We start from the premise that health is a right as enshrined in the Constitution, and that the State is responsible for ensuring that all South Africans have access to adequate healthcare. The key problem that faces our health system today is the massive inequalities associated with low-quality care for the poor at both primary and tertiary levels. This leads to a weak health care outcome, despite the fact that there is a relatively good level of resourcing.

In addition poor working conditions in the public sector, with long hours, shortages of staffing and resources and relatively low pay. At the same time we have a run away private health industry, which is responsible for huge inequalities in healthcare provision and use of state resources. The rapid rise in Medical Aid costs is far higher than medical inflation for most of the past decade.

The Bill needs to combat the iInequalityities and poverty that impacts on people’s health. is what we expect the Bill must address, and Iits relevance in addressing this will determine whether we shall be able to make a substantial shift in health care provision.

The drafting of health legislation has been a long process. Since the White Paper for the Transformation of the Health System in South Africa, there has been serious debate in various spheres of government, amongst civil society organisations, trade unions and the private sector regarding the implications of this legislation. COSATU and NEHAWU therefore welcome the opportunity to make their submission to the Portfolio Committee on Health on the National Health Bill.

The Bill is being introduced at a time when the Department of Health is engaged with a number of parallel processes, which will have an impact upon the content of the Bill., Thesebut processes however, which will not be complete, before the Bill has been passed. These include health care financing and the integrated public service.

Critically the Bill should address the main problems of the Health system, which can be summarised as follows: -

• Substantial under budgeting, and as a result understaffing, including in primary health clinics. Whilst the health budget has grown since 2000, after four years of cuts, it has also had to deal with the escalating responsibility for HIV/AIDS.
• Co-existence of public and private health sectors pushes up national spending on healthcare without benefiting the majority. In fact the private sector drains skills from the public sector thus aggravating inequalities in health care provision.
• High cost of patented medication and the lack of an industrial strategy to support local production. Whilst a legal framework for producing medication locally has been introduced, and this will lower the costs of medication, we have lost two decades of lost production capacity as foreign investors have taken over and shut down local production in favour of imports.
• It is important to tackle the Ssoaring costs of medical aids and the causes thereof. this are important to tackle, and Wwhilst government through legislation seeks has attempted to regulate this industry increasing, private capital has moved to push up the cost of medical aids, in a response to increased regulation. Deteriorating Public health services have lead to a flight to the private sector.
• Poor management at local level plus lack of understanding of national policies, compounded by provincial policies on how to deal with the equitable share of the division of revenue.
• Hierarchical work organisation and oppressive labour relations practices.

With Tthe publication of the National Health Bill, we aretakes us one step closer to an overarchingthe promulgation of the National legislative frameworkHealth Act. Yet, the provisions contained within this Bill are significantly at odds with the original intention of the envisaged objectives of in the White Paper calling for a transformed National Health System.

For the public sector, the inadequate budget allocation is further compromised by an increasing population and disease burden. Limited financial resources are by far one of the major challenges facing the viability of implementation of this Bill.

In our submission on the Draft National Health Bill, we raised concerns regarding the policy orientation of the Bill, especially the weight accorded to availability of resources or the lack thereof. We argued for a reversal of the decision-making process and instead advocated that greater ‘emphasis be placed on budgetary allocations being determined in accordance with national commitments to achieving transformatory goals’, rather than problematic fiscal targets determining the degree to which objectives can be met. Specifically, we stated the shift in health policies since 1994 reflected a shift in emphasis towards favouring the historically disadvantaged. A year ago, we noted with concern that:

Our concerns were warranted. Despite calls for the redrafted version of the Bill to be sent to the NEDLAC Development Chamber for consideration, detailed submissions, and considerable engagements, these trends are being entrenched.ment and further curtailment of the proposed Shifts away from the original vision of our health policyies continued unabated and are reflected in the Bill. This complex Bill is an omnibus piece of legislation addressing various entities and sectors of the health care structure. Significant by its absence, is proposed legislation for the introduction of National Health Insurance (NHI), which we comment on later in this submission.

One useful tool for measuring the progress of a country in striving to provide a better life for its inhabitants is the human development index (HDI). For South Africa in particular, the HDI is a telling indicator of our health crisis.

As a summary measure of human development, it is premised on three basic dimensions of human development, and is the simple average of these three dimension indices. They are:

• a long and healthy life, as measured by life expectancy at birth;
• knowledge, as measured by the adult literacy weight (with two-thirds weight) and the combined primary, secondary and tertiary gross enrolment ratio (with one third weight); and
• a decent standard of living, as measured by GDP per capita (PPP US$).

From table 1 above, it can be seen South Africa, ranks 111^th out of 175 countries, in terms of HDI ranking. We compare poorly with countries such as Mauritius that has far fewer resources. Between 1995 and 2001, the HDI dropped markedly from 0.741 to 0.684, without a concomitant drop in other countries. Yet, South Africa spends a significant 8.5% of its GDP on health. Clearly, these resources are being used inefficiently, and it disproportionately benefits a very small group of people.

It is apparent that the Department of Health is reluctant to address various concerns around the private health industry issue. This may be one reason why the financial implications and related matters such as the National Health Insurance scheme has been omitted from this Bill. COSATU and NEHAWU find this unacceptable. and Tthe omission willould result in the Bill being applied in a system that remains structurally flawed and highly unequal. With this in mind, we call upon the Portfolio Committee to seriously consider this crucial gap in the Bill.

Other than the very short section entitled ‘Financial implications for the State’ (Section 4 of the Memorandum on the Objects of the National Health Bill, 2003), the Bill is completely silent on financing mechanisms for health care delivery. One then has to assume that the current problematic mechanism of funding remains largely intact.

The only reference to some form of national health insurance in the Bill is contained in (section 51). This system makes it obligatory for private health establishments to ‘maintain insurance cover sufficient to indemnify a user for damages that he or she might suffer as a consequence of a wrongful act by any member of its staff or by any of its employees.’ If anythingAgain these recommendations would invariably push up the cost of medical aid insurance to the subscriber, thereby making it even more unaffordable to lower income workers. The absence of policy recommendations in the Bill addressing health insurance (other than the example quoted above) prompts us to briefly describe the core proposals of the National Health Insurance Scheme.

Bearing in mind that at Bboth the 50^th and 51^st Conferences of the ANC, passedthere were resolutions made to implement a national health insurance system.

Specifically, the resolution taken at the 50^th ANC Conference in Mafikeng, 1997 called for a National health insurance system and resolved that government find urgent answers to the outstanding, unresolved issues in relation to the social health insurance system so that it can be speedily implemented.

This resolution was more strongly reiterated at the 51^St National Conference of December 2002 in Stellenbosch. The Conference resolved that, as part of attacking poverty and developing a Comprehensive Social Security System, ‘to call on the government to continue with plans towards …, the introduction of a national health insurance’ and that ‘government must speed up the implementation of the recommendations of the commission of inquiry into a comprehensive social security system in the spirit of the Mafikeng conference resolution on the National Health Insurance (NHI). The NHI should enhance the equitable access by the general public to health care and reduce the inequities between the private and public health providers. Specific emphasis should be placed on strengthening the capacity of the public health system to generate revenue from those who can afford to pay and ensure that such revenue is used to improve the public health system’. Yet, the Department of Health has a Directorate for Social Health Insurance – as opposed to National Health Insurance. We consider this a distinct contradiction. It has to be acknowledged that there is no agreement on the issue.

Our submission therefore proposes the development of a chapter for enabling legislation on NHI to be promulgated (see recommendations). However, this may delay the Bill. If this proposal cannot be accommodated, we motivate for separate legislation to address the NHI issues. COSATU would be keen to assist the Portfolio Committee and the DOH with the drafting thereof.

At a minimum, the NHI would:

• fully cover everyone under a single, comprehensive public insurance programme,
• pay hospitals, clinics, nursing homes a total (global) annual amount to cover all operating expenses,
• Fund capital costs through separate appropriations,
• Pay for health professional services and ambulatory services in any of three ways – through fee-for-service payments with a simplified fee schedule and mandatory acceptance of the NHI payment as the total payment for service or procedure (assignment), through global budgets for hospitals and clinics employing salaried doctors, or on per capita basis (capitation),
• Be funded, at least initially, from the same sources as at present, and
• Containing costs through savings in billing and bureaucracy, improved health planning and the ability of the NHI, as a single payer for services, to establish overall spending limits.

The NHI’s structure and financing mechanism is meant to be self-funding, as it will be raised as a levy. The funds raised through the levy would be ring-fenced, and used for medical care for all South Africans.

1. SHI vs NHI

COSATU is opposed to the notion of Social Health Insurance (SHI), as but advocates for a National Health Insurance (NHI). The SHI is an option being forwarded by cabinet and the DoH as an alternative to the NHI. Table 2 captures the differences between these two systems. COSATU strongly urges for the progress in this regard.

In a post-Cabinet Lekgotla Media Briefing on 31 July 2003, it was frustrating to learn that ‘a policy approach on Social Health Insurance (SHI) was noted and the implementation strategy will be submitted in detail to Cabinet for approval after the Lekgotla.’ Discussions with senior officials within this Cluster suggesting that this is a staged approach towards a National Health Insurance scheme remain unconvincing. Given the stark differences as outlined in Table 2, an SHI appears to be the inadequate in addressing the huge inequalities in the health sector. COSATU and NEHAWU remain diligent in their attempts to engage government and Parliament in this matter.

Access to emergency treatment is too important an issue to relegate to a mere regulation. If no health care provider or health establishment may refuse a person emergency treatment, any amendment to this right, as is suggested in the regulation, diminishes or compromises this right. COSATU suggest that this be changed to ‘Emergency Treatment means that treatment which is mandatory and must be provided for within the South African Health System in terms of Section 27(3) of the constitution, and as defined in regulations’.Emergency medical treatment means treatment that must be provided immediately on demand by a health care provider or a health care establishment (definition used in Bill)

to a person who has an emergency medical condition, as provided for in section 27(3) of the Constitution.

A shortcoming of the Bill is the absence of a definition for an ‘emergency medical condition’ that could be used to identify the conditions when emergency medical treatment must be provided.

A suitable definition should be provided for an emergency medical condition that would include the following elements, namely:

• an event threatening or causing acute injury or illness which requires immediate preventative or remedial medical intervention; and
• where failure to provide immediate preventative or remedial treatment would result in serious impairment to bodily functions or a serious dysfunction of a bodily organ or part, or death.

In response to a question posed by a Portfolio member during the DOH’s presentation on the Health Bill, it was explained to the Committee that the State Law Advisors suggested the definition of ‘emergency treatment’ may require an amendment to the Constitution. Since the definition cannot address the issue of how long the State is compelled to provide emergency treatment, a Constitutional amendment is necessary. Specifically, the health official quoted the Soobramoney case as an example regarding the ‘emergency treatment’ dilemma. This case is worth examining in order to highlight some important underlying principles.

Briefly, in November 1998, Thiagraj Soobramoney, a man suffering from kidney disease asked that the Constitutional Court order the health authorities to provide him with dialysis, but was turned down and died soon afterwards. It is significant that Mr. Soobramoney had been receiving private medical treatment for his condition until his finances were depleted.

Interestingly, the Director of the constitutional litigation unit of the Legal Resources Centre, Geoff Budlender, argued that to the court that the government's attitude results from an "impoverished and mistaken understanding" of the Constitution's promises to the people of South Africa.

Budlender also referred to the Grootboom case, where the Constitutional Court ruled that emergency housing be provided to her and her family, after her home was destroyed by the municipality. Budlender stated that the cases of Soobramoney and of Grootboom represent the opposite spectrums of socio-economic rights under the Constitution.

Soobramoney had asked for high-tech tertiary health care and if the court had granted his request it would have had only a temporary effect. The claim of Grootboom and her community, on the other hand, was for "the most basic and fundamental human need". If the court intervened to grant the help they sought, it could substantially transform the lives of some of the most vulnerable people in South Africa.

This example aptly highlights the need for political will to ensure the that progressive realisation of socio-economic rights should be preceded and not curtailed by a minimalist approach to government intervention or that ‘limited resources’ are used as an excuse to prevent Constitutional rights from being fulfilled. It also highlights the purely financial nature of private health care intervention.

If indeed this route is to be pursued, Iit is imperative that the above definitions be defined in law, since it would allow the state to deal with the it be resolved as a matter of urgency. A Portfolio Committee member raised the illegal, but common practice of private hospitals and clinics turning away persons that have emergency medical conditionsare in life-threatening conditions (e.g., such as a heart-attack, poisoning or , serious trauma injury). It is immoral to turn away This because the persons requiring such treatment, if they are are unable to provide a substantial deposit for private care, or araree not contracted in to a medical aid scheme that would cover the hospitalisation costs, or have exhausted their medical benefits.

Preamble - We welcome the Preamble, which attempts to locate the Bill in an objective context of both pPolitical and sSocio-economic, realities and Constitutional obligations. The following amendments are recommended:

Section "Recognising": first sentence, insert: "and which remain the key challenge in health care provision today"

Section " And In Order To": Omissions and vision of the Bill - the content of the Bill does not express itself adequately in this section the first and fourth sentence of this section. Omissions in the Bill seriously weaken the vision as expressed in the Preamble and we would put forward that there has to be a strengthening in specific Chapters in order to realise the intentions of those sections of the Preamble we have referred to. The issue of equity is not addressed - the key challenge today is to provide a health service that is equitable.

Insert: At end of second sentence "and equity in provision of services"

• National Health System (NHS)

As defined a NHS is a tax based funded Public Health System. It does not incorporate Private Health, and Private Health would under such a system be strictly funded out of private revenue, unlike in South Africa where Private Health is kept afloat by the State.

The definition as it stands runs contrary to how Health systems are definedthe above definition. What is needed is a definition which takes into account the present situation that exists in health care provision, and allows for transition within that definition so that in moving between different system, there will not be the need to continually seek amendments to the Act.

The omission of this from the draft Bill is serious. This has been explained at length in section 4 of this submission.

Leaving it to regulations will address the technicalities of micro-definition, but there needs to be two points of reference in the definition, that emergency treatment is mandatory irrespective of ability to pay and the constitutional obligations.

• Informed Consent

Given that this area is so highly contested and results in frequent legal wrangling, it would be best to insert a brief description of informed consent and leave the rest to regulations. SWhat such a definition should attempt to do is to protect the user. Bbuut at the same time wouldgive giveprotection protection to the department so as to prevent abuse of a legitimate right to legal recourse.

• Private health establishment

The distinction between "for profit establishment" and "not for profit establishments & organisations" needs to be made. The current definition is limited since it does not address the financial status of private health establishments, which is critical, since both directly and indirectly receive state subsidisation.

• Essential Health Services

Essential health services include primary health care, short term general hospital care, prenatal and postpartum care for uncomplicated births, pharmacy services, and emergency medical services. It is also important to understand that access to such services is affected by such factors as time, transportation, geography, distance, socio-economic factors , language, and culture.

Whilst this is the term ‘essential health services are’ referred to in Chapter 1, the omission of this definition is problematic, since there are both Constitutional and International provisions that obligate the department to act in the provision of such services. The Minister in consultation with the National Health Council and Parliament should determine this.

its constituents e contained in regulations.

• 2 (a) delete: national health system

Refer to our motivation under definitions above.

• 2(a) (ii) "that available resources can afford"

(c) (i) "within available resources"

Section 28 of the Bill of Rights speaks to progressive realisation of the right to access to health care. The constitutional court has equally ruled on this matter. That Wwhilst one cannot argue for health care provision that would lead to massive budget deficit, neither can government hide behind restrictive fiscal policies that negatively impact upon its constitutional responsibility to provide adequate health care provision, covering basic and essential services. Equally this must apply to the private health care sector as well. We need a Bill that is progressive and enabling, not restrictive and negative.

2 (c) (i) speaks to the progressive realisation of the constitutional right of access to health care services. Therefore it is unnecessary for the Bill to continually refer to restrictions in respect ocontain a restrictive and narrow approach tof available resources.

2 (c) Constitutionally the State is obliged to protect rights, therefore it is

disturbing to find that this has been left out of the introductory line.

3. (1) Delete: "must, within the limits of available resources"

3. (e) Delete; "and available resources"

3. (2) Delete; "within the limits of available resources"

Eligibility for Free Health Services in Public Health Establishments

4. Delete (1) and (2)
5. . Means testing in South Africa, in one department alone last year cost R400 million. The draft Bill, by entrenching means testing, adds seeks to add onto the health system further administrative costs, and administrative and burdens. It is far more cost effective, and an efficient use of health workers time and resources to standardise free services available at Public Institutions, and put these into regulations. Deferring a Constitution right to the Minster’ s discretion is completely incorrect.

A major omission in the Bill is its silence on the rights of Health Care Providers. Often the environment in which Health Care Providers have to work is extremely stressful, dangerous, and lacking in both essential and basic resources. Within all of this the Provider is expected to render quality care on a daily basis. We believe that the omission is extremely serious and leaves health care providers vulnerable to all sorts of attack. These rights should not be stuck away in regulations but rather be found in the main body of legislation.

15. (1) This clause needs to be qualified and strengthened in the interest of

the user. It is far too open at present.

In line with the major omission in this chapter we propose the following new sub-clause. Insert: 19 (d) "treat the health care provider with dignity and respect and

The establishment of the three national health structures is most welcomed, but we must ensure that there is a are clear lines are demarcated work and division of labour. If this is not the case, duplication of work and unnecessary wastage of resources can occur. We believe the wording in Chapter 3 needs to be tightened so as to prevent any confusion that may arise. We recommend the following:

• That the National Health Council (NHC) is responsible for the development of policy and legislation, in conjunction with Parliament.
• That the National Health Advisory Council (NHAC) is responsible for co-ordination of policy implementation and the making of recommendations to the National Health Council on matters arising from this co-ordination (these are 2 distinct committees, so named by the Department of Health).

Health Care Providers are critical in any Health System, and given the powers of the NHC, it would be important to have a representative of health care providers on the Council. Recommendation: New 21 (2) (h) "one representative of health care providers"

The main concern here is that the Bill gives functions to the NHAC which duplicates work that should be carried out by the NHC, especially since the NHC may create one or more committees to advise it. We believe that the primary function of the NHAC should remain co-ordination of policy implementation, and that any additional functions should arise out of these functions.

The length of time between meetings of the NCHF is too long, especially during a period of transition where major developments happen in a rapid space of time.

As we put forward under the NHAC, we believe that there is duplication at Provincial level. Primarily, the PHAC should be involved with the co-ordination and implementation of intergovernmental policy.

The restructuring and transformation of health care delivery is felt most acutely at the provincial and local government spheres. Therefore to deal with the ongoing transition it would be important that the frequency of the meetings of this body be annually. Recommendation: 33. (3) (b) Delete: "every two years", Insert: " a year"

COSATU and NEHAWU We welcomes the spirit of this clause and the need to ensure proper and strict regulation in the operation of a health establishment..

COSATU and NEHAWU recommendOur specific comments:s that this clause, viz - 41 (3) ( c ) be dDeleted.

This clause is highly contentious issue and has never been defined other than through the use of public private partnerships and service level agreements. Therefore what constitutes "appropriate" finds its way into draft legislation whilst there has been no national debate between government and service providers on what constitutes "appropriate". It is our firm belief that the continued existence of the two systems is one of the major contributing factors to inequalities in health care provision. Finances that could best be used in the Public Health System find their way into the "for profit private health system".

If we are to address appropriateness, we have to discuss what constitutes

social responsibility and social solidarity by the private sector, in the construction of a National Democratic State and providing affordable health care provision. In addition private health care policy on the indigent is singularly lacking. We believe that until we have a national consensus on this matter the sub-clause should be deleted.

41 (3) (j) This clause should refer to private health institutions only.

In respect of the pPublic hHealth eEstablishments, these are generally located in areas of great need, and whether a Public Health Establishment is financially sustainable should not be the reason to withhold a certificate of need.

The current situation where in Public Health Establishments, they have to cover the costs of negligence out of their budgets, is untenable. This has a severe impact upon their operational budget. The National Treasury needs to amend Treasury regulations and absolve Public Health Establishments for covering the costs of negligence. This money can be sourced from specific funds held by the National Treasury.

So whilst we cannot offer wording, since this is a separate regulation outside the ambit of the department of Health progress should be made to effect the amendment in the Treasury.

57(1^st line): Insert: (after Minister)" through the health & welfare sectoral bargaining council"

Whilst the Bill speaks to both Public and Private Health Care, the regulation and social responsibility of private health care is largely left intact. We recommend that regulations on the Private Health sector need to be promulgated. This could then become an addendum to the Bill.

Hospitals now commonly have separate amenities within the same establishment for medical aid patients and non-medical aid persons, primarily as a means to generate revenue. There are two major problems with this arrangement. Revenue generated internally is deducted by the Provincial department of health from Public Health Establishment budget as a saving. This forces a vicious cycle of struggling to generate revenue and seeing your budget declining at the same rate.

Hospital personnel are often seconded to the private wards first. By the time they reach out-patients and treat patients who are unable to pay, their level of capacity is diminished. This approach also , resultsing in long queue’s waiting for private wards, setting the unhealthy precedent of chasing revenue generation above serving the needs of people. This is discriminatory and unconstitutional.

The Bill must speak to this practice where doctors and health professionals have financial and other vested interests in a particular institution.

Chapter 5 of the Bill establishes a district health system for the Republic. It provides for the demarcation of health districts with due regard to municipal boundaries and for the governance and management of health, an alignment that is much needed to integrate and co-ordinate services at a regional level. A positive linkage, from the perspective of coordinating development plans, is the provision of health services by municipalities being mandated by the preparation of district health plans.

A key feature for the implementation of the primary health care approach (PHC) has always been the district health system. In our submission on the Draft National Health Bill in March 2002, we raised our concern regarding the absence of an approach to PHC, as well as the absence of and the lack of definitionng of a minimum package that is to be provided through the DHS.

Neither definitions are present in this Bill at all. At best, this is a serious oversight. At worst, it is a perverse and seriously problematic restructuring exercise to absolve national government of its duties and so devolve responsibilities to the local level, without the concomitant funding, a phenomenon termed ‘unfunded mandates’. Effectively, the original intention of the DHS has been scuppered, and all that effectively remains is the district health system, being a ‘system [that] consists of various health districts, and the boundaries of health districts coincide with district and metropolitan municipal boundaries’, in other words, merely a geographic definition.

At the inception of the DHS system, NEHAWU raised the concern that this progressive system would be constrained if run along the National Health System (in the United Kingdom), along Thatcherite principles, effectively leading to the squeezing of budgets anandd which led to antagonism in the health sector. This approachIt forced the formation of internal revenue systems for hospitals and clinics, rather than the expected support coming from national government.

The Bill now has no definition for either for "municipal health services", or ‘primary health care.’ As part of a transitional arrangements concerning municipal health services, ‘until a service level agreement contemplated in section 37(3) is concluded, municipalities must continue to provide, within the resources available to them, the health services that they were providing in the year before this Act took effect’.

Provinces are now responsible for funding local government to provide those additional PHC services through service agreements. Whilst there have been some significant increased allocations to primary health care, there is no formal guarantee that national government will provide funds in the future for PHC, as originally envisaged. The whole notion of having health functions assigned, rather than delegated, with national government retaining little responsibility, remains highly problematic and confirms our perception that this Bill is effectively absolving national government from any responsibility to continue supporting provincial and local government in the progressive realisation of socio-economic rights.

Occupational health services are now defined as only within the domain of the province (section 28 [r]), a shift away from incorporating it in the district health system. No collaboration with other government departments is called for. No mention is made offor the provision of facilities for the recognition of ill health due to occupational exposure, as supported by the White Paper. This Bill does therefore not support a more accessible service for vulnerable workers who are more likely to work under unsafe conditions. This is yet another element that has been eroded from the National Health Bill and which continues to frustrate labour.

None of our concerns raised in our submission on the Draft Health Bill were addressed in any way. Instead there has been regression. Human resources planning now appear to be implicitly linked to academic health complexes, since it is all dealt collectively in Chapter 7 of the Bill. This Bill now bluntly states that ‘The Minister, with the concurrence of the National Health Council, must determine guidelines to enable the provincial departments and district health councils to implement programmes for the appropriate distribution of health care providers’. Other than stating in the regulations that the Minister may make regulations regarding human resource development, the Bill is chillingly silent on this crucial component of a progressive health service. There is no evidence of this framework being based on an integrated approach at all. There are also no regulations relating to new categories of health care personnel, the recruitment of health care personnel from other countries.

The Minister may also, in order to ‘make up the deficit in respect of scarce skills, expertise and competencies’ prescribe strategies for the recruitment and retention of health care personnel within the national health system. This approach, it is hoped will remain a transitional arrangement, until such time that health care personnel are adequately skilled, although this is not stated in the Bill.

COSATU demands that an in-principle agreement be reached on anthe integrated approach to human resource development. The absence of any details regarding a human resource development approach policy is indicative of a problematic perspective in dealing with health care challenges. COSATU is unhappy with the discretionary powers accorded to the Minister regarding the recruitment of health care personnel from other countries; the increasing reliance on the private sector to fill the gaps experienced in the public sector; and the absence of details regarding training and development of existing medical personnel. It reflects a serious and flawed approach to good human resource management. We hold that Batho Pele principles can never thrive under these conditions or be instituted by the private sector.

As raised in the Draft National Health Bill, there is now and even more urgent need for a meaningful and appropriate response to the issue of HIV/AIDS. As shown earlier, Mmany of the gains made, are now being eroded by the HIV/AIDS epidemic. The complete absence of any legislative intervention is unacceptable.

Even asT the formal recognition of the epidemic in the Bill, will would begin to dispel some perceptions created by the the manner in which the DoH has treated this crisis. Again we reiterate that theEven though the National Health Bill, aswhilst a piece of general health legislation, does nnot have as its main focus the management of specific diseases, it should provide the enabling framework/systems capable of addressing this crisis.

One of the few positive developments in the Bill, is policy of establishing a single blood transfusion service for the Republic. The only transfusion service that has not merged into the National Health Laboratory service is the Western Province Blood Transfusion Service (WPBTS). This service has been generating profits and has contributed to a skewed laboratory service, and which is now competing against the National Health Laboratory Service (NHLS). We therefore welcome the requirement that WPBTS needs to align with legislation applicable to other provinces.

A key question in assessing the efficacy of the Bill, is to examine whether it adequately addresses what is contained in the ‘preamble’ and ‘objects of the Bill’, as contained in Chapter 1.

We are of the view that the National Health Bill, as it is currently formulated, will not accomplish the goals originally formulated in the White Paper, calling for the Transformation of the Health System in South Africa. The transformative goals of the RDP, the unification of a fragmented health service into a comprehensive and integrated National Health System, and the promotion of equity, accessibility, utilization of health services and the fostering of community participation are compromisedlost in the drafting of this Bill.

We cannot see how the continuation and mild reform of a two-tier system that has promoted a maldistribution of resources increased wastage, and inflated health costs, can accomplish the objective of health care for all.

There are aspects of the Bill that we certainly do support. But, it is the areasWe we have outlined, that require significant redrafting in order to meet the objects and preamble of the Bill.therefore cannot support the National Health Bill in its current form and call for the extensive reworking thereof, as indicated.