On-line version ISSN 2078-5135
SAMJ, S. Afr. med. j. vol.99 n.10 Cape Town Oct. 2009
OSD furore - Sama bloodied but unbowed
The South African Medical Association (SAMA) leadership is licking its wounds after 4 months of unprecedented doctor strikes, ideological battles and nasty personal attacks which marked Occupation Specific Dispensation (OSD) pay talks.
Tempers flared and cracks appeared as various SAMA spokespersons pronounced on the latest twist and turn in the on-off doctor strike, splitting negotiators from members at the coalface and alienating SAMA leadership during the public sector pay talks.
Post-OSD settlement interviews with SAMA leaders caught up in the wrangle, asking what specific lessons could be gleaned, uncovered a sweeping new restructuring initiative by SAMA President, Professor Ralph Kirsch.
Kirsch, with Public Sector Committee deputy chairperson and OSD negotiator, Dr Pophi Ramathuba, and backed by some key SAMA committees, want SAMA restructured into at least three business units to improve the lot of disparate interest groups. They say the new business model would address what they described as a long-standing systemic problem that makes scapegoats of SAMA chairpersons forced by media pressure to pronounce publicly outside their areas of expertise.
It would also, said Kirsch, 'match ideological horses for ideological courses', and avoid alienating various internal groupings from the SAMA mother body. This is something that has plagued the organisation and its leaders for years, most acutely over the last two.
The semi-autonomous units would cater for GPs, private practitioners and public sector doctors respectively, and each have their own board and chairperson taking responsibility for the unit's affairs, including pronouncing on issue-specific topics.
SAMA leaders take heat
Recent examples of SAMA chairpersons riling interest groups include the immediate past chairperson Dr Kgosi Letlape's attack on the Medical Schemes Act as a 'piece of apartheid legislation that divides our nation into haves and have-nots,' which he said contributed to the country's notorious rising infant and maternal mortality rates.
Letlape also called private practice 'privatised practice running on the coat-tails of the Medical Schemes Act'.
This antagonised private practitioners, many of whom broke away from SAMA to form the SA Private Practitioners Forum (SAPPF), in what Letlape, an ophthalmologist in private practice, described as a 'sad misinterpretation' of his views. Under intense internal pressure to resign, he did so 6 months short of his maximum 9-year tenure.
The reigns were picked up by his then deputy chairperson, Professor Denise White, an academic of long standing and a psychiatrist in the public sector. Her comments (as chairperson) on the OSD strike, backing SAMA's patient-centred ethical stance, won her instant adversaries among the more militant junior strikers (mainly breakaway United Doctors' Front (UDF) members), and an ugly and personal electronic hate-mail campaign forced her to change cell phone numbers.
Ramathuba, during a visit to Durban to update her constituents on progress in negotiations, was shouted down, had beverage cans thrown at her and subsequently was also subjected to a sustained electronic hate-mail campaign. Ramathuba told Izindaba: 'When doctors are angry they behave like any other workers and want somebody to vent their frustration on. They were monsters - they didn't want to see any of us (at SAMA). We must be prepared to take the heat. I don't believe they did anything wrong, so when I see what they wrote about me on Facebook, I just grin.'
She added: 'This arena is not a lecture hall or theatre; we lead frustrated, angry people who demand the impossible. The problem is that our leadership is from disparate backgrounds and histories.'
Ramathuba claimed that on her third visit to update the Durban doctors, 'they rolled out the red carpet because they realised I wasn't personalising issues'.
SAMA to adjust trade union sights?
Kirsch confirmed Ramathuba's contention that the public sector component of the proposal was to set up a shop steward network at the main hospitals in every province, 'like any good union', to ensure the flow of accurate information and improve mandates. 'We've never built that up and we were caught with our pants down here, disparate leaderships grew up all over,' he said, a reference to the strike-instigating, breakaway UDF which disowned SAMA as 'sellouts to government'.
The industrial-relations-naïve UDF found itself in a legal culde-sac, its striking members exposed and vulnerable. Unlike SAMA, it had no legal standing in the bargaining chamber. Whatever turn it took, the UDF discovered that all dispute resolution paths led back to SAMA.
Kirsch also wants shop stewards in as many rural settings as possible 'so we can work with Cosatu (SAMA is a member union), so that there's good information'. The Rural Doctors Association of South Africa (RUDASA), affiliated to SAMA, fired off a vitriolic letter to the relevant government ministers, decrying the low OSD hikes granted to mid-level sector doctors, whom it said were vital to rural health care. Izindaba learnt that at least five surgeons at the Groote Schuur/Red Cross Hospital complex cited the OSD settlement, either in part or as the main reason, for resigning to work overseas or in the private sector within the next few months. This was in spite of the possibility of supplementary hikes from April next year.
Cape Town public sector specialist, Dr Mark Sonderup, said the OSD had failed the 'Level 11 and 12' mid-level management cadre 'miserably - they're very thin on the ground. Who will be the professor or head of department of tomorrow? Who is being groomed now? These guys don't happen overnight, it takes (up to 15) years and they've been virtually dismissed via the OSD.' He said that in the global context of the collapsing public health sector, the OSD settlement for these doctors was 'the last straw'.
'We must stop using the words crisis and impending crisis. We're in the middle of a full-blown disaster in the public sector here,' he added. A unique opportunity to "turn the ship around" had been tragically lost by placing more OSD emphasis on recruitment than on retention.
Izindaba learnt that Daan Groeneveld, a human resources guru who helped create the Patterson Grading Scale, has been retained by SAMA to compile an OSD analysis and address the 'washing line sag' of increases to mid-level sector doctors. The intention is to call government to account in advance of the re-opened mid-level negotiations by graphically illustrating the anomalies and inequities of its own OSD policy - and the potential consequences of any continued hard-line approach.
In spite of so many public sector doctors being alienated from SAMA by the controversy, its public sector membership grew by at least 800 during the pay-talks (June to August). Ramathuba attributed this to SAMA's exclusive ability to deliver at the negotiating chamber, 'even though we don't expect congratulations on the outcome'.
At present, SAMA is the biggest doctor union and the only real game in town even though it's emasculated by the bargaining chambers' 10 000-member per union seat threshold. Kirsch said that SAMA's existing committees (Ethics, Education, Health Policy) and business units (the Health and Medical Publishing Group, and the Foundation for Professional Development), would remain 'as is' in terms of the business model. The SAMA board would consist of chairpersons of all groups, with an overall SAMA chairperson rotating annually.
'Put the power where it needs to be' - Kirsch
'Power would reside where it needs to - within the interest groups,' Kirsch said. A central tenet of the proposal was to avoid a conflict of individual leadership value systems with those values they were forced to represent. He gave the example of a private practitioner in De Doorns being represented 'by a socialist who is anti-private sector' during vital talks with government.
Kirsch said he had attended talks at Luthuli House (ANC Headquarters) and Cosatu House recently and found 'they were very hostile and anti-SAMA'. This is largely due to the recent controversial departures from SAMA of both Dr Letlape and SAMA secretary general, Dr Aquina Thulare, both of whom have strong socialist leanings.
Letlape's predecessor was Dr Percy Mahlati, now Director-General of Human Resources in the national health department, a fact UDF members were quick to capitalise on, accusing SAMA negotiators of 'having ambitions for government jobs'.
Kirsch said he found these comments 'particularly hurtful'. 'It seems that in South Africa we're not yet mature enough to differ in a civil way - just look at Julius Malema and Helen Zille - we need to grow up and be a little more sophisticated and it's happening in SAMA as well.'
It was time SAMA members realised that those representing them had to 'be civil to government - you can't just persuade by marching and toyi-toying up and down'. Ramathuba said that were it not for the striking doctors (hundreds of SAMA members joined the UDF-led strike), 'we would not have got the gains we had. Whether we like it or not, those guys delivered.' She said she and Professor Matt Lukhele, Chairperson of the Public Sector Committee and lead SAMA negotiator, intended burying the hatchet with the UDF. 'I understand their anger. I probably would have done worse. They did and said what they did out of anger.'
Ramathuba said she believed SAMA should 'only pronounce on professional issues - the mother body should remain pure and not be torn by sectoral issues', hence her support for Kirsch's proposal. Professor Denise White said her priority now was to reunite doctors by making SAMA more relevant to all its diverse groupings. She said the strike had 'left a lot of casualties along the way in terms of relationships built within SAMA and its doctor groupings'.
SAMA could ill afford the fall-out caused by the lack of definition between its existence as a trade union and/or as a professional organisation. 'We have not gone belly up, which is the main thing. We're still vertical and I think we've learnt a lot about how to deal with an unprecedented phenomenon.'
Her damage control priorities in her three remaining months as SAMA chairperson included aiming for a government commitment to a minimum service level agreement with essential services, better government recognition of SAMA's professional status at the bargaining table and in health task teams, plus engaging the Health Professions Council (HPCSA) around the 76 strikers facing potential professional conduct enquiries.
Of the HPCSA striker-probes she added: 'We need to ask, is this the network within the political system that's swung into action or did the HPCSA act independently?'
SAMA's Public Sector Committee (consisting of subcommittees of the Junior Doctors Association of South Africa (JUDASA), the South African Registrars' Association (SARA), the Senior Doctors Association of South Africa (SIDASA) and the Academic Doctors Association of South Africa (ADASA), met from 18 to 20 September to plot a post-OSD way forward. Their recommendations will be put to the full SAMA council in late October.
Indications at the time of going to print were that several powerful no-nonsense resolutions, including the restructuring proposal and addressing the 'subversion' of staff retention aims in the OSD pay hike settlement, would emerge. The HPCSA's 'lopsided' attempts at protecting the public (i.e. victimising striking doctors and not criticising government) were also expected to feature strongly.
SAMA's leadership was effectively 'blooded' by the first-ever South African doctor strike - and it survived. The coming months will test its creative and adaptive mettle.