Community service placements for young doctors have been beset by poor planning, uncertainty and financial insecurity, leading to a group of experts questioning whether it's time to ditch the programme, writes MedicalBrief.
Compulsory community service – introduced in 1998 – has long outlived its purpose, and should have been phased out nearly a decade ago, according to the local specialists, who say practicalities have increasingly outweighed the original ideological rationale needed to forge a new way in our healthcare system.
In a letter published in SA Medical Journal, they write that when the government introduced the policy 26 years ago, unsurprisingly, the first category of public sector workers affected were medical practitioners.
In the ensuing years, others followed, with healthcare professionals representing the dominant sector forced to perform mandatory community service after completing their basic training.
The community service plan had an ideological root within the framework of 1990s ANC health thinking, and was something the late President Nelson Mandela envisioned as part of his Reconstruction and Development Programme.
The community service policy was ideologically understandable in the 1990s, when rural and peri-urban areas had fewer doctors and other healthcare workers. The aim was to direct and ensure an adequate supply of community service medical officers, or ‘COSMOs’, to these underserved areas. Junior doctors initially resisted, but Health Minister Dr Nkosazana Dlamini-Zuma prevailed, and enacted it.
Community service was set as a one-year requirement after a one-year period of internship. The policy was enabled through a regulatory change to the Health Professions (Medical, Dental and Supplementary Health Service Professions) Act 56 of 1974 that created a category of ‘Medical Practitioner – Community Service’ after the period of internship.
Completion of community service became mandatory before registration in the ‘Medical Practitioner Independent Practice’ category.
The situation was further compounded by the extension of internship to two years in 2004; within a short period, new doctors went from a one-year internship to facing a minimum of three years before they could register for independent practice and pursue their careers.
No other cadre of healthcare worker or professional group in SA is held to such an extended period of state-controlled practice. In total, our medical graduates now face a minimum of nine years (six years of undergraduate study, and three years of internship and community service) before they can freely choose where to live or how to work.
In addition to this highly discriminatory legislation, the annual application and allocation process for interns and COSMOs to the various health facilities has created an administrative nightmare for the National Department of Health (NDoH), and has consistently proven to be a complex logistical challenge that it has struggled to manage effectively.
Each year, the process repeats itself: interns and COSMOs left without posts, spouses separated, changes and allocations occurring so late in the year that neither the doctors nor the facilities can plan appropriately.
The uncertainty, inefficiency and unfairness of the process cause significant harm to the well-being and mental health of our graduates.
We now face a crisis.
Austerity is real, and economics is a demanding and unemotional task master. This year, the NDoH has made a unilateral decision to reduce internship posts and expand COSMO posts for 2025. This decision appears to be in response to the looming crisis of available COSMO posts.
The consequence of this incomprehensible decision is potentially disastrous for our current healthcare systems. The fact that most of us learnt of it through a media report in a newspaper, Business Day, in early October, is unfathomable.
Internship posts have been cut, and some (but not all) are being replaced by COSMO posts, often in urban areas, inherently undermining the foundational principles of the original policy.
COSMOs are not interns, and will not function seamlessly in parallel, and already overburdened systems will be pushed beyond their current limits.
This situation highlights a lack of foresight, planning and judgment.
In addition, these decisions are still unsettled by mid-November 2024, leaving no time for doctors and healthcare facilities to make informed adjustments.
The COSMO legislation is outdated, and much has changed since its inception. We are now facing massive urbanisation, increased immigration, and an evolving and intensifying disease burden. The question as to whether the policy has had a meaningful impact is not the purpose of this opinion and warrants a separate factual interrogation.
It is clear that the NDoH’s decision on 2025 illustrates that the community service policy has long outlived its purpose. It should have been phased out nearly a decade ago.
The internship programme needs strengthening, and after completion, medical officer (MO) and registrar posts must be made available.
These positions should offer both generalist and specialist career paths that align with the needs of our healthcare system, address the current disease burden and support the career aspirations of the doctors we aim to train and retain in the system.
Internship is a crucial stage in the training of newly qualified doctors, forming the foundation upon which the careers of the next generation of medical professionals are built. Altering this process unilaterally poses a risk to both healthcare services and the development of the next generation of young doctors.
To ensure the integrity of medical training, every graduate must be given an opportunity to complete the internship without delay, and the additional posts created by scrapping the COSMO cadre must be made available for much needed MO and registrar posts.
Signing the letter were Mark Sonderup – University of Cape Town and Groote Schuur Hospital; Shakti Pillay – UCT and Groote Schuur Hospital; Jennie Morgan – UCT and Metro Health Services, Western Cape Department of Health & Wellness; Tania Moolman-Timmermans, UCT and Groote Schuur Hospital; Marc Nortje, UCT and Groote Schuur Hospital; and Ayesha Osman– UCT and Groote Schuur Hospital.
Struggles to specialise
It doesn’t stop there, however. Those doctors wanting to specialise say there are “waiting lists to work free” in the public sector – simply to gain experience and advance their training – because accessing registrar training posts has become so difficult.
The jobs come with long hours and gruelling work with no pay, but the hope of eventually attaining a registrar post at some stage.
The challenges they face are significant, several young professionals working to qualify as anaesthetists told Daily Maverick.
Kyle Kretzmer, who completed his community service in 2023, has been working in an unpaid, “supernumerary” medical officer post in the anaesthetics department at Chris Hani Baragwanath Hospital for three months.
“The motivation is quite challenging… but I see it as a future investment. It’s just tough at the moment,” he said, “and unfair on multiple levels. You shouldn’t have to work and not be paid just because the posts aren’t there. It is very competitive and some people are more qualified than others… the problem is, more and more doctors are graduating – with fewer and fewer posts. But how long do you go working for nothing?”
Time spent as a medical officer – paid or unpaid – does not count towards the registrar component of specialisation training, but it does allow young doctors to “beef up their CVs”, according to Dr Celeste Quan, consultant anaesthesiologist at Chris Hani Baragwanath and lecturer at Wits University.
A minimum requirement when applying for a registrar post in an anaesthetics department is passing the Fellowship of the College of Anaesthetists of South Africa 1 examination.
“Then (young doctors) try to beef up their CVs by getting diplomas… For example, for anaesthesia, the College of Anaesthetists runs a Diploma of Anaesthesia (DA).. .To do your DA, you’ve got to have six months of training in an accredited hospital. So, what these young doctors are doing is working free in an accredited hospital so they can get the work experience to write the diplomas… to try to improve their chances of getting into a (registrar) training post.”
The College of Anaesthetists of South Africa is one of 29 constituent branches of the Colleges of Medicine of SA, representing all of the disciplines of medicine and dentistry.
Unfair and exclusionary
Kretzmer told Daily Maverick he had saved money during his internship and community service, knowing he might have to take an unpaid post. He and his wife, who is working, have also moved in with her parents to save money. However, he said that for many newly qualified doctors, working unpaid was not financially viable.
“Most people I know… haven’t got medical officer posts. Most of them are just doing work as private casualty locums,” he said.
Quan said those without financial support were usually unable to take on unpaid positions. “That’s where the inequality comes in,” she said.
“Most doctors won’t practise without paying medical insurance with the Medical Protection Society or one of those, and it’s not cheap. So … it’s a travesty that you’ve got a young doctor who’s paying to work.”
*Fiona is a young doctor who started working in a paid medical officer post in an anaesthetics department in Gauteng in October this year. She completed her community service in anaesthetics in 2022 and was able to acquire her Diploma in Anaesthetics during this phase of her training.
She said the challenges of getting medical officer or registrar positions in state hospitals was driving young doctors out of the public health system.
“They’ve not increased the number of registrars in any training programmes in the past 10, 15 years, but more and more people have been graduating med school, doing the internship and community service. So, there’s this complete bottleneck of medical officers trying to get into registrar spots, and even a bottleneck to get the medical officer jobs,” she said.
Earlier this year, former Health Minister Dr Joe Phaahla said universities had increased the number of medical interns they trained by about 60% in less than a decade, but the budgets for provincial Health Departments have not increased at the same pace, meaning they are unable to employ the increasing number of graduates.
“I think the big problem now is the gap between community service and trying to get into a registrar training post… I chatted to a woman who’s 35 and still waiting to get into a registrar training post,” said Quan.
Long-term strategy
Recently, head of the Western Cape Health Department Dr Keith Cloete told Daily Maverick there was a “significant shock” to public healthcare financing in the country during the 2023/24 financial year, and that over the past year, posts at hospitals countrywide – including registrar posts – have been frozen or left vacant due.
Professor Johan Fagan, head of the division of Otorhinolaryngology at Groote Schuur Hospital, said that one of the biggest concerns around cost-cutting had been the need to cut salaries, as 70% of the hospital’s budget went to that expense.
“(In) the Western Cape, we were asked to cut our staff budget by about 9%… but the difficulty is, it’s been a random process because they can’t fire people. They can only freeze positions or discontinue positions as people leave,” he said.
“In ENT, they’ve discontinued one of our registrar posts, and that’s happened nationally. So, it does create problems in terms of training opportunities. And of course, then you’re going to pay a long-term price. That’s also part of the strategic thinking – what does the country need? Not today, but what did you need for the next 20 years? You might prioritise training positions because that’s what the country needs in the long term.”
Fagan said the haphazard process behind freezing positions has been a “missed opportunity”. He advocated for a more strategic approach that retained medical practitioners in key positions.
On how to reduce the barrier to specialisation at the stage of registrar training, he said, “We need the posts, that’s number one. And the posts are linked to funding. We may find that the posts might be linked to the number of consultant (specialists) as well, because of the ratio the HPCSA determines between the number of consultants and registrars for the programme to be accredited.”
He said the most recent round of budget cuts could serve as an opportunity to refocus and pursue a strategy of frugal innovation.
“I think we’ve been living in a false economy for too long… We often forget we are an upper middle-income country… it’s an opportunity for us to focus our minds on what we can afford… and what services we offer… It’s an opportunity for us to introspect and to really define what our mission and our role is.”
See more from MedicalBrief archives:
Minister tweaks community service posts to reduce shortfall
Healthcare system held together by inexperienced junior doctors
Review of SA’s 15 years of compulsory community service for doctors