Decentralisation in South Africa : options for District Health Authorities in South Africa

Abstract

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 and cost-effectiveness. 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.