COSATU Parliamentary Submission on the

White Paper for the Health System

Presented to the Portfolio Committee on Health, 20 March 1998

 

Contents

  1. Introduction

  2. Re-organising the health service

  3. Financial and Physical Resources

  4. Developing human resources for health

  5. Occupational health and safety

  6. Environmental health

  7. Infectious and Communicable Disease Control

  8. Conclusion

  9. Summary of recommendations



  1. Introduction

    2. The White Paper for the Transformation of the Health System in South Africa (hereafter the 'White Paper'), deals with a broad range of issues including reorganisation of the health service, financial and physical resources, developing human resources for health, essential health research and nutrition. This submission will focus on the reorganisation of the health service, financial and physical resources, and developing human resources. In terms of programmes, we will limit our comments at this stage to occupational health and safety, environmental health and communicable disease control, although other sections of the White Paper are also important.

    The White Paper is an important milestone in the transformation of the health system in South Africa. The Health System that we have inherited was hospital-based, fragmented and marked by inequalities on the basis of race, class, gender and geography. The missions, goals and objectives of the health policy underpinning the White Paper should be applauded. The basic philosophy underpinning these goals reflects the transformative goals of the RDP, to unify fragmented health services into a comprehensive and integrated National Health System, to promote equity, accessibility and utilization of health services and to foster community participation.

    An important benchmark to measure the performance of the health system is the extent to which the constitutionally entrenched right to health care services is achieved. The de-emphasis of the hospital-based health system towards comprehensive primary health care (PHC) is a revolution in the health system in South Africa, and an advance towards achieving this constitutional obligation. A key component of the PHC approach is that society should address the socio-economic causes of poor health and make provision for basic health needs. This calls for an inter-sectoral approach geared towards ensuring that all South Africans have access to water, sanitation facilities and refuse removal. The move towards a PHC does not make hospital care irrelevant or superfluous. It emphasizes preventive rather than curative health care. Thus, integration of various levels of care is important.

  2. Re-organising the health service

  3. Financial and Physical Resources

    4. The debate on financing of health has to be informed by broader macroeconomic considerations and take into account the institutional framework within which the health system operates. The health system is transformed within a macroeconomic strategy (GEAR), which sets arbitrary fiscal deficit and revenue targets. Notwithstanding the increase in social expenditure in the 1998 / 99 Budget, rigid adherence to GEAR will result in cuts in the coming years. This statement is borne out by the allocations to social expenditure in the last two years of the Medium Term Expenditure. Social expenditure declines from its 1998 / 99 level of 63 per cent of non-interest spending to 59,8 per cent in 2000 / 01. If the projected economic growth targets are not realised, this will translate into further cuts. This is likely to have an impact on health and other social services.

    Secondly, fiscal federalism has an impact on the sustainability of the DHS. Provinces are not bound to maintain the reprioritization of expenditure towards social expenditure as done in the national budget. The recent crisis faced by certain provinces around the payment of old age pensions is illustrative in this regard. However, in their 1998 / 99 Budgets most provinces have followed the national trend and reprioritised expenditure towards social services. Nonetheless there is a need to protect the integrity of the national health programme, by ensuring that provinces do not under budget for health and other social services when they make their budget allocations. Conditional grants for health to provinces are currently limited to the tertiary health sector. This regulation of provincial spending needs to be extended to other areas of health care, particularly primary health care. There are a number of objectives of the conditional grant, including compensation for spillovers, cross-boundary usage of facilities, the need to plan and control national services, and training and research.

    Recommendation:

    In this regard we welcome the commitment in the White Paper (p.43) that "in the absence of DHS grants from central government, as proposed by the FFC, DHS funding should be earmarked by agreement between provincial health departments and treasuries, in the context of provincial medium term expenditure plans. The FFC projections may be used as benchmarks of DHS expenditure which would result in basic health care being provided to all South Africans within a 10 year period."

    However, such commitment will be undermined by the imposition of inappropriate macroeconomic strategies. Macroeconomic parameters that undermine fundamental government policy such as health must be changed. Secondly, reprioritisation of expenditure towards social expenditure, including the district health system, must be sustained at provincial level. Failure to allocate adequate resources will seriously impact on the health status of the nation as a whole.

    Further, we need to address the current situation where cutbacks in public service personnel is frustrating implementation of the new health system. The health system is one of the areas that face a chronic shortage of staff. The reduction of public service health workers will therefore make it impossible to effectively transform the health system. No where is this more clearly demonstrated than in the existence of non-operational clinics. Out of 576 new clinics built since 1994, 121 remain non-operational due largely to shortage of staff and/or equipment. The majority of these clinics are located in KwaZulu Natal and the Eastern Cape. It is therefore clear that the new health system will only become effective once the necessary resources are released. The wisdom of fiscal cutbacks, which endangers this programme, needs to be fundamentally questioned.

    The broad thrust of chapter three of the White Paper depends on the adoption of appropriate fiscal policies. This includes the White Paper’s goal of providing basic health care for all South Africans within 10 years, by increasing the average number of public primary health care consultations per person from a low baseline of 1,8 in 1992 / 93 to 2,8 by the end of the century and to 3.5 over the following five years. These targets are likely to be compromised by current budgeting processes which are driven not by the need to address the social deficit in health, but by rigid fiscal deficit targets.

    The White Paper points out that it is broadly affordable to provide basic health care for all South Africans within a 10 years period subject to two conditions. First, is the redistribution of public health resources and secondly, that there are new sources of public health finance over and above general government revenue. The proposed new financial sources are the health insurance and retention in the health service of fees collected by hospitals. We will limit our comment to social health insurance and proposals for public/private mix in South Africa. However, we welcome specific proposals dealing with redistribution of public health resources, the protection of funds for DHS, funding of tertiary and highly specialised public health services, funding of academic related health service costs, revised procedures for budgeting and equitable distribution of physical resources.

  4. Developing human resources for health

    5. Our aim is not to comment on all proposals in the White Paper regarding the development of human resources for health. The basic philosophy underpinning the White Paper’s approach should be commended. An emphasis is placed on the optimal use of human resources and a commitment to training and re-skilling of health workers. The Department of Health should look into ways to incorporate community-based health workers and traditional healers.

    A problem of the White Paper’s approach to human resource development is that it is biased towards developing skills of professional workers, and is silent on training and development for other workers in the public health system. Specifically, no reference is made to Adult Basic Education Training (ABET), which needs to be integrated in education and training policy of the public health system. Training for workers at the lower end of the system is essential to uproot illiteracy and open career paths. Above all, the aim of human resource development should be to bring all human resources on board the strategy of the new health policy. For instance, cleaners and other workers should understand the link between their work and health, in order to regard their work as contributing to the new health strategy.

    Whilst we welcome the commitment to affirmative action to ensure a non-racial and non-sexist public health system, there's a shortcoming in the manner in which it is conceptualized. First, it is important that it is seen as a mechanism to transform the organisation and its culture inherited from apartheid. The White Paper tentatively moves in this direction by proposing that change management programmes should be developed at the national level to facilitate a process of institutional change at all levels. The second condition is that it must have a direct impact on the entire workforce in the organisation. It is in relation to the latter that the conception of affirmative action has a limitation in the White Paper.

    The White Paper's approach is exclusively focused on changing the composition of the management echelon. Changing composition of management structures so that they are more representative is not a problem per se. However, this is not the sole objective of affirmative action.

    Recommendation:

    A related matter is the concept of participatory management proposed in the White Paper. It is important that workers participate in the management of the health system. An appropriate mechanism to effect this should be negotiated with the relevant trade unions.

  5. Occupational health and safety

    6. As the White Paper cogently argues, occupational injuries and diseases have profound effects on productivity and economic and social well being of workers, their families and dependants. The Department of Labour in its five-year programme of action committed government to develop an overall national policy and strategy on occupational health and safety and to create a National Occupational Health and Safety Council. This was in recognition of the fact that South Africa lacks an overall national policy or strategy on occupational health and safety. Further, there are a number of agencies responsible for occupational health and safety issues and their efforts are currently fragmented and insufficiently co-ordinated. In this regard, the White Paper will consolidate the efforts of the Department of Labour to reform the Occupational Health and Safety regulations in South Africa. COSATU supports the principles underpinning the White Paper’s approach on Occupational Health and Safety, viz.:

    In our view the Department of Labour has the primary responsibility to spearhead legislative reform and ensure the prevention of occupational diseases. The Department of Health must provide facilities for the recognition of ill health due to occupational exposure. The envisaged new legislative framework, which makes provision for improved co-ordination of the various components of occupational health and safety is imperative and should clearly delineate responsibility for various government agencies and Departments. The creation of a co-ordinating body along the lines of a health and safety agency with national and provincial components will be supported by COSATU. COSATU further supports the set of proposals which flow from the principles enumerated above.

    These proposals should not exonerate employers from taking the necessary measures to ensure occupational health and safety of workers. In this regard, we welcome the investigation to ensure that the requirement that all workplaces provide occupational health services is fulfilled. The health and safety needs of vulnerable workers such as domestic and farm workers should also form part of the investigation. The emphasis on interdepartmental and inter-sectoral collaboration is also supported. It is important that inspectorates of Departments of Labour and Minerals and Energy Affairs be strengthened to undertake proactive inspections. This will go a long way in ensuring prevention, compliance and early detection of employers who infringe on occupational health and safety legislation.

    In addition, the inclusion of occupational health and safety in the PHC package is important and should ensure accessibility of health services to workers. There must be an investigation as to the relationship between work place based occupational health workers and the entire health system. We believe that more resources should go into the following areas:

  6. Environmental health

    7. Workers have a direct interest in Environmental Health issues. They often face the highest levels of exposure to dangerous substances. They face dangers from toxic substances in the air, water and soil in and around their workplaces. Toxic substances are either used or produced as by-products in many industrial processes. These include most mining and mineral refining processes, oil refining, the chemical and plastic industries, food processing, printing and electronics industries; the clothing and consumer goods industries and agriculture.

    Particulates (dust particles) that can cause lung disease are a danger in many mining operations and in some manufacturing processes. Workers in many industries including agriculture may face physical dangers form machinery and equipment, lack of adequate safety measures and training and badly designed work places. Exposure to noise can seriously affect workers’ health. Workers in the nuclear industry for example face the threat of exposure to radiation.

    Environmental health for workers is not confined to their work environment. Workers are members of communities and are equally affected by industrial pollution faced by communities. Our constituency is drawn largely from communities that lack basic services such as drinking water, latrine facilities and domestic refuse removal/disposal. Thus workers’ health and members of their family is negatively affected by lack of basic services. Therefore, for COSATU occupational health and safety issues are inextricably linked with environmental health issues arising from the work environment, the negative impact of pollution on the natural environment and lack of basic service.

    The White Paper should develop linkages between occupational health and safety and environmental health. The chapter on environmental health exclusively focuses on community environmental health and no clear linkages with occupational health are developed as a result. One of the principles on Environmental Health in the White Paper is that "every South African has the right to a living and working environment which is not detrimental to his/her health and well-being."

    Recommendation:

    Having said the above, COSATU welcomes the principles and proposals on Environmental Health. We emphasize the need to harmonise environmental legislation and policy. This should be driven by the need to overcome the current fragmented and un-co-ordinated legislative and policy framework. Fragmentation arose from the fact that different Acts have sections dealing with the environment and which are un-co-ordinated in that many government departments have responsibilities to implement aspects of these Acts. Whilst the Department of Environmental Affairs and Tourism (DEAT) is the lead department in this regard, the health department can play a significant role in ensuring a coherent environmental policy through interdepartmental mechanisms. The DEAT released a White Paper on "Environmental Management Policy for South Africa" in August 1997. This White Paper provides an overarching policy framework on environmental management.

  7. Infectious and Communicable Disease Control

    8. COSATU supports the view that the prevention, diagnosis and treatment of communicable diseases are essential components of comprehensive primary health care. Thus, we welcome the proposal that TB and malaria diagnosis and treatment services should be available in all primary health care facilities. We also support efforts to ensure that the capacity of the district, provinces, and the national level is enhanced to deal with these diseases. Primarily this will be achieved by ensuring that every district should have a co-ordinator responsible for TB and one for Expanded Programme on Immunization replicated at provincial and national level.

    As many people who develop communicable disease like TB are working, the White Paper proposes that as far as possible, after the acute phase such people should receive treatment under supervision at their place of employment. In order to implement this proposal the feasibility of integrating this within the overall facilities for occupational health in the workplace should be explored. This is particularly relevant in situations where there is no primary health or any health care facility near the workplace.

  8. Conclusion

    9. In conclusion, we thank the portfolio committee for affording us the opportunity to make an input on the White Paper. We raised a number issues and proposal ranging from the governance of the District Health System to occupational health and finance and physical resources for the health system. We hope that the recommendations we raised in this submission will be integrated in the White Paper. We will closely monitor the implementation of the policy proposals contained in the White Paper and we are prepared to engage in further discussion with the department and the portfolio committee on issues raised in this submission or any issue pertaining to health.

  9. Summary of recommendations:



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