South Africa’s health infrastructure headed down the same road as Eskom’s power plants

20 Feb 2023

The reported underinvestment in health facility maintenance and infrastructure development may deliver the fatal blow that will see health services in South Africa suffering the same fate as the nation's power utility.

When Eskom declared Stage 6 rolling blackouts indefinitely on 11 January 2023, South Africa went into a state of shock. This followed a similar announcement made just a month earlier in December 2022, only this time accompanied by loud calls for the president to cancel his planned trip to Davos.

South Africans have now realised that high levels of rolling blackouts will be an unavoidable part of life for the foreseeable future. They also know that critical services such as health, already under strain, will be negatively impacted due to a drop in the availability of electricity.

Adding insult to injury, the reported under-investment in health facility maintenance and infrastructure development may deliver the fatal blow that will see health services in South Africa suffering the same fate as Eskom.

The recently gazetted draft National Infrastructure Plan 2050 (NIP 2050) paints a dreadful picture of the current status of public infrastructure in the country.

Issued by the National Department of Public Works and Infrastructure (NDPWI), the plan describes the status quo regarding public infrastructure in various functional areas.

About health infrastructure the plan characterises “public healthcare facilities (hospitals and clinics) as at a risk of failure”. This is due to “up to one-third of the existing PHC facilities requiring significant maintenance” and up to 20% requiring complete replacement.

Additionally, the plan indicates that a significant investment will be required to bring the digital infrastructure and medical equipment up to the required levels for facilities to operate efficiently.

The picture painted above gets worse when one considers the findings of the latest available Annual Inspection Report issued by the Office of Health Standards Compliance (OHSC).

This report is an outcome of the assessments conducted by the OHSC to determine whether health establishments comply with prescribed norms and standards. While the report covers four functional areas, of particular interest are the findings around the maintenance of health infrastructure.

Among the litany of adverse findings, the standout finding is the non-existence of maintenance plans for most facilities across the eight provinces audited. Flowing from this, it is therefore not surprising to note other adverse findings related to the maintenance of buildings, equipment and vehicles.

Most facilities were found to be non-compliant with the applicable safety regulations. This can be correlated with the finding that a significant number of facilities do not have engineering services units in place. Another pain point identified involves the widespread poor waste management practices across facilities.

The saying goes, “the way you do the small things is the way you do everything”. So, while poor waste management has an obvious negative impact on the health of patients, workers and the surrounding communities, it may also be symptomatic of the state of the entire healthcare system.

The OHSC’s overriding finding that 85% of the facilities are not in compliance with the national norms and standards should not come as a surprise.

The NIP 2050 estimates the annual cost for the maintenance of health facilities as R2.5-billion. This number was calculated at 2015 prices and if expressed in current terms and adjusted for inflation it would amount to about R3.75-billion.

This amount assumes that maintenance is being conducted as scheduled, which is not the case when one considers the findings regarding maintenance as contained in the Annual Inspection Report. The annual amount for maintenance estimated at R3.75-billion will be significantly higher due to the maintenance backlogs.

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In fact, the backlogs are so severe that the NDPWI estimates that “up to 20% of existing primary health care facilities will have to be replaced at a cost of nearly R8-billion”.

Maintenance is a stitch in time saving you nine. It’s about preventing things from slipping into a state of such disrepair that costly replacement is the only option.

As we have seen with maintenance backlogs at Eskom it can reach such levels that funds get diverted from building new capacity towards maintaining existing capacity. The inability to create additional capacity puts strain on existing capacity as the demand for electricity increases. This reaches a stage where the strain becomes so big that the system collapses, requiring even more maintenance.

To question whether the same fate awaits the health system would not be entirely unjustified. The backlogs reported in the Annual Inspection Report as well as in the NIP 2050 are significant and ignoring them would certainly be disastrous.

However, the NIP 2050 contains concrete activities which if executed, will hugely prevent health from going the Eskom route. For example, one such activity entails the upgrading of “access, flooring, electricity, security, ICT systems, pharmacy cooling, ventilation, waste management, portable and fire water, sewerage, roofs and stormwater management” to enable public health facilities to attain “Ideal Clinic and Ideal Hospital” status.

This status is important as it is a prerequisite for registering as an accredited service provider under the National Health Insurance.

While the activities and intended outcomes are well presented in the plan, one cannot help but be sceptical about its successful execution. After all, we have seen plans like this being presented before with little evidence of the goals being achieved.

The National Infrastructure Maintenance Strategy, produced by the CSIR for the NDPWI in 2007, comes to mind. There may be others now quietly gathering dust in a filing cabinet somewhere.

The notion that government is good at drafting plans but less so when it comes to implementation is widely accepted, including by government itself. While the reasons for implementation failure are complex and manifold, many analysts will point to underfunding as the main culprit.

But although funding is certainly a critical success factor it cannot be regarded as the chief instigator of failure in all cases. As we have seen with Eskom and other state-owned enterprises, endless bailouts did not necessarily produce the desired outcomes. It may be more useful to look at the underlying structural deficiencies which are inherent in our government system and which may inhibit the successful implementation of critical plans.

One such structural deficiency is the disconnect that sometimes occurs between the planners and the implementers. In this instance, the plan is drafted by the NDPWI while the bulk of its implementation is set to take place at provincial level.

The Division of Revenue Act allows provinces to use their equitable share as they see fit. There is, therefore, no guarantee that provinces will provide the funding required for the implementation of a plan drafted by the NDPWI. And even where the NIP 2050 is prescriptive about the percentages of their budgets that provinces should set aside for maintenance, there is no legal way for either the National Treasury or the NDPWI to enforce it.

This tug-of-war between national and provincial departments is observable in many areas where the two spheres of government share functions concurrently. This is easily solved by giving a sole mandate for a function to either the national or the provincial sphere of government. This is easier said than done as it has obvious political implications.

This may be a hard decision for the politicians to make but the consequences of not doing so may be too much for the country to bear. DM

Dr Claire Botha is an independent health economist.

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