Health Department blunders left Gauteng doctors without overtime pay in the past month, sparking an outcry and adding to uncertainty and growing concern over a ministerial review of overtime for state health workers, notes MedicalBrief.
A number of public sector doctors at facilities across Gauteng were not paid for overtime work on 29 April, without any notice, and affecting staff in facilities across the province. Only by 6 May did some doctors start to see payments reflect in their bank accounts.
More payments are expected soon given that, according to the Basic Conditions of Employment Act, the employer has seven days to settle, said the South African Medical Association (SAMA).
The national Minister of Health has convened a committee to review the future of overtime for state doctors, but there is growing resentment and tensions are rising as this payment blunder follows a protracted row over the department’s unilateral decision to cut and change the terms of commuted overtime in the province.
The current furore coincides with a study published in the SA Medical Journal revealing that nearly half of the total of 1 397 health professionals who completed a survey in Gauteng and Mpumalanga said they would resign if the remunerative work outside the public service (RWOPS) policy were to be ended.
Meanwhile, the delayed payments and the ongoing review of cuts and changes to commuted overtime pay has led to threats of protests and legal action, writes Ulfrieda Ho for Spotlight.
SAMA says it will make civil claims for salaries owed, including for interest and legal costs.
Registrars and medical officers at Dr George Mukhari Academic Hospital in Ga-Rankuwa collectively wrote to the hospital giving notice of withdrawal of overtime services until the non-payment issue is completely resolved, and on 7 May, the Head of Anaesthesiology at Sefako Makgatho Health Sciences University wrote to the CEO of George Mukhari Hospital to say no anaesthesia services would take place at the hospital starting on 8 May, given the decision by registrars and medical officers to down tools outside regular work hours.
Spotlight spoke to several health professionals who highlighted various concerns. These include resignations, an exodus of doctors, especially specialists from the public sector, plummeting staff morale, and negative impacts on the training of doctors as fewer consultants and seniors are available to supervise – putting universities’ training accreditations at risk.
Committee appointed
Last month, after a meeting between the SA Medical Association Trade Union (Samatu) and Gauteng Health, a circular was issued saying the National Department of Health was conducting a review of its own, instructing provinces to hold off on their plans.
Health Minister Dr Aaron Motsoaledi then set up a committee of experts to review certain human resource policies, including community service, commuted overtime, RWOPS and rural and related allowances.
Commuted overtime is a pre-determined amount of overtime that doctors employed by provincial Health Departments are allowed to work. The amount is historically decided by hospital management and is based on an employee’s role, seniority, their department and the amount of overtime they are allowed to safely work. It’s a fixed rate of 1.3 times the applicable hourly tariff for a specific work grade.
Doctors are now being required to motivate why they should remain on contracts that pay for more overtime hours, with junior doctors saying they are being pressured to sign option C contracts, which will pay for fewer overtime hours. There are also proposals to change some of the terms relating to overtime, including scrapping overtime payments for doctors who are on call but not physically present at a facility.
Many doctors already exceed the maximum hours of their contracts because of the emergency nature of their work, gross understaffing and backlogs at their hospitals.
Costly, but essential
The commuted overtime pay model has been contentious for years because it adds up to a sizeable chunk of the healthcare budget. According to a spending review in 2022 (on behalf of National Treasury), Health Departments spent R6.9bn on commuted overtime in 2021 – about 70% of the total R9.9bn spent on all types of overtime.
In an editorial published in the South African Medical Journal last month, and reported in MedicalBrief, health sciences academics, associations, and unions slammed Gauteng Health’s handling of pay issues. They argue that the basic salaries of medical professionals in the public health sector are already much lower than what would be considered fair pay.
“COT (commuted overtime) has long served as a critical mechanism to ensure that doctors are available beyond the standard workday, safeguarding round-the-clock care in the public health system…The abrupt curtailment of this framework risks hollowing out the after-hours safety net, leaving emergency rooms, wards and clinics dangerously under-resourced,” they wrote.
A co-author of the editorial, SAMA CEO Dr Mzulungile Nodikida, told Spotlight: “Medical doctors in South Africa’s public sector are severely underpaid. A study by SAMA has shown that even the annual cost of living adjustments that have been made on the salaries have not matched inflation in the past five years. Commuted overtime has had the effect of masking a deficient salary.”
View from the wards
Two doctors who spoke to Spotlight independently, and from two different Gauteng hospitals, say the commuted overtime pay disaster is yet another symptom of weak human resources and poor management from the Health department.
Dr A, based at Charlotte Maxeke Johannesburg Academic Hospital, said: “Instead of having a system in place to record how many hours each doctor is actually working and what overtime that person should be paid, the department pays everyone this commuted overtime fixed sum….You could be a dermatologist or a psychologist and have very few overtime hours or be a surgeon who is doing a lot of overtime but you all get paid the same if you’re on the same contract option.
“But right now, I’m working way more overtime hours than my contract and I’m not being reimbursed for any of it.”
Dr A said the overtime pay cuts and proposed changes will have an impact on her decision to stay in the public sector, and that doctors are now being under-valued and coming under attack by their own employer.
Dr B works at Chris Hani Baragwanath Hospital and he said the debacle over doctors’ overtime pay has pushed him to the edge.
Doctors are already overworked and disheartened from working within a failing system, he said. He sent photos of theatres and wards in darkness as power went off at the hospital for days at the end of April.
He said staff take their own toilet paper to work because they’re told there’s none. Most alarming, “doctors are not getting the training and supervision they need” and regularly perform surgeries and procedures without adequate experience and with no supervision.
“They are overwhelmed, overworked and doing way too many overtime hours that they’re not being paid for.
“We, doctors, are literally the ones putting patients’ lives at risk,” he said, adding that he is “surviving on anti-depressants” and has sometimes shut himself away in hospital storerooms crying tears of sheer frustration, exhaustion and exasperation.
Resignations and impact on training
Professor Shabir Madhi, Dean of the faculty of Health Sciences at the University of Witwatersrand, said the proposed cuts and freezing of posts and changes to commuted overtime pay had already resulted in resignations of some senior staff at state hospitals.
“If we don’t have the proper consultant staff complement in these hospitals who can provide supervision throughout the day, it compromises our training of specialists as well as of undergraduate students.
“If the Health Professions Council of South Africa were to do an audit and find that there isn’t adequate consultant cover and supervision, they could remove the accreditation of the training programmes offered by the universities.
“The medical schools are completely dependent on the Gauteng Department of Health to retain consultants and other categories of staff, and to ensure that staff are allocated time for supervision and training of future medical doctors, including specialist, as well as other academic activities.
“It means decision-making around cuts to overtime pay need to be cognisant of the overall impact that it would have, and not only in how it would assess budget constraints. This situation needs meaningful and informed decision-making,” he said.
Dr Phuti Ratshabedi, Gauteng chairperson of Samatu, said the non-payment of commuted overtime pay in April was a slap in the face from the provincial Health Department. He said the union had held a meeting with the department last month, and the agreement was that their contractual agreements for commuted overtime pay would be left unchanged at least until the end of March 2026 – the end of the financial year.
“We will be holding them to what they stated in their circular or we will look to legal action.”
Prove you’re not a ‘ghost’
In Soweto, a doctor at Bara was not only unpaid for the month of April – during which time she clocked up 80 hours of overtime – but she also had to prove she was not a “ghost worker”.
She was just one among many medics struggling to survive after Gauteng Health failed to pay their salaries, with some being unpaid for three months.
On Saturday, the department gave a long list of reasons for the salary debacle, warning that some doctors may not receive their May salaries either, reports the Sunday Times.
When the Bara doctor, who has worked for the department for more than a decade, asked why she had not received her April salary, she was told by the hospital’s HR department that she needed to prove she was not a “ghost employee”.
Now, two weeks into the new month, she’s still in the dark about when or if her outstanding salary will be paid.
Last week, doctors at Dr George Mukhari Academic Hospital held a two-day protest over non-payment of salaries. Some have not received pay for two months.
While there appears to be no pattern to the non-payment, the issue is believed to have affected most hospitals across the province, although Charlotte Maxeke, Dr George Mukhari and Bara are believed to be the ones worst affected, along with several clinics in the Johannesburg and Ekurhuleni metros.
The department’s spokesperson, Motalatale Modiba, initially decribed the non-payment problems as a result of “administrative and financial challenges”, but later said the issue was “confined to a handful of facilities owing to a number of factors, such as appointments made without the correct process (having been) followed”.
“Other submissions were only submitted by candidates as late as 7 and 8 May, which means they might not meet the next payment run. This was explained to them by their respective facility (managers),” he said.
Corrected submissions had since been captured, and mandates had been sent to e-Government for processing, with the next payment run set for this week.
Modiba said there were also allegations some supervisors had deliberately withheld application forms and submitted them late.
“(We) don’t take these allegations lightly, and they will be investigated to hold those responsible accountable,” he said.
Moses Mphahlele, an official at the National Union of Public Service and Allied workers in the City of Johannesburg, who has been assisting the unpaid doctors, accused the department of “arrogance”.
“In terms of the agreed policy, they cannot just freeze someone’s salary without notifying that person first about not having verified them,” Mphahlele said.
Meanwhile, a doctor in a paediatric unit said the food served to patients for the past two weeks consisted of instant soup and bread or pap, which did not meet the dietary requirements of some patients, and that they had used their own money to buy food for the patients.
When the Sunday Times visited Charlotte Maxeke, patients said they were bringing their own food with them, or buying it from vending machines, mobile kitchens or shops.
Modiba admitted there were food supply problems at Charlotte Maxeke. They were caused by compliance issues and the hospital got “contingency orders for in-house cooking”.
Outside work
Recently, a survey was conducted by three researchers from Wits, entitled Perspectives of doctors, nurses and rehabilitation therapists in Gauteng and Mpumalanga provinces’ public hospitals on remunerative work outside the public service (RWOPS), and published in the SA Medical Journal.
The authors, B P Matiwane, D Blaauw and L C Rispel from the Wits School of Public Health, concluded that there was significant variation in obtaining multiple job holding (MJH) permission among health professionals.
“The diverse perspectives underscore the need for targeted communication and stakeholder engagement to clarify policy and improve compliance,” they wrote.
The RWOPS policy enables public sector health professionals to engage in multiple job holding under specified conditions, but empirical evidence on health professionals’ perspectives on the RWOPS policy stipulations is lacking, they said.
Their objective was to examine the perspectives of public sector medical doctors, professional nurses, and rehabilitation therapists on the RWOPS policy, and in 2022, they carried out a survey among 14 Gauteng and 15 Mpumalanga province public sector hospitals.
In addition to demographic and employment data, the self-administered questionnaire collected information on whether the health professionals had obtained permission for additional jobs, their opinions on RWOPS approval requirements and restrictions and the likelihood that they would leave the public sector if RWOPS were denied.
A total of 1 397 health professionals completed the survey, for a response rate of 84.3%. Most doctors (61.1%) and rehabilitation therapists (60.5%) supported mandatory RWOPS approval, compared with 41.5% of professional nurses.
Doctors (OR 2.2, p<0.001), rehabilitation therapists (OR 1.5, p=0.027), males (OR 1.4, p=0.039) and RWOPS participants (OR 2.8, p=0.030) were more likely to consider leaving if RWOPS were denied.
See more from MedicalBrief archives:
Gauteng Health’s ill-considered cost-cutting risks patient care and training
Gauteng plan to review doctors’ overtime pay policy a ‘disaster’
Medical union threatens legal action and protests over overtime cuts
Doctors earning 13% less than they should, says SAMA
Overtime cuts impact on hospital services