It is often said that when you educate a girl; you educate a nation. The same rings true for investing in women's health, which ultimately benefits our entire country. The World Economic Forum has described women's health as the cornerstone of economies and societies worldwide. While some progress has been made in ensuring access to quality healthcare for women in this country, gender inequality continues to negatively impact health outcomes. A public healthcare system that is both adequately funded and capable of ensuring that resources reach the intended beneficiaries is critical to advancing gender equity in the country.
This Women's Month is an opportune moment to reflect on how much we spend on healthcare and the quality of that spending as these can be powerful measures in creating a public healthcare system that narrows the gender gap.
Short-changing women with budget cuts
Since 1994, transformative health frameworks, strategies, and policies have contributed to progress in some indicators of women's quality of life. Adequate funding is imperative for these interventions to protect effectively the health of women and our right to access healthcare.
The aggressive fiscal consolidation path that South Africa's government has undertaken over the past decade in response to increasing debt service costs as well as weakening economic growth has only compounded the under-resourcing of the public health system. In 2018, United Nations Committee on Economic, Social and Cultural Rights (CESCR) experts expressed concern that the austerity in our budget could further exacerbate inequality and restrain the redistributive capacity of our fiscal policy.
Though budget cuts impact the health system's ability to provide quality services to the 85% of people in South Africa estimated to rely on public healthcare, women are doubly burdened by these cuts owing to our unequal reliance on public health services.
In the current fiscal year (2023/24), the National Treasury cut the health budget by 4.9% in real terms. Even during the pandemic, the 2021/22 health budget was slashed by 2.2% in real terms. It is unlikely that this trend will improve. National Treasury has warned South Africans that there would be cuts across the board in the 2024/25 budget, including healthcare funding.
Though budget cuts impact the health system's ability to provide quality services to the 85% of people in South Africa estimated to rely on public healthcare, women are doubly burdened by these cuts owing to our unequal reliance on public health services. Unequal gender norms have resulted in a disproportionate risk and prevalence of HIV/AIDS that is gendered. Furthermore, we have higher and differentiated health needs, including those for reproductive and maternal health. Moreover, gender-based violence survivors require immediate medical attention, life-saving care, and specialised mental health and psychosocial support.
Women are further impacted by a poor healthcare system through employment. Over 90% of nurses in South Africa's public health system are women and, as the first line of the healthcare response, bear the hardship of trying to make an under-funded healthcare system work on the ground. All of this occurs in a global social order where gendered norms have resulted in women carrying the unpaid care work burden. As such, we require more support through public services and reducing the size of investment in these services entrenches gender inequity.
Poor health budget spending
Not only do budget cuts constrain the ability of the health system to provide quality healthcare, but they also reduce capacity to bolster the quality of spending. South Africa has a chronic underspending problem, where billions of rands that were allocated to funding the implementation of social programmes are returned to the national departments and National Treasury annually. The healthcare budget is no exception. For the 2022/23 fiscal year, the Gauteng health department, for example, underspent R1.6 billion of its district health services budget, which includes HIV/AIDS treatment services. In the same year, underspending of the health budget by the Eastern Cape resulted in the department losing out on conditional grant funding.
Although underspending disadvantages all South Africans as our access to good quality public services is hindered, the gendered reliance on public healthcare means that each million that is not used to implement healthcare interventions also worsens gender inequality in the country. South Africa needs more robust public health capacity to use this funding and to effect meaningful consequence management for under-utilised budgets. Government departments need to work together to achieve this. While the mandate for gender-responsive budgeting rests with the National Treasury, attracting and retaining excellent public servants in local and provincial health governments is crucial in bolstering the capacity to spend budgets efficiently, thereby ensuring that intended beneficiaries receive better quality healthcare. Training and capacity-building initiatives should be prioritised to equip the departments to utilise this funding.
Although underspending disadvantages all South Africans as our access to good quality public services is hindered, the gendered reliance on public healthcare means that each million that is not used to implement healthcare interventions also worsens gender inequality in the country.
Corruption entrenches gender inequality
Added to waste and underspending of health budgets, corruption is the other ever-present risk to good quality health services in South Africa. According to The Health Policy and Planning Journal, the majority of print media reports on corruption are those in the healthcare sector. Corruption in this sector is prevalent owing to a multitude of factors, including its complex structure, the large amounts of procurement funding, and inadequate health information data that is not yet uniformly accessible across health facilities.
Healthcare funding eroded by corruption can further entrench gender inequities. An information sheet of the Anti-Corruption Resource Centre states that women "become the 'shock-absorbers' of health systems plagued by corruption, which takes a toll not only on their short and long-term health but also reduces their capacity to participate in education and employment". When a health system is not trusted to provide adequate healthcare, women are expected to provide more unpaid care work to family members. The caretaker role that women play also means that we are at the frontlines, absorbing the detriment caused by healthcare corruption. Moreover, Transparency International cites the persistence of gender inequality and exclusion partly due to embedded corruption.
Strengthening fiscal policy accountability has been found to be a powerful measure to combat corruption in the healthcare sector, as has open access and transparency of budget information. Vulekamali is an example of an intervention that can strengthen budget transparency and accessibility and is a collaboration between the South African National Treasury and Imali Yethu. Other effective interventions to overcome the corruption that worsens gender equity include overcoming overall impunity through investing in effective law enforcement, protecting and strengthening the roles of auditors, and capacitating financial management systems in the sector.
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Gender-responsive budgeting
Meanwhile, South Africa's government has recognised the socio-economic disparities that hinder the realisation of gender equity in the country and has responded with a Cabinet-approved Gender-Responsive Planning, Budgeting, Monitoring, Evaluation and Auditing Framework. It has defined Gender-Responsive Budgeting as an intervention that ensures that gender biases are not entrenched by fiscal policy formulation and implementation. While gender-responsive budgeting dates back to 1996 in South Africa, implementation has lost momentum. With the National Treasury - mandated to lead its implementation - announcing the workshopping of the Gender-Responsive Budgeting Framework (GRB) in the current fiscal year (2023/24), this could mark a crucial step in ensuring that the healthcare budget advances gender equity.
A powerful intervention to shaping a truly gender-responsive budget is women's participation in shaping this process. Without a deliberate attempt to involve the intended beneficiaries in creating a budget process that reflects our lived experiences, gender biases and inequalities in public healthcare delivery will likely persist. As such, the workshopping of the GRB Framework must be a public process that will strengthen fiscal policy transparency and accountability by bringing health service delivery closer to the beneficiaries.
Although the country has a way to go, may this Women's Month not be a missed opportunity to reflect on budgeting and policy-making processes that centre us, the cornerstone of our society.
* Lencoasa is a budget researcher at SECTION27 and serves on the Budget Justice Coalition's steering committee.
NOTE: This article is written by an employee of SECTION27. Spotlight is published by SECTION27 and the TAC, but is editorially independent - an independence that the editors guard jealously.
