Shortage: Numbers of state healthcare (above) and education workers have not kept up with population growth since 1994, nor have there been enough efforts to rectify apartheid inequalities. Photo: Marco Longari/AFP
After 28 years of neoliberal restructuring of the apartheid state and the decimation of its capacity through austerity, state capture, corruption and the appointment of incompetent people, the time has come for a broader discussion about the need to significantly expand the size of the state to deliver universal public services, including free and quality education and healthcare.
The public service is not bloated. It will have to increase by up to one million people to be in line with international benchmarks. With a new macroeconomic policy framework that has a 6% GDP growth target that is binding on the treasury and the Reserve Bank, South Africa can generate the resources to make such investments.
The public service refers to national and provincial government. The public sector is a broader category that includes the public service, local government, state-owned companies and other institutions such as universities and chapter nine institutions.
According to a paper by Ebrahim-Khalil Hassen and Miriam Altman, the public service employed 1 269 141 people in 1994. A presentation by the department of public service and administration director general Yoliswa Makhasi shows that there were 1 234 768 people employed in the public service at the end of 2021.
The apartheid public service was geared to serve a white minority. The new government should have increased employment to deliver services to a larger population. But it adopted neoliberal slash-and-burn policies, closing nursing and teacher training colleges and creating what South African Communist Party leader Jeremy Cronin calls a “tenderised state that is a procurer and not a doer”.
The number of people employed in the public service declined by 34 373 (2.7%) between 1994 and 2021. The increase has not kept up with the 48% increase in the population to 60.1-million people in 2021 from 40.6-million in 1994.
If it had kept up with the growth of the population alone, the public service would have employed 1 861 295 people at the end of 2021 — almost 600 000 more people than were employed in 1994. Makhasi says there were 767 695 people employed in health (296 950) and education (470 745) — 62.2% of all public servants. There were 164 461 vacancies in the public service at the end of 2021 with health and education accounting for 112 455 or 68% of total vacancies. There were 336 317 posts in health, of which 39 367 were vacant, and 543 833 posts in education, of which 73 088 were vacant.
South Africa can no longer postpone equalising its health and education systems. This will require an unprecedented mobilisation of resources, including finance, infrastructure, technology and health and education professionals.
In 2019-20, the government spent R221.9-billion to provide health services to 50.7-million people — the 85.1% of the population who did not have access to medical aid. This was equivalent to a per capita spend of about R4 376. In 2020, medical aids paid R162-billion to 8.9-million people, who accounted for 14.9% of the population, according to the Council for Medical Schemes.
The average spend per beneficiary was R18 202, which was equivalent to 4.2 times the per capita spend in the public sector. With efficiencies of scale a well-managed National Health Service (NHS) could possibly provide a similar level of services as the private sector with two-thirds of the resources. This would cost about R600-billion, which implies an annual shortfall of almost R400- billion.
The roll-out of the NHS must start immediately and can be financed by a combination of higher rates of GDP growth, increases in public healthcare spending as a percentage of GDP, payroll taxes, the elimination of medical aid tax credits (R34.5-billion in 2019-20) and copayments.
The Organisation for Economic Development and Cooperation (OECD) says South Africa had 0.8 doctors per 1 000 population in 2019, compared with an average of 3.6 for its members. In April 2020, there were 43 901 medical practitioners registered with the Health Professions Council of South Africa. In 2019, the public sector employed 20 873 doctors. The national density was 0.3 doctors per 1 000 public sector population, according to the department of health.
Using the OECD benchmark and a population of 59.5-million in 2020, South Africa had a shortfall of 170 299 doctors.
The OECD found that South Africa had 1.1 nurses per 1 000 population, compared with an average of 8.8 for its 38 members and six partner countries: Brazil, China, India, Indonesia, Russia and South Africa. According to the South African Nursing Council there were 215 052 nurses in 2020, excluding assistants.
The department of health says the council’s data overestimates the number of nurses because it includes nurses no longer working. In the public sector, there were 102 746 nurses in 2019, says the department.
The OECD benchmark of 8.8 nurses per 1 0000 population translates into 523 600 nurses for South Africa and about 445 060 for the public sector population. To reach the OECD benchmark, South Africa will need to employ more than 300 000 nurses in the public sector alone.
In 2021, the learner-educator ratio in public schools was 31.4, according to the department of basic education. There were 405 050 educators. In independent schools, the learner educator ratio was 16.7. This means that South Africa has to employ 356 541 more educators in public schools to equalise the country’s two education systems.
South Africa has a tertiary enrolment rate of 22%. It must make a rapid transition towards a universal system of higher education with a tertiary enrolment rate of 75%, the OECD benchmark. This will probably require the tertiary education sector to double and for basic education to also double its annual outputs.
If similar benchmarks are conducted in the rest of the public service, including police and correctional services officers and care workers, South Africa would probably need to employ up to one million people. With a new macroeconomic policy framework, South Africans can start to dream again about the kind of country they want to live in.
The government must deliver a basket of high-quality universal public services. Health and education should be seen as human rights. Access should not depend on the ability to pay. It must take profit out of health and education and deliver affordable, subsidised green energy and transport and mass housing.
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The views expressed are those of the author and do not necessarily reflect the official policy or position of the Mail & Guardian.