South Africa is producing more doctors than the country’s under-resourced public health sector — which, in 2021, had a 20% vacancy rate for doctor positions in clinics and a 14% vacancy rate for such posts in hospitals — can afford to employ.
Why the mismatch? Because provincial health department budgets have increased at a slower rate than the intake of medical students, so government hospitals “have not always been able to absorb the new doctors produced in the past years [after completing their internships and community service]”, says Dr Nicholas Crisp, the deputy director general in the national health department tasked with implementing the country’s National Health Insurance (NHI) scheme.
“We simply just don’t have the money to fill all vacant positions or to create additional ones.”
Instead, some provinces cut down on appointments.
In January, the KwaZulu-Natal department of health issued a moratorium on filling posts (except for medical intern and community service positions, as well as those funded by special grants) “until further notice”, despite 29% of doctor jobs at clinics and 9% in hospitals being vacant at the time.
The moratorium was lifted at the end of March, but solving the shortage of health professionals in the public health sector, and distributing health workers more equally among rural and urban areas, remains one of the NHI’s toughest tasks.
The NHI will be similar to a large, state-funded medical aid, which will buy the same healthcare for everyone, regardless of their income. But for it to work, we need enough doctors — and money — in the right places.
Matching public healthcare budgets
The problem with matching public healthcare budgets with employment needs affects medical students while they’re still in training. The country’s health budget for paid-for internships positions has simply not kept up with the pace at which South Africa’s 10 medical schools have ramped up their student intake.
After six years of study, medical students have to complete two-year, remunerated internships at public hospitals, followed by a year of community service at a government facility, before they can practise as doctors in the country.
But over the past decade, the number of medical graduates has increased by 61%. Between 2017 and 2020, the number of medical graduates who started with their medical internships at public hospitals increased from 1 476 in 2017 to 2 369 in 2020.
That’s because medical schools gradually started to take in more first year medical students from 2011, and those students started to graduate in 2016, who now all need internship positions. To address the country’s doctor shortages, South Africa also sends students to Cuba for medical training, who do their last 18 months of education at local universities before starting their internships. The number of Cuban-trained students has increased from 80 in 1997, when the programme was launched, to 650 students graduating in 2020 and 1 291 in 2021.
But provincial health departments, which have to cover the cost of internships and community service posts, have struggled to budget for enough positions, leaving many prospective doctors in limbo for placement to complete their training.
As a result, the treasury has allocated an additional R1.1-billion to the 2022-23 health budget to pay for intern and community service positions, and also plans to make available extra money for such posts in 2023-24.
But, the treasury cautions, if the health department cannot make do with the current allocations, “it will have to finance any future shortfalls within its baseline”. (Read: reprioritise money in the health budget.)
Crisp says: “The additional budget should be enough for now, but the problem will keep growing for a couple more years, so this is a stopgap, temporary solution while we figure out new options.”
To worsen things, the human resources budget (for all positions, not just interns and community service positions) of the health department will only grow at an average annual rate of 1.1% over the next three years, “limiting the ability of provincial health departments to employ more frontline staff”.
In his budget vote speech in May, Health Minister Joe Phaahla raised this concern, and warned: “[This] cannot be good for health services in the country.”
Does South Africa have enough doctors?
South Africa has eight doctors for every 10 000 people in the country, 2019 World Health Organisation (WHO) data shows. Although this figure is higher than in most other African countries, it’s much lower than in other middle-income regions. In Latin America and the Caribbean, for instance, there are about 30 doctors per 10 000 people (when high-income countries in the region are excluded).
Internationally, countries have roughly double the number of doctors than South Africa: about 18 per 10 000 people.
But the problem is more nuanced than a national figure.
When South Africa’s doctors per 10 000 people figure is broken down between the country’s public and private healthcare sectors, private sector patients have access to almost six times as many doctors as those who use government clinics and hospitals. The private sector has 17.5 doctors for every 10 000 people and the public sector three.
This means most of the country has access to three doctors per 10 000 people; 72% of the population is dependent on the public health sector.
What does this look like in actual doctor numbers? According to the 2020 South African Health Review, 15 474 doctors work in the public sector; the Competition Commission says 14 951 doctors work at private practices. Taking these figures together (30 425), this would imply that about half of the country’s doctors serve 27% of the population, while the other half have to serve almost three quarters of the population.
Various sets of doctor numbers have been published, which means that the doctors per 10 000 people and actual doctor numbers don’t always add up. But the different sets all come to the same conclusion: doctors are unequally distributed between the private and public sector.
The NHI Bill says the scheme will address the unequal distribution of doctors by buying healthcare services from both private and public providers.
But efforts so far, mostly in NHI pilot districts, haven’t worked well. Between 2012 and 2018 the government put out calls for private general practitioners in pilot districts where there were few public sector doctors to offer their services. But only 330 took up the offer, largely because the programme was managed badly.
An evaluation found that ”the lack of adequate planning impacted the coordination between GPs and the national health department” as “contracted GPs were essentially viewed as ‘subcontractors’ and could not be paid using national health department guidelines or through the government payroll system”.
This loophole, the assessment found, “allowed contracted GPs to claim for an unverified number of hours and for expenses which typically would not be reimbursed to other staff in the public health sector”. As a result, the salary bill at primary healthcare facilities through GP contracting became unaffordable “to effectively sustain and scale up”.
Crisp says it’s clear that a different contracting system is needed. “Paying GPs for sessions [in other words, per consultation], with the state covering the cost of the medicine used, is not sustainable. Instead, they need to be contracted in a different way.”
And there’s a lesson from Covid-19. “During the pandemic, private pharmacies administered over six and a half million vaccinations, so we’ve learned the role of community pharmacies in primary healthcare,” he said. “Dovetailing that with exactly how private practitioners work in their practices is something that we are particularly interested in.”
The rural problem
The unequal distribution of the country’s doctors doesn’t stop with the public and private sector — it’s as bad when it comes to urban and rural areas.
Public hospitals in rural areas are particularly badly hit. A 2017 study showed that in most districts in Limpopo, there’s hardly one doctor for every 10 000 patients. Analysis of the health department found less than 3% of medical graduates in South Africa end up working in rural areas 10 to 20 years after graduating.
And it’s not a South African problem; countries from around the world struggle to fill posts in rural areas.
There are, however, tried and tested solutions.
Evidence from many countries, ranging from the United States to Nepal, shows that medical graduates who grew up in rural towns are much more likely to return to work in those areas than their urban counterparts. Findings from South Africa say similar things.
A 2016 South African Medical Journal study tracked several hundred young South African doctors for five to 10 years after they had graduated. Among those from rural areas, about four in 10 were practising in rural towns. Compare that to between 5% and 10% of peers who come from urban backgrounds.
Another tracking study showed that having a rural background was the best predictor of medical graduates eventually working in a rural area. In this study among medical graduates from the University of the Witwatersrand, those who came from rural areas were almost five times as likely to practise in rural locations five years after graduating than their urban counterparts.
Medical schools admission policies and rural areas
Although the government has introduced policies to encourage universities to address past inequalities related to race, there is no pressure from the state to boost medical student admissions from rural areas, says Lionel Green-Thompson, dean of the medical school at the University of Cape Town.
Only a few medical schools have explicit admission policies to increase intake of students from remote areas.
For example, the University of the Witwatersrand reserves 20% of its places for top-performing learners from rural areas, while the University of the Free State gives additional points for students who went to rural schools. Stellenbosch University has a rural clinical school, which trains medical students in their final year in an attempt to admit more students from rural areas.
Since such policies aren’t enforced across the board, students admitted to medical schools are still disproportionately urban despite the need for rural doctors.
But admissions from rural schools come with their own problems.
Because students from poor rural schools often grow up with fewer educational and financial resources than urban middle class students, they often face stressors such as fear of failing, financial and accommodation problems at university that make it harder for them to complete their studies.
Rural students therefore often need special support.
A programme from the Umthombo Youth Development Foundation is an example of what can be done. Hundreds of promising students from poor rural schools in KwaZulu-Natal were mentored and later offered scholarships to study a health sciences degree, but on condition that they return to practise in the areas where they were initially interviewed for some time.
Reviews showed that despite students facing various cultural and academic obstacles, the programme has achieved a pass rate of 92% annually, with most students getting their degrees in the minimum period or minimum plus one year.
Management at poor rural hospitals in the province, which had previously struggled to attract and retain staff, say that the programme had given them a consistent supply of health professionals for the first time. Not only did graduates return to rural areas for their compulsory community service, but many stayed on longer as they built ties with the community that raised them.