An open letter signed by more than 16 academic heads of departments and nearly 1 000 senior clinicians, nursing leaders and health workers in the Western Cape, has highlighted the “devastating” impact severe budget cuts are having on the provincial health system.
The letter (see below), dated 4 February and released publicly on Tuesday, is addressed to Minister of Finance Enoch Godongwana, Western Cape Premier Alan Winde and the province’s MEC for Finance Mireille Wenger.
It calls on these leaders to put the well-being of South African people first and reverse the budget cuts in the soon-to-be-finalised budget allocation for the 2024/2025 financial year.
Daily Maverick reports that the signatories represent a range of public health facilities in the Western Cape, including the three tertiary hospitals: Groote Schuur Hospital, Tygerberg Hospital and Red Cross War Memorial Children’s Hospital.
Professor Lydia Cairncross, a signatory and head of surgery at Groote Schuur Hospital, said: “The significance of having so many academic heads of departments and senior clinicians signing on is that these are the clinicians in the system who are managing our health service and leading delivery of care, and the training of doctors and students.
“They are accustomed to doing their best to manage with the constraints, and will always do everything they can…before raising the alarm. That this cadre of health leadership has … said something now means they are truly concerned about the future of our health system.”
Senior staff at Cape Town’s Groote Schuur Hospital and Red Cross Children’s Hospital told GroundUp managers were struggling to fill shift rosters, and that an impact on patient care and waiting times was inevitable.
A Groote Schuur manager said almost half of the doctor posts in the medicine department were vacant, apart from hundreds of other nursing and operational posts, while at Red Cross, “critical medical posts” are being left vacant, including medical officer, registrar (doctors in training for a speciality), and specialist posts.
Daily Maverick reported in November that the budget shortfall for the two hospitals was more than R300m for 2023/2024.
“Things are not great. We are accredited to train 60% to 70% more registrars than we have, we can’t fill nursing posts, and there is no nursing agency budget,” said a senior doctor at Groote Schuur.
“The Western Cape is determined to stay within budget. But this means patients are waiting longer, it is reducing the number of specialists we can train, and the load on staff has increased,” he said, noting that the public health system had yet to recover from the disruption to services caused by the Covid pandemic.
Healthcare professionals at other hospitals said the demands on the system were increasing even as staffing levels shrink due to a growing population and an increasing burden of disease and trauma.
The Health Department said it was doing its best to protect direct service delivery positions but conceded it was employing fewer nurses than a year ago.
Dwayne Evans, spokesperson for the Western Cape Department of Health, said that as part of the hiring freeze, the filling of vacant posts now needed to be authorised by the provincial department to attain “provincial consensus”.
“We have 820 nursing positions earmarked to be filled soon, as well as around 441 doctor positions. Due to the national directive to curb expenditure, restrictions have also been placed on the use of agency staff,” he said, adding that records did not indicate a decline in the number of doctors employed year on year.
BusinessLIVE reports that like all other provinces, Western Cape has been forced to honour the higher-than-anticipated wage settlement reached by the government and unions after Treasury had finalised the 2023 budget.
National government has not fully funded the shortage, leaving Western Cape with a R1.1bn shortfall for the 2023-24 fiscal year, compounded by a R642m cut to its conditional grants announced in the MTBPS.
Slash consumables
The provincial Health Department also de-escalated services at Groote Schuur and Red Cross hospitals for four weeks over December and January, while managers were told to cut spending on consumables by 50%.
At the start of 2023, conditional grants that fund these hospitals were slashed, and mid-year, Treasury announced more cuts, including a R21bn reduction in national government spending for 2023/24.
In August, Treasury wrote to provincial governments recommending several “cost containment” measures for the 2023/24 financial year and a freeze on hiring new staff.
Each province’s Health Department is dealing with the “cost containment” measures differently.
In the Eastern Cape, for example, hiring freezes have been implemented but not for clinical staff, Sizwe Kupelo, spokesperson for that province’s Health Department, told GroundUp.
In the Western Cape, as of May 2022, the vacancy rate of medical posts was 5%, compared to 14% in the Eastern Cape, 20% in Gauteng and 28% in KwaZulu-Natal. Health experts are concerned budget cuts and hiring freezes will have a devastating impact on these provinces.
Senior officials fear the hiring freeze is undoing decades of investment by the government in the capacity of state hospitals. Newly graduated doctors wanting to specialise need to take up a registrar post in a state facility, but with registrar posts frozen in the Western Cape, this is almost impossible.
Hospital managers said some medical officers have resigned from Western Cape facilities to take up registrar posts in other provinces or even other countries.
Officials are also concerned that if hiring freezes are implemented in primary and secondary care facilities, referrals to hospitals will increase, putting further pressure on an already overburdened tertiary health system.
The letter from the academics and experts reads:
“We, undersigned heads of academic clinical departments, senior clinicians, nursing leadership and undersigned health workers in the Western Cape, write this as an urgent appeal to halt and reverse the catastrophic budget cuts being visited upon the health system in our country and in the Western Cape.
“It is our ethical duty to inform you, as our political leadership, what cutting health budgets means for patients … in our hospitals and clinics, most of whom come from the most marginalised and impoverished communities.
“Over the past 12 months, National and Provincial Treasury budget cuts have driven health services in SA and the province into crippling austerity. An initial budget cut at the beginning of the financial year was exacerbated mid-year by a further unplanned reduction. driven by the underfunded public sector wage increase. These cuts have affected healthcare services in the entire country.
“In the Western Cape, they have resulted in the loss of R1.5bn from a R30bn budget – close to 5% of our overall budget. To manage this massive, unexpected deficit, all provinces were advised to take whatever drastic measures were necessary, including freezing clinical and non-clinical posts at all levels.
“This means that today, and … into the foreseeable future, there are fewer nurses, doctors, general assistants, cleaners, clerks, physiotherapists, radiographers, porters, occupational therapists, dentists and specialists to deliver desperately needed healthcare to the population.
“Throughout 2023 we scrambled desperately to increase efficiency and decrease spending and… tried our best to work harder to make every ‘health rand’ count while maintaining patient care. However, in the past three months, the Western Cape health system has been destabilised by indiscriminate freezing of virtually all clinical and non-clinical posts and a freeze on nursing overtime and agency budgets.
“Posts which have become vacant through retirement or resignation or natural movement in the system from training positions, now remain unfilled.
“These austerity measures have an immediate and tangible impact.
“For patients who need surgical and anaesthesia services, it has forced a reduction of theatre lists, which means postponing or cancelling essential operations for patients who have often waited months or years for these procedures. They are women, men and children who are awaiting cancer surgery, surgery to restore sight and hearing, surgery to treat chronic pain, surgery for brain tumours or to remove infection and improve breathing, surgery to treat urinary retention and bowel conditions. and life-saving heart surgery.
“For every one of these patients, delaying their procedures means prolonging their suffering and often putting their lives at risk. It also means they remain unable to return to normal daily functioning, and therefore remain at risk of unemployment.
“For patients who need access to specialist medical care for diabetes, asthma, complex lung and heart conditions, complications of hypertension, autoimmune diseases and other specialist medical conditions, service cuts mean decreased access to hospital beds, longer waiting times in outpatient clinics, longer waiting times for essential investigations. For many of these conditions, timely diagnosis and treatment initiation are critical to ensure good responses to treatment and delays may result in progression to the point of irreversible organ damage.
“These budget cuts also negatively affect emergency care for conditions like strokes and heart attacks.
“For patients who need access to oncology services, service cuts mean a delay in reaching multi-disciplinary oncology services, since patients have a delay in access to staging investigations (especially CT and MRI services), and a delay in their biopsy or surgery.
“It means that cancers are (at a) higher stage at diagnosis, and therefore there is less chance of cure. It also means there will be difficulty in accommodating the number of patients requiring care, and difficulty in maintaining safe and effective radiotherapy and chemotherapy care, due to staff cuts.
“For patients needing access to radiology services, it will mean delays in obtaining scans and x-rays when patients are admitted to the emergency units if radiographers are not employed. Staff shortages place an additional strain on the existing staff, leading to burnout and resignations. Delayed diagnoses due to understaffing will result in increased hospital costs and hospital stays.
“For patients who need access to mental health services, service cuts will lead to reductions in the quantity and quality of care for both serious mental disorders like schizophrenia and bipolar disorder, as well as for common mental disorders like depression, anxiety disorders and substance use disorders.
“Working in an environment where services are being withdrawn and where patient morbidity and mortality is increasing, has a significant negative impact on the mental health of staff and their colleagues in the services.
“Regarding access to care for children, South Africa’s constitution entrenches children’s rights, including access to quality healthcare. Austerity measures will directly result in reversing the gains in neonatal, infant and under-5 mortality rates. For neonates and children who require specialist care, service cuts affect access to hospital admission and timeous outpatient clinic access.
“Additionally, these cuts will have a negative impact on immunisation roll-out as well as lead to suboptimal early child development.
“There will be knock-on effects in which potentially reversible acute illnesses become chronic or worse, overloading emergency services, and (causing) long-term increased morbidity and mortality. The impact on adolescent services will be even greater as this area is already underserved. The consequences in this vulnerable group will be dire. It will deprive our country of future problem-solvers, innovators, leaders and environmental stewards. In short, it leaves us a country with a bleak future.
“Primary Care, which represents the cornerstone of comprehensive primary healthcare and the foundation of universal health coverage, may also be affected through the impact on the delivery of vital community-based services and activities focused on health and wellness promotion and disease prevention.
“It is possible that some emergency centres may need to close, the number of ambulances on the road may decrease and the number of beds available for patients who are severely ill or have faced trauma will be fewer. The number of rehabilitation beds or beds for ‘step down’ or transitional care will be reduced. This, and less access to palliative care services, will increase the suffering of the most vulnerable patients and their families.
“Decreased palliative care services also increase the use of health care services in the last year of life, preventing patients from getting palliative care at the appropriate time. This scale of impact will similarly be felt by the many patients who need obstetric and gynaecological and paediatric services.
“Finally, for health workers who arrive at work to find their normal staff complement down by a third or half, these cuts mean working with greater intensity and for longer hours to fill the service gap for as long as they can. It means increased sleep deprivation, burnout and fatigue-induced errors. At some point, staff will find themselves simply unable to continue at this pace and will then face the harsh inevitability of decreasing services while acutely aware of how desperately these services are needed.
“This is an unconscionable burden to place our health workers and represents a profound moral injury to our frontline staff.
“Despite many challenges, we have a public health care system of which we can, in many ways, be proud; with highly qualified health professionals, committed health workers, functional academic centres and training programmes for specialists sought out by people throughout the continent and beyond. But these budget cuts are putting the entire system, which has taken many decades to build, under threat.
“When a country is in financial crisis and state resources are under pressure, it must make careful decisions about where to spend money. Adequate funding of healthcare and education is fundamental to building a healthy and prosperous nation. and critical to reversing persisting social inequality. While we know that the fiscus is under pressure, we also know South Africa spends many billions of rands on other, less essential state projects and that billions are lost to corruption from the state. Cutting budgets for health and education affects the poorest and most vulnerable in our society and the impact on the entire fabric of society will be immediate, long-lasting and possibly irreversible.
“We believe that you, as the financial and political leadership of our country and province, can and should do better. National Finance Minister Enoch Godongwana, Premier Alan Winde and Finance MEC Mireille Wenger, you are the custodians of the resources of our country and our province, and we believe you have the power and the opportunity to reverse these cuts in the soon-to-be-finalised budget allocation for the 2024/2025 financial year.
“As health professionals, we are obliged to inform you that continued austerity at this level cannot be mitigated with creative planning or improved efficiency. It will result in suffering and deaths among the people you have committed to serve. It will irrevocably damage a health system that has taken many decades to build.
“We urgently call on you to re-examine your budget spreadsheets, realign your fiscal priorities to Health, Education and Basic Services, and put the well-being of our people first.”
GroundUp – Officials raise alarm over hiring freeze at Western Cape’s largest hospitals
BusinessLIVE – Budget cuts hit Western Cape health service
See more from MedicalBrief archives:
Medical school deans urge Treasury to stop Health budget cuts
Hospital CEOs warn of cash run-out as budget cuts bite
Medical experts in plea to exempt child health services from budget cuts