At the end of last year I was privileged — in my capacity as chairperson of the Rural Doctors’ Association of South Africa (RuDasa) — to be part of a panel talking about “rural success stories” on SAFM’s After-Eight Debate with Tim Modise.
He quoted Clem Sunter, who feels that there are many South Africans who are doing remarkable, world-leading work in all kinds of fields, but who do not get celebrated or consulted for their expertise as we grapple with the many challenges we face as a country. And so, as Modise was presenting his last show of the year, he felt that he wanted to do exactly that — recognise people who have done incredible work in the rural parts of South Africa.
As I prepared for the debate, emailed and phoned around and spoke to people in the know, it was easy to find the stories of many remarkable, dedicated, visionary doctors: black and white; English-, Zulu-, Xhosa-, Afrikaans- and Sotho-speakers; South Africans and foreigners — Dutch, Nigerian, Welsh, Belgian, Cuban, Congolese and Indian — all of whom were working way beyond the call of duty, doing exceptional work and delivering healthcare to the poorest of the poor against the odds of a broken public healthcare system.
It is true that many of these extraordinary doctors have not received any recognition for the work they have done, and so it was great that Modise was dedicating a whole hour on national radio to try and do just that.
But as I put the phone down after the “debate”, a thought struck me — why are we relying on exceptional people to keep the rural health system afloat? Would it not be much wiser to design a health system that draws the “ordinary” medical graduate (still competent, hardworking and committed to his/her patients, but who isn’t a masochist, missionary or madman) to spend some time in rural medicine?
If we continue to rely on exceptional doctors to man our rural hospitals they are always going to be understaffed — even in a country like South Africa, which is blessed with a remarkably high percentage of extraordinary doctors. This thought has come to mind again as the occupation-specific dispensation (OSD) negotiations for doctors reopened recently, after the first round of OSD for doctors last year largely bypassed career medical officers, who form the backbone (and, in fact, the muscles and skin too) of professional medical care at rural hospitals.
The original OSD improved the situation significantly for interns, registrars and specialists (who are mostly based in cities), but failed to provide a career path for non-specialists who run hospitals in rural areas. To illustrate: a community-service doctor just out of internship will earn only slightly less than the principal medical officer nine years his/her senior
who supervises him/her and has significant responsibility for patients, administration, the training of nurses and the oversight and planning of clinical services. (Incidentally, OSD for allied health professions has been even more of a disappointment.)
This is not going to draw or retain your “ordinary” doctor to work in rural medicine — instead, the way OSD has panned out has made the pull towards urban areas even greater. So, even some of the more committed rural doctors are being pushed to specialise in the cities if they want to further their career and/ or improve their financial situation.
The glimmer of hope RuDasa held on to — that the second round of OSD negotiations, specifically aimed at reviewing the situation of career medical officers, would address such anomalies — was quickly extinguished by the government’s offer (paltry increases of 1.5% to 4%) and the unwillingness of the largest unions in the bargaining chamber, like Nehawu and Cosatu, to contest it.
The offer and its acceptance by the unions is foolish, shortsighted and profoundly anti-rural. Of course, money isn’t everything and decent salaries and a reasonable career path alone are not going to solve the crisis in the recruitment of rural (and other public-sector) doctors. Working conditions, poor management, stock-outs of drugs and poor accommodation all need to be addressed if we want to keep “ordinary” doctors in the pubic sector.
Yet the unwillingness of the government to offer the doctors who form the backbone of the rural public health system decent increases (which, in the scheme of things, is fairly easy to do) has lowered morale and created the impression that the government doesn’t have the stomach to deal with the bigger challenges that are crippling our public health system.
Despite all this, the exceptional doctors I mentioned earlier will probably stay on in their rural hospitals and clinics, where they’ll continue to work against the odds — but now with even less hope for reinforcements. Yet, unlike interns, who were rewarded by the government for striking with a 50% increase in their salaries, these are the kind of doctors who would never think of striking, against their patients for money.
And so they will continue to do remarkable work, propping up a broken public health system and ironically making things look better to health officials than they really are — some of them burning out in time, others continuing heroically, without expecting or receiving any accolades.
Ultimately, however, the failure to attract more “ordinary” doctors to work in rural hospitals to join the extraordinary ones already there will mean that the voiceless rural poor will continue to receive substandard healthcare, and children and women will continue to die unnecessarily in the same country that can wow the world with remarkable stadiums built for a month of soccer.
The group of doctors who, in RuDasa’s opinion, should have been the number one priority of the OSD has been passed over completely. Go figure.