Finance Minister Trevor Manuel highlighted under-capacity in the struggling healthcare system in this week’s budget.
His department is expecting the number of people who will receive HIV/Aids treatment through the state system merely to double in the next three years, an estimate that Aids experts say could mean that four people will die for every one person who gets antiretroviral (ARV) therapy via the state.
The head of the Southern African HIV Clinicians Society, Dr François Venter, described this estimate as “laughable”.
“It is an extremely conservative budget and that almost implies they don’t have confidence in the healthcare services,” said Venter.
“Stats SA estimates that more than 400 000 people a year will die of Aids, which means that in three years 1,2-million will die, and we’re planning to treat only an extra 250 000. It’s true that at the moment our healthcare facilities are stretched, but we need to build capacity rather than let people die.
“This budget does not allow us to do that. Allowing for an additional 30 000 healthcare workers is woefully inadequate. Either Treasury has no belief in health service upscaling or they’ve been given bad advice.”
Other health experts have also greeted the budget with disappointment, saying that there has been little true overall improvement in expenditure in many areas, even though the finance minister was confronted with a record-breaking budget surplus.
Key figures in the health budget include an additional spend of R3,7-billion in the next three years on the revitalisation of health facilities and the comprehensive plan for the treatment of HIV/Aids.
Of this R1,7-billion is directed towards increasing the number of people accessing ARVs, R1-billion will go to the revitalisation of hospitals and healthcare facilities and R1-billion will be directed towards improving tertiary medical services and emergency services. The emergency services are being beefed up in time for the 2010 Fifa World Cup.
Manuel said the extra money for Aids treatment was based on estimates that in three years half a million people would be receiving ARV therapy from the state — double the number of people accessing the treatment now.
Julia de Bruyn, chief director of social services for the Treasury, said the extra money for the operational plan was calculated using department of health data and that the doubling of state-funded ARV therapy patients in three years is “a good estimate of what the system can handle”.
The Treasury has announced that there will be a 10,5% annual increase in total health and education expenditure at provincial level in the next three years. However, this increase is purely nominal — it does not account for inflation (currently at just under 5%) or for the 2% annual increase in the South African population.
The extra funding will not necessarily end up in health and education because much of it is not ring fenced, it can be spent on whatever the province decides. “If it’s not in a conditional grant then it’s play money; the provinces don’t have to spend it on healthcare at all,” said one analyst.
An example of this is the pressure facing the academic hospitals, which usually share appointments of doctors with provincial government and are unable to fill a post unless the province decides to provide its proportion of the funding.
The result often is added strain on academic hospitals already battling to cope with growing patient numbers fuelled by the Aids epidemic, says Professor Anthony Melck of Pretoria University. Failure by provincial government to fill posts not only has a negative effect on service delivery to patients, but also means cutbacks in research. Academic hospitals traditionally combine research with clinical services to develop treatments aligned with the country’s specific healthcare needs.
Treasury has pledged R4,55-billion in the next three years to improve the salaries and conditions of service of healthcare workers and managers. The majority of the pay increase will be targeted at nurses. Manuel also said his intention was to increase the number of public sector healthcare workers in South Africa by 30 000 in the next five years, from the current 244 502.
But one economist said that reaching a reasonable standard of service for South Africa’s 40-million public sector users would require more than 100 000 extra nurses in the hospitals alone. Just to keep ratios consistent with population growth in the next five years would require about 36 000 new healthcare workers.
Manuel emphasised the need to improve the healthcare system, but health experts question whether this budget has truly done so. For example, one economist said that funding allocated to tertiary services would show just 0,4% growth in the next financial year.
Rabelani Daswa, a researcher at the Aids Budget Unit of the Governance and Aids Programme at the Institute for Democracy in South Africa, said a problem with the budget was that allocations did not match both need and capacity.
Proportions of funding allocated to different provinces should reflect their ability to deliver services, as well as the need to improve capacity. For this reason the budget process required greater consultation with civil society, he said.