The critical factor limiting local doctor supply and exacerbating the already severe shortage of doctors in SA is the constraint on the number of doctors being trained in the first place.
And while race is a criteria factored in the selection process of all SA medical students to address historical imbalances, recruitment of more black students in itself may not be the answer, notes MedicalBrief.
A Financial Mail analysis of the pros and cons of SA medical schools' admissions criteria comes as the SA Medical Association (SAMA) says it is prepared to take legal action if the national Department of Health does not resolve the allocation of posts for aspiring young health professionals still awaiting the opening of applications for positions.
With just a fortnight to go until the posts open on 1 July, the health department has yet to begin accepting applications for community service doctors and medical interns. Director for human resources information systems Victor Khanyile said the system “will open next week”, but was unable to give an exact date, reports BusinessLIVE.
The issue has placed in limbo the futures of hundreds of youngsters, and could delay young medical school graduates from qualifying as doctors while depriving clinics and hospitals of vital staff, particularly in rural areas.
The delay contrasts with the assurance from Health Minister Joe Phaahla in Parliament that all community service doctors would be allocated posts at least a month before they were due to start work.
Khanyile said most community service and intern posts had been filled in January, and the 200 to 300 applications anticipated for the mid-year intake were a “mop-up operation” to cater for people needing extra time to complete all their study blocks.
Meanwhile, the current dispute raging over who gets to be a doctor in SA is driven by the scarcity of opportunity: only 1,900 first-year places are available at 10 medical schools, reports Financial Mail.
The Organisation for Economic Co-operation & Development (OECD) put SA’s average at 80 doctors for 100,000 people – the second lowest of 36 countries measured.
It’s worse regarding specialists. A 2019 study by Percept found just seven full-time specialists in the public sector for every 100,000 people. The private sector averages 69 specialists per 100,000 people. Combined, the local public and private sectors provide 17 specialists for every 100,000 people – below the OECD average of 274.
Partly, the emigration of healthcare professionals and restrictions on foreign doctors working in SA contributed to the shortage.
However, attempts to ease the shortage is hamstrung by limited places in medical schools. That, in turn, has focused attention on the criteria determining selection to those few places – as in academic merit against race and demographic factors.
So how are applicants chosen?
Nine of 10 medical schools responded to the Financial Mail’s requests about admission criteria. All said their selection criteria include consideration of academic merit, race, gender and socioeconomic background. Most use the school quintile system as a determinant: quintile 1 schools are those receiving the highest state subsidies, and quintile 5 the lowest.
Universities also split classes between school leavers and students with relevant degrees.
Nelson Mandela University: NMU selects 60% of its students from the top three quintile schools (non-fee-paying), favouring students from the Eastern Cape and then elsewhere in SA.
Sefako Makgatho Health Sciences University: 80.2% of places for black applicants, 8.8% to coloureds, 8.5% to whites and 2.5% to Indians or Asians. A foundational medicine programme is reserved for black students from schools in the top two quintiles.
Stellenbosch University: 120 of the 290 places are reserved for top-ranked applicants. The remaining 170 slots ensure diversity: race and socioeconomic factors. The university tries to ensure the gender profile of selected candidates reflects that of the pool of applicants satisfying the minimum requirements.
University of Cape Town: Applicants meeting the basic requirements for the 240 places are categorised in three bands based on matric marks and national benchmark tests. Band A is guaranteed acceptance; for Band B a weighted-point score is used calculating a disadvantage factor, considering the school quintile school, family educational profile, income etc. For Band C, UCT ranks applicants according to a “faculty point score”. No Band C candidates were accepted in 2022 because applicants in bands A and B filled the available spaces.
University of the Free State: Minimum male or female representation of 40% for 180 places. At least 70% must be black, and the selection takes regional demography into account. It allocates 30% of its places to white students, five places to students from Lesotho, and 20% to students who already have a relevant degree.
University of KwaZulu-Natal: Of 250 places, 69% are reserved for black students, 19% for Indians, 9% for coloureds, 2% for whites and 1% for “other people”. UKZN favours top-performing applicants from the first three quintiles, and requires “sufficient applicants from rural areas”.
University of Pretoria: Of 300 places, at least 128 are filled to satisfy diversity factors. Ten of the remaining 187 are for applicants sponsored by the SA National Defence Force.
Wits University: The available 200 places are awarded to top-performing applicants as follows: 40% on academic merit, 20% to rural applicants, 20% from schools in the top three quintiles; 20% to black and coloured applicants falling outside the other categories.
Walter Sisulu University: Of 120 places, 80% are reserved for black applicants, 8% for coloureds, 7% for whites, 3% for Indians and 2% for “other”. Applicants are selected on academic merit and socioeconomic status, with most successful applicants from schools in the top three quintiles. There is no gender screening.
The University of Limpopo did not respond.
A controversial issue
The issue boiled over in January when Dr Angelique Coetzee, then chair of the SA Medical Association (SAMA), told CapeTalk that the selection process for medical schools was “highly political” and “racially biased”, and reduced the focus on academic achievement.
“Someone who has a D in maths, a C in science and a C in biology gets into med school,” she told the radio station. Coetzee’s remarks brought her into conflict with the medical association. When she stepped down as chair in February, SAMA released a statement saying she had “apologised … for any emotional hurt this may have caused”.
She said SAMA threatened her with a disciplinary hearing, but dropped that when she resigned from the board. “I’m still a SAMA member, and I serve on SAMA committees,” she said.
Months later, her position hasn’t changed. She tells the FM she has proof a medical school accepted a student with the marks she mentioned on CapeTalk.
But it’s not only SAMA that was up in arms. Prof Lionel Green-Thompson, chair of SA’s committee of medical deans and dean of health sciences at UCT, was also offended by Coetzee’s remarks.
“Nobody is admitting students with science (marks) below 60%. The maths marks are much higher than that,” he says, speaking in his capacity as deans’ committee chair. “Even if people get in with differential performances, this comment – that you can get in (to a local medical school) with a D in maths – is offensive, suggesting candidates are unworthy.”
Whatever criticisms of their admission criteria might be, the pass rates at SA universities’ medical schools seem up to scratch.
University of KwaZulu-Natal spokesperson Normah Zondo said the UKZN medical school has a pass rate of about 96%.
Stellenbosch University spokesperson Martin Viljoen said 97% of the 289-strong first-year cohort pass, while the rate at the second-year level is 94%. And Sefako Makgatho Health Sciences University spokesperson Lusani Netshitomboni said the university’s pass rate for the 149 students it accepted into its first-year MBChB programme last year was 97.5%; the second-year pass rate was 97.3%.
The University of Limpopo is the newest of SA’s medical schools, having opened in 2016. Of its original cohort of 60 students, 47 have now graduated – a 78% throughput rate.
More than academic results
In 2016, Green-Thompson co-authored an article in the SA Medical Journal that looked at local medical school admissions criteria.
The authors found that 39% of undergraduate medical school students were black, against a general population that was 80% black; 33% were white (against a national demographic of 9%); 14% were Indian or Asian (national: 2.5%); and almost 14% were coloured (national: 9%). So, relative to the national population, black medical students were severely under-represented, while other race groups were over-represented: 62% of local medical students were female.
But the article also found that stronger evidence was needed to link medical school throughput, academic success and future career paths to selection criteria. And an emerging black middle class complicated the definition of disadvantage by race.
Prof Shabir Madhi, health sciences dean at Wits, said the university’s medical school tries to be objective with admissions. “We try to remove any subjectivity … focus on academic performance. It (admission) is not a political issue, but to redress the inequity of the past.”
Still, Madhi said SA medical schools could not expect students from poorly resourced schools to compete with students from private schools. To suggest admission criteria are political, he added, “shows complete naiveté”.
In search of a solution
Given the high throughput rate of SA’s medical schools, and the competition for placement, a solution to the doctor shortage should be to increase training opportunities.
Frikkie Booysen, professor of health economics at Wits, said if SA is to increase the number of locally registered doctors, it needs more medical schools. “But building infrastructure takes time, and training facilities need to be appropriately resourced.”
There are other immediate ways to ensure a sufficient supply of doctors to meet SA’s growing demand. The government could bring additional foreign doctors into the country.
However, the importing of Cuban doctors has raised the ire of many South Africans, a News24 report last week stating that the government had coughed up a massive salary bill of R257 917 774 for 229 Cuban doctors.
DA MP Mimmy Gondwe had asked acting Public Service and Administration Minister Thulas Nxesi how many Cuban teachers, engineers, nurses and doctors were currently employed and the total cost of their employment. There are no Cuban teachers or nurses on the government’s payroll, but 65 Cuban engineers had already cost the state R50 394 855 in remuneration
Booysen said the government could work a lot harder to keep its doctors in South Africa, and stop them from emigrating by improving working conditions. This would reduce the need to import doctors from anywhere else.
State cash crunch for interns
Before practising as doctors, medical graduates must complete two years of internship and a year of community service. But in recent years, the government and the medical profession have been clashed over a lack of money and inadequate places for interns and community service doctors.
SAMA chair Dr Mvuyisi Mzukwa says in some years, about 600 of the about 1,500 medical interns who qualify from local medical schools (2,000-2,500 if graduates from Cuban schools are included) cannot find posts. This year, all graduates and interns were placed, he adds, but only after a fight with the government.
“It is incompetence,” Mzukwa says, blaming the national department of health.
Writing for Bhekisisa Centre of Health Excellence, Jesse Copelyn points out that it’s not just academics and race, but language and where people actually come from that “must matter” when it comes to the how universities select medical students.
Copelyn says research shows the race of a doctor in relation to his or her patients, the language they speak and where they grew up, can influence quality of care.
How well patients communicate their symptoms to a physician, and whether the doctor understands them is influenced by language, culture and background (like whether someone grew up in a rural or urban area).
Medical schools take some of these aspects into account when admitting medical students — but do these go far enough?
Copelyn observes that admission policies incorporating demographic factors like race, rather than solely using academic achievements, does not mean medical students who get in aren’t up to scratch.
Medical students have a much better pass rate than students in other courses, with graduation data showing more than two-thirds of SA’s medical students finish their degrees in the minimum six years: roughly 91% graduate within 10 years.
Plus, the drop-out rate is unusually low for medical students. Only 5% who started their degrees in 2008 had dropped out a decade later – compared with one in five for engineers and scientists.
And admitting only students with the highest marks would not necessarily give SA better doctors.
When it comes to clinical training, academic marks don’t seem to be a strong predictor of performance. US and UK research shows academic marks higher than the minimum requirement for getting into medical school don’t have a big effect on how well trainee doctors will work with patients.
Lost in translation
For good-quality care, doctors and patients also need to understand each other, but this becomes difficult when physicians and patients don’t speak the same language. A 2006 study at a paediatric hospital in Cape Town, where most patients spoke isiXhosa as a first language, but where doctors mainly communicated in English or Afrikaans, found that less than one in 10 medical interviews were in the patients’ home language.
Moreover, more than six out of 10 of the child patients’ parents said they struggled to understand the doctors’ English, while more than five out of 10 found it difficult to express themselves.
Yet even when doctors and patients speak the same language, race can affect their relationship.
Researchers think patients may be more comfortable discussing personal issues with a doctor of the same race, and trust them more. This argument is supported by a US analysis of studies investigating how race affects the doctor-patient relationship.
How much these findings apply to South Africa is hard to know, but local researchers have seen cases where race seemed to have a negative impact on the relationship between doctors and patients, even without language barriers.
But even being the same race is no guarantee doctors and patients will communicate well. Lekan Ayo-Yusuf, deputy vice-chancellor for research, postgraduate studies and innovation at Sefako Makgatho Health Science University, says simply admitting more black students to medical schools isn’t enough to fix communication issues between doctors and patients.
“If you post a (black) person who came from a private school in Pretoria to a rural area, they have a different culture even if they’re both Africans. So it should not just be about black Africans; it should be about rural black Africans.”
And rural dialects can complicate communication. As one isiXhosa nurse at a Cape Town hospital said: “Some patients speak that deep isiXhosa which we don’t know because we grew up here and ran away from that proper isiXhosa.”
We have a shortage of rural doctors. Medical graduates who grew up in rural towns are likelier to return to work in those areas than their urban counterparts. But only a few medical schools have policies to boost intake of students from remote areas.
Then there’s the language issue. Simply introducing language modules as part of students’ coursework isn’t enough to overcome communication difficulties.
Six out of 10 medical students from UCT said isiXhosa language classes didn’t help them when treating patients.
At Wits, where students took a weekly isiZulu class, one student said the course counted so little towards final marks that people didn’t make much effort. “Why study for something that counted for 1%, when you had a whole medical syllabus to learn?”
Financial Mail article – SA’s missing doctors (Open access)
BusinessLIVE report – Aspirant doctors in limbo over community placement
See more from MedicalBrief archives:
Medical school admissions: ‘SAMA slaps on a bandage while avoiding the wound’
Female medical students win compensation over entrance test bias
Ex-student to appear in court over alleged UKZN medical school bribe
Ban on affirmative action had ‘devastating impact’ on diversity at US med schools
UKZN on cash-for-places: 'We're committed to transparency'