SPECIAL SERIES ON THE DISTRICT HEALTH SYSTEM

 

Special series on the District Health System

 

 

The District Health System (DHS) is the building block of South Africa (SA)'s national health system. The DHS was formally established through the National Health Act No. 61 of 2003^[1] as the most decentralised public governance structure for the achievement of an equitable health system based on primary healthcare.

In the decade after 1994, the DHS was a central focus of national policy and system development, but following the advent of the Millennium Development Goals and the rise of HIV, attention shifted to disease priorities and programmes - notably HIV, tuberculosis and maternal and child health. This selective focus has resulted in some successes. Yet it has also, probably unavoidably, left a legacy of fragmented interventions in multiple, poorly co-ordinated programmes, little decentralised authority and insufficient capacity in the DHS. Subdistrict governance and leadership remain underdeveloped, with significant consequences for service delivery.

However, there are signs that the district, and more specifically the subdistrict, is (re)emerging as an important unit of governance and innovation in SA. This is driven by:

• multiple intersecting crises - including COVID-19, climate change and reduced budgets, requiring new ways of 'being' and 'doing' in health systems

• the need for new paradigms of service delivery, intersectoral collaboration and a greater orientation towards health promotion, disease prevention, health and wellness, as the burden of communicable diseases shrinks relative to violent injury, mental health and chronic non-communicable diseases^[2]

• renewed recognition of the importance of engaging communities and the public as well as patients and frontline providers and managers in the co-creation of health and wellness

• National Health Insurance (NHI) reforms, focused on the 'contracting unit for primary healthcare', 'comprised of a district hospital, clinics or community health centres and ward-based outreach teams and private providers organised in horizontal networks within a specified geographical sub-district area'.^[3]

As the National Department of Health undertakes a process of consultation and prepares to formulate a new 2024 - 29 DHS strategy, we believe it is time to bring the DHS and DHS strengthening back into focus. There is much happening at subnational level on the DHS, including service reorganisations, innovative practices and 'pockets of effectiveness' that merit communicating and disseminating. To this end, a network of health policy and system researchers from higher education institutions, decision-makers in provincial and national government and non-governmental partners convened several meetings over the last year to share current research, experiences and thinking on the DHS. We have formed the SA Learning Alliance on the DHS to plan and take forward a series of activities that will connect players and conversations on the DHS in SA. These activities will unfold alongside, and can inform, the national policy process.

As part of these activities, the South African Medical Journal (SAMJ) has agreed to host a special series on the DHS. We believe the SAMJ, as a national journal with an interest in policy and health systems development, is an ideal portal for dissemination of evidence-informed, independent and critical approaches to documenting the current strengths and challenges of district and subdistrict health systems.

The Learning Alliance is preparing submissions spanning original research, reviews and 'in practice' reflections, co-written by researchers, practitioners and decision-makers, and addressing a range of DHS-related themes. These themes will include service delivery optimisation and improved quality of care, multisectoral collaboration, community participation, governance, leadership and management, monitoring and performance, financing, human resources for health, learning partnerships and a historical view of policy on the DHS since the advent of democracy. The series will run in the SAMJ.

We hope that the initial contributions from the Learning Alliance will stimulate wider interest and encourage others to put pen to paper and share their innovations, experiences and research on the DHS to the special series. Learning together is essential for strengthening our health system.

Helen Schneider

Professor and Director, SA Medical Research Council Health Services to System Research Unit, School of Public Health, University of the Western Cape, Cape Town, South Africa hschneider@uwc.ac.za

Thulani Masilela

Outcomes Facilitator, Department of Planning, Monitoring and Evaluation, South Africa

Jabulani Mndebele

Chief Director, District Health Services, KwaZulu-Natal Department of Health, South Africa

Krish Vallabhjee

Advisor, Clinton Health Access Initiative, South Africa

Inge Petersen

Director and Research Professor, Centre for Rural Health, School of Public Health, University of KwaZulu-Natal, Durban, South Africa

Lucy Gilson

Professor, Division of Health Policy and Systems, School of Public Health, University of Cape Town, South Africa

Beth Engelbrecht

Adjunct Associate Professor, School of Public Health, University of Cape Town, and Extraordinary Associate Professor, Faculty of Health Sciences, North West University, Potchefstroom, South Africa

On behalf of the South African Learning Alliance on the District Health System.

 

References

1. South Africa. National Health Act No. 61 of 2003. Government Gazette Vol. 469, Number 26595, Cape Town 23 July 2004.         [ Links ]

2. Nojilana B, Debbie Bradshaw D, Victoria Pillay-van Wyk V, et al. Emerging trends in non-communicable disease mortality in South Africa, 1997 - 2010. S Afr Med J 2016;106(5):477-484. https://doi.org/10.7196/SAMJ.2016.v106i5.10674        [ Links ]

3. South Africa. National Health Insurance Bill B-11, 2019.         [ Links ]