Provinces hamper health equity

Provinces are undermining central government’€™s attempts to ensure that that there is countrywide uniformity of health services, as required by the Constitution.

This is the finding of four health economists writing in the 1999 Health Review, released on Wednesday (9 feb).

They argue that since “fiscal federalism” was introduced in 1997, giving provinces the power to decide how to allocate their own budgets, provincial health departments have been vulnerable to arbitrary budget cuts.

“There is a fundamental conflict between provincial level decision-making and equity within a particular sector,” argue University of Cape Town (UCT) economists Di McIntyre, Stephen Thomas, Sandi Mbatsha and Luvuyo Baba.

“As the allocation of resources between sectors in each province is fundamentally a political process, the relative influence of the MEC for health in budget debates is seen as important in securing adequate funding for health services.”

Some provincial health officials complained to the economists that “unsympathetic treasuries” did not take the delivery of health services seriously.

Treasuries have the final say in how money should be divided between competing sectors in a province.

Health services may get some relief from national government’€™s recommendation to provinces that 85% of their budgets should be devoted to social services ‘€“ health, education and welfare.

However, centrally determined pensions and salaries swallow a huge amount of provincial money, and there is more political pressure to allocate funds to education than health.

The economists propose that the national department legislates “norms and standards” to ensure a uniform health service.

One way of setting standards could be the development of a basic health package, which would make an official distinction between essential and discretionary health services. Another way of doing so could be to define staff to population ratios.

“Provincial treasuries would need to allocate sufficient resources to their respective health departments to ensure that health sector norms and standards are met,” argue the economists.

But the process will not be easy. Provinces’€™ are likely to protest against the reduction of their powers, and may claim that norms and standards are “unfunded mandates”.

Responding to the concerns, deputy finance minister Sipho Mpahlwa said central government wanted to ensure that there should be norms and standards to “ensure that national priorities are replicated in the provinces”.

Government was trying to ensure this through the new forum of premiers convened by President Thabo Mbeki, as well as through meetings of cabinet ministers and their provincial counterparts, so-called “Minmec meetings”, said Mpahlwa. ‘€“ Health-e news service.

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