Order! I want to remind members again to switch off their cellphones. I want to welcome the hon Minister and the Members of Executive Councils who are here as well. I call on the hon Minister to open the debate.
Chairperson, Deputy Minister of Health Dr Molefi Sefularo, hon chairperson of the portfolio committee Dr Bevan Goqwana, members of the committee, hon members of the House, distinguished guests, ladies and gentlemen, good afternoon! I know that everybody here is listening attentively to hear about the occupation-specific dispensation. I am deliberately leaving it till the end, so that when my time is over, you will ask the Chairperson to increase my time, so that I can tell you what is happening!
It is an honour for me to present to this House the budget of the national Department of Health for 2009-10 for your consideration. I am presenting this budget at a very challenging time in the history of health care in our country, and also around the world as a whole.
Let me start with the world. There are two contemporary issues in health care around the world which I shall mention. The first one is the ever- threatening H1N1 influenza, which has spread so widely that it has moved up to stage 6 alert. Fortunately, it is not virulent, but just spreading widely. However, I must state that it is under control throughout the whole world.
In our country we are able to control it, despite the fact that we have had many visitors from all over the world in recent weeks, attending various sporting activities.
The second issue in health around the world is the global economic meltdown. It has a great bearing on health care around the world, and especially in Third World countries such as ours. For this reason, the United Nations Secretary-General, Mr Ban Ki-Moon, convened the Secretary- General's Forum on Advancing Global Health in the Face of Crisis two weeks ago, at the United Nations headquarters in New York.
His rationale was that the world has learnt during previous economic crises that social outcomes are the first to suffer during such crises, and recover least after such crises.
He went on to point out that during such crises countries are tempted to cut on social spending such as health. The results are that while rich people inside rich nations may lose their jobs and assets, such as their mansions, luxury cars and other property, these may be recovered when the economy recovers, but in poor countries poor people may lose their lives through extreme poverty and poor health care, and they will never ever recover these lost lives, even after the crisis is over.
Hence I wish to bring this message home to my own country, that this is the time the poor need protection more than ever before, to cushion them from the devastating effects of this global economic meltdown.
Coming back home, the challenges in health are overwhelming. During the state of the nation address, the President of the country, His Excellency Mr Jacob Zuma, said, and I quote:
Fellow South Africans, we are seriously concerned about the degeneration of the quality of health care, aggravated by the steady increase in the burden of disease, in the past decade and a half.
We have no option but to be fired up to take the bull by the horns in tackling this state of affairs, as the President has said, and we are going to deal with it decisively.
Unfortunately, present events within the public health sector do not help the situation either. I need to mention that we as the governing party started getting concerned some time back. Hence the resolution of the ANC at the 2007 Limpopo conference, that health and education be top priorities for the next five years and beyond.
To this end, the government then adopted a 10-point plan, which is going to be our programme of action for the next five years. The public health system is also forced to carry an ever-increasing burden of diseases, obviously made worse by poverty, HIV and Aids, and other communicable diseases.
However, let me take this opportunity to accept and acknowledge upfront that some of the factors contributing in no small measure to the deterioration in health care are the following: Lack of managerial skills within some health institutions; failure to act timeously on identified deficiencies; delayed response to quality improvement requirements; unsatisfactory maintenance and repair services; poor technological management; poor supply chain management; inability of individuals to take responsibility for their actions; poor disciplinary procedures and corruption; significant problems in clinical areas related to training and poor attitude of staff; and inadequate staffing levels in all areas.
We are going to be facing all these issues head-on, and we will do so without fear or favour. [Applause.] We owe it to our country that these issues will be tackled head-on.
Hon Chairperson, some of the issues I have mentioned as contributing factors to the problems the health system is facing are very urgent, and will be dealt with very urgently. For instance, the Gauteng Department of Health last week already launched Operation Kuyasheshwa-la to deal with such matters urgently.
Our programme of action, however, with its 10-point plan, has been designed to deal with these issues systematically and in a sustainable manner. Its implementation will be both decisive and incisive.
Hence, our 2009-10 to 2013-14 programme of action will allocate resources for the following ten priorities, in line with this programme of action.
The first priority is the provision of strategic leadership and the creation of a social compact for better health outcomes. While issues of strategic leadership are very clear, I wish to add that the social compact part of this point speaks to "working together we shall achieve more". Mooney states in 2008, and I quote:
The view of patients as passive receivers of health care is being replaced by one of communities as equal partners in decision-making about health care priorities, contributing their opinions alongside those of bureaucrats and policy-makers.
We shall follow this line very closely.
The second issue on our programme of action is the implementation of national health insurance, or NHI. In recent weeks there has been a raging debate in the public arena about the intended introduction of the NHI by government. This debate was introduced prematurely by people who wanted to scuttle the NHI as an unworkable system. South Africans were urged to run for cover because the NHI was going to be a marauding monster that would destroy everything that we hold dear in the health care system of the country.
Hon Chairperson, while I am not yet presenting an official document on the NHI, because it is policy in the making - it is going to come, very soon for that matter - I wish to make the following points known. Firstly, the present system of health care financing can no longer be allowed to go on, because it is simply unsustainable. In no way can we perpetuate a system where we spend 8,5% of GDP, with 5% catering for 14% of the population, or 7 million people, while we spend the remaining 3,5% to cater for a whopping 84% of the population, or 41 million people. Nowhere in the civilised world can you find that state of affairs.
The second point I want to make is that the present model of health care financing is outright primitive, and we are going to abandon it. The Secretary-General of the United Nations, Mr Ban Ki-Moon, on 15 June 2009, just two weeks ago, had this to say at the United Nations, and I quote:
Out-of-pocket expenditure on health is the worst form of health care financing.
That says it all.
Critics of the NHI were hard at work to prove that we were going to overburden the rich, and that the economy would not cope.
Hon Chairperson, what is the NHI? It is a system of universal health care coverage where every citizen is covered by health care insurance, rich or poor, employed or unemployed, young or old, sick or very healthy, black, white, yellow or people of whatever colour or persuasion. It is this part about covering the poor and the unemployed that is bringing discomfort and unprecedented anger in the minds of the enemies of the NHI.
Let me read the following paragraph of a speech made by Dr Margaret Chan, director-general of the World Health Organisation, at the meeting of the United Nations, also two weeks ago. For those who don't know, Dr Margaret Chan was the minister of health in Hong Kong before taking over the post as director-general of the World Health Organisation. She said, and I quote:
Fairness, I believe, is at the heart of our ambition in global health.
A quest for greater fairness dominated the agenda of the UN Forum. We see this in our concern about vulnerable populations and about health systems that exclude the poor. We see this in your support for global health initiatives and funding mechanisms that redistribute some of the world's riches towards the health needs of the poor.
On the issue of fairness, let me again state the obvious. Our world is dangerously out of balance, also on matters of health. Differences within and between countries, in income levels, opportunities, and health status are greater today than at any time in recent history. She went on to say:
Let me make another obvious point - a health system is a social institution. It does not just deliver pills and babies the way a post office delivers letters. Properly managed and financed health systems that strive for universal coverage contribute to social cohesion and stability.
Hon Chairperson, the aims and objectives of the NHI are to achieve exactly what the World Health Organisation's director-general has alluded to - we are going to add nothing, and subtract nothing.
The third issue on our programme of action is the accelerated implementation of the HIV and Aids plan and increased focus on TB and other communicable diseases. Let me go back to the President's state of the nation address, and I quote:
We must work together in the implementation of the Comprehensive Plan for the Treatment, Management and Care of HIV and Aids so as to reduce the rate of new HIV infections by 50% in the year 2011. We want to reach 80% of those in need of ARV treatment by 2011.
Hon Chairperson, here is the scorecard on HIV and Aids challenges that South Africa is facing.
This year, on 9 June, the Human Sciences Research Council, together with its partners the Medical Research Council, the Centre for Aids Development, Research and Evaluation, and the National Institute of Communicable Diseases, published a report on HIV and Aids, based on interviews and testing of a random sample of the population of South Africa during 2008. The survey included people of all races, age groups, rural and urban, and from all provinces.
The research concluded that: The epidemic was stabilising at 11% between 2002 and 2008; HIV prevalence at national level decreased by nearly half among children aged two to fourteen years between 2002 and 2008; and HIV prevalence decreased slightly among youth aged 15 to 24 from 2005 to 2008.
Encouragingly, there was a substantial decrease in new HIV/Aids infections in 2008, in comparison to 2002 and 2005, especially for the single age groups 15, 16, 17, 18 and 19. What was most encouraging was the change in behaviour among South Africans. More South Africans for all age groups protected themselves against HIV infections by using condoms, more than 95% knew where to access condoms and the use of condoms had indeed increased, according to this research.
Furthermore, half of South Africans now know their HIV status, which means that the message of the "know your status" campaign is being heeded. The researchers also reported that there has been an increase in exposure to one or more HIV/Aids communication programmes from 2005 to 2008, with 90,2% of youth aged 15 to 24 years being reached, followed by 83,6% of adults aged 25 to 49 years and 62,2% of adults aged 50 years and older.
However, despite these successes, there is still some unevenness in infections as well as in behavioural change. Worryingly, HIV/Aids prevalence is still highest in KwaZulu-Natal, at 16,8%, followed by Mpumalanga, at 15,4%. It is also still highest among young women in this country aged 25 to 29 years, where a third of the women are HIV positive. Among all provinces, the Free State continues to have high rates of multiple partnerships, perhaps due to the migratory labour patterns in that area.
We take note of the recommendations made by the researchers, especially that we need to introduce targeted interventions in some of the provinces with very high HIV prevalence, and secondly, that we assist young women who want to have children to do so without risking HIV/Aids infection. We plan to support research that will generate evidence to be used in attaining this goal.
We furthermore support that we intensify our efforts to help provinces implement interventions aimed at reducing rates of multiple sexual partners, including intergenerational sex.
We also take the recommendation that we should consider implementing provider-initiated HIV/Aids testing in all health care facilities. This is as distinct from demand-initiated testing.
Finally, we take seriously the concern that Khomanani should increase its reach and coverage to all South Africans, particularly those who are aged 50 years and older, because most of them believe that they are out of reach of HIV and Aids, that is, people of my age, hon Chairperson.
I would like to thank the following people for continuing to undertake research that informs policy and programme development on HIV and Aids. These are Dr Olive Shisana, Prof Leickness Simbayi, Prof Thomas Rehle and their staff at the Human Sciences Research Council, as well as their colleagues from the Medical Research Council and the Centre for Aids Development, Research and Evaluation, especially Dr Warren Parker. Finally, the support of the US President's Emergency Plan for Aids Relief in conducting this important study is very much appreciated.
Hence, hon Chairperson, we will work with provinces in 2009-10 to ensure that 80% of HIV-exposed infants receive ARVs for preventing mother-to-child transmission, based on dual therapy. This figure will increase to 95% over the two years of the Medium-Term Expenditure Framework, 2010-11 and 2011- 12. The proportion of pregnant women who are tested for HIV/Aids will be increased from 80% in 2009-10 to 95% in the 2010-11 and 2011-12 financial years.
To strengthen the prevention of mother-to-child transmission of HIV/Aids, 80% of pregnant women who are eligible will be placed on ARV prophylaxis based on dual therapy in 2009-10.
Hon Minister, unfortunately your time allocation has expired.
Thank you, hon Chairperson. [Applause.]
Thank you, Chairperson Ms Oliphant. Hon Minister Dr Motsoaledi, hon Deputy Minister Dr Sefularo in absentia - oh, sorry, I thought you were supposed to sit this side - hon members, officials from the department, ladies and gentlemen, I think we all agree that the Department of Health has done phenomenal work over the past 15 years. I think a lot of clinics have been built, hospitals have been built and a lot of hospitals have been revitalised. Patients throughout the country have been started on antiretroviral treatment and even prevention of mother-to- child transmission has been introduced all over the country.
Different departments of health have been collapsed and combined into one national health system - I think we are all aware of that - which is doing the strategising and policy-making, and the provincial departments of health are actually doing service delivery in their areas.
Despite all this, we still have huge challenges in the Department of Health. I don't want to repeat what the Minister has said; he has just quoted the President. I wanted to quote the same quotation, but since he did so, I don't want to repeat it. I just want to say, to me, that statement that the President made, that was quoted by the Minister, actually says to us that all is not well in health. What it means is that health is not healthy!
You don't have to go far. You look at infant mortality in South Africa, which is one of the millennium development goals, which we are supposed to work on. You look at maternal mortality; you look at the control of TB and its allies, multidrug-resistant TB and extensively drug-resistant TB; you look at the shortage of personnel in our institutions - all this shows us that all is not well in the Department of Health. There are high death rates from infection, unlike in other countries, where most deaths are owing to degenerative conditions, which is very much a concern to us as African countries.
These are some of the things which make one feel that all is not well in health. I would like to interpret, in medical terms, what the president of the ANC, who is the President of the country, was trying to say. I think the President was saying to us that the health leadership, in medical terms, makes a diagnosis and treats the condition. Now if you make a diagnosis, there is no way that you cannot handle the problem. All I am trying to say is that this problem is not a very serious one for the ANC; we will be able to handle it. For ANC cadres who have been deployed in this department, this is not a very difficult task. We have cadres who are driven by passion, honesty and humility and this request is a very easy task, much as some of us might look at it and think that it is a difficult task. This task is neither too big nor too small to be procrastinated on by the ANC, because of these cadres I have mentioned.
If I had to take a bird's-eye view of the Department of Health and try to make the diagnosis I was talking about - as I said, if you make a diagnosis, you know what the problem is and you are sure to be able to fix it - the first problem that is a very big challenge is the inequities we find in South Africa. There is a big gap between health service to the poor and health service to the rich.
The rich in our country have very good health care service, and the poor have a very poor health care service. Obviously, this cannot be allowed to go on. This is not a normal situation, and it is making our country very unhealthy. Until health services are good for all, the Department of Health will remain unhealthy.
I want to say, people forget that if you sit in a country where there is this gap, even those that think they have a good health care system will be affected by those who don't have a good health care system. In fact, to make an analogy, I think my heart cannot rejoice and say I am well when my kidneys are having problems. I am not talking about my heart; I am talking about all of us. Your heart cannot claim that it is well, when your kidneys are diseased.
If I can use the medical terms again, if your kidneys have a problem, the next thing is going to be high blood pressure. When you have high blood pressure, your heart is going to be under strain. And when your heart is under strain, your blood supply is going to be poor and your heart is going to be affected by what is happening in your kidneys. All I am trying to say is that you cannot think that because certain people have good health care services, those that are poor can remain there and it is not going to affect you. It is going to affect you, irrespective of your situation.
You can go further and say you can be well and have your good health care system, but the person who is working in your garden, or who is cooking for you, might actually have multidrug-resistant TB, which you might not be aware of, because it has not been diagnosed, and sooner or later your children are going to be affected by that person. So you cannot have a system that caters only for you and think that you are going to be well.
I want to say, definitely, the ANC will handle this situation. As has been mentioned, we are looking to health care that will cater for everybody, so that all of us can be healthy.
The second area, which is a very difficult one, is primary health care. It has been the policy of the ANC for the past 15 years that primary health care is the policy of government.
Order! Hon member, this is not about you. This side of the House is whispering too loudly. It knows this. Sometimes the whispering is so loud that I fail to hear the hon member, because the whispers are louder than the speaker. So this side of the House must stop whispering so loudly.
Chairperson, I don't think it is whispering; I think they are talking. Probably they need to be told to stop talking. If it is whispering, it is only two people.
I am deliberately speaking in parables. Allow the parables to stand. [Laughter.]
Chairperson, as I said, primary health care is one of the policies of government, but, honestly speaking, I don't think we have done well in terms of primary health care. The consequence of that is that, if primary health care has failed, because we have not concentrated on it, most people are going to end up in hospitals, and hospital management of patients is much more expensive than actually concentrating on primary health care.
I am very clear that as the ANC government we are going to go back to the primary health care approach, where people are going to be referred by the clinics to the primary health care hospitals, and then to level 2 and level 3 hospitals. As it is now, 70% of patients that you find at any hospital in the outpatient departments are patients that could have been handled by the clinics, and they cause a burden in the hospitals. I am sure this will drastically reduce the finances that are needed in health.
We have made primary health care a viable option which will reduce costs, and as the ANC we are clear that the targets of the millennium development goals will be promoted by primary health care, as it is supposed to be done. It will definitely make sure that things are happening.
The other area, looking from above, is that human resources in the department are a problem. I talked about the shortages. Secondly, there are people in the department who are professionals, who are at the coalface of delivery, and there are those who are supporting those that are at the coalface of service delivery. I think the request here is that, firstly, we should employ more, and that secondly, we should make sure that those who are supporting those that are at the coalface of service delivery should be assisted, so that their morale goes up and that they can be interested in what they are doing. That is something that we need to look at, and the ANC will definitely be able to handle that.
Chairperson, I am not working in the Department of Health, but I have looked at the funding. Much as we support the budget we have, we feel that the budget for health is not enough. Something needs to be done. As I said, I don't work in the Department of Health, but I am just talking about something I have noticed, especially when you look at the disasters that occur time and again. We need more funding to go to the Department of Health.
Chairperson, I am sure that the President wanted us to make a diagnosis, and give a prognosis. Now when you give a prognosis, there are three categories you can talk about. The first category is those patients that you can cure totally. The second group is those conditions that you can control, and the third group is where you cannot do anything. [Interjections.] I want to say, Chairperson, that the diagnosis is that the condition of health in South Africa is curable. The ANC will definitely be able to cure it. I am not sure about those who are not good doctors, who don't know when the prognosis is good, but I can tell you that the prognosis is very good. The President of the country and the ANC prioritised health, so we will be able to make sure that the ANC cadres who are deployed in health go according to what the President has said.
The Department of Health is very important. We are brought into this world through the Department of Health and we leave this world through the Department of Health.
Order! I shall name names! Please respect the Chair, the House and the decorum of the House. Interjections are acceptable as part of the robustness of this House, but loud speeches and conversations disrupt the decorum and the process. Please, I don't want to be calling names. Stop it.
Thank you, Chairperson. I was saying that the ANC president and the ANC have prioritised health. We know that the Department of Health is one of the most important departments. We come to this world through the Department of Health. When we leave this world, we leave through the Department of Health. So it is one of the very important departments.
I think the ANC is next to godliness. [Laughter.] [Applause.] I think God created a few departments. There are two departments that were created by God. All the other departments were created by us to co-ordinate certain things. The first department that was created by God was the Department of Agriculture. The second department that was created by God was the Department of Health, because he operated on Adam. He gave Adam an anaesthetic and operated on him. That is actually in Genesis. So this is one of the very important departments. [Interjections.]
Mr Chairperson, on a point of order: May I understand whether the hon speaker is saying that God has a very good sense of humour? What is the point that he is really making when he says that God created certain departments?
Thank you very much. I don't think we want to be doing theological interpretations now. If people want that, come to my church on Sunday. We will handle that. It is not a point of order.
Thank you, Chairperson. I was actually going to say the same, that if he does not have a Bible, I prefer to give him one outside this House. I will give him a Bible.
Thank you, hon member. Hon member, God has not expired, but your time has expired.
Thank you. [Applause.]
Chairperson, hon Minister and members, may I take this opportunity to wish my twin brother a very happy birthday today. [Applause.]
Minister, in your speech you mentioned the national health insurance - you dedicated about 25% of your speech to it. You promised during the presidential debate that we would have a document on the national health insurance by the end of June. Today is the end of June, and we do not have that document. I shall reserve the DA's comments on the national health insurance for when we actually have a document in front of us.
We respect your honesty and we appreciate it: It is very refreshing to hear a Minister talk about the challenges facing health care. The previous Minister of Health, Manto Tshabalala-Msimang, was a denialist, to say the least, and we appreciate your candour.
But if we are going to be honest, we have to say that the current crisis in the public health sector with regard to the doctors' strike has been a long time in the making. It is extremely unfortunate that doctors have been forced to go on strike in order to have their grievances heard.
The groundswell of support for the strike among doctors must set alarm bells ringing for the ANC government. The fact that a junior doctor in the public sector earns the same amount as a bus driver is indicative of the indifference with which this government has taken doctors' concerns over the years and the degree to which it has taken advantage of their commitment and compassion. It also clearly demonstrates where in the ANC's priorities health care really sits, and it is not at the top of your priorities.
If one looks historically at the budget allocation for public health, it is obvious that from 1998 to 2003, in per capita terms, the budget flatlined, because the government had other priorities, such as recurring arms deals, in order to fight nonexistent enemies. In 2003 the government began to realise its mistake and the budget did start to increase in real per capita terms. However, the automatic notch and rank increases of 1998 and budget constraints meant that as people left the public health system, they were not replaced, and an estimated 60 000 people left during this period. Hospitals have still not recovered.
And while the government may say that from 2003 there were significant budget increases, most of this allocation went to clinics and to the new antiretroviral programme. No compensation has really ever been made available to reduce the strain the whole health system was placed under during those years.
We must remember that the burden of disease has increased dramatically, placing an ever-increasing strain on hospitals. Given that hospitals' budget allocations have been on the same trajectory since 1998, we have the current meltdown. There were insufficient funds to replace doctors and nurses who left the Public Service, and therefore the workload increased and working conditions deteriorated.
You simply cannot offer a health service with 12 000 vacancies for doctors and 42 000 vacancies for nurses.
Equally, you cannot neglect a system for so long and expect to fix it in a once-off adjustment - it is obviously beyond this government's capabilities. The department mishandled nurses' occupation-specific dispensation increases through grossly underestimating the cost to the fiscus, and now you cannot or won't deliver on the doctors' occupation- specific dispensation increases. This ongoing neglect of 11 years is finally taking its toll.
Back in July 2007, some two years ago, the government promised, through Resolution 1 of that year, that they would implement OSD increases for doctors in July 2008. The ANC government reneged on that promise.
My question to you, Minister, is: If the government made a promise some 24 months ago, why then were no budget allocations made in the 2008-09 budget or even this year's budget? The answer is clear: This government had no intention of honouring its promise to the doctors.
It was only after the doctors started marching and threatening industrial action that you, your department and this government sat up and started to take them seriously.
The doctors have been asking for a 50% increase, which may seem excessive to most South Africans. However, research commissioned by the SA Medical Association into doctors' remuneration shows that in the South African public sector, doctors are paid 50% less than other professionals such as accountants, engineers and lawyers. That is what I call a disgrace.
Since the threat of industrial action, the doctors' association and yourselves have been shut behind closed doors negotiating, when an agreement was expected to be announced last Wednesday.
However, in what can only be described as bizarre, you made a public announcement on the doctors' increases while negotiations were still ongoing - thus undermining the entire bargaining process and showing bad faith. You announced in your media conference that doctors would receive increases of between 29% and 53%, which most organisations welcomed, including the DA. However, this was misleading, to say the least.
When one scrutinises the finer detail, it is clear that the offer was not genuine, and either you deliberately misled the nation or your officials misled you. I believe it was the latter, hon Minister. Whose idea was it to hold a press conference while negotiations were still ongoing?
The real increases for most doctors range between 2% and 13% over a two- year period. The offer excludes experience and only commits itself to looking at this principle again in April 2011, subject to availability of funds.
There are also questions hanging over whether doctors have the right to strike, but it is entrenched in the Constitution, with a limitation clause, meaning that, as an essential service, skeleton staff must be in place. After the 2004 and 2007 public sector strikes, the government agreed to negotiate a minimum service level agreement which would stipulate the conditions of industrial action - and surprise, surprise, the government still has not fulfilled this promise. How many more promises are you actually going to break?
When I was at Groote Schuur yesterday to witness for myself the strike by the doctors, I was impressed to see that they did not close down the trauma or emergency services and they are dealing with this strike in a very responsible manner indeed. They are implementing their own minimum service level agreements.
The attitude of the MEC in KwaZulu-Natal is also of concern. On what basis does the MEC state that there is a third force at play and that doctors are destabilising the country? Dismissing doctors won't help either. There are so few of them, you will have to re-employ them anyway when the strike is over, unless you want a further meltdown of the public health system.
If the government can find an extra R1 billion for expanding the cabinet, or R2 billion to R4 billion for saving the SABC, it can surely find the money to pay the doctors. [Applause.]
The question of budget allocations also needs to be seriously looked at. The ramifications of the miscalculations of nurses' OSD allowances continue to eat into the budgets of the provinces, and some health experts believe that by August this year provinces will be running out of money and we will see a repeat of what happened in the Free State in the last financial year, but on a much wider scale. The department also admitted that due to a lack of funds not everyone who is entitled to ARVs will actually be enrolled into the programme, as there simply is not enough money. This, Minister, means people are going to die, and you stated that this was the third priority of the government; I think you said this in your speech. If it is such a high priority, why is there not enough money? One thing that has been proved around the world, Minister, is that if you want to reduce the number of new infections, you need political leadership, from yourself and the President, and this has been lacking in this country over the past 15 years. [Interjections.]
We need to separate the HIV/Aids budget from the rest of the health budget. It should be treated as a grant where central government underwrites it and guarantees that all who need ARVs can actually access them, and it should not be limited to provincial budgets.
Minister, whether you were misled by your officials with regard to the doctors' increases, only you will ever know. Whether you were set up for failure by hosting a premature press conference, only you will ever know. However, as the political head of the Department of Health, you, Sir, and only you, must take political responsibility for the atrocious mess we find ourselves in. I thank you. [Applause.]
Hon Chairperson, Cope believes that health is the foundation of the productivity and prosperity of any country. As a result, all members of society should have access to care and receive treatment when they are ill or injured.
Cope believes that the primary health care model should be strengthened. The quality of health care should be improved as a matter of urgency in a systematic programme which can be monitored and evaluated.
Preventable and communicable diseases should be prioritised for eradication and healthy lifestyles should be promoted, while health literacy among the public is increased. All clinics should operate at all appropriate hours. They should be staffed by appropriately skilled and qualified health professionals who must have access to medication. All hospitals must be clean, and have medication, beds and linen.
The problem of dirty hospitals and clinics without medicine is a direct result of the deployment of unskilled and unqualified cadres who have no commitment to serving our people. This type of cadre deployment is counter- revolutionary and reactionary. It must be brought to an end immediately. The ruling alliance's barrage of excuses about why clinics and hospitals cannot be run efficiently has passed its sell-by date. Service delivery should not only be heard - it is time that it should be seen. Health care professionals can only be retained through the use of incentives such as training and good working conditions.
During the state of the nation debate, the hon Minister said, and I quote:
We must improve the remuneration of doctors and other health workers.
The hon Minister spoke as if the ruling alliance had just discovered that the remuneration of doctors and other health workers was low after the 2009 elections. He spoke as if he was not aware of the occupation-specific dispensation agreement, which should have long been implemented.
The Minister waits for the doctors to embark on industrial action and only then puts an offer on the negotiating table. Chairperson, I am saying "industrial action", because the doctors are not on strike. They are on what is commonly known as "work to rule". The state is the one which is on strike by locking them out. As a result, the Minister must take responsibility for the deaths of our people.
To show disrespect for these hardworking doctors, the Minister makes the offer public before putting it on the negotiating table. Minister, that was a bad negotiating strategy. It is tantamount to blackmailing the doctors, because what you said to the media does not seem to be what you put to the doctors. This tactic is called "negotiating in bad faith".
By the way, if you always had the money, why did you wait until the doctors were on industrial action before you could put the offer to them? Do you regard the lives of our people as so cheap that you put them at risk while playing tricks with the doctors? How many people should die before you realise that your negotiating tactics are flawed and amateurish? [Interjections.]
For the hon Minister's free education, Ministers don't participate in collective bargaining. They employ people skilled in industrial relations to conduct collective bargaining. Ministers are regarded as mandating authorities. The hon Minister should stop playing games with the lives of our people. Don't wait for other health workers to embark upon industrial action before implementing existing agreements.
During the state of the nation debate, the Minister assured the nation that he would be releasing the national health insurance documents "within a few days' time". [Interjections.] Typical of the ruling alliance, the "few days" might become a few months, if not a few years. Mr Minister, when will your "few days" expire?
All the same, Chairperson, the hon Minister's unreleased concept document or policy is well publicised and has attracted a lot of commentary. The introduction of the national health insurance should start with clean clinics and hospitals which are properly staffed with the requisite medicine.
Your unreleased but well-publicised policy on the national health insurance states that the people will be directed to where they would acquire health services within the district. This is contrary to the ruling alliance's election manifesto, which states that "people will have a choice of which service provider to use within the district". I am sure, hon Minister, that if public health services are effective and efficient, the public will voluntarily utilise them. They don't need some Stalinist directive about where they should acquire health services. Improve services at hospitals and clinics, and people will use them.
The President, during his state of the nation address, assured the nation that he was going to "step up the fight against HIV and Aids, TB and other diseases".
Chairperson, I just want to ask the member if he will take a question.
After I have finished my speech I will take the question, Chairperson.
To me and thousands of other people, this is a hollow promise when one takes into consideration the fact that in the Free State money destined for ARVs was distributed among political parties as election funds to print T- shirts instead of saving lives. [Interjections.] The worst was when, instead of buying ARVs, the money was jived away at the Mangaung African Cultural Festival, or Macufe. In the meantime, large numbers of our people died as a result of the nonexistence of ARVs.
During the state of the nation debate, the hon Minister boasted of how South Africa is spending 8,5% of its GDP on health. The majority of the poor who use public hospitals and clinics don't share your optimism because of poor service at these institutions. This is compounded by lack of medicine and cleanliness.
On 16 April 2009 the SA Human Rights Commission launched a report entitled "Public Enquiry, Access to Health Care Services". In this report, the SAHRC says that the government is responsible for the failure of the country's health care system.
As a result of everything I have said, Cope does not support the budget.
Hon member, your time has expired.
I thank you. [Applause.]
Hon Chairperson, the aim of the Department of Health is to promote the health of all people in South Africa through an accessible, caring and high-quality health system. If one looks at the state of our health care system and the service that people actually get from it, then I am afraid that the department is failing in its efforts to reach this aim.
Government hospitals and clinics are generally in a run-down state, and short of equipment and medicines. Anyone who has ever been to a government hospital or clinic would have experienced first-hand just how unpleasant this visit actually is. People sometimes have to wait for hours just to get medical attention, and many people who are admitted to these hospitals are neglected and end up in a worse condition than when they arrived. The situation in rural areas is even worse, as people have to travel for miles to receive medical attention from clinics, and this costs them time and money, which they cannot afford.
These problems are compounded by the inefficient management of funds by government officials in the provinces. The KwaZulu-Natal Department of Health, for example, overspent by R1,3 billion in the last financial year, and now we hear that it owes the National Health Laboratory Service R169 million. This is simply not acceptable.
The doctors' strike, which has been ongoing for some time now, could have, and should have, been avoided. It should not have been allowed to reach this stage. The situation has now reached a point where the patients, who are innocent in all of this, are suffering. These doctors work long hours in unpleasant conditions and their efforts should be rewarded accordingly. It is important to realise that human resources are the most important resource of any organisation, and they should therefore be treated as such.
The dire state of our health care system means that the less fortunate South Africans suffer the most, as they cannot afford private health care. The inability of this department to fulfil its aims makes it more difficult for the poor to escape their lives of poverty.
Chairperson, I do understand that the new Minister has inherited a dysfunctional system with many problems and some incapable officials and administrators, but our health care system is failing.
Drastic changes are needed within this department and our health care system if the aim of promoting the health of all South Africans is to be reached. [Time expired.] I thank you.
Hon Chairperson, on behalf of my party, the ID, I would like to extend our congratulations to the Minister on his recent appointment to what we believe is an extremely challenging position. We look forward to engaging with the department to find solutions to the massive health challenges that we face.
Chairperson, the ID is extremely concerned about the implications of the doctors' strike. While we understand the frustration doctors feel because of their unacceptably low salaries, the long working hours and the department's empty promises, the fact remains that it is morally wrong for innocent people to suffer and die, and we as the ID cannot sit back and watch as if nothing is wrong. Our doctors did not study medicine for this, and while we stand with them in solidarity, the ID urges doctors to go back to work and to give the negotiations with the department a chance. The department must bear equal responsibility for this crisis because of its failure to deliver on its promises. We call on the department to negotiate in a transparent manner and to take responsibility for its mistakes.
The ID would also like to call on the department to re-evaluate its quota on the number of foreign doctors permitted to work in the country, because this is having a devastating effect on the health of the poor, especially those who live in the rural areas.
We must revisit our government-to-government contracts and appeal for assistance from other nations through this crisis.
Chairperson, inequalities in health care have always been a major concern to us and this is why we have advocated for the national health insurance.
We cannot continue to have a situation where only 35% of doctors cater for 35 million people in public health facilities, while 65% of doctors cater for 7 million people that are covered by medical aid.
Our nation must understand that uniting to address the massive inequalities in our health care system is unavoidable. [Time expired.] I thank you, Chairperson.
Hon Chairperson, hon Minister and Deputy Minister, hon members, I rise on this occasion to make my maiden speech in Parliament. I am proud to represent the ANC, the movement of the people, as they overwhelmingly confirmed in the recent 2009 national elections. Once more the people have expressed their faith in the ANC's policies and leadership in government.
While we have made great strides as a country, we also understand that much more has to be done. Health care, a key priority in this administration, is one such area that requires our attention. Health care is a human right. It is therefore an imperative for government to ensure the fulfilment of that right.
Primary health care emerged in response to the growing demand for health, particularly in developing countries. The most common understanding of primary health care is that it is the first point of contact with the health system. Primary health care is therefore our first line of defence. It is the first level of contact with the individual, the family and the community. Bringing health care as close as possible to where people live and work constitutes the first element of continuing health care progress.
The comprehensive approach of primary health care advocates for universal accessibility, but it is also an approach to focus on disease prevention and health promotion. In this regard, the Alma Ata Declaration suggests that primary health care should include a number of basic elements, namely: An adequate supply of safe water and basic sanitation; promotion of food supply and proper nutrition; maternal and child health care, including family planning; immunisation against the major infectious diseases; the prevention and control of local endemic diseases; appropriate treatment of common diseases and injury; health education; and the provision of essential drugs.
Social and restorative justice strongly informs the concept of comprehensive primary health care, recognising the importance of addressing the underlying social, economic and political causes of poor health. This is not an ideological or philosophical position, but these priorities and position agree with the World Health Organisation, to which South Africa is a signatory.
Chairperson, with regard to health the Freedom Charter states that we must commit ourselves to a preventive health scheme to be run by the state, and free medical care and hospitalisation to be provided for all, with special care for mothers and young children. We have succeeded in many areas, but we have to put in great effort to bring health care closer to the people, especially in rural and remote communities. Much more needs to be done to improve the quality of care and ensure better health outcomes.
The lack of private-public partnerships in health care is a barrier to better health that must be overcome. We cannot continue with a situation where the bulk of resources are to be found in the private sector, serving the minority of our people, while the public health services serve the majority with limited resources. Some may argue for free enterprise in health care, but how do you justify this when millions of our people are suffering due to lack of access to health care? How do you justify profits over the lives of people? Can there be no social and restorative justice for our people, who have suffered for so many years, and continue to suffer?
I am grateful to see that, as part of the department's strategic plan, there is a programme beginning to establish a public-private partnership. This is especially critical in areas where there are private hospitals, but ordinary people from the same areas are not allowed to use those facilities. They are therefore forced to travel long distances to get health services. This cannot continue to be the case.
The ANC is determined to end the huge inequalities that exist between the public and private sectors by making sure that these sectors work together. It is in this regard that the ANC, at the Polokwane conference, identified a number of essential priorities for major improvement in our health care system. [Interjections.] I don't blame you, because I also did not know where Polokwane was. I had never heard of it.
Among other things, the following have been identified as essential priorities for improving the quality of health services: Meet the national standards of quality care and ensure better health outcomes; overhaul the management system - a key priority is to ensure that management receives relevant training in order to perform optimally; improve human resource management - an effective retention strategy is essential; and revitalise physical infrastructure - this must include adequate provision of equipment. The lack of equipment and support leads to extreme frustration and undermines the ability of our health professionals to deliver a quality service to our people. Frustration is very high among health professionals in rural and remote areas.
Hon member, you are fortunate: You still have two minutes. [Laughter.]
Hon Chairperson, our first line of defence, primary health care, must be taken far more seriously, and must be funded appropriately if we are to meet the needs of our people and provide this service.
In conclusion, the challenge facing South Africa is to redress social and economic injustice, eradicate poverty, reduce waste, increase efficiency and promote greater control by communities and individuals over aspects of their lives. The ANC recognises that every person has the right to achieve an optimal life. An ANC-led government is therefore determined to fulfil this right. While there are significant advances in technology and access to information, we must remember to apply our collective wisdom as well. Building strong primary health care will reduce pressure on the hospitals.
Together we can do more. It may sound like a broken record, because it is the truth. [Interjections.] You can say what you like: I have been stretching my mind to try to remember what your manifesto said. I cannot remember. [Applause.]
Thank you, Chairperson. Minister Aaron Motsoaledi, hon members of the House, let me start by congratulating all government departments, Fifa and the Local Organising Committee on hosting an extremely successful Confederations Cup. Let me also congratulate Bafana Bafana, who have made us very proud. They have improved their game. They have played well.
Now that the Fifa Confederations Cup is behind us, we can pause and reflect on how the health system met its obligations in the provision of health and medical services for the tournament. In general, the provision of these services is considered successful, and the detailed planning and preparations that took place has resulted in an incident-free tournament. However, there are also areas where we believe that we can improve. A thorough debrief will take place in the middle of July 2009. Lessons learnt will be carried forward as we begin to prepare for the 2010 Fifa World Cup.
With the World Cup involving 10 stadia, as opposed to the four used for the Confederations Cup, now is not the time to rest on our laurels. The Health Sector Preparations Workgroup will critically revisit its plans in minute detail to ensure that all aspects are suitably prepared for.
The World Health Organisation, working together with the department, sent a nine-member delegation of experts in communicable diseases and mass gatherings to South Africa to evaluate the implementation of communicable disease control strategies during the Confederations Cup. This team commended us for the good work that was done. It also left us with minor recommendations.
The first identified case of swine flu in South Africa occurred during the visit of the WHO delegation. It provided the delegation the opportunity to observe first-hand how we, as a country, dealt with such an incident. The reports received were positive. The delegation gave us the assurance that they would continue to support our efforts to ensure that we have a 2010 tournament that is free of any disease outbreak. To this end exchange and training programmes will take place over the next 10 months.
I am confident as I stand here today that we will be able to tell the nation in April 2010 that the Department of Health, along with its partners, are fully prepared to ensure that we are more than adequately ready for the 2010 Fifa World Cup.
Let me now turn to the priority issue of improving quality of care. Our patients and their families, and the communities they come from, are the most important voices that we will be listening to during this year as we move towards implementing more equitable and higher quality care through health systems strengthening. We will also continue the recent successful efforts to work with our own staff and the many partners who are passionate about improving the quality of care in our country. We will formalise some of these relationships by appointing a number of our recognised experts to advise us on accepted best practices on an ongoing basis.
Since starting work last year, the Office of Standards Compliance has already initiated the process of reviewing and benchmarking performance against national standards in a number of hospitals and community health centres. This was followed by support to improve identified areas of weakness.
Hon Chairperson, hon Mpontshane is sleeping while I am speaking.
Hon Deputy Minister, what did you say? [Interjections.]
I wanted to say ... [Interjections.]
Please allow the hon Deputy Minister to respond to the Chairperson's question. What did you say?
I wanted to establish whether it is parliamentary for hon Mpontshane to sleep while am I speaking. But I shall proceed while I await your ruling, Chairperson.
In this financial year the national standards and assessment tools have been revised to ...
Hon Deputy Minister, I am allowing you to continue because nobody is raising a point of order or a complaint.
Thank you, hon Chairperson. You've asked the hon member what he said and he proceeded to tell you that he was trying to ascertain whether the member was sleeping. He wasn't trying to ascertain; he implied and said that the member was sleeping.
Thank you, hon member. We should not sleep in Parliament. [Laughter.] Let me continue. But if a person, as a human being of flesh and blood, occasionally slumbers, let us remember that some of them work into the early hours of the morning. Please proceed.
Thank you, Chairperson. In this financial year the national standards ...
Chairperson, on a point of order: Is it parliamentary to tell lies about another Member of Parliament? I wasn't sleeping. [Laughter.]
Order! [Interjections.] Please be quiet. That is what is out of order, not what you have raised. Hon member, no lie has been told in this sitting. Please proceed.
Thank you, Chairperson. In this financial year the national standards and assessment tools have been revised to ensure that the most critical areas where quality or safety could be at risk are adequately covered, for both hospital and primary level care. These standards will be extensively publicised and used throughout the health system to guide our work and our managers.
We will continue to review progress in relation to our previous findings in every province, as well as rolling out the performance review and benchmarking exercise so that we cover a quarter of our facilities this year. In doing this, we will be seeking the most effective ways to ensure that such an exercise is credible and provides our department at all levels with an objective assessment of our problems and the underlying or contributory causes, thus enhancing accountability.
It is important at the same time to build our own capacity to make the best use of these findings. These reports will give a detailed guide to managers, both those at facility level and those who provide support at provincial and national levels, as to what needs to be done to reach the required standards. The aim is to enable all these facilities to receive recognition as having met the required standards.
To turn the quality challenges around, we will use the methods shown internationally to be most effective. We will be pulling together a network of 100 targeted quality improvement projects around the country. These will be focused on measures to protect the safety of our patients, including the prevention of health care facility-acquired infections, long waiting times, plus basic cleanliness and maintenance of our facilities.
Through these projects, we will be able to improve poorly functioning systems, weak management and poor supervision, and hopefully motivate and energise our staff working at different levels, as well as identify and effectively solve some of the problems. This focus at delivery level is what in the end will make the services as a whole work for the benefit of our patients.
One particular mechanism that is widely used in the private sector to improve quality is through proactively analysing and addressing the complaints and concerns of our users, both in terms of providing an explanation and an apology where necessary to them, and taking strong measures to avoid their future repetition. This will be the main aim of our national 24-hour toll-free line, which will start operation during this financial year. It will work in close collaboration with all the provincial centres.
As the hon Minister has said, the implementation of the national health insurance represents a defining moment for the South African health system. It has been a long and winding road and many alternative considerations have been put on the table as to how best the country can achieve universal coverage. We have reached a decision we shall implement.
In the ANC's national health plan of 1994, it was clearly envisaged that the introduction of a mandatory prepayment-based national health insurance would go a long way towards the progressive realisation of ensuring that the South African population have coverage and access to adequate, good quality and affordable health care within the public and private sectors. Ke nako - it is time to implement such a system.
A key area in the strengthening of the health system and the implementation of the national health insurance is an integrated health information system. The World Health Assembly has identified the need to strengthen the health information systems in member states. The WHA subsequently identified the Health Metrics Network to facilitate evaluations and to develop strategic plans based on the needs to achieve this important objective within member states.
Some of the areas that would need attention in order to strengthen the country's health information system are the following: The current fragmented health information sub-systems; capacity building of our staff; establishment of an integrated national data warehouse for all data sources, and paying particular attention to enabling tracking of human resources, equipment, physical status of facilities and expenditure; and methods and estimation of provincial national health accounts, chronic disease surveillance, cause of death certification and survey methodologies.
The successful implementation of the national health insurance will need a very strong information and communications technology infrastructure. It is therefore paramount that an integrated national health information system which will cater for all service providers, public and private, is developed as part of an e-Health Strategy.
We have prioritised the improvement of service delivery in our hospitals. The Department of Health launched the Health Facilities Improvement Plan with 27 hospitals throughout the country. The Minister has already indicated that each province should add at least 10 hospitals to this pool. The 27 hospitals were appraised against core standards across seven domains, namely patient safety, patient clinical care, patient experience of care, patient access to care, management and leadership, infrastructure and environment or facilities management, as well as public health.
Facilities were a mixture of district, regional and tertiary hospitals across seven provinces. In working with these facilities we moved closer to creating good ownership and team building of all the internal stakeholders of the facilities. Our focus on hospital improvement plans will deal with patient experience of care in the health facilities.
In addition, we will address the backlog of equipment that needs to be provided for health workers to use. There are standards that are being developed to assist in the procurement and maintenance of these health technologies, so that levels of hospitals and health facilities have the appropriate technology. We are modernising equipment for cancer treatment. Along with this increased attention to technology, there shall be emphasis on the appropriate maintenance training. We shall also focus on equipment that is necessary for strengthening primary health care. We shall collaborate with other role-players, including academic, research, donor and nongovernmental organisations, in this regard.
Emergency medical services are at the centre of enabling our people to reach places of care in times of emergency. With the aim of reaching the targets of the Millennium Development Goals, of reducing maternal and child deaths by 75% and 67% respectively, the response of emergency medical services teams is crucial. To this end we are embarking on the modernisation of emergency services. We will be concentrating on purchasing more response vehicles, building more base stations and strengthening training programmes. The hospitals will also be equipped to deal with emergencies, particularly maternity emergencies.
Last but not least is the importance of the cleanliness of our facilities. The environmental health supervision will be increased, with the engagement of communities and other partners in creating a conducive environment for the patients and the health workers. Hospitals need to be places for healing and rehabilitation. They need to be clean and representative of the search for health.
Our budget shows that government is committed to health system strengthening. We want to return to the basics of primary health care, as my comrade hon Segale-Diswai said. We want to return health to the people, so we urge hon members to approve this budget. I thank you. [Applause.]
Chair, hon Ministers, the ACDP notes the growth in the allocation for HIV/Aids and STI subprogrammes. Provincial spending of this grant, which is clearly intended to facilitate the roll-out of dual therapy for the prevention-of-mother-to-child-transmission programme, as well as expanding access to antiretrovirals for people living with HIV, must be closely monitored.
Hon Minister, reports that government will be short of R1 billion for HIV and Aids drugs in this financial year raised serious concerns. Are we going to see a repeat of the shortages experienced in the Free State earlier this year, which prompted the province to stop giving treatment to new patients? South Africa has one fifth of the world's HIV-infected people. Do we know what we require to meet the need for treatment? Has there ever been a proper costing, or is it just hit-and-miss?
The maternal, child and women's health and nutrition subprogramme, which barely increased - less than 1% in real terms - is another concern for the ACDP. Statistics reveal each year 1 600 women are dying from complications in pregnancy and childbirth, 20 000 babies are dying before they are a month old, 75 000 children are dying before the age of five, and 20 000 babies are stillborn. The ACDP mourns the loss of these women and their little ones.
Shockingly, some have concluded that the easy way out of this dilemma is for women not to carry their babies to full term, and in addition to these statistics, hundreds of thousands more babies have been destroyed while still in their mothers' wombs, in line with government policy.
Efforts to strengthen emergency medical services, in line with the 2010 Fifa World Cup commitments, are noted and welcomed. Appalling conditions in hospitals, with drastic shortages of beds and staff, however, do not appear to be a major consideration in this budget. The previously minimal increases in the health budget have barely kept up with inflation, let alone addressing escalating needs. Will this budget increase of 2,1% in real terms be sufficient to turn things around?
The ACDP will be supporting this budget, if only to give the new administration and new Minister the benefit of the doubt, despite our grave concerns. I thank you. [Time expired.]
Hon Chairperson, hon Minister and Deputy Minister, any other Ministers present, hon members and guests, my focus is going to be on human resources for health.
It is now widely accepted that the dire shortage of health workers in many places is among the most significant constraints to achieving the three health-related Millennium Development Goals: to reduce child mortality, improve maternal health, and combat HIV/Aids and other diseases, such as tuberculosis and malaria. Shortfalls exist in all categories of health workers.
The World Health Organisation clearly articulates the view that central to every health system, the health workforce is central in advancing a nation's health. It is the backbone.
It has been suggested that a nation's budget provides a clear indication of its policy priorities. In the case of the national health Budget Vote, it should however be taken into account that while provincial health budgets give effect to health priorities, via implementing departments, the national department provides leadership and co-ordination for health services in South Africa. Therefore its budget does not reflect actual implementation of health strategies and programmes.
The national Department of Health received a total allocation of just over R17 billion for the 2009-10 financial year, which translates to 3,9% of the total Budget. Of this, R306,5 million was allocated to personnel expenditure. This includes compensation of employees, as well as training and development. Therefore personnel expenditure constitutes 1,8% of the departmental allocation for 2009-10. On examining the budget allocation, our portfolio committee came to the conclusion that this R17 billion was quite inadequate. As a caring government, we would like to receive more and do more. A constraining budget is a handicap.
Compensation of employees increased from R287,7 million in the 2008-09 adjusted appropriation to R299,9 million in the present year. While this suggests a nominal increase of 4,24% from the previous financial year, in real terms expenditure on compensation of employees declined by 1,1%, when taking into account the impact of inflation.
Further, training expenditure as a percentage of compensation of employees remained stable. However, it declined significantly since 2007-08, when it constituted 3,7% of compensation of employees. The number of persons trained in the department declined to 261 in 2008-09, from 625 in 2007-08, so there is a remarkable decline there.
Human resources for health cannot afford not to be seen within the context of primary health care. With the advent of democracy in 1994, South Africa's newly elected democratic government was faced with the challenge of transforming a highly inequitable and fragmented health care system. In addition, the health care system was biased towards curative care and the private sector. The transformation of the health system was operationalised through government's commitment to developing a unified health care system capable of delivering quality care to all, as envisioned in our Freedom Charter.
Key to efforts to ensure quality health services available to all South Africans, government adopted a district-based health care model, driven by the primary health care approach. This approach has at its core the reorientation and reorganisation of the health workforce. A more equitable distribution of the health workforce, broadening of the cadre of workers, sufficient numbers of health workers, as well as skills development to ensure appropriate and adequate care, have been at the centre of policy debates since 1994.
Research conducted during the late 1990s and early 2000s indicated that doctors and nurses were often ill-prepared to render services in primary care settings. Since then there has been significant expansion in needs and service expectations of the primary health care system, brought about by the HIV and Aids and TB epidemics. A related shift in disease burden towards chronic noncommunicable diseases will exacerbate this in future, and perhaps we will see that we will be having chronic noncommunicable diseases for quite some time in the future, unless we concentrate on things such as nutrition.
Skills requirements have therefore changed, and health sciences faculties are confronted with the need to restructure curricula and make decisions about teaching priorities, but to varying degrees, and focusing primarily on medical curricula. The general focus has been towards strengthening community-based education, to alter teaching methods to improve problem- solving and critical thinking skills, and to foster multidisciplinarity. However, the impact of these reforms has been not evaluated, and a comprehensive audit of health science curricula is urgently required, Minister, particularly in light of changing needs and service expectations. Questions need to be asked as to whether health professionals in general, and nurses in particular, are indeed prepared to address the changing burden of disease, and to function effectively in primary and community care settings. An important step in this direction is the Collaboration for Health Equity through Education and Research initiative, a research collaboration between all universities in the country to assess the educational factors that would improve the supply and retention of health professionals in rural and underserved areas.
Early evaluations of the community service programme suggest that new graduates continue to feel ill-prepared for service in rural areas and primary health care settings. Many expressed "a disjuncture between the academic training expectations and the actual conditions in the Public Service".
One graduate described his experiences as follows: "There wasn't enough emphasis on patient management in a lower level institution ..." [Time expired.] [Applause.]
Hon Chairperson, Minister, Deputy Minister, hon members and guests, during the apartheid era most, if not all, African people, especially blacks, were living in poverty and degradation. Most African people earn very little to survive. Our history has been dominated by colonialism, racism, apartheid, sexism and repressive labour policies. We are definitely not going back but moving forward to a free and better South Africa.
There will be no political democracy if we still have people living under adverse conditions of poverty, with no housing, food and other basic needs such as access to health care. The public health care system provides low- cost care to millions of poor South Africans, and for this reason it needs to be prioritised, nurtured and revived so that it will be able to offer patients more compassionate care and a higher quality of medical attention.
Constitutionally, everyone has the right to have access to health care services, and the Constitution further stipulates that no one may be refused emergency medical treatment. This clause simply implies that the issue of the doctors' strike and the emergency medical staff strike should be given urgent attention by government to ensure that this right is respected. I will focus on the critical effects that this budget will have on quality service delivery, the realisation of the Batho Pele principles and the patients' rights charter.
After the briefing by the Department of Health on their strategic plan for 2009-10 to 2011-12 and the budget, the biggest question was the alignment of the budget to the overall plans of the department. The two do not correlate. There is not sufficient money for the department to cover the programmes as outlined in the strategic plan.
Hon Minister, the health institutions are falling apart and will continue to do so, if the situation does not worsen, if this budget is not urgently reviewed. For example, the biggest hospital in the southern hemisphere, Chris Hani Baragwanath Hospital, is one of the tertiary hospitals deteriorating day by day. It is faced with problems that undermine the quality of health care, including: a lack of resources, be it financial, human, equipment or drugs; a lack of management and administrative capacity; a financial crisis and mismanagement; a poor and inadequate referral system; a lack of commitment and discipline; a high attrition rate leading to shortages; a lack of information communication technologies; and poor procurement processes with the Gauteng Shared Service Centre as the middle man. The list goes on. I'm very happy that the Minister has already alluded to this.
The amount of funds requested by the Department of Health for a comprehensive HIV/Aids plan for the financial year 2009-10 was R1,4 billion, but we only received R200 million. What a gap! Recently the Human Sciences Research Council released the results of their 2009 survey on HIV prevalence and related behaviour. The results indicated that, irrespective of the decrease in prevalence among young children, there is an alarming increase of HIV prevalence in young women in their twenties. We are concerned.
Motsamaisi wa lefapha la bophelo, Setjhaba sa rantsho se a lla, se a bokolla ke lefu la kwatsi ya bosolla tlhapi.Ha ho phomolo malapeng le meyeng ya batho. Moqebelo o mong le o mong, Sontaha se seng le se seng ke mafu. Ho bolokwa batho ba hlokahetseng ka lebaka la 'HIV' le 'AIDS'. Uwele hle! Motsamaisi bana ba setse ba le bang malapeng. Ba hloka bahlokomedi mme ba qobelleha ho hlokomela bana ba bang. (Translation of Sesotho paragraph follows.)
[Hon Minister of Health, black people are concerned. They are anxious about HIV and Aids. There is no rest in families and in the souls of people. People who die from Aids-related diseases are laid to rest every weekend. Please help! Hon Minister, many families are headed by children because there is no one to look after them.]
Those are child-headed families owing to HIV and Aids.
Ho iphapanya le boima bona ba tsuba dithethefatsi, ba nwa jwala, ba kena mekgatlong e sa lokang ya bakgothotsi, ba rekisa ka mmele ebe qetellong malapa a qhalana. Lefatshe le a dubeha jwalekaha le se le qadile. (Translation of Sesotho paragraph follows.)
[In an attempt to reduce the weight of their plight, they use drugs, drink alcohol, join criminal gangs and get involved in prostitution. These ultimately lead to the break-up of families. The world is changing for the worse.]
The cut in the budget for the hospital revitalisation project has serious implications for the deterioration of health infrastructure conditions and the poor work environment of health workers.
The DA believes that the provision of quality health care to all who live in South Africa is a key priority and should be given urgent attention. In order to avoid a total collapse in health care, the Minister should put smart - and I emphasise smart - interventions in place. To minimise these effects the government should, amongst other things, prioritise health programmes to ensure better health and therefore a better life for all; ensure that the appointment of health institutions managers is based on what a person can do, their capabilities, and how hard they can work - not on who they are and who they know; empower these managers, not only to comply, but to perform as well; have strict control measures in place to ensure accountability and responsibility by all - this includes from top management down to the lowest level of operational people; and cut out the middleman, the Gauteng Shared Service Centre. Why should the GSSC buy the Chris Hani Baragwanath Hospital's milk, sugar and all that? We need to start buying direct. The government should also do a statistical analysis, which includes a staff count, in relation to staff-client ratios of all staff categories. This includes the allied medical personnel, particularly the radiographers in hospitals.
The DA further believes that no country can prosper without an affordable, effective and easily accessible health system. [Interjections.]
Hon member, will you take a question?
I shall take the question after I am finished.
Continue, hon member. [Interjections.] Order, please.
The DA believes that no country can prosper without an affordable, effective and easily accessible health system. Such a system requires both a dependable primary health care network that prevents diseases and treats minor illnesses, and a secondary and tertiary health care network to provide hospital-based care for more serious illnesses.
In conclusion, health is life, and life translates directly to the people who voted for us. [Time expired.] Thank you. [Applause.]
Hon Chairperson, hon Minister and Deputy Minister, hon members, distinguished guests, departmental officials, comrades, friends and all people present: Dumelang! Awusheni! Molweni! Sawubona! I greet you all and I wish you all the best of health!
It is a singular honour for me to stand here today - I'm a little nervous, a little anxious, since it is my maiden speech, but I am strengthened by the proud history of the organisation I represent, the ANC, which has for decades been the vanguard organisation in the fight against apartheid and the fight for freedom, democracy, equity, dignity and a better life for all! [Applause.] I am also proud to stand here as a doctor, because on 9 March 1947 it was three doctors - I repeat, three doctors - Dr Alfred Xuma, Dr Monty Naicker and Dr Yusuf Dadoo, who signed the joint declaration of co- operation, which is now called the "Doctors' Pact". This was the forerunner to the 1955 Freedom Charter, and was the first tripartite alliance - it had a communist, a unionist and the president of the ANC. The actual words, "South Africa shall belong to all who live in it, both black and white", were taken from this "Doctors' Pact". You see, Chairperson, these three doctors, like Che Guevara, knew that to treat a disease or an illness, you need to treat the aetiology, you need to treat the cause; you can't treat symptoms. And therefore they embarked on that particular direction, and that is what informs us today when we make a proposal on the national health insurance.
We have more than 150 years of mismanagement in health. The previous minority governments were just catering for the minority of the plus-minus four million white population and have left a legacy of mismanagement. They started in 1833 with the Public Health Act. They went on to the Tomlinson Report in 1954, which proposed Bantu health services, and then to the 1983 tricameral system, with 17 distinct political entities with no political legitimacy. [Interjections.]
Order, please!
Wat beteken dit? Dit beteken ... [What does this mean? It means ...]
I can't speak Afrikaans. We have a legacy of mismanagement. The effects of decades of apartheid on the psyche and minds of our people have disempowered and impoverished our society. [Interjections.]
Order, hon members!
Most importantly, it has created a fragmented, inequitable and fractured health system, to which we have just been applying plasters and bandages, trying to hold it together. This is what we inherited. [Interjections.]
Order, please!
You cannot expect that 150 years of mismanagement will be corrected by 15 years of ANC policy and rule. [Applause.] It is not possible. Therefore we agree with hon Msweli, who said that we need a bold new change, a bold new change that stops using plasters and bandages to hold us up. And that is why we are proposing the national health insurance. [Interjections.]
Order, hon members!
This ANC government was built on the foundation of "galit" - for those who do not know what that means, it means to be free, equal, open, uncensored, unrestricted, a classless society.
Kudala sizabalaza kulonto asikafiki izolo. [We've been in the struggle for a long time; we did not hear about that issue yesterday.]
Therefore we understand that health is a fundamental and basic human right, and we have steadfastly fought for the progressive realisation of this right. Health is not a commodity that can be left to the whims of a capitalistic free market system. As our hon Minister has said, of the 8,5% of our GDP spent on health, we spend 5% of GDP on the 14% privileged people, and 3,5% of GDP on 86% of the people. How is that equitable? [Interjections.]
Order, please!
There is a deafening silence on what this causes. We hear from the opposition and the newspapers about the concerns of the privileged 14% of society, yet there is a deafening silence about the plight of the 86% of the population who are totally dependent on this government for their health services. [Interjections.]
Order, please!
Surely in our egalitarian society the needs of the vulnerable must take precedence. I repeat for those who do not understand: The needs of the vulnerable must take precedence. [Interjections.]
Order, hon members!
I am the first to admit that no country has solved the problem of health care financing. However, we have to strive for "galit". [Interjections.] I will explain the staff shortages. This nation has embraced the idea of "Ke Nako - It is Time, We Can Do It!" I repeat: It is time, we can do it! However, despite our achievements ... [Interjections.]
Order, please!
You know, these prophets of doom and gloom, we have been hearing them since 1994. When we came in in 1994, they said there would be civil war, chaos, and everything. Yet we had a transition to a constitutional democracy and we have had three elections. We were told by these prophets of doom about the World Cup. We know what they are saying; they are still saying it. When we introduce the national health insurance, we must not be surprised if these prophets of doom and gloom start drumming up these fears again; in fact, we must expect it.
Hon Minister, the national health insurance is not an ideological aspiration. [Interjections.]
Order, please!
It is absolutely necessary for our fragmented and divided country. Many will argue right now that in this time of recession we do not have the fiscal capacity to implement the national health insurance. Our hon Minister has told you why at this point in time vulnerable people need to be protected. While the rich can go and buy cars again and recoup losses, the poor will perish. Therefore at this point in time we cannot further delay the implementation. We have consulted enough about this, and in our country we have a disease of "consultitis" - we keep consulting and consulting, but we consult with stakeholders who have a vested interest. No one consults with the majority of the people out there. [Interjections.]
Order, hon members!
This leads to paralysis and analysis, and then it leads to inertia of initiation. [Interjections.]
Order, please!
Our President, in his state of the nation address, has said we will introduce the national health insurance scheme in a phased and incremental manner, and after urgent rehabilitation of our public hospitals. Our Minister has said, in his state of the nation debate speech, and I quote:
I want to put it upfront that we will never impose the national health insurance upon poorly functioning and poorly managed health institutions. Our first task towards the implementation of the national health insurance is to overhaul the whole system ... The message cannot be clearer than that. He also said there will be a quality improvement programme. So for those who have these fears about quality administration, this and that, listen to this, we will show you.
I want to tell you something else. [Interjections.]
Order, please!
There is a myth in our country about an efficient private health care system. I would like to quote from a report:
No health care system in the world is as heavily commercialised as ours, and none is as expensive, inefficient, and inequitable - or as unpopular ...
[Interjections.]
Order, hon members!
The report continues:
There is now abundant evidence that private businesses delivering health care for profit have greatly increased the total cost of health care and damaged - not helped - their public and private not-for-profit competitors. [Interjections.]
Order, hon members!
You see, hon Waters, I want to engage you carefully: This thing of migration of doctors, it will always happen because people follow where the money is. As long as 5% of GDP is there, people will follow. [Interjections.]
Order, please!
I was also a member of the Council for Medical Schemes and I have personal knowledge of hundreds of millions of rands being siphoned off.
Hon members! Please take your seat. Hon members, will you please allow the Minister to hear what the hon member is saying, because at the end of the day the hon Minister has to respond. Except if you are saying you don't want the hon Minister to respond, then I will allow that noise. You may continue, hon member.
Thank you, Chairperson. I repeat: I was on the Council for Medical Schemes, a body that regulates private health care and medical schemes, and I have personal knowledge of administrators ... [Interjections.]
Order, members!
... and people who have siphoned off millions. I can tell you of one administrator who had to return more than R900 million to a scheme! If anyone reads the Council for Medical Schemes reports of the year 2000 they will know that we have a very sick private health care system. We have 7,5 million people, hon Waters, 7,5 million lives on 122 medical aids, based on 386 benefit options administered by 23 administrators. We spend R8,9 billion on non-healthcare expenditure. Solvency is plummeting and membership is not increasing. If you tell me that is an efficient private health care system, there is something wrong. [Interjections.]
Order, please!
I need to come back. The Minister and the Department of Health presented the budget to us with the strategic 10-point plan under six programmes. The hon Trevor Manuel has said the budget is a programme and an instrument of reform. Therefore we must use it thus. Therefore I would like to say that we are also concerned ...
Chairperson, on a point of order: Is it parliamentary for the opposition, despite having been cautioned, to continue with a running commentary, which is against the Rules? I would urge you to consider sending them out of the Chamber, because they are disobeying your ruling.
Hon Mike Masutha, if I have to send anybody outside, that should include the ANC members, because all of you here in this House are making a lot of noise. [Applause.] So, hon Masutha, can you please take your seat. Hon Masutha, just take your seat. You may continue, hon member.
Hon Chairperson, therefore I raise my concerns. I would agree with hon Waters that from 1994 to 2006 there has been a progressive and a real decrease in the allocation of the budget against the substantial increase in the burden of disease and HIV, which has contributed to a significant deterioration in the health care infrastructure and morale. We will fight for a bigger budget; we will fight for this together. But we need to say that that did not happen because we invested in the arms deal. It happened because we also had to pay foreign debt which we inherited, and we had to invest in Gear - if you want I will give you figures. Our quasi- federal system has also contributed to inequity, and that needs to be looked at. [Time expired.] I thank you. [Applause.]
Hon Chairperson, let me start with a question, directed at hon Kganare. Why is it that when comrades leave the ANC and go to Cope, their level of reasoning deteriorates so quickly? [Laughter.] How does that happen? [Interjections.]
Order, please! Hon Kganare, you will respond outside this House. Hon Minister?
Hon Mr Waters ...
... agbare Mnr Waters ... [... hon Mr Waters ...]
... mohlomphegi Mna Waters ... [... hon Mr Waters ...]
... muchamuseki Tatana Waters ... [hon Mr Waters ...]
... I stand here in front of this hallowed House of Parliament for hon members and South Africa to know: I never lied to anybody. The negotiating document about the salaries of doctors, which I put in front of the bargaining chamber, is as it is. There is nothing wrong with it. There is no trick; the numbers are as they are. I stand by them today; I stood by them yesterday; I will stand by them in the future. [Applause.] I challenge you to call a judge in a court of law to go through this process and see if I have done anything wrong.
The reason I went public about what was said in the bargaining chamber - by the way, on the same day that it was presented - was that for the past weeks, over the radio, public media, everywhere, people were debating this very important thing without facts. I took it as my responsibility to give facts, because there was no way you were going to remove this thing out of the public arena. It was debated more publicly than in the chamber, and I thought, let me give members of the public the facts. That was all I did.
Now, the issue which you are accusing me of, Mr Waters - but I don't blame you - comes from this document. The 22% you are quoting comes from this document. It bears no resemblance to what I put in the chamber. I am compelled to give you the history of this document, because what happened over the past five days should never happen in South Africa again. Never! After I presented the document of what was given to doctors, they took this thing and put it to a company in the corporate world, a company of supposed wage experts. They analysed what I did and wrote this document, from which Mr Waters quoted today, in front of this House. The figures he mentioned, of 1% and 22%, appear in this document. This document bears no resemblance to what I put in the chamber. After I heard these complaints, I called our negotiating partners. I don't negotiate with anybody. [Interjections.]
Order, hon members!
On the 27th of this month I demanded a meeting with the people who wrote this document, and said they should deal with me. It was a crunching of figures and percentages. I met them and we discussed this issue. And the author of this document apologised. I don't expect the author to apologise in public, and I won't name them. If they want to be named, it is up to them - I will oblige, but now I am not naming them, because my aim is not to destroy any company, for the simple reason that I don't think what they did here was deliberate. They made an honest mistake, for which they apologised.
Unfortunately, this paper has been posted on the internet. Doctors are downloading it left, right and centre, and fighting. This document nearly burned my country, for something that does not exist. Doctors are downloading it. Yesterday, when I met professors and leaders from some of the very highly acclaimed medical academic institutions, they were shocked when I presented to them what is in the chamber, as opposed to this document. They also believed it. It nearly burned the country. Every doctor who appears on TV or the radio is quoting this document.
Let me tell you what I put in front of the bargaining chamber, which I stand by. [Interjections.]
Order, please!
Firstly, I had things to resolve in this country, for our country to go forward. The fact that interns, doctors who were working for the first time in their lives, were underpaid: I acceded to it even before the march. I am a doctor myself, I know. I said, I want to encourage the children of this country to do medicine when they pass matric. So the first thing I did was to check the offer on the table with regard to the salaries of interns, which put them at the level of assistant- director in government. That was the document I put to them, not this one. I want to encourage children to study medicine.
My second area of focus was people who are called registrars. These are people who have gone back to study, to become specialists, to specialise in gynaecology, surgery, anaesthetics, etc. In our country, when you do medicine, as a medical officer, having finished your internship and community service, when you go back to study, you take a salary cut. This was a disincentive. That is why many of the people who are doing senior degrees in our medical institutions are not South Africans. I want South Africans to go back, so I placed emphasis on registrars. I am giving you the principles.
Thirdly, I don't want academics to leave our academic institutions and go elsewhere, especially professors. In this document, from tomorrow, if it is signed, any person who becomes a professor will end at the level of director-general or higher. [Applause.] That is what I presented. That is what I have here. In fact, people who have been professors for a long time are now earning more than Deputy Ministers in cabinet. This is the document I have presented. [Applause.] This is what I have presented to the unions.
I am challenging you, when this document becomes public, after the unions have signed, to check area by area, and compare. In terms of this document, it is better to remain a doctor in a hospital than to become a manager in government, in terms of this new document I have presented - not this one, which nearly burnt my country. [Applause.] I am not sure whether Mr Waters is also using the same group of consultants, but they made an honest mistake. That is why I don't want to name them.
How do you inject more than R1 billion into the salaries of so few people? Doctors are very few.
Madam Chair, on a point of order: The Deputy Minister, who has already been economical with the truth in the House this afternoon about what he said, has again uttered something that is totally unparliamentary. He has said that the document that the hon Minister referred to, that nearly burnt the country, is a "Waters document". I would like him to withdraw that remark. [Interjections.]
Hon Deputy Minister? Order, please. Order, hon members! Deputy Minister, can you withdraw that?
I withdraw it.
Thank you, Deputy Minister. You may continue, hon Minister.
Chairperson, there is no perfect salary system, and I am not saying what has been presented is 100% perfect. It is subject to negotiation. But it is not what has been presented here. It was deliberate for me to do so, because I am sure you will agree with me, I want as many professors as possible to stay in hospitals. I want as many South Africans as possible to do senior degrees. I want as many matriculants as possible, from next year onwards, to study medicine. That is why I am going to ask hon Blade Nzimande, together with university principals, to increase the intake of medical students to three, if not four times what it is now. [Applause.]
Hon Minister, can you round up, please?
And I use this document to attack them.
I just wanted to make clear in this House that what we have heard is not what I have presented in the chamber. The only areas of weakness of this document are in the middle. Those who understand medicine, know that it goes from interns to medical officers, to professors, etc, but the three areas I have mentioned, especially the ones I have mentioned in the press, are as they are, and I stand by that.
The last issue is the fourth principle. Because of the shortage of doctors and the desperation, people were placed on wrong salary scales. There are as many diverse salary scales for doctors in this country as there are doctors. In this document we are trying to make them similar, the same. Some have had to be on the same level, because they had the same qualifications, same experience, same everything, but just because they were in different institutions or different provinces, they had different salaries. I had to bring them up from the bottom, just to arrive at a common figure. Others had to be adjusted just a little bit. That is why the percentages are not the same - they will never be. There are interns who had to be brought to the level where interns are, which is actually higher than assistant directors. They had to get a 53% increase. But there are those who needed only 31% to arrive at a similar level. Among registrars, there were those who needed a 60% increase to arrive at a particular level, whereas others needed only 18% to arrive at the same level. It shows the diversity. So this document sets out to achieve parity first. The other things will follow later. They are not here.
Things such as the rural allowance, etc, I said you cannot do that unless you have a common structure. This is what this document achieves, and I can assure you I am very, very proud of it. [Applause.] I am very proud of the work that the management committee has done, because it will normalise health care, and because everybody wants health care to be normalised.
Please let us support each other. Let us not destroy each other if it is not necessary. But I forgive you, because you did not know the truth. [Laughter.] [Applause.] I forgive you with all my heart. I am not angry with anybody, just as I am not angry with this company, because when I met them I realised that they had made an honest mistake of not understanding what we are doing. [Applause.]
Thank you, Minister. Thank you, hon members. In fact, earlier you were a good audience, but not during the last part. That is why I am not going to say you did well today.
Debate concluded.