Complaints about our health service abound. Even in the Western Cape, which spends more on health per person than most provinces, problems have been arising thick and fast.
Clinic queues are so long that patients wait hours for a five-minute consultation with a doctor - inadequate time for a proper diagnosis.
Stocks of life-saving drugs have at times run dry at clinics and hospitals, and patients have been sent home without medicines for life-threatening illnesses.
Tertiary hospitals have been running out of money and cutting services, including bypass surgery and immediate operations for all cancer cases.
We are told that healthcare is our right, yet the country's public health system seems to be failing us. Why?
The Western Cape health department argues that the national health budget is inadequate and the health system is inefficient. Academics and health researchers agree.
Institute for Democracy in South Africa health researcher Alexandra Vennekens-Poane, who has completed extensive analyses of the health budget, finds that we spend more on health than other countries do, yet we are a far sicker people.
The average South African spends 18 years in poor health, the World Bank reported of South Africans in the years 1990 to 1998. These figures are likely to be worse now, given the rising number of people with AIDS.
South African men on average lived until they were 47, and women until they were 57. In low-income countries, supposedly poorer than South Africa, health was better. The average man spent 13 years in poor health and died aged 55.
Yet South Africa spends more money on health than poorer countries. We spent 3.3% of our GDP on health in the years 1990 to 1998, the World Bank found. In low-income countries, the figure was 1.2% on average, and in upper middle-income countries the figure was 3.4%.
Vennekens-Poane calculated that on average R843 was spent last year on each South African who does not have medical aid. Three years ago the figure was R820, and in three years' time it will be R900 after adjustment for inflation.
This seems to indicate that South Africans should be getting a fair health service. This is not the case.
Provincial disparities remain enormous. The Western Cape spent R1 264 per person this year and Gauteng R1 387, while Limpopo spent R629 per person, Mpumalanga R717 and the North West R697.
The disparities are decreasing, but differences will remain for the next three years. And the spending per capita does not tell the true picture for several reasons: they are based on 1995 medical aid membership figures; since then unemployment has risen and medical aid tariffs have soared. Far more people are likely to be using the government health service than is calculated for; there have been small yearly real increases in health spending per person, but HIV/AIDS is taking a huge toll; some hospitals are under-utilised. In the Eastern Cape, Mpumalanga and Limpopo, the bed occupancy rate in many hospitals is around 50% to 60%, the most recent government fiscal review says; the national health department's aim is that each person dependent on public health should visit a primary care facility
three times yearly. We are far from achieving this aim. Last year, the average was 1.8 visits per person. This indicates that people are either going to hospitals, which provide a more costly service, or not getting treatment - in which case they are likely to land up in hospital later, with a more serious illness; and, on the one hand, the health budget is simply too small to meet people's expectations, and even to meet government's own
expectations. On the other, the health system is not streamlined.
I find it difficult to point to one particular thing, but there do seem to be inefficiencies, said Vennekens-Poane. Maybe it's a combination between these inefficiencies, the number of patients with AIDS-related illnesses and free primary healthcare all having to be catered for, without significant increases in the health budget.
Vennekens-Poane found that health expenditure per person is rising very slightly over the period 1999 to 2005 - an average of 1.6%, when inflation is taken into account.
But the national health budget is not increasing in proportion with the total budget. Health spending is rising more slowly than other sectors, including housing and welfare. In the past three years, average growth in health has been 11% without adjusting for inflation. That of total government spending has been almost 4% higher, at 14.7%.
The average annual growth in health spending over the next three years is expected to be 9.3% and the average annual growth of total spending will remain higher, at 10.4%.
Vennekens-Poane calculates that consolidated national and provincial public health expenditure declined from 3.8% of the GDP in 1997 to 2.9% two years ago, and can be expected to stabilise at around 3.2% between 2003 and 2005.
In a government-commissioned study, the National Health Accounts (NHA) project, academics including Di McIntyre of the UCT Health Economics Unit found that government healthcare funding boomed between 1992/3 and 1997/8, and then began to tail off.
It was worrying, the academics wrote that problems experienced by large sections of the South African population in accessing healthcare services and enjoying quality care persist.
It's very clear. The trend was established, and we are seeing nothing to suggest that it might change, McIntyre confirmed last week.
The academics recommended in the study, which was published in the South African Health Review of 2002, that the government should reconsider the amount spent on health and the mechanisms by which it distributes funds to poor areas.
Unless this is undertaken seriously, the earlier gains in healthcare provision made by the new government will be squandered, and patterns of service delivery on the ground will contradict stated government policy.
Their predictions still seem to be coming true. Gerrit Muller, chief financial officer of the national health department, confirmed that the burden on health services was increasing but, after a leap in the late 1990s, the budget's growth had diminished.
The health department was constantly pushing for a bigger budget and health spending was set to increase in coming years, although not dramatically so, Muller said.
Provinces determine the range and structure of their health services, so national health has no control over efficiency in each province, he said.
When Western Cape health MEC Piet Meyer delivered his budget speech earlier this year, the provincial health department made another argument for a bigger health budget.
Provincial health chief Craig Househam said recently that the standards in the Western Cape were the minimum that one would aspire to.
The Western Cape health department said it is trying to make its service more efficient by introducing Healthcare 2010, a plan to treat patients at a level of care that provides the best treatment at the least cost.
The plan has been heavily criticised by tertiary hospital doctors. Healthcare 2010 may result in a diminished total package of services rather than a more streamlined system, as many academics predict.
Whatever the merits of the plan, there is broad agreement on two scores. The national health budget should be increased and inefficiencies in the system must be ironed out. If this doesn't happen, health in South Africa is likely to limp on from one crisis to the next. -
(Source: Jo-Anne Smetherham: The Cape Times, 27 August 2003)