Why the health department can’t employ these doctors

The medical negligence claims of close to R900m paid out in only one South African province in a recent financial year would have been enough to employ the country’s documented 694 unemployed doctors, health minister Joe Phaahla announced on Monday during a press conference.

Though Phaahla didn’t name the province, a 2023 report from the auditor-general shows that in 2021, the Eastern Cape paid out almost R867m in claims, while the salary bill for 694 newly qualified doctors (in 2023) would have been around R838m. 

But Phaahla did admit: “It is a paradox. On the one hand, we’re dealing with amounts of money being paid out for claims, while at the same time we’re unable to employ people who help to reduce this.”

In 2024, the South African Medical Association Trade Union, the watchdog for health practitioners’ rights, informed Phaahla that it had at least 800 unemployed medical doctors on its records. According to Phaahla, this number dropped to 694 after the list was double-checked against the state’s employee database, which showed that these doctors had completed their community service on December 31. 

One example was Sunhera Sukdeo, who graduated cum laude from the University of KwaZulu-Natal in 2023. In early January, she wrote in the Daily Maverick: “It is now January 2024. I am a cum laude medical doctor. I am sitting at home unemployed. But I am not alone — most of my peers are in the same boat as I am.” 

To this, the deputy director-general for human resources in the national health department, Percy Mahlathi, responded: “The problem that primary employers, the provincial departments of health, face is the struggle to receive adequate budgets. The current financial squeeze felt by every government sector and the country impacts on the resourcing of health services.”

Phaahla says 239 medical officer positions have now been advertised and 400 more will follow in the next few months. (A medical officer is an entry-level GP who works in the public health sector). Most of the positions are in Gauteng, Mpumalanga, Free State and the Eastern Cape.

Ironically, South African universities have, in less than a decade, increased the number of medical interns they’ve trained by about 60% — from 1,470 to 2,365, Phaahla said — in order to address the doctor shortage in government hospitals and clinics, but the National Treasury has not increased provincial health departments’ budgets at the same pace. As a result, they don’t have budgets to employ the increasing number of graduates, despite many vacant positions. (Medical interns are medical students who have completed their degrees but still have to complete two practical years in a government health facility under the supervision of staff who work at a state hospital.)

Provincial health departments, according to Phaahla, spend 70% of their budgets on health worker salaries — but it’s not nearly enough. 

In 2021, about one in seven doctors’ positions in hospitals were unfilled, while one in five positions for doctors were vacant at clinics. This shortage of professionals in the public sector and given that more than 70% of South Africans use government facilities, this means that there’s about three doctors for every 10,000 patients in the public system.

Because of the increase in the number of medical students universities trained between 2018 and 2023, the state therefore had to find that money to pay 895 more interns within five years, which, according to Phaahla, amounted to just over R800m at a salary of R900,000 per intern per year (this includes overtime). 

The number of community service doctors, who earn around R1.2m per year (R1.3m if they work in a rural area), according to Phaahla, grew by almost 60% too between 2020 and 2024 (from 1,340 to 2,101), which meant the government had to fork out an extra R913m for their salaries. 

Phaahla warns that the pressure on the health department’s purse is made worse by a 7.5% increase in public health worker salaries, which was negotiated between the government and trade unions in 2023, which means fewer new workers can be appointed.

“We received around 65% of the additional costs [caused by the salary hike]. So it was a bit of a cushion, but we still needed to find within our budget the remaining 35%.”

Phaahla warned there’s no “automatic placement” for qualified doctors in the public sector: 

“[While] we wish that [employing newly qualified doctors] would be seamless, we must take into consideration that, once [a doctor is] out of the regulated training and community service, [they] are almost like any other profession: when [you’ve] completed all your training, you are going to [apply] where opportunities are.”

A health system in crisis? 

Pressed about whether the department’s funding woes are plunging the public health system into crisis, Phaahla responded that “it’s really a choice of description” as to what you call a crisis.

But in December, a committee of deans representing health sciences faculties from universities across South Africa warned that failing to fill community service posts — whether for doctors or any of the other health professions where graduates need to complete this mandatory year or two of work, such as dietitians, dentists, physiotherapists and radiographers, could lead to exactly that in future.

Why?

Because not having enough money available for community service posts will affect the quality of care for patients, especially in rural areas — the exact communities the in-service training programme was supposed to help, they wrote in a statement.

“We already have poor provision of [these types of] services across our system and community service appointments are often the only care that our people get,” Lionel Green-Thompson, dean of health sciences at the University of Cape Town and chair of the South African Committee of Medical Deans, told Bhekisisa.

The money crunch affects staff across all health professions, not only doctors. Since 1998, newly graduated health workers like dentists, physiotherapists, radiographers, dietitians and environmental health practitioners have all been required to work at public hospitals or clinics for a year of community service before they’re deemed fully qualified. 

The policy was introduced to make sure that people who use state health facilities, especially those in rural areas, will also have access to specialist and rehabilitation care.

But more so, Green-Thompson explained, medical schools were concerned about posts not getting filled being a regular occurrence. Indeed, Phaahla conceded at Monday’s briefing that “the pressure on the fiscus did not happen overnight”.

Treasury vs training

In their December statement, the committee of deans said they’re concerned that budget cuts will affect the quality of training for health sciences students — which will have a knock-on effect on service delivery in state facilities. Already, community service placements are determined more by the needs of the facility, with less of a focus on training and improving the skills of newly graduated health-care workers. 

Rural facilities in particular don’t have many permanent health-care workers, as it’s difficult to keep staff there because of poor conditions, such as equipment at hospitals or clinics not working, too few personnel and bad roads making it difficult to get supplies. Many of these facilities therefore rely on the work provided by new graduates doing their community service. 

Though universities have answered the government’s calls to increase the number of graduates in health sciences, provinces are struggling to match the supply with available posts, said Green-Thompson.

“We have called [in the past] for a clearer management of the required financial resources and the emerging numbers of graduates,” he said. 

Green-Thompson added that having graduates sitting at home while they could have been deployed to areas in need will leave many patients without access to professionals like speech pathologists and occupational therapists in the public sector.

Indeed, as Phaahla said: “We are not in the best of situations. We would have preferred to be in a position to employ everybody who wants to serve [in the public sector]”.

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.