ECBUDGET – Long road to universal health care

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By Tlamelo M Mothudi

In the 2019/20 Provincial budget speech, the MEC for Finance Honourable Lubabalo Oscar Mabuyane tabled a provincial budget of R83.2 billion and a health budget of R 25.2 billion. In his address, the MEC placed emphasis on the need to enhance the capacity of the state to deliver services. While the allocation of funds (R 440.9 million in 2019) to provide this capacity in departments like Health and Education is encouraging – a brief review of performance to date does little to allay concerns.

During his budget speech, the MEC outlined that the provincial budget allocated seeks to continue to provide universal health care services to South Africans – an incorrect statement as it implies existing universal coverage. The attainment of universal health coverage seeks to ensure that all people obtain the health services they need without the risk of financial hardships that come from out-of-pocket payment towards healthcare services. This idea is one that seeks to provide equitable healthcare services which, according to the World Health Organisation (WHO) includes the promotion of health, prevention, treatment, rehabilitation and palliation healthcare services, coverage and financial risk prevention.

South Africa has not obtained universal health coverage and with a 5% increase in nominal terms from R 24.0 billion in 2018/19 to R25.1 billion in 2019/20 in the health budget and a 3% decrease in real terms from R24.0 billion in 2018/19 to R 23.4 billion in 2019/20, the country has a long way to go before Universal health coverage is realised.  This budget is a clear indication there will be even further strides needed to be taken by the Eastern Cape Department of Health (ECDoH) in its attempt to attain the universal health coverage mentioned by the MEC during his budget speech.

The Public Service Accountability Monitor (PSAM) is alarmed by the burgeoning costs of medical malpractice. In the Eastern Cape alone the total payments facing the department amount to an estimated R23 billion, according to a recent report by Medical Brief. Medico-legal claims are claims that are brought by patients against doctors, surgeons and hospitals in South Africa for medical errors. The cost of medico-legal claims on the equitable share allocation must be considered to determine budget trade-offs in the delivery of healthcare services. In the current state of healthcare, the issue of lack of adequate access to healthcare facilities due to the poor distribution of clinics and hospitals in the Eastern Cape, the shortages in human resources for health and the shortages in medicines means that those most vulnerable who are affected by lack of access to equitable and universal healthcare will continue to be affected.

At the heart of the medico-legal claims, there is an issue of human error – the basis of which is the practitioners liable for the claim and the problems in the healthcare sector shortages of doctors, nurses, delays in ambulance arrival time, lack of enough machinery and equipment which in turn exacerbates the crisis. In the budget speech, the MEC for Finance outlined the department’s commitment to capacitate health facilities with human resources and modern ICT equipment so that healthcare professionals can provide healthcare with diligence, care and avoid conduct that leads to medico-legal claims. Later this month, the MEC for Health is expected to table the Health Budget and Policy Speech. It will be imperative for the MEC to clearly outline the strategies to strengthen accountability and improve provincial health services to combat malpractice.

The Health Science and Training programme, responsible for training and development opportunities for actual and potential employees of the department was allocated an amount of R 929.8 million in the 2019/20 financial year, the third lowest programme allocation. The programme experienced a 6% increase in nominal terms from R880.5 million in 2018 to R 929.9 million in 2019 and a decrease of -2% in real terms from R 880.5 million in 2018 to R 861.5 million in 2019.

R 1.6 billion was allocated to provinces for the hiring of health professionals in the MTEF period. While this is a positive step towards dealing with the shortage of health human resources, the allocations use was mentioned as having gone towards a growth in compensation of employees under the District Health Service programme and not towards the appointment or training of health professionals. Without the conditions of the grant to clearly outline whether this grant is intended to be used for the hiring of health professionals or if it can be used to subsidies the payment of employees in the 2019 Division of Revenue Bill, oversight will be a difficult.

During the period 1 April 2017- 31 March 2018, the ECDoH employed 39 365 people and of those, it appointed 4770 and terminated 3721 employees. At the beginning of the period, 1577 permanent medical practitioners were employed, of those, 607 were appointed, 435 were terminated resulting in a termination rate of 28. The highest number of terminations were due to resignations, the second highest, the expiry of contracts. A comprehensive plan is needed for the health workforce along with an evaluation of the working conditions of the health personnel to find better ways to retain staff.

The condition of health facilities impacts heavily on the level of access. If there is no clinic in a rural area and instead a community hall or house must be used, this impacts on the type of services that can be offered in this facility. If a facility is dilapidated, does not have access to water and sanitation or if there are inadequate beds or linen, this impacts on the level of services that can be offered and in some instances the health of those admitted. The Health Facilities Management programme had a 16% increase in nominal terms from R 1.2 billion in 2018 to R 1.4 billion in 2019 and an 8% increase in real terms from R 1.2 billion in 2018 to R1.3 billion in 2019. The programme is estimated to decrease by -4% in nominal terms and -3% in real terms over the MTEF period.  This is significant because the programme is tasked with providing access to health care through the provision of new facilities, upgrading and revitalisation. It is also tasked with the maintenance of existing facilities. The programme’s budget allocation grows between 2018 and 2019 but it decreases on the MTEF period, this indicates that the province is not investing in the infrastructure development as mentioned in the budget speech.

To continue with the renovations of hospitals and clinics in the Eastern Cape as outlined by the MEC during his budget speech, will the funds come from the R19.2 billion allocated to the health facilities revitalisation grant or the R 4.3 billion allocated to the health facilities component of the NHI indirect grant? The two grants have certain conditions that must be met for their use, if the department is not able to use these grants, they cannot be shifted elsewhere, and this may impact the amount allocated to the grants in the future and most importantly, service delivery.

Considering the health budget tabled, there is no indication that the current problems faced by the health department will be sufficiently dealt with anytime soon. This places the ECDoH further away from its goal of establishing Universal healthcare for its population, ultimately, those who will suffer will be the most vulnerable. Due to the increase in unemployment, more strain will be placed on public healthcare and this needs to be addressed urgently to avoid continued human right abuses.

Before Universal healthcare can become a reality, the current conditions of health facilities must be addressed, more so in the rural areas of South Africa. A comprehensive human resource plan is needed to determine the extent of the staff shortages, the extent that they can be filled and the costs of ensuring that they are filled and retained so ensure service delivery. The rising problem of medico-legal claims must be addressed, and an investigation conducted into the causes of the claims over and above the unscrupulous lawyers who collude with clients to fabricate claims. Its is clear that the problem runs deeper than that.

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