DEMOCRATIC NURSING ORGANISATION (DENOSA)
Comments on the White Paper for the Transformation of the Health System in South Africa
18 March1998

1. INTRODUCTION
The Democratic Nursing Organisation of South Africa (DENOSA) expresses overall support for the direction the White Paper is taking. The Department is commended for the comprehensiveness of the document which addresses the realities facing the health system of our country.

An extensive written submission was made during June 1997. Many of the comments and questions on clarification have been addressed in some of the health related legislation promulgated during 1997. Most of the comments are therefore still applicable although some answers are still outstanding.

We have been made aware of the fact that the Health Bill will be based on the content of this White Paper and therefore would like to submit this document for your consideration

2. ISSUES FOR FURTHER DISCUSSION
2.1 Quality Assurance
No reference to quality improvement and quality control programmes are found in this document and due to the fact that DENOSA did attend a meeting on quality assurance in the health services at the Department of Health, it could be an oversight. Provision of quality health care is the professional and ethical responsibility of all health care practitioner and contribution to a safe environment for both the patient and the health care personnel.

2.2 Reorganising the Health Service
2.2.1 Structure of the Department of Health
The process of the transformation of the health services indicates a move towards primary health care. Management of the health services also needs to be transformed and persons at the lower levels empowered to manage the services at their levels with clear policy guidelines from the central level. It is strongly recommended that person at the lower levels be informed of the developments.

2.2.1 lntegrating the Public and Private Health Sectors
The principle of a public-private mix of health care to promote equality in service is approved of. The nurse can play an extremely important role in this sector as indicated in a submission made to the Department of Health during November 1995. As the private sector has to be able to provide a comprehensive package, the implication is that the health practitioners have to be enabled to form a group practice. This is currently not possible as the legislation of the Medical, Dental and Supplementary Health Service Professions Act states that these person may not go into a partnership with persons other than those registered under the same act. The Nursing Act also has the same provision but nurses can, on a written request, obtain the necessary approval from the Nursing Council to go into a partnership with a person not registered under the Nursing Act.

Caution should be exercised with regard to regulating the private sector to prevent over regulation as this may be counter productive. DENOSA is aware and is participating in the consultative process in the subcommittee on the Regulation of the Private Sector

2.2.3 Primary Health Care
The terminology used for the various categories of workers in the primary health care field and the hierarchy of service provides should be clearly defined to prevent any misunderstanding of the new structure. It is further strongly recommended that the team should included translators in order to leave the nurses who usually do the translation, free to do what they are supposed to do. Nurses are usually equipped to service the patients in languages of their choice which not only saves time, but also limits the possibility of making mistakes due to lack of understanding.

The definition of the core package of services that should be available is also still outstanding. DENOSA supports the principle that all South African citizens of this country should have access to health care, irrespective of their ability to pay. The Government should, however, define the minimum services that everyone is entitled to. In doing so quality and ethical considerations should be made.

2.3 Developing Human Resources
DENOSA would like to know more about "vocational training" which means different things to different people. Education and training of nurses have for many years included a service delivery component. If "vocational training" means internship, it would therefore not be necessary for nurses to do additional vocational training. Should obligatory services/ internship/ vocational training become a reality, it should include all students in higher education and not only the health care professions. Adequate mentorship should then be available for these students.

To enable and motivate people to work in the rural areas, the necessary infrastructure and incentives should be created. Other incentives which do not need to have financial implications could also be looked at, e.g. access to higher education for further training can be made easier for those who worked in the rural areas by providing them with additional credit or by placing them at the top of the list.

The curriculums of nurse training are being addressed to ensure a full primary health care approach and the enabling legislation for the nurse to deliver a primary health care service as the communities' first contact with the health service is appreciated. Updating and further education is, however a serious problem due to the lack of sufficient training facilities and the serious shortage of staff making it very difficult for nurses to enter into further education opportunities. As an Organisation looking after the interest of nurses, DENOSA has to indicate that this situation (lack of training and shortage of staff) places the nurses in a situation where the nurse runs the risk of making mistakes.

2.3 Occupational Health
DENOSA is pleased to note that development of occupational health services has been identified as a priority for the Department of Health.

Occupational Health Clinics also provide a very important primary health care service to the workers of the company. It is clear from the whit paper whether primary health care and occupational health will be separated. In practice the occupational and primary health care aspects are integrated e.g. a person presented with a back problem. Back problems can result from the job the employee is doing. If the primary health care service was not available together with an occupational health service at the work site, the problem could become worse and the symptoms, but not the root of the problem, be addressed or a suitable solution obtained.

The combination of services conforms with the "one - stop supermarket" principle referred to in the white paper by providing a holistic service to the employee. This has proven to be a system which contributes to the employee's health and well being resulting in reduced absenteeism, improved productivity and reduced injuries in the work place.

2.4 HIV/AlDS and sexually transmitted diseases
DENOSA fully agrees and supports the statement that the emphasis in containing the spread of HIV/AIDS will be on adequate capacity building at all levels. Empowering the nurses of South Africa with relevant information is a priority for DENOSA and some examples are enclosed as an annexure.

2.5 Other issues
Some other issues identified that could possibly be considered are:
investigating the role of transport to make services accessible - not only to get the patient to the service, but also to get the service to the patient/ community
the role of the rehabilitation team which is one of the four pegs of health service delivery. No indication has been given how this issue will be addressed by the Department of Health
provision of domiciliary services for patients recently discharged from hospital.

3 CONCLUSION
In conclusion we would like to confirm DENOSA's commitment to the transformation process and express our appreciation for the opportunity to participate in the process.

ANNEXURE C

COMMENTS ON THE WHITE PAPER ON THE TRANSFORMATION OF THE HEALTH SYSTEM OF SOUTH AFRICA.
APRIL 1997

GENERAL COMMENTS
There is overall support for the direction the white paper is taking. However, the process is questioned in that it is not clear why some bills/policies are first published as a green paper or a draft white paper but this document was immediately published as a white paper with no option to comment on the document.

The terminology used should be defined somewhere as it is not always clear what is meant by the specific type of health practitioner. It is also suggested that the term health personnel be used uniformly throughout the document and not be alternated, e.g. with health workers.

Concern was expressed about the structure being created in this document. It appears top heavy, over bureaucratic and unaffordable. Is such a structure workable? Many departments are created - such a functional management structure is very expensive. How will liaison and collaboration between all these departments take place? Can some of the Departments not be combined, e.g. food and oral health? What is the cost implications of this model? A projected costing for this structure is requested, including a comparison with the cost of the health structure before 1994.

No mention is made of translators as part of the health team, but should the possibility not be considered to appoint translators in the Department in order to make the nurse free to do the work she should actually be doing ?

SPECIFIC COMMENTS
CHAPTER 1
Health sector mission, goals and objectives

Page 15
(d)(v) IncIude promotion of healthy lifestyles healthy behaviour and health seeking practices.
(c)(vi) lnclude promotion of lifelong learning and commitment.

Page 16
(f)(ii) appropriate feedback systems should be put in place.
(f)(iv) lnclude: empowering the community representatives adequately to improve meaningful participation.

What about quality improvement strategies? How well is the service being valued by the personnel of the service and the users of the service? The Council for Health Services of Southern Africa (COHSASA ) is in existence and has already accredited a number of hospitals - why can their expertise not be utilised for this purpose?

CHAPTER 2
2.1 National Department of Health
Page 17, 18
The National Department should assist in making resources available interprovincially.

2.1.2 With regard to the staffing patterns that will reflect the national demographic structure, DENOSA will be monitoring the appointment of nurses to appropriate positions.
(a) Please clarify the role/functions of the policy co-ordinating unit.

Page 19
(c) Policy and Planning Branch - does it fall under (a) or is it a structure on its own on the same level as (a)?

Page 20 (ii)
Is private hospitals included in the subdirectorate on Hospital Development? Will this directorate also be responsible to do facilities audit?

Page 21 (iv)
No mention is made of continuous quality improvement or continuous quality programme planning.

Page 22 (v) and (c)
Implementation of continuous quality improvement strategies, including consumer evaluation, should be incorporated.

Page 23 (ii)
The phrase should read Women, Maternal and Child health because maternal health will automatically improve if women are healthy.

Page 24, 26
Concern is expressed about the many departments that are being created and need they all be separate departments, e.g. national disaster services and special services (can possibly be incorporated in HRD).

2.2 Provincial Departments of Health
Page 27 (a)
What does "where relevant" mean in this sentence - academic health services is a national issue. Clarity should also be provided of the responsibility, functions and resources of national and provincial services.
(g) This is reactive - proactive programmes should be instituted.
Include continuous quality improvement and control programmes.

2.3 District Health System
Page 29
(b) With reference to the conditions of employment and all district level staff getting the same benefits, serious problems currently exist. DENOSA would like to have the negotiating strategy that will be followed during the process of transfer of personnel from the province to the districts as well as a time frame regarding when this process will be taking place as DENOSA is a significant role player in this process.
2.3.2. What is the time frame for the implementation?

Page 30
(d) Does parity relate to the type of work, e.g. the doctor and the nurse/midwife doing the same work (normal delivery)? Will they be getting the same salary?
DENOSA wants to be involved in the negotiations for incentives for health personnel working in the under served areas. Does the Department have additional funds (separate from the budget allocation) available from which this will be funded?
What happened to the separate bargaining chamber requested for nurses?
(a)(ii) Include adequate empowerment of the community representatives to improve meaningful participation.

Page 31
Include the following:
(a)(viii) Continuous quality improvement and control programmes.
(b)(iv) Continuous quality improvement and control programmes.
(c)(v) Continuous quality improvement and control programmes.

2.4 Integrating the Public and Private Health Sectors
Page 32
2.4(b)(l) It is not clear why only some practitioners are listed as private practitioners - it is suggested that only the term practitioner be used in this section as the whole of section 2.4 refers to the private practitioner. The reference to midwife in this section should be nurse/midwife.
2.4(b)(iii) will this team include the nurse/midwife? The concept "MCWH management team" should be defined and should include all professional practitioners in the private sector.
2.4(b)(v) Management protocols should be appropriate, but it should not become over regulated. Although DENOSA supports the principle of managed health care, we want to caution against over regulation and limiting of choice.

2.5 lnvoIving the community
Page 33
(c) It is very important that it be ensured that a basic acceptable standard of service will be delivered. Accountability is therefore of the utmost importance. Community representation on the Boards is essential and these representatives should be empowered to improve meaningful participation. Add the following under 2.4:
(d) Strategies should be developed for appropriate cross referral systems. e.g. from doctor - to - nurse, and from nurse - to doctor. Financial imperatives should be developed for utilising appropriate services.
(c) Strategies for continuous quality improvement and -control programmes should be developed.

Page 34 (a)(ii) Add community structures and resources.

Page 35
2.5.2(a)(v) Add empowering the community representatives to improve meaningful participation.
2.5.2(a)(ix) Consumer evaluation should be done.

Page 36
(iv) "mechanism for responding timeously" - this is heartily endorsed. but this concept needs clarification.
(vii) also quality of care and satisfaction of the client population.

2.6 Primary Health Care
2.6.2 PHC package
This section is extremely confusing and differs quite significantly from the HRD workgroup's document. The terminology should be defined - what is the PHC nurse and what is the difference between the PHC and the Community Health Nurse? The hierarchy of service providers also needs to be defined. The generalist nurse needs to be the first contact for consumers, first referral the PHC Clinician nurse and then the doctor. The table is not complete in that it left nurses out in many of the sections e.g. mental health services, health education, communicable diseases, occupational health, health services support and emergency nurses (trauma nurses). Should speech therapists not be included?

Page 39
Will private practitioners for sessional work include nurses? Nurses must be included at district level where the private sector is necessary to deliver public health services. Appropriate referral systems should be developed and should include all health professionals.
Add 2.7 Implementation of continuous quality improvement and control programmes by using COHSASA which is already established and has accredited a number of hospitals.

CHAPTER 4
Developing Human Resources

4.1 Planning Human Resources
4.1.1 National Framework for Training and Development
Page 54(a)(ii) Clarification on this issue is needed - by whom and on whose authority will this audit be done and on what basis? Will it include standards?

4.1.2 Optimal use of skills and expertise
Page 55 4.1.2.(a)(l) and (ii)
Clarification on this section is necessary. Where does these figures come from? This section is extremely confusing. e.g. the composition of the health care teams.

Page 56
(iii) What is a mid level worker and what skills, level of knowledge and information will these workers have and where will they fit into the service? Distance learning is not sufficient for developing skills.
(v) The fact that no more medical assistants will be trained is appreciated. DENOSA does not support the current training of medical assistants and this must be guaranteed. What is the scope of practice of these assistants? What salaries will these people be receiving - it should not be more than nurses are getting.
(vi) Although community health workers will not be incorporated into the public service, they will be trained. What type of control and standardisation will there be? Once trained who has control over them and supervise them? What is the long term view - how is it envisaged that public safety will be guaranteed?

Page 57
(viii) Foreign practitioners should be restricted to the public sector. Volunteer doctors MUST register with the INMDC. Language problems should be taken into consideration and the Department must guarantee that the nurse will not be used as an interpreter.
(ix) Consultation on legislative changes should be addressed with an appropriate consultation process. This section is not significant and confusing. It does not highlight the problems or priorities for consultation. The whole principle of deregulation and conditional authorisation is not addressed. The nurse's scope of
practice should be changed to enable her/him to make a diagnosis and not only a nursing diagnosis.

Page 58
(x) Role clarification should be done regarding the function of SAQA and the SANC. DENOSA supports the authority of the SANC. SAQA should not undermine the educational role and responsibility of the
SANC.
(xi) Vocational training needs the terminology further defined. What is the intention of vocational training -there is no transparency here. If there is an educational imperative, it must be supported with sufficient reason, and if there is a service imperative, there should be transparency. Must all professions be included (even non-health professions) and if so how? Introduction of such a process must be a negotiated one. What about mentoring and support of the students? There should be commitment and support from senior staff members and the Department should make additional personnel available.
How does this section link to obligatory service discussed in 4.1.3(a) (iii) on page59?
(xii) Some clarity regarding the incentives offered is necessary - these people should not get paid at a higher rate than others who stayed in the country. There should not be discrimination against the loyal members of the health team

4.1.3 Equitable distribution
Page 59
(ii) Some more detail on the content and the financial feasibility are needed. What is the definition of professional staff - who will be included and what about the other health care workers?
The recommendation regarding the funding of nursing education is contradictory to what the National Commission on Higher Education is recommending. This statement is not acceptable as it stands until the placement of nursing education has been decided and an opportunity to discuss this issue with the Minister of Health is urgently requested.

(iii) Obligatory service requirements and/or internship should not only include health care personnel, but all students completing their formal higher education and training. The current working environment is not optimal and these students will have to be mentored/supervised - who is going to do that? The resulting extension of time to complete the course or to obtain registration with a professional council. will impact negatively on the recruitment of applicants for these courses.

4.2 Education and Training
Page 60
4.2.1 Education should also provide for critical thinking, clinical judgement and contextual sensitivity.

(a)(l) To ensure appropriate training of students there should be a link between the Department of Health and the Department of Education.

Page 61
The folIowing concepts need to be clarified/defined.
- PHC nurses
- District health managers
- Chronic disease managers

(ii) Co-ordination of training
DENOSA supports the co-ordination of health education and training in principle but is of the opinion that:
*a co-ordinating education committee (CEC) and the proposed functions is an education and not a health function This department should develop human resources in the services.
*how wiIl this CEC link with the proposed Higher Education Council?.
*how will this CEC impact on the autonomy of the professional councils?;
*such a CEC may lead to bureaucratisation.

This section states that the CEC will amongst other functions be responsible for recertification and accreditation which is contradicting what stands in paragraph (iv) on page 62 where it is stated that the professional councils will be responsible for this.

(iii) Visiting consultants should not be used as this is not in line with the RDP. The use of visiting consultants in general is not supported as it only' empowers people at the periphery' on a short term basis. It may' further also disempower the permanent employee.

Page 62
(iv) Who is going to pay for ability assurance and registration ? What resources will be made available for people to further their education?

(v) Why is oral health personnel identified as a separate entity in this section? It is a very small group of personnel and the motivation for making an exception of this group is not clear at all.

(a)(l) Outcomes based programmes should be identified.

Page 63
(iii) Refer to education and training. The expert task group referred to is not defined - who will this be? Is evaluation of post - graduate education not the function of the professional councils? Why should yet another body be established to do this which will also have a financial impact? In view of the list on page 61 how will this section apply?
4.2.3.(a) DENOSA supports the principle of equity and equalising balances.

4.3 Creating a caring ethos
Page 64
(a)(i) An ombudsman system for health should be established utilising the media.
(a)(ii)The rights of personnel should also include adequate remuneration, safety and respect for differences of opinion.
(a)(iii) Caring ethos
DENOSA supports the need for a campaign to engender a culture of caring, but this cannot happen before there is adequate resourcing of service delivery points.
Rewards for compassionate and caring service is a good idea, but how will this be measured objectively? Selection of health science students should also include personal qualities. The economic incentive to come nursing if nurses stay salaried workers, may nullify; the impact of the campaign.

4.4 Nature of management
Page 66
(a)(i) The health service manager should be defined and who will occupy this posts - will nurses be considered for these posts'? What is a chief nurse and what does this job entail?

Page 67
4 4.2.(a) The Department of Health has an in-service education role but not a primary, formal education role.
Democratic management principles are not supported - if every decision have to be voted over, it will paralyse the health service and disempower the management's authority. Participative management must rather be supported.

Page 68
(a) Outcomes based management evaluation should be implemented.
Include (b) Quality improvement.

4.5 Building capacity
Page 69
(a) Implementation strategy
The principle of managers with clinical management is supported.

The proposed appointment of an investigative committee is a surprise - what/who is the source of this? The appointment of such a committee has not come up at any of the consultative forums and certainly not from this stakeholder group. This proposal is unacceptable as:
* it constitutes vet another committee of the Department of Health with financial implications.
* it is not the function of the Department of Health, but the function of the SA Nursing Council.
The Department of health is exceeding its authority. The Department should approach the SANC to do this and submit input in the process/discussions as an important stakeholder.

Page 70
(a)(v) A rigid job description is not supported as it may lead to nitpicking and allow important things to fall through.
(a)(x) If appointment of managers on a contractual basis is not an interim measure, it should be clarified further.

4.6 Affirmative action
Page 72
(a)(i) Mechanisms should be established to review the representation of woman and nurses in the higher echelons of management at all levels.
An audit should be done to ensure that woman are enabled to be represented at all levels, e.g. by providing for child care facilities, job sharing and flexibility of hours. These issues should also be addressed in the benefits of service.

CHAPTER 5
Essential National Health Research

5.1 Research agenda
Page 75
5.1.1 (a) This represents another research structure in addition to others already in existence. How will this structure liaise with bodies such as the MRC and the HSRC? What will the authority and liability be and to whom will this body report to?

5.2 Research methodologies and priorities
Page 76
Research priorities should be re-evaluated on a regular basis. e.g. every 3 years. In addition to being goal-orientated, the research agenda should also have clear implementation phases and accountability in terms of funding and participants to achieve its goals.

Page 77
(c)(i) The Department of Health should not be the sole co-ordinator of the public health research activities as this represents a conflict of interest. There should be a strong community representation on this committee board to ensure that the process is not driven by political motivations.

5.3 Research should be relevant
(c)(iii) Incentive-driven process should be defined - this process must be equitable.
(c)(iv) It is recommended that the following statement be added: The principle of equity should be established in the allocation of funding for health research by nurses.

CHAPTER 6
Health Information
DENOSA approves this section in principle and has the following comments and questions:
* who will be responsible for the input and administration for this system?
* appropriate levels of personnel will have to be appointed for this purpose, thus additional staff;
* data collectors must be empowered and feedback provided to them.

CHAPTER 7
Nutrition
Page 89
(b) Reference is made in the first paragraph to strengthening of household food security - what does this mean. Please clarify this statement.

Page 90
(b) Control systems for feeding/nutrition programmes should be built in to ensure that it reaches the right people.

Page 92
(ii) More information is required regarding advocacy will be initiated to formulate policies for implementing income transfer that will improve the entitlement package for the rural and urban poor.
(iii) Concern has to be raised of additives being added to essential foods and water as people will not have a choice to have non-fortified products.

Page 93
The statement that the emphasis should be placed on information for action, and efforts should be made to avoid paralysis of action through overzealous analysis is strongly supported.

CHAPTER 8
Maternal, Child and Women's Health
All the right words are used but this chapter does not seem to have any substance. It is recommended that the name of this section should change to Womens. Maternal and Child Health as healthy women will automatically lead to health mothers and children.

Many aspects concerning women has not been addressed anywhere in this document, e.g. the status, empowerment (literacy, economic) and abuse/violence. Family health (body, mind, spirit), social well being (social rolls, social status, development of a coherent family structure) and a whole person approach has not been addressed anywhere.

8.1 Accessibility of services
Page l00
(b) Adequately resourcing midwifery resources is of extreme importance as these services had to bear the brunt of the impact of free health services and in addition to this the right sizing of the public service.

8.2 Comprehensive and integrated MCWH services
(a) A one-stop, supermarket/multi service approach is strongly supported. The community does not yet get a full holistic service and have to stand in various queues to get the necessary health services. Midwives should manage the pregnancies.

8.3 Clear objectives
Page 102
(a) The Eleventh Commonwealth Health Ministers meeting was held in Cape Town during December 1995. All the Health Ministers at this meeting including South Africa, approved the principle of developing a three year plan of action for nurses and midwives in Commonwealth countries. DENOSA are requesting information on this plan and the progress that has been made in this regard as no information on this three year plan has been made available, nor has it been mentioned in this White Paper.

8.4 Adequate knowledge and skills
Page 104
8.4 Aspects of parenting skills should be included as well as community empowerment.

Page 105
(d)(v) add nutrition, contraception and strengthening family relationships.

8.5 Quality services
(a)(ii) Some midwife educators regard the Perinatal Education Programme (PEP) as limited and it wiIl have to be developed in order to fulfill needs.

Page 106
(iii) Funding should be made available for the Decentralised Education Programme for Advanced Midwives (DEPAM).
(I) add address issues on the girl child, menarche, and teenage girls.

CHAPTER 9
HIV/AIDS and sexually transmitted diseases
Addressing this issue is of extreme importance for South Africa. This issue will be addressed in depth by other organisations but we would like to make some comments on behalf of the nursing profession.

Page 113
c) Key Strategies. Education and life skills programmes should receive high priority and should not only be targeted to the general community but also to health workers to keep them updated so that they are empowered to inform and council their clients correctly and efficiently.

Page 118
(d) universal precautions is essential in the workplace and should be addressed as a matter of urgency in order to get a standardised set of criteria in place. However, it is not only about reducing the risk of the health care staff, but also about determining the protocols for needle stick injuries and other exposure accidents in which nurses may be involved. Who should pay for the preliminary testing and prophylactic viral treatment of the exposed staff member? Currently the Compensation Commissioner only pays when there is proof that the staff member has contracted a disease as a result of work related exposure.

CHAPTER 10
Infections and Communicable Diseases Control
This chapter concentrate on the main problems but excludes many other diseases which are also problematic for our country. The representivity of the disease profile is therefore questioned.

A lot of attention will have to be paid to the possibility to implement the policies which are on paper as the infrastructure at the service level is not always conducive to implementing everything that is on paper, e.g. obtaining sputum for TB testing may be a problem as in certain areas there isn't transport available to take the sputum to the laboratory in time.

Capacity building should also include persons on the infra-structural level.

CHAPTER 11
Environmental Health
Page 131
(b) Intersectoral collaboration should include industry - this is a very significant sector.
(f) Include the following recommendation: Implement and facilitate recycling.
The Constitutions Bill of Rights is not interim anymore.

CHAPTER 12
Mental Health and Substance Abuse
The issues is on family matters mentioned earlier can also be included here as a healthy family is the basis for mental health

Page 137
(a) National level
Rehabilitative services should also be included here.

Page 139
What level of intention is available or anticipated at the primary care level e.g. counselling posttraumatic debriefing, etc?

No reference is made to quality insurance or quality programmes and it is recommended that this be included.

CHAPTER 13
Oral Health
It is once again not clear why this section is singled out from the rest of the health care package.

Page 44
13.2.1(b) Systemic fluoridation of water does not leave people with a choice as to whether they want this or not. Quality control and improvement programmes are not included here and it is recommended that it be included

CHAPTER 14
Occupational Health
Page 146
Where reference is made to occupational medicine it should include and nursing

Occupational Clinics also provide a very important primary health care service to the workers at the industry which is not referred to in this section and should not summarily be excluded without consultation. In practice the occupational and primaryhealth care aspects are integrated, e.g. back problems. Back problems could be as a result of the employee's job and if the primary health care service was not available together with an occupational health service at the work site, the problem could perpetuate without the root of the problem being addressed or a suitable solution for his problem being obtained.
This combination of services conforms with the "one-stop supermarket" principle referred to in chapter 8 on page 101 of the White Paper by providing the employee with a holistic service. It has been proven that this system contributes to the employee's health and well being resulting in reduced absenteeism, improved productivity and reduced work place injuries.

Page 148
14.2.1 No occupational health services are available in the public service and should be addressed.

Page 149
Will the recommended referral centres include promotive care in addition to diagnostic and rehabilitative capacity or will the promotive care be developed in each and eveninstitution for the workers?

Page 151
No reference is made to quality control or quality improvement and it is suggested that this be included.

CHAPTER 15
Academic Health Service Complexes
Page 152
Please replace academic medicine with academic health care. Private hospital should also be included in these complexes.

Page 154
(iv) Include professional organisations and health services when making recommendations in terms of numbers and types of health care professionals to be trained.
The recommended committee for student selection should not operate in isolations but collaborate with the selection committees of the Department of Education - will this not be duplication of selections committees?

15.4 Curricula of Academic Health Centres
Page 157
(a) The Department should only play a consultative role in the curriculating process.
(b) How affordable is another Council for the Country?
c) How will the research functions link with the ENHR - this is not reflected in this chapter. There is a need to clarify the line function between Ministries and the Universities/Technikons.

CHAPTER 16
Laboratory services
Page 160
(a)(l) Basic laboratory services should be available at the lowest level.

Page 161
16.3.1(c) It is not clear why"another statutory bodyis necessaryand this recommendation is therefore not approved of

CHAPTER 17
The Role of Hospitals
Page 164
The statement that the primary health care system cannot function efficiently without the support the hospitals to which they can refer patients is strongly, supported. It is therefore of concern that additional resources for primary health care resources will have to be mobilised from the existing allocation to the hospital sector. This will remove resources from the hospital sector that is extremely,necessary and important until the facilities are fully, equipped and available at communitylevel. DENOSA wants to caution against placing the emphasis on primary health care so much that support systems do not exist for it.

Page 167
17.2.1(d) Guidelines for staffing should be a negotiated process with appropriate stakeholders.

Page 168
(i) Quality improvement and quality control programmes and the utilisation of COHSASA should be included.

Page 170
(b) DENOSA is of the opinion that a separate bargaining chamber for nurses should be established, or at the very least, a chamber for health care personnel.

CHAPTER 18
Health Promotion and Communication.
Page 178
It is extremely important that there must be outcomes- based evaluation of any health promotion that has been done.
Health programmes should be piloted
Evaluation should further determine whether funds was spent effectively.
Quality of the programmes should be improved on an ongoing basis.

Page 82
18.2.1(b) Include healthy families.
18.3.1 Implementation strategy is very vague. Reconstruction and development of communities should be part of the implementation strategy.

Page 183
18.4. (a) Health promotion should be an integrated function in everything that health care workers do.
Skilled health promoters should be controlled, supervised and received updating regularly - who will be responsible for this?
c) It is good to see this here but it will be a big challenge!

CHAPTER 19
Donor Agencies and NGO's
Page 184
It is of concern that donor funding seems not to be available for Non-governmental Organisations (NGO's). DENOSA believes that NGOs have a role to play at local level. The Department of Health should utilise existing NGO's and make them accountable for the funding that is channelled to them. Appropriate resources should be allocated for targeted programmes.

Page 189
19.2.2 Guidelines should include transparent guidelines for existing funds at the Department as well as financial disclosure of donors and the purpose the money was awarded for.

CHAPTER 20
International Health
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(b) These programmes should include nurses in these positions in view of the number of nurses in the country and their value in health.
(c) National and local expertise should be utilised. Local partnerships should be developed with international consultancies for empowerment. Policies and programmes should be accountable and transparent.

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(g) Add the following: Implementation for foreign/international strategies. These should not be imposed
without negotiation with health and consumer stakeholders.
20.3 Clarity is requested of the meaning and intention of this section.

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(d) Clarification is needed on this issue as it states that NGO's will be funded but in practice this appears not to be so.

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20.5.1(a) There should be equity in the distribution of research funds for all professional groups including nurses.

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c) The promotion of the utilisation of South African expertise is appreciated and DENOSA will be monitoring this in relation nursing and midwifery.

CHAPTER 21
Goals, Objectives and Indicators
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2 1.1 The indicators in the table are not measurable - these must be quantifiable and target dates should be set.
Some of the dates in the list of objectives have expired - should these not be removed or other target dates be developed?

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Include and families in the problem statement on mental health.