Healthcare … how should the priorities be determined?

I read with interest a recent report of the proceedings from a recent conference¹ held in Cape Town. The conference, it was reported, brought together healthcare workers, researchers and community activists from 11 African countries. The focus of the conference was the unequal provision of surgical procedures to those living in rural areas and those without a medical aid or medical insurance.

At the conference it was stated that before the COVID-19 pandemic the lack of access to surgical procedures was a challenge for public health services but that this had been exacerbated by restrictions on surgical procedures during the pandemic with an estimated 175 000 people now waiting for surgical procedures. This situation was attributed to what was termed “a lack of government investment as a result of a failure to make these services a political priority”. Dr Dubula-Majola, described as an outspoken HIV activist, is quoted as saying, “If government doesn’t come along, you must drag them along.” She likened the current situation related to the surgery backlogs to that of the struggle for antiretroviral therapy in South Africa indicating that, “Rights are not given but fought for by the poor and oppressed.” Another participant reflected that “unlike cancer or HIV surgical, care is not a single diseases so advocating for HIV (treatment) is different from surgical care.” This view was echoed by someone familiar to me from my time as the Head of the Western Cape Department of Health, Professor Lydia Cairncross, now the Head of general Surgery at Groot Schuur Hospital. Cairncross went further indicating that in her view quality surgical care requires improvement of the whole health system and that surgical care “should be recognised as part of the package of population-based healthcare”. The latter are sentiments with which I would agree. She appealed for the whole of society to be brought on board to improve health care and that “people must declare it is their right to receive affordable and timely access to surgical care”.

These were rousing calls for action that I am sure were well received at the congress but what happens when resources are limited. In the case of AIDS, the key issue at that time was denialism of both AIDS and the treatment thereof with antiretroviral drugs by the then President and Minister of Health rather than a resource issue which thankfully has been reversed. A wider issue remains and that is the ability of a country to afford the wide range of health services required and expected by the population and more especially so within the current severely resource constrained fiscal environment.

Professor Cairncross will recall the matter over which she with others and I differed so strongly in 2007, which illustrates only too well the dilemmas that are faced with regard to the funding of healthcare services. At that time due to budget constraints resulting from reductions to what are termed “conditional grants” for highly specialised services imposed on the department by the National Department of Health, the Western Cape Department of Health was obliged to reduce the numbers of operational beds at both Groote Schuur and Tygerberg Hospitals. A storm of protest at this decision resulted, lead by the then heads of medicine and surgery at Groot Schuur Hospital, the late Professor Bonging Mayosi and Professor Del Kahn. The anger was captured by a phrase coined by Professor Mayosi that I will always remember,“Househam puts cash before care”. I encourage readers to refer to this section of my book² for a more detailed description of the saga but a quote from then surgical registrar, Dr Cairncross, in the Cape Argus newspaper describing the cuts as “a callous disregard for the lives of the patients entrusted to our care and to the care of the administrators of the health system” illustrates the level of invective directed toward me at the time.

The need for clinicians to seek treatment for their patients remains an important part of their ethical and professional responsibility and as an administrator with a medical background a responsibility I have always respected, even in the face of considerable disrespect from my erstwhile colleagues. In an ideal world resources for healthcare would not be limited, but the reality is that of the many priorities face a government healthcare is only one. Health activists like those at the Afrosurg3 Conference will understandably motivate strongly that the priorities that they have identified such as the need for increased resources for surgical procedures must be addressed. Equally, however, activists representing education, housing, security, nutrition and many others will with similar passion advocate that their priority must be addressed by government. Even within the health various sectors will advocate that their specific areas of activity and expertise such as child health, mental health, adolescent health and primary health care amongst many others should be prioritised. These would also include the need for more accessible surgical care that received attention at the Afrosurg3 Conference.

With a fixed amount of funding available from the national budget and assuming that no resources are squandered through fraud, corruption and wasteful expenditure, how then should decisions be made which priorities can be addressed in a particular financial year? Further, after government has made the decision how much can be allocated to the health sector, how can decisions be made as to which aspects of healthcare will be prioritised? In a previous post I reflected on the differences between health and wellness and the need to focus on wellness to reduce the burden of disease in communities. Directly related to surgical care, what amount is required for surgical procedures, often in an emergency situation, necessary for injuries resulting for avoidable trauma? These funds could rather be utilised for other surgical procedures for which patients are forced to wait an unacceptably long time. Much of the avoidable injury to which I am referring occurs as a result of societal issues outside the health sector. These include poverty, unemployment, failures of the education system and social inequality that should all be government priorities. To refer to the quote above that government should be “dragged along”, possibly the issues that increase the burden of disease are of greater importance than the accessibility of surgical care to which it was said government should be “dragged”. Poor nutrition, abuse of alcohol and poor living conditions are some of the issues which contribute to the burden of disease either directly or indirectly, that also should enjoy a high priority for government. How then do these compare to that of health care services and more specifically to the need for surgical care? Difficult questions to which there are many answers

A collective of decision-makers and finally an individual, the Minister of Finance, must take these difficult decisions. It is vital that the health sector makes its case strongly, which I always did when I headed a health department, in terms of the resources required to ensure an accessible and quality health service to those who depend on the public health sector. To do so it is important that those within the public health sector ensure that every health rand is effectively and appropriately spent … wasteful expenditure and failure to spend funds that have been allocated do not strengthen the case of the public health sector for more funding. Within the health sector those responsible for both the management and delivery of healthcare must collectively both assume responsibility for how funds are allocated and ensuring that once the allocations have been made that there is the most effective utilisation possible of what is available. Once these difficult decision have been reached, it serves little purpose for individuals and pressure groups to then complain that their priority has not been fully addressed when others in other sectors face similar challenges.

Activism and activist rhetoric has its place, but those who were and are activists must face the challenge to also become “constructionists” as a very wise Kenyan public health activist once said to me in the heady days of early 1990’s as it finally became clear that apartheid was coming to an end. Solutions seemed simple then when decisions had been made elsewhere by those whom were regarded as discredited. But once in the position of being required to make the decisions, the complexity quickly became apparent even to the most ardent of activists of the 1980’s and 1990’s. In 1995, I rapidly faced decisions that made others unhappy having moved from a clinical to a managerial position. I have previously opined on the manner in which these difficult decisions can be reached and indicated that as a senior manager I adopted a utilitarian approach, that is that the most ethical choice is the one that will produce the greatest good for the greatest number. I utilised that philosophy in the 2007 decision to close beds at Groote Schuur and Tygerberg Hospitals as difficult as it was and the abuse that fostered. Similarly I would advocate that the activists who spoke at the Afrosurg3 Conference do the same. Undoubtedly more resources are required to address the estimated 175 000 people awaiting surgical procedures and in particular to address the challenges faced by rural communities. I would be surprised, however, if many public sector health administrators and managers in South Africa are unaware of these facts, but whether all the resources required will be available is the question. If not, it is important that there is transparency as to how decisions are made but that also that there is acceptance that there is a limitation for what funds can be allocated.

Rhetoric goes down well with an audience as many populist politicians know. However, it is important that in many aspects of South African life including the health sector that we move beyond rhetoric and become the “constructionists” that to which my friend, Dan Kaseje, referred over two decades ago.

1. Afrosurg3 Conference
2. Walking the Road of Healthcare in South Africa. My 40-year Journey Dr Craig Househam Pages 138-144 Quickfox Publishing 2021