Fixing the provinces means dealing with political cronies and sycophants who occupy crucial positions in the health system but are unable to deliver on their responsibilities.

Fix The Provinces and Rural Health to Make the Health Budget Work for All

16 May 2013

On 15 May 2013 the Minister of Health, Dr. Aaron Motsoaledi, delivered his annual National Health budget and policy speech (here). The speech provides an opportunity for the Minister and his department to communicate progress they have made in delivering health services, the challenges they face and what they plan to do to advance the right to health.

The speech, along with the tabling of the Department's budget and strategic plans, is also essential in fostering transparency and accountability in how the department plans to meet its obligations in terms of SECTION27 of the Constitution.

In this regard, the Minister of Health continues to be an example of transparent, responsive and accountable government. We believe his speech provided both an honest appraisal of progress made and acknowledgement of the challenges the department faces in fulfilling its mandate. As civil society organisations that advocate for the advancement of social justice in health, we appreciate this.

In his speech the Minister highlighted a number of areas of progress that should be commended.

For example, the government's progress in expanding access to testing and treatment for HIV since the end of government sponsored AIDS denialism in 2006 is remarkable. According to Minister Motsoaledi:

·         · There are now 3540 facilities providing ARVs to patients.

·         · There are now more than 1.9 million people on treatment.

·         · The recent introduction of fixed dose combinations of ARVs will greatly improve access and adherence while reducing costs to the system.

Whereas the impact that this kind of commitment has had on the right to health cannot be denied and the Medical Research Council's most recent Rapid Mortality Surveillance Report (2011) reveals that combined life expectancy at birth has increased from 54 years in 2005 to 60 years in 2011, there are still serious problems in HIV service provision that need to be addressed. Regular drug stock-outs in most provinces; inadequate and poorly maintained infrastructure and equipment; and an inability to ensure the consistent supply of quality basic services to the population undermines progress in expanding access to testing and treatment for HIV/AIDS. We welcome the re-evaluation of the depot system of drug supply, which has often served as a barrier to access to healthcare rather than facilitating greater access. TA C and MSF recently intervened in the Umtata depot to ensure continued access to medicines (here).

While we welcome the Minster's continued commitment to combating Tuberculosis (TB) in the public system and acknowledge the government's continued investment in GeneXpert technology and the expansion of family teams to trace infection as important steps in the early detection and treatment of TB, a great deal more needs to be done to diagnose and treat TB in our mines, prisons and deportation centers. It should not take threats of legal action by social justice movements to compel the government to develop reasonable plans, with appropriate budgets and monitoring systems, to combat this disease.

We recognise the Minister's continued commitment to far-reaching health care reform through the introduction of the National Health Insurance (NHI). This is no easy task in the face of opposition from many sectors of our society and against the reality of the quality of care currently being provided in public health facilities. We support the Government's efforts towards the implementation of the NHI but are concerned about the lack of sharing of information and engagement with civil society on the progress made with regard to NHI, especially in the crucial ‘pilot districts'.

Careful regulation of the private health sector and the containment of costs for the care that it provides are crucial for improving access to health care. The Market Inquiry into the private health care sector, announced by Economic Development Minister Ebrahim Patel in his budget speech has the potential to provide a strong evidence base for reasonable regulatory measures that aim to increase transparency and improve access to health care services. It is vital that the market inquiry is transparent and inclusive of all stakeholders and that the relevant regulators and government departments implement the recommendations that may come out of the inquiry. The unfortunate truth, however, is that the NHI will only be successful in its goals and objectives if there is serious and far-reaching commitment to fixing the public health system and reforming how services are funded and provided.

Fix the Provinces!

The sad truth is that most provincial health departments, which are the primary providers of services in the public sector, continue to fail to deliver on their core constitutional obligations. This is particularly acute in the Eastern Cape and Gauteng, closely followed by the Free State, Mpumalanga and Limpopo.

Mismanagement of the health system and rampant corruption has meant that budgets are no longer sufficient to support the full range of health care services that provinces should provide. We need only to look at the long-running health crises in the Eastern Cape, Limpopo and Gauteng to get a picture of problems in the public system.

Decisive action must be taken urgently to deal with these weaknesses. Oversight bodies such as the Auditor-General, and legislative oversight have provided findings and recommendations that provide a roadmap on how this could be achieved. The Department itself has a tool in the Integrated Support Team reports from 2009 to guide a strategy to improve the delivery of health services. The only thing that appears missing is the political will at the highest level of government, the Presidency, to make change happen. Fixing the provinces means dealing with political cronies and sycophants who occupy crucial positions in the health system but are unable to deliver on their responsibilities.

A good start would be to start taking swift and decisive action against those officials who continue to loot the public health purse for their own gain. Dealing with corruption would rescue billions of rand and go a long way in improving access to health through better management of resources.

Fix rural health!

One of the most significant barriers to the provision of good quality health care and the NHI's fundamental goal of universal access has been the government's failure to implement policies that effectively deal with the inherent inequities within health system. While the Minister reiterated the Department's commitment to dealing with the inequities between the public and private health care sectors through the implementation of the NHI, there has been no similar commitment to dealing with inequities in the public health system itself.

The legacy of apartheid's policies of separate development can be seen in the significant disparities between urban and rural settings in terms of expenditure infrastructure and human resources. There is good data, provided in the Health System Trust's (HST) most recent District Health Barometer (here), that shows health care expenditure per capita is far higher in largely urban provinces such as Gauteng and the Western Cape than it is within largely rural provinces such as the Eastern Cape, Mpumalanga, Limpopo and the North West. This is reiterated by data, also from t he HST, that reveals that inequities persist within provinces too, where expenditure is far higher in metros than districts with largely rural populations.

Recent research has revealed that these inequities are sustained because of a persistent infrastructure-inequality trap. Historical budgeting, where allocations are based on ability to spend rather than need or performance in achieving outcomes means that poorly resourced, largely-rural provinces and districts continue to suffer while comparatively well resourced largely urban provinces benefit from any additional resources when they become available.

There has been some movement to at least recognise this trend. The Department's most recent Human Resources for Health Strategy (here) contains a rural chapter that clearly outlines what is needed to attract and retain health care professionals in rural areas. Despite the existence of this chapter, which acknowledges and articulates the need for a rural strategy, there is no implementation plan or budget to give it life. Things like good accommodation for health care workers and other forms of support are all within reach with existing resources. It is just a matter of prioritisation.

The Minister has again highlighted the importance of drawing on the resources in the private sector to expand access. We endorse this, but it is unlikely that rural communities will benefit from these resources.

There is currently no significant private sector within rural areas. The Minister's push for a well-developed system to contract GPs to provide services in the public sector does undoubtedly hold benefit for rural users, but it can only really make a small dent in what is a massive need. There is no real incentive for any other elements of the private sector to establish health services in these areas. Simply, there is little profit to be made from poor people.

It is for this reason that we would argue that the Minister must carefully consider private sector involvement in the NHI to ensure that it does not further entrench the infrastructure-inequality trap. Accreditation and participation must be based on what will benefit all users and not just those who live in areas where private providers see greatest profit margins.

Conclusion

Minister Motsoaledi and his senior management team are the best custodians of the health system South Africa has ever had, and we commend their commitment. We are happy to listen to a budget speech that makes concrete promises, such as the introduction of the HPV vaccine to prevent cervical cancer through the Integrated School Health Programme, as well as the revival of the HIV Counselling and Testing campaign. But, through no fault of his own, we frequently see a sharp mismatch between what the Minister says and what his officials do on the ground.

SECTION27, RHAP and TAC are this week meeting health workers and users across the Eastern Cape. The situation here is dismal. At ground level many health facilities are in crisis and constitutional rights are not being provided for. We therefore call for wider support for the Minister. But where, for whatever reason, the Minister does not have the power to bring change, we will have no choice but to turn to our Courts and ask them to empower the Minister by ordering him to urgently implement and monitor plans to fix the public health system.

Statement issued by Treatment Action Campaign, SECTION27 and Rural Health Advocacy Project, May 17 2013

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