The response has been similar to previous years with vague but general consensus that spending in health needs to increase. There has been little debate, though, what an adequate increase should be to adequately address the some fundamental issues in the current collapsing health care system.

The reality on the ground is that most of the provincial departments of health have massive budget deficits (many of a R2-3bn!) over many years. With massive vacancy rates particularly in rural areas (in some instances 80% of available posts on the establishment of some categories of professional staff) it seems that the scale of over-expenditure is more due to inadequate budgeting than inefficiency, incompetence and or at times corruption. In order to cope with staying within the budget, provincial departments of health have introduced measures over the years, such as ‘€˜freezing’€™ posts or centralising appointment processes (leading to inefficient micromanagement of local needs by the Head of Department or the MEC) (in KZN, Limpopo, Mpumalanga, NorthWest Province). Other provinces have run into other troubles, such as medicine stock outs (as in the Freestate and the Eastern Cape) defaulting on paying for services (Gauteng, Mpumalanga and Limpopo) etc. Many of these situations have not been due to wasteful expenditure or corruption, but budgets running out at times as soon as half way through the financial year.

In this light how do we assess the adequacy of the budget? Is the budget adequate to deal with the over-expenditure of the provinces? As long as there is a deficit, the posts will continue to remain vacant and medicines will continue to run out ‘€“ and the current status quo of inequitable allocation will continue. In the same vein, does the current budgetary allocation adequately take inflation in health care into consideration (which is considerably higher than consumer inflation)? And does the budget cover the expansion of services, not only ARV’€™s but issues such as that a greater percentage of the population is dependent on the public sector for their health care? Just answering these 3 question, it may well seem that the current budget merely maintains the status quo of a dysfunctional health care system.

More fundamental issues are maintaining the poor state and the profound inequities that characterize the health care system.3 inequities have been identified that characterize the health care sector ‘€“ the inequity between private health and public health, between tertiary care and primary / community care and between urban and rural health care. In order to be able to assess whether the budget meets the promises made by politicians and the rights enshrined in the constitution in an equitable manner ‘€“ and addresses these 3 inequities mentioned – the budgeting process needs to focus at a minimum on the following:

1)           Norms and standards of care ‘€“ National norms and standards for different levels of care, specifically at PHC clinic, Community Health Centres and District Hospitals, have been available for many years but have not been costed or implemented. The norms and standards have not been used to drive service delivery development in a consistent manner, mostly due to the perpetual crisis the health care system has been in, and thus there is considerable variation of service delivery between provinces, but at times even within a single district.

2)           Human resource norms ‘€“ The HR norms are central in the 2004 Strategic Human Resource Plan and the development of the norms was to be ‘€˜fast-tracked’€™. However, to date little work has been done on this and the historic inequities of staffing differences have been maintained.

3)           Implementation of programmatic interventions ‘€“ Many programs have remained unfunded ‘€“ meaning that already overstretched services need to stretch a bit further to meet the ‘€“often politically motivated ‘€“ promises of what the population can expect from the health care system. Furthermore, programs that do not have a high profile ‘€“ such as mental health, eye care or disability ‘€“ fall off the table and often the most vulnerable in the health care system receive the worst care.

Not taking the above issues into account implies that the current budget is a thumb-suck, and maintains historic inequities. Incidentally, all of the issues mentioned above need to be in place before any serious discussion regarding the NHI can take place.

Meanwhile, working in a rural hospital, desperately trying to recruit staff and ensuring that the local systems and processes are functioning, is bleak business: the larger system is crumbling and not able to support the work that is being done on the ground. There is no budget to appoint anyone. There are hospitals where the doctors are only able to do a ward round every 3 days, due to the work load they face. There are wards that run without a professional nurse, many hospitals are without pharmacists.

The ‘€˜turn-around strategy’€™ mentioned by Dr Motswaldi needs to urgently address the issues mentioned above. However, it also needs to take care of the current crisis on the ground. In order to move forward immediate administrative measures need to put in place to be able to fill posts ‘€“ and the budget needs to be available to do so. The current budget by Gordhan does not seem to be able to do either of these.

This article first appeared in The Business Day on 5 March 2010.