In 2022, as the health sector and economy recovered from the pandemic, the government missed opportunities to provide the financial resources to protect access to healthcare for the most vulnerable, writes Matshidiso Lencoasa for Spotlight.
Corruption, underspending, irregular spending and fruitless and wasteful spending continued to chip away at investment in healthcare and public health facilities.
After the February 2022 main budget, there was an average real reduction in healthcare funding of -4.3% for the 2022/23 financial year, limiting the sector’s ability to tackle backlogs created by the pandemic.
SECTION27, where I work, called for increased funding to bolster the quality of care for the 76% of the population using public health facilities by redressing the structural issues in the sector.
However, with the Consumer Price Index (CPI) inflation projections for 2022/23 increased to 6.8%, this real cut has only become more pronounced, resulting in a cut to health funding of -8.2% this financial year.
The Medium-term Budget Policy Statement (MTBPS) also did not respond to this with the much-needed upward adjustments to health budgets for this or future years. Instead, the MTBPS pencilled in an overall real cut to spending per public healthcare user of -R610 from R5 036 in February this year to R4 426 this financial year.
What this means for public healthcare users
i) Healthcare infrastructure
In 2022, we raised concerns that the budget allocations to the Health Infrastructure Revitalisation Grant would constrain government’s ability to address backlogs in infrastructure and maintenance. There have been no upward adjustments to this grant – despite rising inflation.
Moreover, this coincided with extreme weather, which National Treasury noted in the Budget Review and MTBPS. While the Department for Basic Education received an increased allocation for repairs to schools, the MTBPS 2022 did not explicitly recognise damage to healthcare facilities caused by extreme weather events like the floods in KZN, with the Health Facility Revitalisation Grant receiving no funding adjustment.
In April, 85 health facilities were damaged during floods but the KZN Health Department received no additional funds from Treasury and claimed it had to reprioritise R200m of its funds intended for other health priorities within the province. The Eastern Cape also had 12 health facilities destroyed by floods, but no additional allocations were provided for repairs.
In the National Budget tabled in February 2022, the Health Facility Revitalisation Grant increased by 5.2% (R349m) but with the 2022/23 CPI inflation rate – now revised to 6.8% – this resulted in an increase of only R8m. With no adjustments to this grant planned in 2023/24, the government will be less equipped over the medium term to spend on health infrastructure.
Any relief granted to repair health facilities affected by floods should either be ring-fenced, or the Health Facility Revitalisation grant should be adjusted upwards to account for the impact of extreme weather events in KZN and the Eastern Cape.
ii) District Health Programme Grant: HIV and TB
The 2022/23 fiscal year saw the consolidation of the HIV, TB, malaria and community outreach conditional grant into the District Health Programme Grant (DHPG).
Considering our assessment last February that the 2022 Budget ignored underperformance of important HIV indicators, we welcome the MTBPS’ refocus on core health services and addressing accumulated backlogs. However, this refocus is not evident in the adjusted figures provided in the MTBPS for the current fiscal year.
In the 2022/23 budget, the HIV, TB and STI component of the District Health Services expenditure shows an average annual decline of -3.4% over the next three years (before accounting for inflation), with no adjustment made to improve this. There has also been no adjustment to the TB management sub-programme’s allocation, responsible for the formulation of policy, guidelines and norms and standards on TB. Instead, again, the commitment to allocate additional funds was deferred to the 2023 budget for services backlogs, including antiretroviral treatment and TB screening and treatment.
Treasury’s failure to provide an increase to HIV, TB and STI funding is despite the government not being on track to meet its goal set in the February 2022 main budget of retaining 5.7m patients on antiretroviral therapy (ART) by the end of this fiscal year. Having only retained 5.3m patients in the first half of the fiscal year – instead of adjusting the allocation to pursue the initial goal – the MTBPS has adjusted this figure down to 5.5m.
More concerning about the failure to make adjustments regarding HIV is that the reality is inconsistent with government’s policy choice. The Thembisa model (version 4.5), a mathematical model of SA’s HIV pandemic, shows mixed progress towards the achievement of our 95-95-95 targets set by UNAIDS. Regarding the first target to get 95% of persons living with HIV (PLHIV) diagnosed, progress has been good with many provinces achieving around 93%. Satisfactory progress has also been made toward the third target of getting 95% of people on ART virally suppressed.
On the second target to have 95% of people diagnosed with HIV receiving ART, progress has been poor, with ART take-up varying between 59% in the Western Cape and 79% in KZN. Additionally, since 2019, the Medium-Term Review of the National Strategic Plan on HIV, TB, and STIs (2017-2022), had already shown that the country was not on track to meet its ART uptake goals.
The 2022 Estimates of National Expenditure show that by March 2021 the number of PLHIV accessing ART was 5.1m, and the objective was to increase this to 6.7m by March 2025.
If government seriously intends to address HIV, it must renew efforts to increase ART uptake and allocate resources accordingly.
iii) District Health Programme Grant: Oncology
Deferring an adjustment to oncology funding also signals that, despite growing waiting lists for radiation oncology services, this is not a priority. The backlog includes 3 000 patients awaiting radiation oncology services in Gauteng alone: many have been waiting for three years. Radiation oncology is time-sensitive and must be performed within a short window after surgery and/or chemotherapy.
In breast cancer, the international best practice provide that patients get radiation oncology treatment within three months of surgery, failing which, there is a significant risk of recurrence. So, deferring an increase in the oncology budget to 2023 will be too late for many patients.
In the 2022 main budget, it was announced that mental health and oncology funding would be shifted to the district health programme grant. The MTBPS provided no increase to the district health services grant in the medium term, nor any increase to the National Health Insurance Fund grant – which both hold funding used for oncology.
Instead, the budget for non-communicable diseases shrank by R1.1m – despite the National Strategic Plan for the Prevention and Control of Non-Communicable Diseases (2022-2027) published last year, with government stressing commitment toward the prevention and control of NCDs.
In coming years, any government decision to cut funding for healthcare services must be based on transparent and participatory human rights impact assessments, showing that the funding reductions will not increase inequity in healthcare access or undermine the rights of the most vulnerable members of society to access quality, timely healthcare services.
*Lencoasa is a budget researcher at SECTION27.
Spotlight article – OPINION: 2022’s health budget decisions in review (Creative Commons Licence)
See more from MedicalBrief archives:
South Africa’s health sector in the 2022 budget
Government slashes already under-funded health budget
Crisp says Health budget has to be bigger if NHI goals are to become a reality
KZN floods: 318 autopsies, 80 healthcare facilities damaged, fears of disease