Citizens access to healthcare services a right guaranteed in the Constitution — has deteriorated in many areas since 1994, despite the fact that pregnant women and children under the age of six now get free care.

Experts blame this problem of access — together with a decline in the quality of healthcare — on “fiscal federalism”, the failure of the government to set up a district health system to deliver primary healthcare and human resource problems.

In 1994, the national department of health allocated money directly to provincial health departments. But in 1997, the Department of Finance put a stop to this when it introduced “fiscal federalism” a system whereby provinces were given a lump sum and could then decide how the money should be spent.

Economist Lucy Gilson from the Centre for Health Policy at Wits says that fiscal federalism has “reversed many of the equity gains made after 1994”.

“The Department of Finance’s formula [for provincial allocation] seems to favour the provinces that contribute the most to gross domestic product,” Gilson told the Health Systems Trust (HST) policy conference last week.

Since taking responsibility for their own budget allocations, well-resourced provinces such as the Western Cape now allocate more money to health, whereas the country’s poorest province, the Northern Province, has cut its health budget.

The National Health Department’s Vishal Brijlal described the federal system as “good for fiscal discipline but doing nothing for service delivery”.

“All we are worried about is coming in on budget. There is a higher emphasis on financial discipline than delivery,” Brijlal told the HST conference.

His view was echoed by Dr Lahla Ngubeni of the Johannesburg Metro. According to Ngubeni, because of the city’s financial problems, health had become a “Cinderella service” while officials focused on “bringing the budget back into the black”.

Dr Eric Buch of Pretoria University’s School of Public Health, said that the government was “underfunding public services” as it would need to spend R600 per person each year if it were to deliver “sufficient public healthcare services”.

However, Professor Barry Kistnasamy, dean of the University of Natal’s medical school, warned “if we shift too much to primary health care” this could destroy the secondary and tertiary levels of health, and that restoring these would be very difficult.

The national department of health has identified the need to “stabilise the hospital sector” as a key strategy. To help achieve this, the government has applied for a loan of some $200-million for hospital rehabilitation from the World Bank.

But this is likely to prove highly controversial, given that World Bank loans are usually given with onerous conditions.

Aside from a shortage of money, service delivery has been hampered by the lack of district structures to deliver healthcare to every corner of the country.

In some areas where districts had been set up, the Demarcation Board’s reorganisation of municipal boundaries has thrown these into disarray.

In the Free State, for example, the 14 districts set up in 1995 in line with local government had to be reduced to five this year.

“We had to restructure and redeploy staff,” said Free State health official Basie Polelo. “It took us three months and it was a painful process but we just had to do it.”

Another problem compounding the district system is the failure of the health minister to table the National Health Bill before Parliament.

The Bill, which has been in the pipeline for five years, is supposed to set out how the different spheres of government should interact in health service delivery, regulate both public and private healthcare, and entrench patients’ rights.

National health department official Dr Yogan Pillay told the HST conference that “many units in national and provincial departments are struggling to define their new role”.

“They have little idea of what decentralisation is and no clue of their own role,” said Pillay.

In addition, he added, although the Constitution gives local government executive powers to administer “municipal health services”, these had never been defined.

The simplest model is to equate municipal services with the district health system. However, some officials feel that local councils should only administer a primary health package and not take over district hospitals.

In the North West, for example, district hospitals have been “de-linked” from local government and remain under the control of the province.

“The crux of the matter is to get national consensus on the vision and the definition of municipal health services,” stressed Pillay.

Financial and structural problems have been compounded by human resource problems, particularly demotivated and overworked staff.

Fees for pregnant women and children under six were “removed fast with limited planning”, said Gilson. This had resulted in a substantial increase in the workload of health workers and led to a decline in the quality of care.

Since the introduction of free services, there had been a “haemorrhaging of nurses from the public service”, according to Johannesburg’s Ngubeni.

“In 1994, 950 000 patients attending primary health clinics in Soweto were seen by 800 nurses. Today, there are about two million patients and only 500 nurses,” said Ngubeni.

The problems are huge, cannot be addressed overnight and are compounded by the HIV/AIDS epidemic. But a functioning district health system should be the first step towards ensuring that sick people have access to primary care to ease their pain. Health-e News