Decentralisation of district health services in the Free State Province

[摘要] Experiments with decentralisation began in the late 1970s and continuedthroughout the 1980s. Decentralisation is regarded as a key element of theprimary health care approach. It is initially seen as having important politicalvalue that can be used as a means to enhance health service policy. However, inmany instances, western donors who believe that because one form ofdecentralisation works in developed countries, it will also work in thedeveloping world often pursue decentralisation.The challenge facing the South African National Health System and the FreeState Health System in particular, is to design a comprehensive programme toredress social and economic injustices brought about by apartheid to themajority of the population to ensure that emphasis is placed on health and notjust medical care so that issues relating to socio-economic conditions such aspoverty, water and sanitation, and proper housing should be addressedadequately. At present, implementation of the District Health System (DHS)based on primary health care (PHC) approach is provided by the Free StateDepartment of Health (FSDOH) and by local municipalities on an agency basis.The above approach is concerned with keeping people healthy, as it is withcaring for them when they become unwell.In an endeavour to address aforementioned challenges, the South AfricanGovernment of National Unity (GNU) has adopted decentralisation as a modelfor both governance and management. Decentralised governance is embodiedin the Constitution of the Republic of South Africa, 1996, in the form of powersand functions for the three spheres of government. The powers and functions ofthe local sphere of government bear testimony to the importance of this spherein particular. The GNU, through its adoption of the Reconstruction andDevelopment Programme (RDP) in 1994, committed itself to the developmentof a DRS based on PRC approach as enunciated at the Alma Ata conference in1978.The hypothesis for this study indicated that decentralisation of DRS in the FreeState Province will enhance efficiency and equity and thus make local publicrepresentatives accountable for services rendered. The hypothesis and researchobjectives for the study were validated by means of literature review andempirical survey.The thesis outlines the conceptualisation and forms of decentralisation and alsodraws lessons from the experiences of various countries including Canada,Zambia, Indonesia, and Brazil and highlights the need to approach theformulation and implementation strategies for health sector reformssystematically, rather than importing, uncritically, structural models developedabroad. Political considerations are inherent in any decision made and apolitical environment limits the extent of decentralisation. Without doubt, themost serious mistake any reformer can make is to assume decentralisation to bea managerial exercise devoid of political cause and consequences.The thesis concludes by presenting analysis and interpretation of researchfindings while also outlining key recommendations that might be of assistancefor identifying an appropriate form for decentralisation of health services.

[发布机构] University of the Free State