Doctors working in South Africa’s state clinics and hospitals are heavily underpaid, according to the South African Medical Association (SAMA) – yet they earn up to three times more per month than what some make in a year in other middle-income African countries, like Kenya and Nigeria, writes Zano Kunene for Bhekisisa.
Last week, Finance Minister Enoch Godongwana allocated more than R15bn to the national Health Department to help deal with its staff crisis, and create jobs for around 700 unemployed medical graduates.
The department will have R848bn to work with over the next three years, of which R11.6bn will cover the 7.5% wage settlement from last year and an extra R3.7bn will pay salaries in the current financial year.
However, SAMA says public sector doctors are not being paid enough, with CEO Mzulungile Nodikida saying that a study commissioned by the association showed doctors employed by provincial Health Departments “are earning 2015 salaries”.
He conceded, though, that their salaries are “above what other similar income-level countries pay their doctors”.
For example, in Kenya medical interns were paid around Ksh122 000 and Ksh145 000 per month (including risk and housing allowances) according to the 2013 Salaries and Remuneration Commission’s allowances for government employees. This works out to around R16 000 to R19 000 a month, compared with the almost R28 000 a medical intern earned monthly in South Africa that year.
Similarly, an entry-level medical officer (which, in South Africa, means the completion of two years’ internship and a year of community service) was paid Ksh250 000 (about R32 500) a month in Kenya from 2013, whereas their South African counterparts earned almost R62 000 per month.
Salaries for doctors in Nigeria – which is experiencing a large-scale exodus of doctors – are even lower.
Data from the National Salary, Income and Wages Commission in Nigeria shows that an entry-level doctor currently earns roughly NN1.8m (about R22 000) per year, compared with someone in a similar post in South Africa getting more than three times that per month – in other words, South African medical officers earn 40.9 times more than Nigerian entry-level doctors (R900 000 vs R22 000 per year).
The Health Department says it has not yet looked at why SAMA claims doctors should earn more. But spokesperson Foster Mohale said they have “had meetings …and are planning to review our salary scales”.
How increases are calculated
After negotiations between the government and trade unions last year, the department settled on a 7.5% annual salary increase for its workers (as for the rest of government employees). This took a large chunk out of departments’ budgets, leading to their having to cut costs elsewhere.
Ironically, finding the money for the salary increases contributed strongly to vacant posts at state hospitals not being filled. More than 70% of the health budget is spent on salaries.
In 2009, the Health Department implemented an occupation-specific dispensation (OSD) for its employees – a table stating the basic salaries for government workers across different departments given their skill level and expertise.
It was established specifically to keep skilled professionals in the government service by making sure they get salary increases aligned with their field of expertise and experience.
Each post in which doctors work has different levels, with a specific basic salary linked to it, e.g, an entry-level medical officer would be on a Grade 1 salary, which sits at just more than R900 000 a year. A medical officer is a doctor who has completed their mandatory two-year internship and a year of community service and works at a public sector hospital.
After five years in the position and depending on their performance, they can move on to a Grade 2 salary in that post, and earn a basic starting salary of just more than R1m. Grade 3 medical officers earn between R1.2m and R1.5m a year.
Have increases kept up with inflation?
The SAMA-commissioned study suggests money is a big issue. Like all other public servants, doctors get an annual increase, yet the study notes that doctors have felt “a significant erosion in income levels” over the past few years because of small increases, particularly, they say, considering “inflation as well as cost-of-living pressures”.
Between 2013 and 2019, yearly increases were above inflation, but in 2020, the government implemented a salary freeze to keep its wage bill in check.
For two years after, increases have been below inflation: 1.5% in 2021, against an inflation rate of 4.5%, and a 3% increase in 2022 while inflation sat at 6.9%.
“If you’re to retain the current doctors, then you need to compensate (them) appropriately,” said Mzukwa.
Long working hours because of too few personnel, and safety concerns, both at urban and at rural facilities, were also mentioned as deterring doctors from staying in public service.
More than 70% of South Africans use government facilities, yet there are only about three doctors for every 10 000 patients in the public system. A 2021 study showed that working almost 60 hours a week is common, contributing to more than 80% of these workers experiencing burnout.
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