Business Day, 9 February 2009

LAST November, a roadmap for health reform was finalised by a range of stakeholders in the field of health care, including the government. The purpose of the roadmap, which was developed under the auspices of the Development Bank of Southern Africa, is to provide guidance to the next government on priorities for health reform. It reflects a rare consensus regarding the achievements and failures of the health system, as well as new priorities.
Importantly, it acknowledges the sobering fact that health indicators in SA are worsening. One devastating example is the rise in maternal mortality. One of the United Nations Millennium Development Goals is to reduce maternal mortality by 75% by 2015. But in SA, maternal mortality has increased from 230 deaths per 100000 births in 2000 to 400 in 2005, exceeding Iraq’s rate by 33%. Latest estimates average about 600. The main cause of maternal death is non-pregnancy related conditions, particularly HIV/AIDS and pneumonia.
If SA does not act swiftly to reverse the disastrous trends in health, there is a risk that the decline of the health system will become irreversible. It is unconscionable that our society accepts preventable illness and death on this scale.
There is a broad consensus that public health services have been insufficiently funded. But the problem is not simply inadequate financial and human resources. It is also one of inefficient use of resources.
Our fiscal system has two problematic features. First, it does not allow for effective parliamentary scrutiny of the budget that is presented by the treasury or of expenditure by national departments. Effective scrutiny would require the necessary expertise within Parliament, as well as the power to make amendments.
Second, there is simply no guarantee that funds allocated to the provinces will be spent on nationally determined priorities.
Both of these features can be corrected, and in respect of the first, progress is under way in the form of the Money Bills Amendment Procedure and Related Matters Bill. The provisions of the bill will finally allow for parliamentary scrutiny of the allocation of resources, the efficiency and effectiveness of individual departments’ use of available resources and an assessment of service delivery given the available resources.
The second problem arises from an insufficiency in the conditions that are attached to the allocations of resources, resulting in large variations in the extent to which provinces implement national health policy. Systemic reform is necessary to move away from an unreasonable division of each province’s equitable share towards budgets that complement national priorities.
The necessity for adjustments to the fiscal system is evident from the current budget crisis in health. It is reported that as a result of the poor implementation of the occupation-specific dispensation for nurses, the national health department is facing overspending of about R9bn. This, combined with poor management and monitoring of funds, is affecting delivery of all health services in most provinces.
In November, for example, the Free State health department said it was imposing a moratorium on the initiation of new patients onto antiretroviral (ARV) treatment. Despite the apparent intervention of the national department, the moratorium continues. Free State cannot even guarantee that it will be able to sustain current patients on ARV treatment. Needless to say, the effect of this on individual lives and public health will be dire. Free State starts about 1500 patients on ARV treatment every month. Since the moratorium, therefore, the waiting list has grown by about 5000 patients.
This is a historic crisis to do with poor planning and implementation. However, if this year’s budget does not reflect an increase in resource allocation to health, the department and its provincial counterparts will not be able to sustain the increasing demand for ARV treatment or carry out the major health reform envisaged in the roadmap. The government will fail to fulfil its constitutional duty to realise access to health services.
Parliamentary scrutiny of budget allocations, spending and service delivery is therefore urgently needed. However, Parliament’s power to amend a money bill will not cure the dysfunctionality between resource allocation and outcomes. That needs to be addressed as a problem in itself. The bulk of revenue in SA is raised nationally. It is entirely appropriate to accompany the equitable share allocation of revenue to provinces with strict conditions for expenditure. Attaching conditions to resource allocation to ensure an alignment between national priorities and provincial expenditure, quality of services and accountability is not only permissible in terms of the constitution, it is necessary in order to meet the constitutional mandate for social transformation. Without these fiscal reforms we will, like Sisyphus, just keep pushing the rock up the hill.

  • Hassim is head of litigation and legal services at the AIDS Law Project.