Covid-19 has exposed the incapacities of the global health system to swiftly deal with pandemics and save lives. However, not only did Covid-19 expose the inability to save lives, but has also exposed the problems and incapacities of the public healthcare system to create conducive working conditions for nurses and other healthcare workers.
The problems that nurses face today, cannot be understood at face value as merely the consequences of failures of managements at our hospitals and clinics. To be understood
better, these problems must be located in the political economy — the political economy of neoliberal capitalism.
In South Africa, neoliberalism has decapacitated and rundown the public healthcare system through defunding and budget cuts.
In the Medium Term Expenditure Framework (MTEF), the budget allocation for the public healthcare system is set to increase by a measly average of 0.2%, whereas inflation is projected to increase at an average of 4.5%. In other words, budget allocation in the MTEF will decline by 4.3% in real terms.
Budget allocation will take a big decline by R11.3 billion from R259 billion in the current financial year (2022/23) to R247.6 billion in 2023/24.
The effects of the overall budget cuts means that the wage bill for healthcare workers will decline by R3.9 billion from R159.5 billion in 2022/23 to R155.6 billion in 2023/24, goods and service expenditure will decline in real terms at an average of 7% (11.9% actual inflationary rate) and 10.1% real decline in the budget for equipment and machinery. TB, Malaria and HIV budget allocations are also amongst those areas of healthcare which will
suffer serious defunding, declining at the nominal rate of 3.4% and a real decline of 7.9%.
Due to these budget cuts, the wage increases and total number of employees are affected severely in the department. By international standards, public healthcare workers in South Africa are underpaid, and this is highlighted mostly by the public health
sector losing nurses through brain drain to more capitalist developed countries which pay better.
Reducing overall healthcare workers in the public healthcare system is one method in which Treasury hopes to reduce the budget, as demonstrated by the Medium Term Budget Review. Consequently, about 22 000 posts were reported to be unfilled in the public healthcare sector at the end of 2021. More posts are going to be lost as government conducts retrenchments through attrition, and simply refuse to absorb the new nursing graduates.
The impact in terms of infrastructure is best illustrated by reports of hospitals filled to overcapacity where pregnant women sleep on the floor. Hospitals have also grown synonymous with lack of medication as many chronic and trauma patients constantly do
not find medication.
These are conditions which have made the nursing profession unbearable, and quite distressing to the nurses, employed and unemployed.
Unemployed nurses are stressed because they are not able to easily find employment, and with the continued cuts, the Department of Health is likely to continued cutting the
number of healthcare workers’ posts.
The reduction of the headcount weighs heavily on the employed nurses and other healthcare workers such as doctors. It means a lesser number of nurses and healthcare workers have to service an increasing population. That is the reason why the nurse to
patient ratio is high at 1:213, which is an understatement of the nurse to patient ratio because it includes the private sector.
In addition to lacking machinery and equipment, clinics and hospitals have become stressful places of work. In a paper published as early as 2006, JC Rothmann et al cites “insufficient staff” as one the key contributing factors to stress levels amongst the nursing staff in South Africa
In a nutshell, this shows how understanding problems nurses face on daily basis cannot be realised adequately outside of analysing the political economy. The bemoaning of the
worsening conditions of work for nurses in hospitals and clinics are in the final analysis, mainly traceable to neoliberalism.
The nurses and other healthcare workers must commemorate this day with pride, for it is a day that marks the development of their profession and commemorates the honourable and divine task of saving of human lives, a fact that demonstrate the importance and fundamental necessity of this profession. In addition, it is a day that symbolises the historical paths that nursing has travelled, and the struggles nurses had to conduct to
arrive where they are today.
As a result, nurses must join with the rest of the working class to fight against budget cuts and neoliberalism, because it is a system that has worsened conditions for healthcare workers and the beneficiaries of those services.
Below, we republish our 2021 tribute to nurses.
In history, healthcare has been the most important factor in mitigating against untimely deaths, whether due to war, accidents, or illnesses. Now, capitalism’s new “zoonotic”
pandemic diseases – like Covid-19, spreading from animals to humans as ecologies come under attack from profiteers – are being amplified by the climate catastrophe, economic crisis, austerity policies, neoliberal health systems and privatised health care, social inequality, hunger and squalor.
These make the world much more prone to more varied diseases, so health care is even more important than ever before. Hence the working-class movement has been calling for this to become a universal free service, through the kind of National Health Insurance for ending healthcare financing apartheid, and ultimately a full National Health Service, as enjoyed by Cubans as well as residents of social democracies.
Nurses are critical to making health care possible. From the first midwifery in the primitive societies to the shamans in the pre-colonial societies, and from health care in monasteries to the development of nursing as a profession since the 1850s, nurses have remained vital to improving their compatriots’ health. In their different ranks, the nurses nurse patients. From the emergency door to the surgical theatre room, and from
treatments to post-surgery until patients are reunited with their loved ones, the nurse provides the most visible and consistent caring.
Nurses in the capitalist system
Healthcare did not develop holistically or in a linear form, especially on a global scale. But pandemics before capitalism and casualties from wars have always raised the need
for a more organised, wider-ranging health care system. So much as nursing was important in home health care, it became even more important in the transition to clinics and hospitals.
The division of labour under capitalism necessarily accelerated nursing into an organised craft whose role was to make workers fit after injury or illness, so as to keep the wheels of capitalism moving. This transformation included increasing the capacity to care for people in an organised manner. Mass professionalisation of the various health care skills was underway, but so too was a hierarchy emerging which gave overweening power to the (mostly male) doctors and administrators. Today that hierarchy has reached an untenable level, as community health workers, auxiliary nurses, general nurses and other more specialised support workers are fending off the privatisation, inappropriate
automation and deskilling of their trade.
Indeed, the problem with capitalist health systems is that as soon as conditions for nursing and healthcare were ushered in on a wider scale, financiers began to see healthcare as a potential site of capital accumulation. In the leading capitalist country, the U.S., workers were not only denied a state health financing system – thus relying on employers who therefore had additional spending to factor in, but also more power of the vulnerable employee – but also found healthcare-for-profit increasingly debilitating.
Not only was the “fee for service” system creating massive class divisions and overtreatment incentives, the 1990s answer from private health insurance firms was a “managed care” strategy that super-commodified health care. Whereas doctors told their
specialist friends to over-treat patients in one version of capitalist healthcare, the more organised system over the past quarter-century has flipped the incentive structure.
Insurance companies which now own large parts of the system now not only shut down the less profitable sites – rural clinics, inner-city (ghetto) hospitals or teaching facilities – but they have a disincentive to provide treatment, because they take premiums and then typically find ways to prevent people from getting their money’s worth in treatment.
The U.S. system is replicated in many ways in South African healthcare financing, with perverse incentives and substantial administrative layers that create far more costly treatment than is necessary in the private sector. Hence only 14% of South Africans are privately insured, yet the privileged elites’ use of health services amounts to 50% of the combined public-private health care budget.
And this insatiable desire, which is unique to capitalism, to turn every sphere of human existence into a commodity to be bought and sold on the market no matter the damage to the society’s public health, means the provision of healthcare globally is being wrecked by vaccine imperialism. As we see in the World Trade Organisation, Big Pharma and its supporters – now especially Angela Merkel in Germany (and others in the European Union) plus Jair Bolsonaro in Brazil – refuse to address the desperate need for a vaccine, in spite of U.S. retreat from its Trump- era opposition to an Intellectual Property waiver on vaccines and treatments. Regrettably, the new WTO head, Ngozi Okonjo-Iweala, remains two-faced in welcoming Joe Biden’s retreat but refusing to push for rapid adoption of a
full IP waiver.
The importance of organising and activism in this and other health care advocacy is obvious. Although the first nurses’ union based on a presence in hospitals was only founded in 1919, in Ireland, trade unionists had lobbied for health care protections for their members decades earlier, due to the high rate of injuries at the factories and unhygienic conditions in the urban squalor where they lived.
The pressure of unions on employers, and employers’ tendency to offload the burden of carrying costs of health protection for their employees (or to use job-based health care as a weapon in the class struggle), convinced labour of the need for a public health care system. This helped transcend sporadic public obligations caused by pandemics, or convenient national obligations during wars, or charitable, church- related and community health care.
In some Western countries, national health systems were rapidly established after World War II, when conditions were ripe since the Soviet Union presented a counter- model.
But elsewhere, unfortunately, capitalists also an opportunity to privatise rare skills in public health and create a market from which they can accumulate. Such a development created a two-tier health care system in places like the U.S. and
South Africa, and with it, adapted the role of the nurse in line with market tendencies. Nursing, Nurses, and Neoliberalism
The increasing need for the state to carry out its responsibilities for the provision of not only public healthcare, but also the training of the healthcare professionals, reflects the unstable character of capitalism.
During crises, as we are in the middle of now, workers are paid less, and inflation undermines the buying power of such meagre wages, especially as medical costs rise far higher than general CPI, resulting in such workers unable to afford healthcare.
Due to capitalism’s general tendency to cut input costs, structural unemployment keeps many out of work, and thus vast numbers of our working class have no income to afford healthcare services. This is a contradiction capitalism cannot afford – that of a sick labour force and pool of unemployed, precisely because it needs increased production as well
as a consumer market with sufficient buying power, in good health.
Since the 1980s, governments across the world have adopted neoliberal ideology, and as a result, have unleashed cuts on public health and underfunding the sector.
South Africa is at the leading edge of this barbaric trend: “Treasury is set to cut the health budget by over R50 billion in the next three financial years, despite the ongoing pandemic. The budget increase from 2009 to 2012 was followed by a plateau at 1.52% from 2013 until 2019, far below the healthcare inflation rate.” Coupled with corruption and sheer looting of resources, the public healthcare system is near collapse.
The neoliberal cuts in healthcare funding include an assault on nursing as a profession, and in practice. Stunningly, one resulting cut to the higher education budget is NSFAS discontinuing funding for the Bachelor of Nursing Science (B Curr).
There is also a crippling lack of adequate infrastructure and equipment for South Africa’s public hospitals and clinics. And reflecting the public sector’s understaffing due to Treasury cost-cutting, in 2018, South African public health had 37 000 unfilled posts, the majority of whom are nurses of different ranks.
These factors have created unbearable conditions for nurses to operate:
• they get infections from patients with airborne infectious diseases due to lack of protective equipment,
• they clean after themselves because hospitals and clinics lack an adequate number of cleaners,
• they are prone to rape and attacks at the workplace because there is inadequate security,
• they are unable to fulfil their duties effectively because the shortage of nurses thanks to frozen posts overwhelms them,
• they have lost morale and suffer from work-induced depression regularly,
• they often wish to migrate into the private sector or abroad, and
• they suffered an effective wage cut in 2020 and further frozen wages (not even inflation adjustments), apparently until 2024.
As a result, in some situations of desperation, these conditions have unfortunately “made
Nurses enemies of the communities they serve.” The lack of equipment, infrastructure, medicine, staff, leadership, and morale leads to increasing horror cases in hospitals.
Communities have blamed these horrors on nurses, overlooking the non-conducive environment in which nurses operate under, and the objective structural conditions that setup nurses for failure in the public sector healthcare system. Nurses during the pandemic
During the pandemic, nurses and other healthcare workers are the ones in the frontline, and suffered from both much higher rates of infections and psychological trauma. In
March, Al Jazeera reported an estimate of over 17 000 health care workers across the world who had perished from Covid-19. In January, South Africa had over 35 000 cases reported amongst its health care workers, and over 400 deaths. The majority of the infected and those who died were nurses.
Despite the harrowing conditions in hospitals, and their lack of infrastructure, equipment and staff, nurses and other healthcare workers soldiered on, and continue to soldier on.
They risk their lives everyday for the communities they serve, and the people in general.
Theirs is a noble cause, whose preoccupation is saving lives.
SAFTU salutes all healthcare workers and in particular nurses for their sacrifices on their international day.
It is also important to restate that labour organisations are not only important in fighting for your wages but improving the very environment through which you can serve your communities with devotion and diligence. Sadly, some traditional unions in the health sector have allowed conditions to deteriorate in clinics and hospitals under their watch.
In contrast, trade unions in the health sector affiliated to SAFTU are fighting for justice, including targeting Treasury for its austerity, and opposing the tendency to privatise health care.
Forward to their victories in the sites of struggle they – like all South Africans
– are desperately trying to improve: hospitals, clinics, healthcare education and home health care.
Support your nurses, they deserve all our solidarity, today and every day.