title: Downsizing of a provincial department of health--causes and implications for fiscal policy.
abstract: OBJECTIVE
  To analyse the financial basis for downsizing of a provincial health department and suggest implications for fiscal policy.
  
  
  METHODS
  Analysis of relevant departmental, provincial and national financing and expenditure trends from 1995/96 to 2002/03.
  
  
  METHODS
  Western Cape (WC) Department of Health (DOH).
  
  
  RESULTS
  Downsizing involving 9,282 health workers (27.9%) and closure of 3,601 hospital beds (24.4%) over 5 years. Total aggregate provincial transfers (all provinces) remained fairly constant in real terms. The WC's share decreased from 11.8% in 1996/97 to 9.8% in 2002/03. This was offset by the DOH's share of the WC budget increasing from 25.6% to 29.6%, mainly because of an increase in national health conditional grants. The net effect of financing changes was that the DOH's allocation in real terms was similar in 2002/03 and 1995/96, which suggests that financing changes are not the major cause of downsizing. Expenditure analysis revealed a 39.7% real rise in the average cost of health personnel. Substantial interprovincial inequities remain.
  
  
  CONCLUSIONS
  The major cause of downsizing was wage growth, particularly following the 1996 wage agreement. Disjointed fiscal and wage policy has affected health services. Simultaneous application of policies of fiscal constraint, redistribution and substantial real wage growth has resulted in substantial downsizing with limited inroads into inequities. Inequities will continue to call for further redistribution, reduction in conditional grants and downsizing, much of which could have been avoided if fiscal and wage policy choices had been optimal.
authors.affiliation: Directorate of Policy and Planning, Department of Health, Cape Town.
authors.forename: Mark
authors.initials: M
authors.lastname: Blecher
mesh_terms: D005377:Financial Management, Hospital / Q000379:methods*; D006271:Health Facility Closure / Q000191:economics*; D006801:Humans; D020415:Personnel Downsizing / Q000191:economics*; D012456:Salaries and Fringe Benefits / Q000639:trends*; D013019:South Africa; D013222:State Medicine / Q000191:economics*