According to a University of Cape Town study, a worrying number of doctors are not showing up for compulsory community service, writes Karen MacGregor for MedicalBrief. On the positive side, the proportion of medical graduates intending to emigrate has plummeted and the overwhelming majority of these new young doctors believe they made a difference and experienced professional development during one-year community service.
This despite often challenging circumstances, and the fact that a shocking 64% had perceived a risk to their personal safety during community service.
The proportion of doctors who plan to move overseas dropped steeply from 43% in 2001 to only 5%. At the same time, up to 16% of doctors are not showing up for compulsory community service and may be lost to the health sector, up from an average of 11% from 2001 to 2007.
There are several possible reasons for this, including exit from the profession, emigration and career interruption. Also, if doctors not satisfied with posts they are allocated for community service, they might not turn up initially.
However, said Professor Steve Reid of the University of Cape Town: “The most intriguing finding is that doctors’ attitudes towards community service changes for the positive through the course of the year, and this has become more positive over the past 15 years.
“This is despite the challenging nature of the public health services, and points to the resilience that South African doctors are known for,” Reid told MedicalBrief this week.
Another interesting finding is that doctors in rural health facilities had generally more positive attitudes than those in urban facilities, despite having less supervision. “Almost all of them felt they had contributed positively and developed professionally,” said Reid.
The number of medical doctors eligible for community service varies from about 1,150 to 1,300 a year, with another 300 dentists. Overall, 91% believe they made a positive difference during community service, and 81% experienced professional development.
The first systematic review of 15 years of community service was collated mainly from annual surveys of doctors and dentists conducted with the national Department of Health, and draws on work by Africa Health Placements, the Health Professions Council of South Africa (HPCSA), the University of Cape Town and the Foundation for Professional Development (FDP).
The report on Community Service for Health Professionals was produced at a summit held in Tshwane last month, convened by the FDP Lighthouse Project, which uses research to provide evidence to inform policy and interventions.
The aims of the initiative were to initiate a review of community service policy and propose improvements, to understand community service in the context of the National Human Resource for Health Strategy 2012-2017, and to survey 15 years of experience by doctors and dentists in order to understand what affects its implementation, positively and negatively.
There are some 70 countries globally that have a system of compulsory service for health professionals, which was introduced in South Africa to ensure the availability of human resources in underserviced areas and also to provide an enabling environment for new professionals to acquire experience.
Community service was legislated in 1997 and implemented in 1998, starting with medical practitioners and then expanding. Today, all newly qualified health professionals – some 8,500 a year – are legally required to complete a year of service, which involves paid work in public sector health institutions around the country.
Typically, service placements are allocated when a graduate registers for the first time with a professional council. Professionals who do not complete community service are restricted from practicing independently in South Africa – but, importantly, graduates are able to practice outside the country without completing community service as it is not part of the academic curriculum.
More research findings
Overall, the research found, the community service experience has been increasingly seen as positive. Since 2001, experiences of good clinical supervision had improved, along with the availability of senior professionals and support for doctor concerns.
But there was declining satisfaction with community service orientation and facilities management. Nine in 10 respondents said they had done overtime work and, in 2013, 71% of doctors reported doing more than 20 hours overtime a week. Some 61% of doctors found their accommodation satisfactory – but a shocking 64% perceived risk to their personal safety.
The research found that future work intentions varied annually. While plans to move overseas dropped substantially, 8% of doctors surveyed intended to move into the private sector, 62% said they planned to specialise – and only 2% intended to work in a rural area.
The proportion of doctors allocated one of their top five placement choices grew from 77% in 2001 to 81% in 2009 and then remained in this range. But in 2014, only 70% of doctors were satisfied with the allocation process.
The number of respondents who said they received a provincial bursary has doubled, from 22% in 2009 to 42% in 2014. The percentage of doctors placed in rural areas in recent years hovered around half – a vast improvement on the 25% placed in 2001, according to Reid.
In 2014, the research found, 36% of community service practitioners intended to remain at the same facility, quite evenly split between doctors in rural and urban areas. Four in 10 had no bursary obligations “and presumably made a voluntary choice based on the experience during the community service”.
The research found that more populous provinces received more doctors – but this is not the case for more rural provinces.
“The number of accredited facilities is less than the number of allocated professionals in Limpopo, Mpumalanga, North West, KwaZulu-Natal, Northern Cape and Free State – some of the more rural provinces. This suggests a lack of infrastructure in underserved areas, and potentially supervisory support, which remains a barrier to support isolated professionals.”
The research showed that the Community Service Policy is still relevant and appropriate in advancing the National Human Resource for Health Strategy 2012-2017 and other policies such as the National Development Plan.
There were two primary areas of weakness – standards and support, and retention in rural areas after community service.
First, many health facilities did not provide a safe and adequately equipped working environment, and clinical and managerial support was often lacking. Policies were needed to improve orientation, clinical supervision, management support, and availability of equipment and pharmaceuticals. Also, safety and security concerns should be addressed.
Second, policy did not tackle the problem of retaining professionals in rural, underserved areas after community service, resulting in low retention and high staff turnover.
Proposals to improve the experience include professional development opportunities, study leave, job security through contracts that extend beyond the service year, and universities to prioritise doctors from rural services for specialisation posts.
With South Africa’s public health system dependent on doctors and dentists, the report makes recommendations that “draw heavily on the concept of multi-stakeholder partnerships” to tackle challenges linked to community service.
Partnerships between government and the health profession could improve problem areas such as doctor accommodation, continuing professional development, personal isolation, lack of community support, inefficient and untransparent service placements, lack of orientation and clinical supervisors and technical assistance, and documentation of completion.
Community service is meeting its objective of increasing skilled human resources in rural and underserviced areas, with around 50% of doctors receiving rural allowances.
An unstated objective of community service was the hope that exposure to rural practice would grow interest in practicing in such an environment. But on average only 16% of community service doctors reported intending to work in rural and underserved communities. And the percentage has been dropping – to 11% in 2013 and only 2% in 2014.
This, along with the trend towards fewer doctors showing up for community service, should provide “major motivation” for the urgent implementation of the recommendations to improve the acceptability of community service.
Professor Steve Reid
Head of the Primary Health Care Directorate
University of Cape Town
Tel: +27 (0)21 406 6781