Special Reports:

National Health Insurance

< Back to special reports

The National Health Insurance (NHI), for which membership will be compulsory, is a funding scheme that aims to address healthcare inequity in South Africa. The scheme will do this by creating a fund that the government will use to buy healthcare services at set fees from accredited public and private health providers. The NHI Bill was passed in the National Assembly in June 2023. It has to go to the National Council of Provinces for approval.

HomeArticlesCould rural students solve SA’s doctor dilemma?

Could rural students solve SA’s doctor dilemma?

  • South Africa has eight doctors for every 10 000 people. Less than half the global average. But the shortages are more concentrated in the public sector than in private healthcare and even worse in rural areas — most Limpopo districts don’t even have one doctor for every 10 000 people.
  • Medical schools have ramped up the number of students they’re admitting, and record numbers of students have returned from Cuba in recent years. But restricted health budgets mean government facilities simply can’t absorb them, leaving clinic and hospital vacancies open.
  • One way of shoring up the gaps in rural areas is to adjust the admissions criteria at medical schools to allow more rural students since they’re much more likely to return to remote areas once they’re qualified. 

South Africa is producing more doctors than what 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 departments’ 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 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,” Crisp explains.  

Instead, some provinces cut down on appointments.  

In January, the KwaZulu-Natal department of health, for example, issued a moratorium on the filling of 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 unfilled 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 like 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. 

We break down the doctor conundrum.

How South Africa’s medical student intake has been ramped up faster than its 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 internship positions has simply not kept up with the pace at which South Africa’s ten 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 dramatically increased. Just between 2017 and 2020, the number of medical graduates who started with their medical internships at public hospitals increased by 61%: 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. In order 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.    

[WATCH] Meet the clinical associates filling the gap when doctors and nurses are few and far between

When a rural hospital brought this woman into its multidrug-resistant TB programme, it saw a 20% jump in the people who were cured. The catch? She’s not even a doctor.

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 within 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 his 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. Why? The private sector has 17.5 doctors for every 10 000 people and the public sector three.  

This means most of the country only has access to three doctors per 10 000 people, as 72% of South Africa’s population is dependent on the public health sector.   

What does this look like in actual doctor numbers? According to the 2020 SA Health Review 15 474 doctors work in the public sector and 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 its population, while the other half have to serve almost three quarters.

Various sets of doctor numbers in the country 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 (GPs) 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. 

Watch Jesse Copelyn unpack this article on Newzroom Afrika

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: “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. 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 10–20 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, reveals 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 five and 12% of peers who hailed 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 (Wits), 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.

Do medical schools have admission policies that favour students from 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 faculty of health sciences at the University of Cape Town (UCT) and current chair of the South African Committee of Medical Deans.

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 challenges. 

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 passing 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.

Jesse Copelyn was a health journalist at Bhekisisa between 2022 and 2023.