Healthcare … a victim of a self-inflicted government funding malady?

Various questions trouble me when I hear that a public sector health department has a major shortfall in the budget allocation that will result in people being unable to receive the healthcare that they need. Who is accountable? Who is responsible for the consequences? Is it immoral that the cost of healthcare should limit access? Who should decide which treatment should not be provided? What is an acceptable package of healthcare? What can be done to alleviate the problem? I could go on …

I have great empathy with a doctor who although the treatment plan is clear must inform the patient that due to affordability constraints that either a particular treatment modality is not available or that the surgical procedure that is urgently necessary cannot be performed due to a long waiting list for that procedure. I similarly have great sympathy with the health manager who is faced with projected expenditure that exceeds the available funds and the administrative official who faces the wrath of creditors not paid as expected for the same reason. These people are at the sharp edge of the consequences of a budgetary crisis while those responsible, for whom I have no empathy or sympathy, often sit comfortably removed from this anguish.

With the advances in modern healthcare, the cost of healthcare has escalated exponentially exceeding the limits of affordability of all but the most wealthy. If that is accepted, then it seems reasonable that at some point decisions must be made about what can be funded, either by the individual or the state. It follows further that in the case of the state, that a utilitarian approach through which that, which will provide the greatest benefit to the most people, should be prioritised. Based on this argument, it appears that while an uncomfortable truth, that the cost of healthcare can limit access and that it is not necessarily immoral to do so. A caveat however is that inefficiency, wastage or fraud are not the reasons why adequate funding is not available. In this case the limitation of access to healthcare in my view would indeed be immoral as is wastage and fraud. It is true of course that those with unlimited resources will have similar unlimited access to all that modern healthcare can offer, a reality that is not limited to healthcare alone.

In a South African context with incontrovertible evidence of widespread inefficiency, wastage and rampant fraud and corruption across many spheres of government, those in positions of power and influence who have failed to address these issues cannot escape the fact that the consequences of their actions are the unnecessary morbidity and mortality that has resulted and will continue to do so. It is important to accept that there is indeed a link between a lack of responsibility and accountability at a political and senior management level and the negative consequences for the public health sector that are now being experienced.

If funding in real terms for public sector healthcare is arbitrarily reduced, it implies that staff numbers will need to be reduced and that similarly the funds available for goods and services will be reduced. When a patient is diagnosed with a treatable condition with a good prognosis, the health professional will be unable to provide that treatment be it medical or surgical or if so it may be required to delay such treatment resulting in a poorer prognosis. Poignant examples of this are patients with a diagnosis of cancer initially amenable to surgical intervention that becomes inoperable due to delays in undertaking life-saving surgeries. By doing so, the health professionals at the front line are unable to fulfil their responsibilities and, by default, rationing of healthcare occurs. The anguish, pain and suffering that results is not felt by the policy makers comfortably ensconced in positions of privilege but rather by the patient, their family and the treating health professionals.

The current government funding crisis has its origins in the granting wage increases amounting to an additional R37 billion to public servants as part of a two-year wage agreement against a background of declining revenues due to factors such as persistent power outages and the fallout from steps taken during the COVIS-19 pandemic. The decision to grant salary increases to public servants without the ability to make provisions to fund these increases which then requires a reduction in real terms of the availability of funds for health would appear to be an abdication of responsibility both by organised labour who demanded this wage settlement but also by the policy makers who saw fit to accept the settlement both of whom were aware of the government funding constraints. Since healthcare is a basic right can it be politically acceptable to have done so and should the politicians responsible not be held accountable for doing so? If the broader population had been or indeed are made aware of these consequences would they have raised their voices in protest and will they do so when next they have that opportunity at the ballot box? I fear that the relationship of these facts may be lost in the political speak that floods the South African media.

It seems entirely reasonable that an affordable package of healthcare could be determined through a process of consensus by experts accepting that the need for healthcare is infinite and the funds available are finite. However, it is completely unreasonable that the package of healthcare is arbitrarily limited by a budget decision taken at the highest level without apparent consideration of the consequences for the provision of a basic service such as health. On one hand government has proposed National Health Insurance as the mechanism to provide healthcare to all South Africans but on the other hand failed by its own actions to even adequately fund the healthcare that is currently provided by the public healthcare sector.

I am afraid that looking at the bigger picture, the funding crisis that faces public sector healthcare along with other government departments is a self-inflicted government funding malady the cure of which will require drastic intervention. The treatment of the malady, which lies outside the public health sector, will not be palatable for many but in particular the South African leaders of organised labour and government. Stated in simple terms the country can only have what it can afford and can’t have what it cannot. A country cannot continue to borrow incurring a burgeoning national debt to fund its operational costs amongst which are the salaries of its public servants. Everyone at the highest level must accept this reality as must every citizen when managing their personal budget!