Each year, at about this time, I start preparing to produce an analysis of the national budget and publish a statement on its implications for public health and social justice. The importance of the budget in this regard cannot be over-emphasised. More than any other policy document, the budget outlines the government's true priorities. Government policy and strategic planning, no matter how progressive they are, are meaningless if the budget does not ensure that they are properly resourced. When it comes to policy, the budget is supreme.
The problem, though, is that in the rush to get out a statement on the budget that laments its shortcomings in the resourcing of meaningful health reform, we tend to lose sight of the bigger picture. Don't get me wrong, these statements and the advocacy that follow are essential for the work that social justice organisations like mine do. In the past we have seen that rigorous and sustained critique of the budget can achieve big results. You only have to look at the history behind the HIV and Aids conditional grants to find evidence of this.
It is also important that there are critical and alternative voices to the powerful conservative mantra that drones: "The free market is virtuous and will create jobs and grow the economy." As social justice organisations – if we are truly going to influence the resourcing of good policy that will make a real meaningful difference in people's lives – we need to do more to temper the power of this discourse.
One of the major challenges we face with economic policy is that we have never overcome the hangover from the maligned growth, employment and redistribution (Gear) economic policy. Although this has ostensibly fallen by the wayside and has been replaced by a more developmental agenda, recently articulated in the national development plan, nothing has really changed. As a colleague of mine quipped the other day: "They are really good at talking left but walking right, aren't they."
It is at this time of year that this kind of government doublespeak is most evident. The president stands before Parliament and the country and delivers the State of the Nation address. He tells us how well we are doing, but that there are problems and we could do more for the poor and downtrodden.
The real SONA
A week or two later this is followed by the real State of the Nation address, when the minister of finance tells us that we need to rein in our deficit, be responsible and let foreign investors know that we are not about to trample on the Washington Consensus.
To be fair, I do not believe that there is a "neoliberal" conspiracy at play or that the ministry and its technocratic manifestation, the treasury, are deliberately trying to thwart social justice. However, I maintain that a chronically conservative approach to economic policy and expenditure is bad for the poor.
Obviously, the marginalisation of the poor is as much a function of how the money is spent as it is economic policy (perhaps more so). I have argued this ad nauseum before. My argument here, though, is that even if we deal with corruption and financial mismanagement, we are never going to deliver on the promise of the Constitution if we do not make some hard choices in how we think about our economy and, together, commit to social justice (not hand-outs, but justice).
To me, in few ways is this made more apparent than if one looks at the state of rural health. According to the last census, nearly 44% of our population live in and access health services in rural areas. The census also tells us that the country's most deprived districts are rural. They also have the worst access to clean water, sanitation and proper nutrition. Nearly two decades of research and data also tell us that our rural population continues to have the highest burden of disease, but the lowest access to healthcare.
High maternal and child mortality rates in rural areas
This manifests in horrific health outcomes in these areas. Rural districts in South Africa continue to have among the highest maternal and child mortality rates in the world. Tuberculosis and HIV ravage already vulnerable rural families. Chronic conditions such as diabetes and high blood pressure are left untreated, simply because people cannot get to the clinic to collect their medication. Emergency care is often out of the question.
You might ask what this has to do with the economic policy; well, everything. Recently I had a conversation with a former MEC for health in the Eastern Cape about why the province's health department was in so much trouble. Acknowledging its inability to deal with maladministration and corruption, she reminded me that the state has never made any serious attempt to deal with the legacy of apartheid in the rural areas.
This is not hard to prove. An analysis of the longitudinal trends in allocations for health in provinces such as the Eastern Cape and the North West reveals that these allocations continue to be set incrementally from a base that predates 1994 – a base that was inequitable by design. The reason: in terms of Gear and pressure from the World Bank, social spending was "stabilised" in order to deal with the nation's apartheid debt. The consequence: the resourcing of service delivery in rural areas has not substantially improved from the era of separate "development".
The only substantial increases in health allocations have been for the response to HIV. But the government initially resisted even these increases, arguing that universal access was just too expensive. It was relentless evidence-based activism by the Treatment Action Campaign, and many other social justice organisations, that finally forced the government's hand. It was only when we could demonstrate that a conservative approach to antiretroviral drugs, which help to keep HIV under control in patients' bodies, costs the economy more than the commitment to invest in treatment for all who need it that the government started listening.
Economic policy, which is inseparable from economic ideology, defines what is legitimate in the collection and use of resources. Equity in health budget allocations is only seen as legitimate if the government's economic policy uses the discourse of equity. If we cannot reassure foreign investors that we are not deviating from our market-driven path, then there is little hope that any serious commitment to achieving equity in the financing of healthcare will find its way into the division of revenue.
Yet again, we saw nothing in this budget that will have any lasting benefit for rural health. It was largely business as usual and we did not see any meaningful commitment to equity and social justice.
Daygan Eager is programme manager: rural proofing at the Rural Health Advocacy Project (RuDASA), a partnership between RuDASA, the University of the Witwatersrand Centre for Rural health and Section27