Dire consequences for many
Posts not being filled, mental health issues among healthcare workers and more. By
the state sector, who are basically seeing no option for themselves but to be pushed out into either the private sector or overseas, where they are actively recruiting for our very well-trained staff. So, these are not skills that we are going to easily get back,” she warned.
Sean Chetty, executive head of the Department of Anaesthesiology and Critical Care at Tygerberg Hospital, reported that the facility was also facing a large number of vacant clinical and non-clinical posts, as well as a backlog at the level of the surgical department because of the impacts of the Covid-19 pandemic and worsening budget cuts.
“We deal with the consequences of these backlogs… The impact that has for us is that now the patients who are … presented to us for surgery are sicker patients… They require more intensive care and therefore higher resources. It becomes a vicious cycle because as budget cuts … make us cut back on these non-emergency services, we see patients progressing to requiring higher resources for them to just survive,” he said.
Health worker wellbeing
It is “extremely morally distressing” for health workers to see a patient progress to a more advanced stage of illness because they have to wait for the care they need, said Parkes. Many patients also become frustrated with health personnel when their treatment is delayed.
“We try not to make patients who we are treating with curative intent wait for their chemotherapy and radiotherapy but we have to triage them… So, for the combined team, it’s extremely morally distressing. We have to deal with irate patients, irate families.
“There’s been very little communication about the … cutting back of services with the public, and so the public are not generally aware of the stresses and strains that are being dealt with in the hospital.
“There are a lot of mental health issues among the healthcare workers – anxiety and depression about the future, about their career paths,” said Parkes.
This sentiment was echoed by Ntusi, who said there was a “huge amount of anxiety” among medical officers and registrars about whether they would be able to advance to the next stage of their training.
“With the threat of funding cuts, there’s a large amount of jitteriness for a huge complement of our staff who no longer feel that they have job security. That is problematic. I’ve got a number of junior doctors in the last few weeks who have had to be booked off work because of admissions for acute mental health decompensation,” he said.
Ntusi added that a facility like Groote Schuur Hospital had highly specialised services that had been built up over many years.
“These budget cuts threaten to undermine the huge gains that have been made not only in procuring these important services but also in improving the quality of life of South Africans. And once you destroy something like this, it takes an incredibly long time to rebuild,” he said.
The bigger picture
The problems caused by budget cuts are being felt across the health ecosystem in the Western Cape. Cairncross, Ntusi, Chetty and Parkes are among more than 1,000 signatories of an open letter from Western Cape heads of
departments, senior clinicians, nursing staff and health workers, calling on leaders in provincial and national government to reverse the budget cuts in the budget allocation for the 2024/25 financial year.
There are several factors that have contributed to the current funding crisis. In early 2023, a number of conditional grants linked to health saw a decrease in funding in the Western Cape. These grants are allocated by the National Treasury via the National Department of Health.
These grant adjustments differed among provinces – in the Eastern Cape, for example, the provincial Department of Health reported that there had been no decrease in the National Tertiary Services Grant and the Human Resources and Training Grant for the province in the current financial year. However, the Eastern Cape did see a decrease in its Health Facility Revitalisation Grant and District Health Programmes Grant.
Later in 2023, a higher-than-expected wage settlement was reached between the government and public service unions. The National Treasury had not budgeted for this expense. It informed provincial government departments that no new spending would be allocated for the 7.5% wage increase for public servants and they would have to fund it
from their existing budgets for 2023/24.
In a joint media release issued by Western Cape Premier Alan Winde and provincial Minister of Finance and Economic Opportunities Mireille Wenger on 8 February, it was stated by Wenger that this wage agreement was “centrally negotiated without consultation, and unilaterally imposed on provinces”.
The media release noted that the Western Cape health and education sectors had since been provided with “partial funding of the wage agreement”, receiving 70% and 64.5% of what was needed, respectively. However, other departments have had to absorb the full cost of the agreement.
In the Medium-term Budget Policy Statement released in November 2023, the Treasury announced “fiscal consolidation” measures as part of a strategy to avoid a “fiscal crisis”. Spending in the current financial year was revised down by R21-billion, with further reductions expected in 2024 and 2025.
The fallout of this funding crisis is being felt in key sectors, such as health and education, across the country.
Daily Maverick asked the Western Cape Department of Health and Wellness about the amount by which the budget for tertiary hospitals had been revised down in the current financial year. However, spokesperson Dwayne Evans said that the department could only offer “broader, contextualised” responses to queries while it awaited the finalisation of the 2024/25 budget.
He added that the department was engaging in “internal consultative processes” to look at potential cost-saving measures to reduce the impacts on the health system.
“The department remains committed to providing healthcare to the citizens of the Western Cape because we know that it is our most vulnerable citizens who rely on our public healthcare system.
“We are doing everything we can to reduce the impact on our patients. No patients will be refused emergency and basic medical care and treatment. Over time, direct impact may be felt through longer waiting times at health facilities owing to fewer staff being available as well as to possible deferment of maintenance and infrastructure projects.”
Not all provincial departments of health are responding to budget constraints in the same ways. Motalatale Modiba, spokesperson for the Gauteng Department of Health, emphasised that the department had not frozen any clinical or non-clinical posts at the province’s tertiary facilities.
“If anything, the department has ensured that priority is given to its posts so as to not negatively affect delivery,” he said. “The reprioritisation of the departmental budget is part of a normal budgeting process… All departments submit their operational plans and the proposed budget, and Treasury allocates funding accordingly.”
In an internal memorandum dated 15 February and signed by the acting head of the Gauteng Department of Health, Arnold Lesiba Malotana, it was stated that the department was facing a number of challenges regarding the approval and management of commuted overtime.
It continued: “Therefore, it has become necessary to withdraw the delegation to approve overtime applications for the upcoming 2024/25 financial year.”.
When Daily Maverick contacted Modiba about the memorandum, he explained that the delegation to approve commuted overtime had been withdrawn from CEOS of hospitals and that the head of the Gauteng Department of Health would have to approve all applications for overtime.
“This decision is necessitated by challenges over the years related to the management and monitoring of the performance of overtime and consequence management which has resulted in an overexpenditure in the commuted overtime budget,” he said.
Jack Bloom, the Gauteng spokesperson on health, said that the department’s decision to clamp down on overtime for doctors would lead to patients suffering. The Eastern Cape Department of Health has continued to appoint staff in critical areas during the current financial year while still ensuring it remains within budget, according to Mkhululi Ndamase, spokesperson for the department. However, he added that health facilities had been affected negatively by austerity measures, as they had not been able to fill all vacant posts.
“Already, before the austerity measures were put in place, the department had budgetary constraints. Over the last couple of years, the department has had to walk a tightrope and do more with the little that we have,” said Ndamase.
In an internal circular dated 18 February and signed by the acting head of the Eastern Cape Department of Health, Sindiswa Gede, it was stated that the department had been faced with challenges involving newly appointed employees going unpaid from the date of their appointment “to date”.
“Officials issued appointment letters after National Treasury had imposed austerity measures and this has led to those recipients being unable to receive their salaries… Now the department has to follow a process to correct the situation,” said department spokesperson Sizwe Kupelo on the circular.
The circular stated that in future all appointment letters would need to be signed off by the Office of the Head of Department, after it had verified that all due processes had been followed.
Ntusi suggested that one of the reasons cost-cutting measures had seemed far stricter in the Western Cape than elsewhere over the past few months was that the province’s government was more “proactive” and better at taking a “long-term view” about health and other issues, whereas other provinces tended to respond more slowly to crises.
However, he criticised the failure of government officials to communicate effectively with health practitioners on the ground.
“What has been frustrating for me, particularly, is that for us who lead clinical services, we’ve been able to cultivate a very strong relationship with the leaders of health in the province, where we have a seat at the table; we can engage and contribute towards plans. And for the first time since I’ve been in this position, there’s complete silence and lack of engagement,” he said.
The deeper issues
Wenger has emphasised that the fallout from nationally imposed budget cuts is “beyond the control of the provinces”, as they rely almost entirely on funding from the nationally collected tax revenue.
“This is then allocated to each of the nine provinces by the National Treasury through the Provincial Equitable Share (PES), to fund the core constitutional mandates of providing, among other things, healthcare, education and social development services,” she said.
Professor Alex van den Heever, chair of Social Security Systems Administration and Management Studies at the Wits School of Governance, raised concerns about the process for allocating the PES and conditional grants to provinces. Speaking to Daily Maverick
in the lead-up to the tabling of the 2024 Budget, he said that the PES formula had criteria that bore “no relation to actual utilisation” and that were not based in science.
He compared the Western Cape and Eastern Cape, saying: “The Western Cape’s population from three years ago overtook that of the Eastern Cape. But if you look at the budget trajectories going forward, the Western Cape’s is flatlining, effectively, and the Eastern Cape’s is rising.
“This will be because of what’s going on with the [PES] weighting criteria. They’re weighting the Eastern Cape up relative to the Western Cape … despite the fact that the population’s moving to the Western Cape. This is a concern.”
According to Wenger, the latest census data were not incorporated into the PES calculations, resulting in the Western Cape, which is the third-largest province in South Africa by population, receiving the fifth-largest budget allocation. Van den Heever told Daily Maverick that the processes for determining conditional grant allocations had similar problems to those for the provincial equitable share, in that the criteria for determining the funding were not fixed or objective.
“Because there are absolutely no criteria for how these budgets are determined, there are
opportunities for two things. One is a mismatch between the allocation and the actual demand for services, and the second is that the opportunities for manipulation are extremely high…
“These two sets of allocations – [PES] and the conditional grant allocations – are exposed to manipulation. They’re meant to be reviewed by the Financial and Fiscal Commission, but the commission is kind of missing in action. They don’t really do any systematic technical reviews of this kind.”
Van den Heever clarified that he couldn’t confirm that there had been political manipulation of the funding allocations for any of the provinces, but noted that the allocations did look “unusual”.
“It looks like the Western Cape is receiving an unusually low allocation relative to its population, and it’s unclear that the weights themselves are actually a valid basis for this kind of shift,” he said. ”
Daily Maverick sent two queries to the National Treasury, one on the contents of the open letter by Western Cape health professionals and one on the issues raised by Van den Heever. The media department responded that all issues related to budgets would be dealt with during the tabling of the Budget on 21 February.