24 February 2015
Tomorrow (25 February 2015), Minister Nhanhla Nene will table the 2015/16 budget and give his first budget speech as the Minister of Finance. The budget he presents is widely expected to be one that continues and even deepens austerity measures aimed at cutting expenditure with a view to reducing the budget deficit.
The RHAP maintains that without full consideration of how these measures will have an impact on vulnerable populations, budget austerity will continue to compromise access to basic services such as health care for rural and underserved communities. We have already seen how within the health system austerity measures implemented indiscriminately across districts regardless of the levels of deprivation has resulted in The threat of closure of clinics and freezing of posts. At a time when the immunisation coverage is declining, the burden on the poor to travel distances to access clinics is increasing, the importance of continued investment in underserved and rural areas is larger than ever.
It is with the current economic climate and the threats posed to the basic rights of people living in rural communities to have access equitable access to health care that the RHAP calls for a budget that specifically addresses the following issues:
- There must be an articulation of how fiscal policy will address and not inadvertently deepen inequities between well-resourced and underserved areas of health, particularly rural contexts. This must include explicit consideration in budget processes for the impact budget and policy decisions have on rural communities. The budget must be rural-proofed.
- Rural-proofing will require provision of additional resources to and within provincial health departments with the express purpose of overcoming historical backlogs in infrastructure and personnel that continue to be significant barriers to access for people in rural contexts
- As a start there must be a clear directive from both the Treasury and Department of Health that protects critical health worker posts, including those for doctors, nurses and allied health professionals, from freezing or ad hoc removal from the establishment as austerity measures. Decisions on posts must be made based on an assessment of need and not perceived cost
- Ring fencing of money for priority areas and so-called ‘non-negotiables’, particularly around staffing of facilities should be instituted as a matter of urgency. The transfer of funds from critical service delivery areas of the budget to make up for shortfalls in other areas to ‘balance the books’ must be prevented. Community Health Care Worker programmes, for example, should not be compromised because of poor budgeting
- Delays in implementing core components of the NHI and its expansion beyond pilot districts can no longer be delayed by budget constraints. This transformative project must progress as a matter of urgency and the Treasury must prioritise it in the budget accordingly.
A budget that does not reflect rural realities and the government’s obligations to realise the right to have access to health care, as articulated in the Constitution, will continue to bring in to question the extent of government’s commitment to achieving universal access through the introduction of critical reforms such as the National Health Insurance.
What have we seen in the government’s approach to the budget in the recent past?
Over the last few years we have seen that the government’s fiscal stance has become increasingly conservative and talk of austerity and cost-cutting has dominated priority setting. The government has maintained that this conservative stance on expenditure is necessary because of slower than expected economic growth and a growing budget deficit that has become unsustainable.
In the 2014/15 financial year this conservative stance was reflected in the government’s consolidated budget of R1.25 Trillion, which is only 2% in real terms (once inflation has been accounted for) more than was spent in 2013/14. This is barely enough to cover current levels of service delivery, let alone broaden the government’s reach.
Health expenditure continues to stagnate
For 2014/15 allocations to health mirrored the government’s general expenditure trends and only increased marginally by R12 billion from R142 billion in 2013/14 to R154 billion. As with expenditure more generally, this allocation is barely enough to meet existing spending priorities and does not adequately account for the expansion of services through priority programmes such as those relating to HIV and AIDS, Maternal and Child Health and the National Health Insurance.
In that speech, as well as supporting budget documentation, it became clear that austerity meant cost containment in spending on goods and services as well as in the compensation of employees. With regard to the compensation of employees, the containment of the public sector wage bill will involve ‘freezing of government personnel headcounts…and withdrawing funding from posts that have been vacant for some time’. In several provinces we have already seen how these measures have had dire consequences of access to care in rural contexts.
Austerity budgets are bad for rural health systems
While the Minister did not specifically outline how these measures would affect health, based on our work in several provinces, we have seen already cash-strapped provincial health departments, particularly largely rural provinces, being pushed further into trouble due to the deepening of austerity measures.
For example, since late last year we have received a number of reports from the North West Province that the NWDoH was facing a budget shortfall of nearly R600 million for 2014/15. In an effort to control expenditure and avoid pushing the department further into debt in the form of accruals, the NWDoH was forced to implement a number of cost saving measures.
In addition to cost cutting in catering for meetings, hosting of events and staff travel, there have been reports of cost-cutting measures in a number of priority areas. Most troubling amongst these are reports of official embargos being placed on all maintenance of physical infrastructure, purchase of equipment and all new staff appointments.
The NW is not the only province whose health system is buckling due to deepening budget pressures and a lack of funds. The situation in the Eastern Cape and Free State are examples of where poorly managed austerity measures have actually resulted in critical staff shortages, the decline of infrastructure, and failing service delivery at many facilities.
The implications of continued austerity for rural health
Historically rural areas are hardest hit by austerity measures. This is because, even in times when the fiscus is not constrained, the government’s broad approach to expenditure continues to favour urban areas and priorities that relate to city infrastructure, service deliver and economic growth.
Expenditure in rural areas tends to be focused very narrowly on land reform and agriculture. While these are important areas, such an approach does not adequately address all aspects or rural development and equity that include key social services such as health and education.
For health care in rural areas this has meant that investment in health systems, infrastructure and personnel has been inadequate to overcome historical inequities in access to services. There is no consideration of need within rural settings, the dynamic relationship they have with urban settings and Constitutional imperatives of redress and equity. During times of austerity in expenditure this kind of neglect becomes more apparent and entrenched.
The RHAP’s message is simple; without budgets and budget processes that fully account for service delivery in rural contexts the right to health for rural communities, which still constitute nearly 40% of our population, can never be fully relised.
For additional comment on this release as well as the Ministers budget speech and the budget statement, please contact Daygan Eagar on 072 249 3873 or at Daygan@rhap.org.za
 Average immunisation coverage under 1 year increased from 74.8% in 04/05 to 87% in 08/09 but declined again to 84.4% in 13/14. There are significant differences in coverage with the deepest low of 54% in Waterberg (Limpopo Province). District Health Barometer 2012/13.