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Picture: Julio César Velásquez Mejía/Pixabay
Picture: Julio César Velásquez Mejía/Pixabay

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

Unemployed doctors aren’t the health department’s only vice; those who do work in state clinics and hospitals are heavily underpaid, says the South African Medical Association (Sama).

Yet, South African government doctors earn up to three times more in a month than what some make in a year in other middle-income countries in Africa, such as Kenya and Nigeria. 

On Wednesday, finance minister Enoch Godongwana allocated just over R15bn to the health department to help it deal with the staff crisis in government health facilities — and create positions for the close to 700 unemployed doctors who recently graduated from universities.

The department will have R848bn to work with over the next three years. Of this, R11.6bn will be to cover the 7.5% wage settlement from last year and an extra R3.7bn to pay salaries in the current financial year.

But while the government is scrambling to get enough money to ensure that all 694 unemployed doctors as well as recently graduated health-care professionals are employed, Sama says the country’s public sector doctors aren’t paid enough.

At a media briefing ahead of Sama’s annual conference in mid-February, CEO Mzulungile Nodikida said a study commissioned by the association shows that those doctors who are already employed by provincial health departments “are earning 2015 salaries”.

The study found that doctors are experiencing “cost of living pressures”, but also concedes that their salaries are “above what other similar income-level countries pay their doctors”.

For example, in Kenya medical interns were paid around Ksh122,000 and Ksh145,000 per month (including risk and housing allowances) according to the 2013 Salaries & Remuneration Commission’s allowances for government employees. This works out to about R16,000-R19,000 a month, compared with the almost R28,000 a medical intern earned monthly in South Africa that year.

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.

Similarly, an entry-level medical officer (which, in South Africa, means you have completed two years’ internship and a year of community service) was paid Ksh250,000 (about R32,500) a month in Kenya from 2013, whereas their South African counterparts earned almost R62,000 per month.

Salaries for doctors in Nigeria — which is experiencing a large-scale exodus of doctors — are even lower.

Data from the National Salaries, Incomes & Wages Commission in Nigeria shows that an entry-level doctor currently earns roughly NGN1.8-million (about R22,000) per year. Someone in a similar post in South Africa gets more than three times that per month  in other words, South African medical officers earn 40.9 times more than Nigerian entry-level doctors (R900,000 vs. R22,000 per year).

The health department says it has not yet looked at why Sama claims doctors should earn more. But, says department spokesperson Foster Mohale, they have “had meetings [with Sama] and we are planning to review our salary scales”.

Like all other public servants, doctors get a salary increase every year, yet the study notes that doctors have felt ‘a significant erosion in income levels’ over the past few years

How are government doctors’ annual increases calculated? 

After negotiations between the government and trade unions last year, the department settled on a 7.5% annual salary increase for all its workers (as for the rest of government employees). This took a large chunk out of departments’ budgets, leading to their having to cut costs elsewhere, the health department says.

Ironically, getting the money for the salary increases contributed strongly to empty doctors’ posts at state hospitals not being filled, according to health minister Joe Phaahla. More than 70% of the health budget is spent on paying salaries, Phaahla said recently in response to the South African Medical Association Trade Union (Samatu), a watchdog for health-care workers’ rights. According to Samatu, more than 800 qualified doctors were unemployed at the time, but the health department’s follow-up count was closer to 700.

In 2009, the health department implemented occupation-specific dispensation (OSD) for its employees. 

OSD is a table that states the basic salaries for government workers across different departments given their skill level and expertise. It was set up specifically to keep skilled professionals, like doctors, in the government service by making sure they get salary increases that align with their field of expertise and experience so that they can plot a well-paying career path working for the state. 

Each post in which doctors work has different levels, with a specific basic salary linked to it. For example, an entry-level medical officer would be on a grade 1 salary, which sits at just over R900,000 a year.

After five years’ experience in the position and depending on their performance, they can move on to a grade 2 salary in that post, and earn a basic starting salary of just over R1m. Grade 3 medical officers earn between R1.2m and R1.5m a year.

Have doctors’ pay increases kept up with inflation? 

The Sama-commissioned study suggests that money is a big issue. Like all other public servants, doctors get a salary increase every year, yet the study notes that doctors have felt “a significant erosion in income levels” over the past few years because of small increases, particularly, they say, considering “inflation as well as cost of living pressures”.

Between 2013 and 2019, yearly increases were above inflation, but in 2020 the government implemented a salary freeze to keep its wage bill in check. 

For two years after, increases have been below inflation: 1.5% in 2021, against an inflation rate of 4.5%, and a 3% increase in 2022 while inflation sat at 6.9%

“If you’re to retain the current doctors, then you need to compensate [them] appropriately,” says Sama chair Mvuyisi Mzukwa.

However, money isn’t the only issue that stops doctors from working for the state. Long working hours because of too few personnel and safety concerns, both at urban and at rural facilities, were also mentioned as deterring doctors from staying in public service.

More than 70% of South Africans use government facilities, yet there’s only about three doctors for every 10,000 patients in the public system. This means that the doctors who do work in state hospitals have a heavy workload. A 2021 study showed that working almost 60 hours a week is common, contributing to more than 80% of these workers experiencing burnout. Burnout is job-related stress which can cause exhaustion and negative reactions to patients.

“Doctors in South Africa frequently contend with heavy workloads and long working hours … making maintaining a healthy work-life balance challenging,” says Mzukwa. 

Safety at state facilities is also a problem. Between 2017 and 2022, about 200 violent incidents at public hospitals were reported across four provinces — and that’s only security issues that were big enough to get noticed.

In response to this week’s budget announcements, Sama says it hopes enough funds will be put towards dealing with “the shortage of doctors in hospitals and the plight faced by medical practitioners where salaries have been eroded by inflation over the years”.

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