Underspending threatens provinces’ health care

Judging from the overall budget presentations by the nine provinces, the provinces that need the most support are the Eastern Cape, Limpopo, North West and Mpumalanga.

Encouragingly all the provinces are spending money on training managers to effectively manage programme budgets. This will hopefully lead to less underspending.

“It is clear that in some of the provinces there is no sensitivity towards spending on the poor,” said James Ngculu, chairperson of Parliament’s Standing Committee on Health.

He said provincial treasuries were part of the blockages and that is was worrying that it appeared as if autonomous republics were emerging where spending on the poor was not a priority.

Looking at the provincial budgets, the following concerns and encouragement were noted by members of National Treasury, the Department of Health and members of the Standing Committee on Health.

North West

This province received a large encouraging increase (13%) for health. A worrying factor is the loss of nurses to the more well resourced provinces or overseas. Rural incentives implemented are not working and the province will have to look at other measures to retain and attract nurses, doctors and specialists.

North West almost matched the Eastern Cape by spending only 58% of money budgeted for the Primary School Nutrition Programme, a critical safety net for thousands of impoverished children. The department said women in the community were being empowered to take over the feeding schemes. A task team has been appointed to look into the matter of rural incentives. North West expenditure in the previous financial year amounted to R35-million.


This province received a 13,6% overall increase for health. According to preliminary data from National Treasury the province had underspent by R59-million. “They need support in implementing increases,” said Mark Blecher of National Treasury.

Mpumalanga had spent no funds on prevention of mother to child transmission (PMTCT) services or home based care in the last financial year. According to head of the health department in the province, Dr Rina Charles, this was because there was no one in charge of their HIV/AIDS programme. She said the position was filled at the beginning of the year and that business plans and time frames were now in place. She said that, as with the Eastern Cape, the provincial treasury department delayed transfers and that this was a major problem. “In many cases payments are only effected at the start of the next financial year,” Charles said.

Northern Cape

The Northern Cape spent almost all its available HIV/AIDS Voluntary Counselling and Testing Funds, a sign that this province’s HIV/AIDS programme is running at full steam. This province’s biggest challenge lies in reaching all patients considering the vast distances. But funds have been budgeted to maintain and replace the vehicle fleet. The objective of this province is to transform its hospital sector to provide cost effective modern hospitals. Kimberley Hospital has undergone an overhaul in quality of care and service delivery. A new hospital will be built in Colesberg and Gordonia Hospital will also be revitalized. The new Tertiary Services Grant has enabled this province to ensure equitable access to tertiary services, a positive shift. Northern Cape received an 8,7% increase in its health budget.


The best-funded province per capita, received a 6% increase, following a significant 14,5% increase in 2001/2 and a 7,3% increase in 2003/4. The spending on PMTCT services was good in this province. Gauteng has performed impressively in terms of its ability to retain revenue.


The most heavily burdened province in terms of HIV/AIDS received a 6,9% increase. However, if over-expenditure of R289-million in 2001/2 is to be fully carried by the health department, the adjusted increase will be only 4,1%, Blecher warned. But head of the health department, Professor Ronald Green-Thompson said that they had not budgeted for the R131-million needed to roll-out the PMTCT programme. He also pointed out that the department had been forced to fork out R176-million to curtail the cholera epidemic.

“We have not been compensated for it. But we will continue to ask, plead and fight with the national department of health,” he said. Green-Thompson said they had been commended by the national department and the World Health Organisation for their handling of the epidemic which saw just under 120 000 cases being reported and a case fatality rate of less than 0,2%, the best in the world. Clinic and Mobile service (primary health care) as well as HIV/AIDS have been prioritized by the province.

Free State

This province has overspent in 2001/2 by R64-million to achieve a 14,5% expenditure increase since 2000/1. Head of department, Dr Victor Letlhakanyane explained that the over-expenditure had mainly been in the equipment and stores and livestocks departments. Stores and livestock include patient files, medicines and blood products. He said that health inflation had been higher and that salary increases had been more than the budget increase. Blecher said the situation was worrying if the department was forced to carry the over-expenditure fully. “This may be a little  tight,” he said.

Northern Province

This budget is the lowest per capita of all provinces and the increase of 8,9% in 2002/3 is largely a function of a low base and low growth in 2001/2. Blecher explained that one of the main reasons for the percentage increase for health is that the large increases have gone to Social Security – given huge backlogs of eligible persons not receiving grants (the province is facing court action on this issue at present) and because of roll-out of the child support grant. “It is difficult to see how they will implement the conditional grant increases,” Blecher said. An official said that that they were “out there fighting with our colleagues,” but the fact remained that health only received 16% of the provincial cake. Ngculu commented that he found this “laissez faire” approach of allocating only 16% to health odd.

Education received 44%. “This is a priority province in terms of poverty alleviation. It is difficult to understand when education is allocated 44% of the cake,” he said. As with the Eastern Cape, this province is a victim of late transfer of funds from its treasury. The question remains whether this province will have the capacity to spend the increased funds allocated to them.

See related story: Eastern Cape failing to meet health needs

The Western Cape has a fairly tight budget with only a 5,1% increase

Western Cape

The Western Cape has a fairly tight budget with only a 5,1% increase. Blecher said the 2,1% increase in academic medical services may well not be achievable and there was likely to be significant pressure on academic hospitals also from the effect of depreciation on medicine imports. The province is bracing itself for a significant reduction in academic beds. The province was unable to table a strategic plan stating that political decisions still needed to be made. “This could change the face of health care in the province,” an official said. The Western Cape has also managed to retain 100% of its revenue retained. The province is concerned about the high number or nurses it is losing to the private sector and abroad.


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