Despite the chronic shortage of medical practitioners in South Africa, every year hundreds of newly graduated doctors are not placed in internships and community service positions, which raises the question of whether it is time to consider an alternative placement system.
Writing in the SA Medical Journal, legal experts C Eloff and D Eloff, suggest there are alternatives, and investigate whether the regulatory framework could be adapted to provide more flexibility for graduates who have not been placed and thus cannot complete their community service.
The recommended minimum doctor-to-population ratio for middle-income countries like South Africa is 18 doctors per 10 000 people, but in 2022, the actual number of medical doctors per 10 000 population in this country stood at only 7.94, which includes private healthcare facilities, they write.
With three doctors available for every 10 000 patients in the public healthcare system, unplaced doctors means fewer hands in hospitals. That means worse care, hindering the efficient delivery of medical services and exacerbating the existing healthcare crisis, already buckling under austerity measures and budgetary constraints.
Drawing on existing legislation, legal precedents and comparative examples from other jurisdictions, this analysis explores whether alternative solutions could alleviate the healthcare system’s burden while safeguarding the rights of medical graduates.
Experience
The Internship and Community Service Programme (ICSP) is aimed at ensuring newly qualified medical practitioners gain practical experience while addressing staffing shortages in public healthcare facilities. The goal is to provide hands-on clinical training for new doctors, and to distribute healthcare professionals to underserved areas, particularly rural and peri-urban communities.
Placements are allocated through a centralised system, with applicants ranking their preferred locations. Legal provisions under the Basic Conditions of Employment Act 75 of 1997 (BCEA) and the Labour Relations Act 66 of 1995 offer additional protections, but these are inconsistently applied to medical interns and community service doctors.
The BCEA’s salary threshold excludes many medical graduates from protections related to excessive working hours and overtime pay, and this lack of legal protection is particularly concerning regarding community service placements, where unplaced graduates are not only prevented from earning an income but, once placed, may be subjected to excessive workloads without the same labour rights as other professionals.
The combination of placement uncertainty and inadequate labour protections exacerbates the already difficult working conditions faced by the graduates.
Furthermore, section 27(1) of the Constitution guarantees the right to access healthcare services, while section 29(3) supports equitable access to education and training opportunities and section 22 guarantees the right to practise of a trade, occupation or profession.
But there exists a tension between these rights and the systemic inefficiencies hindering the effective deployment of graduates.
On the one hand, the state has a constitutional obligation under section 27 to ensure the provision of healthcare services, which includes maintaining an adequate workforce of medical practitioners. On the other hand, the failure to place medical graduates in community service posts directly contradicts this duty by leaving qualified doctors unable to work, despite the public health sector suffering from severe shortages.
The law says doctors must be allowed to work. The system hinders them from doing so.
That contradiction is failing SA. From the perspective of the graduates, section 22 guarantees their right to practise their profession, yet administrative inefficiencies prevent them from doing so, effectively blocking their ability to contribute to healthcare service delivery.
Section 29 of the Constitution is equally relevant, as it suggests that once a student has lawfully completed their education and met all necessary training requirements, artificial barriers – such as the failure of the state to place graduates in community service positions – should not prevent them from practising their chosen profession.
The state cannot insist on community service as a prerequisite for full registration while simultaneously failing to provide the necessary placements. This places an unfair and unconstitutional restriction on graduates who have completed their formal education and practical training but are still unable to enter the profession.
It calls for a constitutional interpretation of the Health Professions Act and its regulations to ensure that both public health goals and individual rights are upheld.
Inefficiencies
The regulatory framework governing medical internships and community service has resulted in significant inefficiencies and inequities, and it is inconceivable that medical practitioners who are not placed for compulsory community service are also not allowed to get out of this obligation.
Various alternative models could be explored to provide a more flexible and sustainable approach to graduate deployment, including exemption, a buy-out option, private sector placements, or international placements in countries with reciprocal agreements with the Government of SA.
While a comprehensive analysis of each proposed model is beyond the scope of this study, it is evident that the medical placement system requires urgent reform.
This article specifically focuses on the exemption option only, advocating a legally recognised exemption from community service for medical graduates who remain unplaced for more than three months after completing their internship.
The proposed amendment to the Health Professions Act would enable these individuals to enter private practice or pursue further specialisation, ensuring that trained professionals are not lost to bureaucratic inefficiencies that infringe on their labour rights.
However, effective implementation of an exemption system would require a comprehensive legislative and regulatory framework that ensures fairness, accountability, and the continued provision of healthcare services to underserved communities.
The system would have to be codified in legislation, with clear provisions governing eligibility criteria, the administration of exemption, and the obligations of medical graduates opting for this alternative pathway.
The most immediate and effective way to formalise this approach would be an amendment to the Health Professions Act, specifically section 24A, which currently mandates the year of community service as a prerequisite for independent practice.
By introducing a legally recognised exemption for medical graduates unplaced within three months of completing their internship, the regulatory framework would allow them to enter private practice, secure employment in accredited healthcare institutions, or pursue further specialisation without being unduly restricted by administrative inefficiencies.
Proposed amendment
Insertion of subsections (3) and (4) to section 24A: Exemption from Mandatory Community Service for Unplaced Graduates Amendment:
Section 24A of the Health Professions Act 56 of 1974 is hereby amended by the insertion of the following subsections:
(3) Notwithstanding the provisions of subsection (1), any person required to perform community service in terms of this section shall be exempt from such requirement if:
(a) the person has applied for community service placement through the National Department of Health’s Internship and Community Service Programme and has not been allocated a position within three months of completing their internship;
(b) the person has provided proof of completion of an accredited internship programme at a recognised medical training facility; and
(c) the Health Professions Council of South Africa (HPCSA) has confirmed the non-placement status of the applicant and has issued the appropriate certification for independent practice.
(4) The Minister may, after consultation with the Council, make regulations concerning the administration and implementation of the exemption contemplated in subsection (3), including but not limited to –:
(a) the procedure for verifying eligibility for exemption;
(b) the criteria for determining non-placement status;
(c) the obligations of medical graduates granted exemption, including registration requirements with the HPCSA; and
(d) any conditions necessary to ensure that the exemption mechanism does not compromise healthcare workforce planning.”’
In tandem with legislative amendments, the community service regulations will have to be adapted to integrate the exemption option into the existing medical graduate placement system. These regulations will require substantive revision.
The determination of which candidates can be exempted should be carefully calibrated to balance equity and sustainability. Manipulation of the system by medical practitioners to gain exemption should be avoided by appointing a strict oversight committee.
Regulations should stipulate clearly that any offer of placement by the NDoH within the first three months of the end of internship will automatically disqualify the medical practitioner from being exempted, regardless of whether he or she was offered a position that was on their preference list or not.
Where medical practitioners were not offered a position within the first three months of the end of internship, they should not be forced to accept the exemption, but rather be offered it as an option to accept or decline.
Some may wish to wait for a community service job offer, as it is often a beneficial training year and an opportunity to gain experience in a specific chosen field.
This system will necessitate a timeous start of the community service placement process for unfilled or declined posts to be redistributed among unplaced prospective community service medical practitioners.
The consequence of a slow placement process will be loss of human resources, as medical practitioners would be exempted from community service.
Where there is a delay in placing candidates as a direct consequence of administrative inefficiency, but the placement is still offered within the first three months of community service, the medical practitioner will not qualify for exemption but should be remunerated for the months during which they were unable to start work, as the NDoH is applying brakes on their careers, resulting in their only being able to join the free job market later than their peers who started their community service on time.
Scrap the system?
There have been numerous calls to abolish the compulsory community service requirement in SA, with critics arguing it constitutes an unfair and exploitative policy.
Advocates for its removal say no other field outside medical science, including law, engineering and education, requires such compulsory service before full professional registration.
But many state hospitals and clinics, particularly in rural areas, rely heavily on the annually placed community service doctors to maintain essential services, without whom the existing shortage of staff would be exacerbated and patient care would deteriorate further.
Compulsory community service for health professionals has been implemented in more than 70 countries since the early 1900s, often as a condition for government employment, postgraduate training, or licensing for private practice.
Countries like Australia require rural service for full registration of immigrant doctors, while India mandates a year of rural service for medical graduates.
If community service is to be reconsidered, careful thought must be given to what would replace it. Simply removing the requirement without implementing alternative solutions would probably worsen the healthcare crisis rather than improve conditions for medical graduates.
Conclusion
The systemic and repeated failure to place newly qualified medical practitioners in internship and community service positions is not just an administrative inconvenience, it is a fundamental policy failure that threatens the integrity of our healthcare system.
The status quo, in which unplaced graduates are neither allowed to practise nor provided with alternative pathways, is not sustainable.
However, the current rigid and inflexible model ignores economic realities, workforce mobility and evolving healthcare needs.
It also fails to account for the interdependent relationship between public and private healthcare. SA does not exist in isolation; skilled medical professionals are mobile, and failure to modernise policies will accelerate brain drain, with graduates seeking opportunities in countries where their skills are recognised and fairly compensated
Ultimately, the debate over community service is not about whether doctors should serve it, it is about how they should serve in a way that is both practical and just.
SA has the opportunity to lead in creating a fair, accountable and forward-thinking healthcare workforce model.
Whether it chooses to embrace this opportunity or continues to lose skilled professionals to inefficient bureaucracy will determine the future trajectory of its healthcare system.
C Eloff,1MB ChB, DCH (SA);
D Eloff,2 LLM, PGDip Human Rights Litigation
1 Western Cape Department of Health.
2 Faculty of Law, Akademia, Pretoria.
See more from MedicalBrief archives:
More doctors employed in 2023 than last year – Phaahla
Unemployed doctors labelled ‘too fussy’ about job placements
Post-community service doctors struggle to find jobs
Call for overhaul of junior doctors' training