Older public sector doctors are leaving to practice privately but are not staying too long, instead opting out of medicine entirely before the age of 50, according to research by the Board of Healthcare Funders of SA.
The latest research is based on the distribution of ealthcare professional providers (HPPs) registered on the practice code numbering system (PCNS) during the period between January 2000 to December last year. The report focused specifically on professionals registered on the PCNS in the past 17 years.
For a healthcare provider to claim from a medical scheme they need to be registered on the PCNS. The report says the study noted an increasing number of healthcare professionals registering on the PCNS, from 36,000 in 2000 to 54,800 last year, representing a 52% increase. Medical aid scheme beneficiaries also increased from 7m in 2000 to 8.9m last year, representing a 27% increase. “This has greatly increased the proportion of HPPs per patient in the private sector. In the fee-for-service environment, this brings challenges of supplier-induced demand as providers compete for patients,” the study noted.
The report says surprisingly, however, this increase of professionals was in tandem with an increase in their average age in most disciplines. This unexpected observation was “worrying” to the study’s author, Charlton Murove – he said it suggested that there had been an increase in the number of older professionals moving from state facilities to the private sector. By last year, the average age of anaesthetists, for example, was 50.4 years old, that of dentists was 46.6 years old, while that of radiologists and medical technologists was 49.2 years old, among other specialisations.
According to the national Health Department’s deputy director-general of the National Health Insurance, Anban Pillay, this only affirmed to them the need of a radical “transformation” of the health sector. “The movement of human resources as described by the report is also partly our own assessment of the health system and is partly our motivation of why the health system must be transformed. Health professionals respond to incentives like all other categories of workers … They will migrate to an environment that maximises their income.
“In the current two-tier health system that separates the rich and poor, the rich can afford to pay much more for health services than the poor, hence there will be a gradual migration away from the poor,” Pillay is quoted in the report as saying.
The study noted a disproportionate number of HPPs practising in the private sector compared with the public sector, particularly in terms of geographical location and population needs. This disproportionate distribution was acute in more specialised disciplines. For example, the department has a target of at least 3.66 general practitioners (GPs) per 10,000 people. This ratio is much higher in the private sector at 15.69 GPs per 10,000.
The report says the Western Cape had the highest density of specialists, followed by Gauteng. The two provinces’ ratios were above the department target of 2.85 specialists per 10,000 people – when looking at medical scheme beneficiaries, according to the report, the density of specialists was 8.95 per 10,000.
“This leaves a high burden of care for those in public facilities. This report notes the increasing number of HPPs in the provision of private care accompanied by an increase in their average age. This suggests two things – that training programmes to recruit new HPPs are inadequate and that the public sector has lost HPPs to the private sector over the years,” the study said.
Over the 17-year period, 29 300 HPPs deregistered their practice numbers and according to Murove’s report it’s unclear where they went, but possible reasons advanced were that some could have died, migrated or left to be employed in other parts of the health industry. “It is possible that these HPPs return to work in the public sector, but data from the public sector would have to verify this,” the study said.
According to the report, Murove recommended better planning and regulations to enforce efficient allocation of human resources. “The government should be looking at ways to create fair distribution of professionals. The distribution of health resources should be shaped by the needs of the population they service and equity should be a core principle guiding the distribution of resources,” he said.
The report said that it was imperative that the issue of certificates of need – as recommended in the Competition Commission’s health market inquiry recently – be revisited, as well as other incentive approaches, rather than prescribing to specialists where they should work.
The report says SA Private Practitioners Forum’s CEO Chris Archer agreed on creating incentives for doctors to practice in the public sector. “Many young specialists are faced with a situation where there are no posts in the public sector as there’s been a drive and focus towards primary healthcare more than tertiary, so there was a freeze in specialist posts. So, the private sector has been a safety net and has been able to accommodate them,” he said.
However, in relation to the certificate of need issue, which has the intention of encouraging doctors to only open practices in under-served places such as rural areas and townships, Archer said there needed to be a holistic approach. “If people are forced out of practising where they want to they will explore all their options elsewhere, which are more than servicing under-resourced rural areas. You have to take a holistic view. You have to give people options and provide incentives for those thinking of working in under-serviced areas.”
Health consultant Johann Serfontein said in a Cape Argus report that this was an indication of the poor working conditions within the country’s public sector. ‘The conditions in the public health sector are deplorable, and if the rest of the system is falling apart they are forced to leave,’ the report quotes Serfontein as saying.
He added that the interesting part of the research was that some health professionals were cancelling their practice codes. “This is clearly an indication that some of the health professionals are leaving the country, because if they are cancelling their codes it’s not for retirement, it’s usually because they want to practise somewhere else.
“Its deeply concerning because South Africa needs doctors,” Serfontein said.