The transfer of authority and responsibility for some public functions from one
level of government, especially national government, to a second sphere
(provincial) or a third sphere (local governments) has been adopted by many countries with the understanding that such health system decentralisation can help to
address political, managerial and operational issues in terms of systemic efficiency
While South Africa’s health system is already structured with a certain degree of
decentralisation, the implementation of National Health Insurance (National Health
Insurance) and the proposed creation of District Health Authorities as outlined in the
Green Paper on NHI, implies that the country will now have to undertake several
further steps in decentralising its health system. If poorly designed or ineffectively
implemented , decentralisation can exacerbate existing inequalities and inefficiencies
and create new challenges and problems.
This chapter explores several possibilities for the implementation of a coherent
decentralisation system which addresses the health needs of the population. The
authors also provide an extensive overview of the various forms and decentralisation
and then offer some lessons, caveats and important issues that must be taken into
account in the country’s journey to further decentralisation. The potential role of the
National Department of Health in a new decentralised system is considered, and
several criteria to guide and stagger the decentralisation process are offered.
The authors conclude that while decentralisation is not without its disadvantages,
decentralisation of health care services in South Africa can make a phenomenal
impact on the quality and access to much-needed health services for the most
vulnerable populations, particularly women and children and further note that
ongoing monitoring and evaluation against set targets will be needed in order to
achieve successful implementation of the envisaged NHI-funded health system.