Health Minister Aaron Motsoaldi. (Gallo)
Health Minister Aaron Motsoaldi says he doesn’t have the money — or the legal obligation — to hire jobless doctors despite dangerous staff shortages at government hospitals.
“Unemployed doctors should open their own practice or work in the private sector,” was Motsoaledi’s response to an open letter in which the South African Medical Association (SAMA) warns President Cyril Ramaphosa that 1800 junior doctors are without work.
Years of budget cuts, rampant corruption and maladministration got us here. It’s now a given that the system fails patients long before they reach the clinic, SAMA says. Government health staff experience undignified working conditions, limited opportunities to grow or specialise and lots of reasons to emigrate.
Funding health worker salaries is more than a budget line item, it’s a responsibility that reflects a nation’s commitment to its people’s welfare. For instance, a well staffed health system is better equipped to cut deaths among pregnant women, research shows. Allowing health worker numbers to dwindle is also expensive, as evidenced by the health department’s spiralling spending on negligence lawsuits.
Government austerity measures aren’t always justifiable because evidence shows tight public purse strings fuels inequality. Under international rights covenants (which South Africa ratified in 2015), budget cuts must be temporary, reasonable and subject to meaningful review by those affected, explains a report by the Institute for Economic Justice.
It’s rare that governments can show they’ve made every effort to avoid cuts and Motsoaledi’s rebuff reveals his apathy about the wellbeing of those who use and serve the public sector.
Perhaps the minister thinks he’s doing enough by backing the National Health Insurance scheme, but we cannot afford to wait until it’s up and running, which will take years if the legislation survives legal challenges.
The longer the system remains underfunded, the more exposed we all are to the health threats that are on the way.
Have we really exhausted all our options?
It’s shameful that those who call themselves leaders dismiss serious warnings so easily. Rampahosa hasn’t responded to SAMA’s letter directly, which is disappointing given that he’s behind a 2022 African Union plan to boost the continent’s health workforce.
In his State of the Nation address on Thursday, Ramaphosa said his “immediate priority is to strengthen the health system and improve the quality of care”, but he didn’t acknowledge the role proper staffing will play in achieving this goal.
There seems to be no resolve from the health department to find innovative solutions to the problem of expertise fleeing the country.
There are lessons from elsewhere that could be explored. Rwanda, for instance, has low levels of brain drain thanks in part to a well-funded hiring plan specifically for the health service — although that country’s successes are always in the shadow of its human rights abuses.
One part of the Rwandan plan was designed specifically to boost the staff budget sustainably. Initially international donors supplemented the country’s hiring budget as the government steadily increased funds over the course of five years.
Motsoaledi estimates that there’s at least a R2 billion a year gap in South Africa’s total hiring budget, according to the SAMA statement.
Would business or billionaires contribute to the kitty, yet again stepping into the gap?
During the Covid-19 pandemic, fraught emergency negotiations between South Africa’s public and private sectors ultimately didn’t bear fruit, but the talks were reported to have improved trust between the two groups. A public-private partnership could help with resource allocation, job opportunities and budgeting in provinces, possibly mirroring a Ghanaian deal between the government and the Christian Health Association.
If the millions the health sector lost to corruption during the pandemic could be recouped, could that be ploughed back into the health budget?
The health department may already have done calculations to answer these questions but they must also show their work. We are owed clear explanations.
Why we cannot relent
South Africans have a hard-won constitutional right to health that must be protected.
There are many historical examples to fuel that resolve. Unions (including health worker groups) helped to turn the tide against the dehumanising effects of apartheid. Medical professionals recognised their ethical obligation to push for social change.
Then, early in democracy, activists and lawyers forced the health department to buy HIV medicine for everyone.
We have to pay close attention to the budgets that are tabled in parliament.
The treasury allocates a portion of the country’s budget to the health department, but provincial political representatives ultimately decide whether they’ve got a fair share. Budgets are not final when the finance minister makes his speech and often adjusted for months afterwards.
In 2024, high court advocate and former state law adviser Benjamin Cronin argued in the Constitutional Court Review that a government accounting officer should be able to challenge the amount of money they’ve been given if it means their department will fail to deliver their broader mandate, say, of delivering health care.
There are organisations such as Section27 and Public Service Accountability Monitor that make submissions to the committees that approve budgets, but individuals can participate too. You can attend a committee meeting, email your representative or submit a petition.
When it’s time for provinces to report how they spent their money, office bearers must be held to account if they don’t spend all the money they received.
We must not underestimate our power even when the odds seem stacked against change.
Tian Johnson is the founder of and strategist at the African Alliance and International Civil Society Observer at the Robert Carr Fund.