By Russell Rensburg, Rural Health Advocacy Project
In the tabling of the national department of health’s budget for 2017/2018, minister of health, Dr Aaron Motsoaledi, delivered an impassioned address about a health system in transition to achieving universal access. Few could argue with the minister on the need for radical reform of a health system where socio economic status is still a key determinant of the quality of care patients receive or the reasons they seek healthcare. However, in articulating his vision of the NHI and some of the achievements of recent years the minister failed to address the significant crisis currently unfolding in the South African health system.
The delivery of healthcare in South Africa is a concurrent responsibility of the National Department of Health and the nine provincial departments of health. The NDOH supports the attainment of better health for all South Africans by providing policy leadership and oversight of the country’s health system. So, while not directly involved in service delivery it sets the goals and targets that inform service delivery in each of the nine provinces.
The budget tabled by the minister focused primarily on the mandate of the National Department of Health which is delivered through the six strategic programmes managed by the department. The NDOH budget continues to be dominated by HIV, tuberculosis (TB) and Maternal Child Health which together account for planned expenditure of R18 billion in this financial year. 95 % of the 18 billion in planned expenditure is allocated to HIV AIDS – which supports the implementation of the country’s HIV and TB programme in the provinces by way of the HIV TB conditional grant. These grants fund HIV and TB related activities as well as medicines. The grants do not fund the human resources or the physical infrastructure such as the clinics and district hospitals through which the programme is delivered.
So, while the real increase in budget of 7,5% in this financial year to accommodate the implementation of the expanded HIV treatment programme is laudable there is a significant risk that the anticipated benefits will not be realized. In a recent joint parliamentary hearing of the standing committee for finance and health, presentations from various provincial departments of health outlined significant challenges in financing the service delivery platform. In the presentation of the North-West province, the MEC for Health indicated that the province will be unable to deliver on the test and treat policy without additional support. Similarly, a presentation by the KwaZulu-Natal department of health indicated accrued expenditure in excess of R1-billion which is likely to impact on its ability to deliver district health services – placing the country’s largest provincial HIV programme at significant risk.
The real reduction in the budget allocation for TB at the National Department is concerning given the size and complexity of the TB epidemic . It is difficult to link how the reduction will impact on service delivery as funding for TB has been integrated into the HIV TB conditional grant . As the integration is a fairly recent event it would be beneficial for the department to report on how the integration of the TB and HIV units is progressing.
Acute human resource for health crisis
The largest programme under the NDOH with planned expenditure in excess of R21-billion, also known as program 5, focuses on hospital and tertiary health services and human resource development. These investments are critical in ensuring the long-term sustainability of the health system – particularly as it supports the development of key health infrastructure and human resources.
However, the country is currently experiencing an acute human resource for health crisis which is less about available human resources – but rather about a lack of sufficient budget to appoint the necessary personnel. In this context, there is a need to balance the building of new facilities with the maintenance of existing infrastructure and to prioritise investment in dilapidated rural facilities in the most deprived parts of the country. This must include investment in the IT infrastructure and provision of suitable accommodation for rural health care professionals and their families.
The lack of suitable accommodation and services such as internet access among others is often cited as a primary reason why health professionals reject rural placements. This is not an unnecessary luxury in remote places where health care workers live and work on the premises of the hospital. At Canzibe, a district hospital in rural Eastern Cape which is the primary referral site for over 11 rural clinics servicing a population of over 138 000 people, there are currently only two full time doctors one of which leaves at the end of May. Efforts are underway to recruit additional staff but the facility also needs investment in IT infrastructure for both professional and personal purposes to make it a place where healthcare workers will choose to work.
Uncertainties about NHI
In the absence of the revised white paper on the NHI it is difficult to fully understand the impact of the planned establishment of the NHI fund – specifically the accreditation process for public and private health care providers. In a recent evaluation by the office of health standards compliance of 2 647 facilities only 267 managed to achieve ideal clinic status. This poor performance does not bode well for accreditation of public sector facilities to the NHI fund and could lead to the over participation of private PHC units in the fund.
Efforts within the Primary Health Care directorate to strengthen district management services as well as the planned service improvement initiatives to improve performance in ideal clinics is therefore very timely. The strengthening could be further supported by the direct funding of the delivery of district health services through the introduction of a special ring fenced conditional grant to directly fund district health services. District health services including NHI pilot sites across the country are on the brink of collapse and management are currently implementing service rationalization initiatives that includes the closure of clinics which will further limit access to health services.
Official and unofficial moratoria on posts
Without detracting from the need for health sector reform and the potential benefits of the NHI – which we support – there is a clear and immediate crisis that needs urgent attention. Failure to address the official and unofficial moratoria on posts has the potential to decimate health services to the point where they are no longer functional. A pilot project underway in North West Province defining and prioritizing critical health posts with local data and the involvement of local managers may provide a minimal solution. But there is no denying that the system needs more health care workers, and innovative and cost-effective human resource solutions to protect and expand access.
Failure to address the underfunding of district health services will further compromise service delivery to vulnerable communities with no other alternatives to the public system, particularly rural communities plagued by HIV and TB as well as Non-Communicable Diseases. Failure to act on these and other systemic issues is a failure in upholding and realizing our Constitutional rights to health and dignity. What is missing from the Minister’s Budget Vote is an honest reflection on these challenges. It cannot simply be business as usual – we are faced with a serious budget crisis and the question remains how in this climate will we ensure that we prioritise services to the most vulnerable health care users and communities to avoid further marginalization.