TUESDAY, 10 JUNE 2003 __

          PROCEEDINGS OF THE NATIONAL COUNCIL OF PROVINCES
                                ____

The Council met at 14:05.

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

ANNOUNCEMENTS, TABLINGS AND COMMITTEE REPORTS - see col 000.

               DISREGARD OF PROTOCOL BY MR M MALAKOENA

                         (Draft Resolution)

Ms B THOMSON: Chairperson, I hereby move the following notice:

That the Council -

(1) notes with concern the complete disregard for protocol displayed by the hon Mandla Malakoena, the chairperson of the Portfolio Committee on Transport in KwaZulu-Natal, when he unofficially opened a multimillion rand project in Ladysmith over the weekend;

(2) notes that there was no arrangement between the MEC for Transport and the Chairperson for the hon Malakoena to unveil this multimillion rand project;

(3) believes that official responsibilities such as this one fall within the domain of the MEC for Transport or a delegated official in the absence of the MEC; and

(4) therefore calls on the IFP to look into the conduct of this particular member so as to preserve the cordial political relations that exist between the ANC and the IFP.

Mrs J N VILAKAZI: Chairperson, I oppose the motion.

The DEPUTY CHAIRPERSON OF THE NCOP: You oppose the motion? Well, in the light of the objection, the motion may not be proceeded with. It will now become a notice of motion.

         CONGRATULATIONS TO FREE STATE DEPARTMENT OF HEALTH

                         (Draft Resolution)

Rev M CHABAKU: With due respect to the honourable House … [Interjections.] Nifuna ukungithakatha? [Do you want to bewitch me?] [Laughter.]

Chairperson, I beg to move this motion without notice:

That the Council -

(1) congratulates the Free State Department of Health for the top honours which they scored in a national competition to acknowledge the creativity and innovation of organisations in the delivery of service;

(2) commends this department on winning the second position in the category “Improving Efficiency of Internal Processes of Public Service Delivery” at a recent function addressed by Minister Geraldine Fraser-Moleketi;

(3) notes that they received a crystal trophy and a financial sponsorship; and

(4) therefore urges this department to continue to pursue their Batho Pele policy as we seek better health for all.

Motion agreed to in accordance with section 65 of the Constitution.

                CHILD KILLED BY BABOON AT MADIPELESA

                         (Draft Resolution)

Ms J N VILAKAZI: Chairperson, I move without notice:

(1) kaZwelonke weziFundazwe umangaliswa yisenzo esishaqisayo nesethusayo esenziwe yimfene eMadipelesa, esifundeni saseNyakatho Ntshonalanga ngesonto eledlule, ukuthi imfene ingene endlini emini saka yathatha umntwana womfana onezinyanga ezintathu yabaleka naye yagcina ngokumbhodloza ukhakhayi yakhipha ubuchopho bakhe yabudla unina ebhekile eshaqekile engenakwenza lutho;

(2) umangaliswa yilesi sehlo okuthe noma unina womntwana ezama ukuthi imfene imdedele umntwana, imfene yavele yavuka indlobane, yasho ukumcima unina wengane okhale naye kwaqhamuka omakhelwane, kwavele kwanhlanga zimuka nomoya;

(3) uyashaqeka nawo ukuzwa ukuthi imfene ikhwele esigxotsheni socingo lapho ibudlele khona ubuchopho maqede yashona ehlathini umntwana waphelela khona lapho;

(4) weziFundazwe kaZwelonke uyanxusa bandla kwiziphathimandla eziqondene nalezi zilwane ukuba zithathe izinyathelo ezisheshayo ukuvimbela ukuchanasakwalezi zilwane ezinonya olwesabekayo singaphinde senzeke futhi lesi sehlo, sibi kakhulu sinyanthisa igazi;

(5) uzwelana kakhulu nomndeni nezihlobo ezehlelwe yileli shwa, ikakhulu unina womntwana obone lesi simanga esenzeke ngokuphazima kweso, umntanakhe waphelela emehlweni akhe, engenakumsiza ngalutho. Umphakathi awuvikelwe ezilwaneni eziyingozi kubantu. (Translation of isiZulu draft resolution follows.)

[That the Council -

(1) is surprised at the shocking incident committed by a baboon in Madipelesa in the North West province last week, when a baboon walked into a house at midday and took a three-month-old baby boy and ran off with him and eventually cracked open his skull and ate his brain in front of his helpless mother;

(2) is surprised at this incident: even when the mother of the child tried to make the baboon leave the baby alone, the baboon reacted violently, and wanted to hurt the mother of the baby, who cried loudly until the neighbours came over, but the baboon continued to react in that way;

(3) is shocked to hear that the baboon just climbed over the fence, where it ate the brain and then ran into the bush, leaving the baby dead;

(4) appeals to the authorities at the national parks to take steps quickly to prevent the movement of these cruel animals outside of the parks so that the same tragedy does not happen again - it is a very shocking incident; and

(5) greatly sympathises with the family and relatives involved in this tragedy, especially the mother of the child, who witnessed her child being eaten while not being able to do anything to help him. People must be protected against these dangerous animals.]

Motion agreed to in accordance with section 65 of the Constitution.

                         APPROPRIATION BILL

                         (Review of policy)

Vote No 16 - Health: The MINISTER OF HEALTH: Deputy Chairperson and hon members, may I single out my colleagues from the provinces - the MECs as well - because occasions such as this budget debate are a powerful reminder that the spirit of co- operative governance is the lifeblood of our national health system. The people’s contract for a better South Africa starts here. It starts with the national Government, provinces and local government, remaining steadfast in our pledge to work together to improve the lives of all our people. I am honoured, therefore, to present to you the Budget Vote on Health.

Of the total amount of R8,38 billion in the national Health budget, no less than R7,32 billion is transferred to provinces as conditional grants. These grants are targeted at tertiary services in central hospitals and certain regional hospitals, training of health care professionals, the HIV/Aids programme, the Hospital Revitalisation Programme and the Integrated Nutrition Programme.

Resource constraints remain an ever-present reality in the operation of our health services. We have seen respectable, nominal increases in health spending for several years now. However, when these increases are adjusted for inflation and for population growth, we are spending only a little more on the health of each individual than we were in the mid-90s. Of course, we are trying to do a great deal more with this money, including confronting the major communicable and noncommunicable diseases, and some obvious pressures on resources are emerging, even in our better-off provinces.

We have also committed ourselves to levelling the uneven playing field that apartheid left behind. Whilst the gap in per capita spending between the wealthier urban provinces and the poorer rural provinces continues to be narrowed, this gap has not been eradicated and, of course, remains unacceptably wide. This year the budget per capita spending in provinces ranges from approximately R1 670 at the top of the scale to a low of R630.

This pattern of inequity is also reflected in large disparities in the number of health professionals available in the various provinces. Therefore, hon members, in order to discharge your oversight responsibility and stewardship role over national resources, I am appealing to you to pay special attention to three things: the overall pressure on resources in the public health sector; the manner in which resources are allocated among provinces and among the different districts in every province and the manner in which health care resources are utilised by provinces, and opportunities to target services to ensure that they reach the needy and most vulnerable individuals in our communities.

The national Budget this year has some strong, positive features in the areas of capital spending, nutrition, HIV/Aids programmes and human resources. However, we will only reap the benefit of these special allocations if provincial funding of the health system is basically adequate and sustainable. Let me illustrate this point in relation to the area of human resources.

The budget this year includes a special allocation of R500 million in order to assist provinces to recruit and retain health professionals to serve in rural areas and to boost the levels of scarce professions in the public sector. The R500 million will introduce a system of allowances and, in a few categories, pay increases. These will top up the salaries already covered in provincial budgets for the year, but will not fund additional posts. We expect that the new allowances will have a real impact in returning skilled health workers, especially in rural areas, as well as attracting additional professionals to fill vacancies, and special attention will be paid to sweetening the package in the most remote areas.

Presently we have 2 662 young professionals doing community service, contributing critically needed services in the public sector. For instance, one out of seven doctors in the public sector is doing community service and so are about one out of four pharmacists and one out of two physiotherapists. These figures confirm the incredible value of community service to our nation. By investing effort to nurture community service professionals, we can make it worth their while to spend a few more years in the public sector. Several new categories of mid-level health workers have been approved by the professions council and they will help fill some gaps in human resources.

Given the intense public debate on the international brain drain, information in the recent Intergovernmental Fiscal Review might come as a surprise to many. The review reveals that between the end of 2001 and early 2003, provincial health departments actually recorded a 4,5% gain in doctors, while the loss of professional nurses amounted to a mere 0,5%. Again, these oppose the suggestions of the media.

Of course, the review merely records the bottom line. It does not tell us much about the turnover that might be happening under the surface. Those who are familiar with the public health service will tell you that people are not only leaving the service, but we are also gaining some health professionals who used to work in the private sector.

We have consistently taken the view that we have no wish to restrict the freedom of health workers to work abroad. We are concerned, however, about the exploitative recruiting tactics of certain international operatives. We also believe that the international movement of health workers can to some extent be managed to the mutual benefit of the countries and the individuals involved.

I returned just a week ago from the World Health Assembly in Geneva, where Commonwealth health Ministers adopted a code of ethics on international recruitment of health workers, which is now binding on all member states. South Africa intends to build on this foundation by seeking bilateral agreements with Australia, Britain, Canada and New Zealand. We have already had extremely fruitful talks and discussions with my colleague in Britain, the Minister of health. The team, led by the director-general, will visit the United Kingdom this month to pursue discussions on this subject.

The high point of the assembly this year was the unanimous adoption of the Framework Convention on Tobacco Control, which sets the scene for the global expansion of public health measures against tobacco, such as control in advertising, sponsorship and smoking in public places.

Since returning from Geneva we have released the results of our second Youth Tobacco Survey undertaken by the Medical Research Council. This showed a very clear reduction over a period of three years in the number of teenagers who recalled seeing tobacco advertising and a corresponding decrease in the percentage who have ever smoked. We feel confident in claiming that this is directly due to our laws and regulations that ban tobacco advertising and our tax on tobacco products that make it increasingly costly to smoke.

The need for strong, multifaceted health promotion initiatives was highlighted by another major discussion at the World Health Assembly, namely responding to the global epidemic of violence. Last year the World Health Organisation published a major study on violence as a public health issue. The key message of the study was that we are not powerless in the face of violence. It is possible to understand the roots of violence and to take a range of actions to address the diverse causes.

Specialised centres for assisting survivors of sexual assault have been created in some provinces. Gauteng currently has 26 such clinics, while the Northern Cape has established similar services in six towns, with outreach into surrounding communities. The Free State, KwaZulu-Natal, Northern Cape and Western Cape have taken the lead in training forensic nurses. We have donor funding to extend this training nationally and we are currently creating a standard curriculum for training forensic nurses.

There is little doubt that public awareness of women and child abusers has increased hundredfold over the last few years and that many Government sectors, including health, have played a key role in this. But the time has come to dig deeper into the methods of prevention and to expand our conception of programmes against violence to acknowledge that adult men constitute a major category of victims. In recent years nearly half of all deaths among young men in the age group 15 to 29 years are due to unnatural causes, suicide, homicide and accidents. So, you can see that the problem of violence is certainly bigger than we thought a few years ago.

The expansion of our mental health services, with a stronger community focus, is undoubtedly critical to tackling violence effectively. Several provinces have made specific financial provision this year for implementing the new Mental Health Care Act by expanding community-based services and appointing boards to assist in protecting the rights of individuals admitted to psychiatric institutions. All provinces have retained a clear focus on the objectives of our national programme to reduce mortality and morbidity.

The integrated management of childhood illnesses was slow to get off the ground, but it is consolidating quite well. It has the advantage of providing nurses with a clear framework for dealing with a whole range of childhood illnesses. Preliminary evaluation suggests that it results in more appropriate use of medicines, appropriate referral at an early stage and better involvement of the care-giver. The integrated approach will, in the long term, impact on immunisation levels. However, there are still large variations among provinces and low immunisation rates are particularly disturbing when they coincide with the re-emergence of severe malnutrition and high rates of diarrhoeal diseases.

Provincial plans across the board include a major focus on TB control. There has been some soul-searching about how we get better TB cure rates from the Directly Observed Treatment Strategy, Dots, and turn around the rising incidence of this disease. The result in a number of provinces will be seen in greater investment in the management of TB programmes at district level and intensified recruitment of treatment supporters in communities. We are planning much stronger public awareness and information campaigns in order to achieve earlier diagnosis of tuberculosis, a reduction in stigma and a climate more favourable for the completion of treatment. I would like all members of this Council to participate actively in the TB advocacy programme.

In relation to HIV/Aids and sexually transmitted infections, we can confidently say there is a steady build-up of the elements of our five-year strategy plan. For the second consecutive year there is a major increase in the budget for this programme. This year’s allocation in the national Health budget alone is up to more than R200 million and amounts to R666 million.

Provinces are the major beneficiaries of this increase, the bulk of which goes into a single conditional grant which can be allocated to particular services that the provinces judge most appropriate. In 2002 the major areas of progress in most provinces were renewed strategies for preventing HIV infection among the youth; the expansion of the PMTCT programmes across provinces; the introduction of AZT and 3TC for sexual assault survivors; step-down facilities, an additional element in the treatment chain; the expansion of voluntary counselling and testing development in the area of home-based care and the mass media campaigns accompanied by targeted social mobilisation under the slogan Khomanani - Caring Together. The number of facilities involved in the PMTCT programme has increased. We are following the mother-baby pairs to determine the impact of nevirapine when used for PMTCT. We are also committed to monitoring adverse drug events as well as resistance patterns due to a single dose of nevirapine. All provinces are offering AZT and 3TC to survivors of sexual assault, using the national guidelines in administering the medication as part of a comprehensive service.

The development of a trained body of care-givers is a major feature of the HIV/Aids and TB programmes. These care-givers are known by various names and are skilled in different areas such as counselling, support, home nursing and outreach to families in need. Collectively they have become the engine for the continued roll-out of a range of services. I would like to recognise their singular importance here today and salute them for responding with love and dedication to the health care needs of our people.

We are committed to continually reviewing and evaluating our five-year strategic plan on HIV/Aids. In the year ahead, further expansion of the HIV/Aids programmes within the five-year strategic plan can be expected. As you know, the Department of Health and National Treasury established a joint task team to examine and cost various options for strengthening the national strategic plan on HIV and Aids, and in particular the treatment available to people living with HIV and Aids. May I also add that this includes nutrition. This report will be dealt with by the Cabinet very soon.

Among other strategies we will be strengthening the following key elements of our comprehensive national response to HIV and Aids. There will be a greater focus on nutrition, food supplementation and the use of immune boosters in order to encourage positive living and delay the progression from HIV to Aids.

We are working with the Departments of Agriculture and Social Development to provide social support to those who are infected and affected by HIV and Aids. The Medical Research Council has established, as a first step, a unit on indigenous knowledge systems to evaluate the safety and efficacy of traditional herbal remedies. And the results are quite promising.

Turning to the area of non-communicable diseases, we have seen growth in capacity in certain specific areas and dedicated funding for assistive devices for people with disabilities is now routinely allocated in most provincial budgets. As a national department, we have committed ourselves to clearing the backlog of devices by this time next year at a total cost of R30 million. This would then allow the provinces to focus on replacing devices and assisting new cases.

We need to take a careful look at the World Health Organisation’s 2002 study on health risks, a study that concluded that 40% of the mortality disease burden must be laid at the door of 10 major risks. We have taken bold and seemingly successful steps to reduce the risk of tobacco. Now we need to look at some of the other major risks, such as nutrition, obesity, alcohol, unsafe water and inadequate sanitation. Perhaps we need to recall that this year marks the 25th anniversary of the Alma Ata Declaration, the cornerstone of primary health care. We will be commemorating this event in South Africa.

The development of the health infrastructure on which these programmes depend remains a continual challenge. As you know, the Inkosi Albert Luthuli Hospital was commissioned last year, the Nelson Mandela complex in Umtata is due to be opened later this year and 2004 will see the opening of the new Pretoria Academic Hospital.

In the last two years, funding for our Hospital Revitalisation Programme has taken a great leap forward. We have R717 million in the budget and this will be increased by almost R200 million in the year 2004. Presently we have 26 hospitals on our list and 18 of these projects involve the building of entirely new facilities, either to replace the existing hospitals or to create a new service.

The revitalisation of hospitals is as follows: In the Eastern Cape: Frontier, St Elizabeth and Mary Theresa; in the Free State: Boitumelo, Trompsburg and Ladybrand; in Gauteng: Mamelodi, Johannesburg, Johannesburg South and Natalspruit; in KwaZulu-Natal: King George, KwaMashu and Empangeni; in Limpopo: Lebowakgomo, Jane Furse and Lekhomo - I think I am correct; in Mpumalanga: Piet Retief, Themba and Rob Ferreira; in the Northern Cape: Colesberg, Calvinia and Kimberley Psychiatric Hospital; in North West: Vryburg, Tswaraganou, and in the Western Cape: Eben Dönges, George and others. Hospital revitalisation also involves technology, maintenance, replacement and innovation, as well as the development of managers and management systems and improving quality of care. In addition to the boosted funds for the revitalisation programme there has also been an increase in funding for infrastructure as part of the equitable share. Provinces are currently using such funding to sustain the process of upgrading and expanding the network of clinics and community health centres to increase the pace of replacing obsolete equipment and to undertake similar renovation projects and routine maintenance. Systematic audits of hospital equipment revealed that shortages were often caused not by a lack of equipment, but by lack of maintenance and excessive down-time on existing equipment.

We have an acute shortage of specialised engineers and technicians in our public health system to keep our equipment in good repair and we have developed a dual strategy to tackle this critical factor. We plan to train 500 engineers and technicians over a period of five years, with the first 100 commencing training in the next two months. As an interim measure, we have reached agreement with the Cuban government for engineers and technicians to work in South Africa on short-term contracts and the first group will arrive pretty soon.

A further priority in the area ahead is the strengthening of emergency services with the eventual target of meeting a standard set of norms countrywide. We fully recognise that many other services are critically dependent on the support of an effective ambulance fleet with well-trained personnel. Other significant measures to strengthen support services will occur in relation to laboratory services and medico-legal mortuaries.

A major pillar of our strategy to reshape the public health care system is the building of health districts with strong local co-ordination of services and equally strong local accountability. The national health Bill, which will be tabled this year, will recognise the constitutional reality that provinces are designated as the primary providers of public health services. Local government will only become a significant provider of public health care through co-operative governance arrangements. We are exploring the use of service-legal agreements with local government to deliver specified services on behalf of the province with adequate resources. Clearly, this is not a simple system. It is a system that should be informed by commitment to the ideal of decentralised management to improve efficiency and effectiveness and it should promote people-centered development through greater community participation in the delivery of basic services.

There may also be significant benefits to the approach in the area of equity. If the gap between the richest and poorest provinces is still unacceptably large, the gap between the richest and poorest municipalities is even larger and more worrying. If funds for primary health care flow through the provinces to local councils, this can help to level the playing field between the municipal areas. It can also strengthen the co-ordination of health services.

I referred in passing to the national health Bill and I am pleased to say that the state law adviser has now certified the Bill. This means it will soon be tabled for processing by Parliament. We anticipate there will be high levels of interest in the Bill and we look to this Council to play an active role in channelling public input. The traditional healers Bill is also likely to be of particular interest to the provincial constituencies, especially where provinces already have legislation on related matters.

The increasing interface with the private health sector is another factor that is gradually having a bearing on provincial health services. Those provinces that are using the uniform patient fee schedule quite widely and have set revenue targets have reported achieving or exceeding their targets last year. Clearly, there is still untapped opportunity for generating revenue for our public hospitals.

Changes in the medical schemes legislation which allow schemes to designate preferred service providers represent a significant opportunity for public hospitals to increase the proportion of paying patients. Many hospitals are preparing for these arrangements.

I can assure this Council that this new development will not compromise our responsibility to ensure care for those who cannot afford to pay their way, and paying patients will not be allowed to crowd out our poorer patients. The revenue generated by fee-paying patients will benefit the service as a whole and the quality of clinical care provided in provincial hospitals will not depend on whether patients pay or not.

In closing I would like to thank the Select Committee on Social Services and especially the chairperson, the hon Loretta Jacobus, for her guidance and constructive interaction with me and members of the Department of Health. I would like to recognise Deputy Minister Schoeman who has taken up the challenge of entering office late into the term and has strengthened the Ministry by focusing on particular aspects of our complex department.

I would like to recognise my ministerial colleagues in the social services cluster and in Cabinet and pay tribute especially to the leadership of our President, President Thabo Mbeki, and my provincial colleagues, the MECs for health, our partners in the exercise of concurrent powers. I am indebted to them for sharing the responsibility of decision-making. In a similar vein, I thank the Director-General of the Department of Health, Dr Ayanda Ntsaluba, and his counterparts in the provinces, for their dedication and leadership.

I also wish to recognise the support received from my advisers, other members of my office and senior officials in the Department of Health. But when it comes down to it, the health service is run by a huge number of health workers, professional and non-professional, who give it their best effort, seven days a week, 52 weeks a year, and on behalf of the millions who benefit from your skills and your love for your work, I thank all of you. Thank you very much, Chair. [Applause.]

Ms L JACOBUS: Thank you, Chairperson. I think I need protection from my colleagues on this side of the House here.

Hon Deputy Chairperson, hon Minister, Deputy Minister, MECs, special delegates and members, I think I must also commend all the MECs we have here. We have eight out of the nine provinces represented here. [Applause.] I think this debate is probably one of the best attended by the political heads of provinces when we have our policy debates.

It is, indeed, once more a pleasure for me to rise in support of Budget Vote No 16, the Vote on Health. It is also of significance that in this, the ninth year of our democracy, we rise to applaud our achievements, but, in doing so, we do not lose sight of the challenges that still lie ahead, as we move into celebrating the first decade of our freedom from apartheid service delivery.

In preparing for this debate, our select committee decided to embark on a day-long interaction with provinces, where we looked at basically four areas. First, we looked at provincial priorities; we looked at the spending patterns of provinces; we looked at programmes aimed at pushing back the frontiers of poverty and, last but not least, the challenges faced by all the provinces.

By and large, the provincial priorities correspond to that of the national Department of Health, as set out in the department’s strategic plan over the next three years, up to 2006. In looking at the spending patterns, we used as a guide the Intergovernmental Fiscal Review that was tabled in the NCOP about two months ago. The Intergovernmental Fiscal Review notes that provincial health budgets rise significantly in the current financial year in order to strengthen the health sector, in particular, and to intensify a range of specific programmes. These include substantial funding increases, especially for health services, in previously disadvantaged provinces; large increases in the Hospital Revitalisation Programme; increases for the Integrated Nutrition Programme, as also mentioned by the Minister; the further strengthening of the enhanced response to the HIV and Aids strategy, and a R500 million increase to R1 billion additional funding for a new system of rural incentives and a scarce skills strategy for the health sector.

It is also encouraging to note that provincial health spending continues to show strong growth over the MTEF period. Strong growth going forwards specifically applies to some of the most disadvantaged provinces. For this financial year, the health budget for Mpumalanga has grown by 22,7%, for the Northern Cape by 22,1%, for the North West by 20,9% and for the Eastern Cape by 16,9%.

Needless to say, these increases create the basis for substantial improvements in health services. For a breakdown of figures for all nine provinces, I refer members to table 5.1 in the Intergovernmental Fiscal Review, which I hope members are familiar with at this point. Provinces have also received substantial additions to their baseline health budgets. These have grown by 4,5% in real terms for this financial year.

No one can argue with the fact that access to a quality service also means access to a decent, well-equipped physical structure. We, therefore, applaud the increased health capital expenditure, which has tripled since

1. The improvement in expenditure on the hospital revitalisation grant has been a key factor in the turnaround in capital expenditure. This grant targets the funding of large strategic revitalisation projects, such as upgrading, replacement and transformation of hospitals and clinics. This grant increases to over R1 billion in the 2005-06 financial year.

Some key projects have been finalised or are nearing completion, for example, the Inkosi Albert Luthuli Hospital in KwaZulu-Natal and the Nelson Mandela Hospital in the Eastern Cape are completed, and so is the first phase of the Pretoria Academic Hospital in Gauteng.

In a bid to fight child poverty, the Department of Health has been stepping up its Integrated Nutrition Programme. Funding for the Integrated Nutrition Programme has been increased to over R1 billion in the outer years of the MTEF for 2005-06, as part of Government’s anti-poverty strategy. The increases are intended to reach out to a larger number of children and schools, providing meals for at least 156 school days in a year in all provinces. A steady increase is reflected in table 5.21 of the Intergovernmental Fiscal Review to just over R1 billion in the outer year of the MTEF.

However, the challenge still remains: What happens in the remaining 109 days of the year, when kids are not at school? The Departments of Health, Education and Social Development need to put their heads together to try and address this problem, because not all of these children are in receipt of a social security grant.

One of the thrusts of the 2003-2004 budget is a further step-up in the enhanced response to the HIV/Aids strategy. There’s been an increase in earmarked funding and this will rise to about R1,8 billion in 2004-05 to support various preventative interventions.

Starting in this financial year, a further R3,3 billion will be added to provincial allocations to be spent on Government’s enhanced response to HIV and Aids over the MTEF period. These increases take into account the additional costs arising from hospitalisation for Aids-related illnesses, the treatment of opportunistic infections and TB, and for progressive strengthening of medically appropriate treatment programmes over this period.

Having said this, I want to come to some of the challenges that we face, and I want to briefly touch on some of these as they emerged from the hearings that we had. Other members of the committee and the special delegates from the various provinces will probably go into more detail and elaborate more on the challenges that they are facing in their provinces.

I’ve highlighted three main challenges. One is human resources, and the Minister touched on that as well; secondly, the discrepancies in the per capita spending, which the Minister also touched on, and thirdly, interdepartmental and intergovernmental collaboration.

Regarding human resources, reflecting on the vision of the department, it is said, and I quote: … to play a role in securing a caring and humane society in which all South Africans have access to affordable and good quality health care.

The issue of human resources cannot be overemphasised. Needless to say, the more rural provinces bear the brunt of this challenge. The vacancy rate of health workers, which is nurses, doctors and other medical professionals, in the rural areas of the Northern Cape currently stands at 30%. We were informed to this effect during the hearings.

The doctor-to-patient ratio in the North West province is 1:3 300 per population. The active poaching and recruitment by other countries of our health workers adds fuel to the fire. I’m therefore happy to have learnt that the Department of Health has concluded, of course in co-operation with the relevant stakeholders, an incentives package aimed at retaining our health workers or, at least, binding them into a commitment to return to the service of the department on their return from the so-called greener pastures. A shortage of human resource capacity also impacts negatively on service delivery and, indeed, the quality of service that is rendered to our people. I am also happy to note that the Minister, in her input, mentioned a protocol or agreement that was signed to address this particular problem.

On the issue of the inequality in per capita spending, I refer the House to table 5.3 of the Intergovernmental Fiscal Review that reflects on per capita spending per province. I won’t go into the details of that, save to say that Gauteng and the Western Cape, again, top the list with the highest per capita spending, while Mpumalanga, the Eastern Cape, North West and Limpopo are at the bottom of the list currently, and will remain there over the MTEF period.

I still need to be satisfactorily informed about what informs the varying per capita spending. I asked this question when the Intergovernmental Fiscal Review was tabled with the Select Committee on Finance in the NCOP.

Various research and the personal experience of many of us sitting in this House inform us that the majority of people living in rural areas are either unemployed, have a very minimal income or depend on a social grant for their survival. Research also further informs us that the majority of households in rural areas do not have access to some of the basic services, like clean drinking water, sanitation, balanced nutrition and so on. This whole scenario does not bode well for the health of any individual.

The deduction I make from this is that most rural dwellers are more prone or susceptible to diseases of poverty and other ailments. My common sense, therefore, tells me that health spending in rural provinces should, at the very least, be equal to health spending on our fellow South Africans in the urban areas.

Regarding interdepartmental and intergovernmental collaboration, the Minister, the director-general and most of the senior officials who are seated over there are medical doctors. They can attest to the fact that ensuring a healthy nation is not the sole responsibility of the Department of Health.

Other Government departments like Education, Social Development, Agriculture, Housing, Transport, Sport and Recreation, Water Affairs and others all have a significant role to play in promoting and ensuring a healthy nation. A more significant role should also be played by Local Government in the delivery of healthy services, and the Minister also alluded to that.

Between 1999 and the beginning of 2000, the Health Systems Trust invited the select committee on a tour to KwaZulu-Natal, where we visited some clinics and hospitals in the area. There was one clinic in KwaZulu-Natal that we went to visit and, unfortunately, it had rained the day before and the clinic was completely inaccessible. We couldn’t get there. We had to park our bus on the side of the road and ask the management of the clinic to come and meet us on the side of the road.

The Minister can have a state-of-the-art clinic anywhere in the country, but if it’s inaccessible, that clinic or hospital will not mean anything. So, Local Government really has a particular role to play, as well, in the provision and maintenance of roads in our country.

The Minister of Social Development, some time ago, commissioned a study on a comprehensive social security system. The report of this study was tabled in March 2002. It’s called the Taylor Commission Report. Included in this report is a chapter on health and recommendations on the role of health in the development of a comprehensive social security system. I think the Minister must be familiar with that report and the particular chapter I’m referring to, but I, once again, want to point the Minister to that chapter and its recommendations for her and her department’s consideration.

Irrespective of what many people might think, the Taylor Commission Report does not only deal with the basic income grant, as many people want to believe. It deals with a whole range of issues.

I want to quote from the statement of the director-general in the Strategic Plan for the National Department of Health, 2003-06. This is what he had to say, and I quote:

There are multiple determinants of health status. This reality means that we have to work closely with other Government departments and nongovernmental stakeholders to improve the health status of our country.

One key mediating factor is that the delivery of health services, given that health is also a concurrent national and provincial function, is the need for the national department to work closely with provincial health departments.

Needless to say, I agree wholeheartedly with this statement, and it supports what I said earlier on.

In conclusion, I’d like to take this opportunity to thank the Minister and the Deputy Minister, who sat with us during the provincial hearings. In fact, I hijacked him from his lunch to come and participate and sit with us during our hearings, to hear what the provinces had to say. He agreed to be hijacked, yes. I thank the department, led by Dr Ntsaluba, the director- general, and all his staff as well as all the provinces for the constant support. That support is evident in the presence of the political heads here today.

I thank everyone for the support, assistance and guidance given to the committee over the past year but, in particular, in preparation for this debate, and we hope that this support will continue for the new committee that will be appointed after the elections next year. Some of us might be here and some of us might not be here.

Thanks also go to the staff assisting the committee, including Johannes, the parliamentary liaison officer - who I don’t see here - who always keeps the department in touch with us and us in touch with the department.

Last, but not least, we’d also like to salute the thousands of health workers and health professionals who tirelessly work in service of our people and who uphold the principle of Batho Pele, irrespective of what the conditions are that they find themselves in.

Together we can and will build a better life for all. I thank you. [Applause.]

Ms E C GOUWS: Hon Minister, Deputy Minister, MECs and colleagues, Deputy Chair, today I wear a little white heart on my coat and I wear and display it with pride.

This white heart is the emblem of the International Council of Nurses. The ICN launched the white heart on International Nurses Day in May 1999 as a universal symbol for nursing. The symbol characterises the caring, knowledge and humanity that infuses the work and spirit of nursing. The white heart is also a unifying symbol for nurses globally.

Herewith, I salute all the nurses of my country, but especially those in the Eastern Cape, in the deep and rural areas, where they work under very difficult conditions, sometimes only with the basic necessities and many times even without that. It was one of these nurses who once had to hitch a lift for a seriously ill patient. There was no ambulance or other transport available.

Those people, hon Minister, are the backbone of your department, and thank you for mentioning them in your speech. It is not those learned and clever people heading the departments but those who work and deliver for the love of people that are the backbone of the sector.

Of the millions of words written about Winston Churchill, Lady Diana Cooper’s are among the most revealing. She wrote: When I said the best thing he had done was to give the people courage, Churchill answered, I never gave them courage; I was able to focus theirs’’.

Hon Minister, if you can focus the courage of your medical staff in South Africa, you will have done a great job for this country.

The health worker is struggling under difficult circumstances. Their workload is enormous; their support systems are lacking. With the escalating crime, we must look at their safety and see to the security of the facilities.

The Eastern Cape covers 169 580 square kilometres. A vast area, you must agree. To give you some sense of the inequities and scarcity of particular professional groups in the Eastern Cape, I want to mention a few details. One doctor in the Eastern Cape must serve a public sector population of 8 825, compared to Gauteng where one serves 273. One professional nurse must serve 1 278 people; in Gauteng it’s 606. One dentist serves 190 117 patients; in Gauteng it’s 25 000, and one pharmacist in the Eastern Cape serves 53 662 compared to 18 994 in Gauteng.

These are but a few examples to illustrate the statement on the workload of doctors and nurses. If we look at more specialised areas like physiotherapists, occupational therapists and speech therapists, the figures are mind-boggling. For example, there is one therapist for 950 530 people - that’s nearly a million people.

In all these categories mentioned, the Eastern Cape is by far the worst off of all the provinces. The only exception seems to be the medical specialist ratio. Limpopo and Mpumalanga are worse off than the Eastern Cape. These three provinces also have the lowest expenditure in out-of-hospital primary health care services. There is a great reliance on district hospitals to deliver primary health care.

Maar, agb Voorsitter, ons het simpatie en empatie met die Departement van Gesondheid in die Oos-Kaap, veral die oostelike area en verafgeleë gebiede. Soos aangedui, is hierdie ‘n uitgestrekte provinsie en daar is werklik probleme met die infrastruktuur. My vraag en bekommernis is egter, hoekom laat ons toe dat hospitale en gesondheidsdienste en klinieke wat 100% effektief was en in werkende orde was, nou oneffektief en in sommige gevalle gesluit word? Daar is gevalle van sogenaamde gesondheidsinrigtings wat sodanig verswak het dat dit byna beskryf kan word as ‘n gesondheidsgevaar. Kom ons sorg dat hospitale skoon is, dat beddegoed voldoende is dat daar kos vir die pasiënte is. Agb Ondervoorsitter, hierdie hospitale is nie in die verre Transkei en Ciskei nie, hierdie hospitale sal jy in en rondom Port Elizabeth kry.

Ons verstaan dat die Oos-Kaap ‘n agterstand het, maar wat die publiek nie verstaan nie, is dat hierdie staatshospitale ‘n goeie advertensie vir gesondheidsdienste was. Ons was almal trots op hierdie instellings en nou ontbreek selfs die basiese beginsel van netheid en reinheid vir hierdie hospitale.

Die mees basiese medisyne kan nie voorsien word aan pasiënte by klinieke nie. Hierdie is nie klinieke in verafgeleë gebiede nie - ek praat van die klinieke waar daar infrastruktuur en kommunikasiemiddels is. Dis in die westelike Oos-Kaap.

Ons is besig om ons gesondheidswerkers, veral die draers van hierdie wit hartjie, te demoraliseer. Hulle entoesiasme en liefde vir hul professie word hulle ontneem omdat hulle nie die siekes se pyn kan verlig nie; omdat hulle nie die eed wat hulle afgelê het, gestand kan doen nie. Agb Minister, daarom is u besig om die ruggraat van u departement te verloor. Dokters en verpleegsters gaan soek groener weivelde, nie soseer oor die groter salarisse nie, maar waar hulle ten minste dít kan doen waarvoor hulle opgelei is.

As ons visie dan ‘n beter primêre gesondheidsdiens is, laat ons dan ten minste eerste die primêre dinge van gesondheid regstel. Laat ons ons prioriteite regkry. Die armste provinsies moet gehelp word om meer te spandeer op primêre gesondheid. Dit is hier waar die mense finansiële bystand die nodigste het wanneer hulle siek is. Dis hier waar die grootste impak gemaak kan word teen armoede. Ek dank u. [Applous.] (Translation of Afrikaans paragraphs follows.)

[But, hon Chairperson, we have sympathy and empathy with the department of health in the Eastern Cape, especially the eastern area and remote areas. As indicated, this is a large province and there are really problems with the infrastructure. My question and concern, however, is: why do we allow hospitals and health services and clinics that were 100% effective and in working order, now to become ineffective and in some cases to be closed? There are cases of so-called health institutions that have deteriorated to such an extent that they can almost be described as a health hazard.

Let us see to it that hospitals are clean, that there is adequate linen and that there is food for the patients. Hon Deputy Chairperson, these hospitals are not in the far distant Transkei and Ciskei, you will find these hospitals in and around Port Elizabeth.

We understand that the Eastern Cape has a backlog, but what the public does not understand is that these state hospitals were a good advertisement for health services. We were all proud of these institutions and now even the basic principles of tidiness and cleanliness are lacking in these hospitals.

The most basic medicine cannot be provided to patients at clinics. These are not clinics in distant areas - I am talking of the clinics where there are infrastructure and means of communication. They are in the western parts of the Eastern Cape.

We are demoralising our health workers, especially those who wear the little white heart. They are being deprived of their enthusiasm and love in their profession because they cannot alleviate the pain of the sick; because they cannot honour the oath they took.

Hon Minister, for that reason you are losing the backbone of your department. Doctors and nurses are going in search of greener pastures, not necessarily for the sake of larger salaries, but to go where they can at least do that for which they were trained.

If our vision is a better primary health service, let us then at least first of all rectify the primary things of health. Let us get our priorities right. The poorest provinces must be helped to spend more on primary health. This is where the people are most in need of financial assistance when they are sick. This is where the biggest impact can be made against poverty. I thank you. [Applause.]]

Dr M B GOQWANA (Eastern Cape): Thank you, hon Deputy Chair. Firstly, I want to honestly apologise for walking in not knowing the proceedings were on. I apologise. It is probably because we do not have rooms like this in the Eastern Cape. [Laughter.] I just want to tell you about the Eastern Cape firstly. The Eastern Cape occupies about 13,9% of the country’s earth surface and the Eastern Cape is one of the rural provinces. As you know, about 36% of it is urban and 63% is rural.

Let me quickly just talk about the statistics, especially those relating to children, women and TB so that you can see what is actually happening. When I talk about the challenges and our priorities, they are going to be related to what I’m going to mention now.

Our infant mortality rate in the Eastern Cape is 61,2 per thousand live births and is the highest in the country. This is related mainly to the diarrhoeal diseases, malnutrition, the communicable diseases that are not supposed to be there, HIV/Aids, and tuberculosis. Even though we are primarily a rural area and poverty-stricken, we still share with the other provinces the car accidents and the injuries at birth that affect the mortality of the infants.

On the issue of women’s health in the Eastern Cape, at the moment we stand at 133 maternal deaths per 100 000, and 32% of these are primigravida patients. Surveys have shown that some of these patients actually have problems with HIV/Aids.

Regarding TB, we have seen an increase in the TB statistics in the recent past, and this is probably related to the fact that we are reaching areas where there used to be no primary health care. Now we are able to collect patients that were never known to have TB. They were dying in silence in those areas. This is what has led to our statistics increasing and, partly, it is because we got the HIV/Aids pandemic affecting us. In most of our hospitals, 10,2% of admissions are related to TB.

Our major challenges in the Eastern Cape are the escalating TB prevalence; the brain drain that we have, with doctors and nurses who are moving to other countries; the low rate of immunisation in the Eastern Cape; some of the cultural factors like the circumcision problems that we have in the Eastern Cape; the high infant mortality rate, and maternal mortality. These are some of the challenges that we have.

In the light of escalating crime in some areas that is related to our health professionals, in the Eastern Cape two nurses have been raped at work, but that situation has been corrected in the sense that we have now got security in those institutions. This is related to the fact that the community does not realise and does not respect what is actually being done by Government to improve their health status.

The increase in motor vehicle accidents has an impact on our medical services in the Eastern Cape and the backlog in health facilities development.

Our priorities, mainly, are to make sure that we contain HIV/Aids, that we control the spread of TB and that we control the spread of sexually transmitted infections. We want to reduce the infant and child mortality rates. We want to increase our immunisation rate. We want to control communicable diseases. We want to develop the district system and the delivery package of primary health care. We want to improve our emergency services. The Eastern Cape, as I mentioned, occupies 13% of the land of South Africa. That makes it one of the provinces that are very large. Unlike some of the provinces that are bigger than the Eastern Cape, each and every corner of the Eastern Cape is occupied by people. There are people that are staying there and, in this sense, we definitely need good emergency services that are going to be able to cater for all those people that are in those areas.

We would like to improve our logistical and other support services to implement the Hospital Revitalisation Programme to improve capacity and access to regional and tertiary services in the province, and to develop human resources for quality and management of the services.

We have eight programmes that we are using to make sure that we render proper health care services in the Eastern Cape. I am not going to go through them, but I just want to mention that the budget that we have, which has increased from the budget that we had, for next year is about R5,1 billion. We are very happy that it has been increased from what it was. We think that we are going to be able to handle most of the things that we could not handle with the smaller budget that we had.

I am sure that you have heard that it is an increase of 16%, up from the previous year’s budget, so I do not have to repeat that. Over 68% of that budget will go to personnel, but I am not going to dwell that.

Let me just talk briefly about expenditure. The money that we are using for the districts and subdistricts amounts to R2,2 billion. It is an increase of 5% on the previous year’s budget and the budget on HIV/Aids goes up to R71 million, which is a 33% increase from the previous year. The nutrition programme has increased by 51% and has gone up to R172 million.

We are trying to render our services through the local authorities, but not the whole province is actually using local authorities for primary health care services. It is only in certain areas that we are using local authorities for primary health services. The money that we are giving them, which has increased from last year to this year by 6%, is R134 million. We are still using provincially aided hospitals. There are 18 of them. There are reasons why we are still keeping them. We are giving them R70 million to make sure that they run the services in those particular institutions. We are still using life care hospitals and we are giving them R94 million and we still have SANTA hospitals that we give R74 million to.

The expenditure per capita in the Eastern Cape is at R634 and that is excluding the conditional grants. Obviously, I do need to mention that it is lower than some of the provinces. Regarding the conditional grants, we have got the national tertiary services grant, which has increased to R145 million; the health profession training and research grant which is R88 million, and has decreased slightly; the HIV/Aids grant - as I have mentioned, it has increased; the hospital revitalisation grant which is standing at R109 million, and the Integrated Nutrition Programme, which I just mentioned, as well as the hospital management improvement grant, which is at R9 million.

I just want to talk briefly about what we are doing to push back the frontiers of poverty. We are working on HIV/Aids programmes where we are improving the access to VCT by increasing the number of testing sites by 30%; implementing post-exposure facilities for rape survivors; expanding our PMTCT programme; improving care and support for the people infected and affected by HIV/Aids, and increasing community involvement in HIV/Aids, which we are doing through the HIV/Aids Council. We are providing services to vulnerable groups like the community sex workers. We are providing a continuum of quality care through the provision of step-down care in designated hospitals. We have set up centres of excellence in partnership with medical schools to provide models of prevention, treatment and research.

On the issue of TB programmes, we are improving our monitoring of the drug supply to the areas where we are treating people with TB. There is increased case detection by smear microscopy among all TB suspects to 80%. We have improved the MDR programme, that is, the Multiple Drug Resistant programme. We have also decreased treatment interruption, expanded the Directly Observed Treatment Short Course, and finalised the TB advocacy plan for the Eastern Cape.

In reference to the reduction of the infant mortality rate, we are increasing our immunisation coverage to 85% in 2005-06. We have improved access to ordinary health care facilities, and the prevention of mother-to- child-transmission of HIV/Aids. There is the management and follow-up on children with HIV/Aids, and implementation of integrated management of childhood diseases.

Regarding integrated nutrition, we are intensifying the implementation of the Integrated Nutrition Programme, as guided by UNICEF, in terms of the conceptual framework and the triple approach. We are promoting community- based growth monitoring and strengthening nutrition interventions at health facilities and community levels, and have rehabilitated malnourished children to work with other sectors in detecting the root cause of malnutrition and poverty, and facilitated the transfer of primary school nutrition to the Department of Education.

One other challenge which we mentioned was the brain drain. Here we are actually developing incentives which, I am sure, some of the members here might not know about. We have got incentives for nurses in the rural areas to make sure that we understand the commitment that they are actually putting in. We have the provision of accommodation for doctors; induction programmes for community service staff and interns; the creation of senior posts, promotion of doctors to higher posts and making sure that there are training courses in some of the smaller hospitals; filling of critical posts using utilisation of grants to attract and retain staff, and the intense marketing of the province.

In terms of the reduction of maternal morbidity and mortality, we are increasing the level of reporting and surveillance of maternal deaths, implementing maternal health guidelines, increasing access to maternal services and expanding top services. [Time expired.] [Applause.]

Ms E D PETERS (Northern Cape): Chairperson, hon Minister, hon Deputy Minister, my colleagues from the provinces, and members of the NCOP, I just wanted to say today that, like the hon Gouws, I believe we are all wearing the little white hearts, but as MECs for health, that little white heart is one we wear day and night. Even in our sleep, we dream about the conditions under which our nurses work. We strongly believe that nurses are the backbone of our health services. Without them, we would not be where we are and we would not be able to deliver the services. [Applause.]

I just want to say to the hon chairperson of the committee that I was bit disappointed when she said that they had requested the management of the clinic to get to them, instead of taking that extra step to get to the management and the nurses and to understand that, irrespective of the conditions, and irrespective of the deserted Northern Cape - even if there is a group of twenty people somewhere - we have to get the services to them, my hon colleague from the Free State … not from the Free State, sorry, but from the Eastern Cape.

The budget that the hon national Minister has just tabled here today reflects the unwavering commitment of this Government to ending the suffering of our people, especially as a result of lack of health care services. This budget will instil a sense of hope in many of our people, especially those residing in deep rural areas. It complements the good work that we are doing at provincial level and is much welcomed.

The Northern Cape is a province at work, irrespective of the small number of people that we have there. We are at work to restore the dignity of our people through the provision of quality and accessible public services, including health care services. To sustain this progressive programme of bringing health care services closer to our people as a province, the equitable allocation to the department of health was increased. If you listen to the amount, you may think that that amount cannot deliver a quality service, but it has. We had R488 062 million, and it has increased to R564 818 million, which is an increase for our province of about 15,73%. The conditional grant allocation is also increased from R110 152 million to R171 694 million, an increase of about 55,9%. I do not know whether that is an indication of a motion of confidence about how we can utilise the conditional grants.

This large increase in the conditional grant is attributed to the substantial increase in the allocation of two conditional grants, namely, the Integrated Nutrition Programme and the Hospital Revitalisation Grant. These grants were increased by more than 100% each in the 2003-04 financial year as compared to the previous year.

In line with the budget reforms instituted by National Treasury, the programmes of the Department of Health in our province have changed in order to be aligned with areas of service delivery. This has resulted in the number of programmes increasing from five to seven. The budget allocation programme is as follows: administration, 5,2%; district health services, 46,4%; emergency medical services, 6,3%; provincial hospital services, 30,1%; health sciences, 1,9%; health care support services, 0,8%, and health facility management, 9,3%.

In line with this allocation, our provincial health priorities relate to infrastructure development. As the Minister indicated, we are in the process of building the psychiatric hospital for the year 2004-05, and we are busy, for the same year, on the Gordonia hospital project, and we envisage building a totally new provincial hospital to replace Kimberley Hospital. You will understand that Kimberley Hospital functions as a level 1, 2 and 3 hospital. For the Frances Baart district, there is no level 1 facility and therefore there is confusion about the level that Kimberley Hospital actually functions at.

We are also in the process, in partnership with the Nelson Mandela Foundation, of building the Garies Hospital, which will commence in August

1. We are also going to build five new clinics. When you hear what our budget is, you will understand why our figure for the building of clinics might not compare with Gauteng, hon Gouws. We are going to be upgrading five clinics to make them modern and so that they are accessible to the communities.

We have also been given a donation of four container clinics by the Gift of the Givers Foundation from KwaZulu-Natal, which is helping us to get a facility to communities that still have a tree stump as a clinic, where the mobile services get to a community and stand under a tree in order to deliver services in the rural areas. That is one of our key focal points in infrastructure development.

We are also going to strengthen our primary health care services. We are also ensuring that, in the process, we are going to deal with human resource development. I am going to refer to this document, because it is very important for me to be able to give you the full details on our human resource management plan.

We are in the process of finalising our job descriptions for the various categories, and implementing a performance appraisal in that arena. We are strengthening our primary health care clinics, especially in rural areas, and improving the availability of doctors and nurses. An important challenge for the department has been the recruitment, production and retention of particularly nurses as an essential human resource.

In this regard, a range of initiatives have been undertaken, and others are being contemplated. With respect to the training of professional nurses, we have increased the intake at the college. Two years ago, the select committee challenged us to put our money where our mouths are, because we complained about a lack of personnel and yet our intake at the college did not reflect that. We are determined to increase the number of nurses in our college. In that year, we had an intake of 20 students per annum in the nursing college, and in the ensuing year we increased that number to 39. This year, we have increased the number threefold to 60. These students are also expected to sign a four-year contract to work in the province after qualifying.

Professional nurse numbers are also being increased through a bridging programme for enrolled staff nurses. These nurses live in rural areas in the province, and return there after completing their training. Nurse numbers are also increased by the appointment of general assistants, clerks and porters in nursing assistant training posts. They are then trained as nursing assistants. This programme also ensures career pathing of various categories of people in the health care field.

In an attempt to curb the uncontrolled emigration of nurses, we have introduced a nurse scholarship programme in conjunction with the Oxford Radcliffe Hospital in the United Kingdom. Fourteen nurses left to work in this hospital in August 2002 and returned in January 2003. A second cohort of 16 left on 14 January 2003. We will also be implementing the rural allowance scheme for nurses from July 2003.

The other programme that is a priority of the province relates to forensic services. The taking over of medico-legal mortuaries from SAPS by the department of health is in progress. The recruitment and appointment of a forensic pathologist will be pursued. The department utilises the services of medical practitioners to assist with post-mortems in areas very distantly located in the province.

The other programme is the telemedicine project. You would understand, with the province being so vast, that we need this type of facility or project to succeed in our province. The telemedicine project has been evaluated. Rolling out poses certain challenges that will require further preparation. The ultrasound equipment will have to be more widely available. During 2002 and 2003, we will begin to equip 13 level 1 hospitals with ultrasound machines in order to roll out that type of project. We are also in the process of creating permanent doctors’ posts which will ensure continuity and will create the conditions for the roll-out of the programme.

Regarding gender mainstreaming, which is also one of our key programmes, ensuring the advancement of women into decision-making positions, this objective is currently being addressed in that the gender focal person is sitting in on all departmental recruitment interviews, appointments, study loans and scholarships, especially in strategic positions, to ensure gender equality and balance. A target of at least 50% of women in senior positions is aimed at by the year 2005.

The successful implementation of these identified priority programmes will ensure and speed up the delivery of quality health care services to all our people.

During his state of the nation address, the hon President, Comrade Thabo Mbeki, reminded us of the people’s contract for a better life. The Minister said that it starts here in this Chamber where provinces are represented. The President challenged us to push back the frontiers of poverty in order to deliver on this contract. Central to our departmental programme of pushing back the frontiers of poverty, teaching and training … [Time expired.] [Applause.]

Nk J N VILAKAZI: Sihlalo ohloniphekile. Ngqongqoshe womnyango wezempilo nendlu yonke. Kwisethulo sakho semali siyezwa ukuthi unezigidi eziyisishiyagalombili nangaphezulu kanti futhi yiso esikhulu kunazo zonke izabelo emnyangweni wakho. Kufanele, siyakuncoma lokho. Impilo yiyona kuqala, akukho into engenzeka abantu bengaphilile begula.

Okufike kube nohlevane emnyangweni wakho Ngqongqoshe kuseyikho ukuhamba kwezisebenzi ezimnkantshubomvu ziye kosiza amanye amazwe. Kuhle nokho ngoba azifihli ukuthi zixoshwa yini ezweni lethu.

Kudingeka kakhulu ukuba kuvalwe lo mgudu owenziwa ukuhamba kwezisebenzi eziseqophelweni eliphezulu zethu kuyosizakala amanye amazwe.

Okokuqala nje, uma ngicaphuna enkulumeni kaMhlonishwa uNgqongqoshe uthi: (Translation of isiZulu paragraphs follows.)

[Thank you, Chairperson. Hon Minister and the House, in your budget speech we heard that you have allocated R8 million and more and it is the biggest budget in all sections of your department. It should be so, and we appreciate that. Life should come first, nothing can happen if people are sick.

The bad thing, which does not sound good in your department, is the leaving of experienced health professionals for other countries. It is good because they do not hide the fact that they leave our country. This route of experienced health professionals leaving the country should be closed; they leave because it only benefits other countries.

Firstly, and I quote the hon Minister, where she said in her speech:]

A significant portion of the budget will be used to consolidate existing programmes. However, I would like to highlight a notable, new feature that is the special allocation to attract and retain the valuable services of skilled health professionals.

Kuhle kakhulu lokhu okushiwo uNgqongqoshe, futhi kungafezeka uma ukwaneliseka kwezisebenzi kulo mnyango kuqala laphaya besaqeqeshwa, belolongwa, bephekwa ukuze babe yilokhu esithanda babe yikhona. Ababuzwe ubumnandi bokuthandwa nokunakekelwa, nokukhuseleka emsebenzini abawufundelayo, bangafisi ukuwela baye kwamanye amazwe anamathuba angcono nemali phela.

Sengathi izitshudeni ezifundela ubudokotela, umkhakha phela esishoda ngawo kangaka eNingizimu Afrika azinakho lokhu kukhuseleka. Abanazo ngisho izinto zokuhamba ezibahambisa ezikhungweni ngokomsebenzi abawufundelayo, bayazibonela njengechwane lenyoka, bagibele amatekisi, izitimela nokunye nokunye, bese kuthi-ke laba abazalwa ngongxiwankulu ababevele bebusa bahambe ngezimoto zabo. Izitshudeni ezifundela ubudokotela neminye imisebenzi aziphumi emakhaya ongxiwankulu, ziyahlupheka.

Siyawubonga uMnyango wezeMpilo ngokubanika imifundaze. KwaZulu-Natali bahamba phambili ngemifundaze. Siyabonga Ngqongqoshe womnyango ngale mifundaze, sengathi lunganda lolu sizo kubantwana bethu abaludingayo. (Translation of isiZulu paragraphs follows.)

[What the hon Minister is saying sounds very nice, and can be fulfilled if the satisfying of health professionals starts when these people are still being trained so that they will become what we want them to become. They should feel the joy of being loved and cared for and also of being protected in the work they they are trained to do, so that they will not desire to go overseas to find greener pastures.

It looks as if the students who are training to be doctors, a career in which we are greatly lacking here in South Africa, do not have this security. They do not even have transport that will take them to the hospitals in which they are getting some of their training. They have to see how they can get there. They use taxis, trains and other modes of transport. But those who come from rich families use their own cars. Students who are training to be doctors and students in related fields do not come from rich families, they are poor.

We would like to thank the Department of Health for giving them some study loans. In KwaZulu-Natal they are number one in giving study loans to these students. We would like to thank the hon Minister for these loans and bursaries. We wish this assistance to our children to be extended.]

My great concern here is the lack of security our medical students experience while they are training for such a wonderful career in an area in which South Africa has a great need. No official transport is allocated or provided for their use when visiting areas of tuition, whether in townships or suburbs or other hospitals. They have to rely on their own transport. They feel neglected and insecure, especially those of our children from previously disadvantaged communities. Day in and day out, they suffer torment, while their counterparts from well-to-do families use their cars for such trips. This leaves much to be desired. Certainly these students, once they have completed their training, will leave the country for better pastures abroad.

Zolo lokhu eKhayelitsha, khona lapha eKapa kubulawe unogada, abahlengikazi bayesaba ukuqhubeka nomsebenzi bafuna ukhuselo oluthe xaxa. Kunzima ukusebenza esikhathini samanje ngenxa yokwanda kobugebengu nokungahloniphi impilo yomunye umuntu. Kuningi engabe ngiyakusho isikhathi asingivumeli. Futhi ngiyambona nje uSihlalo laphaya usezovele angicishe. Angivele ngizicishe-ke khona ungakangicishi. Ngiyabonga. [Ihlombe.] (Translation of isiZulu paragraph follows.)

[Recently in Khayelitsha, here in Cape Town, a security guard was killed and nurses are afraid of continuing with the work and they need intensified security. It is difficult to work nowadays because of the crime and those disrespectful of other people’s lives. I have a lot to say, but time is against me, and I see that the Chairperson is about to switch my microphone off. Let me switch it off myself, before he does.] Thank you. [Applause.]

The DEPUTY CHAIRPERSON OF THE NCOP (Mr J M Mahlangu): Akusiye uSihlalo okuncishayo kodwa yilabo abakunikeze isikhathi sokuthi ukhulume. [Uhleko.] [It is not the Chairperson who deprives you of time, but the people who allocated the time for your speech. [Laughter.]]

But, I heard Mrs Dipuo asking us to warn her beforehand. I agree with her. When I press the button the first time, members should know that they have one minute left. When I press for the second time, members should end their speeches as their time would have ended. [Laughter.] Dr G M RAMOKGOPA (Gauteng): Chairperson, hon Minister and Deputy Minister, colleagues and hon members of the NCOP, I stand here to support the policy direction and priorities as outlined by the Minister of Health in improving the health of our people in South Africa. We must agree that, as we enter the second decade of freedom in our country, we have acted decisively to improve the quality of life and health of our people.

We must also agree that we have made significant progress that could only have been made by people focused on making our country a better place to live in. Equally, we must also agree that we still have some way to go in ensuring that we deal decisively with the consequences of 300 years of fighting to destroy an ill system of colonialism and apartheid.

We remain guided by the knowledge that there are many ordinary, indeed extraordinary people who paid dearly with their lives for us to attain our freedom. Our inspiration comes from the ideals of stalwarts such as Victoria Mxenge and martyred doctors such as Ribeiros of Mamelodi, and also those ideals expressed by the young MK soldier Solomon Mahlangu who, when sentenced to death by the apartheid regime, declared that “my blood shall nourish the tree that will bear the fruits of liberation”.

As we prepare to celebrate a decade of our liberation, the fruits that Solomon Mahlangu spoke of are evident in the improved accessibility of health services for all our children, women, people with disabilities, the elderly and communities in general. There are areas that we still need to reach, but overall there has been an improvement.

Gauteng has been given an R8,1 billion budget which represents 30% of the Gauteng provincial budget. This will certainly go a long way in investing and building a caring and quality health care system and contribute to better health for our people. I have listened quite passionately and agree fully that we need to move towards a situation of equity, but we must also acknowledge that even in provinces such as Gauteng inequity remains.

Gauteng has the second largest population in the country, surpassed only by KwaZulu-Natal. The discrepancies are quite wide. The richest live in Sandton, and the poorest live just a stone’s throw away in Alexandra. The budget will be used to ensure that we achieve our vision of health for a better life for all our people, especially those who are vulnerable to diseases and injury. Through this budget, we will be able to build on achievements and will focus on three strategic goals. These are promoting health to prevent illnesses … re gopole gore thibela malwetsi, e phala kalafo … [… we must remember that prevention is better than cure.] … providing quality, accessible and efficient services in terms of clinics, hospitals and ambulance services and ensuring value for money and being an effective organisation by investing in our personnel and human resources as well as improving systems that will enable us to deliver better.

The budget aims to help the people of Gauteng to push back the frontiers of poverty by investing in its most important resource, our people. Working together with our sister departments and communities, we will continue to advance the frontiers of health and prosperity. In this financial year we have been able to focus on equity within the province. In this financial year we have allocated the budget in such a way that there is an equitable distribution of resources amongst the three regions. All regions have received an above-inflation increase, but some have received more than per capita expenditure that is more equitable and based on the needs of the communities.

The spin-off will be a positive incentive for patients to access services closer to where they live, thereby reducing overcrowding in areas previously better resourced. In this case, the Ekhuruleni-Sedibeng region will benefit with a higher increase for primary health care services. We have also ensured that we protect the centres of excellence in our province which are also our national assets, and we are the envy of the private sector and other First World countries.

To this extent, we have identified a number of these centres and we will be able to pool them at tertiary institutions. This includes health public schools, the neurophysiology unit at the Pretoria Academic Hospital, the trauma oncology unit at Johannesburg, and the renal and hand units at Chris Hani Baragwanath Hospital. The list goes on. We will continue to build on these centres of excellence which are a national heritage.

In addition to the 5% direct increase allocated to tertiary services in the budget, additional resources for general and specialist services will be funded at regional hospital level. Family medicine and public health posts with universities will also be strengthened. I am raising this because a concern has been raised by our universities that the decrease in allocation for tertiary services for Gauteng means that we, as the ANC-led Government, do not treasure these centres of excellence. The redistribution of resources to other provinces will enable those provinces to provide quality care even at the tertiary level. I have met with the deans and vice- chancellors of these universities and we agreed that the contracts and capacity will be built in other provinces. We will also build other levels of services in our province as we restructure our health care system to fit the budget.

We have also prioritised the revitalisation of hospitals in previously disadvantaged communities and these received the second largest budget increase of approximately 9%. The biggest winner of our budget is indeed primary health care clinics.

Since 1997, there has been a huge increase in terms of visits to primary health care clinics. We had 4,1 million visits in 1997 and in 2002 this had increased to 10 million. Obviously, our people are voting with their feet. We have been able to increase the number of nurses and doctors and the availability of medicines at primary level. We are seeing a shift from hospital outpatients to our own primary health care services.

With respect to the improvement of investing in our staff, we fully support the national strategy of recruiting and retaining primary health care nurses. In this case, we have strengthened our ability to have nurses equipped to support the survivors of violence. We were trailing behind, but we will train our forensic nurses within this financial year. We have also provided more than R20 million annually to create new permanent nursing posts across all sectors of public health. We are continuing with initiatives of aggressive recruitment and retention strategies for nurses as well as those with other scarce skills, such as pharmacists.

I want to conclude by saying that we have been able to work with other service providers in particular in the private sector to ensure that we improve our initiative to reduce the burden of HIV/Aids. In this instance, we have successfully reduced the syphilis infection rate by 83% through this co-operation with the private sector. However, we also call on our colleagues in the private sector to assist us in improving the immunisation coverage for our children from 79% to over 85% in this financial year. Recent studies that we have undertaken show that whilst the public sector seems to be doing well, the private sector still trails far behind in this respect.

I wish to share with the NCOP our progress around improving our capacity to attract resources into the public sector, especially now that Gauteng has a higher proportion of private health resources. We have introduced units in a number of our hospitals starting with Johannesburg Hospital, Helen Joseph Hospital and the Pretoria West Hospital. We will continue with this approach. These facilities have been highlighted by a number of people who have used them, including some of my colleagues in the provincial government, as centres of excellence. I note that some members here have used these centres. These private wards are there to attract those who are privately insured. This will help to increase the purse of the public health service.

I must indicate that these are a benchmark. We are working towards reducing the gaps between the public and private sector and all our facilities will be of that quality. This is a benchmark that we have set for ourselves and we will achieve it.

We have been able to invest in the overall improvement of the health of our women. This year we will strengthen our province-wide cervical cancer screening programme so that women are able to identify cancers such as cervical cancer early on and do something about it.

Finally, I would like to say that we have made progress. We have invested in our people’s health, improved the human resource of our economy and made significant strides in pushing back the frontiers of poverty. I thank you. [Applause.]

Ms M A MOTSUMI-TSOPO (Free State): Hon Deputy Chairperson of the NCOP, hon Minister, hon Deputy Minister, colleagues from the provinces, hon members of the NCOP, honourable guests, ladies and gentlemen, as we enter the first decade of our hard-won freedom, the clarion call by the President, President Thabo Mbeki, made a while ago for the acceleration of service delivery, becomes louder. There is no question about the fact that the fruits of this freedom must be enjoyed by our people in their entirety, irrespective of their creed, political orientation or the colour of their skin. There is further no doubt about the fact that, since the onset of this democracy and freedom, this ANC-led Government has worked tirelessly to ensure that our people do indeed enjoy the fruit of this freedom.

As we engage one another around the Budget Vote that the hon Minister has tabled in this House, we are indeed mindful, as the ANC, that the challenges are still mammoth. Despite all the gains we have made in our endeavours to create a better life for all and to roll back the frontiers of poverty, many challenges still exist and we will not shy away from stating and addressing them.

This is particularly so in the health sector, as in any other sector of our society. As the deployees of the giant people’s movement, we of course take the lead from this movement to address these challenges and build on the people’s contract for a better life for all.

During its 51st national conference, our movement took resolutions around the following health matters, amongst others: strengthening primary health care services, especially in rural areas; improving the management and governance of hospitals and clinics; decisively attacking communicable and preventable illnesses; accelerating appropriate decentralisation of certain health services to local government; strengthening programmes for child nutrition; food security and improvement and nourishment, and so on.

Allow me to share with this House our plans to implement these resolutions this year and the progress we have made during the past years on these issues.

One thing that is key in the delivery of quality health services to the constituencies is the issue of personnel, as some of the members have correctly put it today. One of the resolutions of the 51st national conference of the movement states as follows: We need to ensure that norms and standards including staffing and service delivery, that are applicable across the country are implemented over the period of five years.

Undoubtedly, without proper personnel in our facilities we will not be able to advance quality health service delivery. It is for this reason that we have moved to ensure that we have proper minimum staffing levels in our institutions. We have managed to develop the new staff establishment for our hospitals, our community health centres and clinics around Qwa-Qwa, Thaba-Nchu and Botshabelo, which are currently run by the provincial government, and we are in the process of reviewing all the staff establishments of local authorities, including those of emergency medical services.

We have also managed to cost all our staffing levels needs, which come close to R135 million. We nonetheless have available an amount of R37 million and, during the course of this financial year, we will do everything in our power to ensure that we have the necessary personnel in place and will thus not rest until we have a positive outcome of this process.

Secondly, one other thing that is of critical importance in the battle for quality health service delivery, which is pinned on our primary health care services, is the accessibility of our people to our health facilities, particularly the clinics. The 51st national conference resolution on this matter is very clear: Strengthen primary health care, especially in rural areas. It is our intention as the province to train 100 community health workers in rural areas. Thirty-five mobile clinics have been procured to address rural health challenges and will soon be allocated to our various districts in the province. We will further implement the provincial rural health strategy in this financial year.

The clinic building and upgrading programme is also one of the critical programmes through which quality primary health care services can be realised, both in rural and urban areas. We have embarked fully on this programme. For example, since the implementation of the clinic upgrading and building programme, in 1994-95, 79 projects were handled and completed. During the 2002-03 financial year alone, we handled 25 clinic building and upgrading projects to the tune of R28,4 million which are now completed. Twelve of these projects are new clinics, 13 are upgradings. We are currently busy with 20 projects, of which 9 are new clinics, one is a community health centre and 11 are upgradings, amounting to a total of R35 million.

Surely we cannot just simply spend money on personnel and infrastructure to heal our people when they are ill without us looking into measures that can be employed to ensure that they do not fall ill in the first place. The role of health promotion is critical in this regard. As the Free State, we held our first conference on health promotion from 7 to 9 May 2003. The conference was funded by the World Health Organisation. This conference has given further impetus to our health promotion activities, as we now have a clear costed health promotion plan also funded by the WHO. As we embark on these health promotion initiatives, one of the diseases that should be at the centre of health promotion campaigns is the scourge of HIV/Aids.

The 51st national conference has taken a number of resolutions on this matter, one of which is the need to mitigate the impact of HIV/Aids. This disease remains a challenge that has to be addressed alongside other debilitating diseases, because in the province we are not going to elevate HIV/Aids alone and leave other debilitating diseases aside. Our battle against this disease has been advanced by the launch of the PMTCT sites and many other programmes that we have embarked upon. The PMTCT expansion programme, immediately following the court order, constituted the first phase of the expansion of sites in this province. The Free State health department is currently running a comprehensive prevention-of-mother-to- child-transmission programme in eight hospitals and 60 clinics. We are not going to rush, because we must make sure that as we deliver the service it is going to be of acceptable standard.

One programme that continues to present us with enormous challenges in some of the areas of our province is the emergency medical services. As part of the process of addressing this, we are in the process of establishing a control room which we anticipate will be operational before the end of the 2003-04 financial year. This control room is very unique. It will, beyond any doubt, improve the response time of our ambulances. We have placed an order for an extra 32 ambulances to replace some of our worn-out ambulances, as well as six commuter transport vehicles, amounting to a total amount of R9,5 million. These endeavours are in line with the resolution of the 51st national conference to ensure access to health care on a 24-hour basis. I must further mention that we are reviewing all 24- hour clinics and have designated all clinics as either 8-hour, 12-hour, 24- four-hour or on-call service clinics.

In order to address the challenge of the revitalisation of our hospitals, we have deemed it fit to enter into a public-private partnership with community health management, particularly for the revitalisation projects taking place at Pelonomi and Universitas Hospitals. This is the first collocation or public-private partnership concession agreement that we have entered into in terms of the Public Finance Management Act. The agreement with community hospital management involves Universitas and Pelonomi Hospitals. The department will generate an income of R206 million.

In conclusion, I want to congratulate the hon Minister Dr Manto Tshabalala- Msimang from the bottom of my heart, and thank her for the leadership she is giving to the health sector. You mustn’t become impatient and tired. You must continue in the manner in which you are doing things.

We must also make sure that the doubting Thomases of this world do not view this kind of advancement in the lives of our people as insignificant. Despite all their denunciation and accusations, we continue to work hard in responding to the call of the President for the acceleration of service delivery. Like the President, we are all moved by the squalor of our people, which they have been facing since the previous dispensation. We will never rest until the tide has completely turned around. One thing is for sure, the tide has turned. [Applause].

Dr P J C NEL: Dankie Voorsitter. Voor ek begin, wil ek graag die agb Adjunk- minister wat ook vandag in die Huis is, sterkte toewens met sy nooienstoespraak in hierdie Huis vandag. Nie dat hy dit rêrig nodig het nie.

Ek volg graag op die agb LUR van die Vrystaat. Soos u kan hoor, is daar geen twyfel dat die agb LUR in die Departement van Gesondheid in die Vrystaat onder haar leiding poog om ‘n kwaliteit gesondheidsdiens te lewer ten spyte van ‘n beperkte begroting. Ek sê ‘n beperkte begroting, want Die “equitable share” wat vanjaar aan gesondheid toegeken is in die Vrystaat, het maar net met 10,4% gestyg en as die gesondheidsinflasiekoers wat altyd omtrent 3% hoër is as die gewone inflasie in berekening gebring word, dan was daar in reële terme eintlik ‘n vermindering in die toegekende bedrag. Dit plaas ‘n geweldige las op die lewering van gesondheidsdienste in die Vrystaat.

Ek wil aan die hand doen dat by die toekenning van “equitable shares” aan die provinsies eerder die gesondheidinflasie as die gewone inflasiesyfers in aanmerking geneem moet word. Miskien kan Statistiek SA ook poog om gesondheidsinflasiesyfers gereeld te publiseer in die toekoms. (Translation of Afrikaans paragraphs follows.)

[Dr P J C NEL: Thank you, Chairperson. Before I begin, I would like to wish the hon the Deputy Minister, who is also in the House today, all the best with his maiden speech in this House today. Not that he really needs it.

I take pleasure in speaking after the hon MEC from the Free State. As you can hear, there is no doubt that the hon MEC in the department of health in the Free State, in her leadership, endeavours to render a quality health service in spite of a limited budget. I say a limited budget, because the equitable share that has been allocated to health in the Free State this year has only risen by 10,4% and if the health inflation rate, which is always about 3% higher than the normal inflation rate, is taken into account, then there was actually a reduction in real terms in the amount allocated. This places an enormous burden on the rendering of health services in the Free State.

I want to suggest that when equitable shares are allocated to the provinces the health inflation rather than the usual inflation figures should be taken into account. Perhaps Statistics SA can also try to publish health inflation figures regularly in future.]

I would like to thank the hon Minister for making available an amount of R500 million for the first time to try and attract and retain skilled professionals by improving the working conditions, accommodation and salaries of health workers in the rural areas. To retain the highly professional medical staff in our training hospitals, the provinces need more funds to maintain and replace highly sophisticated equipment that is vital for training purposes and for the highly skilled professionals to perform the work that they are trained for. Hon Minister, is it not possible that a conditional grant for the maintenance of equipment can be allocated to the provinces? Ek vra maar net. [I am only asking.]

It is of the utmost importance also that the mentioned incentives be implemented as soon as possible. The fact that according to the Democratic Nurses’ Association of South Africa approximately 300 nurses are still leaving our country monthly is appalling, as is the statement in the SA Health Review 2002 that 43% of the medical students have indicated that they are going to leave the country after completing their community service here.

That brings me to the HIV/Aids issue - the most serious threat to our people that this country has ever experienced. I have no doubt in my mind that the Department of Health has a comprehensive approach to this major challenge. However, the critical element that is still missing at this stage is a guideline for using antiretroviral drugs as part of the national treatment strategy.

We have learned from the hon Minister today that the report of the Joint Health and Treasury Task Team into the cost of various treatment options, including the use of antiretroviral drugs, would be presented to the Cabinet pretty soon in order to take a decision on this issue. I hope that this will be next week or sooner. Although the hon Minister has stated that the latest HIV prevalence survey at antenatal clinics confirmed that the rate of infection has stabilised, I can assure the hon Minister that this is not the case in the Free State. In this respect, I would like to quote from a speech delivered by the hon MEC of the Free State on 6 April in Bloemfontein:

Despite the progress we have made regarding our programme on HIV/Aids, I am nonetheless still troubled by the levels of HIV/Aids in the province. I want to give you a picture of this instance with statistics as regards regional hospitals in the province.

At the Bongani Hospital (Welkom Regional Hospital) in 2002, a total number of 3 045 children were tested for HIV and, out of this, 2 101 (69%) tested positive. In 2003, a total number of 709 children were tested and 663 (93,5%) children admitted to the hospital tested positive. Between February and April of this year, a total number of 529 adults were tested for HIV/Aids and 349 (66%) of these adults tested positive. This is a clear indication of the mammoth challenge we are facing.

I am aware of the fact that one of the arguments is that antiretrovirals are not a cure for this disease, but neither are the drugs used for hypertension, some malignancies, Parkinson’s disease, and many other diseases, but at least these drugs improve the quality of life and prolong the life expectancy of these patients.

There are millions of patients infected with HIV who need treatment urgently. South Africa has a moral duty to assist these people. Nobody knocking on the door of the health sector for help can be sent away empty- handed. I thank you. [Applause.]

Dr Z L MKHIZE (KwaZulu-Natal): Thank you very much. Chairperson, the hon Minister, Dr Manto Tshabalala-Msimang, Deputy Minister, Renier Schoeman, my colleagues and MECs and members of this House, firstly I want to congratulate the Minister on her speech and I also want to thank her for the leadership in the health sector. I must say that it’s a very demanding portfolio from a distance where we stand, but we also are impressed with your commitment and dedication. Equally, the staff in the department, from what we have seen, are also quite dedicated, hardworking, supportive and committed. And therefore my comments, as we start, are based on the fact that that is the kind of team that is working on the issues of health.

I want to say therefore that I was pleased to hear the Minister focusing on the issue of the budget, saying to the members that she would like the members to focus on the overall pressure on this department vis-á-vis the allocation of the funds. In particular, I want to say that, with all the dedication that we have, there is a lot of pressure on this department. One form of pressure comes from the problem of HIV/Aids. Another bit comes from the exodus of staff, and the other part comes from inadequate resources.

My colleagues here and myself are going to be indicating, and some have already done so, what has been achieved with the amount of money which we are grateful to have received. I want to submit that the hon members here in this House and the National Assembly need to focus on reviewing and improving or increasing the budget to the health sector. In particular, we have noticed that with the increase that we have received, we still have a challenge to deal with the queues in our precious department. They are becoming quite long and unmanageable. In fact, we still have a problem of staff members that are overworked and the shortages of staff. In some cases, we have had to reduce or freeze the posts in keeping with the budget. And sometimes when we look, at the end of the year, at a budget that is well-balanced, then I say to my colleagues in the Treasury that they must always remember that good bookkeeping does not equal good health care. And, in this case, we would only appeal to the members of this House to use their influence to assist us to deal with the situation where the health budget has to deal with an increase in patients who are sicker, with fewer staff and, therefore, patients come in more repeatedly, mainly because of the pressure of HIV/Aids.

I have also noted that in our case, for example, R2,9 billion is the backlog on the revitalisation of our facilities. At the rate that we are getting the conditional grants, it will take us 25 to 30 years to cover that. Therefore, I’m sure that this is the challenge that my colleagues are also facing in the different provinces. Therefore, we need to be careful with the increase - we need a little bit more of an increase - because we want to avoid a situation where we have to continue cutting down on the staff complement until the services collapse. On the issue of HIV/Aids which, as I said, is a major challenge, I think this is one which is responsible for the increasing numbers of patients that are coming in. We have, in our province, mobilised the churches together with Government and NGOs to do just about all that needs to be done in relation to the prevention, counselling and mobilisation of communities and families on the issue of care of HIV/Aids.

We also moved onto intensifying the treatment of opportunistic infections. As an example, just under a million Diflucan tablets have been distributed to deal with cryptococcal meningitis. This is over 60% of the distribution for the country. In this case we are very grateful to the Minister for clinching this deal, because it’s been very helpful. Post-exposure prophylaxis for staff who are involved in accidental injuries is available in all the hospitals and for rape survivors also. It is available at all major hospitals and community health centres. The prevention-of-mother-to- child-transmission programme is also available at all the hospitals and is now being rolled out to the clinics.

In so far as we are concerned with dealing with the issues of antiretrovirals and any other problem in relation to our five-year strategic plan, we have embarked on almost all the issues and now we’re preparing, as the whole discussion is now, for the issue of antiretroviral treatment. The issue here is that we need to have very careful and good planning in our antiretroviral programme, because we don’t want a programme that will come in and then collapse. And therefore we welcome the review that has been done by the Treasury and health committee on this issue, because it will help us embark on a programme properly.

Having said so, we are also focusing on the priority for this year, namely tuberculosis, and our main concern is the rising rate of multiple drug resistance to TB. We have set for ourselves, for 2005, the goal of increasing the cure rate from 29% to 85%, and the detection rate from 30% to 70%, and we want to halve the instance of TB by 2010.

We also have a target which was set by the President to eliminate malaria and here we are saying that we are on course to deal with that issue. Here again, we rely on the support from the Minister, because she’s been working on a huge programme in the SADC countries to deal with the problems of TB. We hope that our colleagues in Mozambique will start using Dots and we will also have to put up clinics on the border with Mozambique to actually deal with and treat patients there as they walk into the country, because 28% of our patients with malaria actually have come from the neighbouring countries.

Having said so, we also just want to say that we are concerned about the fact that the school nutrition programme is going to be under the Department of Education. If we were sadists we would also be saying ``good riddance’’, but it is actually quite a complicated programme and we are worried about the fact that the conditional grant is not going to be merging with the targeting strategy that has been set by national. If you are going the route of farm schools, rural schools, informal and township schools, we in our province estimate that we need an additional R500 million to cover that, and we believe this House needs to be aware of those particular issues.

I also want to echo the sentiments in the President’s speech when he opened Parliament and said, “The tide has turned.” We have the pleasure of having noticed a 76% reduction in the malaria rate in KwaZulu-Natal and here again we are grateful for the contribution of the national Minister in this case and, of course, we also congratulate her on receiving the SADC award on the best malaria control programme for South Africa.

We have also seen the reduction of cholera to about a 0,5% mortality rate and here the issue is related to problems of poverty, water, health, and education shortages. In this case, interestingly, we have reduced cholera, but in the area where it started, we have just seen an upsurge of a simple problem of scabies. This says that Health alone is not the answer to good health, but that we need an overall comprehensive development strategy.

We have also recorded 5 116 cataract surgical operations where we have people who were blind as a result of cataracts and have now regained their sight.

Minister, as mentioned, we have the commissioning and opening of the state- of-the-art Inkosi Albert Luthuli Central Hospital. I must invite members to come and view it, so that you are able to see the balance between some of the concerns that we have with regard to the Third World kind of health services, and the extent to which we can advance technology so that we are able to accommodate the best equipment available in the world as represented by what we can offer as well in this country.

We are increasing the number of ambulances from 218 in the next two years to 306, and the 24-hour clinics from 41 to 63. We are also increasing the number of community health centres by two every year, and we are going to be building an additional 20 new clinics every year. We will be doubling the nursing intake and increasing the number of community health workers. At this moment we stand at 5 000. We have allocated funds for additional equipment and our hospitals have also won good governance awards.

So, we are saying with this budget, with all the limitations that it has, that we are committed to pushing back the frontiers of poverty and providing a better life for all. I thank you, Mr Chairperson. [Applause.]

The DEPUTY MINISTER OF HEALTH: Thank you, Chairperson. Hon Deputy Chairperson, hon Minister, hon provincial Ministers and hon members of the NCOP, it is a pleasure to follow my colleague, the hon Zweli Mkhize, who I have a lot of contact with on nonmedical matters in our respective party connections in KwaZulu-Natal.

When I was appointed as Deputy Minister of Health on 4 November last year, I said I saw my appointment not only as a challenge, but also as a great opportunity to serve my country. I must say that this view has been reinforced by all my experiences since my appointment. I have also made a point of repeating, as often as I can, that I believe there is a new and positive political dynamic of putting South Africa’s interests first, which is gaining momentum in our country. I hold this view, because I think there is an increasing acceptance that the problems of South Africa are shared problems, which call for a shared commitment to resolve them. I will continue to play as positive a role as I can in this regard in the knowledge that, I believe, by serving the common good, the interests of all are best served.

I also wish to record in this House my appreciation for the warm welcome I have been afforded in the National Ministry and the Department of Health, also from the provincial health Ministers and their departments, from the chairpersons and members of the portfolio committees dealing with health in the National Assembly as well as the NCOP and from the health private sector. I must also share with this House that, as a functionary in the national Ministry, I have been impressed by the excellent and valued co- operation in Minmec, which is chaired and led by the hon Minister of Health.

I believe it is a good example of excellent teamwork and the collective effort in the spirit of common purpose. And I think their strong presence in this House here today again proves and underlines what I am saying.

So ek wil sê dit is ‘n voorreg om deel te wees van hierdie groot en toegewyde span wat oor die lengte en die breedte van ons land strewe vir gesondheid en gehalte in mediese sorg. [I therefore want to say that it is a privilege to be part of this large and dedicated team which strives for health and quality in medical care across the length and breadth of our country.]

In supporting the Budget Vote of Health in this Chamber today, I would like to recognise the special and valuable role played by members of the NCOP, especially in portfolios where the Constitution assigns concurrent functions to national and provincial spheres of government. The role of this Council in terms of the processing of legislation is well understood. I sometimes think that its value in terms of assuring accountability is perhaps underestimated and not given adequate recognition.

In portfolios like Health, where the greater part of the national budget is spent by provinces, the Select Committee on Social Services, under the able leadership of the hon Loretta Jacobus, promotes significant interaction with provinces, which assists in not only monitoring expenditure, but also in understanding the particular successes and challenges of individual provinces. I would like to acknowledge them specifically today.

The combination of provincial visits by members of the NCOP, reports to the NCOP, NCOP hearings and active participation of Health MECs in the debates, like we have seen today, contributes in a very unique way to the vital, interactive role that the NCOP plays in health administration in South Africa.

Ek wil net in hierdie stadium my voorbereide toespraak onderbreek en net verwys na berigte wat na my gestuur is deur ‘n bejaarde persoon wat sê dat hy baie bekommerd is oor gevalle en insidente en hy het ‘n aantal mediaberigte aangeheg, meeste van hulle uit die koerant, Beeld, in Johannesburg, wat gaan oor gevalle van slegte gebeurtenisse in hospitale. En ek gee onmiddellik toe dat wonderlike werk gedoen word in ‘n baie groot persentasie van provinsiale hospitale. Maar al wat dit weer vir my gewys het, en hy het geskryf, nie in ‘n negatiewe gees nie, maar in ‘n bekommerde gees; en dit het dit net weer vir my gesteun hoe dit ongelukkig werk dat, wanneer daar iets sleg gebeur, dit onmiddellik na vore kom en baie aandag kry, en baie goeie werk wat gedoen word nie na vore kom nie. Maar dit wys net ook weer wat die uitdaging is en in watter mate daar ‘n kollektiewe poging moet wees, op provinsiale, nasionale, en op elke vlak, om te kyk om ook hierdie soort van gebeurtenisse en voorvalle tot ‘n absolute minimum te beperk. (Translation of Afrikaans paragraph follows.)

[I just want to interrupt my prepared speech at this stage and refer to reports which were sent to me by an elderly person who says that he is very worried about cases and incidents, and he attached a number of media reports, most of them from the newspaper Beeld, in Johannesburg, which concern cases of unfortunate events in hospitals. And I immediately concede that wonderful work is being done in a very large percentage of provincial hospitals. And he wrote about it not in a negative spirit, but in a worried spirit; and this has just emphasised to me once again how unfortunate it is that when something bad happens it immediately comes to light and receives a lot of attention, and very good work that is done does not come to light. But that simply shows again what the challenge is and to what extent there should be a collective effort, provincial, national, and on every level, to see to it that events and incidents such as these are reduced to the absolute minimum.]

A critical factor in the quality of provincial health services is access to support services, such as laboratories, blood supplies, and so on. Both of these services have been restructured in recent years to form national entities that strive to serve all South Africans on an equal footing.

The National Health Laboratory Service was born as a public entity in October 2001, and is the sole provider of laboratory services to the provincial health departments. It has almost 300 laboratories around the country and its budget is close to R970 million, most of which is funded by fees for services provided. The fact of the matter is that the laboratories, large or small, are going to determine the success of this NHLS. Its laboratories in all parts of the country that support clinicians and thousands of public hospitals and clinics on a daily basis are going to be the test.

I believe it has got an important role to play in the rebuilding and building of this country’s health infrastructure, also in provinces and also in the very needy area of rural hospitals.

I am also pleased to be able to tell you that, in recent times, the NHLS has had an improved, more stable period after a difficult period that also culminated in the resignation of its first chief executive officer, but there has been a caretaker CEO in place since October last year, in the person of Dr Crisp. I want to thank him for his guidance and say thank you for the guidance of the chairperson, Ms Sesi Baloyi. It has stabilised and its services are improving steadily, and I think it is appropriate to thank them for the effort they have invested to get that service back on a firm footing. There is a new appointment of a CEO and I am confident that he will have the necessary insight and experience to continue to take the NHLS forward, paying close attention to the needs of provinces where the service is least developed, and the needs are the greatest.

Reference was made by one of the hon members here also today to the question of medico-legal laboratories and this is another area where restructuring has been long awaited. I would say that this year we hope to see further movement in terms of the transfer of these mortuaries from the Police Service to the provincial health departments where they belong, for very good and logical reasons.

Treasury has allocated funding for the capital works that need to be carried out at mortuaries to create facilities conducive to high-quality work. We are also discussing with Treasury the flexible utilisation of such finance over two or three financial years.

All provinces are giving their full co-operation and four provinces have already indicated that they will be in a position to begin the transfer of medico-legal mortuaries within 12 months of receiving funding for the renovations that are contemplated. From the side of the national department, we will continue to deal with and approach this matter with a sense of urgency.

Another area where collaboration with the criminal justice system has become critical and increasingly successful is that of combating pharmaceutical fraud. I am informed that a number of provinces have in the past year made significant breakthroughs in unmasking criminal syndicates at work, selling state drugs to the private sector. But, of course, criminals are notorious for their inventiveness and the Internet is increasingly becoming a vehicle for illicit trafficking of pharmaceutical products. The illegality of it lies in the cross-border nature of the operation and the fraudulent issuing of prescriptions to support Internet mail orders, and the fact that the drugs are often unregistered and of dubious quality.

Fortunately also this is investigated by the police and, just last month, one such operation was uncovered in Cape Town, where the so-called pharmacy to which foreign clients were sending their orders was nothing more than a suburban home. The prescriptions needed to dispense the Schedule 5 drugs on offer were issued by Cape Town doctors who have never seen their so-called patients. Clearly, the public needs to be made aware of how dangerous such operations are and that so-called virtual pharmacies are no substitute for the real thing.

In my participation in the Health Vote in the National Assembly a few weeks ago, I made the point that the view sometimes expressed from outside the system that the major challenges of HIV/Aids and TB are not taken seriously enough from the side of Government does simply not accord with the commitment I have seen within the public health sector to strengthening our ability to face up to the twin scourges of HIV/Aids and TB.

I believe that at this very moment serious consideration is being given by the Government, inter alia, to a number of aspects, but also to the matter of the extent of antiretroviral treatment, which underlines the seriousness with which the challenge of HIV/Aids is being approached. The position of the New NP, in respect of this, is on record and Dr Nel has also again referred to it today, and it is not necessary that I then repeat it at length, although it is taken care of in my prepared speech.

What I want to say is that, apart from this issue - and I say it again today - there is clearly a sense of purpose that lies behind a clear programme of action that is unfolding in accordance with the department’s five-year national strategy, and any claim that there is currently no plan for HIV/Aids is simply not true - it is very far from the truth.

Among the more interesting developments of the past two years is the birth of various partnerships between the public health care sector and private enterprise. They range from enterprises where the shares are divided between Government and the private sector, to differentiated facilities within public hospitals, to Government funding of nonprofit organisations and private sector sponsorship of public health campaigns.

A new entity for vaccine production has been brought into existence as a result of a partnership between the Department of Health and the Biovac Consortium. The purpose of this is to revive South Africa’s vaccine production capability through an infusion of private investment. Hospitals in a range of provinces have accommodated private patients or private sector initiatives within their provinces. And amongst them, the Johannesburg Hospital experienced immediate success with the provision of amenities for private patients to the extent that I believe they had to extend their capacity within just a few months of the launch. Also, there is the question of Universitas and Pelonomi Hospitals in Bloemfontein, which the hon MEC Tsopo actually referred to as well.

In KwaZulu-Natal, the flagship PPP is the new Inkosi Albert Luthuli Hospital, where a range of nonclinical functions are being outsourced. The underlying objective is to achieve better service in fields where the public sector has not been particularly effective.

When it comes to partnerships with nonprofit organisations, the department has recognised the potential of loveLife to add value to public health programmes. The department has entered into a three-way partnership with loveLife and the Kaiser Family Foundation to enhance health services for young people. At the heart of this programme is the process of creating youth-friendly services within primary health care clinics. The aim by the end of 2003 is to have a 150 youth-friendly clinics up and running and, thereafter, the pace of roll-outs should increase to reach 3 000 clinics in three to five years.

The recent multicountry Racing against Malaria initiative could not have been achieved without the generous support of a whole set or number of private sector companies. The 4x4 vehicles for the rally as well as many other costs were covered by donation. As in all the above examples, the real beneficiaries have been the millions of people who depend on the public health sector.

In conclusion, since taking up my position as Deputy Minister, I have come to appreciate the special and useful co-operation that exists between the health Ministers of the SADC countries. I have also become aware of the extent to which Minister Tshabalala-Msimang plays a significant role in promoting and nurturing this co-operation. For example, her presence at every major event along the route of the recent malaria rally demonstrates the kind of time, energy and commitment she devotes to regional co- operation to the benefit of the entire region.

Finally, I propose that the Budget Vote for Health be supported. The programmes that are funded are appropriate. They are central, both to the continuing improvement of the health sector and to providing ongoing support to provincial health departments in their delivery of service to the people of this country.

Ek steun graag hierdie begrotingspos en doen dit met vrymoedigheid. [I take pleasure in supporting this Budget Vote and I do so with confidence.]

Mnu M A MZIZI (KwaZulu-Natal): Sihlalo, Sekela likaSihlalo, ngivumele ngifake izwi lokuhoxisa likaDkt O S Baloyi okunguyena obezokwethula le nkulumo namhlanje la kule Ndlu. Ngenxa yezizathu ezingaphezulu kwamandla akhe, akaphumelelanga wase enginxusa-ke ukuthi angiyethule le nkulumo yakhe. Cha, Ngqongqoshe! Umbono wenkulumo elapha ukuthi ukuba bekungeyami bengizofaka isicelo ngisibhekise emadodeni asathenga iViagra. Cha, ayiqedwe laphaya emakhemisi ukuze kutholakale iNevirapine neminye imithi yalolo hlobo ukuze sikwazi ukulwa nalesi sifo esingunkuzi kayihlehli. [ Uhleko.] (Translation of iZulu paragraph follows.)

[Mr M A MZIZI (KwaZulu-Natal): Chairperson, Deputy Chairperson, allow me to pass on Dr O S Baloyi’s apologies for his absence. He was scheduled to deliver this speech today in this House. For reasons beyond his control he could no make it and therefore he asked me to deliver the speech on his behalf.

Minister, if this had been my own speech, I would have come up with a request directed to those men who still buy Viagra. The chemists should discontinue its supply so that nevirapine and medicines similar to that can be acquired in order to fight this devastating disease. [Laughter.]]

We all know that the greatest challenges facing the Government of our country are those faced by the social services cluster departments. The Health Department is one of the departments in that cluster.

In this debate, I will touch on the subject of health professionals. I will also touch a bit on the per capita health expenditure and spend a little more time on the primary health care services. This is the area I am familiar with and, in certain cases where relevant, I shall use the province of KwaZulu-Natal to illustrate points that I raise in my debate.

Let us take a look at the situation of health professionals in the province’s health department. There continues to be a decline in the number of professional nurses: 207 fewer in February 2003 compared to December 2001; a decline of medical specialists and registrars: 236 fewer in February 2003 compared to December 2001. There is also a decline in the number of dental practitioners and psychologists.

Initiatives to improve distribution and retention of personnel by increasing an existing rural allowance and broadening its scope to a wider range of health professionals are highly appreciated. The increase of R500 million to R1 billion is a case in point. The concern remains, however, that the inequities still exist in personnel distribution between urban areas and rural areas.

With respect to capital expenditure, we note that the department has budgeted for a major upgrading, replacement and transformation of hospitals. Of special note are the attempts to step up the hospital revitalisation grant in the 2003 budget where 18 hospitals are going to benefit in this financial year.

Having said all that, I would like to turn to more mundane issues that remain problems facing provincial departments of health. I will cite examples as I see them in my province, KwaZulu-Natal.

According to the report provided to us by the department in my province, they have 391 clinics including local authority clinics, which provide 1 135 consulting rooms. All of these clinics provide primary health care. Currently 41 clinics are providing a 24-hour service, and it is hoped that this year the number will increase by an additional 22 clinics - two in each district. This is highly appreciated. Of these clinics, it is a matter of concern that 13% are in a poor condition. Client transport to the clinics remains problematic with 28% having access roads to clinics. It is very poor. [Time expired.]

The DEPUTY CHAIRPERSON OF the NCOP (Mr J M Mahlangu): Order, hon Mzizi. I do not want to comment on your opening remarks. However, I see the hon Windvoël is very unhappy with that statement. [Laughter.] Maybe the Minister will comment about that; I’m not sure. [Laughter.]

Nkst M P THEMBA: Mgcinisihlalo, Make iNdvuna, tiNdvuna tetifundza, malunga eMkhandlu waVelonkhe wemaProvinsi, ngetfuke kakhulu bengingati kutsi KwaZulu-Natal basebentisa le-viagra. Yona ikhona kona kodvwa abalinciphise leliphilisi bangalisebentisi lonkhe. [Luhleko.] (Translation of Siswati paragraph follows.)

[Mrs M P THEMBA: Chairperson, madam Minister, Ministers in the provinces, members of the NCOP, I was very shocked; I did not know that in KwaZulu- Natal they are using Viagra. Yes, it is there, but has to be minimised. They should not use the drug as it is. [Laughter.]

The Select Committee on Social Services last month invited all nine provinces to participate in the Intergovernmental Fiscal Review interrogation process with the specific purpose of examining what provincial priorities are with regard to their health budgets.

All provinces were also asked to outline some of the challenges facing them in meeting the health needs of their communities. Almost without exception, all provinces highlighted the fact that their budgets do not adequately cover their human resource needs. Some provinces, due to both the public service moratorium and shortfalls in their budgets, found themselves unable to fill critical posts, leaving service delivery in a shocking state.

It became abundantly clear during our deliberation in the select committee that we need to re-examine the system of allocation to some of our provinces, especially the poorer provinces, when the time comes for the adjustments estimate. Although the budget information has improved remarkably in scope, reliability and availability largely as a result of a system overhaul in Treasury, including the introduction of an MTEF programme, the passing of the PFMA and a presentation of audited statements on spending by government departments, legislatures and other public entities, we still need to balance the real needs of each province with reliable programmatic costing analysis.

Macondzana neNgculaza, HIV/Aids, leliTiko leTemphilo kanye naletinye tinhlangano litibophelele ekucedzeni lolubhubhane lwengculaza. Kungako nje kulesabiwotimali kukhushulwe kakhulu sabelo lesimacondzana nalesifo. (Translation of Siswati paragraph follows.)

[With regard to HIV/Aids, the Department of Health and other organisations have taken responsibility for eliminating the pandemic scourge of HIV/Aids. That is the reason behind the increased allocation for this in the budget.]

We believe that the allocations to provinces are not going to be a problem but a challenge for provinces to rise to the occasion and spend money wisely. Already provinces have risen to the challenge by putting measures in place, such as treatment, care, prevention, education and training, and research programmes.

Under the aforementioned categories, provinces have run social awareness campaigns, have had condom distribution programmes, capacitated community members with regard to home-based care, launched local HIV/Aids counsellors, embarked on ongoing training of health profession and community members with regard to voluntary counselling and testing, piloted sites in almost all provinces for the prevention-of-mother-to-child- transmission programme services and introduced improved life skills programmes in schools, among other endeavours. The list is endless. Obviously, with the increase in the HIV/Aids budget, these programmes are expected to both increase in number and intensify in deliverables.

I would like to congratulate the MEC of the Northern Cape for giving us the information on the gender focal point because, with regard to the gender focal point in the department, most provinces reported that contrary to the National Policy Framework for Women’s Empowerment and Gender Equality and the national Department of Health’s gender policy commitment, provinces were not paying sufficient attention to this vital function.

The GFP bears the responsibility of supporting and monitoring all directorates and institutions in identifying and addressing gender inequality or inequity. It is therefore an obligation on all sectors that they have fully functioning provincial and local GFPs to assist in fostering gender awareness, lead the process for developing health sector- specific indicators, conduct health sector-specific analysis on gender disparities, and to develop a comprehensive sector plan, amongst others.

From the provincial hearings, it appeared that these gender focal points did not have sufficient support in all provincial health departments. In many provinces there was only one person allocated who would raise an alarm around gender issues within the Department of Health. Clearly, we need to improve on this phenomenon.

The GFPs need to able to give input and participate in gender-related issues. They should be allocated at the heart of management and management decision-making. This means that they should be placed in the office of the head of the department at the provincial level. However, the Department of Health has a number of programmes. I have got in front of me the National Gender Policy and it has policy guidelines.

Also very important is that it promotes new attitudes, values and behaviours, and a culture of respect and gender equality throughout the health system - actually promoting the concept of Batho Pele. If we can help in the implementation of this policy, it will actually improve the service that we are getting in our hospitals and in the clinics.

However, the Department of Health has a number of programmes for the improvement of women’s health, which include the reduction of maternal mortality rates, the expansion of the awareness campaigns for screening of cervical and breast cancer, termination of pregnancy services and the prevention-of-mother-to-child-transmission programmes, amongst others. Most of these programmes are directed through maternal, child and women’s health directorates.

The challenge of providing reasonable health service for all remains an area in which the Department of Health and all of us should work together to improve service delivery. We have provided progressive legislation and policy to bring about health standards that can compete with the best in the world, but it is in the area of implementation that we need to focus our attention, especially in … [Time expired.] [Applause.]

Ms M N S MANANA (Mpumalanga): Mr Chairperson, hon Minister of Health, Dr Manto Tshabalala-Msimang, Deputy Minister of Health, members of the NCOP, my colleagues, delegates from provinces, ladies and gentlemen …

… ngithanda ukuqala ngokuhalalisela uNgqongqoshe wezeMpilo ngesabiwomali asethule lapha kule Ndlu. Ngithanda futhi nokumhalalisela ngendlela aphethe ngayo umNyango wezeMpilo. Yingakho siphelele sonke lapha singama-MECs avela ezifundazweni. Ngisho khona ukuthi sisemuva kwakho kukho konke okwenzayo. (Translation of isiZulu paragraph follows.)

[… I would like to firstly congratulate the Minister of Health on the budget that she has presented here in this House. I would also like to commend her on the manner in which she is running the Department of Health. That’s the reason why we are all here as MECs from the provinces. I am saying that in everything that you do, we are behind you.]

The Director-General of the WHO, in her address to the 55th World Health Assembly on 13 May 2002, said:

Forging real change is not easy, you have to confront established ways of thinking and working. But if you are convinced, as I am, that change is essential for our shared purpose, then there is no opportunity to yield to short-term pressures because this would be the more comfortable way to go. I have never seen real change happen easily. Never in history was equity achieved without a battle. That is why I am not demotivated by facts, but am inspired by the truth.

In the past few years, we’ve been through an exciting and challenging programme of transforming the organs of state both physically and mentally so as to accelerate service delivery. The public health system has been transformed from a racial one into an integrated comprehensive primary health care system, responding to the needs of the people with a particular bias towards historically disadvantaged communities.

Our journey to the provision of quality health care services has not been an easy one. The manner in which we have carried ourselves has been a good one in responding to the health needs of our electorate.

The previously disadvantaged communities, especially the poor, know how much we have achieved because they know and understand where we come from and where we are supposed to go. These are the people who never allowed the past to deter their conviction that, one day, a better life for all shall be the order of the day.

Health is brought within the reach of everyone in the community and implies the removal of obstacles to health, including, among others, malnutrition, ignorance, an inability to earn a living, poor sanitation, water supply and unhygienic habits.

The core responsibility of the Department of Health is to keep citizens healthy in order for them to be productive members of society, and a healthy and secure community is much more likely to be able to play a positive role in development. Poverty remains a threat to health for all.

The department will contribute and work with other departments on an intersectoral programme led by the Department of Agriculture and Land Affairs, as the President of this country has indicated that we should push back the frontiers of poverty.

With regard to primary health care, the approach remains at the centre of ANC health policy. More South Africans today have access to health care. We have deracialised our clinics and hospitals, built new facilities, and started on the physical rehabilitation of many of the existing institutions. We must increase the effectiveness of our integrated comprehensive health care, understanding the interconnection between poverty, nutrition, clean water, sanitation, hygiene and health.

I would like to announce to this House that the Mpumalanga College of Nursing has been accredited by the South African Nursing Council to train the post basic course in primary health care. The training will start in July in this financial year.

Regarding the Integrated Nutrition Programme, in terms of combating hunger, the primary school nutrition programme has improved in sustaining delivery over the period of nine years. As a result of this, the budget allocation for the programme has been increased from R39 million to R62 million.

Concerning HIV/Aids, STI and TB, the department started with the site in September 2001. Currently, the programme is available in 20 hospitals and 19 clinics. We intend to increase the number of sites to 55 by the end of this financial year.

Voluntary counselling and rapid testing have been expanded to 99 sites. This financial year we intend increasing voluntary counselling and testing sites to 183. For the promotion of the use of condoms as a means of empowering women, distribution of female condoms has been extended to 13 sites. The rates of syphilis infections among pregnant women remain stable and this is due to most clinic staff being trained in the syndrome management of sexually transmitted infections. Furthermore, we have also noted the general increase in the usage of condoms due to an accelerated and concerted awareness campaign.

Regarding the partnership campaign, we have officially launched a women partnership against Aids. On 5 December, we launched the traditional leaders’ task team because we believe that traditional leaders can play a vital role in the fight against Aids. The department is in the process of launching Mipa - Men in Partnership against Aids - in this financial year. We believe that men can make a difference in the fight against HIV/Aids. [Interjections.]

It is an undeniable fact that tuberculosis remains one of the major challenges facing us. This is due to the fact that the majority of people still live under conditions of poverty. Hunger is a factor in the interruption of TB treatment.

With regard to cholera, there were 228 patients who were admitted and treated at Tonga and Shongwe hospitals for diarrhoeal conditions; and 91 patients were positively confirmed as having cholera and at least three patients have since died. I visited the hospitals and the area mostly affected by cholera, like Block B, on the 12th. I was so impressed by the dedication and the commitment of the nurses who are the backbone of this department. Patients were happy to be nursed by the nurses. I was amazed by the teamwork displayed by the health workers, that is, the medical managers, doctors, nurses, environmental health officers, health promoters, etc. I would like to repeat myself by saying: Thank you once more. Keep up the good work you are doing.

Concerning malaria, in April we participated in a major advocacy and social mobilisation initiative known as Race Against Malaria. I would like to thank professional nurse, Mr Victor Gwebu, who was part of the convoy that drove from South Africa to Dar es Salaam on behalf of Mpumalanga. This financial year we will continue to use DDT in spraying the households.

With regard to expanding programmes relating to women’s health, we need to empower women to take informed decisions about their health and to prevent unwanted pregnancies. We have engaged in awareness campaigns educating women about the health of their bodies and the availability of the termination of unwanted pregnancy services.

On the question of improving child health, it is critical to ensure that we set our target of immunisation by implementing the integrated management of childhood illnesses programme. [Interjections.]

Before I conclude, I would like to report that, with regard to chronic health services, the department cares about people with disabilities. The budget for the provision of assistive devices is increased from R5 million to R7,6 million.

In conclusion, I would like to inform this House that the construction of the new Piet Retief Hospital is progressing well, as is that of Themba and Rob Ferreira. In line with the above, the total amount allocated to the department of health is R2 101 811. For the equitable share, it is R1 821

1. For the conditional grant, it’s R269 974. I thank you. [Applause.]

Mr S MOLOTO (Northern Province): Chairperson, the democratic Government has, since its inception in 1994, adopted a primary health care policy as the backbone of the new health system in the country. Lessons learned in the past nine years of democratic rule in South Africa have consistently indicated the significance of this policy approach, with the building and upgrading of more clinics which improve access to health services.

The 2002-03 financial year presented us with the rare opportunity to interact closely with communities we serve. From April, health Letsema month, various imbizos and road shows were able to assess the impact and constraints of our policies from the community’s perspective. We listened judiciously to the complaints and concerns raised by our people during these interactions. What has been exciting about these interactions is the fact that our people are fully supportive of the Government’s policy and programmes. The people’s concerns mainly revolve around policy implementation. This calls into sharp focus the need for us to re-engineer and re-oil our delivery machinery in order to cope with the new delivery mechanisms.

We have raised the point before in this House that most of the challenges which we continue to confront and deal with in the health sector normally originate and reside in other sectors. These external factors, which have a direct bearing on the delivery of quality health services, will include, as has been mentioned by the colleagues before me the adequate supply of water and sanitation; electricity supply; a reliable road network and infrastructure, and security in our facilities.

These factors are a nightmare in the rural and underdeveloped provinces like Limpopo, obviously the Eastern Cape, and KwaZulu-Natal and the Northern Cape. At the moment, we are battling with a backlog in the supply of water to about 112 clinics in our province. You can imagine that if even an important public facility like a clinic or school is without an adequate water supply, what about the communities themselves? We have been fortunate that, in the past rainy season in Limpopo, we have not experienced any cholera outbreaks like in the previous seasons. We believe that our community mobilisation and general health promotion programmes are beginning to take root and are being internalised by our people.

We have seen a gradual increase in our immunisation coverage since the adoption of a primary health care policy. It is not surprising that the younger generation may not know much about the diseases which have been haunting our people even though they are preventable. There is a remarkable reduction in the incidence of small pox, measles, polio and others.

This is one achievement we are overlooking as a nation as a reason to celebrate because, in the past few years, these diseases were imposing untold misery on the lives of our people. We hold a view that as a Government and a nation we are more susceptible to the dictates of our detractors whose aim is to derail us and make us focus somewhere else. It is time that we count our achievements and join our people in celebrating the achievements of our democracy.

The major challenge which we need to overcome in relation to our immunisation programme is the break in the cold chain as our electricity supply in the rural areas has not, as yet, reached every facility and, in some instances, the supply is not that reliable.

One of the issues which our people constantly raise and complain about in the various forums has always been the issue of ambulances and emergency services. In our province, we have been trying to cope with the demand for fleet replacement and proper management. The state of our road network and infrastructure has proven to be the major obstacle in the realisation of this goal. In some instances, the new fleet does not survive for more than six months and the vehicles will then be parked in the state garage. The question which we are constantly asking ourselves is whether we should not concentrate on the provision of a proper road infrastructure in order to keep our emergency service vehicles, that is ambulances and other support services, on the road longer. We remain convinced that the fleet replacement route is not a sustainable solution to this problem. The problem of the road infrastructure also affects the provision of mobile services to the rural communities and the outlying farming areas.

There have always been two factors which impact on our ability to provide a 24-hour service in our clinics. One is the shortage of personnel and the other is the provision of adequate security. As has been mentioned by the colleagues before me, many of our nurses are continually threatened, mugged and even raped in clinics whilst on night duty. Besides adequate and appropriate staff numbers, the issue of security provision in our clinics stands out as one of the obstacles which prevent access to primary health care services in our province. We have decided to allocate funds for the provision of at least one armed security guard for 24 hours in all our clinics this financial year. The number of guards will increase depending on the risk assessment from area to area.

We cannot agree more with the assertion made by the President when he called for a development which is integrated. The issues of intersectoral and multisectoral collaboration in development cannot be overemphasised.

We have previously used this platform to raise an issue which continues to be a nightmare in the health sector, and I think my colleagues have already alluded to it. There is a shortage of health care professionals in most of our facilities. The staff provision in the country follows resource allocation and development patterns. It is common knowledge that there are still inequities in our resource allocation. The 2003 Intergovernmental Fiscal Review reflects a per capita expenditure on health for Gauteng at R1 668, while Limpopo stands at R627. That is a difference of more than double what Limpopo is spending on health. Surely this type of situation cannot be allowed to continue lest, like my colleagues said, the poor will have to continue voting with their feet. We will continue to call for the review of the equitable share formula.

We are succeeding in making our facilities and service points cost centres in order to improve our management systems. We have appointed CEOs in most of our hospitals and both our human resources and financial management have improved tremendously. These managers are confronting the issues of corruption, fraud and theft head-on. We have also seen an improvement in management of repairs and maintenance.

Despite the challenges and constraints we have alluded to, we are confident that we are on the right path. We have gradually been seeing our health indicators becoming more comparable with the more endowed provinces like the Western Cape. This is one factor which motivates us to continue persevering.

Important issues have been raised and I deliberately ignored the temptation to respond to the issues raised. Let me state that I am going to be quoting someone who is a very notorious person these days, a person I am not very comfortable quoting, but I am inspired by the essence of the statement he makes. That person is Tony Blair. Tony Blair once said that if he could not get his national health system right, he would quit office before he was pushed out. I think the essence of this statement tells us how important health is, if you look at Britain and how it has developed as a nation. [Applause.]

Mr A E BALOYI (North West): Chairperson, hon Minister Dr Manto Tshabalala- Msimang, hon MECs and hon members of the NCOP, let me present to you the report from the North West province’s department of health. I am here representing the MEC, Dr Sefolaro, who is out of the country on other governmental matters. I stand here to support the policy direction on health as presented by the Minister of Health, Dr Manto Tshabalala-Msimang. Indeed, the ANC-led Government is on track in accelerating service delivery in line with the RDP which emanated from the Freedom Charter of 1955.

Let me give the profile in terms of the North West province. The population of the province is around 3,4 million. We have four districts and 22 subdistricts. The outline and guidelines forwarded to us are as follows: provincial health services in terms of the overview background, health services priority programmes, expenditure patterns and budgetary allocations for 2003-04 and pushing back the frontiers of poverty.

Allow me to put our strategic goals as a department: providing quality health care and accessible, equitable and affordable comprehensive primary health care services and well-functioning and competitive hospital services, and improving the health status of communities through the implementation of what we call integrated health programmes. The list is endless.

I am going to highlight strategic issues for budgetary considerations which emanated from the President’s speech and the Minister of Finance, Trevor Manuel, in terms of poverty eradication, HIV/Aids, the equipment budget and partnership with local government structures.

Of course, in terms of Black Economic Empowerment through the SMMEs and in line with the macroeconomic strategy, in terms of the preferential procurement policy framework, medicine procurement, home affairs and birth registrations, combating of crime and the Skills Development Act of 1998, the list is endless.

In terms of pushing back the frontiers of poverty, in terms of household food security, income-generating projects through small-scale farming, NGO and CBO sector approach, access to health services and supplies, PSNP benefits children and women. The scheme targets severely malnourished children and TB patients.

In terms of incoming-generating projects, of course, we have implemented small-scale farming in Ventersdorp and other centres so as to benefit the youth, women, disabled and the larger communities.

I have an overlapping document here. Please pardon me.

In terms of HIV/Aids and STI, the male urethral discharge incidents decreased from 3% to 2,8%. The syphilis prevalence rate remains at 4%. The HIV prevalence rate among antenatal clinic attenders increased from 22,9% in 2001 to 25,2% in 2002. Also, in terms of HIV/Aids and STI, we have established 322 VCT sites and they are functional. About 1 310 nurses were trained in rapid testing and 664 were trained in counselling.

In terms of PMTCT, we have increased from 2 to 89 and, in terms of health care workers, we have trained about 392. Out of 82 children tested for HIV at nine months, only nine were found to be HIV-positive.

With regard to decentralisation, we have completed what we call the PSNP, and we have implemented the programme accordingly in terms of national standards. In 2002, it reached 85% of targeted children as opposed to 58% in 2001. More than 660 women groups benefited from this initiative. Of course, the income was about R5 000.

In relation to oral health services, the number of outreach clinics visited increased by 30% and prevention services have increased by 35%. Twenty new fully-equipped surgeries with state-of-the-art equipment were opened between 2001-02, 80% of them in rural areas.

In terms of our capital project achievement, for the HR and R projects, doctors reside in three district hospitals, for example, Schweizer-Reneke, Ventersdorp and Jurie. There is a medical psychiatric unit in Taung and there are maternity units, a laundry, kitchen and boilers in the Mafikeng complex.

I think we have some challenges in terms of, firstly, human resource development and what we call interdepartmental collaboration. There is the unavailability of doctors when it comes to the doctor-patient ratio. There is inequality in capital spending with specific reference to other provinces. We need to review this particular matter, hon Minister.

We have a lack of health facilities in rural areas. There are inadequate facilities for HIV/Aids campaigns and we are doing little about that.

Batho ba a tlhokofala. [People are dying.]

In conclusion, let me take this opportunity to thank the Minister and the support staff of the Health department. Hon Minister, keep up the good work. We support you. [Applause.]

Mr P MEYER (Western Cape): Deputy Chairperson, before I start with my prepared speech I would like to register my deepest sympathy with the family of Dineo Thuledi, a female security guard who was shot and killed at one of our health care centres on 1 June 2003 in Khayelitsha. I would further also like to inform the Council that an awaiting-trial prisoner, Mr Johannes van Rooyen, an inmate at the Valkenberg Psychiatric Hospital, was found in the ceiling where he had been hiding since Friday afternoon.

National Minister of Health, Dr Manto Tshabalala-Msimang, Deputy Minister Schoeman, fellow MECs, members of the Council, I rise to support the budget of the hon Minister. I wish to use this opportunity to share the Western Cape’s view on health priorities, the Western Cape’s expenditure pattern and the provincial allocation for 2003-04, and health programmes aimed at pushing back the frontiers of poverty.

Health services in the Western Cape are famous for their achievements. At the same time, the services are subject to severe budget constraints, and we have to work very hard to make ends meet. I believe that an urgent debate is required in South Africa to determine the minimum acceptable levels of health service and funding.

In view of an increased burden of diseases, the Western Cape identified the following health matters to be among our priorities for the following year: fetal alcohol syndrome; diseases of lifestyle - diabetes and hypertension; tuberculosis - especially the combination of TB and HIV/AIDS; mental health and patients on treatment prescriptions for chronic medication. Waiting times are increased and drug shortages occur, which complicates health matters for this province.

Restructuring of the health service is another priority. Health management realised that we could not continue to deliver the service in the manner of the past, and our current budget provides for the new approach towards health service delivery as contained in our Health Care 2010 Policy in the Western Cape. Health Care 2010 was approved by the Western Cape provincial government in March 2003, and contains 10 important initiatives to enable Health to provide an improved quality service, which is accessible to all citizens of the Western Cape and beyond. These are: clarity on health services to be delivered at all levels of care; agreement on the location of facilities; revision of the staff establishment; replacement of obsolete equipment; development of standard treatment guidelines; preparing clear referral guidelines; upgrading of the emergency medical services; stimulating health promotion; restructuring of the service for chronic TB and mental health patients, and aligning the budget with Health Care 2010 and the department’s strategic plan.

During 2003-04, my management team will address 24 crosscutting priority projects. The total health budget for 2003-04 is R4,29 billion. The health budget constitutes 26,2% of the provincial budget. We shall spend 62% on staff salaries.

I would like to spell out the challenges and pressures in the budget for 2003-04. If expenditure for the previous financial year was projected into 2003-04, and the effects of inflation factored in, my department faces a theoretical shortfall of more than R100 million. The budget for drugs and medical consumables is under enormous pressure, particularly in the large teaching hospitals like Groote Schuur and Tygerberg.

I cannot therefore categorically pledge that my department will be able to remain within the allocated budget if we are to meet our obligations to the people of the Western Cape. Something will have to give.

Some health programmes, such as the Integrated Nutrition Programme and programmes for the disabled, aim to alleviate poverty directly. It is therefore vital that health provides for these in our budget. Health services to pregnant women and children under the age of six and primary health care are already provided free of charge.

Die nasionale Minister van Gesondheid het op 13 Mei 2003 in haar begrotingstoespraak aangekondig dat mense wat permanent gestremd is, én dit daartoe lei dat hulle matig tot ernstige probleme ondervind om normale lewenstake uit te voer, later vanjaar in aanmerking sal kom vir gratis mediese sorg. Hierdie diens sal nie gratis beskikbaar wees aan diegene met mediese fondse, diegene wat tydelik gestremd is nie, en chroniese siektes wat nie aansienlike verlies aan funksionele vermoë skep nie.

My Departement van Gesondheid in die Wes-Kaap sal met betrekking tot die gratis sorg vir gestremdes verantwoordelik wees vir die verskaffing van vervangbare toestelle, soos brille, en vir bystand aan nuwe gestremdes. (Translation of Afrikaans paragraphs follows.)

[The national Minister of Health announced in her budget speech on 13 May 2003 that people who are permanently disabled, where this leads to them experiencing moderate to serious problems in executing normal tasks in life, will be considered for free medical care later this year. This service will not be available to those with medical aid funds, those who are temporarily disabled, and those who have chronic diseases that do not create a considerable loss of functional ability.

My department of health in the Western Cape will, in regard to the free care for the disabled, be responsible for the provision of replaceable equipment, such as spectacles, and for aid to people who have become newly disabled.]

The Western Cape will receive a conditional grant of R34,6 million for the Integrated Nutrition Programme during 2003-04. We managed to feed 158 000 children attending 881 schools during the course of 2002-03, and we intend to reach at least 147 578 learners at 861 schools during 2003-04.

Health, as hon members know, is complex. For this current financial year, the budget which I presented to the Western Cape legislature will buy in essence the following for the people of the Western Cape: nurse-driven primary health care services for more than 3 million residents of the province in 242 fixed and 130 mobile clinics; medical practitioner- supported primary health care services offering more than 12 million patient contacts per year; admission for more than 180 000 patients and 450 000 outpatient visits at 36 level 1 hospitals; reduced prevalence of HIV/Aids through various programmes including PMTCT and VCT programmes; increased cure rates for tuberculosis and supplementary food for all eligible primary school children for the 170 days of the school year.

It will also include: emergency medical services provided by trained staff in fully equipped EMS vehicles that cover 14 million kilometres per year; specialist care in 9 regional and four psychiatric hospitals that admit 166 000 patients each year and highly specialised care for 950 000 patients in central or academic hospitals. This includes 118 000 admissions from the Western Cape and 94 000 patients from other provinces at the Groote Schuur Hospital, Tygerberg and Red Cross.

Please be assured that the Western Cape health department will do everything in its power to tackle its responsibilities towards the poorest of the poor, ensuring that a quality health service is rendered to all the citizens of the Western Cape and beyond.

We shall continue to strive towards: “Better care for better health, all day, every day.” I thank you. [Applause.]

Ms N P KHUNOU: Chairperson, hon Minister, hon members, health involves the whole sum of a human being, which has spirit, body and soul. If you talk of health, you think of conditions of living which have to be improved. Section 27 of our Constitution says:

(1) Everyone has the right to have access to -

   (a)  health care services, including reproductive health care;


   (b)  sufficient food and water; and


   (c)  social security,  including,  if  they  are  unable  to  support
       themselves and their dependants, appropriate social assistance.

(2) No one may be refused emergency medical treatment.

The President in his statement of January 8 addressed to the ANC said that:

… our movement long recognised the fact that good health is a fundamental requirement of a better quality of life. Many of our people are victims to diseases of poverty. We must adopt a comprehensive and balanced approach to the challenge of providing health for all, based on a more accurate understanding of the incidence of disease in our country.

It is true that in order to improve the quality of our lives, we need to tackle all setbacks including poverty, segregation and so on. Hunger brings instability and vulnerability to diseases. In our country we have terrible scourges, which are tuberculosis, malaria, cholera and HIV/Aids, which increase the mortality rate of our people. More children are orphans because of these pandemics.

Indeed, our Minister once said that we have fought many wars and won them, and we will win this battle. Today, she reported that there is a great improvement in combating this pandemic. Health, as it relates to the wellbeing of individuals, brings knowledge together. Knowledge is to know both what one knows and what one does not know. It makes our minds work together. It brings attention to all, irrespective of political affiliation, race or gender. Instead of attacking our Minister every now and then in the media, we need to be contributing positively to ridding ourselves of these scourges, and give our suggestions. There is a lot that has been done by the Government and we need to congratulate our Minister on that. To ensure quality services, which is the basis of any equitable sustainable health care programme, and to ensure sustainability to enhance motivation and certify ownership, health facilities must be part of a quality improvement process. The apartheid regime in South Africa established a fragmented health service which lacked the strategic approach and community involvement needed to ensure high-quality care. We have policies and other measures have been introduced. There is a progressive realisation of the right to health care services. We are conforming therefore to international best practice and the Human Rights Commission report of 2000-02 agrees with that.

Implementation is still the biggest challenge. A lot of clinics have been built, but the question of accessibility to them is still a problem in rural areas. Roads still need to be built to access these clinics. At times, when it rains, no one can walk on those roads. It is still a problem for the people who are working. I am talking about the closing times of the clinics. Even during weekends, people who are working cannot access clinics.

Implementation of the national HIV/Aids/TB syndrome intervention programme provides services to the youth and women. The expansion of services through the use of mobile clinics has promoted the right to health care, especially in rural areas. The Equity Project is a package which defines basic standards, personnel, equipment and suppliers needed at each level of the health system. Community involvement improves the working-together spirit. We need to help our Government in any way we can.

The Equity Project partners have improved clinical skills to deliver primary, secondary and tertiary health care services through training and technical assistance. It also addressed transport challenges to improve effective delivery of priority programmes. There are women in rural areas who have skills in delivering children, who are not recognised. Children are born at home through the assistance of the women with these skills. When their mothers have to get their birth certificates at Home Affairs, it becomes a problem because this is not recognised at all. Is there any way of recognising these skills? For example, accreditation should be looked into.

Most of our health care workers do not want to work in rural communities. We need to look into the question of incentives. The question of nurses who, after being trained by the Government free of charge, go overseas is also a question that needs to be looked into. We need a serious investigation into this and to improve the quality of standards so that they stay in our country. Stringent measures need to be taken. Contracts need to be signed, which will bind them to doing their work here. It is therefore heartening to learn that the department has a budget allocation of R500 million for recruitment and training of health professionals to serve in rural areas, as the Minister said today. This allocation will also address the question of incentives, which I talked about earlier. As the Minister puts it, the international brain drain has been addressed as there will now be laws regarding professional nurses.

We had visits from provinces on budgeting issues. Limpopo reported that the equitable share formula from Dora dictates that 19% of the provincial allocation has to be given to health. The Department of Education and the Department of Social Welfare … [Time expired.] [Applause.]

The MINISTER OF HEALTH: Are you the Deputy Chair? I want to know so that I can address you correctly. Are you the Chair of Chairs? [Laughter.] I honestly want to say thank you to all who have participated in this debate and those who listened patiently to the debate. I think it has been quite an exciting debate.

Just listening to the debate this afternoon, a thought crossed my mind, particularly when listening to the achievements of the department, particularly in the provinces. I just wondered what the apartheid Parliament used to debate, particularly on the health budget, if you take into account the backlogs that we inherited from them. I was just wondering. I can’t believe that they spent an afternoon like this debating a health budget. [Laughter.] [Interjections.] But I am sure you used to listen.

Of course you heard that we did not shy away from challenges that we face. We will confront these head-on. I am happy that all of us have heard from the MECs what is happening in the various provinces. I think you can see for yourselves that we are trying our best to provide quality health care services to our people. I also hope that you have noted the interprovincial inequities, which we must continue to address. In spite of all this, I think you have gotten a sense that we are trying our best to deliver quality health care services to our people.

There are a number of things that seem to flow from the presentations by the MECs. I think these are about, for example, narrowing the gap in terms of equity and resource allocation. It seems to me that in improving the equity, it may also help - I hope that the NCOP colleagues here will help us in this regard - to challenge provinces not to reduce health budget allocations from equitable shares, whilst the conditional grants increase, because that does not help us. I hope we will monitor that as members of the NCOP. But, also, we need to continually ensure that interprovincial equity is also prioritised. I am hoping that the members of this Chamber will assist us in this regard.

I think another priority that came out in the debate is that of recruiting and retaining our human resources. I will not elaborate on this, because I dealt at length with this issue. The other one was the revitalisation and maintenance to our health care facilities. I think another area which most of the MECs referred to was the emergency medical services. The last one which also seems central to our debate is the improvement of quality of health care services that we deliver to our people to ensure that our patients are treated with respect and dignity.

I just want to acknowledge, in particular, the point that was raised by Ms Themba regarding the importance of the gender focal points and the need to mainstream gender issues into the health policy and programme implementation. I hope that the NCOP will monitor the establishment of gender desks in all our provinces to ensure that they are structured and placed appropriately. I am hoping that this is something that we can discuss with MECs on Friday in our Minmecs, so that I get first-hand information as to how the gender focal points are functioning.

There are just two last things that I want to refer to. As you know, on 23 May, by consensus, we adopted the Framework Convention on Tobacco Control. I must pay tribute to our negotiators, particularly from our country, because I think they played a very important role in ensuring that Africa always, in every debate and discussion, had one voice. We spoke in one voice. I think, in this regard, I would like to honestly single out Advocate Patricia Lambert, because she stood in for me and chaired all the sessions. I think that, with her able navigation of the process, we were able by consensus to even influence the United States to adopt the Framework Convention on Tobacco Control. [Applause.]

I just want to announce that 16 June - of course, as South Africans we were very clever; we chose this date because, as we all know, it is our Youth Day, and it was thus that we decided to influence the World Health Assembly

• has been designated as the date on which to sign the framework convention. We will be travelling to Geneva to sign the framework convention. I will be taking with me two young people to demonstrate our focus on the youth of our country with regard to tobacco control. I wish I had money to take one from each province, but it is not possible because the funds don’t allow me to do so unless, of course, the members of the NCOP will donate money so that each province … [Laughter.]

The last thing that I would like to say is that, on 6 June this year we signed the agreement with the Global Fund for the malaria control programme. I am sure that it is going to please most of us in this Chamber. The primary recipient of the funds is the MRC. As you know, this programme includes Swaziland, South Africa and Mozambique. So we are very excited that we were able to sign this agreement with the Global Fund. [Applause.] Thank you very much. May I say that you are all invited for a Chakoda. [Laughter.] [Applause.]

                   JUDICIAL MATTERS AMENDMENT BILL

  (Consideration of Bill and of Report of Select Committee thereon)

Mr R M NYAKANE: Thank you, Chair. I am instructed by hon members to be kort. [brief] I am going to be kort. Chairperson and hon members, I rise to table this statement in respect of the Bill before us, on behalf of the Select Committee on Justice and Constitutional Development. I table it with a full understanding that not a single member was opposed to the passage of this Bill during our interrogation of the Bill.

The amendments before us are aimed at correcting deficiencies that have arisen in practice and giving effect to Government policy, especially with regard to the advancement and empowerment of the previously disadvantaged. In order to address the imbalances that exist with the appointment of trustees, liquidators, judicial managers, and similar functionaries in solvency related matters, and in order to actively advance and empower previously disadvantaged people, in line with Government policies, the Department of Justice and Constitutional Development is developing a policy on the procedures for the appointment of these functionaries.

The aims of the policy are, inter alia, creating uniform procedures in all the Masters’ offices with regard to the appointment of trustees, liquidators, judicial managers, and similar functionaries; promoting consistency, fairness, transparency and achievement of equality for persons previously disadvantaged by unfair discrimination, and thus making the industry accessible to them, and promoting the image of the insolvency practitioners and the Masters’ Division.

We are therefore amending the Insolvency Act of 1936, Companies Act of 1973, and Close Corporations Act of 1984 to make it clear that the Master must act in accordance with policy prescribed by the Minister when making this appointment. In order to ensure that the policy is developed with the involvement of the role-players, provision is also made for the policy to be tabled in Parliament before publication. This amendment will ensure that there is necessary transparency in the appointment of these functionaries.

The Cabinet member responsible for the administration of Justice appoints a Master for each High Court in terms of the Administration of Estates Act, Act 66 of 1965 and they are obliged to carry out their duties and exercise their powers in terms of this Act, the Insolvency Act of 1936, and other related legislation. It is undesirable that each Master has different approaches and practices in respect of important or highly publicised matters such as the appointment of trustees, liquidators, and similar functionaries in insolvent estates.

We are therefore amending the Administration of Estates Act, 1965, to make provision for the appointment of the Chief Master of the High Courts. The Chief Master will, as the executive officer for the Masters’ offices, exercise such supervision over all the Masters’ offices as may be necessary in order to bring about the required uniformity.

As I said in my introduction, all members of that committee agree to the passage of this Bill, unless somebody decides to be impossible at this particular juncture. Thank you very much. [Laughter.] [Applause.]

Debate concluded.

Bill agreed to in accordance with section 75 of the Constitution.

The Council adjourned at 17:39. ____

            ANNOUNCEMENTS, TABLINGS AND COMMITTEE REPORTS

ANNOUNCEMENTS:

National Assembly and National Council of Provinces:

1. Introduction of Bills:

 (1)    The Minister of Environmental Affairs and Tourism:


     (i)     National Environmental Management Amendment Bill  [B  29  -
          2003] (National Assembly - sec 76) [Bill and prior  notice  of
          its introduction published in Government Gazette No 25052 of 3
          June 2003.]


     Introduction  and  referral   to   the   Portfolio   Committee   on
     Environmental Affairs and Tourism  of  the  National  Assembly,  as
     well  as  referral  to  the  Joint  Tagging  Mechanism  (JTM)   for
     classification in terms of Joint Rule 160, on 11 June 2003.


     In terms of Joint Rule 154 written views on the  classification  of
     the Bills may be submitted to the  Joint  Tagging  Mechanism  (JTM)
     within three parliamentary working days.

1. Draft Bills submitted in terms of Joint Rule 159:

 (1)    The Minister of Environmental Affairs and Tourism on 29 May 2003
     submitted the following Bills:


     (i)     National Environmental Management Amendment Bill, 2003
     (ii)    National Environmental Management: Biodiversity Bill, 2003
     (iii)   National Environmental Management:  Protected  Areas  Bill,
             2003


     Referred to the Portfolio Committee on  Environmental  Affairs  and
     Tourism  and  the  Select  Committee  on  Land  and   Environmental
     Affairs.

1. Bills passed by Houses - to be submitted to President for assent:

 (1)    Bill passed by National Council of Provinces on 10 June 2003:


     (i)     Judicial Matters Amendment Bill [B  2B  -  2003]  (National
          Assembly - sec 75).

National Council of Provinces:

1. Messages from National Assembly to National Council of Provinces in respect of Bills passed by Assembly and transmitted to Council:

 (1)    Bill passed by National Assembly on 10 June 2003 and transmitted
     for concurrence:


     (i)     National Small Business  Amendment  Bill  [B  20B  -  2003]
          (National Assembly - sec 75).


     The Bill has been referred to the Select Committee on Economic  and
     Foreign Affairs of the National Council of Provinces.

1. Referrals to committees of tabled papers:

 (1)    The following papers are referred to  the  Select  Committee  on
     Finance:


     (a)     Report and Financial Statements of the Sasria for 2002.


     (b)     Government Notice No 631 published  in  Government  Gazette
          No 24845 dated 16 May 2003: Borrowing powers of  Water  Boards
          listed  under  Schedule  3,  Part  B  of  the  Public  Finance
          Management Act, 1999 (Act No 1 of 1999).


     (c)     Proclamation No R 34 published  in  Government  Gazette  No
          24772 dated 17 April 2003: Commencement  of  the  Division  of
          Revenue Act, 2003 (Act No 7 of 2003).


 (2)    The following papers are referred to  the  Select  Committee  on
     Local Government and Administration:


     (a)     Strategic Plan for the Department of Provincial  and  Local
          Government for 2003-2006.


     (b)     Medium Term Strategic Plan  of  the  Department  of  Public
          Service and Administration for 2003-2006.

TABLINGS:

National Assembly and National Council of Provinces:

Papers:

1. The Speaker and the Chairperson:

 (a)    Report and Financial  Statements  of  the  South  African  Human
     Rights Commission  for  2001-2002,  including  the  Report  of  the
     Auditor-General on the Financial Statements for 2001-2002.


 (b)    Strategic Plan of the South African Human Rights Commission  for
     2003-2006.

1. The Minister of Arts, Culture, Science and Technology:

 (a)    Report and Financial Statements of the Foundation for Education,
     Science and  Technology,  including  the  Report  of  the  Auditor-
     General on the Financial Statements for the period 1 April 2002  to
     30 November 2002 [RP 38-2003].


 (b)     Report  and  Financial  Statements   of   the   South   African
     Geographical Names Council for 2001-2002.

1. The Minister of Water Affairs and Forestry:

 (a)    Southern African Development  Community  Protocol  on  Forestry,
     tabled in terms of section 231(2) of the Constitution, 1996.
 (b)    Explanatory  Memorandum  to  the  Southern  African  Development
     Community Protocol on Forestry.