An open letter signed by more than 16 academic heads of departments and close to 1,000 senior clinicians, nursing leaders and health workers in the Western Cape has highlighted the ‘devastating’ impact that severe budget cuts are having on the province’s health system.

The letter, dated Sunday, 4 February and released publicly on Tuesday, is addressed to Minister of Finance Enoch Godongwana, Western Cape Premier Alan Winde and the province’s MEC for Finance Mireille Wenger. It calls on these leaders to put the well-being of South African people first and reverse the budget cuts in the soon-to-be-finalised budget allocation for the 2024/2025 financial year.

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The signatories represent a wide range of public health facilities in the Western Cape, including the three tertiary hospitals: Groote Schuur Hospital, Tygerberg Hospital and Red Cross War Memorial Children’s Hospital.

Professor Lydia Cairncross, a signatory and head of surgery at Groote Schuur Hospital, said, “The significance of having so many academic heads of departments and senior clinicians signing on is that these are the clinicians in the system who are managing our health service and leading delivery of care, and the training of doctors and students.

“They are accustomed to doing their best to manage with the health system constraints they face, and will always do everything they can, within that system, before raising the alarm. The fact that this cadre of health leadership has raised up their hands and said something now means that they are truly concerned about the future of our health system.”

The full text of the open letter reads:

“We, undersigned heads of academic clinical departments, senior clinicians, nursing leadership and undersigned health workers in the Western Cape, write this letter as an urgent appeal to halt and reverse the catastrophic budget cuts that are currently being visited upon the health system in our country and in the Western Cape.

“It is our ethical duty to inform you, as our political leadership, what cutting health budgets means for patients who seek care in our hospitals and clinics, most of whom come from the most marginalised and impoverished communities in our society.

“Over the last 12 months, National and Provincial Treasury budget cuts have driven health services in the country and the province into crippling austerity. An initial budget cut at the beginning of the financial year was exacerbated mid-year by a further unplanned reduction driven by the underfunded public sector wage increase. These budget cuts have affected healthcare services in the entire country.

“In the Western Cape, they have resulted in the loss of R1.5-billion from a R30-billion budget — representing close to 5% of our overall budget. To manage this massive and unexpected deficit, all provinces were advised to take whatever drastic measures were necessary, including the freezing of clinical and non-clinical posts at all levels. A reduction in posts means that today, and tomorrow into the foreseeable future, there are fewer nurses, doctors, general assistants, cleaners, clerks, physiotherapists, radiographers, porters, occupational therapists, dentists and specialists to deliver desperately needed healthcare to the population.

“Throughout 2023 we scrambled desperately to increase efficiency and decrease spending and, as clinicians, we have tried our best to work harder to make every ‘health rand’ count while maintaining patient care. However, in the last three months, the entire health system in the Western Cape has been destabilised by indiscriminate freezing of virtually all clinical and non-clinical posts and a freeze on nursing overtime and agency budgets. Posts which have become vacant through retirement or resignation or natural movement in the system from training positions, now remain unfilled.

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“These austerity measures have an immediate and tangible impact on health services.

“For patients who need access to surgical and anaesthesia services, it has forced a reduction of theatre lists, which means postponing or cancelling essential operations for patients who have often waited months or years for these procedures. They are women, men and children from our communities who are waiting for cancer surgery, surgery to restore sight and hearing, surgery to treat chronic pain, surgery for brain tumours, surgery to remove infection and improve breathing, surgery to treat urinary retention and bowel conditions and life-saving heart surgery. For every one of these patients, delaying their procedures means prolonging their suffering and often putting their lives at risk. It also means that they remain unable to return to normal daily functioning, and therefore remain at risk of unemployment.

“For patients who need access to specialist medical care for diabetes, asthma, complex lung and heart conditions, complications of hypertension, autoimmune diseases and other specialist medical conditions, service cuts mean decreased access to beds in hospitals, longer waiting times in outpatient clinics and longer waiting times for essential investigations. For many of these conditions, timely diagnosis and treatment initiation are critical to ensure good responses to treatment and delays may result in progression to the point of irreversible organ damage. These budget cuts also negatively affect the provision of emergency care for conditions such as strokes and heart attacks.

“For patients who need access to oncology services, service cuts mean a delay in reaching multi-disciplinary oncology services, since patients have a delay in access to staging investigations (especially CT and MRI services), and a delay in their biopsy or surgery due to pressure on those services. It means that cancers are [at a] higher stage at diagnosis, and therefore there is less chance of cure. It also means that there will be difficulty in accommodating the number of patients requiring care, and difficulty in maintaining safe and effective radiotherapy and chemotherapy care, due to staff cuts.

“For patients who need access to radiology services, it will mean delays in obtaining scans and x-rays when patients are admitted to the emergency units if radiographers are not employed. Staff shortages place an additional strain on the existing staff leading to burnout and increased staff resignations. Delayed diagnoses due to understaffing will result in increased hospital costs and hospital stays.

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“For patients who need access to mental health services, service cuts will lead to reductions in the quantity and quality of care for both serious mental disorders such as schizophrenia and bipolar disorder, as well as for common mental disorders such as depression, anxiety disorders and substance use disorders. Working in an environment where services are being withdrawn and where patient morbidity and mortality is increasing, has a significant negative impact on the mental health of health professionals and their colleagues in the services.

“Regarding access to care for children, South Africa’s constitution entrenches children’s rights, including access to quality healthcare. Austerity measures will directly result in reversing the gains in neonatal, infant and under-5 mortality rates. For neonates and children who require specialist care, service cuts will impact access to hospital admission and timeous outpatient clinic access. Additionally, these cuts will have a negative impact on immunisation roll-out as well as lead to suboptimal early child development. There will be knock-on effects in which potentially reversible acute illnesses become chronic or worse, overloading emergency services, and [causing] long-term increased morbidity and mortality.  The impact on adolescent services will be even greater as this area is already underserved. The consequences in this vulnerable group will be dire. It will deprive our country of future problem-solvers, innovators, leaders and environmental stewards. In short, it leaves us a country with a bleak future.

“Primary Care, which represents the cornerstone of comprehensive primary healthcare and the foundation of universal health coverage, may also be affected through the impact on the delivery of vital community-based services and activities focused on health and wellness promotion and disease prevention. It is possible that some emergency centres may need to close, the number of ambulances on the road may decrease and the number of beds available for patients who are severely ill or have faced trauma will be fewer. The number of rehabilitation beds or beds for ‘step down’ or transitional care will be reduced. This, together with less access to palliative care services, will increase the suffering of the most vulnerable patients and their families. Decreased palliative care services also increase the use of health care services in the last year of life, preventing patients from getting palliative care at the appropriate time. This scale of impact will similarly be felt by the many patients who need to access obstetric and gynaecological and paediatric services.

“Finally, for health workers in our system who arrive at work to find their normal staff complement down by a third or half, these cuts mean working with greater intensity and for longer hours to fill the service gap for as long as they can. It means increased sleep deprivation, burnout and fatigue-induced errors. At some point, staff will find themselves simply unable to continue at this pace and will then face the harsh inevitability of decreasing services while acutely aware of how desperately these services are needed. This is an unconscionable burden to place our health workers and represents a profound moral injury to our frontline staff.

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“Despite many challenges, we have a public health care system that we can, in many ways, be proud of; with highly qualified health professionals, committed health workers, functional academic centres and training programs for specialists sought out by people throughout the continent and beyond. But these budget cuts are putting the entire system, which has taken many decades to build, under threat.

“When a country is in financial crisis and state resources are under pressure, it must make careful decisions about where to spend money. Adequate funding of health care and education is fundamental to building a healthy and prosperous nation and critical to reversing persisting social inequality. While we know that the fiscus is under pressure, we also know that South Africa spends many billions of rand on other, less essential state projects and that there are billions lost to corruption from the state. Cutting budgets for health and education affects the poorest and most vulnerable in our society and the impact on the entire fabric of society will be immediate, long-lasting and possibly irreversible.

“We believe that you, as the financial and political leadership of our country and province, can and should do better. National Finance Minister Enoch Godongwana, Provincial Premier Alan Winde and Provincial Finance MEC Mireille Wenger, you are the custodians of the resources of our country and our province, and we believe you have the power and the opportunity to reverse these cuts in the soon-to-be-finalised budget allocation for the 2024/2025 financial year. As health professionals, we are obliged to inform you that continued austerity at this level cannot be mitigated with creative planning or improved efficiency. It will result in suffering and deaths amongst the people you have committed to serve. It will irrevocably damage a health system that has taken many decades to build.

“We urgently call on you to re-examine your budget spreadsheets, realign your fiscal priorities to Health, Education and Basic Services, and put the well-being of our people first.”

Among those who signed the letter are: 

• Professor Lydia Cairncross | Head of Surgery | University of Cape Town/Groote Schuur Hospital
• Professor Jacques du Toit | Executive Head Surgical Sciences and Head of Division: Orthopaedics | Tygerberg Hospital/Stellenbosch University FMHS
• Professor Jac Odendaal | Acting HOD Division of  Surgery | Tygerberg Hospital
• Professor Ntobeko Ntusi | Chair and Head, Department of Medicine | Groote Schuur Hospital/University of Cape Town
• Professor Graeme Meintjes | Second Chair and Deputy Head of Medicine | University of Cape Town/Groote Schuur Hospital
• Professor Neshaad Schrueder | Head: General Internal Medicine | Tygerberg Hospital/Stellenbosch University
• Professor Sulaiman Moosa | Head of Radiation Medicine | University of Cape Town/Groote Schuur Hospital
• Professor Jeannette Parkes | Head of Division Radiation Oncology | Groote Schuur Hospital/University of Cape Town
• Professor James Warwick | Executive Head of Department: Medical Imaging and Clinical Oncology | Tygerberg Hospital/Stellenbosch University
• Professor Soraya Seedat | Executive Head and Chief Specialist, Department of Psychiatry | Tygerberg Hospital/Stellenbosch University
• Professor Dan Stein | Head of Dept of Psychiatry | Groote Schuur Hospital/UCT-affiliated West Metro Mental Health Services
• Professor Justiaan Swanevelder | Head of Anaesthesia | University of Cape Town/Groote Schuur Hospital
• Professor Sean Chetty | Executive Head of Department – Anaesthesiology & Critical Care | Tygerberg Hospital/Stellenbosch University
• Professor Steve Reid | Interim Head of Department Family, Community and Emergency Care | University of Cape Town
• A/Prof Clint Hendrikse | Head of Division: Emergency Medicine | University of Cape Town
• Professor Mushi Matjila | Head of Obstetrics and Gynaecology | University of Cape Town/Groote Schuur Hospital Academic Complex and Chair of National Health Research Committee
• Professor Hennie Botha | Executive HOD, Obstetrics and Gynaecology | Stellenbosch University/Tygerberg Hospital
• Professor Gert van Zyl | Head, Department of Pathology | Stellenbosch University/National Health Laboratory Service
• Professor Komala Pillay | Head of Pathology | University of Cape Town/National Health Laboratory Services
• Professor Regan Solomons | Executive Head, Department of Paediatrics and Child Health | University of Stellenbosch
• Professor Rudzani Muloiwa | Professor and Head, Department of Paediatrics & Child Health | University of Cape Town

See the full list of signatories to the letter here.

Behind the healthcare funding crisis

In early 2023, a number of conditional grants linked to health, including the National Tertiary Services Grant for tertiary hospitals, saw a decrease in funding in the Western Cape.

Later that year, a higher-than-expected wage settlement was reached between the government and public service unions. The National Treasury had not budgeted for this expense. It informed government departments that no new spending would be allocated for the 7.5% wage increase for public servants and they would have to fund it from their existing budgets for 2023/24 and the following two years.

Read more in Daily Maverick: SA’s delivery of crucial services under threat after Treasury desperately calls for public ‘fiscal consolidation’

In the Medium-Term Budget Policy Statement released in November 2023, Treasury announced “fiscal consolidation” measures as part of a strategy to avoid a “fiscal crisis”. Spending in the current financial year was revised down by R21-billion, with further reductions expected in 2024 and 2025.

The fallout of this funding crisis is being felt in key sectors, such as health and education, across the country.

Read more in Daily Maverick: Joe Phaahla: Budget constraints to blame for unemployed medical graduates

In a media briefing on Monday, 5 February, Minister of Health Dr Joe Phaahla blamed budget constraints for the high number of medical doctors and other health professionals who were unemployed.

Phaahla stated that the National Department of Health was working with provincial health departments and treasuries to address the issue of unemployment, but added that funding remained a significant challenge.

“There is a lot of pressure on the budgets… Another challenge came with the 7.5% salary adjustment agreement at the Public Service [Co-ordinating] Bargaining Council [in 2023],” he said. DM

This article will be updated with responses from Godongwana,  Winde and Wenger  if and when received.