Hansard: Debate on Developing an improved Health Care System capable of dealing with National and Regional Challenges

House: National Assembly

Date of Meeting: 28 Jan 2009


No summary available.




Wednesday, 28 January 2009 Take: 26





The House met at 14:02.

The Speaker took the Chair and requested members to observe a moment of silence for prayers or meditation.





(Draft Resolution)

The DEPUTY CHIEF WHIP OF THE MAJORITY PARTY: Madam Speaker, I move without notice:

That the House revives the following item, which was on the Order Paper and that lapsed at the end of the 2008 annual session, for consideration by the National Assembly:

(1) Consideration of Report of Committee on Private Members' Legislative Proposals and Special Petitions (Announcements, Tablings and Committee Reports, 20 June 2008, p 1330 – Legislative Proposal to amend Remuneration of Public Office Bears Act (No 20 of 1998) (Mrs S A Seaton).

Agreed to.





(Draft Resolution)

The DEPUTY CHIEF WHIP OF THE MAJORITY PARTY: Madam Speaker, on behalf of the Chief Whip of the Majority Party, I move the draft resolution printed in his name on the Order Paper, as follows:

That the House –

(1) notes that the Ad Hoc Committee to consider the Criminal

Law (Forensic Procedure) Amendment Bill was due to report

on 23 January 2009;

(2) further notes that the committee has not yet reported on

its mandate;

(3) notwithstanding Rule 214(6)(c), condones the continued

existence of and the work conducted by the committee after

its term had expired; and

(4) resolves to extend the deadline by which the committee is

to report to 13 February 2009.

Agreed to.





(Consideration of Bill and of Report of Portfolio Committee of Transport thereon)

Mr B L MASHILE: Madam Speaker, the committee considered the National Land Transport Bill 2008 in August 2008. The completion of the consideration of the Bill marked a major achievement in the conclusion of the national land transport transitional regime in South Africa. The consideration of this Bill saw a flurry of interested parties making input from different sector perspectives. These included owners, users and authorities of transportation systems.

Considerable time and energy were spent to analyse and incorporate the appropriate and useful input into the legislation. There is consensus in the committee that the maximum benefit has been derived from the variety of presentations made. As the country is mandated to organise the 2010 Soccer World Cup, the provision of transport in general is constantly under scrutiny to ensure successful transportation of goods and the public during the tournament.

The transformation of our public transport system, in the form of taxi recapitalisation and general public transport integration, generates constant consideration of some aspects of the new land transport regime. The committee feels that these emergent new proposals cannot be incorporated now, given the parliamentary legislative processes. We therefore strongly recommend that the Department of Transport, in its wisdom, concede and consolidate these new proposals for consideration by the fourth Parliament.

The difficulty and intense work put into the crafting of this legislation saw a lot of chopping and changing of a number of clauses and text to the extent that the cleaning of the body text was not concluded satisfactorily. The majority, if not all, of the amendments are text corrections and consequential amendments to align to the latter and spirit of the law.

As the Portfolio Committee on Transport we applaud the work done by the Select Committee on Transport on this Bill by ensuring that the final draft is clean of text mistakes. We are in agreement with the consequential changes brought by the select committee.

The Portfolio Committee on Transport is certain that a progressive and transformative piece of legislation is in place to govern the provision of land transport in South Africa. We, therefore, as the portfolio committee, request this honourable House to accept these amendments and consequentially pass the National Land Transport Bill. I thank you.

There was no debate.

The DEPUTY CHIEF WHIP OF THE MAJORITY PARTY: Madam Speaker, I move that the Bill be passed.

Motion agreed to.

Bill accordingly passed.




(Consideration of Bill - Report of Portfolio Committee on Arts and Culture on proposed amendments by National Council of Provinces)

Mr P A GERBER: Madam Speaker, thank you for the privilege to report back to this august House on this very sensitive and emotional Bill. The Bible Society Repeal Act was adopted by the Portfolio Committee on Arts and Culture and then sent to the NCOP Select Committee on Education and Recreation, which adopted it with amendments after consultation with the Bible Society and its lawyers. These amendments are just technical amendments to soften the transition of the Bible Society from a statutory entity to that of a section 21 company.

Many people, especially my colleagues, have asked me over the past 20 months how I got involved in the scrapping of these six old, redundant religious Acts, and may I confess today that two people, miles and poles apart, were indirectly and quite by coincidence responsible for me discovering these old, redundant religious Acts.

The one person was Comrade Winnie Mandela and, without her, I would not have discovered these old Acts. As a Member of Parliament her office was at E444, just above where we are sitting now – not far from my office at E463. When she retired from Parliament the parliamentary cleaners threw all her old books and reports into the passage, as usual. Amongst these was an old set of statutes and, as I can't stand any wastage, I took over the ownership of these statutes which would otherwise have been turned into toilet paper.

The second person was a frustrated sheep farmer from Fraserburg, a Mr van Schalkwyk, who I don't think is related to Martinus, who asked me for information about the Fencing Act of 1963. I had to look this up in Winnie Mandela's statutes which I had picked up from the passage. Going through the alphabetical list of statutes, I discovered the Dutch Reformed Churches Union Act of 1911. I then investigated all the statutes to see how many other religious acts were on the Statute Book. That is how the process of repealing the outdated redundant Acts started 20 months.

It has been the greatest honour for me as a Member of Parliament to have experienced this, to have been enabled to draft, process and have both Houses of Parliament adopt these four private members' Bills of mine. After all, we are legislators. These four private members' Bills, as far as we know, are the only four private members' Bills that have been adopted since 1994, and I hope there will be many more in future.

I would like to thank all Members of Parliament, the parliamentary staff, the parliamentary legal advisers, especially Adv Adhikari, the churches, the NGOs and everybody for their support. It has been a learning exercise and experience for all of us.

Special thanks go to the chairperson of the Portfolio Committee on Private Members' Legislative Proposals and Special Petitions, the hon Vytjie Mentor, the chairperson of the Portfolio Committee on Arts and Culture, the NCOP select committee chairperson and the acting chairperson, the Speaker's office, Mr Doidge's office while he was still in his previous capacity, and Mr Mansura who was very supportive all the way. Lastly, thanks go to the ANC who never doubted my intentions when I started with this process.

To end, the decision to repeal the Bible Society Act was a very difficult decision for me, having grown up in a parsonage as a son of a dominee. But we had to take the state out of the business of the Bible Society. We are actually liberating the Bible Society of SA today. When I bought each of my four young daughters a big proper Bible for Christmas last year, it was good to know that the Bible lying on the shelf of the bookshop was there without state protection or privilege. May the Bible Society of SA continue to enjoy their growth and may the gods bless the whole of South Africa, never mind which book we read. With these words, I put this report to you. I thank you. [Applause.]

There was no debate.

The DEPUTY CHIEF WHIP OF THE MAJORITY PARTY: Speaker, I move that the Bill, as amended, be passed.

Motion agreed to.

Bill, as amended, accordingly passed.




(Consideration of Report of Portfolio Committee on Public Service and Administration)


(Consideration of Report of Portfolio Committee on Public Service and Administration)

Ms M J J MATSOMELA: Hon Speaker, hon members, I would like to table these two portfolio committee reports which are based on the reports of the Public Service Commission.

The first report is on monitoring and evaluation. The Portfolio Committee on the Public Service and Administration received a briefing by the Public Service Commission on its Fourth Consolidated Monitoring and Evaluation Report on 11 June 2008. The focus of the fourth consolidated report was service delivery. The Public Service Commission is perceived as an ineffective structure due to its power to only make recommendations based on its constitutional mandate, hence the portfolio committee's decision to table these reports so that the reports of the Public Service Commission are accepted as reports of Parliament so that we are enabled to enforce them.

The Public Service Commission's findings in the report reflect negatively on the Public Service's ability to deliver services and its embodiment of the nine basic values, as outlined in section 195(1) of the Constitution. There were, however, a few departments that scored above average and, in some instances, scored 100% for specific performance indicators.

The Public Service Commission made many valuable recommendations in this report, and overall the committee was pleased with the report. The recommendations emanating from the report are the following. One, guidelines for public participation in policy-making should be developed by the Department of the Public Service and Administration in conjunction with the Department of Water Affairs and Forestry and the Public Service Commission.

Two, departments as per the Public Service Commission report should put in place a strategy of prioritising skills development activities. The Public Administration Leadership and Management Academy, that we normally refer to as "Palama", should be consulted by the relevant departments.

Three, departments should ensure that planned training is implemented, and that the impact of the training on the enhancement of service delivery is monitored. This, also, should be done in conjunction with the Public Administration Leadership and Management Academy.

Four, a review of the disciplinary codes and procedures should be done with a view to tightening enforcement of disciplinary procedures, specifically related to absenteeism. The Department of the Public Service and Administration should report to Parliament by March 2009 on progress made with the aforementioned recommendations.

The fifth recommendation is that the dispute-resolution time periods, as set out in the disciplinary codes and procedures, should be adhered to by the departments mentioned in the report and unresolved disputes should be resolved as a matter of urgency. Again, in this instance, we would like the Public Service Commission to report before March 2009.

Members of the executive and directors-general of the departments sampled in the Public Service Committee's report should report to Parliament on progress in the implementation of recommendations from the above-mentioned report by the end of March 2009.

The Public Service Commission should report in writing to Parliament by the end of March 2009 on progress made with departmental implementation of recommendations from the Fourth Consolidated Monitoring and Evaluation Report. So, we are expecting reports from the departments, from members of the executive and directors-general and from the Public Service Commission itself.

The Public Service Commission should consider, as part of its future monitoring and evaluation reports, a section dedicated to departmental implementation of previous reports. This will enable us to keep track of the progress being made, to review the recommendations and to make the necessary amendments from time to time.

The committee therefore recommends that the National Assembly adopt the Portfolio Committee on Public Service and Administration's Report on the Public Service Commission's Fourth Consolidated Monitoring and Evaluation Report of 2007.

Regarding the State of the Public Service Report, the committee again received a briefing by the Publication Service Commission on the State of the Public Service Report of 14 May 2008.

The committee's report focused on the findings and recommendations of the State of the Public Service's report per constitutional principle. The basic values and principles governing public administration are set out in the Constitution, Act 108 of 1996, under section 195(1), which states:

Public administration must be governed by the democratic values and principles enshrined in the Constitution, including the following principles:

(a) A high standard of professional ethics must be promoted and maintained.

(b) Efficient, economic and effective use of resources must be promoted.

(c) Public administration must be development-oriented.

(d) Services must be provided impartially, fairly, equitably and without bias.

(e) People's needs must be responded to, and the public must be encouraged to participate in policy-making.

(f) Public administration must be accountable.

(g) Transparency must be fostered by providing the public with timely, accessible and accurate information.

(h) Good human-resource management and career-development practices, to maximise human potential, must be cultivated.

(i) Public administration must be broadly representative of the South African people, with employment and personnel management practices based on ability, objectivity, fairness and the need to redress the imbalances of the past to achieve broad representation.

The Public Service Commission found that overall good progress has been made during the period under review. However, there should be an appreciation of the fact that more needs to be done and that the quality and pace of service delivery should be accelerated.

It was found that the Public Service has sufficient operational experience in implementing new policies. It is important that effective monitoring of performance continues and that action is taken where concerns are identified.

The committee therefore made the following recommendations. Departments identified in the Public Service Commission's report should implement recommendations made by the Public Service Commission in its State of Public Service Report 2008. Progress on the implementation of these recommendations should be reported to Parliament by June 2009. The Public Service Commission should report to the committee the success of departmental implementation of the recommendations made in the State of Public Service Report in writing by June 2009.

The committee recommends that the National Assembly adopt the Portfolio Committee on Public Service and Administration's report on the Public Service Commission's State of Public Service Report 2008. I thank you. [Applause.]

There was no debate.

The DEPUTY CHIEF WHIP OF THE MAJORITY PARTY: Madam Speaker, I move that the Reports be adopted.

Motion agreed to.

Report of Portfolio Committee on Public Service and Administration on Public Service Commission's Fourth Consolidated Monitoring and Evaluation Report of 2007 accordingly adopted.

Report of Portfolio Committee on Public Service and Administration on State of Public Service Report 2008 accordingly adopted.




The MINISTER OF HEALTH: Madam Deputy Speaker, events during the last couple of months, from about mid-November, will convince us that health in South Africa is not just a South African issue; it's a regional issue.

With the advent of cholera, we have seen that what happens in our neighbouring states affects us here in our country. And, as we have always learnt, no country is an island unto itself. So, health is a regional issue; it's a national issue; and it's an issue for each and every one of us – and everyone in this country.

Before entering into this very important debate, I first want to pay tribute to the thousands and thousands of health care workers who, as we speak here today, are providing care and support to millions of people in our country under difficult conditions, with limited resources and for very long hours.

On a daily basis I get letters from people complaining about what happened to them in this or that hospital. I have many MPs coming to me to tell me what their experiences are in their constituencies. Yes, those are very, very valid experiences, and this is what we have to deal with in health. But, let us not forget those thousands of health care workers who are valiantly working with much passion to help our people with their health needs.

I am overwhelmed by the passion and devotion of people in the health care profession. It is perhaps one of the few professions in which there is so much of almost a calling, in which health becomes a vocation, not just a job. Okay, I can see the Minister of Education saying that teachers are the same. We are in agreement, Minister. We have the same projects in mind. Teachers – and, let's add, policemen and policewomen - are people with passion. So, I want to pay tribute to these people in our country who assist us.

But what do we need to do as government, what do we need to do as civil society to assist these people to do their jobs, to assist our people to receive the good quality of care? It is daunting when you look at what we are up against. We inherited a system in which there was, and still is, vastly inequitable access to health care. We have a public health sector that services mainly the poor and we have a private health care sector that services the middle class and the wealthy. Access to quality health care is a constitutional right. It cannot be dependent upon how wealthy you are and what kind of arrangements you can make to access care in the private health care sector.

But let us not just say that health care is bad in the public health care sector and good in the private health care sector. We have all had experiences to know that there is good quality care in the public health sector and, at times, bad quality care in the private health sector. Those who are dependent on the private health care sector face escalating costs because their medical aids can no longer provide the insurance they thought they would get when they accessed them.

Similarly, in the public health care sector, we face a number of huge challenges. Let me start spelling out some of those challenges. I do not want to give promises about how quickly and how fast these will be dealt with. But having spent time in the health care sector, we, as the ANC, have outlined a number of initiatives which we believe are essential for the transformation of the health care sector. Firstly, there are the issues of governance, accountability and strategic leadership. It is very difficult in the health care sector to deal with many, many levels of decision-making. In other words, you have a national Department of Health, you have provincial departments of health and you even have health care at municipal level. There are many tiers of decision-making. In terms of what goes from the equitable share to a province: a provincial treasury makes the decision as to how they will allocate to health care, social development and so forth. So, it may be that the amount you thought would go to health care in a province isn't allocated. That decision is up to the provincial Treasury. A provincial health department has the constitutional right to decide how they will allocate resources.

So, how do we get a national project with national priorities going about the reform of our health care system when we have this multiplicity – these dreaded schedule 4 functions - which put us in difficult relationships with each other? How do we understand accountability in that kind of environment? Take, for example, the Ukhahlamba district and the failure of the health care sector there. I had a very interesting question from an opposition party member who asked: "Minister, what steps are you taking to hold people to account?" I have pondered this time and time again. Who is responsible? Is it the person in charge of that particular health care facility? Is it the person in charge of the primary health care district? Is it the MEC or the head of department of health in the province? Who is it? Until we understand accountability and what that range of accountability means, we cannot talk about an effective, functioning health care system. I have commissioned legal opinion on this matter, on accountability within our health care system because that is an essential part.

But we can't just look at provinces as being particular fiefdoms and at the national department as somehow just being the standard-setting department. We have to look at leadership in the health care sector. We have a provision in the Act for a body called the National Health Council. The National Health Council consists of the provinces with their MECs and their heads of department, and of the Minister, the Deputy Minister and the director-general. This is the agency at which all policy decisions get passed and at which all decisions related to health are taken. This is the engine with which we need to start driving health care reforms and a holistic approach to health care issues.

Finally, when we talk about leadership, we are also talking about a social compact – those people in the health care industry who are represented by unions. We need, more than ever before, a social compact with these unions. There are encouraging signs that the unions themselves are coming to the table in this regard.

Let me quickly go through the other issues. The first issue is that of information systems. We are unable to dig down to get the information we need. At times it is even difficult to know how many people on a daily basis have highly drug-resistant TB. We can't even get that. We have to develop information systems so that we can manage health. We have initiated a patient information system, but that is not enough. This will be a central focus of this department going forward.

The next issue is that of financial management. We know that we are underresourced in terms of the baseline. We know that the cuts that were effected in the health care sector from 1998 onwards have affected us badly. But that does not mean that we abrogate our responsibility for good financial management in the health care system. We need to be able to present focused, good bids when we bid for budgets. This cannot be based on inefficient spending.

The national Department of Health, with the agreement of MECs of health, has already set up teams of people who will be going to the provinces to assist provinces to analyse what the cost drivers are in our health care system. We are experiencing massive overspending in our health care system in all provinces at the moment. Some of it might be due to bad and inefficient financial management. But there are cost drivers there that, I think, we need to uncover and pin down. Because unless we begin to understand what those drivers are, we are not going to be able to fund our system adequately.

We are also setting up a proper donor mobilisation unit in our national Department of Health. There is a wide range of donors that include the US President's Emergency Plan for Aids Relief, Pepfar, and the Global Fund that are able to provide funding, and we need to get our act together in that regard.

The management of our human resources is critical. At the moment, we do not have a national human resource strategy which indicates specific targets for the provision of health care workers according, even, to numbers of our population. How can we plan ahead if we do not know what the basic package of care should be? This package of care is going to be a very important focus. We have to start specifying. I know treasuries don't like it, don't want norms and standards because then they are held to account in terms of what the norms are going to cost. But we need to know because there are far too many vacancies and far too many people who are inappropriately allocated in our health systems for us to be able to take a good view of how well we are delivering.

The reopening of our nursing colleges is very important. So, too, is the placement of our academic hospitals. Are they at the right level – at the provincial level? Do they need to come to national level? Do we need to look at, as the ANC is saying, the decentralisation of management - not the facilities – but management?

The management of our health facilities requires a lot. We established the Office of Standards Compliance in April 2008 which will examine the quality of care in each of our health facilities on a routine basis - every three years. They have already produced reports on 27 hospitals, and this is going to provide us with an invaluable base for understanding what the problems are with our quality of care.

It is not only the quality of health care, but what we call the "hotel factors" - the queues, the lack of sanitation, poor quality food – those kinds of things that our people constantly complain about when they go to health care facilities. There are the difficulties of just standing in queues and waiting and waiting and then having to go to another queue for drugs. And so there is that management. Interesting exercises are being done at Chris Hani Baragwaneth Hospital, which are yielding very interesting results on how we can better manage our health care facilities. There, of course, the social compact with our partners is very important.

The issue of inequity of access is perhaps the primary policy engagement that we have to have. We cannot have a well-funded private sector and a poorly funded underperforming public sector. That is why national health insurance becomes an important policy initiative. I will not go into details about this. But let me assure everybody that on this particular initiative, we will be consulting broadly and very widely and with a wide range of participants, because we have to get this right. We cannot afford to get it wrong. We look forward to lively engagement on this issue, particularly because it is addressed to dealing with inequality of care. Let me say upfront that national health insurance will only succeed if we bring the standards of care in the public health sector up to speed. We cannot have national health insurance with a poorly functioning public health care sector.

The revitalisation of the physical infrastructure of our health facilities is extremely important and we have made good progress on that. More than 249 facilities out of more than 400 hospitals have undergone renovation already. Eighteen new hospitals have been built, of which three are major teaching hospitals. That's a considerable achievement. But we need to then look at how we are staffing these, how they are being maintained.

The accelerated implementation of HIV and Aids policies, the reduction of mortality, and the care around TB and associated diseases are vital ingredients in our health improvement plans. We live under a high disease burden in this country, not only with HIV and Aids – an actual pandemic – but with TB, malaria, and cholera which we are now experiencing.

Obviously, we are very, very blessed to have the National Strategic Plan on HIV and Aids and TB. With all our partners, we have agreed to it in Sanac and now it is up to us to get this plan implemented. We have now set in motion getting a proper secretariat for Sanac. The resource mobilisation committee is now busy with our round 9 proposal to the Global Fund and, hopefully, Sanac will now become an efficiently run organisation that will assist us to drive the HIV and Aids prevention programmes and treatment programmes.

Let me say with pride that with regard to those on antiretrovirals, we wanted to add on, in terms of the National Strategic Plan, 180 000 extra people this year. We have exceeded the target. We are on 216 000 this year, which is a considerable achievement. I wish to congratulate everybody on that.

That means that there are over 700 000 people in our country at this moment who are on antiretrovirals, who do not need to be in our hospitals, who have the possibility of a good life ahead of them, who can care for their loved ones. That is what we want to focus on: getting people onto those antiretrovirals, but at the same time prevention is extremely important. We will be driving the prevention of mother-to-child transmission programmes with a great deal of energy and vigour.

We have identified 18 primary health care districts that are performing poorly, not only in terms of PMTCT but also in terms of health delivery. We have teams of people there at the moment who are isolating what the problems are and preparing us for a massive uptake in the prevention of mother-to-child transmission.

But let us not forget that these are not the only illnesses we have to deal with. We have lifestyle diseases – heart disease, stroke, diabetes, hypertension. How many people in our townships at this moment are suffering from hypertension alone? How many people in this room alone are suffering from hypertension? [Interjections.] Yes, I'm sure the DA is suffering from hypertension. [Laughter.] We need to have mass mobilisation around healthy lifestyles. We need to look at the position of our people who are disabled. Are they getting the quality of care that they need?

Finally, there is our drug policy. There is a lot that we need to be doing around our drug policy. Do we need our own home-based pharmaceutical industry? What is our procurement policy? Are we doing things right?

I'm sure there are a lot of other things that we can speak about. But what I do want to speak about is the necessity for us all to join hands around improving our health care facilities in this country. I have been struck by the activism of our opposition parties with the number of questions they file in Parliament to the department. This actually makes for very instructive reading and often alerts you to where some problems lie. I look forward to an engagement – a constructive engagement – with our opposition to see what it is that we can do better. Every MP here has a constituency office. Every MP here has contact with health facilities in their area. And, in future, we would want to be able to receive accounts from them about what we should be doing to improve our health care facilities - and then out there, in civil society, everybody must come on board. We want everybody to be involved. We want everybody to know that they have a role to play. And may we, in the years to come, thrive and prosper with a growing and improving health care delivery system in our country. Thank you. [Applause.]



Mr M WATERS: Thank you, Deputy Speaker. Hon Minister and members, how refreshing it is to hear the new Minister of Health speak compared to the previous Minister of Health. The South African health environment is vastly better today than it was six months ago. We now have a Minister of Health who recognises that HIV/Aids is a real disease and who does not dismiss the problems of our hospitals and clinics as the hysteria of opposition parties. The doctors and nurses and other health professionals who work so hard every day to provide the best service they can now know that they at least have a Minister who is working with and not against them.

Many organisations and individuals have expressed their enormous relief at this change and have made themselves available to help make our health system work better, which the Minister has just appealed for. The DA shares this relief and we too will do everything we can to help our system get back on track. The DA intends to run, at least, the Western Cape after this year's elections. We have a range of policies which will make a substantial difference to the quality of care in our public hospitals. But nothing shows how far we still have to go than the cholera outbreak which the Minister mentioned. This has, so far, killed more than 30 people in our country and does not seem to be under control.

Cholera is an easily treatable disease from which no person should ever die, but a basic rehydration mixture, costing only a few cents, is not getting to people who are sick. We must remember that the rehydration mixture is basically a primary health care responsibility, primary health care that this government has been prioritising for over 10 years but which still cannot ensure that clinics have simple medication.

It is a hard reality to absorb that the life expectancy in South Africa is now 12 years lower than it was in 1996 and that our maternal mortality is worse than Iraq's. In fact, we are one of only 12 countries in the world where the infant mortality rate is actually increasing.

So what can we do? I would like to highlight three of the DA's priorities. The first is to improve the management of hospitals and clinics. With all the money in the world, no health facility can work without a capable, qualified, committed and dedicated manager. There are many hospital CEOs and clinic managers who do exceptional jobs. There are many others who have benefited from the ANC's closed, patronage approach.

I would like to give an example. The CEO of the East London hospital complex is a previous ANC councillor with no qualifications in administration and is responsible for a budget of over R170 million a year. He is also responsible for the dilapidated state of affairs at Frere Hospital which the then Deputy Minister of Health and now the Deputy Speaker went to see for herself and who said that nurses were playing God deciding which babies should live and which should die. In fact, in one year 199 babies were stillborn in that hospital.

Questions to replies the DA has asked about hospital CEOs from across the province show that many others also lack the knowledge and skills required to run a proper hospital. In any province the DA controls after this year's election we will make it a priority to audit the qualifications of all health facility managers to ensure that they have the skills that the patients need. We also undertake to regularly evaluate the quality of services that our hospitals and clinics provide, as the Minister has also mentioned. We call on the national department to expand the evaluation of services in the 27 hospitals already done.

Our second priority is human resources. I do not have to mention the figures. We all know how dire it is and that many hospitals and clinics face devastating shortages. In any province the DA takes over, we will embark on a vigorous international recruitment drive to attract foreign health professionals. We would like to see the Minister of Health taking some of these steps.

For example, it is outrageous that the Health department restricts the number of nurses that can be trained in the private sector. Along the same lines, a policy decision that prohibits private medical schools is in place. There are a couple of examples around the world where successful public-private partnerships in developing countries can be looked at. It would cost nothing for us to lift these prohibitions.

In addition, it would also cost us nothing to include medical professionals on the Home Affairs database scarce skills list. What it would do is to enable us to attract them and get them into the country a lot faster. I know of some nurses who have waited over two years to be allowed to work in the country.

The DA would also utilise the private sector to reduce the long queues at hospitals by allowing patients to choose for themselves which pharmacies they would like to collect their repeat medication from. Currently, tens of thousands of people have to take a day's leave in order to collect their medication.

There is more hope for real improvement to our health system now than there ever has been. The DA and its health MECs, after the election, look forward to work with you to transform this hope into reality. I thank you very much. [Applause.]



Dr R RABINOWITZ: Deputy Speaker, hon Minister, around the globe health care has similar challenges, and whether it is Democrats under Obama or socialists under Motlanthe governments must opt for solutions that work. Essentially, challenges relate to reducing health costs and corruption and increasing access and quality of care.

More specific issues of Aids, TB, malaria and cholera must be addressed here in which our public sector is constantly under threat of collapse and in which the private sector people are paying more, often for less. How to respond?

A healthy lifestyle is the cornerstone of preventive primary health care. As in the East, let's organise daily workouts in public spaces, switch off TVs and mobile phones and switch on sports, music and art in schools and in our homes. Let's immediately ban trans fats as proposed in my private member's Bill agreed to by the department and by the private members' legislative committee. They are produced for commercial gain and contribute to heart disease, diabetes, weight gain and cancer.

To ensure quality treatment, let's register conventional doctors, homeopaths, acupuncturists, chiropractors, naturopaths, Ayurvedic and Chinese doctors through a single, independent democratically elected, medical council. A traditional healers council should deal only with herbalists, surgeons and birth attendance, not abaprofethi [prophets] and sangomas whose work on a metaphysical dimension cannot be monitored or controlled.

We must ensure that at national and regional levels formal structures exists to provide for co-operation and collaboration between all these health professionals. This should follow through into working groups and research teams that tackle issues like Aids, TB, malaria and cholera regionally and locally.

Hon Minister, we welcome and support many of your initiatives. I will dwell on our differences. Let us scrap the most damaging of our failed policies, the centralised model with unfunded mandates, bureaucratic conditional grants - the idea that one size fits all. It is confusing and lacks accountability and should be simplified and decentralised.

Let national government establish frameworks and minimum standards. Let provincial and local governments control funds and choose priorities. Then hold them accountable. Let discipline be meted out close to where doctors and nurses work; build stronger health districts and improve co-ordination between hospitals, clinics, mobiles in rural areas and between these schools and local police; install integrated information system - here we agree with the hon Minister. Let us remove constraints that prevent districts and hospitals from negotiating partnerships with the private sector or working with NGOs and international donors.

Currently, most NGO funding is politically motivated, weakening the impact it has on major epidemics in South Africa. To improve access to quality care let's embrace public-private partnerships, PPPs; contract the private sector to run mobile services in rural areas and to manage clinics or hospital works and to train nurses; do away with licensing according to need - it is subjective and open to patronage and corruption. Rather, we should draw health workers to underserved areas through incentives which achieve more than coercion.

The greatest burden on public hospitals is HIV and TB. Here, the IFP also suggests major changes. Let us treat HIV like an ordinary disease without special secrecy provisions. Testing should be the norm with an opt-out provision for those who refuse it. Let us change the focus of rights from privacy to nondiscrimination. The excessive pro-focus on privacy adds to the culture of denial and gives people the sense that HIV is something to be ashamed of.

How do we reduce medical costs? Require all who work to pay a percentage towards a medical scheme of their choice with a low-cost option offered by government. Enforce caps on medical-scheme administration fees which enable schemes to hide huge profits.

In hospitals, let government hospitals establish private wards and retain profits. Let government reduce costs by bulk buying of private services for registered patients, paid for per day or per capita or per procedure. Where medicines are concerned, enforce transparency along the entire chain of medicine supplies. [Time expired.] Thank you.



Mrs C DUDLEY: Thank you, hon Minister. Deputy Speaker, at the heart of all measures to improve the South African health system and making it more accessible is the issue of transforming it from a fragmented and inequitable system to a health system that is integrated, inclusive and responsive to the needs of all South Africans.

Primary health care services are the backbone of health care, and equity, effectiveness and efficiency in the provision of these services are critical to the functioning of the entire health system. A stronger multisectoral approach is urgently needed as rural health care has often been compromised by lack of infrastructure and services such as roads, water and electricity. Hopefully, integrated municipal development plans will offer some solutions.

Of course, health systems remain severely underresourced despite interventions such as recruitment of health professionals from outside South Africa, community service in underserviced areas and rural and scarce skills allowances.

Migration of skilled workers from developing to more developed countries remains a very real challenge, and efforts to counter the situation must be reviewed and intensified along with innovative measures to train health care aids to assist professionals in communities. Disparities in salaries and service conditions between health workers in provinces and municipalities - and disparities in quality of service as a result of inequitable distribution of resources - must also be addressed.

Reliable and timely health information is essential and sufficiently strong and effective systems are not at present in place. We need dedicated health information services personnel at hospitals,

subdistrict and district levels, relevant skills development, staff training and ongoing support in all areas of health information systems.

Lastly, HIV and Aids place enormous pressure on all aspects of the national health system and must not continue to be just a funding priority, but must be recognised as the national emergency that it is. When we stand in any of our hospitals that are struggling with no beds, people queuing, people sitting, people on floors and health professionals depressed and stressed, we obviously realise the emergency in a much more real sense. Thank you.




Ms S RAJBALLY: Madam Deputy Speaker, poverty has left its scars on every aspect of South African's lives. It has indeed been this democratic government that has churned its wheels to eradicate poverty and diminish its effects on living in our country.

However, like most countries plagued by the challenges of poverty, severe health risks and health problems exist. With the coming of a new regime, there are great expectations that the country's problems will be wished away by the wave of a wand. But, in time, when the changes do not meet the expectations, we are met with impatience and intolerance.

The MF believes that the department's focus has primarily rested on making health more accessible to South Africans, especially those from previously disadvantaged backgrounds. And we cannot argue that many have gained this access.

However, the challenges of minimum resources and areas that still do not have access to adequate health systems still remain. It is time for us to get back to our drawing board and address our challenges so that our soon-to-follow Budget Speech by our hon Minister of Finance, Trevor Manuel, will include special funding to address these shortfalls and challenges.

The MF has full confidence in our new hon Minister of Health and her abilities to steer South Africa to better and more accessible health care facilities. We feel that each province comes with its own challenges, and we expect these to be reported to us and for much more oversight to be done by Parliament so that we work efficiently at tackling the country's health issues and assist the department in its endeavours in the health care. I thank you, Madam Deputy Speaker.




Mr L M GREEN: Deputy Speaker, I wish to commend the Minister of Health for her open and frank input here this afternoon. My input starts by way of saying that despite improvements in living conditions over the past decade, the health of South Africans has worsened, according to the South Africa Health Review. It doesn't have to remain like that, but that's the status as we see it.

The World Health Organisation has warned that in times of financial crisis, people tend to turn to bad health habits, such as alcohol, tobacco and drugs as a measure of coping with such times.

A concern has also been raised by the World Bank that about 60 million people will be exposed to severe poverty if economic growth in developing countries is halved during the year, which is a possibility.

According to the South Africa Health Review published last year, the overall health of South Africans has worsened considerably. HIV/Aids is, of course, the major cause of our country's worsening health. The three main factors that impact on our nation's health and mortality rates are unsafe sex, interpersonal violence and alcohol abuse.

The FD, a member of the Christian Democratic Alliance, the CDA, suggests that there is a need for increased public education targeting bad behaviour patterns in an attempt to limit those factors of concern. Considerably more must be done to improve public health funding so that it keeps pace with rising inflation, and district health services in poorer areas must invest more funds to meet the growing demands of its people.

In conclusion, the FD feels that an intersectoral approach is required since the first line of attack is to reduce the impact poverty has on the behaviour of all our people. I thank you. [Applause.]




Mr S SIMMONS: Deputy Speaker, hon Minister, the challenges of the health care system are not limited to the national and regional structures. This government has, since day one, embarked on prioritising primary health care and rightfully so, I believe.

It therefore goes without saying that one depart with an analysis of the primary health care system. It is clear that the primary health care service has efficiency problems, putting immense pressure on the national and regional health care systems. Sometimes the solution lies in simple, yet effective, planning.

I wonder if the hon Minister is aware of the fact that even before the poorest of the poor can get to a clinic, they have to stand outside these clinics most of the time, from as early as five o'clock in the morning, and half of them are elderly or sickly people - a situation that flies in the face of the ANC government's promise of a better live for all.

The NA wishes to share its concrete and practical approach to problem solving. To the hon Minister: this situation can be addressed by simply introducing a delivery system for those patients receive the same medication every month. This will alleviate pressure on clinic staff and allow them to attend to patients that need immediate and urgent medical attention.

I trust that the hon Minister will seriously consider this proposal in the spirit of ensuring a better live for all. I thank you. [Applause.]




Mrs S V KALYAN: Minister, your speech was very much like the vitamin B12 cocktail, an inspiration and, I hope, an immune booster and an injection of hope. A senior colleague of mine on the opposition benches said this was the first time he could remember the opposition applauding the Health Minister.

Aids treatment and prevention pose some of the greatest challenges to our health care system. Currently, at least 16 000 new people go onto antiretroviral medication every month. Access to medication is a human rights issue.

The MEC for health in the Free State, the hon Belot, is violating this right as we speak because, despite a R9,5-million transfer from Treasury, no new persons from the Free State are on antiretrovirals, and baseline blood work for people living with HIV and Aids has been suspended since November 2008. Other medicines are also in short supply, no explanations are forthcoming and his silence and inaction on the issue only make the situation worse.

You alluded to taking legal opinion earlier and I hope that it becomes available quickly, because, in my books, the MEC is accountable.

Last year in South Africa, 64 000 children under the age of five died, and one in seven deaths were Aids related. Currently, fewer than 30 000 children are on treatment, and it has been proven that effective mother-to-child-transmission interventions can significantly reduce the infection rates by 50% to 90%.

Minister Hogan, you have been referred to as a breath of fresh air, but fresh air alone cannot save lives. Access to medication can. I was stunned to hear at a recent seminar on HIV and Aids that five years ago a month's supply of ARVs cost R10 000, but that it now costs the state R250. So the question is not about affordability, but more about accessibility.

HIV and Aids affect the economically active population, drain human and financial resources, affect livelihoods and cause child-headed households. The stigma and discrimination generated by this disease was starkly highlighted by the desperate tragedy of the mother in Lusikisiki who murdered her four children and then committed suicide because she could not deal with the whisperings in the community about her status. In view of this, it is the considered opinion of the DA that a deputy ministry for HIV and Aids is vital so as to deal holistically and yet specifically with the pandemic.

We in the DA also echo the Speaker of Parliament in calling on all public representatives to encourage a culture of knowing your status. We firmly believe that if you know your status, you can make informed decisions on managing your health.

Minister, several months ago the DA wrote to the Department of Health requesting a list of sites authorised to provide prophylactic treatment for rape survivors. There has been no response to date. I appeal to you to today to publicise this information so that any person who is raped will have access to antiretrovirals. As an MP I cannot access this information, so can you imagine then the trauma a rape victim goes through as they go from clinic to clinic looking for an authorised site?

In conclusion, I support the call by the Deputy Speaker for a crossparty committee in Parliament, specifically to address issues on HIV and Aids and I echo the Minister's acknowledgement of the many dedicated health care professionals. I hope that you will go one step further, Minister, and that you will inspire those health care professionals who have left the country to return home. Thank you. [Applause.]



Mr A F MADELLA: Madam Deputy Speaker, Deputy President, Ministers and Deputy Ministers, hon members, officials of the national Department of Health, distinguished guests, "dames" and "here" [ladies and gentlemen], firstly, let me to take this opportunity to wish everyone an excellent 2009 characterised by good health and happiness.

The recent cholera outbreak that has hit our country is noted with grave concern by the ANC. We wish to express our sincere condolences to everyone who has lost a loved one: a mother, a father, a child, a brother, a sister or a friend to this dreadful disease.

A few days ago, to be exact on Monday, 26 January 2009, the national Department of Health indicated that a total of 6 202 cases of cholera were reported across all nine provinces. The provinces with the highest number of reported cases were Limpopo with 3 045; Mpumalanga with 2 922; the Western Cape with nine, although I think the figure is now 11; the North West with seven - this is the province that the DA hopes to govern, but I have bad news for them as they will still be in the opposition in a few months' time ... [Interjections.] They will continue to be in the opposition. [Interjections.] In KwaZulu-Natal there were two cases, and the Eastern Cape, the Northern Cape and the Free State had one case each. A total, hon Waters, of 44 people died as a result of this dreadful disease. Twenty-nine were from Mpumalanga whilst 11 were from Limpopo. Three were from Gauteng and one was from KwaZulu-Natal. Statistically, we can say that KwaZulu-Natal is the worst off province, with 50% of its cholera patients dying, but that would be mischievous because they have had only two reported cases of cholera.

What is cholera? How is it transmitted and who is at risk? Cholera is a waterborne disease and is generally considered to be an acute illness that results in profuse watery diarrhoea caused by the bacterium Vibrio cholerae, an organism that lives in fresh water.

According to the distinguished professor Willem Sturm, head of the Medical Microbiology and Infectious Diseases department at the Nelson Mandela School of Medicine in Durban, there are more than 60 strains of cholera, but only two of them are deadly or cause diarrhoea. The two strains are called serogroups 01 and 0139. Serogroup 01, importantly, is prevalent in Africa – and this is probably what we are confronted with at the moment. The other strain is more prevalent in Asia.

It is said that under normal circumstances your body, with specific reference to the stomach, absorbs water and nutrients from the food you eat and drink. However, when infected with cholera, the opposite happens. The toxin released by the bacteria causes increased secretion of water and chloride ions from the intestine, which result in watery diarrhoea. Instead of absorbing water you are losing water. If the diarrhoea goes untreated, death can result from severe dehydration and shock.

The national department presented clinical guidelines on cholera infections. The following signs and symptoms characterise this dreadful disease: its onset is very sudden; the diarrhoea is profuse; the dehydration occurs very rapidly; and, of course, all complications result from the effects of loss of fluids and electrolytes in the stool. Vomiting, muscle cramps, acidosis, peripheral vasoconstriction, and ultimately renal and circulatory failure may occur if treatment is not given timeously which could lead to death.

Cholera can be transmitted through the following means: drinking water – and this is important - that has been contaminated, through contaminated food, by soiled hands and, of course, through fish, particularly shellfish taken from contaminated water and eaten raw or insufficiently cooked.

As said before, cholera is usually transmitted through contaminated water and food and remains an ever-present risk in many countries. It occurs especially in parts of the world where water supply, sanitation, food safety and hygiene are inadequate. These kinds of characteristics are more common in developing countries such as ours. Our beloved South Africa has experienced outbreaks of cholera.

Without a doubt the people most at risk of contracting this disease are the poorest of the poor - those living in conditions in which there is limited or no access to safe piped water and to adequate and proper sanitation. Those who still have to access water for their daily consumption from rivers and streams are most at risk of falling prey to this disease.

The World Health Organisation argues that the treatment of this disease is straightforward: basically, rehydration, and believes that if applied appropriately, it could keep fatalities to the absolute minimum and even prevent them. It further states that in the long term, improvements in safe water supply and adequate sanitation are the best means of preventing cholera. In the case of a cholera outbreak, the best control measures include the early detection of cases and treatment of patients.

Improving the socioeconomic conditions of our people – and I'm happy that many of the speakers have made reference to this - to prevent communicable diseases is our number one priority. Indeed, the areas worst affected by the cholera outbreak, the Mpumalanga and Limpopo provinces in particular, have communities that are still plagued by conditions in which they have limited or no access to safe piped water and are forced to fetch water from streams and rivers.

As the ANC we acknowledged with pride the enormous progress our government has made over the past 14-odd years in delivering safe drinking tap water to millions of our people who, under the yoke of apartheid, were denied this right. We also acknowledge the progress made in eradicating the bucket system prevalent in the main amongst the poorest of the poor. Eighty-eight percent of our population today have access to safe drinking water delivered through pipes to their homes. Eighty-eight percent and more do not have to go to rivers and streams to fetch water.

Sanitation has also improved tremendously over the same period. In 1994, when we came into government in this country, 609 675 households used the bucket system, whereas by June last year it was a mere 14 812. Indeed, the complete eradication of the bucket system is about to become a reality. These measures by our government intend to improve the quality of life of our people and, indeed, continue to create conditions for a better life for all.

Our ability as a country to contain the cholera outbreak tells us in no uncertain terms that though we have done well, we must do more.

We are absolutely, resolutely committed to doing more. In the coming period we have set our sights on achieving the following objectives, as outlined in our election manifesto: the continued democratisation of our society based on equality, nonracialism and nonsexism; national unity in diversity which is the source of our strength; building on the achievements and experiences since 1994; an equitable, sustainable, and inclusive growth path that provides for decent work and sustainable livelihoods, education, health, safe and secure communities and rural development; targeted programmes for the youth, women, workers, rural masses, and people with disabilities; and, of course, a better Africa and a better world.

As the ANC we acknowledge the many achievements in improving access to health care and we would be the first to say that much more still needs to be done in terms of quality of care and ensuring better health outcomes. The hon Minister has referred to this.

We will continue to work towards reducing the inequalities in our health system, to improving quality of care and to bettering public health facilities. We will also continue, even after the elections when we are returned with an even larger majority, to boost our human resources in the public sector, increasing our onslaught against HIV/AIDS and other diseases. [Interjections.]

As the ANC, we can confidently say that through implementing programmes to achieve these noble objectives, we will be able to avoid incidences such as the cholera outbreak we are currently confronted with.

The short answer to the question, hon Deputy Speaker, as to whether we are capable of dealing with this particular health challenge, the cholera outbreak, is yes - a resounding yes. International organisations, such as the Red Cross, have declared that we have successfully contained this dreadful disease. This is a clear and unambiguous vote of confidence in our government, our Ministry of Health and everyone that assisted in fighting this disease.

This outbreak of cholera occurred in Zimbabwe, as the Minister has indicated, in mid-October 2008, and within weeks areas bordering Zimbabwe became prone to this infection. We want to stress that cholera is spread by water and not by people. We cannot, and we should not, fall prey to blaming people for this disease. We must understand that it is spread by water.

We have noted with immense pride the speed at which our government has acted to contain and prevent the disease from causing more harm. In this regard, we wish to salute the Minister of Health Comrade Barbara Hogan and her team of experts, officials from the national Department of Health, the National Institute for Communicable Diseases, the World Health Organisation, local and international nongovernmental organisations such as the SA Red Cross Society, the private sector, in particular the Hospital Association of SA, together with other officials from provinces, municipalities and all other role-players, and especially members of the affected communities who collectively worked around the clock to address this disease.

The president of the ANC, the hon Comrade Jacob Zuma, accompanied by the Minister of Health, Comrade Barbara Hogan, visited the Musina area in Limpopo yesterday to apprise themselves of the good progress being made, and to demonstrate ANC and government support and commitment to all those who have been involved in the fight against cholera and to the struggle for quality, accessible and free health care for all.

As the ANC we strongly believe that rallying behind government's efforts to deal with this outbreak is the right thing to do. Stopping this outbreak and eradicating all symptoms of cholera must become a collective effort. [Time expired.] Thank you very much. [Applause.]

The SPEAKER: Order! Hon members, I wish to recognise the presence at this important debate of the Deputy President of the Republic. Thank you, Ma'am, for attending this debate. [Applause.]

Debate concluded.

The House adjourned at 15:21.



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