Currently there are according to reports several hundred unemployed young doctors in South Africa, a country that according to recommended doctor to population ratios requires more and not less doctors. It has been previously reported that some amongst other categories of health professionals are similarly finding it difficult to find employment in the South African public service leading to some even emigrating from this country to find work elsewhere. This situation has been attributed to the shortfall in funding for public health services. The current financial crisis in government departments largely results from a wage agreement with organised labour that increased the salaries of all public servants by 7%. These increases were not fully funded through increased budget allocations, a so-called “unfunded mandate”, increasing pressure on departmental budgets. In my previous post I reflected on the funding challenges facing the public health sector as a result of the budget cuts and the difficult choices facing senior management in these health departments.
Many may justifiably ask how is it possible that doctors trained, some in Cuba, at a high cost to both themselves and the government, are unable to find employment in the South African public health sector? An important fact is that under the current regulations, many categories of health professionals are unable to fulfil the requirements to fully register with their professional councils until they have undertaken an internship and community service. This they are largely obligated to do as employees in the South African public service. Failure to do so leaves these health professionals effectively in limbo unable to work in the professions for which they have trained.
When I became the head of the Western Cape Department of Health in 2002, the department was faced by a shortage of nurses. At that time the training institutions were challenged to increase their intake to enable more nurses to graduate annually. This they did with support from the department in the form of generous bursaries and by 2008 increased numbers of nurses were graduating. However, over the same time period what had been projected in terms of the expected budget allocations failed to materialise and the department was forced to reduce the number of funded nursing posts. This resulted in a situation where nurses whose training had been fully funded by the state were unable to be employed in the Western Cape. While some were able to obtain work in other provinces or the private sector, some were not resulting in a public outcry. Given the fact that medical training is prolonged, that those now unemployed commenced their medical training at least 5 to 6 years ago and there was then a push to increase the number of medical graduates, I fear that a similar situation now faces health departments managing unforeseen real term reductions in the budget allocations.
Faced by public sector health budgets that have declined in real terms and the dilemma of unemployed doctors what are the options open to the public health service in South Africa? While essential to a health service doctors are by no means the only health professionals necessary for the delivery of healthcare services. Certainly the fact that there are unemployed doctors attracts attention but what is more relevant is the relationship of doctors to the other members of the healthcare team and that this relationship should be optimal for the delivery of quality healthcare. In addition, it is essential that the managerial, administrative and technical support components are optimally staffed to ensure that there is an environment in which health professionals can operate effectively.
The salaries of many categories of health professionals, including doctors, were adjusted significantly upward in 2007 by the implementation of what is termed an “occupational specific dispensation” (OSD) that differentiates categories of staff from the standard public service salary scales. At the time this was intended to increase the competitive nature of salaries and improve the recruitment and retention of occupations designated as scarce skills in the public service. This dispensation was applied to various categories of health professionals but also other professional categories in the South African public service.
Doctors are an expensive commodity within the public health service, both with regard to their training and remuneration. The cost-to-company package currently for a South African medical intern is just over R770 000 per annum, while similar packages for medical officers range from R1 million to R1.3 million per annum. The cost-to company packages for medical specialists range between R1,9 million and R2.3 million per annum.
The dilemma is that if funds allocated to the public health sector are limited the priority is not necessarily only to ensure that more doctors are appointed but rather to ensure that the staff complements of health departments reflect an affordable ratio of all the categories of staff required. An unintended consequence of the requirement to employ recent graduates to meet the obligations placed on health departments to ensure that all graduates are placed for both their intern and community service years is the inability with limited funded posts to appoint more experienced and senior health professionals. As a result inexperienced health professionals of all categories can be placed in a position where they find themselves functioning without adequate supervision at a level at which they are not yet competent. The consequence of this may be not only unnecessary errors with medico-legal consequences but also stress and burn out in young health professionals resulting in them deciding to leave the profession.
Unemployed health professionals are demanding that they should be employed immediately irrespective of the financial realities facing government. However, in my view this is a simplistic although understandable response to a complex problem. I would suggest the following, amongst possible others, for consideration to alleviate the plight of unemployed doctors and other health professionals:
- Funds available for the appointment of staff within the health sector must be optimally utilised with no unnecessary and wasteful expenditure in health departments. This includes ensuring that all current staff are gainfully employed and that those who are deemed supernumerary, incompetent or guilty of misconduct are effectively and expeditiously dealt with.
- In the absence of additional funding for staff appointments in the public health sector, explore options to allow unemployed health professionals to undertake community service in the private sector. In the case of doctors this would require an amendment of Health Professions Council of South Africa (HPCSA) regulations to allow private hospital groups to employ doctors.
- Consider amending the requirements for community service to allow these health professionals to immediately enter independent clinical practice in South Africa on condition that it is under the supervision of more experienced colleagues.
- Consider options to develop intergovernmental agreements with other SADEC countries, and possibly elsewhere, to allow health professionals, funding permitting, to undertake the community service required for registration in these countries.
- In the longer term review the number of students accepted for degree courses that lead to professional qualifications and registration falling within the ambit of the health sector in the light of the projected availability of funding to ensure a greater match between supply and demand in this sector.
It is however in my opinion unconscionable to do nothing and allow highly trained health professionals to remain unemployed for reasons beyond their control. Every problem has a solution and what is required is an innovative and flexible approach that within current realities permits these colleagues to get on with their lives.
