Human Resources; Community Service Programmes

HEALTH PORTFOLIO COMMITTEE
19 October 1999
COMMUNITY SERVICE PROGRAMMES; HUMAN RESOURCES: BRIEFING

Documents distributed:
Slide presentation on Community Service 2000 (attached to end of minutes)

SUMMARY
Dr S. Hendricks of the Human Resource Development and Planning Directorate gave a briefing on where the Department stands on key issues such as water flouridation; the doctor, dentist, and pharmacist community service programmes, and foreign doctors in the country and how they are dealt with by the Department. The community service doctors have already been placed in positions, while the dentists are set to start working in July 2000 and the pharmacists are due to begin in January 2001.

MINUTES
Doctor Community Service Programme for medical students
Dr Hendricks discussed the compulsory community service that medical students must take part in. He noted the growing realisation on the part of health care workers that they have an important role to play in the community. They are beginning also to move away from curative measures and looking more towards preventative measures in health care. There is already a doctor community service programme in place and for the year 2000 there were 1158 interns placed, 849 were placed in their top 5 choices. 245 reapplied and all were placed. 68 people who did not reapply were asked to reapply and out of those 27 did not do so. Those who reapplied were allocated spots giving a total of 1158 interns placed out of the 1164 that originally applied. A committee was formed to investigate the reception of these doctors by the community and also the reaction of the doctors themselves. At first many of the community service doctors were opposed to the programme, but they soon realised the benefit they reaped in terms of experience gained. Some still do not like it, but on the whole the programme has been well received. The doctors have been asked for suggestions on how to improve the programme.

Dentist and Pharmacist Community Service Programmes
More infrastructure is necessary for dentists. Some dentists are working at multiple clinics even though each clinic has the facilities to accommodate its own dentist. These dentists could act as supervisors for interns placed in these facilities.

70% of pharmacists do internships in the private sector (e.g. working for pharmaceutical companies). The country is producing 650 pharmacists a year. It is thus important to look at using pharmacists in a community service programme as well.

The Directorate is also looking at a programme for rehabilitational categories, like speech therapists and physical therapists, however at the moment the cost is too heavy to focus on.

One good thing about these programmes is that many of the interns decide to stay in the public sector because right now the private sector is not so rosy. It is rather difficult for solo practitioners to open up practices.

First round of questions followed by answers
Chair, Dr. Nkomo (ANC): It seems that the thrust of your programmes is for professionals, what about nurses and a better distribution of them? Also, what about the interface between health care workers and traditional healers?

Dr Jassat (ANC): In Bangladesh, a mostly Muslim area, they trained Imams at the mosques to be health care workers, so every mosque becomes like a clinic. Could we not train the priests here in the same capacity? Also, what about doctors and workers who come to this country and then cannot work because of the moratorium on foreign doctors? Could we not put them in the community service programme?

An ANC member: Is there a pool from which they take pharmacists and allocate them to various places, or is it provincial? Also, what about the regular workers, the regular staff workers? What kind of recognition do they get?

Mr Ellis (DP): There are foreign students now in medical school who cannot participate in community service internships, how does this affect their degree and their status as doctors? Also, do you look at married couples differently when placing them in their first choice, second choice, etc., because I have had a lot of letters from such couples who have to be split up and how it hurts their family. Also, who is going to look at water fluoridation? Lastly, how many dentistry and pharmacy interns are there at present?

Dr Hendricks (answering the questions in order): About the nurses. Nurses are often put into paid posts from day one. They are vital to keep everything running. The problem is distribution. We have not chosen to send people to the most outlying provinces because there are not enough well equipped hospitals. There is right now a R1 billion allocation of funds to better equip these outlying areas. We are also looking into improving the
working conditions/job satisfaction of nurses and other health care workers. We're trying to come up with non-financial incentives (like assuring work for spouses and better working conditions).

When it comes to the interface between health care workers and traditional healers, I think there is a quite good interface. There is a report on that and we've also had meetings with traditional healers to see how they feel about everything. Many traditional healers are employed in the HIV/AIDS realm and we are looking at how these two groups can work together in more ways. There is even a health insurance system in place that will pay for visits to healers.

As far as how the community service programme is going, we had an independent group do a report on it (since there was a lot of controversy about it) and they praised us on most things and gave a couple of suggestions of what we could improve.

We have just had a meeting on foreign doctors and what to do about them. We will look for government to government agreements in the future. But about those already in the country, we must be very cautious because there are some court cases right now brought by foreign doctors (who do not feel that they have been given the accreditation they deserve) against us and we would not want to jeopardise those cases. The Health
Professions Council has asked for the regulations on foreign doctors to be published within a certain amount of time, and if it is not published by then, then they request that the moratorium be lifted. The issue around foreign workers and students doing community service is the problem of temporary work permits. That is being dealt with at a national level. We are looking at that with the proviso that South Africans need jobs as well and although we may not have enough people to fill the posts right now, that could change. We do not want to say to these foreigners, "Go home!" but at the same time we must think of South Africans as well.

The question of the ordinary class workers is very important. We stress that it takes a team to treat people effectively. For example, the surgeons could be ready and waiting in their white gloves in the operating theatre but if the patient does not show up, then they have nothing to do, they are useless. The porter is needed to take the patient up to the operating theatre. So you see it is a team. Everyone is important, from the porter to the general assistant to the specialist.

I think it is also a great thing that we have broken through the Standard Ten ceiling and begun to acknowledge workers who have prior learning. To keep these people out just because they may not have Standard Ten is a waste, so we have begun to accredit prior learning. It gives us many more people to use and gives them the sense that they are vital.

Regarding married couples, this is a tough question. We have had this debate around the organisation of the programme. We asked the question, whose rights are more important? We decided that marriage cannot be important except where it would devastatingly affect the family life, or in a critical family situation, where there is a dead parent. Only in these cases do we look at marriage factor.

Water fluoridation is critical in oral health. The Minister of Water Affairs has jurisdiction, so we can only strongly recommend the idea. It will be a process of consultation.

There are 650 interns in the pharmacy field who will be starting on 1 January, 2001 and 280 dental students who will start July 2000.

Second round of questions and answers
Dr. S. Cwele (ANC, KZN): We must integrate at the local level, are you going to look at that?

Dr. S. Gous (NNP): The community service programme started off as a vocational training programme because it was felt that people were not good enough. Now it seems you have sent these people off on their own because they are so good. You're saying they are so good they can go and run a rural clinic all by themselves. How can they be on their own? You need a supervisional system. Also we had wanted people to go to the rural areas and it seems that they are mostly going to big city hospitals.

Also, if the private sector is not so good, people do not automatically decide to go to the public sector, many leave the country. You can't compare these people to civil servants because it is not their choice to do this, it is conscription. Also it is not fine for these people to be sent out of the country, like to Angola. It is alright if they volunteer, but the original purpose was to have them go to the rural areas.

What about the South African students training in Cuba? How will they be integrated into the South African doctor pool? What will their accreditation be?

Also, I think we should let the private sector train their own nurses.

Dr. R. Rabinowitz (IFP): I know you say everyone was placed, but I have heard that there some students in the Western Cape who were not placed. How will this affect their degree?

Regarding the court cases, why don't you just drop them? You are always saying how compassionate to circumstances you are; these foreign doctors have been here a long time and sometimes have served our country for over ten years. Why don't you just give the same accreditation you give the other doctors?

Also, I know that the private sector would like to train their own nurses. What do we do about doctors who are not working the full hours that are required of them? I think we should make them punch in and out, I don't think that they should find that too painful or degrading.

Dr Hendricks response: We had a meeting with traditional healers and assured them that we think they are important. We have also looked at the relationship between local clinics, the health workers and traditional healers. It was the Minister of Health who came up with community service idea. The Medical Board wanted the vocational training, but they weren't fast enough and so we put through our programme and they just went along with it.

And about putting people in the rural areas of the hospitals, hospitals are a national asset, they belong to the people, so we must send interns there as well. Right now we have specialists who are over-trained, we don't need that. Everyone does not need to be a specialist. People on the ground determine what is needed.

While there are many young doctors leaving for other countries, there are many older ones coming back, so we want people to stay, obviously, but we're not going to stop them.

About the Cuban students, we will determine how to deal with them when they return.

We are about to challenge the private sector about the nurses being lost to them ( moonlighting or full-time). We're also going to challenge doctors about not working their full hours. We're going to ask why they don't request a sessional contract where they can sign up for a 20 hour contract or 30 hour contract or whatever they want to work because we know they aren't working 40 hours.

And when it comes to the court case of foreign doctors, just because the law was not followed before does not mean that we should not follow it now.

Follow-up questions and answers
Mr. Ellis: It is not the issue that these students are in Cuba, but rather that I think it is terribly irresponsible that you sent them off without knowing how you would deal with them when they return.

An ANC member: What do we do normally with foreign students?

Dr Hendricks response: The Cuban trained South Africans will be assessed in the same way as the South African trained Cubans. We have accepted the Cubans, so I don't see why we shouldn't accept the South Africans trained in Cuba. I have full confidence that anyone set looe on the South African public will have been fully qualified and appropriately competent.

Appendix 1:
COMMUNITY SERVICE 2000

Community Service 2000: Medical doctors as on 30 September 1999
- 1164 interns applied for CS 2000
- 849 (73%) allocated in their 1st- five choices
1^st choice=680(58%), 2^nd choice=59 (5%), 3^rd choice 38 (3%), 4^th and 5^th =72 (6%)
- 245 reapplied ( 2^nd round), and all 245 (21%) were placed, leading to a total of 1094 (94%) placed doctors, with a total of 68 not applying
- Subsequent to more posts being made available, all 68 were requested to apply for the 4^th round
- Of the 68,27did not re-apply
- All 68 have been allocated posts
35 in their choices
27 without choice
6 To start CS in Mid-2000
- As of now, no post is remaining
see posts table

Comments on Community Service 2000/2001
- Letters of employment are being sent by provinces from September 13th
- 1287 interns are expected to start community service in 2001, this number posts (1287) will be required prior to the application process
-CS posts should be planned for and provided on an MTEF- type of schedule for2001-2003 and later

More Health Professions to come
- Dentistry - A feasibility study has been completed and community service for dentistry is scheduled to be compulsory from 1 July 2000
- Pharmacists - first Legislation has to enable the process to start (pharmacy Act). Schedule to be Compulsory from January 2001