Alex van den Heever
Alex van den Heever

The national health insurance (NHI) fund appears to have been placed temporarily on the backburner while the government tackles more immediate problems.

This year’s proposed health budget is 6.6% higher, at R222.6bn. But take inflation into account, throw in 1.6% population growth and economists say that, in real terms, there’s actually less money to go around.

The National Treasury estimates that R140bn, or 60%, of the total will go on salaries.

In among all these numbers, there’s very little mention of the government’s proposed NHI. Instead, money that was planned for it will be used in the short term to fill critical vacancies on "the front line of the health system".

The Treasury says the money has been "re-prioritised". A chunk will go towards unfreezing posts, and hiring staff, including community service doctors and medical interns.

The decision appears out of tune with recent calls by health minister Aaron Motsoaledi to intensify the rollout of NHI. And in his state of the nation address, President Cyril Ramaphosa spoke of "introducing the NHI together" and "working towards a massive change in the health-care experience of South Africans".

However, finance minister Tito Mboweni, in his budget address, has allocated money to staff, stating unequivocally: "We need simple, effective interventions."

Between now and 2022, R2.8bn has been allocated to fill gaps at hospitals and clinics. The Treasury says: "[This] will enable provincial departments of health to fill critical posts in health facilities."

Some of the NHI money was destined to fund better mental health care, school health teams and the hiring of private general practitioners by the state. None of these are any less important but a Treasury official reveals that by the third quarter of the 2018/2019 financial year, only 5.7% of R712m budgeted for these services had been spent.

Some of the R2.8bn allocation has been raised by limiting increases in medical aid tax credits. Of the total, R605.7m will be spent in the 2019/2020 financial year, then just over R1bn in each of the two following years, officials explain.

Wits University academic Alex van den Heever says of the spending shift: "They are trying to address short-term crises created in the health system."

Analyst Daniel McLaren, of the Section 27 public-interest law centre, says it smacks of crisis management. He observes: "They could justify that they are using the NHI grant if they were strategically reconfiguring the public health service. But it appears they are just using it for crisis management and filling critical posts."

Staff shortages in response to above-inflation wage increases have been mounting for some time. In 2017, the Health System Review reported: "Most provinces have imposed ... restrictions on filling vacant posts."

It stated that staff costs between 2006 and 2015 exceeded inflation by 38%. As a result, says Van den Heever, provinces had accrued R14bn in debt to suppliers because staff cost increases were not funded.

He says: "The extra R2.8bn in human resources funding is a step in the right direction but it should be ringfenced and implemented with a plan rather than in a haphazard manner."

There is still some money for the NHI this year — R2.5bn, or about 1% of the budget.

Of health’s allocated R222.6bn, district health services will receive the lion’s share, with R98.2bn. Central hospitals will get R43.1bn, provincial hospitals R36.7bn, and others R35.6bn.

Health-care analyst Jill Larkan, of the GTC consultancy, says the fact that Mboweni has retained the medical aid tax credit is "reassuring", but she is concerned about the lack of clarity on the NHI in the budget speech.

She says: "It makes one wonder what is going on and if it means there is less government support for the NHI."

Unusually, the Treasury has allocated R318.8m in its medium-term expenditure framework to combat malaria. This is in addition to what provinces are spending, following a spike in infections and deaths in 2017.

Professor Lucille Blumberg, chair of the SA malaria elimination committee, says antimalarial programmes, including insecticides, have grown more expensive and budget increases have not kept pace.

"This is very good news," she says. "This spending is critical."