Below is our response to the 2020 Budget Speech
The budget announced by finance minister Tito Mboweni on 26 February will intensify our national health crisis. It will weaken the public health system and, at the same time, increase our national burden of disease and ill-health — a two-sided assault on the health of the nation.
Weakening the public health system
There is insufficient financial commitment to reform and improve the public health system in preparation for the National Health Insurance (NHI). The recent audit by the Office of Health Standards Compliance found that only 5 of 696 public sector facilities satisfied the NHI benchmark. Yet the budget allocates only R25 million to the National Quality Improvement Plan—a drop in the ocean of what is required to fix the public health system.
The planned cut to the public sector wage bill of R160 billion over three years will result in further deterioration in the quality of health care. While savings from reducing the wages of often unproductive top civil service positions such as cabinet ministers and bloated management positions with extremely high salaries and all the attendant perks can be justified, the planned cuts seem generalised and don’t focus focussed on these levels.
Cutting public spending at the expense of nurses, doctors, physiotherapists, occupational therapists, psychologists, social workers and others working at the coalface of health care can only be profoundly damaging for both access and quality in health care. Encouraging the early retirement of senior staff will devastate the quality of care – these are the teachers and mentors of the juniors. Furthermore, cutting the wages of public sector workers will exacerbate the inequity between private and public health sectors as we lose even more staff to the private health industry. Are we heading for the scenario of the mid 90’s again where we lost an entire cohort of skilled and trained nurses and teachers, attendant with the closure of training colleges, which we have still not recovered from?
The above measures fly in the face of the NHI’s commitment to Universal Health Coverage (UHC). Ironically, while the DOH consults the nation in a series of public engagements around the NHI and its promise to improve equity in access to quality health care, the budget makes little provision for this. Essentially, this amounts to a recognition that NHI will not come anytime soon.
Long delays between the various iterations of the NHI plan (a Green Paper in 2011, a White Paper in 2015 and a draft Bill in 2019) suggested that powerful vested interests were impeding consensus behind closed doors at high levels in the DOH. Numerous submissions from civil society organisations supportive of the NHI and actively engaged with the process went unacknowledged. Timelines for delivery keep shifting. With the recent budget speech, it is clear that these timelines will shift yet again.
This is a betrayal of the many thousands of people in South Africa in desperate need of quality healthcare. South Africans in their hundreds added their voices at NHI public hearings in the belief that it was a plan with real political commitment behind it. For these people, who expressed the anguish and suffering caused by our dysfunctional public and private health systems, the answer “NHI is coming” is no longer enough.
Increasing the national burden of disease and ill health (BOD)
Our large BOD overwhelmingly affects the poor and marginalised. It is rooted in unequal access to the causes of good health — the goods and services we need to be healthy. These are known as the social determinants of health (SDH) and include good nutrition and household food security; safe water & sanitation; decent housing; an environment that is not harmful to your health; education; personal safety & security; decent work; and a decent income.
Dealing with the SDH goes beyond the ambit of the DoH. It requires collaborative action by multiple government sectors and departments to deliver services in a coordinated manner through a well-functioning civil service. We can mobilise all the strengths that communities have by injecting a modest amount of funding at community level to strengthen community resilience and community capacity to address the social determinants of health. But this austerity budget will make it impossible to enable communities to take action themselves, with their own knowledge, experience and innovation, to address problems that the state is struggling to solve alone.
Moreover, an austerity budget that cuts public spending that weakens the ability of the civil service to deliver public services will increase inequality in access to the SDH, inevitably resulting in a growing BOD for the weakened and understaffed health system to cope with.
The 2020 health budget is a call to action for all of us, in health and beyond, to hold our political leadership accountable to the promise of health for all they have repeatedly made to the people of South Africa. We must build our vision of a better health system now, harnessing resources in both the public and private sectors to develop and build a health service for the nation that is founded on the principles of equity, access, primary health care and intersectional action on the SDH.