some are patient rights. We just talk
them, we don’t practise them.”
(Regional Health Director)

Managers expressed emphatically the importance of the Batho Pele principles and the need for
nurses to apply them. Facility managers and nurses generally have no problem with these
principles but feel that the patients’ rights over-rule the nurses’ rights, as explained by a facility
manager in Mafikeng:
“We as nurses don’t have any rights, we are just workers; we have to please them 9the
community), that’s what we are told. So we just have to – if they say this, even if we are
taking a tea or lunch break, if they say, ”are you going to work?” you just have to stand
up and work. Those patient’s rights are imposed on us and we are suffering. … To me there
is no problem with the patient’s rights as long as they can be emphasised together with our
rights …nurses are still human beings and we also have human rights… they will start
shouting at you. So I think their rights are more emphasised …”
(District Facility Managers Discussion Group)
Members of the community attending health services gave good and bad reports on staff attitudes
to them when attending clinics. It was noted in one group that preference is given to a women
in labour, unless there other emergencies at the same time.
“When a woman goes to labour at least their services are better … if a patient in labour
comes in they leave other patients except emergency to attend the one in labour.”
(District Community Focus Group Discussion)
244
Special mention was also made by various groups on the positive way in which nurses treated
people by HIV/AIDS and those seeking contraceptive services. There is also acknowledgment
that this communication is a two way process and the community can be as much to blame for
the poor service they receive:
“I just want to put out one thing about the community. We always blame health workers
but we as a community we do not look at ourselves first.”
(District Health Forum)
The adult community group in Ganyesa believes that the attitudes of nurses have improved since
the Health Forum was formed and became active:
“The relationship has really improved since after the forum is in place. Because they know
that if those people are not satisfied, they will know where to go. But before....eeeesh....”
(District Adult Focus Discussion Group)
Private sector health services are perceived to be better, with staff having a more supportive and
positive attitude to patients:
“I think that the private health service is much better than the government health service
because you are nicely treated because you are somebody that is favoured.”
(District Youth Community Group Discussion)

Negative comments were made by community members about the attitude of nurses in all study
sites.
In Klerksdorp:
“Yes we have problems, especially when it comes to women giving birth. When you arrive
there [clinic], the nurses would say anything bad to you that she can think of, shout at the
patient and the amazing thing is that some of these nurses are older women who are also
mothers… the reports from other people saying that patients are not treated or cared the
way they are supposed to be treated.”
(District Adult Discussion Group)
“Even the nurse in the hospital don’t have that love for nursing, they will shout at older
people who are sick and who cannot go to the toilet on their own and just messed up on
their bed”.
(District Youth Discussion Group)
In Mafikeng:
“A woman in labour pains, the staff didn’t attend her immediately, like the thing of labour
pains is not an emergency to them …. [nurses] have that attitude of ‘they didn’t send this
women to sleep with men to fall pregnant’. The nurses classify patients, they look at how
clean you are or how poor. They [nurses] prefer patients who are clean. They think before
they help you.”
(District Adult Discussion Group)
245
“The relationship is not good, like they look you in the eye before they help you. The nurses
are rude, it also depends on who are you and where are you from.”
(District Adult Discussion Group)
In Ganyesa:
“The sisters do not have patience with young ill children… During lunch-time there is no
staff to help patients.”
(District Community Youth Discussion Group)
“Relationship is not good because you only get good service when you know some of the
nurses in the clinic”.
(District Community Youth Discussion Group)
Some nurses are frustrated with the image that they, as nurses, are all bad. This is not universally
so. The midwives group in Mafikeng particularly felt that their side is not heard by managers:
Because there is this perception in the whole of South Africa that nurses are bad. Can’t
they interview us and find out what is the problem? All they do is interviewing patients.”
(District Midwives Discussion Group)

Nurses believe that the patients have bad attitudes and are unappreciative of the work that they
are doing. This was particularly noted by the midwives in Mafikeng.
“Another problem is negative attitudes of the patients coming to the clinic. They don’t really
appreciate what you are doing. … the problem is these people who are accompanying the
patients, always giving us the problems because they like to control us when they come to
the clinic. They are asking us to do what… They are demanding. You cannot even go for
tea or the toilet because of their attitude. They have a different interpretation of their rights.”
(District Midwives Focus Group Discussion)
In Klerksdorp, however, a more independent view of nurses’ attitudes to patients was gained
from the District Pharmacist who, at the time of the study, was nearing completion of her
compulsory year of community service in the district. She, in addition, has private sector working
experience. She strongly feels that the nursing staff (and doctors) attitudes are not good in the
clinics. Staff arrive late, take extended tea and lunch breaks and do not practice comprehensive
health care.
246
“People they don’t visit the clinic because they feel like chatting. There is always an
immunisation to be done there is always a - , but now you get a sister because she is from
the antenatal today, she’ll only see first visits antenatal and she maybe do the immunisation.
Now what the other sisters doing the minor ailments and the chronic, they must see the
second and third visits.”
(District Community Service Pharmacist)
Management, in this informant’s opinion, do not understand what is happening in the clinics,
and remain office-bound.
Attitude to Youth
Youth and adolescent health are a focus of the national health services. Policy Guidelines for
Youth and Adolescence Health were published in 2001. (See Appendix 4). The policy prioritises
the need for and outlines the approach to adolescent and youth health. One youth believes that
quality of services depends on staff attitudes:
“Delivery of quality of service depends on the sister’s attitude.”
(District Boys Discussion Group)
The youth groups are generally not happy with the attitude of nurses to them and their problems.
This seems particularly bad when seeking information about reproductive health and sexually
transmitted diseases. The youth in Klerksdorp and Mafikeng were outspoken in their views:
In Klerksdorp:
“The reason why they don't go to clinics is that they are afraid of sisters because they know
they will shout at them! “What are you trying to do you want to sleep around while you are
young, what do you want to do; you want to have a baby!”… So the sisters are not friendly
to these young girls.”
(District Boys Discussion Group)

“The other problem is that the nurse will shout at you “oh no you are pregnant, we are sick
and tired of youth getting pregnant”, even though you are not pregnant…. We are now
scared to go the clinic because we think that we will find those nurses that are shouting at
us immediately when you enter through the clinic door “what do you want, why didn’t you
come with your parents” and “you make the clinic dirty”. That’s what they usually say
when they don’t want to work… When the youth come they always tell them that they are
still young to use contraceptives. All they think is that we are sleeping around and it’s not
like that, we use them to protect ourselves if maybe we are raped.”
(District Girls Discussion Group)
In Mafikeng:
“Once I started asking the sister that I wanted to know more about the STI! She started
saying ‘Hey! What it is that you want to know, you are too fast, what do you want to
experience?’ ”
(District Boys Discussion Group)
“One other thing, when you go to the clinic and ask for information specifically for
contraceptives, the nurses are all rude. … Even if they can give you what you want they
don’t explain when and how to use them.”
(District Girls Discussion Group)
“The relationship is not that good because they think we sleep around if we come to collect
contraceptives. … Others think we will engage ourselves to sex, start doing funny things
with boys, knowing that we are protected.”
247
(District Girls Discussion Group)
“We are not represented as teenagers. If you can be sweet and all that, but health service
providers, they provide their services with attitude. You can’t even complain; when you
complain you have to have an identity document.”
(District Community Discussion Group)
“The thing is that the clinic is the place to go for help, instead of getting help, you are
getting judged”
(District Youth Discussion Group)
In the third district, Ganyesa, the youth in the focus group discussions were less free to express
themselves or did not have any strong opinion on the attitudes of staff to youth issues.
The need for special youth services has been recognised. In the NW Province, the Planned
Parenthood Association of South Africa (PPASA) have, in conjunction with the PDoH, established
Youth Centres in most health districts. These are staffed by the provincial health services and
provide dedicated services to youth. These services collaborate with other NGOs, such as
LoveLife, in providing life skills training and education. This education is extended to the
schools. The Youth Centres, however, are not easily accessible by many communities because
of long traveling distances. Youth, therefore, access clinic services in many parts of the province

etter than the Youth Centres. The NAFCI, a programme of LoveLife, has been introduced in
the NW Province, but has not extended as far as originally anticipated, as shared by a provincial
reproductive health manager.
“We’ve got reproductive health across the board for the youth. We have youth programmes
where we have got Youth Centres at the moment. We have got 6 youth centres in the
province and we’ve a private programme as well, which we call NAFCI) where the public
health facilities are also made to be user friendly for the youth. All in all it's trying to attract
youth to services where they can be of assistance to them in reproductive health and at the
same time to be linked to the general system of primary health care services for reproductive
health.”
(Provincial Deputy Director - Reproductive Health)
“I would say it depends on the strength of the coordinator. I would say that the coordinator
that we have for NAFCI for the North West she is not very, very resourceful. We launched
NAFCI and our MEC launched NAFCI in the province, acknowledged it … we had to
identify clinics where she (the coordinator) had to go and do that… she did only one clinic
out of 8 clinics that were supposed to have been done. She is left with 7 and I don’t how
far she is with the role out? And then she is nowhere to be found right now.”
(Provincial Programme Manager - Reproductive Health and Women’s Health)
248
These impressions expressed by the provincial coordinator of the effectiveness of NAFCI in
NW Province were not supported by the finding of the 2003 National Primary Health Care
Facility Survey. The survey reports:
“All facilities in North West, compared to only 8% nationally, had received support from
NAFCI. All North West facilities reported receiving support on: training (100%); clinic
committees (100%) and youth involvement (100%).” 9
The high teenage pregnancy rate is a concern in all three districts. Similarly Termination of
Pregnancy is still a major challenge. These issued were discussed in detail in Chapter 4 of this
report.
8.9 Professional relations
Transformation has changed the careers paths for many health workers. Nurses, for example,
have become the backbone of the PHC services and, in addition, new careers are being opened
up for them. The management structure in health districts and hospitals have changed so that
nurses and other health or non-health professionals can take on this role. Previously these
positions were all filled by medical doctors.
But certain caution is required in opening up these new career opportunities too quickly and
promoting people into positions for which that are not adequately trained and skilled for. . This
was expressed by a provincial chief director:
“… I was the first CEO to be appointed, I was a doctor but … it doesn’t have to be a doctor.
… it can be a hospital administrator with an administrative background. … the support
9 National Primary Health Care Facility Survey. North West. 2003. Health Systems Trust; 2003.

for that person must be there regarding the clinical fields, nursing, doctor, etc. However
we must make sure that a person doesn’t reach the level of hospital manager so quickly or
too quickly that the foundation of the general management aspects of the hospital is not
there. Due to our … empowerment or affirmative action, we have not always had that
growth regarding hospital administrators, so for us that’s a gap at the moment. Secondly
we try to bridge that gap by training, but the staff turnover in South Africa for public
hospitals is quite high especially for rural provinces where you train and you empower a
manager but he moves quickly on to another province in a higher post. So all these things
impact in the end on decentralised management …”
(Provincial Chief Director)
At service delivery level the greatest impact of these different conditions of service is found in
provision of 24 hour services. Municipally employed nurses are expected to work an eight hour
day, five days a week with no night or weekend duty. Provincially employed nurses work a 40
hour week, but this can include night and weekend duty. Municipal nurses are not prepared to
work at night or weekends and the provincial nurses are not prepared to carry the full load of
after hour’s duties. The net result has been a long delay in opening of some 24 hour services.
Patients, including maternity patients, must attend the hospital after hours which can be difficult
due to lack of emergency services.
A Provincial Manager expressed frustration he has felt working, as an outsider, in the NW
Province. Promotions are difficult to get for those whose homes are outside the province He
also feels that there is a preoccupation with title and position within the department instead of
with a person’s contribution to the organisation. This may be an isolated case, but his statement
is worth noting:
249
“… the other thing that knocks our relationship is this over emphasis or madness, if you
may, about your job title. That you are an assistant director, you are an admin officer, and
you can't tell a director or a chief director a thing or two. Now this madness that I'm
referring to is problematic, because we don’t look at as value that we are adding to the
process we are looking at who you are, okay. That’s one. Two is this question of what you
might call an internal xenophobia; that because you do not come from within you come
from elsewhere, (I was born in Free State); funny enough I was educated here … So these
are some of the interpersonal issues that tend to undermine major processes. For me what
is important is not the position or the power that you command but the value or
the contribution that you make to the process and if you have power on your side to
add more value, so be it. But not to use your positional power other than for good purpose.
That would be my humble facts based on my experience in the department.”
(Provincial Manager)
8.10 Conclusions
At all levels of the system and in the three study sites a number of problems and achievements
in human resource management were identified by stakeholders. Some of these are common to
the three sites and others unique to just one or two sites. These are summarised in the table
below. These can not all be attributed to decentralisation alone as there are many other factors,
internal and external to the Department of Health, that have an impact.

Problems
• Lack of all cadre of staff
• High turn over of staff
• Lack of effective retention strategy for staff
• Lack of capacity in management and clinical
skills
• Expected extended role of the nurses to deliver
a comprehensive primary health service.
• Different salary and conditions of services
between spheres of government
• Inequity / non standardised application of
COS across province – perceived or real?
• Vertical training from province for
programmes
Achievements
• New performance management system
• Decentralisation of some personnel functions
• Hiring up to assistant director level
• Initial disciplinary hearings at district and
regional levels
• Labour relations
• Leave records at district level
• Increased training opportunities available
• District has budget for training and can
determine their own training needs
• Integration of services
• Gap between managers at district level and
facility level
• Inequitable distribution of professional staff
250
• “Favouritism” in selection of staff for training.

9.1 Introduction
Chapter 9
Planning, Monitoring and Evaluation
Planning for health services begins at the national level. Policies and legislation are developed
and the NDoH develops a broad, strategic plan for the country. These strategic plans are usually
published during the year of national elections. The National 1999 to 2004 and 2004 to 2009.
Strategic Plans and the NW Provincial Department of Health Strategic Plan for 1999 are all
summarised in the Table 9.1. The NDoH Strategic Plans inform the PDoH Strategic Plans.
Table 9.1: Strategic Health Plans: National and North West Province
National Strategic Health
Plan for 1999 to 2004
National Strategic Health
Plan for 2004 to 2009
North West Dept. of Health
Strategic Objectives - 1999
• Reorganisation of certain
support services;
• Legislative reform;
• Improving quality of care;
• Revitalisation of hospital
services;
• 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 co-operation
with our partners
internationally.
• Improve governance and
management of the NHS;
• Promote health lifestyle;
• Contribute to human
dignity by improving
quality of care,
• Improve management of
communicable diseases and
non-communicable
diseases;
• Strengthen primary health
care, EMS and hospital;
service delivery systems
• Strengthen support
services;
• Human resource
management, planning,
development and
management;
• Planning, budgeting and
monitoring, and evaluation;
• Prepare and implement
legislation; and
• Strengthen international
relations.
• Providing quality health
services;
• Providing accessible,
equitable and affordable
comprehensive primary
health care services;
• Well functioning and
competitive hospitals;
• Improving the health status
of communities through
implementation of integrated
health programmes;
• Well managed and effective
district health system;
• Competent, empowered and
performance focused staff;
• Integrated and effective
organisational systems;
• Effective management of the
department’s finance and
assets.
251

9.2 Planning processes
Table 9.1 shows that the NW Province has eight strategic goals on which regions, health districts
and hospitals develop their annual operational plans. The regional and district progress quarterly
reports in the NW Province are based on these objectives. These strategic goals are also used
in developing the personal performance management contracts for managers at provincial,
regional and district levels.
The PDoH has a planning process through the Departmental Management Committee involving
all directorates i.e. health programmes, district development, hospital services and support
services. The provincial managers make integrated plans, but at the local and implementation
levels, the plans appear to be vertical. The local levels then need to integrate these for
implementation.
“I think unfortunately many of the things in head office; I think all of them are a vertical
programme. As far as district level it will be possible to sort of integrate them, but it is
quite a challenge to do that really. Because I've said previously you know for each and
every programme manager his or her programme is the most important one you know, and
to manage these things here at district level is more than a challenge.”
(District Health Manager)
The NDoH has guidelines for district planning that are being used in the districts in the
NW Province to assist in the process.
252
In the health districts, planning begins from the lowest health facility level. Each facility is
responsible to plan their services as it suits their area, facility and priorities.
“So each clinic does its own planning, because they differ. So they plan.”
(District ADCHS)
All plans are consolidated in to the health district plan, according to local needs and priorities,
but also according to provincially set objectives.
“We all go together all the programmes and the planning is done with everybody present,
so each one will come up with a meaning or an idea so how she wants and what she wants
and .5other members have got an input into what she does.”
(District ADCHS)
An additional challenge to the health services is the requirement in local government, health
and other legislation for the health plans of a health district to be included in the Integrated
Development Plans (IDP) of local and district municipalities. This requires a close working
relationship between the health sector and local government. The local community are involved
in the IDP planning process and the health governance structures, which may be interpreted to
include a community voice, in the health planning process:
“Our governance structures are also involved, more especially at district level and… we
try to be responsive to community needs … And then from there with the district managers
we do the DHP (District Health Plan) for the district (region), based on that.”
(Regional Health Director)

Developing IDPs in municipal areas is a new process under the Department of Provincial and
Local Government (DPLG). In the first round health plans were not well integrated into the
IDPs.
“They are not well incorporated I must admit that. I would have liked to have seen them
very much more integrated but then on the other hand this was a learning process and our
responsibility now is to go when the IDP’s are being revised and reworked We must now
adopt a very much more aggressive approach to get our district health plans incorporated.
But you must remember that the district health plans are for a much shorter period than
what the IDP’s are. Our district health plans go by here the MTF period but it's based on
a much shorter period than what the IDP’s are.”
(Regional Health Director)
Community members may be involved at a local level in planning specific projects; they are not
involved in planning for general health services.
“Because when we start a project we involve them (the community) with the initial stage
up to the end. And then before involving them, and even after involving them we identify
the gaps in terms of skills development. Then where possible we educate them and then
because we have to rely on them and then we don’t have any problem whether they are left
behind.”
(District HIV/AIDS Coordinator)
The MEC for health said that although planning is done at a local level, the plans are submitted
to the central level for acceptance before being implemented. The IDP is submitted to the National
DPLG and the health plans to the PDoH. 1
253
The experience at the lower level shows that the planning process is not clear cut. The strategic
objectives are set by the provincial department; the health programmes may, however, have their
own specific objectives. Some of these may come vertically from the national level. At the
service delivery level in the districts and hospitals the operational planning process starts without
receiving any specific objectives from the programmes. A regional director’s comments suggest
a disjuncture between provincial and local level planning:
“The operational plans…. We have often requested that head office, like the programme
managers, need to give us their priorities for the year, but most of them do not. You find
that at district and regional level we develop our operational plans before the people at
the provincial level. So what happens is that each coordinator and each facility manager
determines priorities. And these operational plans are evaluated on a monthly basis. Then
we have a minimum data set where we have uniform indicators throughout the province
and these are evaluated on a quarterly basis. We actually set targets that we are moving
from this area, and we intend to be there by then.”
(Regional Health Director)
The provincial programme managers tend to focus on and push projects which they themselves
are being pushed to carry out by the national level to see implemented. This may side track the
local level from their identified priorities. An example given in several interviews is termination
of pregnancy as part of reproductive health services (RHS), which is perceived by some health
1 Interview with MEC for Health: North West Province

workers as being politically driven. It is one programme that requires statistics to be regularly
submitted to NDoH by all provincial DoHs.
“You know to be honest with you with this program, you will find with reproductive health
you will get the CTOP as well … the part of the program that is politically driven, people
will tend to concentrate on that. What I have realised that other parts of reproductive health
services have been neglected, and people are concentrating on TOP more than anything.”
(Health District MCWH Coordinator)
TOP is a sensitive programme to implement and these comments may be part of a broader
problem that requires attention before the CTOP legislation can be fully implemented, such as
“Values Clarification” for health workers.
In summary, the planning process for health is essentially a top-down strategic objective approach
with bottom-up operation and implementation plans. The regional offices appear to be the point
of meeting of the two. The regional director plays a pivotal role in coordinating planning within
the region and ensuring that these are according to the strategic goals of the province, as explained
by the three district managers:
“We have our own strategic plans in place for the region as a whole, and then of course
the districts just add to that. And the regions strategic objectives are linked with provincial
and province with national. So it is the whole chain reaction that occurs right through.”
(District Health Manager)
254
“We, together with the programme managers and the districts managers for the districts
sit down, check what we actually achieved last year in terms of our objectives and also
determine, according to the indicators, what needs to be addressed and to what extent. And
so we sit down together and we plan the future year on the basis our achievements, our
failures of the previous year in terms of the operational plans.”
(District Health Manager)
“No you are not flexible (with operational plans). Because if you have also noted it in that
assessment that we have there you see it’s an assessment for all districts and is the same
for the province. So you have the same thing that you are going to be assessed on so you
better do that, because otherwise you will be seen not to be performing… That is why I say
we more of an operational plan.”
(District Health Manager)
“We do have what we call operational plans where people set their objectives and when
do they want to achieve this, so as far as reproductive health, they do have them. Each and
every facility on a monthly basis, on a yearly basis, they start doing their yearly plans.”
(District Information Officer)
Planning for all health programmes and support services at facility, district and regional levels
is integrated. All managers come together and plan as a unit.

9.3 Information systems
“A comprehensive health information system that begins at the local level and feeds into
provincial and national levels is essential.” 2
A committee was established in 1994 to review health information systems (HIS) in the country
and to advise on establishing a new National Health Information System of South Africa
(NHISSA). The committee included representatives of the provincial MECs for Health, the
NDoH, other relevant government departments, academics, research institutions and the private
sector. The process has involved bringing together multiple, fragmented and incompatible
systems.
Most systems were paper driven, with little computerisation, and there was minimal feedback
of information and little use of the information in planning.
The White Paper for the Transformation of Health Services in South Africa lays out the broad
principles on which the NHISSA is to be established. 3
• The National Health Information System (NHISSA) should be nationally coordinated
in order to support the effective delivery of services at all levels of the health system.
• The NHISSA should be used to monitor the implementation and success of the health
priority programmes, both of the Department of Health and the Reconstruction and
Development Programme (RDP).
• Reporting of NHISSA data at all levels should be timeous accurate and complete.
The National Health Act of 2003, Sections 74 to 76, describes the role of each sphere of government
in coordination of a national health information system. See Box 9.1. 4
255
The NHISSA has developed a system for health information, including defining a national
minimum data set and indicators for monitoring health services in South Africa. A computerised
system is evolving to collect and collate data and calculate standard indicators from all levels
of the health system so that the vision of a comprehensive information system is attained. 5
Box: 9.1 – National Health Information System
Coordination of national health information system - National Health Act Section 74
(1) The national department must facilitate and coordinate the establishment, implementation
and maintenance by provincial departments, district health councils, municipalities and the
private health sector of health information systems at national, provincial and local levels
in order to create a comprehensive national health information system.
(2) The Minister may, for the purpose of creating, maintaining or adapting databases within
the national health information system contemplated in subsection (l), prescribe categories
or kinds of data for submission and collection and the manner and format in which and by
whom the data must be compiled or collated and must be submitted to the national department.
Provincial duties in relation to health information - National Health Act Section 75
The relevant member of the Executive Council must establish a committee for his or her
province to establish, maintain, facilitate and implement the health information systems
contemplated in section 74 at provincial and local level.
Duties of district health councils and municipalities - National Health Act Section 76
Every district health council and every municipality which provides a health service must
establish and maintain a health information system as part of the national health information
system contemplated in Section 74.
2 African National Congress. A National Health Plan for South Africa 1994.
3 National Department of Health. White Paper on the Transformation of Health Services in South Africa, Chapter 6.
4 National Health Act, 2003.
5 National Department of Health. White Paper on the Transformation of Health Services in South Africa, Chapter 6.

Management Information
Surveillance
• National Health Care Management
Information System
• Human Resources Management
Information System
• Financial Management Information
System
• Facilities Management Information
System
• Equipment Management Information
System
• Transport Management Information
System
• Pharmaceutical and Other Consumables
Management Information System
• Service Coverage (i.e. utilisation,
coverage, access)
• Socio-demographic Surveillance
• Environmental Surveillance
• Disease Surveillance
• Nutrition Surveillance
• Health Systems Surveillance
256
“The process is developing. It's is again a process that’s being hampered by not having the
necessary IT systems in place and although the system may be in place in a district level
it's not in place at a clinic level. We really try to take forward in evaluating by having
specific norms and standards that need reports on a monthly basis. The challenge is to do
it in a way where you can actually do audit trails and to make sure that everything is kept.
At the moment it's very much a paper-based system up to district level and then it's fed into
a computer.”
(Provincial Chief Director for Health Services)
Health data and information flow in North West Province
Health district
The collection of data begins at the primary level, in the mobiles, clinics and community health
centres. At this level the system is paper driven and is collected on a monthly basis. The data
is submitted via the clinic or area supervisor to the District Information Officer (DIO). The DIO
is responsible to enter data into the computerised District Health Information System (DHIS),
to identify any gaps in the information and verify the data submitted from the primary level
facility. Any anomalies or gaps are referred back to the facility for correction.
The computerised data is then submitted to the provincial department of health for collation
with data from all other districts. Data and information is also fed back from the DIO to the
Health District Management Team. There are no information officer in the regional offices.
There is no regular collection of data from community level or the private sector. Periodic
national demographic surveys are done which give community based data and information for
use.

Hospitals
There is a separate Hospital Information System. The Hospital Information Officers (HIO)
collect, computerise and collate data from all sections of the hospital. This information is available
for use locally and is also submitted to the provincial offices for collation with other hospitals
and the DHIS.
Data and information collected in the district hospitals is not directly collated with data collected
in the health district which the hospital serves. Both sets of data are submitted directly to the
provincial offices.
Role of the regional office
There is no information officer appointed at this level. The regional director, however, is
responsible for monitoring and evaluating the services in districts within his/her region. This
is done through Quarterly Reviews, attended by provincial, local government and members of
health governance structures. Health district managers and hospital managers present the data
and information for discussion.
Provincial office
The provincial office is responsible for collating all data and information submitted from the
districts and hospitals. This information is made available to provincial managers. Data
and information, according to the minimum data set, is transmitted to the NDoH.
Programme Managers and Management Information
Health programme managers at national level, who manage their programmes vertically, may
request information or data directly from their provincial counterparts, who in turn will request
this from the districts, hospitals or even primary level facilities. Thus there can be additional
flows of information from the local to the national level.
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“What happens if you are running maternal child and women’s health you have your own
indicators. So all these coordinators through out the province are going to give you that
information and then you are going to consolidate it and have it with your director, who
then ends up with the DDG and MEC. …(and) it is going through the DHIS, through the
district managers, the regional managers and then chief director and then the DDG then
MEC. The same information. …but will be more in depth on the other side.”
(District Health Manager)
“We get regular reports from the districts. We get some statistics – look here are some on
termination of pregnancy – in this box and then I collate that. But you know the actual
reporting, you have to dig it, and remember statistics they have to send it also to the IT
people and all these things. And you have got a problem of what you want to do, you know
all those things, to the point in reproductive health what I did I compiled a reporting system
just for us.”
Experiences with Information Systems
(Provincial Reproductive Health Manager)
The whole system is still evolving and quality of data is noted to be improving. At all levels of
the system, however, there are different experiences with the information system.

Managers are still learning to use the information for planning.
“I think the use of information for management is a serious problem. Managers do not use
the information at their disposal. Managers are not editing the information before its being
submitted; in other words the Health Information Officer submits the information for a
regional review for instance. The manager doesn’t use that information for management.”
(Regional Health Director)
“For planning? I think so because I can site an example of using head count, comparing
it with the drugs that are being used in the hospital. So that is the example that I can give,
they are using it because they will ask me how many patients were seen in this clinic and
then comparing that with drugs.”
(District Information Officer)
“The service? As I have said, we monitor it on a monthly basis in terms of reviewing and
the operational plans. We are checking how the indicators are and regionally comparing
ourselves with other districts, how they perform. Where there are gaps coming up, or some
recommendations that needs to be corrected. But also through structured meetings.”
(District Health Manager)
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Facility managers are encouraged to use the data they collect for management at the local level.
In some districts they are trained and encouraged by the DIO to draw graphs and have these
displayed on the walls of the clinic.
“Use of information? In the past information was just collected for the sake of collecting.
Now the --- we are encouraged to make use of information which is very good. As information
officer I called what I told you facility information coordinators telling them their
responsibilities and their roles and one of the things that I emphasised is to make use of
information. There are sets of indicators. So in each and every facility identify a data
indicator and then start drawing graphs and to see what is the problem in my area? And
then once a problem has been identified, what are we going to do about this that we are
encountering? And then I encourage them to document those problems and the actions that
have been taken.”
(District Information Officer)
The use of graphs in the clinics is not wide spread, as noted by the regional director in Central
Region:
“If you look at the number of clinics that have graphs on the walls for instance, there are
some that have, there are some that are very few and far between and that to me is a serious
concern.”
(Regional Health Director)
There are no information officers appointed at CHCs or clinics. A nursing assistant or other staff
member is, therefore, made responsible, in addition to her other duties.
“There is no specific person responsible for this information. They can’t say its shortage
of staff, because they are doing it, though they are short. So let them appoint someone

specific. Call her the facility information officer. It can be an assistance nurse, an enrolled
nurse or even the professional nurse… Or for instance, like when they take an assistance
nurse, you know it doesn’t mean if you are an information officer you must now leave your
work, your duty as a nurse and just focus on it. No, because you are doing the statistics the
very first week of the month to gather all the information the raw data and put it on a form.
So they can just you know appoint someone, specific.”
(District Information Officer)
9.4 Monitoring and evaluation
Monitoring and evaluation of plans are done on a quarterly basis. Reports, compiled from
information available through the District Health Information System and other sources, are
presented by the district and hospital managers to the regional director in the Quarterly Review
Meeting. Provincial officials, members of health governance structures and local and district
government councilors and officials are invited. The presentations are done according to the
provincial strategic objectives. The district managers are held accountable for the services.
Governance structures are included in the review meetings and their opinions noted. No
interviewee, however, gave a concrete example of suggestions which had come from the structures
actually being included in the district or regional plans. The governance structures role appears
to be more passive than active, as illustrated below:
“… for each and every activity or any projects which we need to implement in the district
we usually sit with them (governance structures) in our meetings. We don’t just impose by
saying this is what we are going to do. We get them in and say this is what we need to do,
how can we do it together? So they are involved from the planning sessions.”
(Member of District Management Team)
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Some governance structure members and councilors are knowledgeable on health indicators,
as noted by one health district manager:
“There is this one (local councilors) who understands them (indicators). You know I get
surprised when he talks about the indicators, sometimes he knows more than the health
workers, so he is part of us.”
(District Health Manager)
The private sector is not involved in these reviews or the monitoring process. All private health
facilities, however, are inspected annually by provincial health officials to ensure standards and
to issue a licence to practice. This does not include having access to statistics from the private
sector.
“So what happens is that each coordinator and each facility manager determines priorities.
And these operational plans are evaluated on a monthly basis. Then we have a minimum
data set where we have uniform indicators throughout the province and these are evaluated
on a quarterly basis. We actually set targets that we are moving from this area, and we
intend to be there by then.”
(Regional Health Director)

“We give every manager a chance to collate the information from their facilities and districts
and then to prepare a submission and the entire presentation. That facility manager, district
or hospital manager, is responsible for the collation for the preparation of the report, for
the preparation of the presentation and then to present it there on behalf of the region.”
(Regional Health Director)
Although acknowledged as still developing and not perfect, the monitoring and evaluating system
is seen by health officials to be working. Community members from the governance structures
are part of evaluation meetings, but their opinions are not always acknowledged. As mentioned,
there are councilors with a good understanding of indicators and good knowledge of the health
problems and needs in their own community. A comment made by a community member in a
discussion group indicates some dissatisfaction with the current system of monitoring, especially
in the more disadvantaged, deep rural areas:
260
“I can make a comment on the government policy which includes all the people since 1994.
I was carefully looking at the way they do things; they do not have a follow up or have a
monitoring process, to see exactly whether their implementation of that policy is working
on a local level. Things are working well at the top, provincial and local levels. But deep
down at the disadvantaged communities, that’s where things do not work smoothly. You
see, just at local levels, that’s where there is no monitoring process and the government
need to do something on that. Long time ago, during the old government, the white people
were making use of these government health facilities day and night, 24 hours, making sure
that their government policy works, but this new democracy of ours; we don’t guard it to
make sure that it works for the people. So that is why you could find that this new democracy
is enjoyed by the people at the top.”
(District Community Discussion Group)
Conclusion
Planning, monitoring and evaluating of health services are an essential, although complex,
process. Although improving, a top-down approach appears to still dominate. The national Ten
Point Strategic Plan for 2004 to 2009 has shifted from the previous ten points and does not
mention that services are to be delivered through a district health system. Primary health care
and strengthening governance structures (and presumably community participation) are specifically
mentioned. The DHS may be implicit within the Ten Point Plan.
The National Health Act of 2003, Chapter 5, establishes a DHS for South Africa. For this to be
realised horizontal and vertical gaps in the systems need to be bridged. Planning processes for
the vertical programmes at national and provincial levels require coordination; the voice of the
communities served by the health services require to be heard and noted in the planning process.

Figure 9.1: Data and Information Flow from Local level to National Level
- North West Province
National Department of Health
NHISSA
Programme Managers
Provincial Department of Health
Health Information Section
Programme Managers
District Management Team
Programme coordinators
District Information Officer
Regional Office
Quarterly Review Meetings
Programme coordinators
District Information Officer
Hospitals Management District, Regional,
Provincial Hospitals
261
Hospital Information Officer
Primary Health Care Facilities
Community Health Centres
Clinics
Mobile Clinics
Hospital Sections
KEY
HIS Data Flow
Health Programmes Information
Management Information

Chapter 10
Governance
10.1 Introduction
Developmental, decentralised, cooperative government with full participation of communities
is entrenched in many policies and legislation introduced since 1994. For health services this
includes the following documents:
• The Reconstruction and Development Programme – 1994.
• The African National Congress Health Plan – 1994.
• The Constitution of the Republic of South Africa – 1996.
• White Paper on Transformation of Health Services – 1997.
• White Paper on Transformation of Public Service delivery (Batho Pele) – 1997.
• White Paper on Local Government and Local Government legislation that followed –
1998 to 2000.
• Health Sector Strategic Plan – 1999 to 2004.
• National Health Act – 2003.
262
Several mechanisms for community participation are proposed within these documents. These
include:
• Formal structures;
- Ward Committees and other structures through the Local Government legislation.
- Health Forums, Hospital Boards, Clinic Committees as health governance structures.
• Informal structures;
- Community meetings
• Principles: health providers should follow these principles when providing services to
patients
- Community should demand that health care providers implement the Batho Pele
principles of ‘People First’ at all times when they are accessing health services
- Patients’ Rights Charter - communities should use the Patients’ Rights Charter to
advocate for equitable and adequate services.
Intersectoral collaboration, as part of cooperative government, is critical. This process brings
together government departments, private sector, non-government organisations and civil society
in the interest of service delivery.
This chapter will review the formal governance structures for health and local government, their
roles and functioning; community involvement in health; intersectoral collaboration and public
– private relationships within the health system.
10.2 District governance structures and processes
Governance structures existed in some parts of South Africa prior to the health transformation
that followed the 1994 democratic elections. These governance structures included:

• Clinic Committees – mostly in rural areas of the previous ‘homelands’
• Hospital Boards – often consisting of local business elites and little real community
representation.
A new vision for public health services was developed between 1990 and 1994. The policies
and structures for health services included governance structures to ensure community participation
and involvement in health issues.
The NW Provincial government passed the North West Health, Developmental Social Welfare
and Hospital Governance Institutions Act in 1997 (Act No. 2 of 1997) when Health and Social
Welfare were joined under one ministry in NW Province. This Act predated the establishment
of local government as a distinct sphere of government in 2000, and the passing of National
Health Act in 2003.
Early governance structures of community forums, district health committees and hospital boards
for Health and Welfare were based on the Governance Act. Nominations for membership were
made through traditional structures such as the tribal authorities, but final appointments were
made by the MEC for Health in the province. The health forum included provincial health
officials, ex officio, but no local government officials. These governance structures were seen
as a communication channel between the community and the Provincial Health and Welfare
Department, but, as they were not elected, were not fully representative of the community:
“Those governance structures were not really elected, with the result that there was, in the
beginning, I wouldn’t say friction, but there was not that close co-operation.”
(Regional Health Director)
The health forums did, however, have power to make decisions and, if necessary, refer directly
to the MEC for Health any matters that could not be solved at the local level, as explained by
a district manager:
263
They do have the power to take the decision; they also do have the power to give that
resolution directly to the MEC.
(District Health Manager)
Subsequent to the establishment of the local government sphere in 2000, new community based
structures have emerged. There is possible duplication of function between the local government
structures, such as ward committees and the health governance structures. Councilors are voted
into office by local residents. A mayor and mayoral committee are appointed from the majority
political party in the municipality, and ward committees are formed at a local level to address
local issues, including health.
Both structures, namely Ward Committees and Health Governance structures, are able to
call meetings. The ward committees, however, in terms of the legislation, have greater power
than the health governance structures in implementing recommendations made.
The apparent duplication of structures at a local level (established under different spheres of
government) leads to confusion and possible delays in implementing resolutions or bringing
problems to the notice of authorities. Some health governance structures overcome this by
following two lines of reporting – to the provincial department and to the local municipality.
This was noted by a hospital manager:

“It's sort of being delegated by him because we are reporting to the board, the board is
reporting to the MEC but some of the issues they report to the mayor”
(District Hospital Manager)
Figure 10.1 illustrates lines of communication between local government and ward committees;
and between health services, health governance structures and the political head of health in the
province. There are no formal links between the local government political councils and the
MEC for health in the province; nor official link between ward committees and health governance
structures. Informal links between the ward committees and councilors and the health governance
structures have been established in some areas. Ward committees and health governance structures
have some objectives in common, but officially report to different higher structures.
Figure 10.1: Relationship between Health Governance Structures and Local
Government Structures - North West Province
Provincial
MEC for Health
Health Facilities provincial
Government managed
Health Governance Structures
• Health Forums
• Clinic Committees
• Hospital Boards
264
Community Based NGOs
Local Government Structures
• Mayoral Committee
• Health Portfolio Committee
Ward Committees
The Bophirima regional director shared that these structures are expected to be linked in the
North West Health Act:
“When it comes to the Governance Act and our governance structures… we busy refining
those structures into local municipal structures by means of the Provincial Health Act …
Our governance structures can't call meetings for instance as a Ward Councilor is able to
do.”
(Regional Health Director)
This complexity was illustrated by a provincially employed district manager, responsible for
PHC services in Klerksdorp where there are also local municipal PHC services:
“You can imagine that a representative from the provincial office, whether it's political or
whether it's an official like me, someone else on a higher level, coming down and they say
in terms of the Governance Act this governance structure can take resolutions and make

ecommendations to the MEC to be implemented. The MEC accepts it. Now you can think
about it the MEC or the official is coming down to (….) Local Municipality and then telling
them, you have to implement it by Monday morning. And the local municipality says we are
not a third level of management or of government, we are another sphere of government
(….) we are equally autonomous.”
(District Health manager)
The North West Health Bill of 2001 has drawn on the 1997 Governance Act and incorporated
the changes in local government in developing proposed health governance structures in the
province. These proposed structures and lines of communication and accountability are shown
in Figure 10.2 1 at the end of this chapter. The composition and functions of these structures are
likely to change with introduction of new national and provincial health legislation.
The National Health Act of 2003 was signed into law and the North West Health Bill is expected
to be redrafted to be in line with the national legislation. The Governance Act of 1997 remains
in force. At the local level health officials have recognised the wisdom of including local
councilors, as well as traditional leaders, in health governance structures, as expressed by two
managers:
So as far as I'm concerned you cannot operate without the full cooperation and the support
of your local councils.
(Regional Health Director)
“We are in a process of re-looking at that because we want to involve the municipalities
in it.”
(District Health Manager)
265
There does, however, remain confusion as to the roles and functions of the health governance
structures and their potential value as a link between the health system and the community
served. The impact of the structures on health services remains uncertain, although in some
health districts these structures are seen as having certain power and influence. The experience
of these structures is different for managers and health workers within the health system; and
for health officials and the community.
In some metropolitan areas in Gauteng and Western Cape the ward committees serve as health
governance structures, such as health forums.
Roles and functioning of the health governance structures – North West Province
The MEC for Health in the NW Province may establish, in terms of the Governance Act of 1997,
community health forums, district health forums and hospital boards. The main functions of
these structures is to consider, investigate and make recommendations on matters referred to it
by the MEC or community; and make nominations for Health and Developmental Social Welfare
Boards and Hospital Boards. Details are given in the Act. 2 The main linkage between the
community and the health facilities are the health forums with their community representatives.
Members of the governance structures visit the clinics. The main purpose of these visits is to
see how patients are treated by the staff at the clinic, the opening hours of the clinic and the
1 Hall W, Haynes R, McCoy D: The Long Road to the District Health System: Durban: Health Systems Trust; 2000; page 74.
2 North West Health, Developmental Social Welfare and Hospital Governance Institutions Act No. 2 of 1997.

general well being of the staff. They are not generally involved in decisions of a technical nature.
Items for discussion in meetings include the budget for the facility and the services to be rendered.
A facility manager in Mafikeng explained the structure in her area:
“I have said about the forum – that is the link between the communities, the clinic and the
district. Among these forum members, in the rural areas, is a chief representative, and some
councilors from the tribal office.”
(Health District Facility Managers Discussion Group)
The potential role and importance of the governance structures is recognised by health managers,
health workers and community members. The functionality and experience of this relationship,
however, varies between districts and at the different levels of the system. The responses in the
three districts are discussed below.
Klerksdorp Health District
Local level management recognises the value of governance structures, particularly as a
communication conduit between themselves and the community, and even to the MEC via the
health forum, which can be useful to the management as expressed by the ADCHS:
“The forums are answerable to the MEC for Health whereby we work through them if we
would like to have messages taken to the MEC.”
(District AD Community Health Services)
266
The health forum in Klerksdorp is well constituted and meets regularly. It is valued by the
management team for their input and support in financial and personnel management. The forum
and management meet regularly to discuss issues of mutual interest. The district manager said:
“I give feedback to them on the quarterly expenditure of the office. When we look at the
appointments of people we draw them in on the interview panel. When we experience a
problem at a specific clinic with regard to the rendering of services we draw the representatives
in from that clinic.”
(District Health Manager)
Although the forums have some power to make resolutions they are not able to implement these.
Their involvement is in general health issues that are non technical. They do not make any
decisions on reproductive health services or the referral system as these are the responsibility
of the health officials, as explained by the district manager:
“They have limited power. They can take a resolution on the wish of the community, but
they can't implement, they can't implement.”
(District Health Manager)
Facility managers are generally supportive of the forums, although their function is not always
clear.
Community members and members of the health forums in Klerksdorp at times feel despondent
and powerless in their roles as they are unable to make meaningful changes. They do, however,

take their task seriously and interact with the clinic staff and health managers and assist with
resolving problems. Members of the forum try meeting with nurses to resolve local issues:
“When we get such problems we, as members of the Community Health Forum, we try to
meet and discuss these problems with the nurses themselves.”
(Community Health Forum – Urban District)
There is a feeling of urgency among forum members that issues need to be resolved;
“What I can say, let us not protect these people? We only need to tell the truth. We need
these things to be solved at some stage because as a member of the health forum I know
and understand the dynamics of the health system. But an ordinary person won’t be in the
position to understand and what happens later, such an ordinary person will come to you
and complain and problems must be solved.”
(Community Health Forum– Urban District)
The lack of power, however, is frustrating and some things should be dealt with by the MEC:
“We don’t have too much power. What we do is we take decisions to the District Office and
the district has to manage such problems and if it does not have a solution, the MEC of
Health has to deal with it.”
(District Community Health forum)
Health forum members see themselves as being a source of hope for the community that services
will improve and they do have some positive impacts on services.
267
“It is just that we as Health Forums, we have to be strong and give back to our community
that hope that they have to hang in there. Things will be ok in time and we always talk to
our service providers that this and that is not all right. As a community, we need to keep
on monitoring the health service to ensure that things run smoothly.”
(District Community Health Forum)
For example, forum members assisted in one clinic to resolve the shortage of medication:
“There was a shortage of medication in one certain clinic and we were able to rectify that
and the clinic is now receiving enough medication.”
(District Community Health Forum)
Health workers respect the structures as these structures are the only ones with a direct
communication line to the MEC for Health in the province, although some may not see the
formal governance structures as having positive inputs in management of health services. The
ADCHS said:
“As I say they are the committee, the existing one the governance structure we were talking
about, isn’t it? They are answerable to the MEC. So whatever issues they would, which are
discussed in a meeting and where there don’t have or they don’t agree or where they need

clarity, they are the only ones who can contact the MEC direct.”
(District ADCHS)
Involvement of the municipal ward structures and governance structures has improved feedback
to the community in Klerksdorp. Informal lines of communication have developed. The ADCHS
again:
“What we have now started with these; we tried to involve the wards, and it works better.
So you take the ward councilor and include him in the governance structure. So whatever
is discussed these ward councilors will go back to their different wards and discuss it in
their ward meetings.”
Traditional leadership does not play a significant role in Klerksdorp.
Mafikeng Health District
(District ADCHS)
Health programme managers in Mafikeng generally feel positive about the role of the
governance structures and reported that “it is really working … Even when we come to
conduct interviews, they are always present. … they are active…very active in our areas”.
(District Mother and Child Health Coordinator)
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Health managers are supportive of community involvement and believe that it can assist with
health service delivery. Managers work closely with members of the governance structures, who
are useful as they can be additional eyes in the clinics to assess quality of care and attitudes of
staff to patients. The governance structure members report back to management, as explained
by the Regional Director:
“Our local communities are talking about issues such as health officials not implementing
and not honouring the principles of Batho Pele and the Patients Rights Charter. …. we
involved our governance structures to do ad-hoc meetings and inspections and visits to
clinic facilities. … The hospital board does inspections or visits within the hospital and they
report back to the hospital board and the hospital manager. Okay it's not strictly in
accordance with our Governance Act, but they have had a very good influence and had a
very positive impact. The minute that health works start seeing that here are people from
outside, not our own managers, coming to see what we are doing, we found that people’s
attitudes have in a sense started to change. …”
(Region Health Director)
The District Manager encourages the community to take up issues, preferably through writing
submitting issues through the suggestion boxes. He said:
“… in terms of service I would like to see them complaining, taking up issues, even writing
or filling up the customer complaint survey or suggestion box, those kind of things. Not
really coming to a meeting or whatever that’s making decisions and all that, that’s a different
matter.”
(District Health Manager)

Members of the health forums in Mafikeng visit facilities to see for themselves what is happening
and to discuss issues with health workers, and they report back to the management team. They
are a link between the community, the clinics and the district in a two way communication, as
expressed by facility managers:
“And they link between the community and the clinic staff and the district.”
(Health District Facility Manager)
There is an established health forum in Mafikeng. There appears, however, to be a problem with
its sustainability. This may be related to the transitional phase and waiting for the new legislation,
but may be related to a specific problems within the health district. Membership has fallen and
instead of 12 members there are only three left:
“The health forums are there but they are not structured. The committee has to consist of
12 members but now we are left with three that is the chairperson, me [caregiver] as
assistant chairperson and an old lady of seventy two years. She is old and cannot perform
all the duties effectively.”
(District Community Health Forum)
In Mafikeng district there can be long delays in getting responses back from head office, and
can even take years, despite the provincial head office being located in the same geographical
area. This leaves forum members, who are still, feeling despondent and not wanting to continue
in their role. Members shared these frustrations:
“What we do most, we send our complaints to the district, then to hospital board so it
becomes the long channel and it delays. For in stance the complaints of 1997 up to now
have not come back to the grass root level.”
(District Community Health Forum)
269
“No improvements. … but then we don’t see the importance of serving the community
because we don’t get good results to problems that we are trying to solve.”
(District Community Health Forum)
The health forum nominated one of their own members to the hospital board in their area.
Experience of this has not been good as he never reported back on discussions and recommendations:
“In our sub – district we elected a member who will represent us at the hospital board
during their meetings but he will say that things that are discussed at hospital board meeting
is not important for us to know, while we elected him from the grass root level to represent
us. We elected him to give us any information from the board so thing could change and
to progress.”
(District Community Health Forum)
Despite the difficulties and delays in responses there are some positive achievements reported,
such as repairs to one clinic and improved medicine supplies to another clinic, as a result of
health forum intervention:

“We are aware that there are lot of problems in our clinics, like worn out ceilings and when
the facility manager takes action he will not be taken into consideration by the district office
until we as a forum take action and approach the department of Public Works … When the
clinic forum speaks things are then done in a proper way, unlike the community who are
not willing to take action.”
(District Community Health Forum)
The functioning of governance structures seems poor in Mafikeng. The local context, referred
to in other parts of this report, may play a role in this.
Traditional leadership is seen as important in Mafikeng. A paramount chief resides in the area
and is respected by the community. The traditional leadership, however, is being brought into
the new local government structures and is represented on the municipal councils.
“I think they [traditional leaders and councilors] together cooperate in decision making
nowadays, especially in this area. Because the traditional leadership is represented in the
council. Councilors from the chief are also participating in the main council and together
I think they decide on what is priority”
(District Health District Manager)
Traditional leadership is in turn supportive of health services, and are involved in the selection
process for members of the governance structures. They can offer assistance in encouraging
community members to use the services, as explained by one programme manager in the district:
270
“…we had a problem of women not sort of opting for PMTCT or VCT and low uptake. We
mobilised the traditional leaders to help us with that and it is working.”
(District Health Programme Manager)
Ganyesa Health District
In Ganyesa there have been active health forums and committees for many years. They form a
link between the community and the health services, but also link with the local authorities, as
explained:
“So, we have been elected long ago by the community and represent the community in the
health council. (Our role) is to sort out their problems, if they have any, and if the workers
within the health centre are having problems with the community, then we discuss those
problems with the local authority. … we are a link between the community and the institution.
(District Community Discussion Group)
There is an organised system for reporting back to the community:
“And then our representatives, specifically from the community who are sitting on our
forums, they take it back to the various churches or wherever they take it back so that line
of communication is there.”
(District Hospital Manager)

The hospital manager is positive about the role of the governance structures, but concerned about
their effectiveness because of the long distances from head office and delays in receiving
responses in time.
“Here we are a bit far from the head office, in so much that I think most of our constraints
will reach his office maybe late or, I don’t know, but we don’t have the responses we expect
in time. Because I think it's a matter of a distance.”
(District Hospital Manager)
Health workers, such as facility managers and others working in the clinics and in the community,
have a positive attitude towards the governance structures, although some workers were ambivalent
as to the role of the forums. Some see governance structures as “watchdogs” to which community
members complain about the services. The nurses, in turn, do use the forums to assist with
resolving problems:
“Yes it’s a good thing because if the communities complain they will go to the forum and
complain and even ourselves if there is a complaint from community or if maybe one comes
here and being rude we report to the forum and the forum will tackle that problem.”
(Health District Facility Manager)
The health forum members in Ganyesa remain positive about the services and note improvements.
There appears to be an open communication between the community, the forum members and
the health workers.
“We can say that the service, in general, has improved. … if people having concerns they
bring them, if the workers are having the concerns they take them to their management.”
(Community Health Forum)
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The formal health governance structures in Ganyesa, although the poorest and most isolated of
the three districts, appear to function well. There is a positive feeling from members that, despite
the many challenges they face, they can make a difference in their community and contribute
to the health services.
The Ganyesa Health District health workers appear to have forged a close relationship with the
community through the governance structures. The district manager from Ganyesa demonstrated
an open door approach to the community whom he said “… interact with us as much as they
are in the community.” The health forum members have an understanding of health matters and
actively participate in the quarterly review meetings. One member understands health indicators
and is keen to talk about them, as shared by the district manager:
“There is this one (health forum member) who understands them (indicators). You know I
get surprised when he talks about the indicators … so he is part of us.
(District Health Manager)
He further shared that forum members make positive suggestions for improving services and
feel free to complain directly to him if a clinic is not functioning satisfactorily:

“They do in terms of saying; let us open this clinic so many hours? Let us move this; we
have a shortage of a midwife there? Can't we change sister so and so to this area; so they
do influence how we run services. They do complain … they are able to pick up the phone
and say, hey this clinic has been closed during the weekend, why?”
(District Health Manger)
Members of the forum are active in asking questions at the quarterly reviews, which keeps health
workers “on their toes” and honest:
“And during the reviews they question why things are that way? … the governance structure
members were really firing with questions. Why is the cure rate..? Why is this? So you have
to know that the Chief Director will be there … so I won't be able to lie to them. You can't
lie. So it's very good. I mean I see this helping the service.”
(District Health Manger)
Members monitor service standards and use of Batho Pele principles:
“… the governance structure is also there to monitor whether things have been done
according to Batho Pele, according to the service standards that we have set together with
them. Are we open at the times we have specified or not, those things.”
(District Health Manger)
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Community structures in Ganyesa believe they have a positive impact on the health services.
In the past communication had been through the Tribal Authority and traditional structures.
Communication between the health facilities and the community has changed and is now seen
as being more direct, as explained by a forum member:
“We play a role because we are representing the community. So we always take their
concerns and bring them here, discuss them, and then, take the feedback back to them. So,
there is always improvement, it is better than before where there were no structures.”
(District Community Health Forum Member)
Another forum member was positive about the improved communication, and said:
“Before, as we have been saying, people did not have a say in their things, just put it roughly
that way. But today, people are having a say, through the governance structures, people
are having a say. Because before, there were no governance structures; nurses and
management were on their own. So....communicating with the community, they would just
have to go to the tribal authority, talk to those old men, either being negative or positive,
but not with the majority of the community.”
(District Community Health Forum Member)
Traditional leadership is strong in the district. Traditional leaders are part of the health forums
and attend municipal council meetings. Few decisions of importance to the community as a
whole in the rural areas are made without being referred to and debated by the Tribal Authority.

Conclusion and Recommendations
1. Figure 10.1 illustrates lines of communication between municipal and health governance
structures. These may change with the new national health legislation and provincial health
legislation that will follow. The challenge will to bring these structures together so that there
is no duplication of functions. Under a decentralisation that moves the authority and
accountability for all services to the local government sphere, this is particularly important.
Community structures are actively involved in all local government processes, including
the development of the Integrated Development Plan (IDP), which in itself incorporates
health planning.
2. Community forums are not involved in technical decisions on health services. They do
monitor clinics in the sense that they visit the facilities to ensure such things as opening
hours are adhered to, that patients are treated with respect, that medicines are available and
that the facility is maintained. This involvement needs to be extended if there is to be a
meaningful contribution from the community forums. This requires training and empowerment
and further involvement in quarterly service reviews, as demonstrated in one of the sites
visited.
3. Clarity of role and functions of all structures and clear reporting / coordination lines are
required.
4. Involvement of youth, for example from the Youth Centre Committee should be considered.
10.3 Community involvement
Community involvement in health services is either through the formal structures, as described
above, or informally through voluntary work assisting in the health facilities or community. As
explained above, community participation is entrenched in a number of policies and legislation,
and it is required of health managers to ensure that this is implemented. The extent to which
communities are willing and committed to be involved varies. Health workers and community
members understanding and experience of community involvement also vary between districts.
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Klerksdorp Health District
In Klerksdorp there is generally a positive attitude to community participation, from management,
health workers and community.
Managers and Health Workers Experiences
The Klerksdorp district manager particular appreciates community leaders who are actively
involved in their community and will take up issues of importance. He said:
“I think one of the main characteristics [of community leaders] that I appreciate is their
involvement in the community as such. If you are involved in your community, you will
certainly take the process forward because you know what the needs of this specific
community are. So I think that involvement, involvement again in the community and areas
where they are staying that is important.”
(District Health Manager)
A member of the district management team regularly attends ward committee meetings or invites
community members to meet in the district office to discuss problems:

“The Governance Act it is very clear that they [the community] need to be involved in the
compiling of the budget. I have to give feedback on the quarterly expenditure of the office.
When we look at appointments of people we draw them in on the interview panel. When we
experience a problem at a specific clinic with regard to the rendering of services we draw
the representatives in from that clinic …. She (the ADCHS) usually attends ward meetings
in the various branches, because the man on the ground he wants to speak his mother tongue
so that he can understand himself and that you can hear him over there.”
(District Health Manager)
The process of consultation is working in the district and a number of clinic improvements were
made after the community identified the need for these:
“If you look at for example in the _____ area, a new clinic has been built now. The need
for a new clinic had been identified by the councilors and the community, and we have
motivated for that and it has been built. We are currently upgrading one of the clinics in
_____ to render a 24 hour services and again the need has been identified by the community.
… The process is just slow.”
(District Health Manager)
The ADCHS in the Klerksdorp district office has been resident in the area for many years, is
part of the community and knows and understands the community well. The emphasis is on a
consultative process with the community and the health forum.
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“What I can say for each and every activity or any projects which we need to implement
in the district we sit with them in our meetings. We don’t just impose saying this is what
we are going to do. We get them in and say this is what we need to do, how can we do it
together? So they are involved from the planning sessions… to involve them when you
start.”
(District ADCHS)
She recognises that there are times when consultation is not appropriate and community need
to be informed of a decision:
“But there are issues which you need to go to them and have their decision and others
which you need to go to them and say this is what, are you happy about it. Just to consult.”
(District ADCHS)
The ADCHS understands the importance of involving the community in selection of health
forums and committees and illustrated the point through sharing her experiences when community
was not fully involved:
“We nominated some of those people but we found that some of them were not in good
terms with the whole community. So that is why we had to go back to the community at
large to get their nomination.”
(District ADCHS)

“Like I said the first example was the governance structures, where we thinking of the
people and say so and so, so and so can be in this committee. But when you go back to
people, people just don’t listen. When he calls a meeting they don’t come; there is no
progress. But when you go to them and say this is what we need to do to, this is what
committee we need to have, can you then choose your own people? The people they chose,
when they go to them and call meetings those people come.”
(District ADCHS)
These committee members are used to observe services in the clinic, and be an extension of the
“eyes and ears” of the management team. The ADCHS again:
“I won’t say demanding, they are demanding in a way to help both the department and the
community. …So we’ve requested these people to go, to visit the clinics. So at times they
go to the clinics and observe, when the clinic is full the sisters are busy they won’t notice
that the governance structure has entered the clinic. So she will sit at the back … just to
look at what, how the clinic is run then they’ll go. So in a way they are of help because they
come back and say, you know at clinic so this is what is happening. So when you get
complaints from the community then you know it is true, that it is really happening.”
(District ADCHS)
Other health programme managers in district management team are positive about the participation
with the community through the governance structures, and shared:
“Yes they are involved, because last year when we had a campaign on fighting abuse on
women, we involved them. We had meetings with them; we usually sit around a table and
discuss how to go about with those campaigns. So we do involve them.”
(District MCWH Coordinator)
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“I think they [health workers] like it because they are helping like I said previously, they
are helping us where we can not reach. They are also our eyes, like reporting something.
It is a good service that they are rendering.”
(District MCWH Coordinator)
The health facility managers are positive about the process. Their early fears of the community
wanting to ‘take over’ in the clinics have been allayed and they now see ways in which the
system can help with community outreach. Facility managers shared:
“(Previously) it was only a matter of informing them. But now that there has been a
transformation, now we invite the public, we inform them, we equip them with the necessary
solution, what you expect. Like when the Batho Pele principles were launched the information
was imparted to the public. Now that they know that even if they have a right they go along
with responsibilities, especially when coming to their own health, they must have the initiative
there.”
(District Facility Managers Discussion Group

“What I can say is that the impression that they give us, it's as if before they were told that
you are going to be the governance structure of whatever department. So when they come
to the health facilities they came with the impression that they were going to instruct us to
do this and that and that. That is why the negative attitude; but once we settled down with
them and then showed them what is really expected of them and then both of us realised
we have to work harmoniously.”
(District Facility Managers Discussion Group)
In Klerksdorp, the municipal council is actively involved with the community, and the Member
of Mayoral Committee (MMC) for Health meets regularly with ward committees and community.
“I've got ward committees. … once a month we've got a schedule meeting with the community
explaining to them what’s our agenda. … I do have a very good relationship with the
community at large.”
(MMC for Health)
She does, however, find them demanding and diplomacy is needed in dealing with any demands:
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“Very much (demanding). They don’t understand. You don’t come and tell them there is
no money; there is no ward based budget for this. But if they want this you must give what
they want. But it's not always the case; you need to be - I don’t know, diplomatic leader
to be able to convince them that we are still coming that way. We have these meetings where
before we deal with the budget we call for priority needs; to say what do you think we
should prioritise in this area? … we bring all this things together and start checking the
common issues. And say, but it seems the entire Klerksdorp has got this demand as a priority.
… That is part of the IDP. …”
(MMC for Health)
Even though the governance structures are legally constituted they have limited power when it
comes to implementing any decisions made or resolutions taken. For example, the community
in Klerksdorp, through their governance structures, requested 24 hour clinic services in all areas
of the district. This decision, however, can not be implemented because there are two spheres
of government with different conditions of service for staff involved. The MEC, as the political
head of health in the NW Province, cannot enforce the decision, although it is had been referred
to him via the correct governance lines of communication. The district manager tried, in answer
to direct questioning, to explain the reasons.
“QUESTION: You say the power to make decisions, when they sit in such a meeting, they
take the decision that we want 24 hour clinic or this clinic should operate 24 hours, why
is it that you are saying it is a problem? Because they are the community and they represent
the view of the community? They have power to decide.
ANSWER: A very relevant question. They do have the power to take the decision; they also
do have the power to give that resolution directly to the MEC. But you are getting back to
the situation that as a result of the autonomy of the Klerksdorp Municipality they have to
take, the councilors and the local mayor and whoever has to take the final decision and
they have to liaise with the union representatives.… They (the community) have limited
power. They can take a resolution on the wish of the community. But they can't implement,

they can't implement.
QUESTION: But do they have the legal power.
ANSWER: Not the legal power to implement.
QUESTION: But even the resolution, does it have a legal backing?
ANSWER: Yes.
QUESTION: Then why don’t they go to court and say we decide this; these people are not
implementing it?
ANSWER: I don’t how to answer you but I think as I have said right at the beginning you
know it, to a certain extent there is a political game also, or not game, but there is political
issues that you have to consider also.”
(Health District Manager)
Community Experiences
The community in Klerksdorp is positive about their role in health services and expressed some
understanding of the difficulties faced by health workers in clinics. They acknowledge that they
have a responsibility for the services:
“I just want to put out one thing about the community. We always blame health workers
but we as a community we do not look at ourselves first.”
(District Adult Community Discussion Group)
Participation and cooperation is seen as a two-way process and people need to be informed of
their role, including their rights and how to address problems:
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“The community receives health services. It is just that some of our people don’t know their
rights. I mean if a person is not getting what he/she wants, he/she must know what to do
and what steps to take and if they don’t know, they usually will accept whatever has been
told to them. And also, if people [the community members] do not respond to community
matters, they won’t get valuable information; because we are here and whatever we say
is what the people are complaining about.”
(District Adult Community Discussion Group)
Despite their efforts to discuss and assist the nurses in the clinics a member of the health forum
felt the situation was hopeless as nothing seems to have changed; the health problems are the
same. The informant said:
“When we get such problems we, as members of the Community Health Forum, we try to
meet and discuss these problems with the nurses themselves… At the clinic that’s where
we discuss and usually it’s a good thing if someone admits or accepts his or her wrong
doings … the Provincial Government will tell you that due to the budget constraints some
of the things cannot be done… There have never been any changes! There are no changes!
...... According to me, actually, since the clinics implemented a free service, from that day
we had these kinds of health problems. These problems, they do not get less but instead
they are getting worse!”
(District Adult Community Discussion Group)

Some of the members of the youth groups were more outspoken and not happy with the present
efforts at involving the community in decision-making. Possibly this relates just to youth
involvement as, according to the Governance Act, no person under 20 years may be a member
of the governance structures.
“You know they are busy implementing those things but they don’t involve the community
to ask them whether they are all right or not, they don’t see that. If other areas are covered
with a mobile clinic or ambulances they don’t see the reason why they should help nearer
areas that also have health problems. …”
(District Youth Discussion Group)
“The community is not consulted in the planning of health because we are living in a
community of which the members do not care about their lives in general.”
(District Youth Discussion Group)
“Like for people who are working, they will come from work at 17h00 straight to the
community meeting, and if it takes too long they will say … hey people I am tired …close
up the meeting and let’s go home. If the meeting is on Saturday they will come to the
community meeting drunk and tell the people that ‘let’s close up the meeting, go home and
watch football’. If we are in a meeting we must discuss this and this and that and then go.”
(District Youth Discussion Group)
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“Nothing much is done because even if we try to solve problems, they just grow and the
government is not prepared to help.”
(District Youth Discussion Group)
Conclusion
Community participation, although it is difficult to implement all decisions of the community,
has some success in Klerksdorp. There is a desire from the management side to make it work,
to consult with the community and to work with them in improving the services.
The adults in the community forum have an understanding of the problems and difficulties faced
by the management, but do face frustrations with bringing about change in the health in the
community. The youth were critical, but have not apparently done anything to change things.
Mafikeng Health District
Managers and Health Workers Experiences
Involving communities in health issues is a requirement of the government, according to
the North West Governance Act. However, to some health managers it is seen as a political
decision and that community members are not interested; others believe that community members
want to be involved. This was expressed in several ways by the district manager.
“So as I say it's is something that has been decided that politically it should be done and
politicians are pressing for it and we've also accepted that and go for it as well. But the
communities, no they are not really interested.”
(District Health Manager)

“No, no, political policy is that you should involve your community. Right. … so the political
direction takes precedence over any other consideration.”
(District Health Manager)
“So the community members are rather passive but the politicians are the active ones.”
(District Health Manager)
The district manager believes that a change in mind set is required, particularly from the Africans
(blacks). Mafikeng was a racially divided community under the apartheid era; Whites were
generally freer to express their opinions and the Africans (blacks) more accepting of what is
provided for them.
He further explained, community members, particularly the Africans (blacks) need to be educated
about their role in participating in the health services. The Africans in particular have much to
learn, whereas the Whites have for a long time been more demanding for service excellence.
Community members have a role to play in establishing ‘patient-centred’ health care, as discussed
in Chapter 8.8 – Staff Attitudes.
“We come from an era where the doctor was the God and we have moved to an era where
the perception is that the nurse is the God and we need to break that, because service is
all about the person who receives the service being the God and acceding to his demands
and all that within reasonable limits. To get to that point we need the community. If the
community is not involved we will never have good service. … you will find that good service
is found in predominantly White areas and not in predominantly African areas. Why?
Because in general Whites tend to stand up and say we want it and in general Africans tend
to accept it as it is. So basically there is, if the community is not active we never get it right,
categorically there is no solution; they just have to be involved.”
(District Health Manager)
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Batho Pele principles are applied by health workers, but, as the HIV/AIDS Coordinator in
Mafikeng said, it is a two way process and equally apply to health workers:
They (the community) used to demand but now they are doing it in a joint effort…. because
even with the Batho Pele principles you have to understand that it doesn’t mean them only,
it's a two way process.
(District HIV/AIDS Coordinator)
In the urban area of Mafikeng, however, it is not always easy to get community members to
participate. It is much easier in the rural villages – as explained by the district manager:
“So we have to involve the community. But when we go to the community, most of the time
you will find people that are active, but they will be in the minority of the cases except, as
I say, in the villages; you will find that it's a little bit different. But in the township if you
call people you are unlikely to get a lot – unless there is an urgent matter; like maybe a
child died or a woman died in the area very recently and you know it's still emotionally
fresh, you will have people.”
(District Health Manager)

The rural areas around Mafikeng were part of the Bophuthatswana homeland where there has
been community involvement for many years. These areas are still under some traditional
practices which are largely absent in the urban areas.
Other members of the health management team, such as the HIV/AIDS Coordinator and the
ADCHS, are generally more positive and believe that community involvement has increased
because the community are interested and do care.
“Awareness and the people will be willing to assist because they now show that they care.
They are even encouraged by politicians you know to assist here and there. But political
issues aside, really there is interest and awareness.”
(District HIV/AIDS Coordinator)
“You know the other thing that I would like to say about those community representatives;
really they would not like anything to happen in their community without their involvement
and their participation. Most of the projects have failed because they were being imposed.
So now we have learnt a lesson of involving them. For example if you want to let the mobile
visit a certain area, they don’t accept that, they will not consult, they will not go there, they
will not support that.”
(District ADCHS)
Community participation is seen by the district management team as being beneficial to clinic
managers and nurses working in the clinic.
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“They [health workers] think its [community participation] good, they like that… .things
become easier for nurses working at the clinic. Let’s say maybe the clinic is without the
security, one of the community members just volunteer to come and be a guard at the clinic.
They take the clinic as their own and their property, not the government property…Yes,
definitely it is beneficial.”
(District MCWH Coordinator)
Facility managers, however, generally see the community as passive and not interested in the
health education they offer, although they do consult them on issues:
“I am sorry to say, from the community …. They don’t have any interest. We have tried to
give them health education. … They are the ones who are having negative things. Mainly
they are using traditional medicines… So it is a very difficult thing and there are no
volunteers.”
(District Facility Managers Discussion Group)
“So we normally consult them for any view or suggestion that we have and we normally
take the decision that they are comfortable with.”
(District Facility Managers Discussion Group)
Programme managers are supportive of meetings with members of the formal governance
structures and the wider community. These meetings are opportunities to share ideas and health
issues, although there may be a ‘top-down’ approach in delivering the message.

“The community where there was not much community participation… now they are involved
… they send their representatives. Then they are informed about their health issues, what
is going to happen, like if there is an awareness (day), we organise an awareness (day) to
come and inform the community about a topic that we chose, then they will participate, they
will welcome us.”
(District ADCHS)
“If there is something that the Department of Health want to do in the community, they are
being consulted first to see if that is what they need. Then if that is not what they need, they
will not accept that, and then one would end up failing. So that is why they are always
consulted first.”
(District ADCHS)
“There is nothing that we can really achieve without the community, because we do not do
things for the community. We want them to do things for themselves … We just come with
the ideas, discuss it with them and they accept it and then they will do.”
(District ADCHS)
“There is a policy of HIV/AIDS; it was done in consultation with different stake holders. I
remember it was during 1998 in Rustenburg where we had all stakeholders brought on
board and then it was first discussed, it was drafted and it was circulated for comment and
then it was adopted and then it was utilised and brought to the attention of everybody.”
(District HIV/AIDS Coordinator)
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The Regional Director expressed a strong opinion that participation by the community is not
being optimally used to ensure quality of care. Much more could be done if the community
would complain, justifiably, and carry it through. There are time delays in reaching finality. This
could be due to the bureaucratic system which leads to frustration and feeling of hopelessness.
This was also mentioned in a community group – discussion on, ‘Community Experience’. The
Regional Director said:
“Well if the facility manager does not take it [a complaint] any further; it just retards the
whole process. Because that patient, or that community member, will then have to bypass
the facility manager to try and get to the district manager. It takes a committed person.”
(Regional Health director)
“The patient can go to his ward council and say, look I have had this problem. The ward
councilor can immediately bring it up with the Health Portfolio Committee who will request
the health manager to make a submission or whatever. And this whole process can take up
to two years…”
(Regional Health director)
Community Experiences
Community members in Mafikeng expressed frustration with their interaction with the health
services and feelings of powerlessness in being able to bring about any changes. This was in

marked contrast to the positive impressions spoken of by health workers and managers. Comments
made reflect a disinterest from many members of the community, despite the efforts of the Health
Forum, health workers and others to call meetings and involve them in health issues.
Community members do not respond to a call to a meeting, but blame the forum for not doing
their work:
“As the committee we are representing our community and we are trying our level best as
the health forum but when we call the community to come to the meetings they don’t come
and they are less interested although they go to the clinics everyday. The clinic is always
full of patients of the very same village, those who are always complaining, and it is as if
we, the committee, we are over the clinic staff. They are sick but they don’t have interest.
They keep on saying the clinic forum is not performing its job as a forum, that it’s like the
clinic staff.”
(District Adult Community and Health Forum Discussion Group)
The committee needs community support to do their work:
“We are trying to work hard but we will never be effective (as a committee) without the
help of the community. …We need help to win this battle and we cannot fight alone.”
(District Adult Community and Health Forum Discussion Group)
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The community elected the committee but are not themselves prepared to take any responsibility
with making decisions:
“The community is always consulted but they always turn their backs when coming to take
responsibility and even if you can call a community meeting only few come. You cannot
take decision when those who are supposed to be involved are not there.”
(District Adult Community Health Forum Discussion Group )
The youth groups were more outspoken in expressing their views on community participation:
“Our community is not capable of any responsibility because we are living in a planet
where everyone is waiting for others to act so that they can come and claim that they are
the ones that brought about changes.”
(District Youth Discussion Group)
“How can there be changes when we as the community are not doing anything? I think
maybe if our parents together with youth can come together, maybe there can be changes,
like for instance forming a health committee, increase of ambulances. Because for now if
you call an ambulance to come and take a sick person at home, it takes the whole year for
it to come.”
(District Youth Discussion Group)

A feeling of hopelessness was expressed by forum members at the delays of the health services
to be able to solve problems and to respond to their needs. There is lack of information on issues,
such as moving services to the municipality, as expressed by one adult community member:
“Years and years not even six months (time to solve problems), we always talks about
shortage of staff, ambulances and for the clinic to open for 24 hrs but there are no
improvements…. We heard that the department of health is moving to the municipality,
maybe the municipality will change some of our problems…. It is important that we should
have clinic forums.”
(District Adult Community and Health Forum Discussion Group)
There is unhappiness with the behaviour of nurses:
“They (the services) can only be good when the community take charge of their lives and
the nurses change the way they behave and everything will be good.”
(District Adult Community and Health Forum Discussion Group)
Community care givers are not adequately equipped for the work they have volunteered to do.
“Even the caregivers complain that they don’t have first Aid kit when they visit their patients
in the village. Again we are tired of being volunteers without incentives. They don’t even
give us gloves that we [caregivers] can use to bath a patient who is very ill. Then all we
do is we just give patients their treatment to drink. We as caregivers don’t feel that we serve
our purpose of being caregivers.”
(District Adult Community and Health Forum Discussion Group)
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The official process for laying complaints is long and many people have given up trying:
“If you go to relevant people, they will tell you that ‘many people have attempted what you
are going to do and nothing has been done, what makes you feel if you report they will do
something?’ … Sometimes you feel ‘ok fine, I am going to take further steps for these nurses’,
but so many people have tried to, but nothing happened and sometimes we don’t know
where to go… The other thing, you cannot go straight to the MEC office to lodge a
complaint; there are steps to be followed and it takes times.”
(District Youth Discussion Group)
Conclusion
In the Mafikeng Health District the relationship between health managers and workers, the health
forum and the community members is not a happy one. The District Management Team and the
Regional Director seem keen to see the relationship work and would like the role of the health
forum to be expanded. The community, however, appear to be reluctant to respond to the call
of the health forum, who themselves are struggling to work as a team. The forum has only three
active members.
The researcher did not interview Mafikeng Municipal Councilors to obtain their views.

Ganyesa Health District
Management and health workers experiences
The district management was noticeably aware of the community and appeared to have an open
relationship with the health forum and the community at large. They believe the process has a
potential positive impact on all services. The community can be an extension of the management
in that they can report problems that need to be addressed. This was expressed by the district
manager:
“We do interact with the community. … Yes I do think the process is assisting us in improving
the service and they checking us, they are giving us information as to what they need.”
(District Health Manager)
“Some [health workers] think that this [community involvement] is just nonsense interference,
you know the health workers they do sometimes feel this person is just interfering but we
continuously tell them we don’t accept any other way, the community must be involved.”
(District Health Manager)
There is also community representation on the Local AIDS Council.
284
Traditional birth attendants (TBA) are active in some areas and work closely with the health
services assisting with antenatal care and home deliveries where access to services is difficult.
In other areas community members do not indicate to the health services that they have been
delivered by a TBA and the clinic staff are thus not aware of the TBAs in those areas.
Community health workers (CHWs) and volunteers act as health advisors in the community,
referring people to mobiles or clinics for further advice or treatment, including for VCT. Some
areas have care groups associated with all mobile points and clinics that act as a more direct link
between the community and the health facilities. These assist with the tuberculosis directly
observed treatment (TB DOT) programme, health education and home-based care.
Youth Centres are being established in some parts of the province as a meeting point for
adolescents and the provision of some health services, in particular related to HIV/AIDS and
reproductive health. These are generally considered by youth to be “safe havens” for them when
they want advice or treatment. Youth groups in some communities work with the health services,
but focus more on cultural and sports activities to keep the youth occupied; for example Ganyesa
Youth Cooperation.
Clinics have suggestions boxes available in which community members can place their suggestions.
These are cleared and attended to by the facility staff and district management team.
Community Experiences
Members of a community health forum in a rural district confirmed that health awareness day
campaigns are decided and organised by the health workers and not by the community or the
health forum.

10.4 Intersectoral collaboration
Many health issues rely on services from other departments. An integral part of DHS, PHC and
decentralisation is the requirement that government sectors work together with other stakeholders
within the district or district. The general feeling is that this has improved over the past
10 years, but that the improvement is not necessarily due to decentralisation.
The provincial government departments function within clusters. Health is part of the Social
Services Cluster that also includes Social Welfare Services, Arts, Sports and Culture, and
Education. This cluster is responsible for implementing the National Integrated Plan for HIV/AIDS
for which regular meetings are held.
The Department of Health works closely with:
• Dept. of Social Welfare – on grants, and women and children issues
• Dept. of Safety and Security and the South African Police Services – on rape, violence
against women, and prevention and treatment
• Dept. of Education – on giving health education, particularly on HIV/AIDS and
reproductive health. This is in conjunction with Youth Centres and health promoters
who visit schools.
• Private sector, including private hospitals and clinics. The province is responsible for
licensing all private health facilities, but there is difficulty in accessing statistics of
services rendered in the private sector. This is starting to improve in parts of the province.
…”if we work together we will achieve healthy women and healthy children. Then we will
have a smooth referral between them and us. … there is a start. … we used to fight with
the patient … we don’t want to take a patient from the private. We want to be accessible
… we will be tossing this patient around and we don’t want that.”
(District ADCHS)
285
Klerksdorp District Management is negotiating with the mines to outsource some primary level
public services to their under-utilised hospitals.
Private practitioners – collaboration is difficult, but the department of health endeavours to
involve them in training and does send copies of new protocols and guidelines to general
practitioners.
“They (private practitioners) used never to care and they would say who are you? Now I
can see the HIV/AIDS Coordinator, the Communicable Diseases Coordinator and the
MCWH, they go to their private rooms with any changes, like if there is a change in
immunisation or TB protocol. …we do have a problem … we need to sit together and
(develop guidelines to work together).”
(District Health ADCHS)
General practitioners are being requested to do VCT in some areas, with the department supplying
the test kits.
• National non government organisations, such as LoveLife, and locally based NGOs.
The latter may be funded through the PDoH, who monitor the use of the funding.

• Youth Centres. These have been established in a number of districts by PPASA in
collaboration with the PDoH. Other departments, such as education and social services,
have also been involved.
• Other departments, such as agriculture, home affairs and labour – for example in the
Malelane Village Project.
• Volunteers – who are trained by the nurses and work in the community providing basic
health education.
• Other community based groups – in particular women’s groups and faith based
organisations.
• Traditional leadership structures.
• Agricultural Unions – to assist with health problems of farm workers.
• Local AIDS Council – these have been started in most districts, led by the PDoH. They
are now under the Premier’s office at provincial level.
“I personally did that when I arrived here … I started by conducting meetings with all
government departments and community based organisations and NGO’s and launching
a partnership with them. … we launched the Local Aids Council composed of the NGO’s,
the government department, the non governmental organisations (……)”
(District Health HIV/AIDS Coordinator)
286
The intersectoral linkages listed above assist in the holistic management of patients with clear
communication and referrals lines, as explained by ADCHS in Mafikeng and Ganyesa:
“What we would achieve, you know the referral pattern, you know … where to refer this
woman who has a social problem.”
(District ADCHS)
“… we would like to see the other sectors getting more involved because as it is now people
come to rely more on the Department of Health; that we should do everything. So what one
would like to see is a joint venture with all other sectors to really get into reproductive
health.”
(District ADCHS)
At clinics, particularly in rural areas, there is generally good intersectoral collaboration as all
sectors are working together within the local community. For example, the clinic staff will work
hand in hand with Water Affairs and Public Works.
“Like education, like water, like transport, like public works … It was always like that, we
have been integrating with one another and even after the decentralisation we haven’t seen
any difference, we still talk the same way: we've got a problem, come and assist us.”
(District Local Area Manager)
Women in Partnership Against AIDS is an NGO working with and being empowered by
government to work in the community:

“The one that I know has something in health decision making is this one, Women in
Partnership against HIV/AIDS…. These women are being empowered and given information
on the activities pertaining to the health of women… And then at local level, in the villages,
women are being involved; they are being given information … and they have input in
saying that this is what we think can be done for women.”
(Member of the District Health Management Team)
There is an NGO in Mafikeng, funded by the department, specifically involved with cervical
cancer screening. The NGO works closely with the health facilities in referring patients to them
for further management. The PDoH has funded some of the work, but the health district is
expected to take over this funding role.
287

Figure 10.2: North West Province - Health Governance Relationships
(from North West Health Bill 2002)
MEC for Health
Head of Dept.
of Health
288
PHA
MEC - chair
Health Councilor for Health - each
district council
Organised Local government
Head of Dept. (ex officio)
Others are determined by MEC
Representative of managers of health
districts
Advisory to MEC
Determine policy
Legislation
Consider requests from DHA and
MHAs
Monitor PHMC
Health Plans
Others as determined
DHA
District Council member for health
Local municipality health councilor for
each B within the C
Health District Manager (ex officio)
Others appointed by MEC
M&E health services
Coordinate and support local
municipalities with MHS
Consider district plans
Carry out functions as required
by PHA
PHMC
Head of Department
Each regional health manager
Others as determined by the MEC
Report to PHA
Coordinate policy
implementation
Make recommendations to
the PHA
Other functions as required
by the PHA
MHA
Member of the municipality for
health
Member of each Ward for health
Chair of hospital board
Municipal Hospital Manager (ex
officio)
Rep from interests groups -
determined by MEC and PHA
Nominees from community health
forums
Report to PHA
Coordinate policy
implementation
Make recommendations to
the PHA
Other functions as required
by the PHA
Health
Regional
Manger
Community Health
Committees
Health
District
Manger

Chapter 11
Logistics and Referral
11.1 Introduction
Support services and functional referral systems are essential for delivery of quality health
services. This chapter reviews and discusses the essential support services which include:
• Drug supplies.
• Transport, other than ambulance services.
• Laboratory services.
• Infrastructure and maintenance; and equipment.
• Emergency Medical Services (ambulances) and referral system.
11.2 Drug supplies
Policy and legislation
Pharmaceuticals are second only to personnel as cost drivers for health services. Storage,
prescribing and dispensing of drugs is controlled through national legislation and policies that
are implemented through the PDoH.
The National Drug Policy (NDP) was proposed in the ANC National Health Plan for South
Africa that “will incorporate strategies for the effective application of drugs within the framework
of the National Health System.” 1 It included, among others, an Essential Drug List (EDL) for
use in the public sector, adequate and timeous distribution of drugs, the rational use of drugs
and a mechanism to assure that “all professional and health workers will be suitably educated
and trained to enable them to promote the appropriate and rational use of drugs.” 2 The
development of policies for pharmaceuticals has been separated from other health legislation.
The NDP was published in 1996.
289
The goal of the National Drug Policy is “to ensure an adequate and reliable supply of safe, costeffective
drugs of acceptable quality to all citizens of South Africa and the rational use of drugs
by prescribers, dispensers and consumers.” 3
The policy covers broad principles of prescribing and dispensing of drugs in the private and
public sector. This includes the requirement:
“Medical practitioners and nurses will not be permitted to dispense drugs, except where
separate pharmaceutical services are not available. In such instances/situations where
dispensing by doctors and nurses has to take place, such persons will be in possession of
a dispensing licence issued by the Medicine Control Council. Proven competency of such
persons to dispense drugs will be by virtue of the successful completion of a suitable training
programme. All licences will be reviewed and renewed annually. 4
This requirement has the potential to impact negatively on RHS and treatment of infections,
such as sexually transmitted infections, at the primary health level. The nursing profession form
1 A National Health Plan for South Africa (1994); ANC – page 38.
2 A National Health Plan for South Africa (1994); ANC – page 39.
3 National Healthy Policy for South Africa (1996)
4 National Healthy Policy for South Africa (1996); page7

the back-bone of treatment of patients at this level in the public sector. Each nurse practitioner
will be required to be trained and registered with the MCC.
For procurement of drugs in the public sector,
“The public sector coordinating body for procurement (COMED) will be strengthened.
Price negotiations for the procurement of essential drugs and medical supplies for the
public sector will be undertaken at the national level, using national and international
tendering. After contracts have been awarded provincial authorities will purchase drugs
directly from suppliers. All public sector institutions will procure essential drugs through
the public sector tender system. In the long term this system will be extended to NGOs and
the private sector.” 5
This requirement ensures drug procurement remains centralised to the national level, with the
provincial level responsible for drug distribution.
“Provinces will make their own distribution arrangements to ensure that drugs and medical
supplies are distributed in the most cost-effective manner. Where appropriate, provincial
authorities may contract distribution to the private sector.” 6
The NDP recommends under human resource development that doctors, nurses and pharmacists
are trained, among others, in managing a decentralised health system.
290
Many of the principles outlined in the NDP have subsequently been legislated through the
Pharmacy Amendment Act (Act 88 of 1997) and the Medicines Amendment Act (Act No. 90
of 1997). The implementation of these amendments is being phased in and the requirement for
all prescribers and dispensers to be registered with Medicine Control Council comes into effect
on 1st July 2005. This means that "any prescriber who wishes to dispense must (a) complete
the supplementary training course, (b) apply for the license, demonstrating need and (c) pay the
fee. The course costs at least R2500, the application fee is R2400." 7 There has been little training
of nurses to date.
The possible impact on primary health care services, including reproductive health services, is
of concern to pharmacists, as expressed by the Mafikeng Provincial pharmacist:
“Yes [the hospital will continue to supply drugs to clinics] because I think especially with
this law that is coming. A person who is trained, who is registered, with the council is the
one who’ll be responsible for dealing with these drugs and for dispensing, for doing anything
related to the drugs, handling of the drugs. I think then they will need to train their assistants
there [in clinics] because there will have to be registered pharmacist assistants responsible
for dispensing. I think the law will have been passed by July 2005 and there must be a
qualified nurse assistant. I don’t know how they really going to do it … everywhere where
the drugs are kept. … The mobile as well, there must be somebody trained…... who is
registered with the pharmacy council.”
(Provincial Hospital pharmacist)
5 National Health Policy for South Africa (1996) – page 13.
6 Ibid - page 15.
7 Personal communication; Andy Gray, MSc(Pharm) FPS * Senior Lecturer, Dept. of Therapeutics and Medicines Management.
University of KwaZulu-Natal, 2004

Procurement, distribution and budget
Figure 11.1 shows distribution system for drugs in NW Province. Central Medical Stores
purchases drugs from the suppliers. These are transported to hospitals throughout the province
as per order received. A hospital within a health district is responsible for distribution of drugs
to community health centres and clinics as per orders received from these facilities. Mobile
clinics are supplied by a CHC. Patients receive medication from hospitals, CHCs clinics and
mobile clinics.
Figure 11.1: Drug Distribution - North West Province
Health Sub District
Central Medical
Stores
Hospital
Community Health
Centre
Clinics
Mobile Clinics
Suppliers
Community
291
In NW Province, drugs are purchased by the Central Provincial Medical Stores in Mafikeng.
Purchases are made on national tenders. Distribution of drugs to all district, regional and provincial
hospitals in the NW Province is privatised. Primary level facilities are supplied by the hospital
within their health district. This distribution is done by either the hospital or the district, or both.
The system can cause tensions between the two institutions of the hospital and the primary level
facilities, as expressed by the Klerksdorp Hospital Manager.
“Yes - pre-packs are sent to different clinics, it is done centrally from here. It all depends
on the order that is placed, they are put under constant pressure, the managers that they
always overspent and sometimes the way that they get hold of it is not to order through us.
They run short of medication and then the patient comes here, duplication of services,
going to different facilities to get their drugs. So I think balancing resources versus quality
of care is a constant challenge to managers, clinics and patients.”
(Provincial Hospital Medical Manager)
Distribution from hospital to the clinics is dependent on a vehicle and a driver being available
at the same time. This is not always easy. In Mafikeng, for example, distribution is usually
done using a hospital vehicle with a driver from the district. The two are managed through
separate systems – one by the hospital and the other by the district. The pharmacist explained:

“There will be problem sometimes but it’s only one van, so sometimes it’s not available
even from the district the driver will not be available while the vehicle is available. Like
in the past few months actually we phoned, we are using their drivers by the way then they
will ask them to provide the driver when the driver is not available.”
(Provincial Hospital Pharmacist)
There are no plans to establish pharmacy depots within the health districts to supply the clinics.
The bulk ordering from central stores and distribution to clinics will remain a hospital pharmacy
responsibility.
Clinic staff are responsible ordering drugs from the hospital. These are usually supplied as prepacks,
so that dispensing involves selecting the correct package, labeling it with name and clinic
number of the patient, and the date, before handing it to the patient. At times, however, drugs
are supplied in bulk. This means the nurses are responsible for counting out tablets and packaging
them before dispensing. Professional nurses in some clinics dispense directly to the patient from
a cabinet in their consulting room; the larger clinics have a separate pharmacy where drugs are
dispensed by a nursing assistant or other health worker.
“… the sister dispenses from her medicine cabinet, and they are dispensing. So it’s not the
most favourable that I would like to have. It would help immensely to see pharmacist
assistants in the clinics that can dispense, if only it’s the chronic drugs.”
(District Pharmacist)
292
Drugs and supplies is a standard item on each facility budget. Facility managers are responsible
for the budget in their facility. The budgeting process is done in consultation with the district
management team; final approval is given by the provincial office, through the regional office.
Many managers acknowledge that pharmaceuticals are under-funded. The regional directors
are addressing this.
“We always have an under funding of pharmaceuticals and people have had to buy on other
standard items and journalise and whatever and it never came right. This year we were
given a task and we said right we were going to do it [increase budget for drugs].”
(Regional Health Director)
Hospital pharmacists support the perception that clinics are under funded for drugs. The budgets,
although allocated to facilities, are debited through the hospital system to each facility when
the drugs are distributed.
“All the clinics receive too little, the budget is too small.”
(District Pharmacist)
In Ganyesa district, the hospital pharmacist noticed one clinic was not ordering any drugs. She
was informed that the clinic had overspent on drugs and had been prevented from ordering. She
said:
“When I started here at the beginning there was a clinic that did not order, and when we
asked them but why not they said it was district sisters, they were over their budget and

they cannot order. But you know that - then they are not going to deliver any service to
their community. I don’t really know what happens.”
(District Hospital Pharmacist)
The Ganyesa Hospital Pharmacist further explained that monthly expenditure reports are available
to all facility managers for their own monitoring, but that few have ever asked for these. The
health district manager has never asked for a report. The hospital pharmacist submits reports
to the hospital manager and to the regional pharmacist as they are the hospital pharmacist’s line
managers. She has no direct management line to the health district, nor any direct input into
facility’s budgets.
Over or under stocking of drugs in the clinics is a problem. With over stocking there is likely
to be more expired drugs in the clinic with consequent financial loss.
“I think some clinics do overstock, especially some of the small clinics. … I received more
expired stock from the small clinics than I received from the bigger clinics. … I try to cut
it if I think that this is too big for them. But I'm not exactly 100% sure if I'm giving too much
or giving too little.”
(District Hospital Pharmacist)
The distribution system appears to be functioning well in the districts. Facility managers noted
an improvement in drugs being available and had few complaints.
“… if you order in time you get what you need, and your planning and organisation is up
to standard, you won’t have a problem.”
(District Facility Managers Discussion Group)
293
Drug availability and use
The 2003 National Primary Health Care Facilities Survey (NPHCFS) found in the NW Province
that only 17% (8% nationally) of all PHC facilities had a full stock of EDL drugs. The availability
of commonly required tracer drugs, as traced monthly through the DHIS, was much higher.
Commonly used antibiotics (Cotrimoxazole, Penicillin and Doxycycline) were found in over
90% of facilities (same nationally); injectable contraceptives in 100% of facilities (97% nationally);
and condoms in 97% of facilities (same nationally). 8 The survey data was not disaggregated
down to the health district level. Quarterly reports for 2002/2003 show that the availability of
the EDL tracer drugs in the three study sites were:
• Klerksdorp = 99%
• Mafikeng = 98%
• Ganyesa = 94%
At certain times there are problems with the supply of drugs from Central Medical Stores, which
means that clinics can be short of essential drugs, such as certain antibiotics and some chronic
medications. The cause of the shortage is often a manufacturer’s problem in being able to supply
sufficient quantities. Contraceptives are rarely affected by such shortages, as mentioned by a
pharmacist and a facility manager.
8 Health Systems Trust. The National Primary Health Care Facilities Survey 2003 – North West. Durban: National Department
of Health and Health Systems Trust; 2004.

“The medicine is available all the time unlike before … It is only here and there, but I can
say it’s 90% now. … I think what has improved is that we are getting the treatment from the
hospital and we are ordering it fortnightly … we don’t have a problem with medication.”
(District Facility Managers’ Discussion Group)
“Okay there are some other drugs but not contraceptives [been out of stock].”
(Provincial Hospital Pharmacist)
According to hospital staff, the experiences of primary level facilities do have shortages
of medication. This is noted by the number of patients attending hospital for primary level
medication. This means that the cost of these drugs is borne by the hospital instead of being
borne by the clinic. The medical manager of Klerksdorp Hospital expressed his concern:
“…pre-packs are sent to different clinics; it is done centrally from here. It all depends on
the order that is placed, they are put under constant pressure, the managers, that they
always overspend and sometimes the way that they get over it is not to order through us.
They run short of medication and then the patient comes here, duplication of services, going
to different facilities to get their drugs. So I think balancing resources versus quality of
care is a constant challenge to managers, clinics and patients.”
(Provincial Hospital Medical Manager)
294
As part of the NDP, an EDL for primary, secondary and tertiary level facilities was developed.
The primary level EDL is for use in clinics, CHCs and district hospital outpatients. The EDL
contains treatment guidelines for commonly occurring conditions and the drugs for these are
made available in the clinics. Patients referred from a hospital to a clinic for follow-up should
be discharged on primary level EDL drugs.
A concern expressed by a pharmacist is the poor liaison between the hospital and clinics in
treating patients. Doctors do not regularly visit the clinics and are not always aware of the drugs
available on the primary EDL. On discharge patients are down referred from hospital to a clinic
for maintenance follow-up. These patients, however, may be discharged from hospital on
medication that is not available at a clinic and is more expensive. Alternatively, a patient that
is well controlled on primary level drugs for hypertension through a clinic who then attends a
hospital for an unrelated health problem can be changed by a doctor to other drugs that are not
available when the patient goes home. Part of the problem appears to be the poor communication
between the management of districts and management of hospitals, and non-adherence to the
same treatment guidelines.
Pharmacy staffing and training of Health Professionals
There is a shortage of pharmacists in the public sector, particularly in district hospitals and
primary level facilities. 9 Facility managers are responsible for ordering, storage and control of
drugs. There are no pharmacists or pharmacy assistants based in CHC, clinics or mobile clinics.
There is, however, a post for a pharmacist in the regional offices whose role is to oversee the
use and control of drugs within the whole region. Not all these posts in the province are filled.
In large CHC and clinics the responsibility for drugs may be delegated to one nursing assistant
or professional nurse. In smaller facilities the responsibility is shared according to who is on
duty.
9 Health Systems Trust. The National Primary Health Care Facilities Survey 2003 – North West. Durban: National Department
of Health and Health Systems Trust; 2004. pg 30.

Drug management is a specialised field and training is required. Hospital based pharmacists
give support and guidance to the primary level staff. This role is often given to a community
service pharmacist if one has been allocated to work in the hospital, as shared in Klerksdorp:
”Yes, that’s my job; I have to go every month I inspect the storeroom to see that the drugs
are stored in the correct way. I check if their refrigerator is working. … I check that they
do not overstock on some drugs and that they do not under-stock on some drugs. And then
I check their orders when I go to the pharmacy as well. …”
(Community Service Pharmacist)
Training in drug management, including ordering, storage and maintaining stock levels is given.
This training was originally offered at the provincial level for all pharmacists and their assistants,
who were then expected to train clinic staff. The pharmacist in Mafikeng explained:
“There used to be that (going out to train the nurses). There was an annual drug supply
management course when I started working here. It used to be attended only by the pharmacist
and some of the managers and then we will organise something like a workshop to train
the nurses of the clinics in drugs supply management.”
(Provincial Hospital Pharmacist)
Nurses are now included in the annual provincial training. Some pharmacists, however, are
concerned about the lack of capacity in the clinics to manage drugs:
“I went to a drug management course a while ago and they were talking about their stock
cards and there were sisters from all over the district and very few of them knew what they
were talking about. There are some, they did have the stock cards but … I am not sure in
this district.”
(District Hospital Pharmacist)
295
The hospital pharmacists are not able to provide the additional training due to the shortage of
staff. Ganyesa District Hospital has one pharmacist who wants to start a training programme
for pharmacy assistants in the hospital and who may in time be able to visit the clinics. She is
waiting for the Pharmacy Council to respond to her request.
Mafikeng Provincial Hospital has two pharmacists for the hospital complex of over 500 beds
plus the clinics in the district. It is no longer possible for them to visit the clinics as in the past.
“We used to go to the clinics but because of you know staff shortage that has turned out
to be impossible, because I mean we are only two pharmacists in the hospital. But while I
was doing community service we used to go out to the clinics to check their stock to do
stock levels. I think it helped them a lot because they didn’t, they ordered what they are
supposed to order the right quantities, and they were not over stocked. They were not under
stocked.”
(Provincial Hospital Pharmacist)

Community members’ experiences
Community members express an appreciation for the improvements they have seen in accessing
medicines. The Mafikeng group said:
“They are good and the government tries to provide medication even though sometimes
you won’t find them.”
(District Community Discussion Group)
There are complaints of shortages of medicines at some clinics, but never any shortages of
contraceptives. These are available at all times and for anyone requesting them, even adolescents.
A community discussion group expressed satisfaction with the situation:
“When coming to family planning everything is available, you won’t go to the clinic and
you find out that there’s nothing on family planning. Contraceptives are always available
at the clinic in different types.”
(District Community Discussion Group)
Shortage of medication is experienced in some areas, as shared by members of different discussion
groups:
296
“They are usually available but if there is a stock out we go back home and wait for new
stock to come.”
(District Community Discussion Group)
“All the clinics in this area have a problem of shortage of medication, you will find out that
even Panadol (paracetamol) to give to a sick child is not there….”
(District Community Discussion Group)
“Yes. Last year at times there was a shortage of medicines. But this year we never had such
a problem. But last year and years before, there was really serious problem when coming
to medication.”
(District Community Discussion Group)
Budget constraints are a concern for the community:
“Another recommendation … the government can look into the budget of the clinics, or let
me say of the district, so that more money can be allocated for medicines, especially when
coming to the pharmaceuticals for STI’s.”
(District Community Discussion Group)
Certain problems were noted by some community members. Some of these are related to
the staff attitudes to patients. Professional nurses appear to give preferential treatment to
some patients, particularly friends. A member of one discussion group shared:

“There are a few ladies that I know who are working at the clinics; they tell patients that
certain medication is not available. But if I go there and consult they will give me the best
medication that I was supposed to get but other patients won’t get anything. And I usually
ask myself how come I always get my medications but other patients do not get this
medication?”
(District Community Discussion Group)
Some people noted an apparent leakage of drug stocks into the community.
“If you can go to the families whose mothers are nurses, you will be shocked finding out
that they have opened a chemist at their home. And their children get good medication.
Unlike us going to the clinic, they give us diluted Panadol.”
“The nurses working at the clinic open small chemist at their homes and this usually causes
stock outs. Their children, family and close friends usually get good and best -not dilutedmedication.”
The governance structures, through intervening when there are stock outs, can have a positive
influence on the health services in ensuring drugs are available. See Chapter 10.
Conclusion
• Policy and legislation for drug management is centralised to NDoH.
• Procurement and distribution is a provincial responsibility.
• PHC facilities are supplied by hospitals. However, these are part of different institutional
management systems.
• Drug supply to clinics is better than previously in North West. Some antibiotics may
be out of stock, but contraceptives and condoms are well supplied.
• Management of drugs is a concern because of shortage of trained staff.
• Purchase of drugs outside of EDL is permitted, with motivation, in hospitals.
297
11.3 Transport, other than ambulances
Policy
Policy for transport provision and management within all departments of the public sector is
determined by the National Department of Transport. The NDoH is not consulted on policy for
transport of health services.
In the provinces, the Provincial Department of Transport manages the provincial fleet according
to national policy; all departments, including health, obtain their vehicles on a lease system from
the Department of Transport. The vehicles within the health department and allocate to functions
and institutions at all levels of the health system. It is a complex inter-departmental and
inter-government system, with privatisation of some fleet management functions.
There is a subsidised vehicle scheme available for health workers whose official duties require
them to travel from their official base. To qualify to join the scheme the official must meet
predetermined conditions of traveling more than a preset minimum number of kilometres per
month and meet the financial conditions of a finance institution. This scheme does, to some

extent, alleviate the general shortage of vehicles for health services. The scheme, despite some
inherent problems, does enable clinic supervisors and programme managers who have subsidised
vehicles to visit clinics when required. 10 Positive response to subsidised vehicles was expressed
by district programme managers:
“No, I go out; I have a subsidised car to visit them. It is not a problem for me to visit the
clinic.”
(District MCWH Coordinator)
“Yes [can do supervisory visits] - because the people who are because like I have a subsidised
vehicle. When I go out I take my vehicle, I don’t have to rely on …. The same applies to
the district managers because there are people if they want to visit they just go and visit.”
(District ADCHS)
“I don’t have one [a subsidised car] for now, but I have applied for one. But we've been
allocated a vehicle to run around the other clinics and we've got a mobile vehicle also to
go to the neighbouring posts.”
(District Area Manager)
298
Local government health services are supplied with vehicles through their own local municipality.
These vehicles are managed through a different system. It is not possible for a municipal employee
to drive a provincial vehicle, and vice versa. In NW Province recent agreements between the
PDoH and some municipalities have been reached enabling health workers from the different
government spheres to travel together.
Transport allocation for health service delivery
Transport is an essential support service within the health services. It is not only required for
transfer of patients between levels of health care, but is required for delivery of drugs and supplies
to clinics, supervisory visits by programme and area managers to the clinics, and for attending
community and other meetings. General administration requires access to transport to function.
A district manager is responsible for the day to day allocation and management of the vehicles
within the district.
“Transport, management and allocation I will make decisions as to which car goes where
and when.”
(District Health Manager)
The Ganyesa District Hospital relies on the Ganyesa Health District for transport as the hospital
does not receive a vehicle allocation from the provincial pool. The hospital manager finds the
system difficult, even though she is part of the Extended Management Team for the district.
“Yes, with Mr (…) we plan for transport, because all the transport is received by the district
manager and the district manager allocates the transport for the services. But with transport
we are really having a headache because we don’t have transport… for all the programmes;
patient transport and other programmes that need to run – like administrative services,
10 Hall W, du Plessis D, McCoy D. Transport for health care delivery. In Ijumba P, Ntuli A, Barron P, editors. South African
Health Review 2002 Durban: Health Systems Trust; 2002.

training services and other things… presently we don’t have. The other problem is with the
cars, they are now and then in the garage… and we don’t have anything.”
(District Hospital Manager)
“… together in the extended district management meeting we decide that this is a problem,
say there is a problem of transport … we decide to allocate the vehicle at the district for
a particular service or need.”
(District Health Manager)
The shortage of vehicles is felt particularly at CHCs and clinics. CHCs may have one vehicle,
which is used for all activities, including transporting patients to hospital when an ambulance
is not available. There are no vehicles allocated to clinics. Nursing staff, from time to time, use
their private cars to transport emergency medical or maternity patients from a clinic to a health
centre or hospital.
“We end up using our own transport if we are going to prevent ending up with a corpse….
I can say like once in three months a staff member has to take a patient.”
(District Facility Managers Discussion Group)
Some health programmes have dedicated vehicles supplied by the provincial directorate, often
from special donations, such as for HIV/AIDS services. These HIV/AIDS vehicles are not
available for use by other programmes, although the HIV/AIDS programme may draw on pool
vehicles when necessary.
“We cannot take that vehicle and use it for any other thing but then the other vehicles are
also used for that programme, because then we have to give it a first priority.”
(District ADCHS)
299
A regional director has some discretion in reallocation of vehicles from her regional office to
districts in need, but cannot move vehicles between districts.
“I can only reallocate vehicles from my component because there is really a dire shortage
of vehicles around the district (region). So what I usually do I take out cars from my office,
you know from this office, to help other districts. So far we are not at the stage where we
can say KOSH (Klerksdorp) or Ventersdorp has too many vehicles that we are going to be
reallocating.”
(Regional Health Director)
The lack of adequate transport for health services is a real problem. The distribution of vehicles
is centralised; the regional and health district levels have little say in purchase and distribution
of vehicles for their services. Local and district municipalities, however, purchase, maintain and
allocate their vehicles according their local systems and needs.
Many health workers see subsidised vehicles as the best solution to the problem. Experience,
however, shows that this may not be the case. Health workers are likely to take better care of
the vehicle, but are sometimes reluctant to drive these vehicles on bad roads and request use of
a pool vehicle. Support for subsidised vehicles was strong in Ganyesa:

“If maybe most of the people can be given subsidised vehicles. Because I have realised that
people take care of these subsidized vehicles, because they are partially theirs, unlike using
these pool vehicles. They don’t care about pool vehicles you see, that don’t think and maybe
an incentive that will benefit the worker will be most of them should get this subsidy. Maybe
I should think the government can see a role in that.”
(District Administration Officer)
“Transport is also a crucial problem because the outside clinics have to be visited by the
supervisors. But if a supervisor is not having a subsidised car she can not visit regularly
as is expected of her.”
(District Midwives Discussion Group)
Transport for community use
The public transport system in South Africa is generally poor, especially in rural areas. Privately
owned taxis form the back-bone of the available services. These services are generally expensive
and are not reliably available in the more remote rural areas. Access to health care, therefore,
can be difficult. In urban areas most people live within 4 kms of a health facility and can walk
or require only a short bus, taxi or private vehicle ride.
300
The problem is worse at night and can adversely affect the outcome of a difficult health service
needed; for example, a complicated pregnancy. Regular transport is difficult to find and is
expensive. Ambulance services are not readily available in the more remote areas. Health workers
and community members believe that lack of transport is a major contributing factor to women
delivering at home or arriving at a facility too late for care.
“It is not easy to get transport when you are in labour.”
(District Community Discussion Group)
“…the main thing that affects the people this side and impacts on safe deliveries is the
transport and the distances between facilities. That one is really disadvantaging the people
in the end. For example the patient at Heuningvlei – you know where Heuningvlei is? It is
very far. And the roads are so bad – it is not even tarred. So you can imagine an eclamptic
woman who comes all the way from Heuningvlei…”
(District Hospital Maternity Matron)
“Most of them it is transport.”
(District Facility Managers Discussion Group)
11.4 Laboratory services
Policy and legislation
The need to rationalise and integrate laboratory service in South Africa was recognised prior
to 1994. The ANC National Health Plan for South Africa (1994) proposed the establishing of
a National Health Laboratory Service with the principle tenets of:

• Integration of laboratory services into the PHC system.
• Provision of relevant services by laboratory personnel appropriate to South Africa’s
needs.
• Appropriate training of technologists equipped to work in district laboratories.
• Restructuring of the laboratory training institutions based on the primary health care
approach.
The White Paper for the Transformation of Health in South Africa (1997) quotes the Ministerial
Committee on Laboratory Services and defines the National Health Laboratory Services (NHLS)
as a :
“…comprehensive laboratory services which are nationally controlled or coordinated. They
are responsible for providing a spectrum of laboratory services.” 11
The Paper further proposes that of laboratory services should be:
“…coordinated at the national level by a directorate of the Department of Health. In the
longer term, the possibility of establishing a statutory, parastatal coordinating laboratory
service should be considered.”
The Paper proposes a tiered system from CHC to hospitals and finally to national level with
increasing sophisticated tests available at each tier.
In 2000 the National Health Laboratory Services Act (No. 37 of 2000) established the laboratory
services as a parastatal organisation. The NHLS replaced other institutions and is a “single
national public entity to provide public health laboratory services in the country.” The objectives
of the service are to:
• Provide cost effective and efficient health laboratory services to:
- all public sector care providers;
- any other government institutions inside or outside the Republic that may require
such service; and
- any private health provider that requests such services.
• Support health research; and
• Provide training for health science education.
301
It is set up as a business funded through fees for services, investments, grants, donations and
royalties.
The NHLS is now operating in eight of the nine provinces in South Africa, including NW
Province. The management structure is divided into regions, not all of which are coterminous
along with provincial boundaries. Hospital laboratories have been amalgamated into the NHLS
with all staff and assets. The staff from all previous laboratory services are now under the same
conditions of service. These, however, are not the same as the public service conditions of
employment.
Laboratory staff, although working on hospital premises, are not under the jurisdiction of the
hospital or district management. Hospitals and primary level facilities pay a set fee to the NHLS
for laboratory services.
11 White Paper for the Transformation of Health in South Africa (1997).

Service experiences
The NHLS offers a comprehensive range of biochemical, haematological and pathology services.
However, not all services are offered in all laboratories. When not provided in the local hospital
the specimen is referred to the appropriate laboratory. Results are then returned down the line
to the facility of origin.
The provincial and regional hospitals appear to have few problems with laboratory services.
They are available on a 24 hour basis within the hospital premises. The hospital budget is the
main limitation for tests being done. District hospitals and primary level facilities, however, do
experience some problems. Many of these are expected to be addressed as the NHLS expands
and improves its services.
From the PHC facilities bloods are taken to the hospitals. Transport between the clinics and the
laboratory is often not available in all districts on a daily basis, particularly in rural areas. First
visit antenatal patients are, therefore, requested to come on certain days when transport is
available, to take blood for screening for syphilis. All pregnant women are screen for syphilis
but often this service cannot be offered on a daily basis because of the transport problems to
the laboratory. Provision of all services every day cannot always be met with logistics sometimes
dictating that certain clinics must schedule first time antenatal care for specific days to coincide
with transport services.
302
“Say now it's their first visit and we know we haven’t got transport then we would ask them
to come back the next week when there was transport for the blood, you know, to draw their
blood and so on.”
(District Facility Manager)
Sending results back to the clinics can be problematic, as explained by the medical manager of
Klerksdorp Provincial Hospital
“They can send the blood, they have a sort of a courier system they get to the lab and they
get the results there. Luckily those tests there is no urgency so hopefully it means they will
get the results in one or two weeks. Then if the patient comes back for the antenatal checkup
the results would be checked. But the problem is if you need to get a result within 24
hours, for example, then there is a problem with getting all those within 24 hours. Because
none of these clinics have a fax machine or any form of computer link. If those things were
there it would make communication a lot, lot more easy. In the last meeting I was also
present and we talked about having central point in the lab and the clinics so that the
collection of specimens become more efficient than it is now.”
(Regional Hospital Medical Manager)
There are district hospitals without any laboratory services and other district hospitals with a
limited range of laboratory services or limited hours of operation. This was particularly noted
in Ganyesa in the Bophirima Region:
“… before last year we had laboratories in most of our hospitals and they were under the
direct supervision of the district. Now with the National Health Laboratory Services they
have totally moved away from us, and they sometimes make decisions that affect adversely
our health services. Like their route for the collection of specimens. But we have organised

a meeting where we met with the person responsible for National Health Laboratory in this
area to discuss some of the problems that we have… It is an area that we have not fully
addressed. It may need my intervention to take it up at the provincial level, at the DMC,
the Departmental Management Committee. It has of course a very negative effect. There
are hospitals without laboratories at all….”
(Regional Health Director)
“… that’s what the Chief Medical Officer (Ganyesa Hospital) was complaining about
actually. Instead of getting the correct result at the institution they then moved the patient
to Klerksdorp at enormous cost, a problem to the family and so on. … our understanding
has been in the process of building a referral hospital (in Vryburg) … which also would
include the necessary laboratory services that we want.”
(Regional Health Director)
The Ganyesa Hospital Manager shares the concerns of the Regional Director:
“We are providing laboratory services, though presently we are having problems because
there are other tests that are not being done in the hospital. We are having only one person
who is allocated in our laboratory. … some of the tests are not done here; they are done
in Klerksdorp and that is causing delay… It's really impacting negatively you know. The
laboratory cannot open for 24 hours and the laboratory services are needed throughout,
because the doctor is on call 24 hours. So this person comes on duty at 07h30 a.m. off at
4 pm. meaning that after that nothing can be done.”
(District Hospital Manager)
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Specimens are sent to Klerksdorp on regular trips taking patients and with any emergency
ambulance transfers. The alternative is to refer the patient to the next level hospital for care.
“They are doing it Klerksdorp. So every time that there is a patient that goes to Klerksdorp,
or when there is - a kombi that goes to Klerksdorp on a Monday, Tuesday, and Thursday
weekly that one is guaranteed. So, most of our blood specimens for investigation are
transported with that. But if another emergency goes to Klerksdorp and we have a sample,
a specimen that is waiting, we just send it.”
(District Hospital Maternity Matron)
During the site visits, the researcher did not have a clear indication as to availability of on-site
laboratory testing in the districts. The 2003 NPHCFS for the NW Province showed that:
“… on-site testing has become increasingly available, and this is evident in that approximately
half the facilities in North West have access to all available on-site tests. In all instances,
on-site laboratory tests are more readily available in North West than in the country as a
whole. The percentage availability of syphilis tests (97%) and sputum AFBs (97%) at
facilities in North West were almost double that of the national average (48% and 50%
respectively). Pregnancy tests were available on-site at 94% of facilities in North West
compared to 68% overall. Haemoglobin tests were available on-site at all facilities in North
West, Rhesus tests were available at three quarters of the facilities (75%) and the HIV rapid
test was available at 59% of facilities.”

Information in the Facility Survey are not disaggregated to district level and therefore availability
of outside testing figures for Klerksdorp, Mafikeng and Ganyesa are not known.
11.5 Infrastructure and maintenance
The 2003 NPHCFS for NW Province reports:
“Two out of five facilities in the province had adequate consultation rooms and approximately
three out of five had adequate waiting areas. All facilities had flush toilets, although roughly
a fifth had toilets for the disabled. The majority of facilities in North West required urgent
structural repair at the time of the survey. Eleven percent of facilities in North West reported
incidences of robberies or assaults. Only a quarter of visited facilities had adequate security
features. All facilities had on-site water and the majority had electricity supply. Few water
interruptions were recorded, while almost two thirds of the facilities reported an interruption
in the electricity supply. Three out of five facilities in North West had some form of
communication available, that is, either a phone, fax, two-way radio or internet access.” 13
The survey also notes:
304
“A large proportion (35%) of facilities were built and operationalised within the past 10
years. The majority of these (25% of the total facilities) were established within the first
five years of the first democratic election. In North West, a third of the facilities were built
within the past ten years, of which 22% were established during the latter half of this
period.” 14
The national clinic building programme has increased the number of health centres and clinics
in the NW Province. There are, however, communities who do not have easy access to health
care. Communities are able to approach the PDoH with a request for a clinic to be built. The
process, however, is long and because capital funds are required can take several years to finalise.
The procedure was explained by a district manager:
“The community makes the request; then I will take the request. Firstly, I will have to be
convinced of it; if not I will tell them immediately it’s a no no. … we don’t raise their hopes.
If I agree with them I make my own motivation and I attach their motivation and take it to
the provincial office physical structures under Policy and Planning Directorate. Then the
Physical Structures people will make their own assessment which will be more technical.
And if the technical fits then the approval goes to the MEC for his approval. If it is approved
that clinic will be included in the provincial plan for that year.”
(District Health Manager)
Other departments, in particular Public Works Department, are involved in the process. They
are responsible for the actually building of the clinic and ensuring other essential infrastructure
is connected, such as water supply, electricity and road access. Public Works remain responsible
for maintenance of the clinic after completion.
Communities need to be informed of progress with their request for a clinic, as emphasised by
one regional director:
13 Health Systems Trust. The National Primary Health Care Facilities Survey 2003. North West Province. Durban: Health
Systems Trust and Department of Health; 2004. Page 9.
14 Health Systems Trust. The National Primary Health Care Facilities Survey 2003. North West Province. Durban: Health
Systems Trust and Department of Health; 2004. Page 13.

“But I think what is lacking is that we place these things on the list, there is a waiting list,
we have the clinic building and upgrading programme and we don’t really inform our
communities as to where they are according to their request.”
(Regional Health Director)
The process is likely to change as local government, is strengthened. The Integrated Development
Programme (IDP) in district or local municipalities includes all capital development in that
municipality. The health sector, according to legislation, is part of the IDP process. This facilitates
open communication between the health sector and the council on proposed new health facility.
The maintenance and management of clinics is likely to be handed over to local government
when PHC services are decentralised.
Where there are local government and provincial government facilities within one municipal
area, the two spheres liaise with building or altering any health facilities, as shared by a municipal
health manager:
“… what we are doing is that whenever we want to do a certain change into a certain clinic
we liaise with the department (PDoH). They also liaise with us. For instance the (…) Clinic
is supposed to be extended… they already informed us that there is a certain budget of a
certain amount and that is how we should work together. … even with us we can't build
clinics; most of the clinics have been built by them (PDoH), except that they will then hand
them over to us. So as we do that, as we feel that there is a demand for a certain clinic in
an area we will then notify them and they will put that into their budget, approve it and
notify us that they have approved that budget.”
(Municipal Health Manager)
305
The PDoH has a policy to provide a clinic within four kilometres of every home. This is ambitious
and expensive, particularly in the sparsely populated rural areas.. The NW Province is investigating
building smaller units, a two-roomed clinic, which would be staffed by a midwife
and visited regularly by a professional nurse. A Regional Health Director explained:
“We are looking provincial wise at sort of phasing out our mobile clinics and we would
actually look at a situation where we have what we call a two roomed health post. … the
facility is visited by a professional nurse on a regular basis…”
(Regional Health Director)
The maintenance of provincially owned clinics buildings is the responsibility of Public Works
Department (PWD). The municipal council takes responsibility for their clinics. Health workers
experiences of the two systems for maintenance indicate that the PWD system is seen to be less
efficient and clinic staff experience long delays in having simple maintenance carried out, such
as replacing a window pane. Expressed below are experiences in the provincially managed
facilities:
“…almost half our clinics are battling because of the procedure that the government is
using. We have to send in our recommendations and it will take two to three years before
anything can go through.”
(District Administration Officer)

“Where there is maintenance they [facility manager] provide a request for that maintenance
and then we will interact with public works who do their assessment for us and then make
their quotation. They have their own contract as well which the DoH does not have because
they (PWD) deal with maintenance. So we will participate in their contract and if there is
no contract we will go out to quotation and then we get the maintenance done.”
(District Health Manager)
“Yes, it was better that time when you talked to one person [for maintenance], but now
there are too many bosses. As I am talking the toilets are blocked … and I motivate them
and motivate them.”
(District Facility Manager Discussion Group)
“So it’s not so easy. … Because public works is separate to the district management team.
So you are working with another department to ask them to come and fix your building.”
(District Facility Manager)
In contrast, few problems are experienced by the municipal facilities, as noted by a number of
health workers in the districts. These workers also expressed the hope that with decentralisation
the municipal systems for maintenance will be adopted.
306
“To fix a windowpane it will take some time, but local government it might take a day to
fix it. These are some of the issues that we need to talk about.”
(Provincial Chief Director Health Services)
“… there is one other thing which I think is going to be advantageous for us when this
district materialises, and that is maintaining the buildings. I don’t think we will have a
problem, unlike with our provincial system.”
(District Health Administration Officer)
The major difference between the municipal and provincial systems for maintenance is that the
former is under one administration (that is the municipal council) whereas the latter is the
responsibility of a different department and different administration. The PDoH and PWD work
through different structures and have different plans for decentralisation to local government.
“… take public works as a function. At the moment they have regional offices scattered
all over the province; we even have a national department with regional offices in the
province and we have the provincial department with the regional offices within the
municipalities. … there is duplication. …. To me it makes sense if a portion of that function
or the functions (of the PWD) could be devolved to the districts so that they are able to
plan. The municipality knows the kinds of roads that are there in the village, that need to
be scraped, around what period, when and so on. But they don’t have the resources. Public
works… if you want the road to be scraped … in a village, we need to speak to the regional
officer who most of the time does not have the necessary resources. We have to phone the
provincial officer and so on and so forth… Some of the functions themselves, if they are
devolved, will assist the municipalities to plan better within their IDP’s and so on.”
(Chief Director - Provincial Department of Local Government)

To decentralise the building and maintenance of all facilities to local government has potential
to impact positively on service delivery, provided the necessary resources are available. It would
bring the decisions closer to the people who understand the needs of the district and will shorten
the response time for requests for repairs. Currently, however, maintenance functions remain
centralised to the province.
Equipment
Adequate, well maintained and appropriate equipment is essential for quality service delivery.
Most basic equipment is available in over 90% of PHC facilities in the NW Province. The
NPHCFS for 2003 showed that:
Nationally, seven of the twelve items of essential equipment recorded were available and in
working condition in over 90% of facilities. Similarly, eight of these items were available in
more than 90% of facilities in North West. Items less readily available in North West included
delivery kits (78%), oxygen cylinders (84%); otoscopes (85%); and glucometers (85%). 15
In the past, in NW Province, the ordering of equipment was centralised to the province. The
budget for equipment has now been placed at the institutional level. This means that the local
level can decide what they require and they order according to departmental processes and
according to their budget. According to a provincial manager, the sister-in-charge of a facility
is in the best position to decide what is required in that facility.
“My feeling is that a sister in charge and the people that is working in that specific facility
must determine what is their equipment needs, whether it's reproductive health or whatever
and that should be sent to wherever the decision makers are.”
(Provincial Director for DHS)
307
Ordering, however, is regulated at a regional level to ensure that money is not wasted on nonessential
equipment for a clinic, as explained by one regional director:
“We had an uncoordinated equipment procurement system but we’ve regulated it in the
sense that the equipment budget for the district is centralised at the regional level. We have
an essential equipment list for every clinic… now managers come and they bring their
equipment needs to us. We have divided the equipment budget into three components;
medical or clinic equipment, furniture and IT. We have a serious problem, people wanting
to buy more computers but they don’t buy Baumanometers etc. so we decide, as a collective
at regional level, within the budget that we have for equipment that this is what every
institution will buy. They then arrange access to the cost centre and they buy and we just
approve or check that they buy what was ordered”.
(Regional Health Director)
This system appears to be working as money budgeted for equipment is spent within the financial
year. Under the old system districts found that, due to delays in the provincial office, institutions
lost equipment budget because of non expenditure by the end of the financial year.
“But we used to find that we’d go past November without actually procuring even forceps
because the budget was centralised and all those things. So since it was decentralised we
find that it’s much easier.”
(Regional Health Director)
15 Health Systems Trust. The National Primary Health Care Facilities Survey 2003. North West Province. Durban: Health
Systems Trust and Department of Health; 2004. Page 34.

An improvement in ordering of equipment is noted at all levels, including the hospitals. Middle
and top management believe that decentralisation of this function, even if coordinated and
monitored by the regional offices, has made a difference.
The clinic nurses and midwives, however, have a different experience and many feel that nothing
has changed. The nurses in clinics, in particular, compare their equipment to that in the health
centres and hospitals and perceive discrimination, as explained by clinic facility managers and
midwives:
“And the equipment – there is no improvement. We are still using old thermometer, which
you shake and shake and at the provincial hospital they are using this nice devise that
checks everything and saves time. And can cover for staff shortage.”
(District Facility Managers Discussion Group)
308
“Then another thing, we don’t have any equipment in our clinic. As I am talking now we
don’t have any sheets in the clinics – all are torn. And it takes long to repair them. We were
told to supply a priority list of things that we need in the clinics. And then we supplied a
list with dynomaps because we thought that at least they are durable, and even if you are
short-staffed we can use a dynomap - that just records everything at once, temperature,
pulse rate, pressure. Now we are told that they are expensive. Now they buy this one where
you just pump and then next month you find it has to be repaired – it is all broken. … the
equipment that they are buying is bought from a company that cannot be traced. … Now
they are saying they are going to buy dynomaps for health centres only, not the other
things.”
(District Midwife Discussion Group)
The experiences above are from the same district and may not be applicable in all health districts.
There is, however, a feeling of frustration from the clinic level that their needs are not attended
to.
“What is frustrating me is where I trained there was a lot of equipment and equipment was
available. So where I work now you find that there is no equipment and orders are made,
but equipment, they don’t have.”
(District Midwives Discussion Group)
In summary, the experience with ordering of equipment, there appears to be a gulf between the
managers perception of what is happening in the clinics and what the nurses and midwives are
experiencing.
Motivation for orders of equipment starts at the lowest level, the facility. All requests are according
to need, policies to be implemented and finances available. Priority lists are consolidated at
health district or hospital management level and orders placed according to Tender Board
regulations. The emphasis is on joint decisions being made before ordering equipment, as
explained below:
“We call a meeting then we have all the lists and quantify them and see how much it costs
and then we make a decision and we cut wherever - we cut as a group and prioritise as a
group.”
(District Health Manager)

RHS requirements are not considered separate to other programmes for ordering equipment and
other supplies. All orders are integrated for PHC services. Reproductive health, however, is a
central service and one health district manager believes that, if the figures were
disaggregated to programmes, reproductive health is receiving a significant proportion:
“We just look at the whole service that we have to render … but it (reproductive health)
accounts for a major part of our clientele. So even though there is no specific focus on it,
but if you have to go into the figure and have a look you would find that we are
disproportionately spending more on it. …. You also noticed that we measure maternal
death, neonatal death and so on. …. So there is a risk from us as management and as
providers to make sure that we handle reproductive health correctly.”
The four regional offices play a role in prioritising, ordering and purchase of equipment.
11.6 Emergency Medical Services (ambulances) and Referral system
Policy and legislation for ambulance services
The Constitution of South Africa assigns ambulance services as a provincial responsibility. 16
Prior to 1994, ambulance services were fragmented. All health departments (provincial and
‘homeland’) and many local authorities provided these services. Under the new dispensation
and as part of rationalisation and elimination of service duplication, ambulances services were
all centralised to the PDoH in each province. After centralising management ambulance services
established their own regional and district level structures for delivery of emergency services
in the respective province.
The Constitution of South Africa (Chapter 2, Section 27 (3)) states “No one may be refused
emergency medical treatment.”
The need for efficient, equitable and accessible emergency services for transfer of patients
between home and health services, and between levels of health services as required, is discussed
in policy documents, such as the National Health Plan for South Africa, 1994 and the White
Paper for the Transformation of Health Services, 1997.
Referral system
The Primary Health Care approach to health services includes the provision of:
309
“… a seamless referral system from the community all the way to the most sophisticated
health care available.”
In the ideal system, patients present themselves first at a mobile, clinic or CHC primary level
within the health district. If the patient can not be treated at that level an ambulance or other
form of transport is made available to move the patient to the district (level 1) hospital for
assessment and treatment by a medical officer. From this level the patient can be moved, if need
be, to a regional (level 2) or provincial (level 3) hospital to be treated by a specialist. These
facilities are all available within the NW Province. More sophisticated services are available in
the academic (level 4) hospitals in Gauteng Province.
Each level of the system is under a different institutional management. A “seamless” referral
system requires services to be coordinated between the levels such that management protocols
16 Constitution of South Africa, Schedule 5, Part B

are complementary and on down referral the patient is able to obtain the correct treatment as
close to his/her home as possible.
This referral system requires coordination with the EMS for ambulances services between the
levels of care. As mentioned the EMS is a provincial responsibility and has its own institutional
management structures. The ambulances are usually based within the grounds of the district or
provincial hospital, but the hospital management has no authority over their functioning.
The referral system in the NW Province in South Africa is depicted in Figure 11.2
Figure 11.2: Referral Systems - North West Province
National or Academic Hospital
Level 4 Hospital
National Health Service
Regional or Provincial Hospital
Level 2 & 3 Hospitals
District Hospital
Level 1 Hospital
Provincial Health Service
310
Regional or Provincial Hospital
Level 2 & 3 Hospitals
Mobiles Clinics Community Health Centres
Community
Patient down
Patient up
The Ganyesa Hospital manager is appreciative of the support and assistance given by the EMS,
despite having a shortage of transport:
“Yes, we do have the emergency medical services. They are, in fact they are within the
hospital but they are under a different, they are not under my control, they are under
somebody else’s control. But they are here, they really help us with the emergencies, in fact
at they help the district… they do respond though they are also having transport problems…
they are trying their best with the little that they have. Transport is a problem and I'm sure
it's aggravated by the type of roads that they are using, especially emergency services.”
(District Hospital Manager)
EMS being under a different provincial directorate to other district and district services causes
confusion for community members. They know the local level health managers and bring their
problems to them, as explained by the regional director for health in Bophirima.

“I was not really happy about provincialising of emergency medical services (EMS) that
they report now, not to me but directly to the province. But the community members here
don’t know what province is. If there is a problem about EMS, they want to come to me,
they want to come to the district manager there to say, ambulances are not working. I can't
now just say no it's another directory. So that is the challenge that somehow we have also
to coordinate and monitor the service delivery of the EMS. What we have done is that
emergency medical services, station manager must be a member of the hospital management
team and the district management team. The one in the region, we have one person who
is the regional coordinator for EMS and he is part of the regional management team at the
district level.”
(Regional Health Director)
This is an attempt to resolve some of the problems with communication between the different
institutions involved. Communities in other districts struggle with resolving problems because
of lack of response from the regional EMS managers, such as in Klerksdorp.
“There is the specific item of ambulances; most of the time the community is crying on this
issue. The community comes to the Health Forum and we sit down with the district. We
complain about this every now and then, we sit down and talk. Even at yesterday’s meeting,
it was the same story, no answer, no response from EMS and it almost a year now. If the
District does not respond, we might write a letter to MEC so that he can solve this problem
of EMS directly.”
(District Community Discussion Group)
For RHS the referrals are most commonly pregnancy related between the health district facilities
and the district hospital. There are, however, health districts in NW Province which do not have
a district hospital within their boundaries. These districts, such as Mafikeng and Klerksdorp,
refer to the next level hospital (regional or provincial) that is within their boundaries.
311
The functioning of the system has problems and difficulties. These relate to:
• Patients by-passing the primary level services and attending the hospital.
• Non availability of ambulances for emergency access of patients to the service or for
transferring patients between levels of care.
• Poor coordination of treatment and management protocols between primary level care
and hospitals.
• Distances between community and facilities, and between facilities.
By-passing primary level
Patients will often, out of choice, bypass primary level facilities and go straight to the hospital.
When they have their own transport or are able to hire private transport it is often quicker and
easier than going via a clinic or waiting for an ambulance. Many people wish to see a doctor,
which they will do at hospital, but not in a clinic. They can, however, for a non emergency case,
be turned away if they do not have the referral letter from the primary level. Emergency cases
will be accepted at the hospital.
Convenience for patients is another reason to go direct to the hospital – some people live closer
to the hospital than a clinic. This leaves the hospital staff with a sense of being flooded with
patients and over worked.

“It (the referral system) doesn’t (work well) because … we find that those cases who were
supposed to be nursed at the primary level they just come here, so we feel that we are over
worked. We have a shortage of staff and anyone who feels like to come here, she just comes.”
(Regional Hospital Maternity Matrons)
Other patients, who do not have access to private transport, may attend a primary health facility,
even in emergency, with the expectation and hope that the clinic will be able to arrange transfer
to hospital if required. In an emergency, this is done using the EMS.
“When we come from home to the clinic, they write a transferral letter for you… And I
think it is important for the clinic to organise transport for the patients, because some
patients do not have money to travel to the hospital.”
(District Community Discussion Group)
Not all clinics offer a 24 hour service. Patients, in particular pregnant women, are advised by
the clinic staff to go direct to hospital if labour begins at night or over a weekend. Patients have
reported later to the clinic staff that they are turned away from the hospital because of not having
a note from the clinic.
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“The clinic will operate only Monday to Friday and then over the weekend it doesn’t operate.
The patient may have labour pains over the weekend or even at night and then the poor
patient will be coming to the hospital and will be turned back and told, “go and get a
referral letter from the clinic”.
(District Facility Manager Discussion Group)
A similar experience was shared by a community member attending the hospital without a
referral note.
There are some maternity cases, according to referral protocols, that must deliver in hospital,
such as previous caesarean sections. The patient, therefore, becomes a self-referral.
“If it is a previous Caesar, we encourage her to go to the hospital when in labour, on their
own. They should not waste time coming to the clinic and then having to struggle to get
transport to the hospital. Automatically the previous c/s is delivered at the hospitals. But
they usually come to the clinic being in labour then you assess them and refer them.”
(District Facility Managers Discussion Group)
This is discussed below in relation to the relationship between the primary and hospital services.
Clinics that do not provide a maternity service advise all their maternity clients to go direct to
hospital when labour starts. This is easier in a district such as Klerksdorp which is a smaller
geographical area than Ganyesa where the patients have vast distances to travel to access any
health care.
“We are doing ANCs. During ANC visits we are only detailing the candidate; we are not
doing the delivery, so when the pains starts please go straight to hospital. Don’t wait when
the contractions are strong and it is then that you will be asking for transport. Because if
you call an ambulance, like the sister has just said, she won’t get the transport right then.
Then she will deliver at home.”
(District Facility Managers Discussion Group)

Ambulance services 17
The poor ambulance service (EMS) is identified by the district management teams, regional
directors and provincial managers as the main problem in the referral system. The management
of the EMS is centralised to the provincial DoH. This was initially done as a means of bringing
together a fragmented system into one coherent system. It has, however, led to other difficulties
in coordination between district, hospital and EMS management. There is a strong opinion,
including from the MEC for health, that EMS should be decentralised to the district level.
“You see we experienced a problem when they took the ambulances to the province. It’s a
mess. We can't render quality service, so with that experience. … I mean province should
delegate power to us because it is not working at all.”
(Member of Mayoral Council for Health)
“Yes - I think he (the MEC) is starting with the ambulances. He saw from the ambulances
that the issue of provincialising is not benefiting the people of the country. Because, if
ambulances are being controlled directly from the province, it takes many hours to get an
ambulance and nobody takes responsibility on the ground here.”
(Member of Mayoral Council for Health)
This concern is shared by the Bophirima Regional Health Director and others involved in PHC
services.
“I think we would say this, all the primary level services, including EMS, must be decentralised,
so that management decisions can be taken at the lowest possible level.”
(Regional Health Director)
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The Provincial Chief Director believes the problem starts from the top and involves services
throughout the country.
“I don’t think it works well … I don’t think EMS in the country is being managed well at
the moment from a national level right through… so I think we have a lot of work to do
regarding EMS …”
(Provincial Chief Director, Health Services)
“… province do try to take it forward … we've nearly doubled our budget from last year
to this year regarding the EMS. … there needs to be national leadership in this process…
have available norms and standards to build your plans around.”
(Provincial Chief Director, Health Services)
In some districts with a history of good local authority health services, including ambulance
services, the people feel that the services are worse.
“Ambulances used to come when we needed their help but now they will tell you about
distance and kilometres that they will be traveling to come to your place, I think they are
bad.”
(District Community Discussion Group)
17 The views of the EMS managers in the NW Province were not obtained during the research period

In contrast in many rural areas, where there never has been a good emergency and ambulance
service, the community are more positive about the changes and are more accommodating to
assist where they can.
“They were complaining of transport but the transport issues were cleared up, because we
are having ambulances; though sometimes they are broken, and there is no transport. But
we normally devise some means so that a person is taken from home to the clinic.”
(District Facility Manager Interview)
“The system is not so 100% because sometimes the ambulance, there is only one ambulance
maybe he’s gone to the - they will tell you that the ambulance is not here is gone to
Klerksdorp. So we are having only one ambulance, then you have to devise a means
maybe you in the relative are having a car you’ll say, “There is no ambulance. How about
taking this patient to the clinic?” So they are normally willing to do that.”
(District Facility Manager Interview)
The community would, however, like to see an improvement in emergency services to their
areas.
314
“There are no changes (in reproductive health services), because we don’t have ambulances…
if they are in labour at night, and during the day when the clinic is closed, it is a problem.
They (the community) have to hire transport to the clinic. Maybe the emergency services
are not there. Some are not even able to contact them.”
(District Community Discussion Group)
“If there was an ambulance here for 24 hours then we wouldn’t have a problem of referrals.
The only problem would be that shortage of doctors. …. We were having an ambulance
here previously but it was not for Ganyesa Clinic only, it was going to other clinics… It
was not better because when we need it it’s not here, and you have to wait for it.”
(District Facility Manager Interview)
Members of the community face many challenges in accessing health services. If they do not
live within walking distance of a clinic, they must rely on buses or taxis. In rural and some other
areas these are not readily available at all hours and it is expensive to hire private transport,
especially at night. In cases of emergency, the ambulance service is called, but due to shortage
of vehicles and distances to be traveled the response time can be long. The community members
are then left with a feeling that the services are not working for them.
“The service we get is not ok. First, we struggle with ambulances from home to clinic and
the hospital and even when you arrive at the hospital you don’t get help. You almost spend
a whole day until dark. It is possible you die while waiting.”
(District Community Discussion Group)
“Most of the people living in the rural areas have problems with transport; even the
ambulances are not coming to their places because of the poor roads.”
(District Community Discussion Group)

“Sometimes you will call the ambulance, they will take time to attend, if they don’t come
you will give birth either on the streets or at home, they will come late after you have
delivered.”
(District Community Discussion Group)
At weekends ambulances are very busy with transporting physically injured patients from
shebeens (bars) and road accidents. These cases appear to take precedence, even over maternity
cases. The shortage of ambulances worsens this problem.
The clinic staff shared their frustrations:
“No, we only refer them to the hospital. The only problem that we encounter is the transport
especially during delivery. You’ll find that in most cases we struggle to get the transport…
maybe by then it is an emergency. You have a woman who has a PPH, or you have a client
who is having eclampsia. All right, you control it but at some stage you must refer this
person. Or you have a person with a cord prolapse. It is an emergency. You stand there
waiting for more than hour waiting for transport.”
(District Facility Managers Discussion Group)
“… we are having problems over ambulance services. When we phone the control room
they are telling us there is one ambulance that has gone to … so you have to wait a bit and
they will send the ambulance as soon they can… we have got a shortage of ambulances.”
(District Facility Managers Discussion Group)
“The issue of transport. If we had good transport we wouldn’t have any deaths or anything.
Q: would you like a helicopter? … no, no. just a thing with 4 wheels on the ground, so that
you can move a patient.”
(District Facility Managers Discussion Group)
315
“There are no ambulances at the clinic. When you have an emergency, a patient can even
die waiting for the ambulance because it takes 3 to 4 hours before you can take the patient
to the hospital. Many times we have used our own cars to transport these patients…”
(District Midwives Discussion Group)
Even the better resourced and geographically smallest district, Klerksdorp, has problems with
insufficient ambulances, as expressed by a facility managers and the Klerksdorp Hospital Medical
Manager:
“We do encounter some problems. As it is now we are having problems over ambulance
services. When we phone the control room they are telling us there is one ambulance
that has gone to Orkney or wherever so you have to wait a bit and they will send the
ambulance as soon they can. We do experience some problems here and there, but sometimes
we do get an ambulance immediately. We have got a shortage of ambulances.”
(District Facility Managers Discussion Group)
“I haven’t really gone into how many people were denied you know and then they will be
delayed and all of those. It hasn’t come to me as a major problem. So hopefully there is a

fairly good EMS. You see the advantage of this place is, is within 25 kilometres, the primary
referral is 25 kilometres, the four townships. So it's not a lot of distance in that sense
compared to like somewhere it could be 60 or 70 kilometres. Bophirima or if you go to the
Mafikeng areas it would be even longer to get to a secondary level hospital, we are lucky
that our townships are near to the town.”
(Regional Hospital Medical Manager)
Coordination between levels of care
Good, clear protocols of management of patients and open lines of communication between the
levels of care are required to ensure quality of health care when a patient is referred. The NDoH
has, in consultation with relevant stakeholders, developed polices and treatment guidelines for
most reproductive health issues. These are: 18
• Saving Mothers Policy and Guidelines 2001.
• Policy Guidelines for Youth and Adolescence Health 2001.
• Guidelines for Maternity Care in South Africa 2002.
• National Contraception Policy and Guidelines 2002.
• National Guidelines for Cervical Cancer Screening Programmes.
• Essential Drug List and Standard Treatment Guidelines.
316
These guidelines are for use in all health institutions and provide standardised quality of care
across the country. Local adaptations are introduced to suit local needs.
Apart from the transport issues, the community are generally happy with the way the referral
system runs. They are treated by the clinic staff who refer them when x-rays are required or
when they do not have the necessary medication.
Facility managers express difficulties with the referral system, to the point of one describing it
as “pathetic”. The main areas of concern appear to be related to transporting patients to hospital,
the hospital staff accepting the transfer and receiving feedback on patients they have referred.
The third problem is back referral. A patient, after attending or being discharged from hospital,
is not given a note for further management. The clinic sister must then telephone the hospital
to get the report:
“The referral system – it is easy for us to refer, but we don’t get feedback from the district
hospital. … We send patients with letters, but they come back with nothing.”
(District Facility Managers Discussion Group)
For maternity patients, the back referral is generally better because a carry card system is used
for antenatal care. The findings and treatment given to the patient at any facility can be entered
on to the ANC card.
The hospital staff who receive referrals from the clinic have a number of problems with the
system. In the maternity wards, for example, there is an impression that the clinic nurses do not
manage patients correctly according to the guidelines and often make inappropriate referrals.
The delay is often due to lack of transport, which the hospital staff do acknowledge. As mentioned
by a hospital midwife:
18 See appendix 4 for further details

“… then they’ll tell you that they have a problem of transport. … they will phone at about
7 or 8 in the morning saying that we are referring two ladies and … those ladies will arrive
here at 1am. … It seems they are having a problem with transport.”
(Regional Hospital Midwives Group)
Another concern is apparent mis-diagnosis of patients at the clinic or inappropriate action taken
which the hospital staff are left to address and correct. These problems are addressed in bi-lateral
meetings between the managers and midwives from the hospital and clinic. Protocols for referral
are discussed and the hospital midwives, many of whom have an advanced midwifery qualification,
express interest in training the clinic midwives. However, the shortage of staff in the hospital
maternity units makes this difficult.
There are at times tensions between the primary level services and hospital staff. The split in
management between the two systems possibly contributes to this. A doctor, who has worked
in a rural district for several years, shared that she has in the past worked closely with the clinic
midwives and developed a system by which the clinic staff informed the hospital of potential
problem cases seen in their antenatal clinics. Mention of this system was made by the district
MCHW Coordinator.
“So we have a form that you fill in for antenatal patients, then you give it to our doctor at
the district hospital then. At least she has an idea of how many complicated cases you have
picked up and how many do you refer to her and then she can plan because she is the only
doctor that can do caesarean section.”
(District MCWH Coordinator)
The hospital maternity staff and clinic staff in Ganyesa met regularly. With the separation of the
district hospitals and the clinics, the doctor is no longer able to do this as her job is now only
hospital based. These changes create an antagonism between the two systems which adversely
affect a smooth referral system.
317
The semi-urban (Mafikeng) and urban areas (Klerksdorp) appear to have more problems between
the services at the primary level and the hospital than the rural (Ganyesa) area.
“When you do meet as the clinic personnel and the hospital personnel, you should see each
other as colleagues. The hospital, they don’t see us as doing a continuity of where they have
stopped. I don’t know how they perceive us because every time when we come to a joint
meeting it will be that, at the clinic you don’t do this; and that is not what you are here for
we are here, but rather to find a way forward. At the clinic we give them adequate education,
“when you feel contractions go to the hospital, take what the hospital expects you to bring
along, take your record, put it safe and then you can just go straight to the hospital.” but
when they arrive at the hospital – wow!!”
(District Facility Managers Discussion Group)
“The sister calls the doctor and then the doctor discusses the patient with the sister…. if
the sister can be advised as to how to manage that patient, that sister will manage the
patient at the clinic. Most of the times they say refer the patient and the patient is referred
to the hospital by the EMS. … I cannot say we are 100% satisfied with the service, but,
because sometimes you have one ambulance, maybe you have a maternity case that the
doctor can not manage at a level one hospital, that patient has to be taken to Klerksdorp.

Then 20 mins later a sister calls from a clinic and she says the patient is eclamptic or what
ever and you have to refer the patient to the hospital. So some where there is a delay of
the patient being at the right place at the right time, even if the doctor says, transfer the
patient to the hospital, it may take another three hours to get here, and by then, especially
for high risk cases, especially BPs and …., you know three hours is too long.”
(District Hospital Maternity Matron)
The midwives in Mafikeng Provincial Hospital are willing to assist to strengthen the clinic
services. They suggest that midwives with advanced midwifery training could visit the clinics
for in-service training and clinic midwives could spend time in the hospital upgrading their
skills. However, staff shortages in both the hospitals and clinics make this difficult to accomplish.
Distances to be traveled to access health facilities/services
Reference has been made to the long distances between some communities and health facilities
and the distance between facilities. This compounds the problem of lack of transport and
ambulances for referrals, as expressed by a number of stakeholders. This is most marked in
districts with extensive rural areas, such as Ganyesa and Mafikeng:
318
“In terms of transport availability, that would be the far away areas, it is really terrible
when one has to travel from that part to the hospital. But provision had been made for those
patients to be transferred to health centres. But, like I said that the furthest clinic that wants
to send patients is 127 kilometres. The health centre from that area is about 68 km. So you’ll
find that maybe a person at the health centre will say, “No, I won’t be able to manage this
case” and then has to refer it further to the hospital.”
(District MCWH Coordinator)
“I don’t know exactly (how many ambulances are available); you can ask with those people,
but on an average day maybe we have two. But sometimes we are just left with one and
it very far between here and Klerksdorp when …. And the clinics from the clinics to the
hospital, I think the nearest clinic is, about is only this one, the health centre which is
about maybe 5km away from the hospital, otherwise the rest are very far.”
(District Hospital Maternity Matron)
“Ganyesa has an ambulance but it does not reach the homes to transport pregnant women.
Heuningvlei struggle with ambulances: the community has to phone Morokweng to get a
transfer to Phatsima.”
“So that is something which one picks up all the time, a lack of transport or delays in
response to emergencies, particularly from clinics into hospitals which has a great impact
on reproductive health, safe motherhood in particular and are there plans to re decentralize
those services or is that too soon to know?”
(Regional Health Manager)

Chapter 12
Issues and Conclusions
The broad process of analysis in this research is illustrated below:
Figure 12.1: Pattern of Analysis 1
Broad Historical Change and Policies
Policy Process
• Policy rationale and content
• Policy understanding
• Policy linking
• Policy implementation
System of
Decentralisation
and SRHS
Impact of decentralisation SRHS interrelation
Policy changes do not happen within a vacuum. They come from a historical background into
the present changing political, social and economic system and will impact on the future health
outcomes. This research has looked broadly at context at national, provincial and local levels
in an attempt to understand how these impact on the development and implementation of
reproductive health policies within an evolving decentralised form of government.
319
The research illustrated the uniqueness of each case study site used and re-emphasises the
principles that “one boot does not fit all” in implementing policies. The impact and outcomes
of policies can not be predicted without due consideration of the context in which they are being
implemented.
Chapter 12 explores some of the key issues that have emerged from the research in South Africa.
The two comparative reports of the RHD project (the two country comparative report of South
Africa and Uganda; and the four country comparative report of South Africa, Uganda, Mali and
Burkina Faso) draw out further issues for consideration.
12.1 National, Provincial context
Understanding the context in which we are working is essential. It explains why decentralisation
and reproductive health are on the policy agenda, the feasibility of policies, the position of
stakeholders, and the effectiveness of decentralisation.
An understanding of the national and provincial contexts emerges in the South African research.
These factors seem to mould the actual structure and process of decentralisation and reproductive
health services. Within the broad economic process of the South African transition, the key
factors would appear to be:
1 Charles Collins, Nuffield Institute for Health and International Development, University of Leeds, 2003

a. Reproductive Health and reproductive health policies – changes of policy since 1994
incorporate a human rights approach, freedom of choice on reproductive issues, empowerment
of women and other principles of the International Conference on Population Development
in Cairo,1994.
b. Primary health care expansion – the general health care expansion seems to come from the
centre and is expressed in 24 hour care, free health care, health care integrated at the point
of delivery, and an increase in number of clinics and community health centres. It is the
tension of this social outreach and expansion of services with the national macroeconomic
policy which explains some issues at the point of delivery and the stress on the health
workforce.
c. Decentralisation policies – there is the uncertainty and mix of de-concentration and devolution
which seems to permeate the whole system. It raises the issues of fragmentation, where the
system is moving and the forms of accommodation between the two systems. The lack of
a cohesive national over-arching policy framework for all government departments results
in different rates, and at times different understanding, of the process. This can give rise
to tension between government sectors and even within the health sector.
320
d. Macroeconomic government policy – this determines the impact on the flow of resources
into the health sector and the general position on the role of the public sector. The early
African National Congress policies for the new government in South Africa emphasised
social development and growth through redistribution of resources. The GEAR policy
introduced cost efficiency and fiscal constraint. These latter policies are at times counter
to the social development, human rights approach of the reproductive health policies
emanating from ICPD reforms.
e. Human resource scarcity – this has an impact on the effectiveness of the health care expansion
and is related to the general shortage of health personnel. Health workers have more
opportunities to move within the new systems and retention of staff and stability of the
services is difficult to maintain.
f. Provincial differences – provincial autonomy allows for different adaptation, interpretation
and implementation of national policies. Each province has its own context and history
of development. This is mostly related to the apartheid policy of separate development
in which some sectors were deliberately disadvantaged in comparison to others.
These points tend to run through the analysis, giving meaning to the data.
12.2 Local context and impact on decentralisation and reproductive
health services
Just as there are provincial differences in context, there are differences at the local point of
delivery, which impacts on decentralisation and reproductive health services. These include the
local political, economic and social dynamics within the community; the community cohesiveness
or division; the dominant culture; and history and past experiences of this. The tension between
traditional systems and the changes in establishing local government as the third sphere of
government to be responsible for basic services and any other services delegated to them.
The research points to some of these differences as experienced in the three study sites –
Klerksdorp, Mafikeng and Ganyesa. The experiences of health workers, patients and other
stakeholders are different in each site. Quantitative data that has been gathered, however, has

not shown marked differences in health outcomes. The data available has to be analysed and
understood within the context of each district. For example, maternal mortality ratio appears
to be highest where there are the best resources, staffing levels, and history of good health
services; the Klerksdorp District. These resources, however, are supporting the least resourced
district included in the study, Ganyesa, with a history of poorer health services.. It is only is by
knowing the context of each district that these apparent anomalies can be explained and understood.
12.3 Dispersion and linkages
Decentralisation is associated with uncertainty and institutional dispersion and there is concern
about the impact of this on reproductive health services.
a. Dispersion
• Differences between provinces - provinces have the autonomy to develop and implement
policies based on national policies.
• Two systems of decentralisation developing – health management and political. The
two systems are being implemented at the same time, but are not always complementary
to each other, and there may be confusion.
• Separation of district hospitals from primary care services – the impact of this on the
referral system. The district health system as defined by the World Health Organisation
includes the district hospital services. Their separation can lead to confusion within the
referral system from primary level to hospital level and loss of continuum of care.
• No unified public service - municipal employees, including health workers, are employed
under different conditions of service. Differences in hours of duty, for example, between
municipal health workers and provincial health workers creates difficulties with
implementing 24 hour health services.
• Vertical continuation of national programmes from the centre to the point of delivery.
National health programmes, such as HIV/AIDS, are managed vertically from national,
to provincial, to district levels. This may include separate staffing and funding. Integration
of services at the point of delivery can be compromised. Emergency Medical Services
are managed vertically from the provincial offices, whereas they operate within the
health district.
321
b. Implications
• Staff demotivation is apparent in the three sites due to the confusion and the uncertainty
of personal futures, such as promotions, training and career paths.
• Confused governance - the health services have health forums and hospital boards;
local government structures include ward committees. All these structures have some
duplication and overlap of functions. Community members are unsure which structures
to use to address their concerns with health and other services.
• Amalgamation of the municipal and provincial government services at local level is
difficult when there are different planning and budget cycles. Local municipalities,
which are partly funded by the provincial government for the health services they render,
experience delays in receiving their funds.
• Hospital services are managed by the provincial government; local municipalities
provide some primary level services, such as clinics and mobiles. There is, however,
no direct communication channel between the municipal services and the hospitals –
communication is directed through the health district office.

Implications for reproductive health services are:
• A split of responsibilities affecting service delivery – the health sub-district manager
is line managed and reports to the provincial structures, but also reports to the local
government structures.
• There is organisational separation between the hospital and the clinics and this requires
further exploration. The district health manager and hospital manager report vertically
to the same regional health manager.
• Centralised management of emergency medical services is problematic in addressing
delays in emergency transfer of maternity and other patients between levels of care.
For example, if no public sector ambulance is available for emergency of a patient,
permission to use a private ambulance service has to be requested from the provincial
office; the decision can not be made by the district health manager.
c. Reaction
322
A relatively high level of relationships – formal and informal – at the management level is
required to deal with the problems of dispersion. Management of these requires a high level of
time, energy and commitment from managers within all spheres of government:
• Support links between PHC services and hospital, for example with administrative and
corporate functions have been created.
• There are informal contacts between district health managers and their counterparts in
the local municipalities.
• Regular meetings are held between district, hospital and Emergency Medical Services
to solve problems with referrals, although final decisions are made at provincial level.
• Regular meetings, such as combined perinatal mortality meetings, between the health
district and the hospital management level, and between midwives, are held.
• Merging and integration of municipal and sub-district services, to work under one
facility manager and in one building. This, however, leads to contradictions due to the
different conditions of service.
• Joint appointments, particularly for management positions, between provincial services
and municipalities, are made although the funding for the post may remain with the
province.
• There is a good working relationship between provincial and local municipality personnel
in some areas. This is particularly noted in the rural area, where dual accountability
was apparent.
• Joint management teams are formed between provincial and municipal services,
particularly where there is strong local government. This leads to duplication of
management.
• Regular meetings between the provincial MEC for health and the municipal mayors.
Informal reactions, strengthening formal linkages and building up informal networks to address
institutional problems suggests a high level of innovation among local health managers. Individual
personalities and particularly active managers play an important role in developing these links.
These appear to be more prevalent in rural areas where there is no history of previous local
government.

However, with regard to the reactions these indicated it important to note that:
• These do not cover all institutional problems.
• The Informal links are not sustainable. They are likely to fall away when someone
leaves the district.
• They do not apply in all districts.
• It is difficult to ensure accountability of informal relationships.
• They appear to be limited mostly to managers with not much involvement of health
providers with whom there seems to be a gap.
12.4 Human Resource Management
Districts seem to have some discretion in deciding on training that is related to local needs.
There is also some available space with regard to in appointments.
a. Training
Decentralisation seems to be giving greater attention to local needs for training. The ‘positive’
impact of this training, however, seems to be blown off course by the overall human resource
shortage and the tendency of staff, once trained, to go to other areas. This is particularly noted
among managers, but also applies to the service providers. This introduces the ‘perverse’ effect
of training.
Training for reproductive health is part of the general training needs for primary health services
and does not receive any special attention.
b. Supervision
323
A similar issue of the positive impact of decentralisation being blown off course is the case of
supervision. Many factors impact on the ability of supervisors to carry out their function. One
of these is the workload in the clinics with the shortage of staff making supervision difficult –
some supervisors may even assist with the queue of patients instead of carrying out his/her
supervisory functions.
As with training, reproductive health services do not receive any special attention. Each area
is overseen by an appointed Area Manager who is responsible for all the PHC services in a
number of clinics and mobile services. In addition, each district has programme managers for
provincially (and nationally) driven programmes, such as Maternal, Child and Women’s health.
This can result in dual supervision and lead to confusion and overload for the front line health
workers.
c. Local health managers – health provider relationship – there seems to be a gap between
the local health managers and the primary health care providers, as witnessed by:
• Problems with the way training decisions are made – as to who will go for what training.
Differences are noted in the process followed between the three study sites and acceptance
of the processes. In one site, for example, there was general dissatisfaction with the
process, whereas in the other two sites the process was generally accepted by health
workers.
• Differing views on a number of issues – such as supplies to the clinic. Managers believe
that all supplies are readily available in all facilities, but the reality on the ground, as
expressed by the front line health workers, was different. They noted some shortages
and delays in supplies.

• Feeling of ‘distance’ among providers. Front line workers generally expressed feelings
of being isolated and distant from management, often expressed as managers not caring
about their welfare.
These may need further analysis from the data and secondary sources. It is interesting to note
that the management team in one health district has, subsequent to the data collection of the
RHD, run a staff satisfaction survey. The result of this survey reflected a similar finding to the
RHD research, and the management is now addressing the problems.
d. Professional shift
Nurses seem to have expanding opportunities for management promotion at the district and
hospital level, and higher.
Opportunities for higher qualifications in advanced midwifery and other reproductive health
programmes are available. Selection for these courses can be problematic in some districts as
has been mentioned. Those who do gain higher qualifications often move to more urban centres
within the province, or outside the province, where working conditions are perceived to be better.
e. Motivation
324
Service providers lack motivation. There are many reasons expressed for this:
• Low salaries and few, or no, incentives, such as rural allowances for all categories of
staff.
• Lack of training opportunities, or favouritism being shown to a few to be trained.
• Poor supervision and perceived attitude that management does not care about them.
• Increasing work load with fewer staff to cope.
• Confusion as to future within the decentralised system to local government; or transfer
of municipal employees to provincial government.
The lack of motivation of service providers seems to be a real problem and requires further
investigation.
f. Hiring
The ability of the District Management Team to appoint staff up to Assistant Director
level is welcomed, although the guidelines for appointment are set at national level. There are,
however, problems of scarcity of skilled staff, particularly in rural areas. Advertisements are
placed, and often there are few applicants. Those who do apply prefer the urban areas.
Local government requires permission from provincial government to appoint or promote service
delivery level health workers. These posts are funded by provincial government. This restriction
leads to frustration and exacerbates the shortage of staff in the clinics.
12.5 Finance
Financing of the services is complex. Control is centralised to the national treasury who is
responsible for distribution of funds according to legislation. Finance for health services is
channeled via the provincial treasuries to the Provincial Department of Health, who then allocate
funds to the districts, hospitals, health programmes and other services.

There is no ring-fenced, or conditional grant, funding for reproductive health services. Most of
the funding is within general funding for primary health care and hospital services. Parts of RHS
may have conditional grants, for example HIV/AIDS services. Although many respondents
expressed the need to prioritise reproductive health services there is no clarity as to how this is
done and by whom.
Concerns were expressed that the decongesting of the district hospitals and the use of the referral
systems has not been matched by the transfer of resources from the hospitals to the primary care
services.
The different financial years for local government and the other two spheres of government
causes problems and confusion within budgeting and planning of the services.
12.6 Logistics
a. Infrastructure, equipment and transport
The municipally run systems for maintenance of infrastructure and for purchase of equipment
appear to work more efficiently than the provincial ones. However, the provincial system may
not be a fault within the Department of Health, but rather because it is run by a different
department, the Department of Public Works. intersectoral cooperation is required. This works
better in some districts than in others.
The provincially run EMS does not seem to be functioning well. This is important as the
comments are generally favourable that the overall system has improved, but the EMS is
recognised as not being good. In the urban areas, the previous system of EMS being a responsibility
of local authorities (government) seemed better, although fragmented. In rural areas there is
some difference of opinion as previously there were fewer ambulances providing emergency
services, but the service has not improved as much as expected.
325
Other transport for health seems to be centralised and not functioning very well.
b. Drugs
The conclusion seems to be that drug supply has improved overall. This may not be due to
decentralisation per se, but to other contributing factors, such as improved procurement systems
being in place.
c. Referral Systems
Some important points have been highlighted from the research.
• The EMS has been centralised to the province and there is a strong sense of dissatisfaction
with this. There are often long delays in responding to calls. Maternity cases are not
given preferential treatment over accidents and other emergency calls.
• There appears in some places to be a gap between the hospital midwives and clinic
nurses over referrals – the one group ‘blaming’ the other for either poor referrals or for
not wanting to do their work.
Institutional diversity possibly contributes to these problems.
12.7 Capacity
It is frequently argued that:

• decentralisation is constrained by the lack of capacity at the decentralised level;
• the decentralised level needs to build up or be supported in its capacity;
• capacity is seen in resources, structures, systems, values, knowledge, skills; and
• decentralisation should be developed in a phased process, starting with those districts
with most capacity. Decentralisation needs to be planned, budgeted for, monitored,
evaluated and documented, and that this is not happening.
• There needs to be a definition of decentralisation that is discussed and agreed upon.
The RHD research found that the district with the best governance relationship with the community
and best linkages within the complex sub-systems is the district with the less capacity in the
formal sense. There is, however, a perception that this district may have the best chance of
success with decentralisation.
“I think we have the capacity but it is more than capacity in the office that we need to
manage decentralisation. It is much broader. It is a fact that it is a political issue also and
that you must accept that it is not manageable by me, definitely not… you need the political
support and acceptance of the whole concept of decentralisation and, although I think it
is accepted, it still remains a political problem, yes.”
(District Health Manager)
12.8 Governance
326
A confused system reproduces more confusion. Informal arrangements have to be made to
ensure that the system works in terms of reporting relations.
Although there are criticisms of the governance system, it is interesting to find a fairly impressive
range of responsibilities carried out by parts of the governance system.
The views of the managers, health workers and forum members are sometimes quite divergent.
It appears from the data that rural governance works, whereas the semi-urban area does not. A
key question here is why? Some possible explanations that require further exploration are:
• Communication style
• Geographical area – doesn’t seem to be a problem
• Semi-urban district complains of many delays, despite the fact that the provincial capital
is within its boundaries; the rural area expressed fewer problems.
• Semi-urban area has a greater political division and less contact between the provincially
managed and municipal managed health services.
• The importance of traditional leadership and its relationship with the local government
structures. Traditional leadership is generally stronger in the rural area, is present in
part of the semi-urban area and almost absent in the urban area.
• Relationship between the local government ward structures and the health governance
structures. The two structures run parallel to each other and overlap in responsibilities.
This leads to confusion, particularly for community members, as they are not certain
as to whom to address their concerns and problems.
• Loss of values (loss of Ubuntu) and power struggles.

12.9 Conclusion
Decentralisation is complex. It is not possible to separate the impact of this process from other
parallel policy changes, such as development of reproductive health policies and their
implementation. Context in which this is being introduced impacts on the ability of the local
level to respond to the demands of a decentralised system. This in turn seems to impact on the
implementation of reproductive health policies and the outcomes for reproductive health in each
district.
The findings of the RHD research, however, do illustrate the complexity of the evolving systems
for health services. There is some insight into factors requiring consideration before and during
implementation if there is to be a positive outcome from policy changes. Many of these issues
will be further developed in the comparative reports of the four countries involved in the RHD
research.
327

Appendix
Decentralisation and Reproductive Health Policy
and Legislation Analysis
Full Source reference
(author, date, place, etc.)
Summary of document
(purpose, key point)
Key points / meanings of
relevance to research themes
National Policy and Legislation
Reconstruction and Development
Programme
1994
Policy document of the ANC
African National Congress basic
policy document for transformation
of government.
The five key programmes are:
• meeting basic needs;
• developing our human
resources;
• building the economy;
• democratising the state and
society, and
• implementing the RDP.
Health Services:
Health included as “basic need”;
single Ministry of Health with
National Health Authority; provinces
to have Provincial Health Authority
that supports District Health
Authorities (DHA); services to be
delivered through decentralised
management system with local
accountability and driven by PHC
approach; DHAs to be responsible
for health and part of democratically
elected local government.
Reproductive Health:
Maternal and child to be improved
through access to high quality ante
natal, delivery and postnatal health
care; these services to be free.
Every woman to have right to early
termination of pregnancy, according
to her beliefs.
Improved emergency health services.
Sexual health and AIDS – spread of
STI and AIDS to be combated
through early treatment available at
all health facilities.
Empowerment of women to boost
their role in development.
Services for youth aimed at teenage
parenthood and STIs.
Policy document is foundation
document for developing many
policies, guidelines and legislation
for all sector services after 1994.
For health:
• Emphasises the right of all to
access health services that is
effective and appropriate.
• Decentralisation of services to
the lowest most appropriate
level.
• Encourages community
participation in provision of
services.
• Special mention is made of
reproductive health as a free
service.
• The right of a woman to choose
to terminate a pregnancy.
• Improving emergency health
services.
• Focus on decreasing HIV/AIDS
problems.
• Focus also on needs of the youth
and adolescents.
328

329
Full Source reference
(author, date, place, etc.)
National Policy and Legislation
Constitution of Republic of South
Africa, Act No 108 of 1996
White Paper on Transforming
Public Service Delivery, 1997
(The Batho Pele White Paper)
Related to the White paper on the
Transformation of the Public
Service, 1995
Summary of document
(purpose, key point)
The Constitution includes:
The Bill of Rights (chapter 2)
• right to life;
• right to health care, including
reproductive;
• right to emergency health care.
Establishes three spheres of
government – national, provincial
and local – to be distinctive,
interdependent and interrelated and
work together through cooperative
governance.
Outlines roles, powers and
competencies of each sphere of
government and means by which
additional functions can be devolved,
delegated or assigned from National
or Provincial to Local Government.
Schedules 4 and 5 list health
responsibilities of each sphere.
Health services – shared between
National and Provincial.
Ambulance – Provincial.
Municipal Health Services – Local.
Provides a policy framework and a
practical implementation strategy for
the transformation of Public Service
Delivery.
Eight principles are listed:
• Consultation;
• Service standard;
• Access;
• Courtesy;
• Information;
• Openness and transparency;
• Redress;
• Value for money.
An implementation strategy is
outlined. Each national and
provincial department is mandated
commit themselves to these
principles.
Key points / meanings of
relevance to research themes
Considered to be a progressive, liberal
constitution.
Emphasis is on the rights of the
individual for self determination and
to have a say in government, the
services provided and the quality of
these.
Establishes a decentralised system –
bringing government close to the
people, with national and provincial
having a supportive, monitoring role.
Principles of service delivery within
the public sector, including health.
Every health facility is required to
have a poster with these principles –
and the staff is expected to adhere to
them.
The Patients Rights Charter is similar.
Many complaints are heard from the
community re rude and
unprofessional attitude of staff –
especially towards the youth.

White Paper on Local
Government
1998
Full Source reference
(author, date, place, etc.)
National Policy and Legislation
Local Government Demarcation
Act No 27 of 1998
Summary of document
(purpose, key point)
Contains the government’s vision of
a new local government system for
South Africa and how to achieve this
vision.
Local Government to be
developmental and ensure universal
access to basic services.
Integrated Development Plans (IDP)
to include all sectors (includes
health).
Additional functions can be
decentralised from national and
provincial spheres to local if is better
able to perform the functions
efficiently and effectively.
Discusses establishes 3 categories
of municipalities – A (metro), B
(local) and C (district) – and roles
and functions of each – as determined
by National Government.
Outlines key roles of each sphere of
government.
Finances for local government
through Intergovernmental Fiscal
Relations – National to Province and
Local. Plus “Equitable Share” from
national revenue, as determined by
National for basic services.
To improve management legislation
allows for performance management
system; corporatisation; publicpublic
partnerships; partnerships with
community based organisations and
non-governmental organisations; and
out-sourcing to private sector.
Determines municipal boundaries in
terms of Chapter 7 of the
Constitution.
Includes criteria for determining
boundaries to be such that local
government can fulfil its
constitutional requirement for
integrated development, provision
of basic services and with potential
tax base for this.
Key points / meanings of
relevance to research themes
Outlines roles of local government
as being main implementer of
policies, in all sectors.
Sets the boundaries for Health
Districts - these are required to be
coterminous with local government
demarcations.
330

331
Growth, Employment and
Redistribution (GEAR)
A Macroeconomic Strategy
1999
Full Source reference
(author, date, place, etc.)
National Policy and Legislation
Local Government Municipal
Structures Act No 117 of 1998
Public Finance Management Act
No 1 of 1999
Summary of document
(purpose, key point)
Gives power to MEC for Local
Government in each province to
establish local government
municipalities within the province
as demarcated by the Municipal
Demarcation Board.
Sets out structures for local
government, election procedures and
functions and powers of the elected
councils.
Outlines local governance structures
and processes for community
participation through sub-councils,
ward and other committees.
Establishes the 3 categories of
municipalities – A (metro), B (local)
and C (district). Functions and
powers for local government as
outlined in the Constitution are
divided between B and C
municipalities.
Municipal Health Services (not
defined in the Act) is assigned to C
(district) municipalities.
Applies to all government sectors.
GEAR states that SA seeks:
• a competitive fast-growing
economy which creates
sufficient jobs for all work
seekers;
• a redistribution of income and
opportunities in favour of the
poor;
• a society in which sound health,
education and other services are
available to all; and
• an environment in which homes
are secure and places of work
are productive.
The strategy rebuilds the economy
in keeping with the goals of the RDP.
Key points / meanings of
relevance to research themes
Establishes local governance
structures for community
participation; however, these are not
aligned with health governance
structures which leads to confusion
on the ground.
Introduced stringent financial
controls for all levels of the health
services.
Government economic strategy
forcing a shift from a social
development approach, as a vital
principle of PHC particularly in
development of intersectoral
coordination and community
participation to a market approach.
Challenges the ability to develop the
social and health programmes
required in South Africa.

Full Source reference
(author, date, place, etc.)
Summary of document
(purpose, key point)
Key points / meanings of
relevance to research themes
National Policy and Legislation
It is designed to confront the related
challenges of meeting basic needs,
developing human resources,
increasing participation in the
democratic institutions of civil
society and implementing the RDP
in all its facets.
Health Services:
The systematic restructuring of
health services, with a strong
emphasis on universal and free
access to comprehensive primary
care, represents a clear commitment
to improving the health conditions
of the poor. Within the public health
system resources are shifting from
tertiary services in metropolitan
areas towards overcoming the
inadequacies of hospitals and clinics
in rural areas and townships.
Health Sector Strategic
Framework 1999 - 2004
Ten Point Plan for Health Services
1999 to 2004
• Reorganisation of certain
support services;
• Legislative reform;
• Improving quality of care;
• Revitalisation of hospital
services;
• 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 co-operation with
our partners internationally.
Development of the DHS included
as a strategic objective.
The essential health care package of
services, which includes reproductive
health services, to be delivered
through the DHS.
Special focus on
• Equity;
• Human resources;
• Communication with
communities.
332

333
Full Source reference
(author, date, place, etc.)
National Policy and Legislation
Local Government Municipal
Systems Act No 32 of 2000
Strategic Priorities for the
National Health System, 2004 -
2009
Summary of document
(purpose, key point)
Regulates key municipal
organisational, planning,
participatory and service delivery
systems.
A municipal council may finance the
affairs of the municipality by
charging fees for services.
Municipal council duties include,
inter alia:
• encourage the participation of
the local community;
• promote gender equity;
• contribute to the progressive
realisation of the fundamental
rights contained in the
Constitution.
The Act regulates the process of
assigning powers and functions to
local government. This is important
to ensure that municipalities receive
adequate funding to fulfil assigned
powers and functions and to ensure
that the three spheres of government
work in a coordinated way.
Municipalities are required to
develop Integrated Development
Plans that include all government
sectors, and are participatory with
community.
National and provincial government
have a constitutional obligation to
monitor and support local
government.
• Improve governance and
management of the NHS.
• Promote health lifestyle
• Contribute to human dignity by
improving quality of care.
• Improve management of
communicable diseases and
non-communicable diseases.
• Strengthen primary health care,
EMS and hospital service
delivery systems.
• Strengthen support services.
Key points / meanings of
relevance to research themes
Introduced systems for community
participation in local government,
which includes health issues.
No mention made of DHS.
Strengthen delivery systems for
primary health care, emergency
services and hospitals – reproductive
health services included in these
services.

Full Source reference
(author, date, place, etc.)
Summary of document
(purpose, key point)
Key points / meanings of
relevance to research themes
National Policy and Legislation
• Human resource management,
planning, development and
management;
• Planning, budgeting and
monitoring, and evaluation;
• Prepare and implement
legislation;
• Strengthen international
relations.
Health Policy and Legislation
ANC Health Plan 1994
Lays out the principles for the
transformation of the health services
and establishing of a National Health
System for South Africa in the postapartheid
error.
Stats that: -
• everyone has a right to achieve
optimal health;
• restructuring will be through
PHC approach;
• there will full community
participation;
• there will be inter-sectoral
collaboration.
Development strategies to be used
to improve quality of life.
Contraception is only part of fertility
control.
Services will be decentralised to the
lowest level possible.
Community Health Centres will be
foundation for comprehensive health
services; including 24 hour
emergency and maternity services,
and be part of a DHS.
Role of the centre is defined and
plans for equitable distribution of
resources.
Free health care for all children under
6 years, pregnant and nursing
mothers; antenatal care, maternity
care and contraceptives to supplied
free.
Priority programmes include women
and child health and control of
communicable diseases.
Provides the basis for all health
policies and their implementation
through a decentralised system.
The plan pre-dates Cairo ICPD, but
some of the philosophy of ICPD is
reflected in it.
334

335
Full Source reference
(author, date, place, etc.)
Health Policy and Legislation
White Paper for the
Transformation of Health Services
in South Africa 1997
Summary of document
(purpose, key point)
This is based on the RDP and the
ANC Health Plan above.
Emphasis for health care is on
decentralisation of the services and
the PHC approach through the DHS.
Health services will be
developmental in approach, with
particular emphasis on the
educational status of women and
their participation in planning of the
services.
One of the main five aims is
maternal, child and women’s health,
for which there will be a directorate
at the national level.
The DHS is at the core of the health
strategy and therefore is to be given
the highest priority fro rapid
implementation.
“The following principles will guide
future efforts for MCWH services:
• MCWH services should be
accessible to mothers, children,
adolescents and women of all
ages. A major focus will be on
providing services to the rural
and urban poor and farm
workers.
• MCWH services should be
comprehensive and integrated.
• Clear objectives and targets
should be set at the national,
provincial, district and
community levels. These
objectives should be developed
in accordance with the goals of
the RDP, the health sector and
the United Nations Convention
on the Rights of the Child.
• Individuals, households, and
communities should have
adequate knowledge and skills
to promote positive behaviour
related to maternal, child and
reproductive health.
• MCWH services should be
efficient, cost effective and of a
good quality.
Key points / meanings of
relevance to research themes
No mention of emergency medical
services – ambulances
No mention of ICPD, but does
mention Ottawa Charter for health
promotion.
Mother and child health given
prominence, but reproductive health
is split.

Full Source reference
(author, date, place, etc.)
Health Policy and Legislation
White Paper for the
Transformation of Health Services
in South Africa 1997
Health Sector Strategic Plan
1999 - 2004
Adopted by the National Minister
of Health and the nine provincial
MECs for Health in 1999.
Summary of document
(purpose, key point)
• Women and men will be
provided with services which
will enable them to achieve
optimal reproductive and sexual
health”
Hospital services: -
• Roles to be defined to be
consistent with the PHC
approach;
• Management will be
decentralised;
• A fee system will be introduced;
hospitals to retain a proportion
of revenue collected;
• Private hospitals to be regulated.
Creation of a National Health
Laboratory Service (NHLS) is
proposed.
Principles and implementation
strategies for health promotion and
communication are listed, based on
the Ottawa Charter.
Summarises achievements of first
five years of transformation; health
status as in 1999; strategic plan for
next five years.
Includes a Ten Point Plan: -
• Reorganisation of certain
support services;
• Legislative reform;
• Improving quality of care;
• Revitalisation of hospital
services;
• 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;
Key points / meanings of
relevance to research themes
No mention of emergency medical
services – ambulances
No mention of ICPD, but does
mention Ottawa Charter for health
promotion.
Mother and child health given
prominence, but reproductive health
is split.
Included in the strategies are:
• Reorganising laboratory
services;
• Transforming blood transfusion
services;
• Passing of a National Health
Act to replace Health Act of
1977;
• Introduction of a
comprehensive PHC package
in all clinics, community health
centres and district hospitals;
• Strengthening DHS through
decentralisation and improving
quality of care;
• Reduce teenage pregnancies
• Strategy to reduce HIV/AIDS
and STIs;
• Strategy to improve women’s
health and decrease maternal
mortality;
• Reduction of violence,
particular focus on women and
children;
• Improve emergency medical
services, including increasing
and training of EMS personnel.
336

337
Full Source reference
(author, date, place, etc.)
Health Policy and Legislation
National Health Laboratory
Services Act No 37 of 2000
The District Health System:
Proposal for Terminology
National Department of Health
Policy Document
16 Jan 2002
Summary of document
(purpose, key point)
• Improving communication and
consultation within the health
system and between the health
system and the communities we
serve; and
• Strengthening co-operation with
our partners internationally.
The act establishes the National
Health Laboratory Service. It
replaces other institutions and is a
“single national public entity to
provide public health laboratory
services in the country.”
The objects of the service are to:
• Provide cost effective and
efficient health laboratory
services to:
- All public sector care
providers;
- Any other government
institution inside or outside
the Republic that may
require such service; and
- Any private health
provider that requests such
services.
• Support health research; and
• Provide training for health
science education.
It is set up as a business funded
through fees for services,
investments, grants, donations and
royalties.
Reiterates the vision for health
services to be decentralised to local
government. Takes cognisance of
terminology used by local
government and other sectors and
proposes names for health sub
structures to be in line with these.
Key points / meanings of
relevance to research themes
• Developing an effective referral
system between levels of health
care;
• Development of a human
resource plan for the health
sector, including training,
supervision and retention
policies.
May not be cost-effective to operate
laboratories in small rural hospitals
on 24-hour basis. This can increase
the number of patient referrals after
hours to larger, regional hospitals for
management.
This policy document defines the
level of the DHS within local
government.
Health is part of services to be coordinated
by local government and
is to form part of the IDP within
each municipal area.

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Notes the proposed role of local
government in planning and coordinating
all services within their
area of jurisdiction through
Integrated Development Plans (IDP).
“The National District Health
System is therefore now based on
the boundaries of the District
Municipalities and the Metros.”
The document notes provincial
differences in that some provinces
will need to subdivide the districts
(North West and Western Cape) and
others will not (Northern Cape).
PHC is defined as being the full
package of PHC services, but does
not include the district hospital
services. The two are to remain
separate, but this may change once
the full packages are implemented
and equity has been achieved.
Municipal Health Services will be
defined in the National Health Act
and will, in terms of the Constitution
and Municipal Systems Act, be the
responsibility of the district
municipalities.
Confirms the NDoHs decision to
separate the district hospital services
from the district clinic and
community services.
338
The District Health System -
Proposed Way Forward:
Discussion Document for the
PHRC
31 May 2002
A discussion document prepared for
the Provincial Health Reconstruction
Committee (PHRC).
Reaffirms the vision for PHC
approach through a DHS, based on
the 47 district municipalities and 6
metros. The final goal for health is:
“The goal is to have 53 health districts
each ultimately characterised by:
• Provision of comprehensive
district health services (i.e. the
PHC package plus district
hospital services);
• A district health plan that is
part of the district Integrated
Development Plan (IDP);
• A structure and processes to
ensure cooperative governance
(to ensure joint planning and
seamless service provision);
This document is follow-up to the
above one.
Outlines problems of achieving a
full DHS in the short term and
proposes steps to be taken to ensure
that the vision for health services
remain on track i.e. a decentralised
health system, based on a PHC
approach through a DHS.

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339
• Joint funding from
municipalities and province(s);
• A single budget with clear
components or budget lines;
• A single management structure;
• All staff part of a single public
service; and
• All staff employed by the district
(or metro) municipality.”
Reaffirms MinMEC decision of Feb
2001 – this was a means of achieving
the above goal through delegation
of PHC services to local government
through Service Level Agreements.
Such delegation to be in line with
provisions of the Constitution,
Section 238 and 156.
Problems and possible solutions are
discussed. This includes:
• The definition of municipal
health services. MinMEC
proposed this should be
environmental services plus
preventative and promotive
health. This document outlines
the pros and cons of this
decision and proposes a
minimalist definition of only
environmental health be
accepted instead.
• Funding requirements to cover
potential loss of funds for these
services.
• Implications for staffing and
development of a single public
service for the country. Need to
liaise with DPSA to ensure
health needs are addressed.
• A system of functional
integration between provincial
and municipal health services
is used to ensure seamless
health provision.
• Governance structures for
health to be included in the
National Health Act.

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Health Policy and Legislation
National Health Act No 61 of 2003
The objects of this Bill are to regulate
national health and to provide
uniformity in respect of health
services across the nation by:
(a) establishing a national health
system;
(b) setting out the rights and
duties of health care providers,
health workers, health
establishments and users; and
(c) protecting, respecting,
promoting and fulfilling the rights
of:
(i) the people of South Africa
to the progressive realisation
of the constitutional right of
access to health care services,
including reproductive health
care;
(ii) the people of South Africa
to an environment that is not
harmful to their health or wellbeing;
(iii) children to basic nutrition
and basic health care services
contemplated in section 28
(l)(c) of the Constitution; and
(iv) vulnerable groups such
as women, children, older
persons and persons with
disabilities.
Provision is made for extending
range of free services. Free services
are to continue for pregnant and
lactating women, children below age
of 6 years and termination of
pregnancies.
Chapters 3 and 4 – lay out roles and
functions of National and Provincial
Dept. of Health; formation and roles
of governance structures.
Chapter 5 – establishes the district
health system, districts to be
coterminous with district and
metropolitan municipal boundaries.
Relates to sections 27 and 195 of the
Constitution and section 25 of the
Municipal Demarcation Act.
Governance structures – no special
mention of gender composition. But
this could be covered through other
policies from the Gender
Commission and elsewhere in
government, which is pro female
participation in governance issues.
No reference to EMS, ambulances
or laboratory services.
DHS is established, with
decentralisation as the final aim. But
there are many issues around
resources – human and funding in
particular – that are not dealt with
in this Bill.
The Bill has not been signed into
law – the country is still officially
under the Health Act of 1977, which
is inappropriate for current policies.
The Bill only requires the President’s
signature – this is unlikely to happen
until after the elections in April and
the inauguration of the new
parliament.
340

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Health Policy and Legislation
Summary of document
(purpose, key point)
District Health Councils are
established to promote co-operative
governance, ensure co-ordination of
planning process and to be advisory
to the Provincial Health Council.
District and metropolitan
municipalities are responsible for
municipal health services, as defined
in the Bill; the Exec Council “must
assign such health services to a
municipality …as contemplated in
section 156(4) of the Constitution.”
Chapter 6 – covers health
establishments, including formation
of hospital boards, clinic and
community health centre committees.
Chapter 8 – calls for the Minister to
establish a national blood transfusion
service.
Key points / meanings of
relevance to research themes
Reproductive Health Policy and Legislation
341
Free Health Care for Pregnant
Women and Children Under 6
years 1994
Provides for free health care, at all
levels of the health system, for
pregnant women and children under
the six years of age.
Improved access to health care for
vulnerable group.
Only financial barrier to care is
transport from home to the nearest
health facility.
Maternal, Child and Women’s
Health
Draft Policy document 1995
Develop a national programme and
framework for the delivery,
organisation and management of
health services for mothers,
newborns, children (up to the age of
18 years, including adolescents) and
women.
Equity is the first priority and the
most vulnerable must be focused on
first.
Health problems that result in the
highest morbidity and mortality must
be tackled first and given financial
resources.
An operational plan for this proposal
will be implemented through a
phased approach based on
consultation, and on determined
needs and available resources.
The plan is located within the context
of the RDP.
Detailed plan and framework.
No mention of ICPD principles.
Progress report of 2001 – shows little
progress had been made.

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Reproductive Health Policy and Legislation
The goals are:
For Mothers:
To ensure access to high quality
antenatal care, and quality care during
after delivery to mothers and their
babies.
To implement a population-based
system of service delivery for mothers
and their babies which strives to
achieve agreed objectives.
For Children:
To enable each child to reach his/her
maximum potential within the
resources available, and to enable as
many children as possible to reach
adulthood with their potential
uncompromised by illness, disability,
environmental hazard or unhealthy
lifestyle.
For Adolescents:
To ensure access to relevant and
appropriate information, community
support and health services, which
enable adolescents to cope with the
rapid physical and psychological
changes that occur during this period,
and which expose them to the dangers
of aberrant psychological behaviour
and disorders.
For all woman:
To achieve optimal reproductive and
sexual health (mental, physical and
social) for all women and men across
the life-span of individuals.
To raise the status of women, their
safety, health and quality of life.
The services are to be delivered
through an integrated approach as
part of the DHS, supported by a
vertical management system. Clear
protocols for management are
required.
The framework is designed to address
the inequities of the past and to bring
the needs of women, children and
adolescents to the forefront.
Objectives and targets are included,
as is service delivery and organisation
at all levels of the system.
342

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Reproductive Health Policy and Legislation
343
Choice of Termination of
Pregnancy Act No 92 of 1996
Savings Mothers Report 1999
To determine the circumstances in
which and conditions under which
the pregnancy of a woman may be
terminated; and to provide for
matters connected therewith.
The act recognizes human rights and
freedom of the Constitution; the right
of persons to make decisions over
their own fertility and reproduction;
that universal access to reproductive
health care services includes family
planning and contraception,
termination of pregnancy, as well as
sexuality education and counseling
programmes and services;
termination of pregnancy is not a
form of contraception or population
control.
Sets out conditions for termination
of a pregnancy before 12 weeks,
between 13 and 20 weeks and after
20 weeks gestation.
Procedure can be done be a medical
practitioner or, if under 12 weeks,
by a midwife who has been
specifically trained.
The procedure can be done at any
facility designated by the Minister.
Informed consent is required only
from the woman concerned.
Based on confidential enquiries of
all reported maternal deaths.
Provides policies and guidelines to
address the commonest causes of
maternal deaths.
Focus of recommendations are on
improved clinical management, such
as:
• Guidelines for management of
common conditions;
• Improved criteria for referral
and referral routes;
• Establishing staffing norms
• Expansion of CTOPs sites;
• Monitoring of labour using the
partogram;
Gives women freedom of choice to
terminate an unwanted or unplanned
pregnancy, without consent of
anyone else or lengthy legal
procedures.
Common avoidable factors in
maternal deaths related to patient
problems, such as non attendance at
ante-natal care and delays in
reporting to a medical facility when
in labour.

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Reproductive Health Policy and Legislation
• Improved availability of blood
for transfusion;
• Medical obstetric clinics for
management of related illnesses
in pregnancy;
• Promotion of regional
anaesthesia for caesarean
sections;
• Contraception and family
planning advise for women over
35 years or with more than 5
children;
• Relevant HIV/AIDS policies
for pregnant women.
HIV/AIDS and STI Strategic Plan
for South Africa
2000 to 2005
The primary goals of the strategy are
to:
• reduce the number of new HIV
infections (especially among
youth); and
• reduce the impact of HIV/AIDS
on individuals, families and
communities.
Policies and implementation plans
based on the strategic plan.
344
Four priority areas:
• prevention
• treatment, care and support
• research, monitoring and
surveillance
• human rights
A specific programme targeted at the
youth is included.

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Reproductive Health Policy and Legislation
345
Policy Guidelines for Youth and
Adolescence Health, 2001
The policy framework is developed
in the context of international
agreements and national legislation
and policies. It acknowledges the
inter-sectoral approach to dealing
with youth and adolescent issues.
There are five guiding principles:
• Adolescent development
underlies the prevention of health
problems;
• Problems are interrelated;
• Adolescence and youth are times
of opportunity and risk;
• The social environment
influences behaviour;
• Not all young people are equally
vulnerable;
- “homeless” adolescents and
youth;
- adolescents and youth with
disabilities;
- adolescents and youth living
with HIV/AIDS;
- other vulnerable groups.
• Gender considerations are
fundamental.
The intervention strategies include:
• Promoting a safe and supportive
environment;
• Providing information;
• Building skills;
• Counseling;
• Access to health services.
The settings for these will be in the
home, at school, in health facilities,
in the workplace, on the street,
through community based
organisations and at residential
centres.
Priority will be given to:
• Sexual and reproductive health;
• Mental health;
• Substance abuse;
• Violence;
• Unintentional injuries;
• Birth defects and inherited
disorders;
• Nutrition;
• Oral health.
Involved young people, government
departments and NGOs in various
sectors.
It is comprehensive and much wider
than health services.

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Reproductive Health Policy and Legislation
Saving Mothers Policy and
Guidelines
2001
Saving Babies Report
2000 and 2002
Guidelines for Maternity Care in
South Africa
2002 (2nd Edition)
The policies and guidelines
(published by the National
Department of Health) are based on
the findings of the National
Committee on Confidential Enquiries
into Maternal Deaths. These findings
are recorded in the Saving Babies
reports.
Guidelines for all levels – from clinic
to specialist hospital are presented.
These are for use in developing
institution and district specific
protocols for management and
referral between levels of care.
Similar reports to the Savings
Mothers Reports on causes of perinatal
mortality. Data is gathered
mostly through the Perinatal Problem
Identification Programme (PPIP).
Key strategies focus on improving
clinical care of the mother and baby.
These include:
• Provision of necessary protocols
and equipment for management
of patients;
• Use of the partogram in labour;
• Training in management of the
pre-term and low birth weight
baby. Use of kangaroo care
encouraged.
• Protocols for ante-natal care
and referrals.
At time of confirmation of her
pregnancy to be the first ante-natal
visit for a woman.
These guidelines are more detailed,
but consistent with, those in Saving
Mothers Policy and Guidelines – see
above.
They are for use at all levels of the
health care system – clinics,
community health centres and
hospitals.
National Department of Health has
taken the lead in developing policies
and guidelines to reduce maternal
mortality.
Provincial and local levels adapt these
to their own needs.
Avoidable contributing causes of
death are often related to failure of
support systems, such as transport,
ambulances, laboratory facilities,
drugs.
National Department of Health has
taken the lead.
These guidelines were seen in clinics
and community health centres.
At times these are taken home by
nurses for their personal study – see
provincial interview with MCWH
coordinator.
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Reproductive Health Policy and Legislation
347
National Contraception Policy and
Guidelines
2002
National Guidelines for Cervical
Cancer Screening Programmes
The document gives the historical
back ground to contraception prior
to 1994.
It lays out the current context for the
new policy – this includes:
• International agreements and
charters, such as Cairo 1994;
• National relevant policies that
refer to the rights of women to
free choice.
These are used in the policy
framework, which embraces the new
definitions of sexual and
reproductive health and focuses on
the rights of the patients and the
needs of the providers. The service
is to be comprehensive and
integrated.
The over all goal of the policy is to
“improve the sexual and
reproductive health of all people in
South Africa.”
The purpose is to “enable all people
to exercise their contraceptive choice
safely and freely.”
This will be achieved through
strategies related to three stated
objectives:
• To remove barriers that restrict
access to contraceptive services;
• To increase public knowledge
of client’s rights, contraceptive
methods and services;
• To provide high quality
contraceptive services.
Management Objectives
• To reduce the incidence of
carcinoma of the cervix,
primarily;
• by detecting the treating the preinvasive
stage of the disease;
• to reduce the morbidity and
mortality associated with
cervical cancer;
There was wide consultation with
specialist obstetricians, midwives
and research institutions, as well as
provincial departments of health,
universities, nursing colleges,
professional bodies (Nursing
Council) NGOs and other interested
groups. No mention is made of
consultation with health systems
(except for HST) – but this may have
been there through dept of health.
No community consultation is
mentioned.
The prevalence of HPV infection
changes from 10% to as high as 46%
in some countries. In common with
other sexually transmitted diseases,
younger women tend to have a higher
rate of infection than older women
and are more likely to be transiently
infected with HPV.

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• to ultimately reduce the
excessive expenditure of scarce
health funds currently spent on
the treatment of invasive cancer
of the cervix.
Target Population for Screening
Women 30 years and older
Health Service Target
Primary level of health-care facilities
with adequate infection control and
quality assurance measures in place.
Screening Interval Options
Women aged 30 years or older will
be screened three times in succession,
at least 3 years apart utilising servical
cytological (PAP)
The majority of HPV infections
seems to be latent with no production
of viral particles.
Closely related to transmission of
HIV virus.
National Department of Health
Strategic Plans, 2004 to 2005 and
2006 to 2007
Lays out key objectives, indicators
and targets for next 3 years. Based
on Ten Point Plan above.
Includes MCWH – reduce infant,
child and youth morbidity and
mortality; improve youth and
adolescent health; reduce maternal
morbidity and mortality; improve
health services for school going
children.
HIV/AIDS and STI goals separate.
Improving EMS services – adoption
of National Strategic EMS
Framework through phased
implementation over 5 years.
Objectives, indicators and targets
agreed to by the provinces and local
government. Implementation plans
responsibility of the provinces.
348
North West Province Policy and Legislation
North West Health, Developmental
Social Welfare and Hospital
Governance Institutions Act No 2
of 1997
“To create health, developmental
social welfare and hospital
governance institutions in the North-
West Province; to define the
composition, powers, functions of
such institutions; the appointment
of members of those institutions and
their remuneration; to repeal certain
laws and to provide for incidental
matters.”
Combines health and social welfare
functions.
Entrenches community participation
/ consultation in health.
Members nominated by the
community, but appointed by the
MEC to whom they are responsible.

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Reproductive Health Policy and Legislation
The MEC may establish Health and
Developmental Social Welfare
Forums in the North West Province.
Members appointed by the MEC
from list of nominees from the
community the forum is to serve.
Function of the Forum is to consider,
investigate and make
recommendations on matters referred
to it by the MEC or community;
make nominations for Health and
Developmental Social Welfare
Boards and Hospital Boards.
The roles and functions of each substructure
are outlined.
349
North West, Devolution of Powers
to Local Government Act
Act No 6 of 1998
With amendment – Act No 10 of
1998
North West Provincial Health Bill
2001
“To provide for the rationalisation
of laws pertaining to local
government in the North West
Province.”
Repels all laws that were applicable
under Apartheid in the demarcated
area of the North West Province.
Amends the Act to be in line with
the Constitution.
Makes provision for the Premier of
the North West Province to
decentralise functions to local
government, in accordance with the
provisions of the Constitution.
The Bill creates a Provincial Health
System. This is based on integrated
health services by means of hospitals
and primary health care services
through a district health system.
Health regions are demarcated
coterminous with district (C)
municipalities and health districts
coterminous with local (B)
municipalities.
The Bill stipulates that PHC services
will be decentralised to the local
municipality level; district hospitals
will however remain a provincial
responsibility through the regions.
Brings the whole of the North West
Province under one authority.
The North West Health Bill is under
review – changes will need to be
made so that it is in line with the
National Health Act when it is
promulgated.
There is strong support from the
provincial MEC for Health for
community to participate at all levels.

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North West Province Policy and Legislation
Governance structures are
established at all levels – provincial,
regional and local – plus hospital
boards, clinic committees and heath
forums.
350

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