1. 1 TRANSPORT FOR HEALTH SERVICES IN A DECENTRALISED DISTRICT HEALTH SYSTEM IN SOUTH AFRICA District Health in South Africa Conference 5 and 6 August 2004 Dr Wendy Hall Health Systems Trust

2. 2 INTRODUCTION Transport as a support service, excluding emergency services (ambulances) Why transport?  Essential resource for health services  Neglected in health policies and strategic plans  Policies and plans set outside of Dept of Health by National Dept of Transport

3. 3 OBJECTIVE OF PRESENTATION To put fleet management of transport for health on the agenda  Few studies done  Few publications To share the complexity of current systems To look at current policy directions To make recommendations

4. 4 METHODOLOGY Local Government and Health Research Consortium Project – 2002/03 Literature review Policy and other documents Personal and colleagues’ experiences in the field

5. 5 ROLE OF TRANSPORT IN HEALTH Delivery of health services  Mobile services  Supervisory visits to clinics and communities  School health services  DOTS and other community based projects Patient transfers – elective and emergency Support services  Collection and delivery of supplies and drugs  Collection of blood samples – laboratory services  General administration  Meetings

6. 6 STAKEHOLDERS National sphere  National Dept of Transport  National Dept of Health Provincial sphere  Provincial Dept of Transport  Provincial Dept of Health Local sphere  Local government – municipalities Service delivery level – community served

7. 7 RELATIONSHIPS National Govt Provincial Govt Local Govt Service Delivery Level PDoHPDoT NDoH NDoT Municipal Council District Health System Municipal run services Provincial run services – clinics & hospitals

8. 8 ROLES AND FUNCTIONS National Dept of Transport Responsible for fleet management for all national and provincial sectors  Government Motor Transport, Subdivision of Corporate Services Division  Government garages Set policy and M&E of these policies Negotiate contracts  Wesbank First Auto (RT460) – Fleet Management Service Provider  Tender RT77 – purchase of new vehicles

9. 9 ROLES AND FUNCTIONS National Dept of Health Hire vehicles from National Dept of Transport for own use  Outsourced policies – away from base  Subsidised vehicle scheme No role in provision of transport for health service delivery

10. 10 ROLES AND FUNCTIONS Provincial Dept of Transport Implement national policy Establish Motor Transport Advisory Committee – representation from all provincial departments Management of provincial fleet – supported by Wesbank First Auto  Purchase, licencing, repair and disposal of vehicles Manage and monitor outsourcing contracts in the province

11. 11 ROLES AND FUNCTIONS Provincial Dept of Health Hire vehicles for health services from PDoT Liaise with PDoT and Wesbank First Auto in fleet management Allocate vehicles to programmes, health regions, districts and sub-districts and hospitals for service delivery Financially accountable – PFMA requirement

12. 12 ROLES AND FUNCTIONS Local Govt – Municipal Councils Provide transport for own health services within municipal boundaries  Finance for purchase and maintenance  Monitoring of fleet  Allocation to services Own policies – not subject to NDoT policies

13. 13 ROLES AND FUNCTIONS Service Delivery Level Provincial Services  Day to day management of vehicles allocated by PDoH  Allocation of vehicles to services, programmes etc  Motivate to PDoH for new and replacement vehicles Municipal Services  According to locally determined policies

14. 14 DECISION SPACE FOR TRANSPORT IN HEALTH Nat Treasure NDoTNDoHPDoTPDoHProv local HM Mun Health Facility Man Decision Space Wide Sets guideline for PPPs Wide Sets policy for all govt sectors fleet manage. Narrow Outsource through contract between NDoT and private provider Moderate Implements and monitors national policy Narrow to Moderate Identifies needs; allocates vehicles; financially responsible Narrow Maintain and monitor vehicles; Motivate for vehicles; Wide Own pool vehicles or from municipal pool; Own policies None

15. 15 RELATIONSHIPS National Govt Provincial Govt Local Govt Service Delivery Level PDoHPDoT NDoH NDoT Municipal Council District Health System Municipal run services Provincial run services – clinics & hospitals

16. 16 IMPLICATIONS FOR HEALTH SERVICES Complex relationship – inter- government, inter-department, public-private “No transport” – commonly heard cry  Delivery of medicines to clinic  Outreach programmes  Elective transfers  TB sputum turn around times Peri-natal and maternal mortality  Transport – avoidable cause 2.6% in 2000 and 5.3 % in 2001 – peri-natal 13.% in 1998 – maternal deaths (between facilities) Delays in licencing and repairs  Role of First Auto  Role of PDoH, PDoT and PDoF Decentralisation of functions from PDoT to PDoH

17. 17 NATIONAL DEPT OF TRANSPORT STRATEGIES Fleet management of national fleet – not core business of NDoT General government policy of outsourcing non-core functions Strategic Plan – 2002/2003  Implementation of private-public partnerships (PPPs) where appropriate  Improve reliability and availability of subsidised transport

18. 18 SUBSIDISED CAR SCHEME Transport Circular No 5 of 2003 Supplements pool of vehicles available Prescribed criteria –  Vehicle required as work facility  Travel more than prescribed distance per month  Satisfy Wesbanks financing requirements Monitored by NDoT

19. 19 PUBLIC-PRIVATE PARTNERSHIPS Outsourcing fleet management through a PPP to a company whose core business is fleet management Private company manages the fleet  Ensuring availability of vehicles Guided by National Treasury Public- Private Partnership Guidelines To date – signed in Northern Cape (2001) and Eastern Cape (2003)

20. 20 Both – theoretically improve availability of transport – but….. Subsidised Cars Monitoring distances Non use on dirt roads Lack of funds for petrol Travel alone – several cars to same destination PPP Managed by PDoT  Capacity required Departmental committee Recent conference –  98% availability (no clear definition of this)  No user depts present  Vehicles not requested – too expensive

21. 21 Schemes are centrally developed and monitored and vertically implemented. What is their impact on health service delivery in a decentralised DHS?

22. 22 LITERATURE REVIEW (1) TransAid Worldwide (2001)  Multi-country study – Ghana, Cote D’Ivorie, South Africa and Zimbabwe Importance of functional transport system – policy, operational management, fleet management, information, human resource management Ghana – decentralised system with districts having full budgetary responsibility for transport found to be the best South Africa – report recommends the DoH should manage their fleet in-house as it does not get value for money through their relationship with DoT

23. 23 LITERATURE REVIEW (2) Collins, C et al – “A successful transport scenario for the health sector in developing countries” Transport should be the responsibility of the health sector and “….not merely be seen as a support activity to be provided by others.”

24. 24 LITERATURE REVIEW (2a) “Transport is a crucial area in which horizontal integration of health programmes at the decentralised district should allow for the flexible adaptable and more efficient use of scarce resource. Many of the management and planning problems involving transport derive from the vertical organisation of health services and, thereby, transport services.”

25. 25 RECOMMENDATIONS RESEARCH What is the impact of outsourcing transport management and extending the subsidised car scheme on health service delivery? Are the policies, which might be good for some sectors, actually impeding health service delivery? How will these policies operate in a decentralised health system in which local government is not subject to national policies for transport? How can the equitable distribution of transport for health service delivery be assured in a decentralised system?

26. 26 RECOMMENDATION The national and provincial departments of health should take full responsibility for the provision of transport for health services. Policies need to be developed independent of the Department of Transport and be appropriate to the health services.

27. 27 So – do I have any recruits for the New T ransport A ction C ampaign?

28. 28 THANK YOU