Finance Minister Enoch Godongwana ruffled feathers last week with his letter to government departments directing a freeze on posts and other cost-cutting measures. MedicalBrief writes that, in the public health sector, the impact of such measures will be disastrous and lead to a further deterioration of services, health activists warn.
Godongwanga has remained resolute in implementing the wide-ranging proposals, despite pushback from ANC officials and alliance partners.
The ANC’s top brass, with its alliance partners Cosatu and the SA Communist Party, on Monday met Godongwana and asked him to explain the Treasury’s plans to rein public spending in over the medium term, reports BusinessLIVE.
Figures released by the Treasury show the budget deficit has hit R143.8bn, the largest since 2004 and greater than economists’ forecasts of R115.5bn.
The Treasury’s proposals come before the presentation of the Medium-Term Budget Policy statement in November in which Godongwana is expected to detail the estimated R22bn revenue shortfall for the 2023/24 financial year and details the Treasury’s plans to rein in public debt.
“The alliance partners pushed back against retrenchments of public servants and rather advocated for the government to allow for natural attrition within the public service,” said a source.
The cost-cutting is expected in most departments, lincluding health, writes Gcina Ntsaluba in Health-e News, adding that already, there have been threats of protests and strikes from trade unions.
Activists are calling for the exemption of social services, including healthcare, from the cuts, with Matshidiso Lencoasa, a SECTION27 budget researcher and member of the Budget Justice Coalition steering committee, saying these would further entrench gender inequality.
“Women, more than men, rely heavily on the public healthcare system – reproductive and maternal health services – and the anticipated cuts occur in the context of a system that’s already under-resourced, understaffed and plagued with reports of corruption.”
There would be less money to hire and pay for nurses, doctors and community health workers, meaning ordinary South Africans can expect fewer healthcare practitioners who are also severely overworked and underpaid, Lencoasa added.
Earlier this week, the Progressive Health Forum (PHF), a national health advocacy network comprising health professionals and patient advocates, wrote to the President and the Ministers of Health and Finance, warning that any reduction in health resources would have immediate and catastrophic consequences.
The letter, dated 12 September, argued that the government should have foreseen the financial difficulties before agreeing to improvements in conditions of employment with unions.
Now it was up to provincial Health Departments to “take drastic measures to avoid running out of funds during the 2023/24 financial year”, leaving the millions of people who rely on public health services in “great uncertainty”.
‘No choice’
Frikkie Booysen, professor of Health Economics at Wits University, said the government has no option but to impose cost-cutting measures to keep SA’s debt under control, but should consider this an opportunity “to revisit its allocation of resources across budget votes to ensure expenditure on social services, including healthcare, is protected”.
“What is most important is to make smarter decisions on how we utilise the available health budget. What should not be cut (in real terms) are the resources required to provide primary frontline health services.”
Concerns over freezes
The budget cuts also came under the spotlight at the recent Public Health Association of South Africa’s (PHASA) conference in Gqeberha, where one of the main themes – underlying talks about building healthcare worker capacity – was the Treasury’s cost containment letter.
Last year, the Eastern Cape Health Department admitted there were 3 892 vacant healthcare worker posts, and in the nursing categories, a vacancy rate of 15.3%, writes Luvuyo Mehlwana in Spotlight.
The paramedics (EMS) vacancy rate was 10.7%, medical practitioners 8.4%, and pharmacists 13.7%.
An oversight visit to TB hospitals by members of the provincial legislature (MPLs) recently showed just how bad staff shortages are.
The only remaining hospital in Nelson Mandela Bay dedicated to TB services, Jose Pearson Hospital in Bethelsdorp, has had vacancies hovering around 20% since 2019. The hospital provides dedicated TB services to the western part of the province.
In some other hospitals, vacancy rates are even higher, and non-filling of critical posts in some cases results in further medico-legal claims against the department, as the current staff buckles under massive patient loads.
In her presentation, Dr Prudence Ditlopo, senior researcher at Wits, said nurses already had a huge workload and talk of budget cuts had a huge impact on morale.
“This is not the first time … we understand the economic side, but at the same time, what does it say about the well-being of the nurse practice environment, the patients, and the quality of patient care? If nurses see that they are overwhelmed by the workload, they will find ways to enable them to cope.
“But if what works for them is only seeing 10 patients per day, they will do that and they will be gatekeepers for other patients who are coming to the facility. That alone will influence the quality and standard of care in primary care in South Africa.”
‘Will create more problems’
Dr Busisiwe Matiwane of the Wits School of Public Health also weighed in on the implications of the Treasury letter.
“In the current system, health professionals have to work for the government to fulfil their community service obligations. However, it can be challenging for them to be assigned to specific hospitals when it is time for their community service. Now, with a freeze on posts, many who are not government-funded may have to seek employment outside the government after completing their community service.
“If these posts are frozen, does that mean government will also halt the placement of individuals required to complete community service?
“The implications will create more problems,” she said.
‘Protect what is already there’
Director of the Rural Health Advocacy Project Russell Rensburg said the wage agreement on a 4.5% increase for the public sector had Treasury’s back against the wall since that was not budgeted for in their February budget.
“Treasury is playing hardball and the provinces must decide what they need. National government must also decide what it needs. If it follows through on this, it will be unable to sustain the public health system. There is concern that doctors will leave as part of cost containment measures, and you can’t run a healthcare system without healthcare workers”.
He said he believed “that at the moment they are just testing the market”.
“They are saying we must have one thing, but we can’t have both, so that is the game. Our position is clear. Before any salary cuts or job freezes, we need to protect what is already there.
“We need to retain this year’s cohort of community service doctors, pharmacists, and nurses because these people helped us during Covid-19. Some were interns then, and they are the core that can build the health service in the post-Covid-19 era. So, the immediate priority is to retain those posts because we don’t know if there will still be community service in the future.”
‘Working with what we have’
Dr Krish Vallabhjee, former chief director of Strategy and Health Support in the Western Cape Health Department, said management must use whatever resources they had available to achieve good results.
“Budget cuts are a reality, so whatever we talk about here and in many of these conference sessions, we can’t be talking about wanting more and more. We need to work with what we have. How can we repurpose the people we have? Can’t we use them more effectively to achieve the same effect?”
He said managers need to work with their staff “instead of just sitting in some corner and making budget cut decisions”.
“Managers need to engage with staff to address the problem of not enough budget. How do we work together? What are our priorities? What are the doctors, nurses, and local managers saying? We are one department and we have this problem of a budget. How do we unite and do the best we can?”
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