Budget takes us closer to realising our dreams

On Wednesday, February 18, our Minister of Finance, Trevor Manuel, tabled the 2004-2005 Budget. Commenting on the 10 years of democracy we are about to complete, he said: "We have walked together, one step at a time, on our journey towards growth, towards learning, towards reconstruction, towards solidarity, towards reconciliation, towards prosperity, towards development, towards freedom.

"We have stayed together on this journey, because we share that vision, and we will continue, day by day and year by year, to translate the resources at our disposal and the opportunities before us into people-centred development, human fulfilment and freedom."

Correctly, Minister Manuel also reminded us of the tasks we had set ourselves in the Reconstruction and Development Programme (RDP). As he put it, these were:

• meeting the basic needs of all South Africans;
• building the economy;
• democratising the state and society;
• developing human resources; and,
• building the capacity and institutions to implement our transformation programmes.

It was correct for the Minister of Finance to draw the country's attention to these fundamental objectives. This is because the Budget must itself be judged on the basis of whether it helps to address these goals. It is not an end in itself. It is one of the principal instruments of our democratic state as we strive to meet the larger goals mentioned by Trevor Manuel.

The larger goals he mentioned were:

• the creation of a people-centred society;
• the expansion of the frontiers of human fulfilment; and,
• the extension of the frontiers of freedom.

Taken together with the objectives we had set ourselves in the RDP, these goals mean that we are committed to the pursuit of the historic aim of the fundamental transformation of our country.

We are working to change a society that for centuries had been based on the pursuit of the selfish interests of a few at the cruel and costly expense of the overwhelming majority. Central to the value system of the old order was the pursuit of personal material gain by the dominant, and the abuse of the dominated as nothing else but sub-human agents to be used for the material benefit of the dominant. This was the very opposite of a people-centred society.

When we speak of a society that consciously and systematically pursues the expansion of the frontiers of human fulfilment, we mean that we seek to create a radically new reality, away from a past that defined the majority of our population as "surplus people".

We are striving to build a new society that will work continuously to ensure that every person in our country, regardless of race, colour, gender, class and age, achieves all-round material and spiritual fulfilment.

The extension of the frontiers of freedom marks an equally radical departure from a past during which the majority had no rights whatsoever, while, in reality, even those who thought they were free, did not enjoy true freedom. Even the minority who denied the majority their freedom were themselves imprisoned by fear of the oppressed majority and the future, constrained to subject themselves to varying degrees of regimentation to guarantee the permanence of their position as the dominant.

The society we are working to build aims to guarantee genuine freedom for all our people in conditions of peace, social solidarity, national unity and a shared destiny.

Given the past we are leaving behind, all these are truly revolutionary changes. These changes also mean that in time we will succeed to eradicate the terrible legacy of racism and sexism, which continues to define our society. They also mean that we are determined to ensure the dignity and the entrenchment of the rights of our working people, the children and the elderly.

All this signifies that after our long and painful experience of racist and sexist oppression and exploitation, we will continue to work consistently to realise the goals set in our Constitution of building a non-racial, non-sexist, egalitarian, prosperous and democratic society. To achieve this objective, more than ten years ago we decided that we would group our interventions under the various tasks contained in the RDP, as mentioned by the Minister of Finance.

To effect the revolutionary transformation of our society to which we are committed, we have to carry out specific tasks on a daily basis. This means that we must recognise and sustain the dynamic relationship between the processes of revolution and reform.

Without the revolutionary goals we have set ourselves, we would never be able to determine the correct tasks that would enable us gradually to reform our society to reflect the revolutionary perspective we have chosen.

At the same time, if we do not engage the task of reforming our society in daily struggle, we will not be able to effect the revolutionary transformation for which so many of our people sacrificed their lives during a century-long struggle for genuine liberation.

The Budget is one of the principal instruments in the hands of the democratic state to bring about the changes we need to make, to achieve our revolutionary goals. For us, the Budget is not merely an annual record of revenue and expenditure figures decided by the government to address whatever issue might seem important during a particular year.

It represents the financial interventions of the democratic state to give effect to the dialectically interconnected processes of revolution and reform. This is why we refused to treat the two Budgets immediately preceding the 1999 and 2004 general elections as "election budgets", designed to increase the popularity of the ANC during the impending elections.

On both occasions, we insisted that the 1999-2000 and the 2004-2005 Budgets must reflect our perspective with regard to our revolutionary and reform objectives and not fall victim to immediate partisan political considerations. As the Minister of Finance said after the presentation of the Budget, our movement and government will not create problems for themselves and the country by making promises that are unaffordable.

In reality, each annual Budget is a programme and instrument of reform. However innovative and groundbreaking with regard to particular items, as an annual programme and instrument it cannot assume the character of a comprehensive revolutionary process. Rather, it is the accumulation of annual Budgets that leads to such a comprehensive revolutionary process. This explains why those who think that an entire revolutionary programme can be loaded on each annual Budget would almost invariably be disappointed in their expectations.

Once the detailed and stable revolutionary and reform policy framework has been established, as we have done during our First Decade of Liberation, the funding instrument, the annual Budgets, would also reflect this detailed and stable revolutionary and reform policy framework. This is what characterises the 2004-2005 Budget.

It provides for increased expenditures to meet the needs of the people. This includes additional funds for such social grants as old age pensions and the child support grant, as well as goods and services in the areas of health, education, housing, nutrition, water and electricity, and so on.

This gives concrete expression to the objective in the RDP to meet the needs of the people, which is itself based on recognition of the imperative that the democratic state has a responsibility to intervene to improve the quality of life of the millions deliberately impoverished and marginalized by the previous social order which considered these millions as "the surplus people."

This poses the difficult challenge that while our obligations to the masses of our people would not allow that we should abandon the poor to take care of themselves, at the same time those obligations impose a requirement on us that we should not cultivate a culture of dehumanising dependency on these masses.

Neither can we just concentrate on redistributing wealth through increasing social expenditures, without attending to the central matter of the creation of the new wealth we need to achieve the goal of a better life for all.

For this reason, the Minister of Finance reiterated the objective that we should "increase the number of people in society who depend for their livelihood, not on social grants, but on normal participation in the economy." During the Second Decade of Liberation, we will have to pay particular attention to this question, to ensure that our policies and Budgets increase the possibility for our people to depend less on social grants and more on normal participation in the economy.

That is why the annual Budget contains a whole variety of interventions targeted to addressing the RDP challenge of building the economy. These include large investments in the economic infrastructure to contribute to the growth and development of the "first economy", and similarly large expenditures on the expanded public works programme to build the social and economic infrastructure in the poor and underdeveloped areas of our country, as well as raise skills levels and reduce unemployment in these areas.

They also include funding, tax and regulatory interventions to encourage the growth and development of small and medium business and the further growth of the domestic market. In this context, more resources have also been made available for the land redistribution process and support for the new black commercial farmers.

The 2004 Budget Review makes the important observation that "Capital expenditure (will grow) by 6,1 per cent in real terms over the 2004 MTEF, illustrating the government's prioritisation of investment in general, and infrastructure expenditure in particular."

Additional funds have also been provided further to improve our performance in the critical area of human resource development. This is yet another of the tasks we had set ourselves in the RDP to ensure the development and fulfilment of all our people and the availability of the skills required by a modern economy and society.

Another one of these RDP tasks is the further improvement of the democratic state machinery, to enhance its capacity to meet its developmental and social obligations and effectively implement the policies and programmes for the transformation of our country. Accordingly, the Budget contains provisions relating to a variety of matters affecting all three spheres of government.

These include strengthening our system of local government, integrating the system of traditional government, improving the effectiveness of provincial government, and enhancing the capacity of our system of governance to respond to such challenges as improved health provision, including HIV and AIDS, crime prevention and combating, economic development and the African Renaissance.

At the beginning of this Letter we quoted Minister Manuel as saying: "We have walked together, one step at a time, on our journey towards growth, towards learning, towards reconstruction, towards solidarity, towards reconciliation, towards prosperity, towards development, towards freedom.to translate the resources at our disposal and the opportunities before us into people-centred development, human fulfilment and freedom."

The 2004-2005 Budget constitutes yet another national intervention to take our country further along this journey. Despite a global and domestic economic slowdown, which has limited the resources available to the government further to advance the national strategic agenda, the latest Budget has nevertheless succeeded to take us yet another step forward, building on what we have achieved in the past.

We enter our Second Decade of Liberation confident that we will succeed to create a people-centred society, characterised by human fulfilment and freedom for all. The forthcoming elections will both confirm the health of our democratic system and contribute further to the democratisation of our state and society, a goal we set ourselves in the RDP.

This year's Budget also confirms our determination to transform our dreams about our country into reality. To ensure that it makes maximum impact in helping to change our country for the better requires that we continue to walk together, united in a People's Contract to Fight Poverty and Create Jobs. Budget 2004 has further increased our possibilities to achieve these goals.

Health care transformation

Certificate of Need is a tool for better health care provision

The delivery of the State of the Nation address by our President on 6 February 2004 was a momentous occasion for South Africans. As the day drew to a close some of those entrusted with the care of society's health needs paraded in the streets of Cape Town against health legislation that seeks to consolidate the transformation process in health. The date was in many respects not an ordinary date for the South African medical profession. The week had started on a high note for the South African Medical Association's (SAMA) leadership aided by some sections of the media, whipping the nations' emotions on the state of health care. An impression was created that there was a serious crisis akin to an immediate collapse of public health services.

Through its chairperson Dr Kgosi Letlape, SAMA communicated to the public their displeasure at not getting their privileges protected in the National Health Bill. The profession says it is incensed by a provision in the Bill to have health establishments, which include doctors' surgeries. This licence is known as the Certificate of Need. The media frenzy on this issue served to create doubts in some people's minds about the real intent of the envisaged legislation. It is crucial that we take a step back and briefly discuss the intentions of the Certificate of Need.

The Certificate of Need is a form of administrative planning tool to ensure equitable distribution of resources (health establishments, human resources, health technology) and ensure provision of better quality of services. Its introduction is fully supported by the Health Professions Council of South Africa and a number of other health bodies. The legislative process around the National Health Bill made provision for all stakeholders to comment and in addition make oral submissions before the Parliamentary Portfolio Committee on Health.

The notion that doctors are being targeted and that there is a plot to wipe out private medical practice is malicious. What comes out clearly is that some doctors want to preserve privilege and they want it entrenched in national legislation. All South Africans acknowledge that there are serious challenges in our health care system - public and private. All acknowledge that the health care system we inherited was flawed. Doctors nevertheless had a major influence on the state and shape of that flawed system. The highest leadership position in a public hospital (superintendent) was the preserve of medical doctors. The medical model of public health management could not be challenged and doctors were in most instances the pivotal point around which the administration of health facilities revolved. It would be naïve not to acknowledge that the medical profession still plays a major role in rationing health care, particularly in the private sector.

The indisputable importance of medical practitioners to the health care system must not be misinterpreted to mean that doctors are the only health professionals necessary to develop a national health care system or that they are more important than other professions such as pharmacists, dentists, nurses and other categories of health professionals.

One interesting aspect of the many media pronouncements was that the march to Parliament on 6 February was unprecedented 'because for the first time doctors were marching against government'. One cannot but wonder where those people making such statements were, when the National Medical and Dental Association (NAMDA) and the SA Health Workers Congress (SAHWCO) marched against the apartheid government fighting for the creation of a single national health system. One cannot help but wonder where the marching doctors were when people were being brutalised and murdered in our prisons and other state institutions in gross violations of human rights. Or is this march unprecedented mainly because of the nature of the government that is now in place and the fact that those who were comfortable with the previous regime have now taken to the streets in protest.

Dr Letlape states unequivocally that in their view the state of health services were much better during apartheid days than is the case under a people's government (Pretoria News, Business Report, 12 February 2004). It is of serious concern that the rest of the profession has not publicly contradicted his statements. An even bigger tragedy is for the profession to be led into the political terrain by those who were spectators during the fight to liberate this country.

What is this Bill meant to do anyway?

The basic tenet of the NHB is that it must "provide a framework for a structured uniform health system within the Republic, taking into account the obligations imposed by the Constitution."

Some have argued that the government should be more concerned with public health services and leave the private health sector to sort itself out. The socio-economic injustices and imbalances in health services of the past found clear expression in the private health sector. Black doctors and those white doctors who worked in underserved areas will readily attest to this. However things have changed markedly in the past 10 years due to a number of socio-economic and political advances.

It is undeniable that the struggle for survival - financial or otherwise -is a basic issue among professionals across the board. In view of this it is prudent to examine the problems associated with unregulated markets that trade in issues of life and death for everyone - health care. Currently medical doctors can set up practice wherever they wish. Unfortunately this has led to problems of oversupply in some areas with serious problems of unethical conduct, fraud and many other unprofessional acts that have troubled the majority of doctors who subscribe to good ethical conduct. This prompted the Forum of Statutory Health Councils in 1998-1999 to develop a policy on Perverse Incentives - aimed at guiding the health professionals on what is acceptable and what is not. It was a realisation that medicine (and health care broadly) is now practiced in a commercialised environment with all its trappings and challenges. Relying on broad guidelines is therefore not enough.

Ensuring access to health services is one of the basic requirements for government to fulfil and cannot be achieved without ensuring that resources are distributed equitably. To advance and address issues of equity and social justice, the government has to effectively play its role of stewardship for health care and that includes health services provided by the private health sector. Leaving the transformation of private health care to market forces has so far not yielded the desired results.

A recent case, which is clear justification for regulation of the private sector to be tightened, is that of the radiologists who charged for treatment not given, charged for equipment not used and who paid kickbacks to doctors for referring patients to them. So great has the problem become that the medical funding industry felt the need to establish 'anti-fraud' units to prevent similar abuses of the system by health professionals and their patients. These are just some of the effects of leaving unchecked health care to market forces. While the public would like to believe, correctly so, that the majority of doctors practice medicine properly and abide by the rules, it is clear that there is a significant minority that is lining its pockets at the expense of other stakeholders and even government.

The Certificate of Need has to be seen in the context not only of trying to regulate health better but also as contributing to the development of a sustainable health system. Some doctors seem to believe that there is a constitutional right of doctors to practice wherever they wish. Such 'right' if it exists in law has to be counter-balanced with the constitutional right of access to health care for patients and the constitutional obligation for the state to ensure that access. Since health resources are not unlimited the next obvious means of ensuring better access is to ensure more rational distribution so that the resources that are available are accessible to the greatest number of people. This is an old problem faced by many countries throughout the world especially developing ones.

The private health industry often argues that self-regulation and incentivisation are the only and most appropriate mechanisms to address the shortage of providers and related health technology in rural areas. While the Health Bill adopts the incentivisation and control approach through the Certificate of Need, it also recognises that 'market forces' alone will not act fast enough to meet the challenge. Control through legislation is necessary due to the acute shortages of health personnel in certain areas and the oversupply of some in others combined with the constant threats of the reduction of those resources due to the brain drain, the perverse incentives and other factors that are already in the market. The brain drain to overseas countries is not limited to the public sector because a sizeable number of health professionals are leaving the private sector for overseas countries too.

The Certificate of Need controls not only the distribution of health care services but also the kinds of health care services that may be offered. It attempts to match the health care services offered in a particular area with the needs of the population in that area. There is always a tendency to spend money on expensive medical technology that is 'nice to have' rather than critical for the health of the population.

A new unsubstantiated statistic was released by Dr Letlape last week that "the private sector actually serves up to 60%" of the population (Why doctors are marching; Mail & Guardian Feb 6 to 12, 2004). This is deliberate distortion of statistics. The public sector still has to provide health services to the majority with a split of about 80:20 (public:private) and the situation is not improving. These kinds of statistical trends tend to entrench the position of the wealthy few as well as that of the deprived many.

As the fight for the public's ear intensifies, it is important that the profession does not turn to disparaging statements as these might compromise the profession's standing in society. The Certificate of Need is not a blunt instrument, as some would want the public to believe. It can address not only distribution of health services but appropriateness, efficacy, timeliness of health interventions, the correct mix of mutually supportive health services. Commercialisation of health care services tends to distort the provision of such services and the incentives already attached cannot easily be abolished. However a mechanism to correct the distortion is needed so that the focus is on the need rather than how much money is to be made out of being a doctor. There are surely many medical doctors who would agree with this approach as long as they can comfortably earn their living through ethical means.

There are some extremely useful spin-offs of Certificate of Need apart from its enormous potential for use as a health-planning tool. These include using it as a means of setting up referral systems for essential services, identifying localised disease profiles and offering a rational basis for identifying scarce skills and the appropriate incentives to retain them. The Certificate of Need can be used to manage the interface between the public and private health sectors in terms of partnership arrangements, mutual benefit arrangements and other PPP arrangements. The Certificate of Need can also help to prevent practitioners who have been struck off the Health Professions register etc from practising illegally. Certificate of Need is a process not an event and not a quick fix solution. It is a tool that will be subject to continuous ongoing development in order to keep pace with changing needs and the environment. It can be used to employ or implement broader government initiatives such as BEE.

Lastly the medical profession has to honestly engage with government to address the issue of the survival of the profession. It is evident that market forces have not given it the stability it needs at certain levels. Many General Practitioners now depend on 'selling' medicines to make a living. The stewardship role of government demands of it to intervene where 'market' forces have failed our people so that their health care is not compromised. But this cannot be done on the basis of protecting privilege for doctors. Much as the doctors' concerns are understood, the profession's silence when statements glorifying apartheid health are being published on their name is worrisome.

Opposition politics

The DA cannot disguise its policies of backward change

Trying to imitate this online journal, the Democratic Alliance (DA) publishes a letter from its leader, Tony Leon, under the title 'SA Today'. In the latest issue, Leon writes "I challenge President Mbeki to debate". We have already said that we are willing to provide an ANC Branch Chairperson to engage Leon in a public debate.

In his latest letter, Leon also accuses our President of "making outrageous, false, and inflammatory accusations" in his Letter, which appeared in our last edition (Vol 4 No 6). It is clear from his letter in 'SA Today' that Leon finds it difficult to defend long established positions of the DA.

As our President said, the DA has been very proud to demand wholesale privatisation of state assets. What this means is that the DA wants "the democratic state to stop providing such basic goods and services to the people as water, electricity, transport, telephones and so on".

This is precisely what the DA policies of privatisation mean. The DA has been saying that all these goods and services should be provided by the private sector rather than the democratic state. If the DA has changed its policies on this matter, Leon should say so.

The claims Leon makes about such matters as free basic services and municipal indigent policies are nothing more than a public confession that the DA had no choice but to implement ANC policies in the municipalities it controls. This has absolutely nothing to do with any DA policy against wholesale privatisation.

Consistently, the DA has argued for a minimal state, claiming that this would expand the freedom of the individual. Related to this has been the equally persistent demand of the DA for maximum deregulation. The call for wholesale privatisation is consistent with and an essential part of this outlook.

Leon now argues that our President's observations with regard to the DA positions on such matters as minimum wages and employment equity are "false". Again, Leon should therefore state this categorically, that the DA supports the positions of our movement and government on these matters, in favour of regulation.

This would mean that the DA has abandoned its arguments promoting deregulation, at least as they relate to matters affecting the labour market. This would also signify that, in this regard at least, the DA has moved away from its traditional policy positions in support of "market fundamentalism".

In his response to the debate of the State of the Nation Address in June 1999, President Mbeki dealt with the ideological bases of the DA commitment to this "market fundamentalism". He quoted the then DP, led by Leon, as having said: "We want a country built on opportunity, fuelled by peaceful commerce, driven by the spirit of enterprise, founded on justice, fairness and merit, protected by the law."

He then went on to say: "Behind all the words we have quoted, is the fundamental idea that everything must be left to the great leveller, the market, which is driven by the notion that 'self regarding interest is predominant over social interest', as Bentham put it. In our own specific situation, what this means is that those who are fittest to survive will survive. Those who are best abled will qualify on the basis of merit.This is the soulless secular theology which, indeed, defines the DP as the opposition party."

In last week's Letter to ANC Today, which Leon challenges, President Mbeki returns to this theme. He said that "to the extent that this is possible in our democratic society", the DA and other parties would like to "recreate" the black townships "as they were during the apartheid years".

As to the manner born, in his letter Leon deliberately omitted the words "to the extent that this is possible in our democratic society".

President Mbeki's argument was that during the colonial and apartheid years, capitalism or "the market" in our country operated in an unregulated atmosphere as far as it related to the black and especially African majority. One of the consequences of this sustained policy of oppression and super-exploitation, driven centrally by the objective to maximise profit, was the birth of the black townships "as they were during the apartheid years".

In last week's Letter to ANC Today, he observed that implementation of the DA policies of "market fundamentalism" would perpetuate this situation, "to the extent that this is possible in our democratic society".

The fact that Leon is seemingly embarrassed by this obviously correct observation does not invalidate it. What would rescue Leon from his misery, arising from a clear and unapologetic exposure by our President of the consequences of the policies of his party, would be for him to persuade both himself and the DA to admit that the "soulless secular theology" of the DA is wrong and inhuman.

Making false accusations that what President Mbeki has said is "outrageous, false and inflammatory", and resorting to personal attacks on the President, will not help Leon to disguise the true nature of the DA as South Africa's principal political representative of those who are determined to preserve the privileges they derived from the apartheid system.

Incidentally, we, for our part, will not join in the campaign to debase political debate in our country by resorting to personal, ad hominem attacks against Leon or any other person.

As explained in detail in the book, 'A Marriage Made in Heaven', the DA increased its strength after 1994 by adopting and adapting the policies of the NP when it was still the party of apartheid. Thus it gained the support of the bitter-enders who rejected the NNP as it sought to redefine itself as a party in favour of a non-racial democracy.

As President Mbeki explained in his Letter last week, the "coalition for change" much beloved to the DA, is in fact a "coalition for backward change"

This conclusion has nothing whatsoever to do with "outrageous, false and inflammatory accusations". It has everything to do with the policies of the DA.

** Malusi Gigaba is President of the ANC Youth League and a member of the ANC National Executive Committee.

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