Review of SA’s 15 years of compulsory community service for doctors

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CommunityservicedoctorsThe SA experience of compulsory Community Service (CS) over the first 15 years has been ‘overwhelmingly positive’, largely meeting objectives of redistribution of health professionals and professional development, found a University of Cape Town study.  However, better mentoring and support was needed, as well as more effort to keep doctors in rural areas afterwards.

The report says between 1998, when community service began, and 2014, 17,413 doctors completed a year-long placement in a public health facility. The scheme was expanded to dentists, pharmacists and eventually all health professionals, including nurses, and the annual cohort of 8,000 was now “an indispensable part of the provincial health services”, said Steve Reid, professor of primary health care at the University of Cape Town Medical School.

After “uncertainty and resentment” in the first few years of community service, the study found an overwhelmingly positive attitude had developed among doctors.

“The great majority believed that they had made a difference (91%) and developed professionally (81%) over the course of the year,” said Reid. “But only about half felt adequately supported clinically and administratively. “(Community service) has largely met its original objectives of redistribution of health professionals and professional development.”

Statistics reported in the research paper include: 89% of doctors turn up for their community service. “The 11% who do not take up community service annually is cause for concern, as these 120-150 young doctors represent the output of one entire medical school,” said Reid; the proportion of black doctors increased from 17% in 2001 to 45% in 2012, while the proportion of whites decreased from 50% to 33%. “These reciprocal changes were particularly rapid in the period 2009-2012”; 80% of applicants found places in one of their first-choice facilities, with the rural provinces (Eastern Cape, Limpopo, Northern Cape and North West) finding it hardest to attract doctors; and 30% of doctors decided to stay at their placement site once they completed community service, and 15% said they were prepared to work in rural or under-served areas.

“Clearly the community service workforce is a reliable recruitment strategy, bring 8,000 fresh young graduates into the public service each year to fill the posts vacated by their predecessors,” Reid is quoted in the report as saying.

“But the temporary contract nature of these posts creates a situation of constant staff turnover and does little to create a stable long-term workforce. It is better to have one doctor for 10 years than 10 doctors for one year, as the continuity of relationships in medicine is not only more efficient but also leads to greater job satisfaction.”

Reid said having the skills and confidence to make a difference during community service, which followed a two-year internship, “allows young doctors to stand on their own feet professionally and fulfil a real need”.

He added: “The direct exposure to the consequences of resource restraints in the public health service, including a relative lack of supervision and support, while not ideal, nevertheless serves to develop resilience in our young professionals for the challenges of future practice.

“By comparison, those trained in well-resourced settings do not cope as well.”

Background: Compulsory community service (CS) for health professionals for 12 months was introduced in South Africa (SA) in 1998, starting with medical practitioners. Up to 2014, a total of 17 413 newly qualified doctors and ~44 000 health professionals had completed their year of service in public health facilities around the country. While a number of studies have described the experience and effects of CS qualitatively, none has looked at the programme longitudinally.
Objectives: To describe the findings and analyse trends from surveys of CS doctors between 2000 and 2014, specifically with regard to their distribution, support, feedback and career plans.
Methods: A consecutive cross-sectional descriptive study design was used based on annual national surveys of CS doctors. The study population of between 1 000 and 1 300 each year was surveyed with regard to their origins, allocations, experiences of the year and future career plans.
Results: The total study population varied between 1 057 and 1 308 each year, with response rates of 20 – 77%. The average turn-up rate of 89% showed a decreasing tendency, while 77% of respondents were satisfied with the allocation process. Over the 15-year period, the proportion of CS doctors who were black and received a study bursary, and who were allocated to rural areas and district hospitals, increased. The great majority believed that they had made a difference (91%) and developed professionally (81%) over the course of the year, but only about half felt adequately supported clinically and administratively. The attitude towards CS of the majority of respondents shifted significantly from neutral to positive over the course of the 15 years. In terms of future career plans, 50% hoped to specialise, a decreasing minority to go overseas or into private practice, and a constant 15% to work in rural or underserved areas.
Conclusions: This study is the first to track the experience of compulsory CS over time in any country in order to describe the trends once it had become institutionalised. The SA experience of CS for doctors over the first 15 years appears to have been a successively positive one, and it has largely met its original objectives of redistribution of health professionals and professional development. Greater attention needs to be given to orientation, management support and clinical supervision, and focusing professional development opportunities on the important minority who are prepared to stay on longer than their obligatory year. CS still needs to be complemented by other interventions to capitalise on its potential.

SJ Reid, J Peacocke, S Kornik, G Wolvaardt

The Times report
South African Medical Journal abstract

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