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This is the first issue of Rural Health in Focus, which aims to draw systematic attention to the successes and challenges of rural health in order to improve national health outcomes. This issue focuses specifically on rural health financing, efficiency and equity. To fully appreciate the support rural health care needs in order to meet national goals, we invite the President, the Minister and Deputy Minister of Finance, the Minister and Deputy Minister of Health, as well as the other Finance MinMec and Members of the National Health Council to shadow a rural doctor for a full day.
In his State of the Nation Address, President Zuma reinforced the message that government is serious about improving the nation’s health. The National Minister of Health, Dr Motsoaledi, has announced various strategies to achieve this. These include the National Health Insurance, and first and foremost, the overall strengthening of the public health service through improved ‘Quality and Efficiency’, specifically at Primary Health Care level. A central role has been allocated to expenditure control and equity. Enhanced accountability among public servants is another key ingredient, as pointed out in the ANC Today edition of 29 January – 4 February 2010 by Deputy Minister of Health Dr Sefularo.
The announced plans, and focus on quality, efficiency and equity, pose an important opportunity for rural health improvements. Rural communities have fewer resources, less information, less access to health facilities, fewer health care practitioners and worsening health outcomes. To meet the national call for equity in health, we need to strive for equal access to quality, affordable health care for those in equal need of health care. With the levels of inequality in our society, this thus requires more resources for specific groups and services.
Caution is required. In the past well-intended policy decisions have had a negative impact on rural health. The closing of nursing colleges in rural hospitals, the OSD, and the separation of hospitals from clinics are some examples. How do we ensure that the newly announced plans at national level have far-reaching, sustainable benefits for rural communities, where 43,7% of our population resides? They key question is:
Will the move to expenditure control and achieving quality and equity lead to more funds for rural health care, better planning and less waste?
As we speak today, decisions continue to be made that harm quality, efficiency and equity in rural health. Improper planning, insufficient and inequitable allocations, waste and budget cuts hamper service delivery on the ground. A brief insight into some of the major problem areas:
- Many of the hospital budgets (and staff establishments) are historical: the new budget is based on the previous year’s budget – which leads all the way back to apartheid policies of depriving homelands and poor rural areas. This has not been adequately redressed.
- In the current financial crisis that the majority of provinces are experiencing, many hospitals receive a budget that does not even cover the salaries of the current staff -despite massive vacancy rates. Many budgets have shrunken in real terms compared with previous years, even when the HIV budget is included. This makes it impossible to recruit any new staff – or replace critical staff when some are leaving. This is aggravated by the move of some provinces to freeze positions all together (see insert).
- To make things worse, overspending in the past at head office and regional hospitals has lead to budget cuts for all hospitals, disproportionally affecting poorly resourced rural hospitals. In a small rural hospital a 20% cut may mean a reduction from 5 to 4 doctors, with one needing to spend time on management issues, including motivating for more doctors. With 3 doctors left to do clinical work, inevitably quality of care suffers.
- Contrary to the intention of Community Service, the above scenario also makes it difficult to place Community Service Medical Officers in some rural hospitals as they need sufficient support by senior medical officers.
- While there is acknowledgement of the poor quality of the health care service, and the poor management of the service, there is no public acknowledgement of the degree of underfunding of deprived areas – as evidenced by the variations in Rands spent per population in different districts.
We are not sure how national goals can be achieved under these circumstances. In this light, these are our recommendations to achieve equity and quality, while working efficiently with the scarce resources available:
- Develop, implement and fund staffing norms for hospitals and clinics. This is contained in the National Department of Health Human Resources plan of 2004 but has never been implemented.
- Develop oversight of the budgeting process of hospitals that holds the provincial government accountable for the underfunding of hospitals and focuses on equity while maintaining services in urban centers.
- Design more equitable formulae for budget allocations to hospitals.
- CEOs of health care institutions should be held accountable for worsened health care professionals/ patient ratios as well as the worsening of indicators like child and maternal mortalities at their facilities. This should be incorporated in their Key Performance Areas and taken into consideration for their performance assessment.
- Human resources staff should have clear guidelines:
- Advertisements for posts that have been vacated should be placed within 1-2 weeks of notice being given that a health professional will be leaving his/her post and not only once a person has left their post.
- Professional staff need to be shortlisted, interviewed, and appointed within 1 month of a post being advertised.
- All staff should be paid on time, and the correct amount.
- Where this does not happen, appropriate disciplinary actions need to be taken.
- Key Performance Areas for human resource staff should include indicators relating to recruitment of health care professionals.
- There needs to be public and political acknowledgement of the degree of underfunding of the health care service. Health service improvements are announced, yet at the same time budgets are being cut and staff shortages are on the rise. While South Africa committed to spending 15% of its total budget on health services by signing the Abuja Declaration on health spending for governments within the African Union, it is currently only spending about 11%.
To assess the relevance of these recommendations, and experience first-hand what expenditure control, equity and efficiency means for rural health services we invite the President, the Minister and Deputy Minister of Finance, the Minister and Deputy Minister of Health, as well as the other Finance MinMec and Members of the National Health Council to come and spend a day at a rural hospital:
- Without a prior warning to staff or the management,
- Without speeches, or lunches with the CEO during the day of the visit,
- To shadow a doctor for the whole day as a silent observer.
If we want to prepare the country for a NHI, with the intention of promoting equity, let us plan and budget for rural health appropriately. This can only be done on the basis of a proper understanding of what is happening on the rural ground.
As RuDASA Chairperson Dr Karl Le Roux states: “As Rural Doctors, we are at the coalface of healthcare delivery to the Nation. On a daily basis, we are confronted by poverty, illness, suffering and unnecessary death, but also by the hope and dignity of our patients. We believe that all politicians have something to learn from the people that we are privileged to serve, and hope that many will take up this invitation.”
TO BOOK YOUR VISIT:
Contact Dr. Karl le Roux, Chairperson of RuDASA, who will link you to a rural doctor in a province of your choice:
Cell: 072 858 9751
For general comments or information: Marije Versteeg, Rural Health Advocacy Project
Cell: 074 -106 3800
Office: 011-356 41 00
Fax: 011-339 4311