If you need medical treatment in the public sector, better hope you're living in either Gauteng, the Western Cape or KwaZulu Natal.
That's because vast differences in spending still exist between SA's nine provinces (see graph), despite a five-year plan put into action in 1995 to equalise health-care spend.
Gauteng and the Western Cape spent about R700/capita on health care last year, compared with R300/capita in poorer provinces such as Limpopo, Mpumalanga and the Northern Cape, according to a report by the health department's health financial planning & economics directorate.
Some of the spending inequities could be due to the fact that hospitals in the urban centres of Gauteng, KwaZulu Natal and the Western Cape offer more specialised services, which require more expensive equipment. The larger hospitals in SA's three biggest cities also provide specialised treatment for patients who travel from other provinces, where no such treatment exists.
"But case mix and patient load can't explain the entire difference," says Andy Gray, a senior lecturer at the University of KwaZulu Natal's school of medicine.
Over the past decade, average real per capita spending on public health care has been rising. SA now spends about 8,7% of GDP on health care.
But in provinces such as the Eastern Cape and the Western Cape, health-care spending has been declining in real terms. It has remained static in the Free State, Mpumalanga and the Northern Cape. Unequal spending has led to a range of problems, including the loss of skilled medical staff, patients travelling to other provinces to seek treatment and disruption of service delivery.
Another big concern is that real per capita expenditure in Gauteng and the Western Cape varies widely from year to year - affecting health service stability and sustainability, says the report.
Gray says: "Provincial health budgets change from province to province, and year to year."
According to the report, the problem is government's overarching budgeting process. Under the current system, each province receives a global budget to cover all social service functions. It is then up to the provincial treasuries to divide this funding among different departments, such as health, education, housing and social development.
How much a department gets depends on how well it makes its case.
"In many cases getting a fair share of the budget boils down to the relative power of the MEC for health in a particular province," says Gray.
Instead of reducing unequal spending among the provinces, this budgetary system, also known as "fiscal federalism", has widened the gap.
The national department of health may distribute conditional grants for specific projects aimed at narrowing the gap - for example, for antiretroviral drugs for Aids-stricken provinces, or for hospital upgrading.
However, national treasury is reluctant to grant money outside specific projects for general use. In many cases, large portions of the conditional grants in provincial health departments have not been spent because of a lack of skilled staff.
Part of the solution lies in defining a basic minimum health-care package that provinces must provide.
Until now, the provinces have provided different levels of service. For example, new asthma inhalers on government's essential drug list are available in some provinces, but not in others.
One standard is required.
Government is obliged under the constitution to provide a range of basic services - linked to available resources. It is up to the health department to determine what level of care is feasible.
Some provincial health departments have faced litigation from patients demanding specialist treatment, such as renal dialysis, which is expensive and which not all provinces can afford to give everyone who needs it.
A basic health-care package would oblige provinces to provide at least a minimum of services.
"Ideally, if you seek treatment for cancer in the Eastern Cape you should be guaranteed to receive the same treatment you would get in the Western Cape," says Gray.
So far the national department has tried to develop packages of care for facilities on primary to tertiary level.
These tell hospitals and clinics what services they should provide, how they should do it and how much it should cost. But these norms and standards need refining and have yet to be enforced.
Defining a basic health package would also equip provincial health MECs to argue for more money where it is needed.
