South Africa’s problem of mass unemployment is often attributed to structural causes — a mismatch between the skills that are needed in the labour market and the type of skills workers have. This understanding falls apart when looking at the public sector, where there is no shortage of urgent work to be done, nor a deficit of qualified workers desperate to do it.
There are often claims that the public sector is bloated and the wage bill is unsustainable. While this may be true of ministers and their entourages, it would be hard to argue that we have too many public sector teachers, nurses or doctors. Classrooms are overcrowded. Hospital waiting times stretch for hours, sometimes days. In 2020, the national department of health admitted we needed 97,000 more health-care workers by 2025.
That year has passed. We do not have 97,000 more workers. We have 15,000 fewer. The Western Cape, Eastern Cape and Free State respectively employ 1,061, 789 and 6,217 fewer health-care professionals than they did five years ago. Many newly qualified young doctors are unable to find work or are doing unpaid, voluntary work in public institutions to remain eligible for future employment.
The picture is worse when looking at the entire public service and adjusting headcount trends to match population growth. If the number of jobs in the past 10 years had grown in tandem with the estimated population growth of 1.33%, we should have 190,000 more people in the public service than we do.
During “budget 3.0” in May last year, the finance minister announced an additional R20.8bn spread over three years to cover frontline posts. It sounded substantial. But spread thin, the extra R6.9bn a year must cover 800 community service doctors, plus goods and services, plus old debt. It does not come close to boosting the number of posts to meet population needs.
Hiring is also challenging due to increased recruitment times by the department of public service & administration (DPSA), making underspending likely even when there is post availability. Therefore, there is little guarantee that additional funding will amount to additional workers.
If those with money and power were still invested in the state of our public health, it would not have been allowed to deteriorate to the state it is in today
Austerity has cultivated a crisis in public health care. The response from the government is that South Africa is too indebted and individuals are too overtaxed, and this means more patients sleeping, waiting and hoping not to die on cold hospital floors.
While health-care workers and patients face dystopian conditions, there are tax breaks that benefit the affluent and middle class. One of these is the medical aid tax credit. Those who have the resources to afford private medical aid get R364 deducted from their tax every month.
Austerity is being applied selectively in the world’s most unequal country. The tax break results in the state giving the richest 16% of South Africans money on the basis of medical aid membership. This costs the state R30bn every year. This amount, added to the health budget every year, could employ an extra 60,000 nurses.
Incentivising people to use private health care “to lessen the burden on the state” creates a two-tiered system: those in luck can access higher-quality care. It also drains essential resources from the state. Far from taking a burden off the state, as some argue, its services are rendered using staff that the public sector needs and the state trained.
And it distances wealthier citizens, who hold significant political power, from public institutions, causing them to become detached from public health considerations. If those with money and power were still invested in the state of our public health, it would not have been allowed to deteriorate to the state it is in today. As the minister delivers the budget speech, we are calling for a progressive tax policy that does not keep the rich comfortable by compromising constitutional rights.
It is true that some medical aid members are middle-class and not wealthy. While such a change will worsen their cost-of-living problems, this alone cannot justify providing what is essentially a form of government grant on the basis of medical aid membership.
There are other options that can support the middle and working classes. If it is supposed to ease cost-of-living pressures for the middle class, it is a poorly targeted policy since almost 40% of the R30bn is allocated to cushioning those earning more than R500,000 per year. Subsidising the richest 16% of South Africans is a trade-off that does not weigh up. But as Gauteng health MEC Nomantu Nkomo-Ralehoko would have us believe, maybe patients in understaffed and understocked hospitals prefer sleeping on the floor.
• Chikte and Van Biljon work in the economic justice unit at the Alternative Information & Development Centre. For more information on this and other tax reforms, see AIDC’s publication ‘Tax in the World’s Most Unequal Country: The South African Fair Tax Monitor’.
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