Is the state of South African public health a budgetary or a delivery problem?

I was struck recently when according to a news report the National Minister of Health had appealed to his cabinet colleague the Minister of Finance to “stop cutting health budgets” and in doing do “alleviate the pressure on frontline health services”. He indicated that he had requested that there be no budget cuts in the coming year as had been indicated previously, so there would be no further reduction in frontline services. As an illustration the Minister reported a large number of vacant posts in the Free State Health Department of which the province had indicated nearly 900 were termed as “critical frontline posts” which he attributed to a lack of funding to fill these posts. The Minister responding to parliamentary questions reported that a similar situation existed in other provinces.

In delivering the 2022 Medium term Budget Policy Statement (MTBS) the Finance Minister to a limited extent heeded the plea from his colleague and the amounts allocated over the next three financial years, the period of the 2022 MTBS, reflecting an average annual growth of  2.6% which is below the Consumer Price Index (CPI) and well below inflation in the health sector. The statement indicates that “the 2023 budget will partly reverse the real reduction in provincial health budgets that occurred following the COVID-19 pandemic” but also indicates that “greater efficiency is also needed”.  The average annual growth is below the envisaged increase in public servant salaries for the same period of 3.3%. It should be noted that organised labour has rejected the unilaterally implemented salary increases, demanding an inflation-linked increase, and a public service strike is imminent. Overall in the MTBS 55% of the funds are allocated for the compensation of employees (CoE) in the public sector, i.e. salaries, but this figure is significantly higher in the health sector which means that the amount available for additional discretionary expenditure in the public health sector will remain extremely limited.

While the National Health Insurance (NHI) Bill, which the MTBS notes is being considered by parliament, and seemingly destined to be approved by the ANC parliamentary majority, possibly with some amendments, is seen by some as the “silver bullet” that will solve the woes of the health sector it is unclear how much additional funding will accrue to the public health sector as a result.

Faced with the reality that funding for the public health sector is likely to remain constrained for the foreseeable future, is it realistic to then attribute the genesis of the current challenges faced by the sector as purely financial? What of the other factors, that if addressed, could result in significant improvements in the quality of care provide to the majority of South Africans? In my experience over the last several years, in many provinces there is significant inefficiency and wastage, to which the 2022 MTBS alludes.

Is there maximum productivity of every person employed in the public health sector where excellent performance is scarcely rewarded and under performance is not addressed? In my work I have identified examples of individuals, some highly-paid, being suspended on full pay for lengthy periods for alleged offences including fraud and corruption costing the State millions of rands which could have been more effectively utilised funding the much needed “critical frontline posts”. These instances are not isolated. While I accept that punitive measures are not the only way to improve productivity and staff morale, it is essential that there are consequences for both under performance and more specially malfeasance within the public health sector. Greater efficiency in dealing with disciplinary cases has the potential to both save valuable resources but in addition to reinforce a culture of consequence management which is lacking in many segments of the South African public sector, including health.

There is a performance management system operative in the South African public service, but the fact is that practically, other than being found guilty of gross misconduct and dismissed, the only manner in which an employee, even with substandard performance, can be obliged to leave the public service is either on account of ill-health or on reaching retirement age.

A further inefficiency is employees whose posts or job descriptions are inappropriate for the services which must be delivered. Again, in my experience in many provinces, the staff establishments fail to focus on the essential components required for the efficient delivery of healthcare. A surplus of employees in one area if addressed could result in the appointment of staff in other areas faced with a greater need. The fact that public servants cannot be retrenched, even if rendered supernumerary to the requirements of the services, results in inefficient utilisation of resources and mitigates against the efficient utilisation of funds allocated for the compensation of employees.

Is every health rand allocated to the public health sector for goods and services being utilised to its maximal potential? Funds allocated for this purpose are key to the delivery of healthcare and again the historical challenges related to procurement in the public health sector suggest that there is significant opportunity for greater cost effectiveness.  Too often over the last two decades there have been instances where tenders have been subverted negatively affecting the standard of care provided to the most disadvantage of patients. From costly infrastructure projects that have delivered substandard facilities or facilities constructed in the wrong place to procurement of food for patients at exorbitant prices due to collusion between officials and suppliers amongst other examples, all of which I have experienced myself, have drained much needed resources from the public health sector.

In my opinion, while additional resources allocated to the public health sector would be welcomed, I have sympathy with the Minister of Finance and his National Treasury officials, when they call for greater efficiency and better utilisation of the not inconsiderable R256 billion health budget estimate for the 2023/24 financial year. Both politicians and management and indeed every official within the public health sector urgently need to ensure that every action that they take ensures that very precious health rands are utilised to their maximum potential. While inefficiency, underperformance and malfeasance cannot be tolerated it is also important to ensure that exceptional excellence and dedication is tangibly rewarded with more than a routine letter from their supervisor. To respond to my own question, “Is the state of South African public health a budgetary or a delivery problem?”, it is both and both need to be addressed. However, to convince the National Treasury that additional funds are justified, the delivery challenges must be urgently addressed.