A day after Finance Minister Tito Mboweni delivered his budget speech in Parliament, activists and residents from Khayelitsha and the rest of the Cape Flats, congregated at Community House in Salt River.
The People’s Health Movement of South Africa (PHMSA) hosted a public meeting on the state of healthcare, the National Health Insurance (NHI) and the need for universal healthcare.
Mboweni’s budget also came up in the discussions.
The finance minister had an Aloe Ferox plant he ceremoniously showcased during his speech the previous day to remind South Africans they “can survive anything”. However, for those who filled the room during the public meeting, there was little the finance minister could teach them about ‘survival’. After all, they are the ones queuing at public health facilities and being held hostage by a system that fails them daily.
And by then, a day after Mboweni’s budget speech, it was clear to all at the meeting that change will not be coming soon.
NHI and the Budget
One participant who serves on a clinic committee in Gugulethu got up and said that NHI is being politicised and “this thing is eating us. They’re using our people when they say we have a right to health for all; the community don’t know what is NHI; they (the government) just tell you – you want it. You have provinces scared of losing their power. That is politics. We don’t want that. We want our right to health for all.”
Mboweni in his speech made scant reference to NHI but in the National Treasury’s budget review document government was more forthright on what the R3.9 billion reduction of the Health budget over the next three years will mean for NHI. “This implies that some activities related to national health insurance will be phased in over a longer time frame,” the document reads.
In the coming financial year an amount of R25 million is allocated to the government’s national quality health improvement plan that will now be piloted. It is this plan that must help public health facilities meet the standard for NHI accreditation and by default also help make a dent in the growing mountain of medical legal costs. In their most recent survey of public facilities, the Office of Health Standards Compliance (OHSC) found that only five of 696 facilities met the standards required for NHI.
'Insulted, betrayed, enraged'
During the public meeting in the wake of Mboweni’s speech words like “insulted”, “betrayed” and “enraged” were flung around. Dr Lydia Cairncross affiliated to the PHMSA and one of the guest speakers said the budget shows there is no real financial commitment to reform and improve the public health system in preparation for NHI. She called the R25 million allocated for the quality improvement plan “a drop in the ocean”.
“Timelines for delivery keep shifting,” she said. “With the recent budget speech, it is clear that these timelines will shift yet again. This is a betrayal of the many thousands of people in South Africa in desperate need of quality healthcare. South Africans in their hundreds added their voices at NHI public hearings in the belief that it was a plan with real political commitment behind it. For these people, who expressed the anguish and suffering caused by our dysfunctional public and private health systems, the answer 'NHI is coming’ is no longer enough,” Cairncross said.
In the budget review, government states the NHI Bill is “expected to trigger large-scale reforms”. An amount of R55,6 million will be reprioritised over the next three years to help build capacity to phase in NHI. This will help fund the establishment of the National Health Insurance Fund,” the document reads.
In the review, treasury also acknowledges establishing the NHI Fund is likely to have “significant implications for provincial finances” and these issues are being discussed in consultative structures. “Efforts to strengthen the health system in preparation for national health insurance will continue, including developing and piloting provider payment mechanisms, expanding the national insurance beneficiary registry, and purchasing and providing a prioritised set of health services,” the review states.
Health economist Alex van den Heever said there is a dichotomy between the “political rhetoric that talks the NHI up, and the reality that the project is self-evidently not feasible”. “It is not entirely clear, however, that the faction driving NHI clearly understands just how flawed the proposals are. In many ways this reflects the tension we are seeing in government. While the one faction attempts to frame the NHI project as a struggle of the good against corporate vested interests - seen as the only obstacle to implementation – the other, mainly technocrats, know not to promise anything they cannot deliver, and therefore attempt to manage expectations by avoiding the topic altogether – hoping no-one notices,” he said.
Zukiswa Kota of the Public Service Accountability Monitor (PSAM) told Spotlight funding the piloting of the national quality improvement plan is encouraging. “But until then provinces like the Eastern Cape with already ailing health systems and declining quality of care show particularly grave trends. Current interventions to curtail this trend are vague and limited – raising questions about both the state's capacity and will to do so.”
Almost R56 million is budgeted to establish the NHI fund, but there is still very little detail or substantial assurances on measures to safeguard the fund against possible looting.
According to Atlantic Fellow at TEKANO and Public Health Association (PHASA) René Sparks, a phased approach “to determine gaps and issues is essential as communities and healthcare workers need to see the real system birthed and not only concepts”. “It is a bit hard to understand as we all want the nuts and bolts explained and not only want the end goal highlighted,” she said. “We are on board with the end goal which is ‘Health for All’ but the how remains grey.”
Mboweni’s budget did not do much to elucidate the ‘grey’ areas.
The political and financial will behind NHI was also flagged by Sasha Stevenson, head of Section27’s Health Programme. Stevenson said, “This is not a budget of a government implementing a National Health Insurance programme nor is it the budget of a government investing meaningfully in improvement to the health system. Instead we are seeing continued shrinkage in health budgeting and are worried about what this means for access to quality health care services.” Stevenson said at present many forms of contraception have been out of stock across the country and health facilities, such as the new state of the art clinic in Lusikisiki, are understaffed.”
The PHMSA called the almost R4 billion budget cuts the public health sector will suffer over the next three years ‘a two-sided assault on the health of the nation’. “It will weaken the public health system and, at the same time, increase our national burden of disease and ill health.” And it is the poor who will suffer, said Dr Louis Reynolds, who is affiliated to PHMSA. Reynolds also attended the public meeting. He told Spotlight an austerity budget that cuts (or, in SA doesn’t actually increase accountable public spending) can only lead to a reduction in delivery of public services that are essential for health. “This inevitably will increase inequality – and that is the last thing South Africa needs. It will also increase the already massive burden of disease in the country which will in turn increase the load on the already overburdened and understaffed public health sector. So, it seems that this budget is bad for the country’s health. It will increase the burden of disease, while simultaneously weakening the public health sector,” he said.
There are also concerns about the impact budget cuts may have on central and provincial hospital services, that will bear the brunt of the cuts, as well as emergency medical services. Section27 in a statement bemoaned the impact this will have in rural areas because “patients are already being denied health care due to a lack of reliable ambulance services”.
Director of the Rural Health Project Russel Rensburg in turn raised concern over the proposed target of saving over R160 billion from the provincial wage bill. “Clear guidelines must be given to provinces to protect critical health posts and particular attention must be given to strengthening capacity at primary healthcare level,” he stressed.
Last year Parliament’s Select Committee on Appropriations in its recommendations on the proposed Division of Revenue Bill and the conditional grant allocations to provincial and local spheres of government said while the committee “understands the need to restructure certain conditional grants, it is of the view that grant restructuring, termination or merging must not affect service delivery objectives and proper assessment or analysis of grant performance ought to be conducted before any restructuring can happen”. National Treasury agreed with this sentiment that grant restructuring should not harm but improve service delivery.
But in light of the planned R1,9 billion cut to conditional grants for health, not everyone is convinced.
DA MP Siviwe Gwarube who serves on Parliament’s Portfolio Committee on Health said there are “massive grants such as the one for HIV/Aids which serve a strategic and specific purpose”. “The cuts to these grants are deeply concerning and will no doubt have a direct impact on the provinces’ ability to deliver services.” She said there has been some “creative accounting where existing budgets are seemingly being repurposed to mask the lack of tangible commitment and funding towards NHI”.
Some of the funds in these grants were shifted due to underspending – something the Public Service Accountability Monitor (PSAM) in turn, warns may have negative consequences. Kota said PSAM agrees with the National Treasury on “the need to ensure more effective use of public funds and to reduce wastage”. “But without clear assurances that 'reprioritization' and 'reductions' will not add undue pressure on ailing systems and civil servants, we remain unconvinced that the budget is adequately pro-poor. This is particularly the case at the provincial hubs of delivery,” she said.
Some good news for foot soldiers
There was some good news for community healthcare workers in the budget. In the coming financial year an amount of R800 million, taken from the HIV component of the HIV and Aids conditional grant, is allocated to community outreach services. This should ensure the department complies with the national wage requirement of R3 500 to all community health workers throughout the country. This allocation was widely welcomed and so too the ringfencing of R3,3 billion for medical interns and healthcare workers’ community service.
NEHAWU applauded this. Rensburg also welcomed it, but told Spotlight that more generally he is concerned that the budget does not do enough to address the critical healthcare worker shortages in the public healthcare system. “[Still,]The ringfencing of funding for community service and medical interns is good as well as the standardisation of community healthcare worker wages,” he said.
The financial commitment to strengthen the muscle of corruption fighting institutions was welcomed across the board. IFP MP Elphas Buthelezi who serves on Parliament’s Standing Committee on Finance told Spotlight Mboweni’s announcement that an additional R1.3 billion will go to the National Prosecuting Authority (NPA), the Special Investigating Unit (SIU) and the Hawks is encouraging.
“We need to decisively deal with corruption, also in health. We have not seen any actual successful prosecutions so this will help. No one will take government seriously without actual prosecutions,” he said.
Gwarube agreed there are positive strides being made. She cited the expanded powers of the Auditor-General that can reclaim monies lost to misappropriation of funds from accounting officers and the investment in the NPA.
“The reality is that over R20 billion is lost to corruption in the health sector annually. We need to be able to hold people accountable and have them criminally charged for stealing public money which could go towards healthcare.”
Apart from funds allocated to fighting corruption, key legislation introduced recently has the potential to help in this fight. One such piece of legislation is the Public Procurement Bill – a piece of legislation that makes Kota hopeful. “If the effect will be a simpler, less fragmented and more transparent public procurement environment – the Bill will have achieved a lot,” Kota said. According to her the slow progress with implementing vital open contracting, anti-corruption mechanisms particularly in light to the complexities to be introduced by the NHI, is of great concern.
And maybe here lies the rub, as Rensburg told Spotlight in response to the budget – the elephant in the room is still government’s capacity or lack of capacity to implement.
Note: SECTION27 is mentioned in this article. While Spotlight is published by SECTION27 and the Treatment Action Campaign, Spotlight is editorially independent, an independence that the editors guard jealously. Spotlight is a member of the South African Press Council.
*This article was produced by Spotlight – health journalism in the public interest.