Patients at a public hospital in Gauteng. Photo Delwyn Verasamy
The theme of this year’s World Health Day on 7 April is “my health, my right” and emphasises the right to health and health care. The South African constitution resonates with this theme by saying that everyone has the right to have access to health care services, including reproductive health care, and no one may be refused emergency medical treatment. The state must take reasonable legislative and other measures, within its available resources, to achieve the progressive realisation of each of these rights.
Approximately 83 out of every 100 people in our country depend on the public sector for their health care. As we enter the new financial year in South Africa, the massive budget cuts in the public health sector make one somewhat cynical about the progressive realisation of these rights. As the health sector tries to bounce back from the crisis of Covid-19, a new funding crisis is imposed.
I am familiar with the impact on the Western Cape, but all provinces are facing similar constraints.
What are the implications of this for health care? One of the immediate consequences is a moratorium on the filling of posts. As health workers leave their posts they may not be replaced. In the Western Cape alone 1,958 posts are now unfunded and cannot be filled.
This has a direct effect on the ability to deliver services. Funds for locum staff are not available and many facilities depend on such staff to provide 24-hour cover. At some facilities, hospital beds have been limited. However, fewer hospital beds does not reduce the demand but means patients will spend more time on trolleys or floors in the emergency centre and may not be admitted. Elective surgical services are being reduced, particularly in orthopaedics, which means people will wait even longer for such assistance.
The South African Academy of Family Physicians said: “Our staff, our services, our communities, and the very existence of the medical profession are at risk of significant and long-lasting damage. Is this a justifiable price to pay for this attempt at balancing the national fiscus?” Undoubtedly the erosion of health care services will have a disproportionate effect on poor and vulnerable communities.
In 2023, the department of health and wellness in the Western Cape announced it faced massive in-year cuts to the budget. This resulted from cuts to conditional grants (R718 million), re-formulation of the allocations between provinces (R594 million) and an unfunded wage bill (R1,1 billion). This was due to a public sector wage increase that was agreed to by the government, but not funded by the treasury. The increase therefore had to be absorbed into the existing budget.
In the 2024/25 financial year, further cuts are expected as the 2.5% increase in allocation is overshadowed by the 6.5% medical sector inflation. A further R807 million shortfall is predicted for 2024/25 and this trend is expected to continue for the next three to five years.
How did we end up in this predicament? Many explanations are put forward and many factors are likely to be important. Treasury will say that revenue in South Africa has decreased, and we have been spending above our means. Others will point to state capture and corruption, borrowing during the pandemic, the unfunded wage bill, the funds needed to solve or mitigate the energy crisis, and our huge financial commitment to the ongoing basic income grant.
One must also take a moment to think of the psychological impact on the remaining healthcare workers. Having survived the pandemic and starting to fight back against some of the ground lost with other diseases such as HIV, Tuberculosis (TB) and diabetes, healthcare workers are again expected to rise to the challenge of providing health care but with even fewer resources.
Many managers are distraught and demoralised as their plans for quality improvement are founded on the rocks of fiscal constraints. The healthcare workers left behind as people leave face the same demands and workload from the public but with fewer resources. Burnout and depression are rampant, especially among junior health professionals.
Indeed, many doctors who just completed their community service are unemployed. Ironically our medical schools have increased the training of doctors dramatically over the past two decades in response to government calls for more doctors, but now the government is unable to take advantage of the increased supply. Such doctors may turn to the private sector or emigrate to pursue better opportunities in other countries.
In the Western Cape, there has been a commitment to protect primary healthcare services as much as possible. These services are the one part of the health system that can improve health while saving costs. This is mostly because of the ability to promote health and prevent disease in the communities served. Such community-oriented primary care is a small ray of light in the dark clouds of budget cuts.
Community health worker teams and their primary care facilities continue to offer immunisations, family planning, antenatal and postnatal care, as well as services for TB, HIV, diabetes and many others. However even here services will need to be rationalised and some initiatives, such as mobile wellness centres, may be terminated. It is hard to imagine any new innovations to improve the quality of care being implemented in such a climate.
On World Health Day 2024, the theme of “my health, my right” seems to be besieged with problems and challenges in our country. We need the public and civil society to demand that their right to health and health care be fulfilled.
Prof. Bob Mash is the Executive and Divisional Head of the Department of Family and Emergency Medicine in the Faculty of Medicine and Health Sciences at Stellenbosch University. The views expressed are those of the author and do not necessarily reflect those of Stellenbosch University.
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