A group of senior healthcare professionals have warned that drastic austerity measures introduced by the Gauteng Department of Health (GDoH), including the unilateral downgrading of commuted overtime (COT) tiers, the termination of sessional contracts, and non-filling of posts after resignations and retirement., will have serious consequences.
In an editorial in the SA Medical Journal, they write that the 'unethical' initiatives were also taken without meaningful engagement with affected stakeholders, and that the shockwaves have been felt through Gauteng’ entire public healthcare system.
They write:
At stake are not only overtime contracts and working hours, but the very foundations of patient care, professional training for medical students and specialist training, and the future sustainability of healthcare delivery in South Africa's most populous province.
Remuneration packages for doctors should not be split between standard working hours and after-hours services, and must be comprehensive, owing to the very nature of services rendered.
Furthermore, they should not discriminate among specialities and between specialists and generalists.
The European Working Time Directive (EWTD) offers an integrated model for working hours and compensation. SA should consider a similar approach.
In the current system, doctors’ remuneration in the public sector comprises a basic salary (standard working hours) and COT (after-hours remuneration).
COT has long served as a critical mechanism to ensure doctors are available beyond the standard workday, safeguarding round-the-clock care in the public health system. SA doctors routinely work 60 hours per week, with 40 hours serving as a normal work week and 20 hours forming part of overtime services.
The proposed change in COT will restrict these hours. The basic salaries for medical professionals in the public health sector fall well below a “fair remuneration” for the skills and expertise rendered.
The abrupt curtailment of this framework risks hollowing out the after-hours safety net, leaving emergency rooms, wards and clinics dangerously under-resourced.
In addition, the unilateral removal of sessional contracts compounds this issue, particularly in departments already grappling with unfilled posts and a de facto hiring freeze since October 2024.
A study by the South African Medical Association showed a significant salary deficit for public sector medical practitioners in SA between 2012 and 2022, with all categories of doctors’ salaries increasingly losing their real value.
Between 2019 and 2020, public sector doctors’ salaries reduced by 20% when compared against inflation.
COT, which is critical in ensuring 24-hour access to healthcare services in the public sector, has also significantly supplemented doctors’ salaries, contributing as much as 40% of some doctors’ total income. COT has therefore had the unintended consequence of masking the inadequacy of base salaries.
The study revealed the need for urgent reform to establish parity in remuneration, reduce reliance on overtime and align salaries with inflation, professional responsibilities, disease complexities and the value and social impact contributed by doctors, to ensure fair and sustainable compensation for all public sector doctors.
Three of the largest medical schools in the country fall within Gauteng Province. These universities produce ~25% of the medical graduates in SA, and are major contributors to medical research in the country.
Beyond the immediate impact on patient services, these decisions by GDoH strike at the heart of training for future healthcare professionals. Clinical instruction does not pause at 4pm. Junior doctors, interns and registrars require hands-on mentorship throughout the 24-hour cycle.
Without adequate senior supervision, training will be compromised, and so too will patient safety. Additionally, modern technology allows for both medical care and supervision of junior doctors virtually, telephonically and over platforms such as WhatsApp.
Telemedicine now constitutes an integral part of the SA health system, and should be embraced by the GDoH and implemented in all health facilities. On-call professionals providing essential life-saving cover and advice should be fairly remunerated, and should not be penalised for not being “on site”.
The erosion of training environments threatens the long-term resilience of the public health system itself.
While the GDoH might argue that fiscal constraints necessitate such measures, the method of implementation – unilateral, non-transparent and seemingly disconnected from on-the-ground realities – reflects a profound misjudgement.
Healthcare professionals are not commodities to simply be recalibrated to balance a budget spreadsheet.
They are the core of the healthcare system, and their presence, particularly for after-hours calls, is non-negotiable when it comes to ensuring patient safety and quality care.
This could have a profound effect on the plans for providing universal healthcare and implementation of National Health Insurance. There is a risk that this decision, if left unchallenged, could trigger a cascading effect: loss of morale, flight of talent to the private sector or overseas, de-accreditation of undergraduate and postgraduate training, and a further entrenchment of the inequities between public and private care.
The uncertainty of future salary packages is already creating significant anxiety among healthcare workers, and some doctors have already resigned to take up offers in the private sector. The GDoH needs to immediately rescind the proposed austerity measures and engage meaningfully with all relevant stakeholders – including academic institutions, unions and professional councils.
Fiscal prudence must not come at the cost of lives, dignity and the future of our healthcare system.
Collaboration, transparency and respect for the profession must be the cornerstone of any meaningful reform. Let us be clear: austerity should not be a blunt instrument swung in desperation.
It must be a carefully wielded scalpel, guided by evidence, compassion and consultation.
Anything less is not only reckless, it is unethical.
Flavia Senkubuge, University of Pretoria; Priya Soma-Pillay, University of Pretoria; Debashis Basu, University of Pretoria; Shabir Madhi, University of the Witwatersrand; Feroza Motara, University of the Witwatersrand; Patrick Lekgwara, Sefako Makgatho Health Sciences University; Pagollang Motloba, Sefako Makgatho Health Sciences University; Willy Vangu, University of the Witwatersrand; Mzulungile Nodikida, South African Medical Association; Simon Madini, South African Medical Association Trade Union (Samatu); Mike Sathekge, University of Pretoria; Mhlengi Ncube, South African Medical Association (Health Policy); Lawrence Chauke, University of the Witwatersrand; Ruhann Botha, Junior Doctors Association of South Africa; Tladi Ledibane. Sefako Makgatho Health Sciences University; Ashraf Coovadia, University of the Witwatersrand; Ndlela Dhlodhlo, Sefako Makgatho Health Sciences University; Shakeera Holland, University of the Witwatersrand; Cedric Sihlangu, South African Medical Association Trade Union (Samatu); Zaheer Bayat, University of the Witwatersrand; Risenga Chauke, Sefako Makgatho Health Sciences University; William Oosthuizen, South African Medical Association (Legal); Langanani Mbodi, South African Medical Association Trade Union (Samatu).
See more from MedicalBrief archives:
Medical union threatens legal action and protests over overtime cuts
Overtime cuts impact on hospital services
Sama warning as Limpopo Health aims to slash doctors' long hours