Municipal Health Services The Local Government Perspective Eastern Cape Example

1. Municipal Health ServicesThe Local Government PerspectiveEastern Cape Example SALGA Consultative Meeting on Municipal and Primary Health Care (Discovery Auditorium, Sandton) 08 April 2011

2. Background • Legislative framework • Constitution (Act 108, 1996)– Schedule 4B • Local Government: Municipal Structures Act (Act 117, 1998) – S84(i) • National Health Act (61 of 2003) – Definitions & S32(1) • MINMEC decision – MHS and who should render • DORA Bill, 2006 – MHS – “Basic Service”

3. Introduction • SALGA requested the Eastern Cape to present on our experience with the devolution of MHS • Eastern Cape one of the poorest provinces • The province consists currently of one Metro (NMMM) and 6 District Municipalities • One aspirant metro (Buffalo City)

4. Governance arrangements • ECDoH facilitated and coordinated the Provincial Environmental Health Devolution Task Team (PEHDTT) - 2003 • Chairperson of PEHDTT– alternated between ECDoH and LG. • Consisted of Metro, DM and ECDoH environmental health management • Working Committees established to collect data • Also established District EH Devolution Task Teams at each DM and Metro • Consisted of Local Government and Provincial EHPs • Union representatives (Local Government & Government) • Directors / Managers to whom EHPs report • Politicians (Ad hoc feedback) • Reported to District Management Team (ECDoH); Top Management and Standing Committee and PEHDTT. • ECDoH – reported to PHAC and PHC and subsequently to Parliament

5. Initial process • PEHDTT’s Working Committees collected data necessary for the devolution of MHS e.g. Staff information; available equipment. • Invited DWA – Share best practice with integration of water function to the WSAs • Invited Unions (Government) and the Bargaining Council to inform them and to get direction – S197 of LRA - Medical Aid and Pension fund issues. • Regular PEHDTT meetings from 2003 till 2006 – Aeroplane

6. Challenges • No further substantial progress with ECDoH – irregular meetings • Numerous national due dates were set for devolution (2004 then 2006 and the latest was April 2010) which resulted in: • Provincial colleagues resigning – prolonged devolution process. • JGDM – 45% Provincial EHPs resigned in 18 months • ADM – 5 Provincial EHPs resigned in one month • Provincial EHPs not benefiting from car allowances etc. >90% EHPs are without transport • Lack of establishment cost for provincial staff • Provincial staff mostly without transport and equipment • Lack of an exit strategy from DoH such as DWAs.

7. Challenges (Cont. 1) • LG cannot populate organisational structures – wait for provincial staff • Shortage of EHPs at LG, services that are not properly structured and little to no growth opportunity for EHPs at DMs leads to frustration from LG’s own staff - JGDM 83% EHP staff turnover in past 5 years • Environmental health not regarded as priority • Support from authorities • Governments strategic monitoring of basic services – “Turn Around Strategy” – LGTAS – did not reflect on MHS – weekly monitoring (R 1; R 2; New conservancy).

8. Challenges (Cont. 2) • Ratio of EHP per population (SA - 1:15 000) (WHO – 1:10 000) – Attitude of Management – can never have the ideal situation. • (Community Service EHPs – National Programme) – No transport, office accommodation, some accommodated without skilled EH support • Sustainable funding beyond 3 year funding from ECDoH (2009/10)– National Treasury model (MHS not income generator) • Equitable Share (Basic Services) not ring-fenced for EH – R2m only received R200k internally.

9. Results • After 2006 lack of progress through ECDoH, we resorted to SALGA EC • Meetings with MEC for Health and LGTA • National surveys on the progress with the devolution of MHS – 2006 and DBSA, 2007 – Presented at national forums – give momentum. • Interaction with National Treasury – costing • Department Housing, Local Government and Traditional Affairs made funding available - S78 municipal capacity assessments (R280 – R300k) • Follow up PEHDTT – Workshops (Nov 2009) • Service Level Agreement • ECDoH – funding – 3 years at 100% (2006/07 till 2008/09) • Funding and transfer of staff not synchronised

10. Results(Cont.) • Presentations to SALGA EC resulted in buy-in • SALGA EC – MHS Working Group established • Elevate to SALGA National • SALGBC – 2010 - Working Group • Special Resolution submitted to April 2010 Local Government Summit • Appointment of permanent National Environmental Health Director • Interaction at national level between DoH; COGTA and National Treasury • Functional integration initiatives between LG and ECDoH to use provincial staff locally. • ECDoH – negotiated with individual DMs for transfer • A few DMs in advanced stage to receive provincial EHPs by 1 July 2011.

11. Recommendations • Develop a proper devolution framework and monitor its implementation. • COGTA should be more strategic – Municipal Turn Around Strategy (LGTAS) – focus on “basic services” but it does not reflect MHS • Do such surveys on a regular basis also for MHS – include legal requirements such as S78 capacity reports; budgets, inclusion of MHS in IDP, ornanisational structures and vacancy rates; progress with devolution and integration of MHS at DMs and Metros, etc.

12. Recommendations (Cont.) • Use and understanding of terminology which negatively affects Environmental Health / Municipal Health Services • Health Services • Environmental management • Facilitate a proper national costing study for MHS – National Treasury challenges our figures. • Clarify the use and preparedness of LG for accepting and managing Community Service EHPs.

13. “Usana olungakhaliyo lufela embele kweni” CLAIM YOUR SPACE!!!!

14. Support for Municipal Health Services from National and Provincial Structures Source: National devolution progress surveys - January and July 2006 and DBSA survey, 2007

15. Eastern Cape Provincein relation to South Africa MUNICIPALITIES Metropolitan = 6 District = 46 Local = 229

16. Time Line DBSA Research, Delivery of MHS by DMs in SA, July 07 Draft National Environmental Health Policy October 2004 DBSA Development Dialogue on MHS, Midrand , March 06 Financing EHS in SA May 2004 FFC Submission: Financing PHC and EHS in SA August 2004 SAIEH Conference – Municipal Health Services Feb 2006 Seminar on Implementing MHS, July 2006, Pretoria Monitoring the Impact of MHS Policy Implementation January 2005 National Summit Polokwane May 2004 MHS Conference, East London 28-30 November 2006 MINMEC Decision 21 August 2003 National Framework for the Devolution of EHS in SA – Implementation Strategy, March 2004 National EH Indicators – George, October 2004 SALGA: Workshop on MHS March 2005, JHB 2 year transitional period 2007 2002 2003 2004 2005 2006 9 October 2002 Cabinet decision 1 July 2004 Implementation date 1 July 2005 First Municipalities taking over functions Developments with regard to the interpretation and implementation of MHS in South Africa since the Cabinet decision that EHS will be MHS and the function of Metropolitan and District Municipalities from 1 July 2004.

17. JOE GQABI DISTRICT MUNICIPALITY 41% Municipal Health Services March 2008

19. Progress with the devolution/consolidation of MHS (New or extended service – Municipal Systems Act)

20. Sewerage pump station

21. Sewerage Balance Drain – Engineering solution - >10 years

22. New Sewerage Pumps – 6 months after transfer of LM EHPs to DM

23. Sewerage spills in communities

24. Sewerage spills monitored weekly by EHPs

25. Broken sewerage connections – Who cares?

26. Politicians, Engineers and communities want structures. • MHS/EHS concerned with operations not causing a health hazard to communities to prevent illnesses from occurring – sometimes conflicting – substandard facilities. • Damage to infrastructure - maintenance

27. Housing development: Quality of Workmanship

28. Condition at landfill site – lack of control and management

29. Infrastructure damaged due to a badly managed landfill site

30. Local municipal workers offloading waste in non demarcated area on landfill site MHS monitors and compliance enforce as part of pollution control and waste management

31. each year at least 3 million children under the age of 5 die due to environmental related illnesses • 90% of Acute Respiratory Infections world wide • 80-90% of Diarrheal cases -contaminated water and inadequate sanitation. • 90% of malaria cases are attributed by environmental factors Millennium Development Goals??

32. After 6 years of continued monitoring by EHPs – improved sewerage system – only clean for 2 months – Honey sucker services terminated – EHPs frustrated – what is my role and purpose?

33. Current cost of MHS – 2009/10

34. Future funding implications Eastern Cape - Shortfall

35. 5 – Yrs - DoH

36. Per Capita and Household Income and Expenditure for 2009/10 – MHS NDoH – proposal – HST costing study