Will review of public sector doctors working in private hospitals lead to better healthcare or brain drain?

Health Minister Aaron Motsoaledi’s proposal to review remunerative work outside the public service (RWOPS) could bring both benefits and challenges to the health sector, according to an expert.

Motsoaledi recently attributed the absence and lateness of healthcare workers — particularly doctors — to the alleged misuse of RWOPS.

The minister also dismissed concerns that changes to RWOPS would drive doctors out of the public health sector, insisting that they are fairly compensated under the occupation-specific dispensation (OSD).

Healthcare professionals in the public sector can apply for RWOPS to work in private clinics or hospitals during their off-duty hours.

However, this requires written permission from their department’s executive authority.

Benefits of RWOPS review

Former South African Medical Association (SAMA) board chairperson, Dr Angelique Coetzee, believes that reviewing the RWOPS programme could have significant implications for public healthcare.

One major benefit could be an increase in the availability of doctors in state-owned hospitals and other healthcare facilities.

“If there’s a stricter RWOPS policy, it could mean fewer doctors spending time in private practice, more focus on public health care, and this should then improve waiting times in patient care in state hospitals,” Coetzee told The Citizen on Wednesday.

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She highlighted that a revised system could lead to better service delivery, particularly in reducing surgical backlogs at public hospitals.

“There could be more equitable health care. It might help bridge the gap between your private and public health care, ensuring more equitable treatment,” Coetzee said.

She pointed out that some doctors prioritise private patients over public ones, creating disparities in care.

Therefore, a stricter RWOPS policy could help address this issue by ensuring doctors fulfil their public sector responsibilities before engaging in private practice.

Downsides of a stricter RWOPS policy

On the other hand, Coetzee cautioned that revising the RWOPS could have negative consequences, particularly the potential loss of skilled professionals, as many specialists depend on the programme for additional income.

“A restrictive review could push them to leave the public sector entirely, leading to the brain drain problem as doctors seek better-paying opportunities abroad or in full-time private practice.

“If it’s removed or heavily restricted, some doctors might resign, worsening your shortage of medical professionals in your state hospitals, leading to an increased patient load per doctor, again, negatively affecting patient care.”

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Another potential downside is the impact on medical training.

“There might be a potential reduction in training and mentorship, and if they then leave, it could affect the training of junior doctors, interns, and registrars,” Coetzee explained.

Furthermore, Coetzee warned that if RWOPS was significantly restricted, fewer doctors would be available in the private sector, which could lead to increased costs and longer waiting times for private healthcare services.

“It’s a very difficult situation,” she admitted.

Possible adjustments to RWOPS

To address the challenges associated with RWOPS, Coetzee suggested a system with enhanced oversight to ensure doctors do not neglect their public sector duties.

“They need to adhere to their working hours that they are signed up for. You cannot double-dip; getting paid at the public sector hospital but running your own private practice during office hours,” she said.

One solution could be mandatory reporting of private practice hours to ensure transparency.

Additionally, doctors could be limited to a certain number of private practice hours per week to keep their primary focus on public healthcare.

“Government might also allow RWOPS only for certain specialisations where public services are not effective.

“For instance, allowing part-time private work only in fields with an adequate number of public sector doctors, if that is possible.

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“We know currently we do have a shortage of specialised doctors in all sectors in the public sector,” she noted.

Another approach could involve salary adjustments to make the public health sector more attractive, thereby reducing doctors’ need for additional private-sector income.

Financial incentives, such as student loan forgiveness, promotion opportunities, or housing allowances, could also be introduced to encourage doctors to commit fully to public service, Coetzee suggested.

“Doctors who misuse RWOPS to the detriment of the public hospitals, their duties may face stricter consequences including fines, suspensions or terminations.

“So they need to be held accountable if they’re not at work when they’re supposed to be there,” she added.

Challenges with the OSD

Discussing the implementation of OSD, which was introduced in 2007 to address remuneration disparities and retain professionals in the public sector, Coetzee highlighted several challenges.

“There’s the perception of unfairness around this,” she said, adding that this has led to demoralisation and strained relationships between management and nursing staff.

She pointed to research indicating issues such as incomplete and inaccurate information systems, insufficient planning, and poor communication, all of which have weakened the policy’s effectiveness.

The OSD has resulted in significant salary increases for some categories of state-employed doctors, including interns, registrars, and senior specialists.

However, Coetzee said its effectiveness in adequately compensating higher-level specialists varies.

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Despite these increases, she noted, the public sector continues to struggle with retaining specialists.

“Suggesting that while the OSD has made strides, it may not fully address the competitive disparities between the public and private sectors.

“If you look at giving the ongoing challenges in retaining higher-level specialists, they need to look at market competitiveness.

“So there should be regular reviews that should be essential to ensure that your public sector remuneration remains competitive with the private sector and international opportunities.”

Beyond salary adjustments, Coetzee stressed that working conditions, career development opportunities, and resource availability also play a crucial role in specialist retention.

She concluded by stating that changes to RWOPS and OSD would likely not have a major impact on the implementation of the National Health Insurance (NHI).