COSATU Submission on the White Paper for the Health System
Presented to Portfolio Committee on Health
20 March 1998

1. Introduction
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
District Health System
The District Health System (DHS) is the main vehicle for the realisation of the primary health approach envisaged in the White Paper. In our view, the DHS, working within a nationally coherent framework, will be more responsive to community needs. The White Paper proposes three options for a system of governance for the DHS, viz. provincial option, statutory district health authority option and the local government option. These options are a response to the reality that a single system of governance may not be feasible at least in the short term. The implementation of the DHS has got off the ground with 49 health regions and 180 health districts already demarcated. A Bi-ministerial Task Team, consisting of the Department of Health and Constitutional Development and Provincial Affairs has been established. In spite of these efforts, the establishment of the DHS has raised serious questions especially on the role of local government in implementing the health strategy. In view of the fact that a White Paper on Local Government has been placed on the table, a new Local Government Bill may only be introduced late this year or early next year.

Recommendations:
Discussions with local government need to clarify the issues of boundaries and ultimately governance of the DHS. The role of the provincial government should be clearly articulated. Such discussions should also involve other stakeholders.

An investigation of the present DHS should be launched to inform these negotiations. The broad aim of the research would be to determine how different spheres of government have related to the existing DHS, and what approaches have been most effective.

As proposed by the NPPHCN, municipal health services should be clearly defined and a basic package of district health care, including a national framework of minimum norms and standards, should be developed.

Community Participation
Notwithstanding the commitment for community involvement in the health system, the role and function of the Community Health Committee (CHC) is not clearly spelt out. In particular, the White Paper is not clear as to what are the powers of the CHC vis a vis the DHS. This renders the CHC powerless and unable to effect changes.

Recommendation:
The Department should create an enabling environment for the CHC by clarifying their role s and powers and through adequate training and resource allocation.

3. Financial and Physical Resources
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 our view conditional grants have to be restructured to encapsulate primary health care expenditure in addition to the hospital component of the grants. Alternatively, a mechanism will have to be found to empower the National Department of Health to ensure that provinces allocate adequate and essential resources to implement the national health programme.

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.

Social Health Insurance
COSATU supports the principle of access to free health care at the point of delivery. The proposal to introduce the Social Health Insurance (SHI) is essentially about realizing this goal for workers and their dependants. We note that there are forces in society bent on obstructing the introduction of the SHI and the transformation of the health system in general. Details of the Social Health Insurance are still subject to discussion and COSATU will participate in such discussions. These are therefore initial comments.

Initial scrutiny of current proposals gives rise to a number of concerns pertaining to the SHI. Firstly, the proposal as it stands in the White Paper excludes those in the informal sector from contributing. It is important to eradicate the free-rider problem by those outside the formal sector.

Secondly, whilst the White Paper states that all formally employed people be insured for the costs of treatment of themselves and their dependants in public hospitals, it is not clear whether existing medical scheme members will contribute to the SHI. The scheme will be rendered problematic if it allows medical scheme members to opt out. This will reduce the pool of contributions to the lowest paid, thereby cutting the extent of cross subsidization and redistribution. The system of contributions should be progressive and ensure that society across the board contributes to the public health system, according to their income.

Thirdly, there is no clarity as to the management of the SHI. It is not clear whether it will be state-run or it will be handed-over to a private administrator, such as a medical aid scheme. This would create obvious conflict of interests. An administrative model needs to be designed to contain administrative costs without undermining the credibility of the SHI. Another cost consideration to take into account flows from the notion of shared contributions between employer and employee. While COSATU accepts the need for workers and employers to contribute, this should be combined with the allocation from the fiscus. There is a need for a balance between fiscal contributions and the SHI to avoid this acting either as a disincentive to employment, or a progressive reduction in fiscal allocations.

Fourthly, the vision of SHI needs to be integrated with the goal of developing a comprehensive social security system. SHI should positively contribute towards the long-term goal of moving away from medical aid schemes towards a National Health Service, which provides comprehensive care for the whole population, including the employed and the unemployed. Such a national health care service should be funded by allocations from the fiscus and contribution by employers and employees. Measures need to be introduced such as a prohibition on compulsory medical aid membership as a condition of employment.

A broader concern is that SHI may be conceived as a countervailing mechanism to cuts on health as a result of fiscal austerity. This will be inappropriate and will place undue pressure on workers in particular. If the macroeconomic programme compromises government policy, then the programme should be changed, rather than transferring the burden to workers.

Having said this, COSATU supports the principle of the SHI as a way to improve the quality of the public hospital service and as an incremental strategy to move away from reliance on private provision of health care, as long as it takes the above concerns into account. We will comment in detail at a later stage.

Public / Private Mix in South Africa
The premise, from which we move is that in order to ensure universal access and redress past imbalances, South Africa requires a strong public health sector. At present about 60 per cent of all health spending is in the private health sector, which serves only 23 per cent of the population. Most health personnel except nurses work in the private sector (e.g. 60% of doctors and 93% of dentists). It is in response to this anomaly that the White Paper proposes bringing private health practitioners within the public sector framework to provide services on behalf of the public sector where it lacks capacity. The proposal in itself is not problematic; however, the basic goal should be to enhance the capacity of the public health system to deliver affordable quality care to all South Africans. This should be an explicit goal of health policy, as we do not accept the perpetuation of the current imbalances where expensive private health care absorbs the lion's share of resources. There should be a conscious strategy to move systematically towards a public health care system and away from private provision.

We concur with the White Paper that any contracting-out to the private sector should be carefully thought through to address particular objectives. For instance, roping in the private sector as a mechanism to extend services to communities where service delivery is hampered by lack of public facilities. The proposed strategy for accreditation of Private Providers to serve patients may serve to ensure that services are extended to communities, which lack public health service. Contracting-out to the private sector should be subject to the conditions laid out in the White Paper (p.50).

Recommendation:
Measures should be implemented to prevent and contain costs. The public sector should have a concrete plan over time to build its capacity to provide services that are contracted-out to the private sector.

We welcome the proposal for a set of regulatory mechanisms required to reverse the current deregulation of the private health insurance market, which has resulted in serious instability, increasing costs and reduced coverage. We look forward to contributing to the debate once amendments to the regulations under the Medical Schemes Act have been worked out. We further support the need for tight regulation of conditions under which hospital licenses will be granted with the objective of maintaining the current ratio of hospital beds between the public and private sector and shifting resources to the public sector.

4. Developing human resources for health
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:
Affirmative action programmes should encompass the entire workforce in the health system in line with the approach of the Employment Equity Bill. In this vein, affirmative action should integrate strategies to close the apartheid wage gap in order to achieve wage equity. This must be linked with flattening of hierarchies in the workplace. These issues are part of the agreement in the Public Service Bargaining Chamber and should be reflected in health policy. The health sector should comply with the Employment Equity Bill once it is passed.

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.

Redeployment of Staff
The implementation of the DHS is inevitably going to involve redeployment of staff. In principle the White Paper is committed to ensuring parity in conditions of service for all public sector health workers. This is welcomed and it should be emphasized that in the process of transferring staff their conditions of service should not deteriorate. In the event that there are disparities in working conditions between provinces and local government, for example salary scales, this will retard the process of redeployment.

Another limitation is the absence of a formal agreement on how the redeployment of staff will be implemented. It is important that such an agreement is put in place and the Department of Health should discuss with trade unions on this question. A prerequisite for the agreement is a needs analysis/audit of areas where staff should be deployed to ensure equitable redistribution of human resources. The agreement should make it compulsory for management to consult with the affected workers and their unions.

Recommendation:
An agreement on redeployment of staff should be negotiated with representative trade unions. The agreement should make it compulsory for management to consult with the affected workers.

To protect the deployment process from abuse, there should be agreement that it will not be used as a cover for promotion or a mechanism to victimize staff through demotion. There should be agreement on which levels in both spheres of government can be considered equivalent. This should be linked with creating parity in working conditions.

These issues around redeployment raise a broader question of how collective bargaining is to be conducted in the DHS? There is no clarity as to whether collective bargaining will still be in the Public Service Bargaining Chamber or in the proposed local government collective bargaining arrangements. This flows from the uncertainty surrounding the governance of the DHS.

Recommendation:
We therefore recommend that the bi-ministerial process also clarify the question of how collective bargaining will be conducted for health workers within the decentralized DHS. The relevant trade unions should be consulted.

Inculcating a caring ethos
COSATU supports the development of a Charter of Community and Patients' Rights proposed in the White Paper, geared towards inculcating a caring ethos in the health system. Without preempting its content, the Charter should integrate the constitutionally guaranteed right to administrative justice and to access information. COSATU will participate in efforts to develop such a Charter and it is imperative that space be created for participation of the labour movement and other community organisations including NGOs.

5. Occupational health and safety
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.:

Effective interdepartmental co-ordination and organisation of the various components of occupational health and safety;

The development of occupational health services and associated human resources at national, provincial regional and district level;

Norms and standards for a healthy and safe working environment to be developed in collaboration with other departments;

Benefit examination for the identification of compensable disease in former mine workers should be extended to under-served areas; and

The harmonious development of occupational health and safety across Southern Africa.

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:
Recognition of disease;
Increasing the capacity of the National Centre of Occupational Health;
Treatment of disease;
Co-operation with other departments;
Training for all health personnel to assist workers with compensation claims; and
Training of all health personnel should include occupational health.

6. Environmental health
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:
In order to develop the linkage between environmental health and occupational health we recommend that there should be cross- reference to occupational health in the environmental in the introduction of the environmental health chapter. This should outline the impact on workers' health from work and living environments.

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
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
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:
Discussions with local government need to clarify the issues of boundaries and ultimately governance of the DHS. The role of the provincial government should be clearly articulated. Such discussions should also involve other stakeholders.

An investigation of the present DHS should be launched to inform these negotiations. The broad aim of the research would be to determine how different spheres of government have related to the existing DHS, and what approaches have been most effective.

As proposed by the NPPHCN, municipal health services should be clearly defined and a basic package of district health care, including a national framework of minimum norms and standards, should be developed.

The Department should create an enabling environment for the CHC by clarifying their roles and powers and through adequate training and resource allocation.

In our view conditional grants have to be restructured to encapsulate primary health care expenditure in addition to the hospital component of the grants. Alternatively, a mechanism will have to be found to empower the National Department of Health to ensure that provinces allocate adequate and essential resources to implement the national health programme.

Measures should be implemented to prevent and contain costs. The public sector should have a concrete plan over time to build its capacity to provide services that are contracted-out to the private sector.

Affirmative action programmes should encompass the entire workforce in the health system in line with the approach of the Employment Equity Bill. In this vein, affirmative action should integrate strategies to close the apartheid wage gap in order to achieve wage equity. This must be linked with flattening of hierarchies in the workplace. These issues are part of the agreement in the Public Service Bargaining Chamber and should be reflected in health policy. The health sector should comply with the Employment Equity Bill once it is passed.

An agreement on redeployment of staff should be negotiated with representative trade unions. The agreement should make it compulsory for management to consult with the affected workers.

To protect the deployment process from abuse, there should be agreement that it will not be used as a cover for promotion or a mechanism to victimize staff through demotion. There should be agreement on which levels in both spheres of government can be considered equivalent. This should be linked with creating parity in working conditions.

We recommend that the bi-ministerial process also clarify the question of how collective bargaining will be conducted for health workers within the decentralized DHS. The relevant trade unions should be consulted.

In order to develop the linkage between environmental health and occupational health we recommend that there should be cross- reference to occupational health in the environmental in the introduction of the environmental health chapter. This should outline the impact on workers' health from work and living environments.