The health department is increasingly playing fiscal catch up each year as the trainee intake continues to swell. (Photo by Michele Spatari / AFP)
The department of health has denied claims by the Junior Doctors Association of South Africa (Judasa) that too many trainee doctors are in limbo each year because little notice is taken of the logistics and difficulties of distant placement.
This July and August the health department had to scramble to allocate sufficient money for public sector internship and community service posts because competing healthcare demands – Covid-19 not the least among them – sought priority.
Finishing the three years of public service is a legal requirement to enable junior doctors to register and practice as fully fledged medical officers.
A short-lived mid-year fiscal hiatus affecting 288 doctors came just as the third Covid-19 infection surge crowded out hospitals and dozens of hastily erected and repurposed healthcare facilities country-wide, raising hackles among Judasa executives.
Although the health department is adamant that no qualifying interns or community service officers remain unplaced year in and year out, Judasa paints a picture of scores regularly having to wait for placement each year because of unexpected events such as exam rewrites, pregnancy, maternity leave, child-care, mental health breakdowns, provincial health department dysfunction or late posting notification to distant provinces posing logistical problems.
The latest mismatch in central funding and medical school student output was caused by final year undergraduates who failed or did not write their 2020 year-end exams and then successfully rewrote and passed them in June this year.
Although acknowledging that the personnel budget of the health sector “continues to take strain” from the growing numbers of medical students qualifying from local universities, the Nelson Mandela/Fidel Castro Cuban Students Programme and self-funded students studying abroad, the health department says every mid-year intern was allocated between their first and third of five hospital choices by 3 July this year.
According to Victor Khanyile, manager of the national Internship and Community Service Programme (ICSP), the 288 students had written and passed supplementary exams at different times at six campuses from June onwards and many had not been able to begin their internship immediately for personal and logistical reasons.
Cuban programme straining budgets
The historical context is a major ramp-up of doctor training and output begun in 1996 by the Cuban training programme, which, after a boost in 2011, began pouring 800 more final year medical students into the existing local campus final year training cohort. This resulted in some 2 700 interns entering in-service training annually from 2011 onwards. This has strained the public health fiscus, creating a headache for the treasury on whom the Cuban training policy was foisted with little consultation.
What could have been a funding hiccup for next year’s intern group was narrowly avoided after a second R100-million tranche of a R247-million emergency funding injection was included in the medium-term budget framework outlined by Finance Minister Enoch Godongwana on 11 November.
The first R147-million was to enable the mid-year intern intake to be paid for the remainder of this year. Health budget strategy planners at the treasury have recommended that an extra R1-billion be budgeted annually for at least the next three years to address the increased medical student output and placement. This has yet to be approved by the ministerial committee.
In a June circular to members, Judasa chairperson Dr Tshepile Tlali pleaded for patience, saying the association had been involved with the ICSP for “the better part of four years”, warning them of the future difficulties the programme would face “if funding issues are not sorted out”.
“This not only affects the health of the nation but the livelihood of our members, especially at a time when we need as many hands as possible on the ground,” Dr Tlali said. “Judasa understands and empathises with students regarding challenges during their undergraduate studies. We understand that at times life happens, our mental health gets challenged, sometimes we may fall ill and oftentimes there are financial challenges that hamper our ability to complete medical school successfully.”
Judasa claimed in June that there were up to 1 000 unfunded intern and community service doctor posts in the public sector.
Dr Angelique Coetzee, chairperson of the South African Medical Association (SAMA), said she was assured by the ICSP last week that there were sufficient funded posts for the impending 2022 medical intern intake, but she had no data on community service funded posts.
She and several veterans in South African medical politics said that besides the public coffers depleted during former president Jacob Zuma’s leadership, the Cuban training programme for South African doctors had imposed major strain on state finances. In addition, in 2006, the tertiary education and healthcare authorities tagged an extra year on to the former one-year medical internship, something now being reconsidered as a stringency measure amid fierce academic debate.
What juniors earn
The proposed additional R3-billion three-year treasury price tag is calculated on supplementing a single intern salary and related expenses (including overtime and the less common rural allowances) of about R730 000 annually multiplied by 4 800 current interns (R3.5-billion), to which the R1-million for 1 800 community service officers’ annual salary bill, (R1.8-billion) must be added.
This money is needed to cater for the ever-swelling graduate output. Interns and community service officers were included in the generous 2007 occupation specific dispensation, (a healthcare worker retention measure), further hiking the healthcare budget baseline by hundreds of millions of rands.
South African medical trainees in Cuba are given a R230 daily stipend for the duration of their overseas training.
At present about 1 000 South African trainees return home annually from Cuba for a one-year local medical campus “adaptation” course after their strongly primary healthcare-oriented training.
Alluding to the overall paucity of healthcare professionals in South Africa — a government White Paper says doubling the existing doctor training would still fail to meet growing population healthcare needs — Coetzee described the situation as “a mess”.
“We don’t have enough seniors or specialists to provide the necessary oversight for their in-service training. You can put these juniors into lots of Health Professions Council of South Africa (HPCSA) accredited hospitals, but without enough seniors they learn bad habits, which stay with them for life. If there’s nobody there to tell you how to put up a drip properly and help you with the basics, you also end up with adverse events and mounting patient litigation.”
In a public/private doctor webinar last week, the Medical Protection Society said there are 2 840 cases of litigation against South African registered doctors. Five years ago, the health department confirmed that in addition to the cost in grief and trauma to families and the battered confidence of under-resourced, under-supervised and overworked doctors, the nine provincial health departments faced a R24-billion patient litigation bill (2010 to 2014, with R500-million then paid). A team of medicolegal experts has been attempting to pare this down, sifting out weak and invalid claims, but new claims keep the bill painfully high.
Regular engagement ‘not working’
Khanyile said Judasa executives, SAMA, the South African Medical Association Trade Union and medical school representatives thrashed out placement logistics and potential problems face-to-face at least four times a year. He expressed surprise at the Judasa sentiment.
Judasa’s Tlali, now a registrar in anatomical pathology in Gauteng, told the Mail & Guardian, “I’m at a point where I’m no longer frustrated at the system but have actually lost confidence in the [health department’s] ability to sufficiently place interns and commserves each year. By sufficiently, I mean place them with adequate notice and time to prepare and move. I also mean without any hassle or delays in starting to work. This is especially bad when they have to sit at home without any means to make an income.”
Asked about the health department’s response Tlali said, “That’s a very subtle way of saying it’s not my problem — that my job is simply to place people for January and July.”
He said junior doctors often had to organise their own accommodation, and where it was provided, particularly in remote, underserved areas, it was routinely “deplorable”.
Work pressures were intense, he said, adding, “I can understand when doctors say, as much as I love this, I can’t do it anymore.”
Another Judasa executive member, Dr Sazi Nzama, a medical officer in the Pietermaritzburg Hospital Complex, said the health department releasing placements in the second half of November was “reckless behaviour”.
“They’re deliberately not executing their mandatory duty of placement. We often have to organise furniture and find a place to stay — it’s an unrealistic expectation to place on any human being. It’s becoming an attrition factor. I’d rather go where I’m appreciated and treated with respect — not as a pawn tossed around. There are foreign recruiters out there actively poaching doctors for Ireland, Canada and Australia — I can give you their names,” he asserted.
That official data indicates serious attrition of community service officers. In 2016 there were 2 700 interns, increasing to 4 800 currently, yet community service numbers increased from just 1 300 in 2016 to 1 800 in 2021. Possible answers include data transfer dysfunction between provinces and national health departments and a failure to capture community service sign-ons.
The HPCSA had not responded to a request for comprehensive annual registration figures for all categories of doctors from 2018 to date, by the time of publication.