South Africa’s health care system remains under significant strain. The quadruple burden of disease (consisting of HIV and TB, non-communicable diseases, violence and injuries and maternal, newborn and child health) continues amid human resources constraints, limited budgets, infrastructural challenges, essential medicine stock outs, and poor facility, district and provincial management.
In this context, the budget allocated for the provision of health care services, access to which is a constitutional right, is important. We highlight here a number of key focus areas emerging from the budget.
Non-communicable diseases, the sugary drinks tax and mental health
As a significant and growing contributor to mortality, non-communicable diseases (NCDs) are often discussed and various steps are being taken to combat them. The 2017 budget for NCDs and announcements made in the budget speech are, however, of serious concern.
One proposal to cut down NCDs is the sugary drinks tax – a tax that was announced in 2016 and was set to be implemented in 2017. We are disappointed to note that implementation of the tax on sugary drinks has been temporarily put on hold, and it appears that tax rate will be 11%, which is significantly lower than the proposed 20% tax. This will impact directly on government’s the ability on achieve the intended decrease in obesity and NCDs.
SECTION27 supports the sugary drinks tax as an intervention that has been shown to be effective in combatting obesity and NCDs. We note, however, that the tax alone cannot achieve the goals set. In addition there is a desperate need for nutrition education and health promotion, for more affordable healthy food and for the provision of healthy recreational options. In addition to stalling the implementation of the sugary drinks tax, the 2017 budget sees a decrease in health promotion and nutrition as a percentage of the Primary Health Care budget from 10.1% to 8.9%. This will further hamper efforts to reduce deaths attributable to NCDs.
Finally on NCDs, included within the NCD budget is mental health. The NCD line item is intended to “[establish] policy, legislation and guidelines, [and assist] provinces in implementing and monitoring services for chronic, non-communicable diseases, disability, eye care, oral health, mental health, substance abuse and injury.” Whereas in 2016, a stated goal of the Primary Health Care Programme was to “improve access to and the quality of mental health services in South Africa through the implementation of the national mental health policy framework and strategic plan over the medium term,”in 2017 there is no specific objective that relates to mental health.
The recent Life Esidimeni tragedy highlights the vulnerability of mental health care users and the attempt by the Gauteng Department of Health to use limited funds as an excuse for discarding mental health care users, which led to the deaths of over 100 mental health care users and the neglect of over 1000 such users.
While the mental health budget is not, itself, detailed in the health vote, the 2017 budget sees a decrease in the percentage of the Primary Health Care budget spent on NCDs from 10.8% to 8.2%. The NCD budget decreased by 5.4% from 2013/14-2016/17 and it’s now increasing by 5.4% for 2017/18-2019/20. While we must wait for the Department of Health budget to establish what funding is being committed to mental health, we are concerned about a further shift of focus away from mental health and the tragic consequences that this could have for a particularly vulnerable population.
National Health Insurance
Finally, there were high expectations that the 2017 budget would provide some much-needed clarity on National Health Insurance (NHI). The increase in funding to the various NHI grants is a promising indicator of the government’s commitment to the implementation of NHI, although the details of what NHI will be remain unclear. While there is discussion of a Bill and the setting up of the NHI Fund in the Budget Speech, there has been no public consultation on the NHI since the publication of the NHI White Paper in December 2015 and the exact role of the Fund and possible contents of the Bill remain vague in the eyes of the public.
We have noted for many years the need for improvement to the public health system in preparation for NHI. Our research in the Gert Sibande pilot district indicates that there is still a significant amount of work to be done before the NHI can be rolled out successfully.
HIV and TB
The year 2017 sees the development of the new National Strategic Plan on HIV, TB and STIs 2017-2022. The NSP is South Africa’s strategy for targeting these key elements of our disease burden and incorporates the recently-adopted ‘test and treat’ policy – which requires the commencement of anti-retroviral treatment immediately following a positive test for HIV. Test and treat and the new NSP targets require additional resources – both human and financial and we welcome the increase in funding by R885.3 million for treating 5.5 million people living with HIV and the additional R200 million this year and R460 million next year for implementing the TB investment case, including TB screening. We look forward to more detail on how this funding will be broken down and spent.
Human resources for health
Given the significant human resources demands of the NSP and of the health system as a whole, we are concerned by the decreases of around R10 million per year in the cost of employment budget. This line item has long been controversial. Extra-inflationary salary increases, negotiated centrally, have resulted in the ballooning of the public sector wage bill. Not knowing how to get out of these deals, provincial departments of health seek to limit employment through, among others, freezing posts, rewriting organograms in a manner that does not consider health service need, and refusing to employ community health care workers. These approaches are good for trimming the budget but are bad for the health care system and bad for health. They result in under-staffed facilities, burn-out, long waiting times, and medico-legal claims. The reduction in the cost of employment budget risks exacerbating this already dire situation.