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.

This Women’s Month is an opportune moment to reflect on how much we spend on healthcare and the quality of that spending, since these can be powerful measures in creating a public healthcare system that narrows the gender gap.

Asathandile Rulumeni joins a long list of women in Xhora Mouth with horrific experiences of going into labour without professional medical help. (Photo: Black Star / Spotlight)

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 effectively protect 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 underresourcing of the public health system. In 2018, United Nations Committee on Economic, Social and Cultural Rights experts expressed concern that the austerity in our budget could further exacerbate inequality and restrain the redistributive capacity of our fiscal policy.

Each million that is not used to implement healthcare interventions also worsens gender inequality in the country.

In the current fiscal year (2023/24), 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. Treasury has warned South Africans that there would be cuts across the board in the 2024/25 budget, including healthcare funding.

Women doing laundry in the Mbashe River. (Photo: Black Star / Spotlight)

Though budget cuts affect 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 affected by a poor healthcare system through employment. More than 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 underfunded healthcare system work on the ground. All of this occurs in a global social order where gendered norms have resulted in women carrying the burden of unpaid care work. 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 underused budgets. Government departments need to work together to achieve this. While the mandate for gender-responsive budgeting rests with 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 use this funding.

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 journal Health Policy and Planning, 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.

It is said 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. (Photo: Black Star / Spotlight)

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.

While gender-responsive budgeting dates to 1996 in South Africa, implementation has lost momentum. (Photo: Cory Doctorow / Spotlight)

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 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.

Gender-responsive budgeting

Meanwhile, South Africa’s government has recognised the socioeconomic 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 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 are likely to 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 policymaking processes that centre us, the cornerstone of our society. DM

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. 

First published by Spotlight – in-depth, public interest health journalism.