SAMJ FORUM
ISSUES IN MEDICINE

The South African Medical Association (SAMA) – poised on the perimeter of change

Denise White^*

SAMA Chairperson in 2009. She is Emeritus Associate Professor in the Faculty of Health Sciences, University of Cape Town

2009 was a momentous year for SAMA and the medical profession. In fact that is probably an understatement when one reflects on the unprecedented and landmark events of that year.

The year started off with the axing of the executive leadership of SAMA by its Board of Directors and a walk-out from the Association by a group of dissatisfied members of the Specialist Private Practice Committee. These events were accompanied by mounting tension and unrest among our public sector members on account of SAMA's perceived failure to achieve implementation of the OSD (Occupational-Specific Dispensation) for public sector doctors. The election of the new government at the end of April punctuated the situation momentarily, but doctors did not spare the newly appointed Minister of Health, Dr Aaron Motsoaledi, the full onslaught of their anger around the OSD. SAMA's initial encounter with the new Minister was during the protest march outside the Department of Health in Pretoria, when he valiantly faced the white-coated toyi-toying horde from the back of a bakkie to receive the memorandum of doctors' grievances from the then President of SAMA, Professor Ralph Kirsch. More chaos was to follow as doctors downed tools mid-year and took to the streets countrywide. Remuneration was not the only cause for defiance. Doctors also expressed zero tolerance for the shocking and deteriorating state of the public health system in general, and as tensions erupted into mass action nationwide the gravity and chaos of the situation were exposed in vivid detail to the broader public via extensive media coverage.

The OSD for doctors is currently in the phase of implementation, a year and a half behind schedule and far short of expectations for many long-serving medical officers and specialists. Junior and high-ranking senior public sector doctors have gained financially, some handsomely, but the majority of our doctors have little to celebrate. The 5% lump sum for 2008 was a sop from government and in most cases has largely been gobbled up by the taxman. The Minister has given his assurance that the imbalances will be righted in 2010, but until this is realised the OSD has not achieved its objectives of retaining public sector doctors and attracting doctors to a career in public sector medicine in the here and now. Regrettably the failure to provide an equitable remuneration package across the board in the first round of negotiations was too little too late for some doctors, who have since resigned from the public sector.

How has SAMA emerged from this titanic struggle for public sector doctors? The strike was a bruising encounter for those in leadership positions and a steep learning curve for the Association. It clearly highlighted the gaps and inefficiencies in the organisation, but on the positive side it spurred SAMA into action on many fronts, inter alia improving its communications systems and analysing the way forward with regard to its union function and role. At a personal level the strike was a damaging and crippling experience for some, while for others it was clearly affirming and intoxicating. The lack of a Minimum Service Agreement for Essential Services placed SAMA and striking doctors in an untenable position during the time of protest. Many young colleagues in KwaZulu-Natal, reported to the Health Professions Council of South Africa for their 'illegal' actions, are still facing uncertainty about their futures because of the lack of such an agreement. The continued resistance by government to negotiate a Minimum Service Agreement is incomprehensible and foolhardy and must be actively challenged by Cosatu and its union affiliates. Meanwhile the debate around the ethics and the rights of doctors to embark on strike action continues.

Appreciation and gratitude must go to the many SAMA members, junior and senior, who showed selfless courage and commitment in risking their jobs and reputations during the time of the OSD negotiations and industrial action. Bouquets and thanks are also due to SAMA's recently appointed Secretary-General, Dr Trevor Terblanche, and those in the SAMA Secretariat and Branches who stepped up to the plate and worked tirelessly to assist the processes, as well as to those colleagues in the private sector and members of the public who showed enormous empathy and support for the doctors' plight.

It would be wise for the newly elected SAMA Board to reflect on the extraordinary events of the past year and to capitalise on these evolutionary experiences and the insights they have brought. SAMA's efforts and its budget were largely focused on the public sector in 2009. However, private sector doctors' issues require equal and urgent attention. Talks have continued between SAMA and the breakaway private specialists, but the groups have yet to find common ground and a reason to return to the mother ship and re-establish themselves within the SAMA structures. The dissatisfaction of members, both in the private and the public sectors, must be a red flag for the organisation and the realisation of the 'talk' about restructuring of SAMA must be a priority for the new Council and Board to ensure relevancy and effectiveness for its constituencies.

There are many compelling challenges ahead for SAMA and the profession. Health care reform and the establishment of a National Health Insurance for the country are priorities for government. SAMA must play a central role for the profession in these policy debates. Furthermore, with the confusion and concern around SAMA's union versus professional function it is important that the boundaries between unionisation and professionalism be clearly defined within the governance structures of the Association. It is critical that SAMA's identity as a professional body for doctors is preserved, and not blurred or contaminated by other political alliances and loyalties. Upholding the autonomy, dignity and ethics of the profession is also a vital and core responsibility of the Association. Health policy matters, nationally and globally, must be key focus areas for SAMA in respect of the burden of disease that threatens the health care services of this nation and the African continent. Dominant here are tuberculosis, HIV, malaria, drug abuse, human rights abuse – particularly abuse of women and children – and violence and crime in our communities.

After the trying circumstances and the pattern of dysfunctional leadership of the past decade it appears that a new and exciting era lies ahead for SAMA. The Association has evolved into a transformed organisation, and it is gratifying to note that the new Council has chosen a dynamic and motivated Board of Directors. I have every confidence that under the skilful chairmanship of its highly respected new leader, Dr Norman Mabasa, the organisation will be taken to new heights. And doors of opportunity are opening at other levels. The country is fortunate in having an enlightened and passionate new Minister of Health, who has acknowledged SAMA as a pivotal role player in the health system and as the recognised voice of the profession in health-related matters. This positive relationship with the Ministry needs to be nurtured and respected.

Without doubt this is a time when the medical profession of South Africa, both the private and public sectors, needs the support and guidance of SAMA and a time when SAMA needs the loyalty and support of the profession. It is a time of challenge, a time of change and a time of consolidation. I have every belief that the organisation with its new leadership will take us securely into the future.

* Corresponding author: D White (denise.white@uct.ac.za)