On-line version ISSN 2078-5135
SAMJ, S. Afr. med. j. vol.99 n.7 Cape Town Jul. 2009
Government 'shooting itself in both feet'
The government's lack of commitment to doctor recruitment and retention over 22 000 doctors left the country in the past 6 years1 is 'beyond comprehension', given its first-year wage hike offer of just 0.28 - 5% which virtually ignored juniors this May.
Dr Bandile Hadebe, chairperson of the Junior Doctors Association of South Africa (Judasa), said recruitment and retention, the major aims of the Occupation-Specific Dispensation (OSD), were being wholly subverted by negotiators.
The inclusion of interns and community service doctors in the department's April offer was 'a non-negotiable,' he averred. Little did Hadebe know then that wildcat doctor strikes (mid-April), protest marches (29 May) and a major publicity offensive would diminish the seemingly steely resolve of the new administration.
'This is a joke because you're not going to recruit anyone with the existing junior salaries. You cannot honestly say you're recruiting doctors when somebody studies for six years and takes home R8 000 - R9 000 while his cousin who starts studying two years later, graduates, works as an engineer and takes home R25 000.'
Doctors were asking for a 50% increase across all notches to bring them into line with their professional peers in the civil service and the honouring of ministerial promises to implement the OSD from 1 July 2008.
However, Izindaba sources in Treasury described this back-pay demand as 'wholly unrealistic, given the economy and our overall health care demands'. An impeccable Treasury source said a 50% increase would cost R4 billion, just under half the current spending on doctors, while back pay for just 9 months would add an extra R3 billion to the bill.
'The entire health budget is R70 billion per annum, so R7 billion would imply 10% real growth when we have none and we're not expecting any, anytime soon; it's just not possible.' He said acceding to doctor demands would mean ignoring the financial health crises in KwaZulu-Natal, Gauteng and the Free State 'for starters', being unable to improve doctors' working conditions or relieve pressure on them by filling more posts.
Other vital programmes that could suffer would be the ARV rollout, child nutrition and milk powder for infants.
The health department offer at the end of May translated into (before inflation) increases of 6.8% in the first year, another 7% in the second year and an additional 'about 6%' for the third year. For the national health budget, this translated into R500 million in the first year, R1 billion in the second and R1.5 billion in the third.
As an illustration he said the average doctor (across all notches) currently earned R412 000 per annum (gross). The government offer in early June increased this to R440 000 in the first year, R465 000 in the second year and 'about R500 000' in the third (final costing outstanding at time of going to print).
In dramatic contrast to SAMA's calculations, Treasury's was that the increases tabled varied between 1% (interns) and up to 40% for 'some groups' (the source cited entry-level specialists). 'Yes hospitals are in a terrible state, doctors are overworked and understaffed, but there's no way we can, in any balanced way, do a 50% increase in one year. We'd have to borrow all the money.'
Citing KwaZulu-Natal's budget deficit of R2 billion, he said his treasury colleagues in that province, giving an orientation briefing to their new Health MEC, baldly stated: 'Basically we're insolvent'.
To address accumulated provincial debts in the three problem provinces would mean cutting all other provincial health budgets by as much as 15%, the source said. 'The doctors seem oblivious to the world recession. I understand their anger but we're expecting 0% growth this year and yet we're still budgeting for 4 - 5% spending growth. South Africa shed 200 000 jobs in the first quarter this year and the next quarter could see more. Overseas, people are voluntarily cutting salaries to keep their jobs and job sharing to try and curb job losses.'
UDF embarks on new strategy
Meanwhile the breakaway United Doctors Forum (UDF), hundreds of whose members narrowly escaped being fired for striking illegally in mid-April, were by the end of May describing a second strike as 'inevitable'. The South African Medical Association (SAMA) chose to soldier grimly on at the stalled bargaining council.
Several close to the stalled talks said that unless high-level political intervention succeeded in softening government negotiators' stance, a cross-union doctor strike with well-managed patient care was 'entirely possible'. This would be unprecedented in SAMA's history and create a virtually intolerable headache for government.
Izindaba learnt that in an attempt to change existing bargaining practice, the UDF aims to recruit doctors across unions for a 'stand-alone bargaining entity' and is now setting its sights on official recognition. It believes SAMA doctors being clustered with dentists, pharmacists and emergency service workers, and its seats on the Public Service Co-ordinated Bargaining Council (PSCBC) being per favour of nursing union Denosa, fatally weakens bargaining power.
Professor Bakani Siwele, UDF deputy chairperson and an orthopaedic surgeon at the George Mukhari Hospital near Pretoria, cites health department negotiators cynically breaking promises by their former political chiefs and the almost year-long delay in OSD implementation having ended in May's messy stalemate, as evidence for this. He believes SAMA has 'lost the plot and is too cosy' with government to achieve any significant concessions.
'We need someone else to champion our cause. Why wait until there's a strike to explain all these things (bargaining processes and legal impediments) to doctors? You have to take your constituency with you. It doesn't take a rocket scientist to deduce they (SAMA) have just been reactionary,' he charged.
Siwele said doctors needed to unite across their several unions while keeping patient care at the top of the agenda.
The UDF commanded centre stage in mid-April with a 12-day unprotected strike that paralysed usual service delivery at several hospitals and clinics in Limpopo, Gauteng and the Free State and ended with three patient deaths.
Based on petitions circulated, the UDF claims the support of 5 000 - 8 000 state doctors, but has no constitution or formal membership, while SAMA officially represents 6 000 of the estimated 14 000 state doctors (the largest recognised doctor union).
Siwele revealed that the UDF held a 'national imbizo' on 24 May to discuss the writing of a constitution, registration as a union ('to avoid victimisation of individuals') and to strategise on creating the 'stand-alone' doctor bargaining entity.
'Unity is more important than anything else. I don't know why doctors are in separate unions, they're all just vehicles that take us to the same destination We should all talk behind closed doors and not bash each other that favours the employer we want to go beyond the OSD to the real issues,' he said.
Patient deaths 'unfairly linked' UDF
Challenged on the alleged strike-related deaths, Siwele responded: 'They would have happened even if there was no strike. Suddenly because there's a strike, each and every statistic is due to the strike. That's what people do to victimise you.'
SAMA negotiators, irritated by the 'premature' strike, claimed that only their and Cosatu's intervention at ministerial level enabled the splinter group members to keep their jobs.
SAMA's lead negotiator, Professor Matt Lukhele, said it was clear that 'the difference (with government) is very big and that we will not find one another, so a political intervention is required to soften the mandate of government negotiators'.
He and his team of four (Denosa has given SAMA four of its five seats on the PSCBC, since it won an OSD settlement for nurses last year) were on 26 May busily caucusing with other public sector unions to craft a joint proposal.
Zwelinzima Vavi, President of the umbrella Cosatu, warned that a uniform civil service strike trumping the crippling 2007 one was a certainty if government did not quickly address 'the ticking time bomb', and close the negotiating gaps. Lukhele explained: 'Right now the approach is to try and manage the process before we even present at the PSCBC'.
Health department 'in clear violation'
He said the current lump sum offer to doctors in lieu of promised back payments was in 'clear violation' of a resolution to implement an OSD for doctors on 1 July last year. (Each civil service professional sector was given an OSD implementation date after the 2007 strike.) The department is also offering doctors a phased process of salary increases and a new career-pathing model.
Dr Muthei Dombo, Vice Chairperson of the South African Registrar's Association (SARA), said the UDF misunderstood the 'intricate, complex' negotiating process. The state negotiating team was granted two formal extensions by the PSCBC to properly probe the numbers of state employees in its own sectors. 'We were ready on our side. First they got an extension to November last year and then another to April this year. Government used the chaotic OSD nurse payouts to motivate for proper actuarial probes this time around. Huge mistakes were made around nursing categories and years of experience. They ended up with extra nurses and needed more money,' she explained.
Former Health Minister Barbara Hogan had demanded better accountability while the national treasury insisted on 'verifying the numbers this time'. That process was now complete.
Dombo was asked to respond to the UDF outrage at what appeared to be 'cosy' interactions between health department human resources chief Dr Percy Mahlati and Dr Pophi Ramathuba, Deputy Chair of the Public Sector Doctors Committee, during a televised SABC Masikhulume debate. The pair smiled and exchanged notes while an obviously inexperienced UDF leader made his point.
Said Dombo: 'You don't have to be spitting fire and have angry faces when you negotiate. It doesn't have to be hostile. You can have an adversarial working relationship and be cordial, even friendly.' She warned that the government's much-touted national health insurance (NHI) service would be 'totally unable to deliver' unless the public health sector was fixed first. 'It will never work if they allow the current public sector status quo to continue,' she predicted.
UDF 'has no locus standi'
Lukhele said the UDF did not have 'anything like' the number of members required to gain union representation at the PSCBC (50 000), but SAMA had nevertheless included them at caucus level as a goodwill gesture. He denied reports that the UDF 'walked out' of the PSCBC. 'They were never members we've kept them fully up to speed through the caucuses,' he added.
Professor Ralph Kirsch, SAMA President, said SAMA's position was that doctors should never put patients' lives at risk. He supported the UDF's struggle 'but not their methods'. 'The problem is two wrongs don't make a right. You have to accept that these youngsters feel deeply. I just hope they feel more deeply about their patients than their pockets.'
The doctors' issue was 'about feeling supported and valued. When your job satisfaction decreases, salary becomes more and more important. Doctors get frustrated because they see people dying and they're helpless to do anything because the equipment and support infrastructure is not there.'
Kirsch said government had reneged on every public and private sector promise it had made and was now abandoning young doctors with significant debts who 'barely come out at month's end, let alone repay their debts'. He emphasised that today's young doctors were 'no longer the children of wealthy white parents'. 'We have 35% vacancies in the public sector and if this gets any worse the consequences for South Africa are enormous.'
1. Health Professions Council of South Africa. 22 032 certificates of good standing were issued since April 1st, 2003, with 3 550 'issued over the past year'. Press statement 28 May 2009. [ Links ]