/ 6 July 2022

South Africa’s moonlight sonata: The illicit cash cow draining specialist care at state hospitals

(Photo by David Harrison)

There are 20 babies screaming for attention in the dilapidated paediatric ward of the state hospital in a small South African town.

Just down the road, at a buzzing taxi rank next to a school, children are getting out of white minibuses to start their day of learning.

Emily Benson (not her real name) is growing anxious in the children’s ward. It is 8.45 on an icy Monday morning, her first rotation in that department.

One of the infants is having a seizure. Blood tests show at least two of his organs are failing.

Benson knows she has to treat this baby first — but doesn’t know how.

She is a second-year intern doctor. That means she has graduated from medical school but still needs to complete her last internship year and a year of community service before she can work without supervision. 

There is a medical officer — a general practitioner at a government hospital or clinic — on duty.

It isn’t enough.

The intern and GP need the help of a child health specialist. But the hospital’s only full-time paediatrician has left the facility to work at her private practice.   

Benson hastily puts the infant on a drip but she and the GP are out of their depth.

“I didn’t know what to do to save this child,” she recalls. “I was terrified.” 

There’s little room for mistakes when treating babies and even tiny errors can have devastating effects on a body so small.

But the person who could save the baby, and has been appointed full-time by the hospital, was treating children with much wealthier parents just a few kilometres away.

Money talks

The fact that the hospital’s paediatrician also works in the private sector is not illegal.

Doctors (and many other state employees) in South Africa are allowed to work for both the public and private sectors. “Dual practice” or “moonlighting” is what it’s called.

Government health workers can apply to work a limited amount of time in the private sector – as long as it’s outside their government working hours and doesn’t compromise their state patients’ care.

State health staff have to get written permission for dual practice from their supervisor, who sends a recommendation that goes to the provincial health MEC — or someone to whom they’ve delegated the job, often the hospital’s ethics officer — to make the final decision about whether private work would interfere with a doctor’s government job. 

The call must be made within 30 days. If not, health workers are allowed to assume the request has been approved. But a 2015 study found a quarter of doctors interviewed moonlight without ever applying for permission.

Even when they do get approval, not all of them follow the rules.

The specialist Benson was waiting for is one of them: “She works full time at this hospital but full time in private as well.”

So, she’s being paid a full salary by taxpayers to work in a state hospital and then private sector patients pay her again.

The baby boy Benson is looking after is running out of time.

Benson recalls: “I was so out of my depth. Every minute that this baby was without the right medicine increased [his] chance of dying.”

Skills shortage

South Africa has 9 731 specialist doctors in total, which is not enough — just 17 for every 100 000 people.

When it comes to paediatricians, the country only has 818.

South Africa’s specialist-patient ratio is much lower than in many other middle-income countries. Take Brazil. That country has nearly twice the number of specialists for every 100 000 people as South Africa. In Mexico, the number of specialists per 100 000 people outstrips South Africa’s count nine to one.

Most specialists work in the private sector, which services only 27% of the population. There are 69 of them for every 100 000 private patients.

And in the government facilities?

Only seven.

Benson’s story suggests that things are worse than they appear on paper.

This is because, while the government might be paying for seven specialists for every 100 000 people, many aren’t showing up to work.

Daylight robbery

When Benson and the GP called their hospital’s paediatrician at her private practice to find out when she would come to the baby’s aid at the state facility, her response was, “I’m quite busy at the private hospital.”

All Benson could do in between monitoring all the other sick babies in her care was to run back to the dying boy to resuscitate him after each fit.

About a third of South Africa’s state specialists make extra money at private facilities. But it’s unclear how many are exploiting the system.

“It’s probably about a quarter of doctors [who abuse dual practice] but that places a burden on everyone else and compromises the entire system,” says Shabir Madhi, who heads the University of the Witwatersrand’s medical school.

Research in Gauteng in 2004 showed that abuse of the dual practice concession was so widespread in that province “the majority of doctors work only for four hours [per day] on average before leaving to consult private patients in their private clinics”.

For this story, Bhekisisa spoke to 11 medical professionals — from practising doctors to public health researchers, the head of a medical school and a senior government official.

Most either had a story about the abuse of dual practice or said it was common.

Madhi says when moonlighting is left unchecked, the result is an “artificial shortage” of specialists at government hospitals.

What happens then?

The quality of specialist care at state facilities drops.

What specialists in training lose when there are no seniors

The proposed state-funded National Health Insurance (NHI) is a plan to make the same quality health services available to everyone, regardless of how much they can pay for it.

But, for the system to work, we need enough professionals — and the workforce to train them. 

Specialists in training, called registrars, do a combination of theoretical and practical training.

Theory can be learned from books but practical training requires supervision.

Nicholas Crisp, a doctor and the deputy director general of the health department heading up the implementation of the NHI, says: “As doctors, we learn not just from what’s written in a book but also when someone watches you while you’re putting in stitches and drains, for example. If that senior person isn’t there, how much are you really going to learn as a registrar?”

The dearth of mentoring won’t just affect those training to be specialists, Crisp says.

“If the registrars aren’t around because they’re tired from doing the consultant’s work, and say there are no senior medical officers around, what are the junior doctors going to learn?”

‘It’s white-collar crime’

If dual practice is potentially bad for both patients and doctors, why do managers allow it?

Because in many cases, they’re abusing the system themselves, according to three of those interviewed.

One medical intern, who was often abandoned by her moonlighting superiors, told Bhekisisa that it was hard to lodge complaints because her department heads, to whom she’s supposed to report this, were doing the same thing. 

That culture trickles down to juniors, a clinical manager said, who then copy it when they become supervisors.

Crisp said there’s no real shame about abuse of the system.

“We have senior clinicians at government hospitals who brag that they have not been in the public hospital for weeks.”

For Madhi, however the abuse happens, the bottom line is clear: “It’s white-collar crime.”

And the weak suffer what they must

Back in Benson’s small-town hospital’s children’s ward, it’s 3pm. There’s still no sign of the paediatrician who she called six hours earlier.

The little boy’s mom is waiting at his cot.

Benson tries to explain to her what is happening but her isiXhosa is broken and there’s no translator around. 

The parent is confused and worried. She’s been by her child’s side, plastered to a cheap plastic chair, for days.

It’s people like her who bear the brunt of doctors’ greed, encouraged by a badly managed system.

Moonlighting was originally supposed to compensate for the low salaries offered by the public health sector. The idea was that the government could prevent underpaid doctors from leaving state hospitals by allowing them to earn extra from private work.

But government doctors’ pay has ballooned since 2009.

A new wage policy was implemented then which meant that, in a single year, medical officers saw their salaries increase by up to 68%, and specialists’ pay rose by up to 50% with the annual salaries of chief specialists rising to R1.2-million.

As a result, medical officers in South African government hospitals were earning more than their peers in the United Kingdom and Australia (when considering the actual purchasing power of their wages).

For instance, a medical officer at a South African government hospital with 5 to 9 years of experience, earned R423 846 a year in 2009 after the salary adjustment. Their peers in the UK and Australia were earning R385 314 and R327 127, respectively, (when their wages are converted to rand and adjusted for their purchasing power).

The NHI might, however, make it harder to moonlight. 

There will be far fewer opportunities for dual practice under it because private medical insurers will not be able to cover the services that the NHI provides. This will make it more difficult for specialist doctors to open a private practice separate from the scheme.

But Crisp reasons that rather than relying on the NHI to stop moonlighting, dual practice should be scrapped in the healthcare sector.

“The clinical department head in a provincial hospital now earns millions a year with overtime and then still does [dual practice], sometimes during public sector time. Why would you allow that?” 

Is there an upside?

The silhouette of Devil’s Peak dwarfs Cape Town’s Groote Schuur Hospital, the teaching facility where Allan Taylor has just come out of surgery. He’s the specialist who runs the unit that operates on people’s brains, spines and nerves. 

Taylor works long, long days but he runs a tight ship. His team does dual-practice by the book.

“Banning the practice wouldn’t solve the problems with moonlighting,” he says. 

 “It will erase some of the benefits of the practice.” 

State doctors can gain skills from working in the private sector, which they bring back into government hospitals. 

“They can take the management lessons they learn in the fast and efficient private sector back to state facilities.”

Moreover, spending time in private practice gives doctors the chance to do procedures they would not have the resources to perform in government hospitals, a 2015 paper shows.

John Ashmore, a public health researcher, also warns that changing the rules that allow for moonlighting might not actually stop the practice; it might simply push it underground.

And there could be bad consequences.

Staff who are already angry at the department could feel vilified, Ashmore says.

In June, paediatrician Tim de Maayer was suspended from his post at Rahima Moosa Mother and Child Hospital in Johannesburg for speaking out in the media about the dire conditions doctors and patients face there.

He was reinstated soon afterwards, probably only because of public pressure, including a petition that has since got nearly 70 000 signatures.

The move provoked an open letter to the Gauteng provincial health department signed by more than 130 prominent public health figures, among them HIV researcher Linda-Gail Bekker and Boitumelo Semete-Makokotlela, who heads the country’s medicine regulator, the South African Health Products Regulatory Authority.

Moonlighting, however, remains shrouded in secrecy.

Sources quoted anonymously in this story asked Bhekisisa to hide their identities because they feared speaking out against powerful senior staff.

What happened when the paediatrician returned?

In the small town where Benson works, hundreds of kilometres from Rahima Moosa, the shadows are getting longer. The only full-time paediatrician at the state facility is finally back at her post.

She orders the baby boy to be rushed to the intensive care unit (ICU).

The paediatrician is livid. She says the GP who supervised Benson should have known to admit the infant to the ICU far sooner. “This should have been done this morning already,” she scolds. 

But Emily and the medical officer kept the baby alive for seven hours — not without potential consequences.

He’s doing alright — for now — but doctors can’t rule out the possibility that he’ll show signs of brain damage. 

– Additional reporting by Regan Boden.


This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.