Whistleblowers have alerted the Rural Health Advocacy Project (RHAP) to a decision by Limpopo’s Health Department to release provincial bursary holders from their contractual obligations. 

RHAP has in its possession a letter circulated to health professionals inviting them to a meeting to discuss the decision which will affect approximately 540 health professionals who have received funding from the provincial health department. The affected health professionals include medical doctors, professional nurses, pharmacists and allied health professionals (such as occupational therapists, physiotherapists, speech therapists and audiologists.) 

The decision to release the bursary holders from their Bursary Contractual Service Obligations will have severe implications on health service delivery and does not ensure the protection of the core right to health. 

It will ensure that the reported ratios of 10 pharmacists per 100,000 people will not improve nor will the three physiotherapists and occupational therapists, respectively, per 100,000 people, thus underservicing the population in Limpopo and failing to progressively realise the right of access to health care services.

Constitutional mandate

The Limpopo health department has under half (47%, that is, 33,848 of the 63,460 posts) of the personnel it requires to function effectively. To fix the broken provincial health system, the health department developed a Recruitment and Development Strategy to formalise the bursary scheme and ensure that it can attract and retain health professionals.

The strategy is also intended to address some of the factors that result in the high attrition rate, these include a lack of opportunities for career-pathing, inadequate infrastructure, inadequate and non-functional equipment as well as poor working conditions. 

It is therefore counter-productive that the Limpopo health department, which has historically suffered from low healthcare worker figures would opt to let go of 540 health professionals whose services are obviously needed.

Typical rhetoric would lay blame on the economic recession and austerity measures taken by state departments. However, we should be wary of austerity being the catch-all net for all decisions that fail to meet the Constitutional standard envisioned in section 27 of the Constitution. 

The International Covenant on Economic, Social and Cultural Rights to which South Africa is a signatory is explicit when it comes to austerity. 

It cites the implementation of austerity measures may only be justified when a) less restrictive measures have been exhausted, b) austerity measures must be temporary and that any other course of action would be more detrimental to the realisation of rights and that c) they cannot be intentionally or unintentionally discriminatory, amongst others. 

Limpopo’s ailing health system

In late 2018, President Ramaphosa released a Stimulus Package for Health. This constituted a significant boost of 5300 posts (clinical and support staff) into the public health system distributed across all 9 provinces. The Limpopo Department of Health, in particular, received 227 medical officer posts (for post-community service doctors), 68 pharmacist posts, 309 professional nurses’ posts and 57 allied health professional posts. 

A total complement of 701 new posts were funded, in addition to the number already budgeted for by the Limpopo health department. It is curious that a decision to forego the services of 540 health professionals be implemented with such haste. 

Surely, the lack of available funding was anticipated earlier in the year. If so, a large portion of the 701 new posts could be used to offset the 540 posts that will be lost. There has been no information on how many of the posts created by the Stimulus Package have been filled.

We are also unsure how the Limpopo health department intends to staff the state-of-the-art central level hospital whilst failing to adequately implement its strategy and retain 540 skilled and willing health professionals whose studies the Limpopo Department of Health has already funded. 

The current state of Primary Health Centres (PHC) and district level hospitals also leaves much to be desired and it does not seem that this decision will improve services at these facilities. 

Only 25% of Limpopo’s clinics meet ideal clinic status, the second lowest of all provinces, competing for last place with the Eastern Cape; another predominantly rural province. Spending by Limpopo health department shows a strong focus towards district hospitals. Consequently, it would appear that the bulk of health services are provided at this level. 

Over the 2017/18 period, 51.3% of District Health Services was spent on district hospitals. However, this contrasts starkly with the investment in PHC services with Limpopo being the lowest spender in the country. Over the 2017/18 period, per capita spending on PHC was R352, which is almost R100 less than the national average. 

And therefore, incongruent decision making and spending is not isolated solely to the 540 health professionals who are soon to lose their jobs but rather is characteristic of Limpopo Department of Health. The investment in the studies of 540 health professionals to improve health services in Limpopo will be lost to other provinces or the private sector. 

People bear the brunt  

Due consideration must be given to the inherent challenges that rural provinces, such as Limpopo, face. The government must take into account factors such as low population numbers that are spread across large areas and resultant diseconomies of scale which make providing services to these provinces more expensive, and budget accordingly. 

The users of the healthcare system will bear the brunt of the loss of personnel most and the figures reported by Limpopo Department of Health will not allow for increased access to health care services.

There is contradicting information on the number of posts in Limpopo DoH and the number which has been filled and how many remain vacant.

There has been no explanation as to how the Limpopo health department funds bursary holders but fails to ensure that there is funding for their posts in order for them to continue working once after their community service. There are also no reports on the progress in implementing the strategy.

As a coalition of social justice organisations committed to the protection and advancement of socio-economic rights, we appeal to: 

• the Minister of Health to support the development of costed provincial Human Resources for Health plans that consider the varied implementation contexts in different provinces;
• the Minister of Finance to consider rural adjustments starting with HRH to be included in Equitable Share Formulas;
• the Premier of Limpopo to amend the framework that informs how the province distributes its unconditional provincial equitable share allocation in order to increase the portions dedicated to health and education; 
• the MEC for Health and the administrative heads of health to work together to ensure that the decision to release bursary holders is reversed in order to fulfil their Constitutional obligations of ensuring access to health care services so that the wellbeing of the people of Limpopo is placed at the centre of all decisions. 

This open letter has been endorsed by the following social justice organisations:

Rural Health Advocacy Project 

SECTION27 

Treatment Action Campaign 

People’s Health Movement  

Rural Rehab South Africa 

Rural Doctors Association of South Africa 

Institute for Economic Justice