Amandla! interview with Lydia Cairncross, Steering Committee member of People’s Health Movement of South Africa and Head of Department of Surgery, University of Cape Town.

Amandla!: Tell us about the environment in which you work.

Lydia Cairncross: I’m a surgeon in the public health system, and I work in a tertiary hospital in the Western Cape. So, my personal experience of the health system is not necessarily a reflection of what’s happening in the entire health system. But it is a reflection of the impact of austerity. We have been feeling it, in particular, the last two years, and this year more than for a long time.

Being a surgeon, I see patients in clinic, I do operations. And our biggest resource constraint is human – the nurses, anaesthetists, technicians and surgeons required to safely perform an operation.

And so we always have long theatre waiting lists, people waiting for hip replacements, hernia repairs, even emergency operations – appendicitis, perforated bowel, gunshots, and so on. And those people often wait much longer than they should.

A barometer of access to care in a tertiary surgical service would be how long you wait to get an operation. The longer you wait for care that you need, the less likely it is that the intervention is going to be successful. In the case of a cancer, the more likely it would be that the cancer would spread before we can control it. Or in the case of an operation like a hernia, it’s more likely to complicate before we can do the operation. Or things like joint replacements, it’s chronic pain for years, which impacts on quality of life, ability to work and all of those kinds of things. That’s the health environment in a normal setting. Before we have additional pressures on the system which come from budget cuts.

“A barometer of access to care in a tertiary surgical service would be how long you wait to get an operation. The longer you wait for care that you need, the less likely it is that the intervention is going to be successful. So it really isn’t an exaggeration to say that when you cut health budgets, you actually cause unnecessary harm, and you allow preventable deaths to occur.”

A!: So you’re saying that human beings are the main constraint on your work, not physical space or instruments?

LC: Yes. 70% of the health expenditure on staff is on personnel. And that’s a global phenomenon. What really brings things to a halt is when you don’t have staffing. And we saw that in Covid. We had beds and ventilators and people were willing to donate them. We didn’t have the nursing staff actually to run them. And an ICU bed is not an ICU bed unless it has nursing staff attached to it.

In the surgical environment, trained theatre nurses are our biggest human resource bottleneck, our biggest scarcity. And that relates to what happened in the mid-90s: the closing of nursing colleges and the ongoing crisis of training and educating nurses that we’re seeing right now. That’s kind of the backdrop.

In any health system like ours, we have resource limitations already. In the Western Cape, and in the hospital I work in, it’s a functional system. So things run, things happen, and there’s order and structure to what we’re doing. Staff are appointed; they get paid. The hospital is cleaned. And I say all these things because this is not the norm in all hospitals. So we’re coming from a fairly good baseline.

But this year, for the first time in about 15 years, we are facing a massive decrease in available money. The tertiary hospitals have each taken a huge budget cut. R88 million for Groote Schuur, something similar for Tygerberg, and a little bit less for Red Cross Hospital. We were initially told that district and regional hospitals have been protected from the cut, but what we hear from people on the ground actually haven’t been.

A!: What is the impact of those huge budget cuts?

LC: What a budget cut means for a hospital is that the CEO and the COO of the hospital are told – this is your budget, make a plan. Depending on the leadership of the hospital, some hospitals will just make the easiest plan. And the easiest plan to save money is to freeze posts. When someone resigns, they retire, they go on maternity leave, anything where they vacate their salary for a period of time, the easiest thing for hospital administrators to do is just to freeze the post. And that is what’s happened in many parts of the country already, even before this particular crisis.

This has led to a spiraling deterioration of the health service, because people are left behind, they’re overworked, overstretched, they can’t deliver the service, they burn out, they leave.

And it has also led to a massive escalation in medical-legal claims against the health system, which is a completely stupid way of saving money. The Eastern Cape is now paralysed by medical-legal bills. And they are particularly guilty of freezing posts.

When you freeze a post, it looks like just one budget line on your spreadsheet. But in a hospital, in a clinic, in a theatre, what it means is that you can do fewer outpatient clinics, your casualty queues become longer, your waiting list for theatre becomes longer. Patients who have been waiting a long time already now have to wait longer.

So it really isn’t an exaggeration to say that when you cut health budgets, you actually cause unnecessary harm, and you allow preventable deaths to occur. Deaths that could have been prevented if the health service was working.

A!: Are there any other effects from these budget cuts?

C: In every system, there are places where we spend a bit more money when we have access to it. We may be trying a new technology, or we’ve got a medication which is a little bit better, and it’s significantly more expensive. We use it because there’s a little bit more leeway in the budget. Most health innovation happens like that. And that’s a really important part of building a healthy health system.

That is completely gone. We cannot buy new things. We cannot get some of the new things that we got last year. The equipment budget has been slashed. We can’t get a lot of the medications that we would have wanted for our patients. And it’s just the beginning. We will really start to feel it towards the end of the year and next year.

And then there are the people. From the 2007 public sector strike came the Occupational Specific Dispensation – progressive salary improvements over time. Because of that OSD dispensation, the public sector could compete with the private sector in terms of retaining skilled and super-skilled professionals. Most people, if they’re paid reasonably and they have the equipment they need, and a system that works, would prefer to work in the state sector for many reasons. But I’m seeing that shifting a little bit now. With the public sector wage freeze we’re seeing people drifting more towards the private sector. In particular, nursing staff are being actively poached and taken across, because the nursing shortage is a global shortage.

A!: But the Treasury would say to you we have to reduce the budget deficit. How would you respond to that?

As health workers and activists, we must resist the pressure to help manage this budget crisis through service cuts – it is a crisis created by poor economic planning, corruption and, fundamentally, capitalism.

LC: There are many places within the country where we spend a lot of money, where we could cut first. We could cut high end salaries; we could close the loop on taxpayers who don’t pay tax, and high net worth individuals; we could change our taxation structure; we could stop the leak through corruption, which is a massive thing. And if we are looking at cutting, we need to look at things that don’t really break down our capacity as a country to respond and recover and to build the economy.

Health and education are the two things that are really foundational to building a society that is well and healthy. 

So if you’ve got to cut, you should look somewhere else. And to health workers, I say we must, of course, be mindful of how we spend public money. Make every rand count. But we must never voluntarily reduce any service. It doesn’t matter what the panic is, you just carry on doing your work, you go to clinic, you do your operations, you see your patients, you do your scans, until someone physically removes you and stops you from doing it. Because the budget crisis will come and go.

But if we break down the service, it’s very hard to build that backup.

Reducing the service services we provide is a violation of the principle of the progressive realisation of the right to health, and therefore a violation of the right to health. As health workers and activists, we must resist the pressure to help manage this budget crisis through service cuts – it is a crisis created by poor economic planning, corruption and, fundamentally, capitalism. We need to see the bigger picture, hold the line on maintaining our services, and continue to campaign for a public health system that is free at the point of service, high quality and available to all.

Lydia Cairncross was speaking in her personal capacity.