With the number of unemployed recently qualified doctors standing at almost 700, Health Minister Joe Phaahla this week said provinces are unable to afford to create posts as medical officer salaries are high and the health budget has already taken cuts.
The department is apparently working with provinces to place doctors and other health professionals, writes Zano Kunene for Bhekisisa, but as Phaahla noted, the medical negligence claims of around R900m paid out in just one province in a recent financial year would have been enough to employ the 694 unemployed doctors.
Although Phaahla didn’t name the province, a 2023 report from the Auditor-General shows that in 2021, the Eastern Cape paid out almost R867m in claims, while the salary bill for 694 newly qualified doctors (in 2023) would have been around R838m.
But Phaahla did admit: “It is a paradox. On the one hand, we’re dealing with amounts of money being paid out for claims, while at the same time we’re unable to employ people who help to reduce this.”
The SA Medical Association Trade Unions (Samatu) told Phaahla recently that at least 800 unemployed medical doctors were on its records. But Phaahla said this number dropped to 694 after the list was double-checked against the state’s employee database, showing these doctors had completed their community service on 31 December.
He said 239 medical officer positions had now been advertised and 400 more would follow in the next few months. (A medical officer is an entry-level GP who works in the public health sector). Most of the positions are in Gauteng, Mpumalanga, Free State and the Eastern Cape.
Limpopo has been unable to release posts as there is an ongoing court case between the Limpopo Department of Health and the South African Medical Association Trade Union.
Available jobs
Phaahla said they would like the process to be seamless so that once someone had completed their internship and community service, they would be free to look for any available opportunities.
“It is multi-pronged. We are working with provinces and identifying vacancies so that we can advise those who approach us about where they can apply.”
Ironically, South African universities have, in less than a decade, increased the number of medical interns they’ve trained by about 60% – from 1 470 to 2 365, Phaahla said – to address the doctor shortage in government hospitals and clinics, but the national Treasury has not increased provincial Health Departments’ budgets at the same pace.
As a result, they don’t have budgets to employ the increasing number of graduates, despite many vacant positions.
Provincial Health Departments, according to Phaahla, spend 70% of their budgets on health salaries, but it’s not nearly enough. They also pay doctors for overtime, and offer rural allowances for doctors working in these areas, reports Daily Maverick.
“The risk in terms of this is that it crowds everything, in terms of medicines, linen, clinical equipment like x-rays, ultrasounds… everything you need to run the services becomes quite crowded,” said Phaahla.
In 2021, about one in seven doctors’ positions in hospitals were unfilled, while one in five positions for doctors were vacant at clinics. This shortage of professionals, and given that more than 70% of South Africans use government facilities, means there are about three doctors for every 10 000 patients in the public system.
More money
With the increase in the number of students trained at universities between 2018 and 2023, the state had to find budget to pay 895 more interns within five years, which was more than R800m, at a salary of R900 000 per intern per year (this includes overtime).
The number of community service doctors, who earn around R1.2m per year (R1.3m if they work in a rural area), grew by almost 60% too, between 2020 and 2024 (from 1 340 to 2 101), meaning the government had to fork out an extra R913m for their salaries.
Phaahla warned that the pressure on the Health Department’s purse was worsened by a 7.5% increase in public health worker salaries, negotiated between the government and trade unions in 2023, meaning fewer new workers can be appointed.
“We received around 65% of the additional costs (caused by the salary hike)… a bit of a cushion, but we still needed to find within our budget the remaining 35%.”
He reiterated that there was no “automatic placement” for qualified doctors in the public sector.
“While we wish that (employing newly qualified doctors) would be seamless, we must take into consideration that, once out of the regulated training and community service, (they) are almost like any other profession: when (you’ve) completed all your training, you are going to (apply) where opportunities are.”
Community service
Medical school graduates must complete two years of internship training at designated health facilities accredited by the Health Professions Council of South Africa (HPCSA).
After this, they have to do a year of community service in a facility designated by the National Department of Health in consultation with provincial Health Departments.
“The hospitals designed for community service are slightly different from the internship because the internship is regarded as practical skills training and that’s why it is designed by HPCSA… the purpose of introducing community service was to improve clinical skills and also provide services in the underserved areas,” said Phaahla.
Teaching hospitals and central hospitals are eligible to train interns but cannot be used for community service as they are not considered to be under-serviced.
“For community service, it will be rural hospitals, township hospitals and other marginalised areas,” he said.
Once a doctor has finished community service, they are registered with the HPCSA in the Medical Officer Independent Practice category, meaning they can work independently without supervision, including as a single private practitioner.
Phaahla clarified that the issue of funded posts did not affect the training of medical doctors. He said all graduates who were eligible for an internship had been placed as well as those who had finished their internships and were eligible for community service.
“I want to say unequivocally in terms of internships and community service – which we regard as a statutory obligation by the state – we don’t have graduates fresh from medical school who are stranded in terms of getting internships. Those posts are funded and everybody eligible has been allocated,” he said.
This is possible due to the human resources training and development grant, Daily Maverick reports.
“We do allocate to provinces. That amount is protected, it is ring-fenced, and provinces also do add because this category of doctors also provide very valuable services at the facilities where they are working,” he said.
Pressed about whether the department’s funding woes are plunging the public health system into crisis, the Minister responded that “it’s really a choice of description” as to what you call a crisis.
But in December, a committee of deans representing health sciences faculties from South African universities warned that failing to fill community service posts – whether for doctors or any of the other health professions like dieticians, dentists, physiotherapists and radiographers – could lead to exactly that in future.
Why? Because not having enough money available for community service posts will affect the quality of care for patients, especially in rural areas, the exact communities the in-service training programme was supposed to help, they wrote in a statement.
“We already have poor provision of these services across our system and community service appointments are often the only care our people get,” Lionel Green-Thompson, dean of health sciences at the University of Cape Town and chair of the South African Committee of Medical Deans, told Bhekisisa.
Green-Thompson added that medical schools were also concerned about posts not getting filled being a regular occurrence.
Treasury vs training
In their December statement, the committee of deans said they were concerned that budget cuts would affect the quality of training for health sciences students, which would have a knock-on effect on service delivery in state facilities.
Already, community service placements are determined more by the needs of the facility, with less of a focus on training and improving the skills of newly graduated healthcare workers.
Rural facilities in particular don’t have many permanent healthcare workers, as it’s difficult to keep staff there because of poor conditions like malfunctioning equipment at hospitals and clinics, staff shortages, and bad roads making it difficult to get supplies.
Many of these facilities therefore rely on the work provided by new graduates doing their community service.
Although universities have answered the government’s calls to increase the number of graduates in health sciences, provinces are struggling to match the supply with available posts, said Green-Thompson.
Having graduates sitting at home while they could have been deployed to areas in need will leave many patients without access to professionals like speech pathologists and occupational therapists in the public sector, he observed,
See more from MedicalBrief archives:
Unemployed doctors labelled ‘too fussy’ about job placements
Unions deny that young doctors are refusing rural jobs
Cum laude medical graduate sitting at home, unemployed
Tight budgets hamper state employment of new doctors
Eastern Cape ruling could change how medico-legal claims are settled