The Limpopo health department only recently emerged from four years under the administration by the national government. Could history be repeating?
Healthcare workers' protests have stretched into their second week in Limpopo as workers and politicians warn the health department's money problems could be keeping paychecks out of doctors' hands and health workers out of clinics.
As of Wednesday, nurses were continuing a two-week picket outside the Limpopo health department. Demonstrations follow a two-day stay away last week by doctors in the province over unpaid overtime and late payments to about 40 community service and internship doctors.
Newly graduated medical profes- sionals must complete at least one year of community service before they can register with professional bodies and practise. Doctors must also complete an additional, two-year internship.
Limpopo department of health spokesperson Thabiso Teffo blames the delays on problems with entering doctors' details on to its payroll system. But he admits that the provincial treasury has also not yet approved some community service and intern- ship positions.
Although provincial departments typically do not need treasury approval to create posts, a 2016 provincial Cabinet decision now requires treasury sign-o for all appointments across departments. It's a tactic that some provinces, such as North West, have admitted adopting to try to control spiralling costs amid tight budgets.
Doctors and opposition parties say the move - and recent protests - are not the only signs of a struggling budget. Doctors complain that the state can no longer pay for overtime while nursing unions say the province is reneging on commitments to employ medical bursary holders.
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Seshoka Muila is the provincial secretary for the South African Medical Association. He warns that it's only a matter of time before budget shortfalls force doctors' hands.
Doctors in at least four Limpopo hospitals reported regularly work- ing beyond their contractual over- time without pay, according to research conducted by members of the Aids lobby group the Treatment Action Campaign (TAC) and published on the group's website in October.
About 80% of 21 Limpopo clinics surveyed by TAC were short-staffed. One hospital reported having to restrict weekend surgeries because of staff shortages while another had no chief executive or senior clinical manager.
Meanwhile, the Limpopo health department is only offering newly qualified state nurses who received bursaries to study a one-year contract, says Democratic Nursing Organisation of South Africa provincial organiser Jacob Molepo. Originally, the department had promised four-year appointments.
Last week, the Democratic Alliance wrote to the Limpopo treasury department to request that the health department be placed under administration, meaning that the provincial treasury would take control of the health department's finances.
The opposition party claims that the department has overspent its budget by R1.7-billion since the start of the financial year. Teffo argues this is false anticipates the department will report R800-million in accruals by the year's end.
Although the department's latest annual report is not publicly available, its accruals have increased by more than five-fold since the end of 2015/2016, if Teffo's figure is correct.
The Limpopo health department, as well as four other provincial offices, only recently ended four years of administration by the national government in 2015.
Teffo says the department is cutting costs by slashing management positions as part of what he calls a "turnaround strategy" and to curb rising employment costs.
"We are confident that with the measure in place, this department is on the correct path and will not be put under administration," he explains.
About 70% of the health budget in Limpopo is spent on employee salaries and benefits, Teffo says. Nationally, other health departments aren't far behind. As of 2014/2015, salaries ate up nearly 65% of provincial health budgets, reveals a July 2016 paper by the non-profit organisation the Rural Health Advocacy Project (RHAP).
Above-inflation wage increases have contributed to what has been a 10 percentage point increase in provincial health costs of employment in just a decade.
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But RHAP has been quick to point out that rising salaries aren't only to blame and that good planning could help mitigate some of the risks attached to creeping austerity budgets in provinces such as Limpopo, the 2016 paper argues.
Provinces should plan to spare key posts like doctors and nurses that are crucial to healthcare delivery as they look to save money. They should also use new staffing guidelines developed in consultation with the World Health Organisation to identify which posts should be filled and which can be left vacant. Limpopo has already started using this system called WISN, or Workload Indicators of Staffing Need.
Meanwhile, RHAP's programme manager for health systems and policy Russell Rensburg warns that government's inability to continue delivering above-inflation increases could be a ticking time bomb around the bargaining table.
"There is a public sector wage agreement that is coming to an end. We know that the public sector is looking for something between 9 to 12% increases," Rensburg explains.
"We may not afford above inflation increases at all. At the national level, we are already struggling because we didn't meet our tax targets last year and we had an R50-billion short-fall in our national budget. You may well have labour unrest, which could potentially impact negatively on healthcare delivery."
- Additional reporting by Laura López González
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