Jodi Wishnia | February 2018
I am pursuing a PhD focusing on governance and public financial management in Provincial Departments of Health. How our managers view their job, the ease with which they can make decisions and the coherence of policy are critical to improving not only governance, but also service delivery. These issues are critical if we wish to resuscitate our departments of health.
Gauteng Provincial Department of Health (GPDoH) receives the largest budget share of all the provinces, given its high density and some historical trends that are now perpetuated year-on-year. On top of this, GPDoH received the largest adjustment budget in 2017/18, which happens around September/October annually, of R1.23b, to assist with accruals on goods and services and to pay salaries. GPDoH is also the smallest province geographically, with the most tertiary and quaternary facilities.
There is growing consensus that public health budgets are insufficient to meet the demand for services, however work to ensure efficiency and effectiveness of spend has slowed. Gauteng is a good example of this. Despite the potential for powerful market negotiations based on scale, through transversal provincial tenders, the Province has not managed to secure many of these. The expenditure on Primary Health Care (PHC) by district is shown in Figure 1 below. West Rand, City of Tshwane (CoT) and City of Johannesburg (CoJ) show an increase in expenditure from 2015/16, with West Rand ~14% more, and CoT and CoJ at a 4% increase each, which is below inflation. Sedibeng shows a 6% decrease. The declining spend on PHC is not only against stated policy and the National Health Insurance (NHI) White Paper’s emphasis on primary care, but is also bound to have a knock-on effect on population health and overall health spend, due to care being accessed later down the line or at a higher level than is necessary.
Although the Life Esidimeni tragedy is on all our minds, it is a symptom and not the real problem. Continuing financial constraints, in a population with rising health needs due to the quadruple burden of disease, will cause these crises repeatedly. At what point must we be honest and say that they are not crises but the status quo?