SA’s public-sector healthcare crisis: Post-Comserve doctors bear the brunt

A reality where newly qualified doctors, despite having (more than) paid their dues, cannot find jobs is bitterly ironic. Yet, this is the dire experience of post-community service doctors in South Africa. As victims of the current economic context diluting the availability of public healthcare posts, many doctors now have to find their own ways to make money, and some have to leave the country for work. This critical unemployment of doctors is hardly surprising, considering Eskom’s budget exceeds that of the much-maligned public healthcare sector. This article by veteran healthcare journalist Chris Bateman details the plight of post-community service doctors, the resultant specialist shortage crisis, and how this will remain a perpetual problem unless non-healthcare costs are cut, and admin is reduced. This article was published by Medbrief Africa. – Nadya Swart

Post-Comserve doctors – you’re on your own!

By Chris Bateman

Post-community service doctors must rapidly learn to stand on their own two feet because available public sector posts will almost certainly shrink along with the health budget.

It’s a harsh truth, but neither the national health department nor its nine provincial counterparts are obligated to employ doctors once they complete their statutory service obligations. That’s how the law stands.

A Medbrief Africa probe, sparked by last month’s march by SAMATU (the South African Medical Association Trade Union) and affiliated unions to the National Department of Health protesting ‘some 1000’ newly qualified medical officers (post-Comserve), allegedly “sitting at home” without jobs, uncovered some harsh realities.

Chris Bateman

Interviews with two veterans in healthcare leadership, one a GP and the other a specialist, plus Dr Percy Mahlati, the NDOH (National Department of Health) Human Resources Chief, and well-placed sources in National Treasury led to the following conclusions:

Doctors fresh out of community service have four options; choose a speciality and then try to secure a rare registrar’s post, apply for a somewhat less scarce public-sector medical officer’s post – or acquire (or enhance) your business skills before securing funding and setting up a private practice. Unless you have a philanthropic sponsor, working off your private practice start-up costs will take two to three years. Or you can leave to work overseas.

Hundreds of healthcare professionals affiliated with SAMATU, along with COSATU (the Congress of South African Trade Unions), DENOSA (the Democratic Nursing Organisation of SA,) and YINTU (the Young Nurses Indaba Trade Union) marched at the health department head offices in Pretoria on 26 January.

Carrying placards that read: “Unemployment of doctors – genocide” and “Hire our doctors now”, they handed over a memorandum to Health Minister Dr Joe Phaahla, giving him until 27 February to respond.

Here’s what they demanded. 

  • All qualified and registered medical practitioners currently without employment must be appointed to public healthcare institutions within two weeks.
  • All vacant registrar posts are to be funded and filled within three months – and in filling these posts, South Africans must be prioritised. All contracts of employment offered to doctors must be permanent and non-shift work.
  • The second phase of OSD (Occupational Specific Dispensation) negotiations must be commenced to review the salary structure and compensation of doctors – inclusive of commuted overtime.

Dr Mahlati’s response is phlegmatic.

“Unfortunately, Treasury does not agree – and there’s nothing we can do. They decide how to allocate the budget. The only posts that are ring-fenced are for community service and internship.”

He says the protestors were unable to provide the NDOH with details of the 1000 “sitting at home” post-Comserve doctors.

“Between December (2022) and mid-January this year, this ‘sitting-at-home’ figure suddenly jumped from 200 to 1000. Where did they get the extra doctors? We asked them to give us the names, their HPCSA (Health Professions Council of South Africa) registration numbers, so we can ask provinces to move heaven and earth to accommodate them – but nothing happened,” he says.

Medbrief Africa’s Treasury sources confirm that there’s never been any statutory obligation to hire doctors post-Comserve.

“Once you’re licensed to practice, you can go anywhere you want,” said one.

More alarmingly, they hinted at possible cuts in the 2,000 extra medical officers hired to deal with COVID, possibly in the national budget speech in two weeks. They added, however, that the additional 1,000 interns budgeted for last January were “obviously safe.”

The extra intern allocation is to cater for the ever-increasing numbers of SA medical students returning from Cuban universities for the local campus ‘finishing’ and subsequent hands-on training posts.

A glimmer of hope for registrars

“Some questions have been raised as to whether we should also put the Registrar funding into the (provincial), Conditional Grant, but there’s been no substantive discussion yet,” the source revealed.

Such a move would begin to alleviate the acute, growing shortage of specialists – and address the registrar training crisis.

According to Treasury figures, in 2010, there were 11,668 public-sector medical practitioners and 4,359 public-sector specialists. By September 2022, this had grown to 19,255 State doctors and 4,759 State specialists, respectively – an increase of just 219 specialists (4,6% growth) in 12 years, dramatically illustrating the specialist shortage crisis.

The State-funded medical practitioner cohort growth equates to 39,4% over the same period.

The Treasury source doubted the veracity of the SAMATU claims, saying that overall, the doctor and specialist per capita postings grew from 16,000 in 2010 to 24,464 last year.

“Even if five percent dropped out every year (i.e. died or left the public sector), that would be 1,200 we’d need to replace. If you told me there were 1000 nurses sitting at home, I’d believe it – but for doctors, it’s highly unlikely.”

Painting the broader economic context, he said that after the prolonged COVID lockdowns, the economy had contracted further from its initial 2010 “doldrums.”

“We’re not generating the tax revenue to expand funding for health. There are other government priorities. Take the R350 monthly social grant – that’s R40 billion a month. Look at (things like) taking over the Eskom debt and the response to the Fees Must Fall campaign (R20 billion more to student bursaries). And because the economy shut down, the government took on hundreds of billions of interest debt. That’s gobbling up whatever gains we make in tax revenue. Health will be under real pressure this February budget. Must one raise taxes or rather not fund certain areas? Health used to be the second biggest area of government funding. Now it’s third or fourth, overtaken by social grants and government interest payments. Although not in the budget, Eskom’s budget is higher than the health budget,” he noted. 

He said it was possible that “many or all” of the 2000 extra doctors taken on to deal with Covid would be “let go.”

Two ‘elders’ speak.

Dr Angelique Coetzee, a veteran Pretoria GP and immediate past chairperson of the SA Medical Association, agreed with her predecessor, ophthalmologist and former HPCSA President Dr Kgosi Letlape. 

“Health budgeting is a provincial competence. The NDOH can jump up and down all it wants; if a province decides it needs the money for ambulances, that’s it.”

She said the recommendations in the much-acclaimed 2017 White Paper on Human Resources had never been implemented – and questioned why not.

“Another big problem is the mindset of our young doctors. It’s like, ‘somebody pays my bursary, and then someone gives me work afterwards.’ We’ve not trained our graduates to work for themselves nor included the appropriate business skills in their curricula,” she averred.

With the OSD having boosted young doctors’ salaries, a Comserve doctor could earn up to R70,000 per month.

“The problem is they also have this expectation (of similar income) when applying for private practice work.”

Her experience as part of the United Business Federation Health Group was that it was extremely difficult to train undergrads in how to do practice work. 

“We need a part-time course like they do in England and other First World countries, preparing you for private practice with practical experience. They need to learn coding, accounts, medical schemes, and billing to eliminate fraud and waste. Instead, they come from a public hospital set up with that dependency mindset. In private practice, if you’re rude or make mistakes, the patient won’t come back. You can’t refer so easily and must look holistically at the patient. It’s not a clinic anymore! To expect a young doctor who worked in a deeply rural area public sector hospital to suddenly create their own work, especially if they’ve been spoon-fed along the way, is difficult.”

She believes provinces have “too much power,” especially the Health MECs, who are answerable to their premiers.

“Nobody challenges them. Everyone jumps on the NDOH instead,” she added.

Dr Letlape said there was “too much separation of powers. Unless you make health a national competence, you’ll run into this problem forever. The NDOH has no authority over facilities.”

Asked if the NHI (National Health Insurance) would not provide a solution, he answered, “Not the way they’re going about it. If it’s really for all of us and replaces the Medical Schemes Act, then fine, but if it’s a fund to catch the ones who are employed but not on medical aid, it’s no solution. You’re just creating a pot of money that people can feed on without including overall healthcare.”

Letlape believes the NHI will duplicate infrastructure and waste money on non-healthcare costs.

“Unless health becomes a national competence and is one port for all of us, the problems will recur. The key problem is that the money for healthcare is being spent elsewhere. Unless you cut non-healthcare costs and reduce admin, this will remain a perpetual problem,” he added.

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