Sector becoming a skeletal service

With an estimated 28,000 vacancies in the public health sector, and little money, doctors and nurses have again got the short end of the stick

The health budget is wasting away. For a third year in a row, the money set aside by finance minister Enoch Godongwana has dropped in real terms.

On paper, the R259bn set aside for health is more than last year, but factor in inflation and you’re looking at a real decline of 5.3%. Once more, there is less money to hire doctors and nurses.

Daniel McLaren, a senior researcher and budget analyst for nonprofit organisation Section27, says this illustrates that “we are in the age of austerity, certainly for this year’s budget and [the next]”.

McLaren says that, on a per capita basis, the allocation has dropped every year since 2013 except 2020, when extra money was found for Covid.

It’s a dismal picture because there are already 28,000 vacancies in the public health sector, according to parliament’s select committee on appropriations.

In November, health activists testified to that committee about the lack of healthcare professionals to treat tuberculosis.

Among the committee’s recommendations, according to the Budget Review, was that the health department, and its provincial counterparts, “should ensure an estimated 28,000 vacancies are filled where funding is available, to address staff shortfalls ... for an appropriate level of care”.

The National Treasury, however, simply referred this recommendation to the minister of health, according to the Budget Review.

Quite what health minister Joe Phaahla can do about those vacancies is unclear, since the provinces are given 89.2% of the money allocated by the government for the health budget.

The lion’s share of the total health budget, Treasury documents show, goes on salaries R163.6bn, or 62%.

Overall, the money allocated to salaries rose 2.3% (R4bn), a sizeable amount relative to the R400m growth in the total budget.

Last October, the Southern Centre for Inequality Studies at Wits University released a report, co-written by former Treasury official Michael Sachs, that found the number of public sector health-care workers per 100,000 uninsured South Africans had fallen from 720 in 2012 to 632 by 2018.

McLaren says most of the specific grants issued by the national health department have also been cut. For example, a grant for community health workers and malaria prevention fell 7.4% to R26.8bn; a training grant to address doctor and specialist shortages was cut 0.5% to R14bn; and a grant for 31 specialised academic and central hospitals was cut 2% to R14bn.

The budget this week referred to National Health Insurance (NHI) more fully than in recent years, which suggests it is back on the political radar. But there are still no specifics about where the cash will come from.

The Estimates of National Expenditure says the NHI Bill being considered by parliament “will have considerable implications for how health care in South Africa is funded and organised”.

Overall, R809.4bn has been set aside for the health sector over the next three years, of which only R2.2bn is an NHI direct grant.

And almost R350m has been set aside as part of the indirect NHI grant to build the 488-bed Limpopo Central Hospital.

But with so many vacancies in the public sector, who will staff the hospital when it is finally built?

Stocks of Covid vaccines are still high, and no separate allocation for them was made.

It is also concerning that the allocation for the South African Medical Research Council fell from R1.4bn in 2023 to R1.3bn. The Treasury says the council received extra money for Covid research last year. Still, it’s an illustration of how low a priority medical research is, securing only about 0.5% of the entire health budget.

Finally, the Budget Review issues a disturbing warning: “Additional provincial health budgets remain under pressure and government will have to make trade-offs to ensure that the sector is adequately resourced.” It adds that “greater efficiency is needed to manage services within these budgets”.

Quite how this will be achieved is anyone’s guess.