Johannesburg:  During the debate on the president's State of the Nation address, Health Minister Aaron Motsoaledi referred to media coverage of the uneven quality in the health system, commenting that "the ruling party is the first to publicly acknowledge it and speak about it openly".

It is true that the health ministry has announced various strategies to turn the failing health system around, such as national health insurance and implementation of the national HIV and Aids plan. Yet we are worried about the worsening situation in the rural areas, where 43.7% of the country's population lives.

As Dr Karl le Roux, chairperson of the Rural Doctors' Association of Southern Africa, said recently: "It is unfortunate that rural patients who make up a large part of the poor always receive the worst care across the board."

His comments came in the wake of a call by the Rural Health Advocacy Project to the president, as well as to the national and provincial health and finance ministers, to shadow a rural doctor for a day.

Seeing the terrible conditions in some rural hospitals first-hand might help them to fine-tune national strategies that are relevant to the rural context and to draw up efficient financial systems for rural healthcare services. This call does not come out of the blue.

Too often in the past wellintended health policy decisions were made that turned out to have a detrimental effect on the quality of health services for poor people in rural areas.

The outcome of negotiations for the occupation-specific dispensation, which negatively affected the morale of rural doctors (because it benefits mainly specialists, registrars and interns, the great majority of whom work in urban areas), the closing of nursing colleges in rural hospitals and the separation of hospitals from clinics are examples.

Another was the KwaZulu-Natal health department's instruction in November last year to freeze all critical posts so as to cut expenditure; as a result, it became almost impossible to replace doctors who left already understaffed rural hospitals.

The most deprived districts in the country are rural and yet the per capita expenditure on primary healthcare is less in rural districts than in wealthier urban districts.

We need to strive for equal access to quality, affordable healthcare. With the levels of inequality in our society, this requires more resources for the rural areas.

As provinces finalise their budgets in the next few weeks and develop operational plans, there are areas that need to be given specific consideration if they are to support the national call for quality and equity. Many hospital budgets (and staff establishments) are historical.

As budgets are largely based on the previous year's budget, this takes us back to the apartheid policies of depriving homelands and rural areas. Compared with previous years, budgets have contracted.

Because of the current financial crisis many provincial hospitals have a budget that does not even cover the salaries of the staff -- despite massive vacancy rates.

Furthermore, overspending in the past at head office and regional hospitals has led to budget cuts for all hospitals, disproportionately affecting poorly resourced rural hospitals.

Staff shortages and the freezing of critical positions because of budget cuts make it difficult to place the few community-service medical officers who are willing to work in underresourced rural hospitals.

To achieve the national goals of equity and quality, while working efficiently with the scarce resources available, the following measures are imperative. The draft National Rural Health Strategy, which has been dragging on since 2004, urgently needs to be finalised.

But we cannot wait for that. We need staffing norms for hospitals and clinics. This is contained in the national health department's 2004 human resources plan, which has not been implemented.

National norms and standards of care need to be costed and implemented. There needs to be oversight of the budgeting process that holds provincial governments accountable for the underfunding of hospitals.

We need more equitable formulae for budget allocations to hospitals. Decision-making should be localised and chief executives of healthcare institutions should be held accountable for worsening professionals to patient ratios, as well as worsening indicators such as child and maternal mortalities.

Human resources staff should have clear guidelines on the time frames for the appointment of new staff, especially health professionals, and these should be incorporated in their performance appraisals.

More generally, a process of "rural-proofing" of all policies -- that is, reviewing them for their impact on rural healthcare -- should be initiated. There needs to be public and political acknowledgement of the degree of underfunding.

Although South Africa committed itself to spending 15% of its budget on health services by signing the Abuja Declaration on health spending for governments within the African Union, it spends only about 11%.

To prepare the country for a national health insurance plan, intended to promote equity, let us strengthen the public health system by budgeting for rural healthcare.

*  Marije Versteeg is project manager of the Rural Health Advocacy Project, a partnership between the Wits Centre for Rural Health, the Rural Doctors' Association of Southern Africa and the AIDS Law Project