On-line version ISSN 2078-5135
SAMJ, S. Afr. med. j. vol.100 n.5 Cape Town May. 2010
Occupation-specific dispensation - a hapless tale
Public sector doctor relations with their employer, soured by clumsy, inconsistent provincial implementation of long-awaited occupation-specific dispensation (OSD) pay hikes and further delayed mid-level category doctors pay talks, are on a knife edge.
However, one assurance given to Izindaba by the national health department's chief negotiator, James Cornwall, is that mid-level category doctor increases - when they finally come - will be backdated to 1 April this year. This is when the State had agreed to reach settlement on the supplementary pay hikes but will now miss by more than a month, negotiations not having begun by mid-April.
Disillusioned State-employed doctors began an ongoing, legal 'work to rule' protest on 1 April, the action mushrooming across the country as word spread.
Cornwall, chief negotiator for the employer in the public health and social development sectoral bargaining council, was speaking as understaffed public hospitals began battling to cope without their usual doctor work-hour largesse.
The protest involves doctors actually taking lunch hours and tea breaks, knocking off at 16h30 and refusing to work overtime - a tactical shift from the illegal wildcat strikes of last year's OSD protests, but still certain to put strain on State health care delivery.
In the interview with Cornwall it became clear that the supplementary talks would probably not begin before the end of April.
As the South African Medical Association (SAMA) Public Sector Committee (PubSec) negotiators began a national road show to update increasingly restive members, Cornwall explained why the delay was 'practically vital' to enable the entire OSD model to work.
With the OSD discharged in four phases, the implementation of the second and third phases (years 1 and 2) was essential to enable phase 4 to be correctly 'conceptualised' and tabled for negotiation, he said.
(The first phase was an across-theboard 5% (pensionable) pay hike, dated from 30 June last year.)
Cornwall admitted that 'the addendum' to last year's agreement specifically spoke of negotiations for mid-level doctor categories being settled by 1 April this year. However, he said that for it to have 'appropriateness in terms of exactly what it would reflect', this was always going to prove a major challenge.
'Until such time as the collective benefit from both years 1 and 2 is known it would make it very difficult to table,' he explained.
Doctors received different pay hikes from 30 June last year and again from 1 April this year (phases 2 and 3), enabling them to work out their total percentage gains.
Cornwall said that because phases 3 and 4 were concurrent (both from 1 April), this would have confounded the further roll-out of the OSD, because 'one is contingent upon the other'.
Izindaba industrial relations sources said the health department had created a conundrum for itself by agreeing to a supplementary bargaining agreement deadline which it 'could not meet without negotiating in the dark'.
'Basically the addendum (phase 4) will be informed by a review of the implementation of the agreement so far, but at what date do you conduct a review of something that's incomplete?' one added.
Speaking on 7 April, Cornwall said his technical experts had 'virtually completed' what the addendum should look like and, depending on obtaining the mandate of their principals, 'we hope to table it by the end of April'.
'Our commitment is there. There's no doubt that as government we value our health professionals. We want this finalised as a matter of reasonable urgency,' he said.
Perceptions gap as wide as ever
Yet, what is reasonable and urgent to government has a very different meaning to doctors at the coalface, an Izindaba survey of SAMA-related doctor bodies revealed.
The gap in perceptions was starkly illustrated by official national health department utterances, displaying a deeply out-of-touch belief in the capacity of the 9 provinces to properly implement the central OSD agreement. They amounted to bellowing moral outrage from atop a mountain of provincial incapacity.
Expressing 'shock' that SAMA 'or some individuals were actually using the language of a strike action' last month, national health department spokesman Fidel Hadebe called it 'very, very immature and very irresponsible'.
He complained, 'we've just started the process of building the capacity of the public health sector to perform and deliver in our country and for people to now talk strike action is irresponsible to say the least'.
Therein lay a major part of the problem - the department had only 'just started' building capacity - and patriotic urgings cut little ice.
Doctors on the ground saw little change to their debilitating working conditions - and were experiencing OSD pay hike chaos in sufficient numbers for several SAMA affiliates to threaten a return to the streets. The majority of SAMA members long ago voted to reject last year's tiered and intricate OSD pay hike offer that saw seniors and juniors benefit the most.
The go-slow began on what SAMA's PubSec chairperson and lead negotiator, Dr Poppie Ramathuba, described as 'our April Fool's Day'.
SAMA's negotiators grudgingly accepted last year's deal as a pragmatic compromise, given the realities of their diluted bargaining strength and the prospect of a then imminent across-theboard civil sector 10% hike kicking off from a lower salary base.
The clumsy implementation and latest delays led to the Junior Doctors Association of South Africa (JUDASA), the South African Registrars Association (SARA), and SAMA's PubSec rattling their sabres louder than ever.
SAMA again quickly distanced itself from any strike talk, hoping the health department would manage to iron out the multiple pay-out 'anomalies' and settle the mid-level category doctor pay negotiations quickly and generously.
From SAMA's chairperson, Dr Norman Mabasa, its industrial relations chief, Thembi Gumbi, JUDASA and SARA these were some of the OSD implementation problems to emerge:
many rural allowances excluded
10% annual civil service hike
incorrectly implemented on a pre-OSD baseline
registrars 5th year of training (i.e. surgical specialties) not acknowledged
variances in months when registrars completed an academic year inappropriately translated
underpayment and incorrect overall OSD translations
deductions in error from those on the '37% extra in lieu of benefits' option
doctors on same salary options and category levels receiving different amounts
non-payment of OSD (now a minority)
tax implications resulting in 'just a few hundred rand more'
unreported transfers between provinces
work experience not taken into account
dispute over registrars being at level 11 (3rd years grouped with principal medical officers pre-OSD).
Mabasa said that of SAMA's 8 000 public sector members 565 (7%) had officially reported problems.
'My suspicion is that it's really not so much about poorly implemented OSD but whether what was negotiated was enough. Some categories (such as 3rd- and 4th-year registrars) did not get enough, he opined.
SAMA won't stop a 'go-slow'- Mabasa
Mabasa added that doctors had a right to withdraw their labour 'in a structured manner within a legal framework - we can't get in their way'.
SAMA was working via the health department to address complaints and had already resolved 'many, if not nearly half of them'.
He was hoping negotiators would reach agreement on 'decent' mid-level category hikes as soon as possible because doctor anger was mounting and 'things may spin out - we can't give any more excuses'.
Ramathuba was more blunt: 'I can tell you the problem is huge. You have 14 000 public sector doctors and the department is implementing the OSD incorrectly. How many rural doctors don't have internet and cannot (or will not) file complaints to SAMA?'
Last year hundreds of doctors, most of them wildcat strikers, expressed disillusionment with SAMA's more diplomatic, 'ethical' approach and claimed sole credit for having shifted health department offers upward.
Acknowledging the good intentions and reassurances of new national health minister, Dr Aaron Motsoaledi, Ramathuba observed: 'He speaks the right language but he doesn't have the staff to make good on his promises'.
The 'bottom line' was that 'he still has the same staff who continue to mess things up - they can't seem to implement what he's saying'.
Ramathuba claimed that OSD non-payments, underpayments and suddenly corrected overpayments were rife.
Department 'not learning' from mistakes
'It's been a mess, worse given that the department asked for extra time last year because of fears of repeating the chaos in implementing the OSD for 100 000 nurses. They wanted to jackup their HR personnel and get their systems right - now we have this.'
'We go an extra mile for our patients but our employer who has the ultimate responsibility does nothing to motivate us and instead messes up any agreement it has with us,' she added.
Newly elected JUDASA president, Dr Mathlane Phelane, told Izindaba that if government continued to 'play these delaying tactics we'll meet in the streets again'.
Speaking the day after JUDASA's AGM, he added: 'This time it will be better co-ordinated. I think we are mastering the art of communicating in the only language they understand.'
Phelane said that whether a go-slow or a full-blown strike, the action this time would ensure that not just 258 strikers from one province (KwaZulu-Natal) were singled out for possible Health Professions Council of South Africa (HPCSA) censure. (Decisions on whether these strikers will face preliminary hearings to a full professional conduct enquiry are due within months.)
Asked why JUDASA was so militant given that junior doctors got the lion's share of the OSD payout last year (40% hikes), Phelane said payouts were inconsistent between provinces and even between individual hospitals and staffers.
'I'd like to see how they handle going back and calculating the differences on the negotiated scale!' he said (a reference to the bungled implementation of the 10% pre-OSD hike) .
'It's been a shambles, they can't even do simple arithmetic,' he complained.
The OSD was 'taking longer than CODESA 2 to bring to conclusion,' Phelane quipped, adding: 'How do we move forward into the next phase of implementation when the previous phase is in such a mess?'
There was a direct link between the 'shambolic' implementation of the OSD and conditions of service, which had gone from bad to worse.
Phelane, a community service doctor, claimed that of those doctors who completed community service last year, most had now left for the private sector or overseas, seeing little future in a public sector career.
'OSD was implemented for recruitment and retention and it's failed dismally,' he said.
Doctors were also disenchanted with the HPCSA that 'goes for the weakest spot (doctors) when its vision and mission is to protect the public'.
'In Limpopo we have a hospital that operates 24/7 with 2 doctors where the mortality rate hit something like 500 over the last 2 months. Where is the HPCSA intervention there?' he asked.
He said doctors were now jokingly calling the OSD, the 'occupation strangulation disaster'.
Registrars hit 'brick wall'
Muthei Dombo, SARA's vice-president, said provincial and national human resources departments appeared either confused by or ignorant of the registrars OSD dispensation while the employer refused to acknowledge several realities.
Countless meetings to iron matters out had proved fruitless, 'so we're on board with the go-slow,' she said.
A major problem was the 'abysmal' communication skills in HR departments.
'When we get hold of them they express ignorance, it's not clear if they're waiting for guidance from head office on the agreement or what. Then National tells us they've resolved problems with Provincial, but there's no detail as to what.'
Dombo said there was 'no excuse' for the implementation chaos. 'These are people who're supposed to be strategists and planners,' she added.
Chairperson of RUDASA, Dr Karl le Roux, said his members' views hadn't changed. Their ethical obligations were to their patients and not their pockets, even though the 'disappointing' current OSD dispensation discouraged experienced doctors from working in rural areas.
'With 10 years experience I now earn very little more than my comserves - I must say it makes you feel a bit undervalued,' he admitted.
The restructuring of the OSD deal from one that initially served mid-level category doctors to one that peaked on either end leaving them 'sagging', was short sighted because it did nothing to retain doctors with vital experience.
'We hope the supplementary deal will correct that,' he added.
Le Roux described rural hospitals as 'centres of poverty and suffering'.
OSD complaints 'exaggerated'
A national health department spokesman claimed that 96% of the OSD implementation process had been 'successfully implemented' and that 'the few remaining cases under dispute' were being attended to.
All provincial departments had agreed to carry out the bargaining council agreements correctly and to ensure 'ongoing communication' with all professional categories.
He emphasised that the OSD regime treated each employee as an individual who was free to structure their package according to their individual needs and urged any dissatisfied party to 'work with us' to resolve matters.
In the meantime, quality health care to 'those who desperately need it' should continue undisturbed, he said.
SAMA's industrial relations chief, Thembi Gumbi, said the profile of doctor complaints had changed from January to March this year - from predominantly doctors not being paid OSD, to underpayments and incorrect OSD translations.
Just 20% of the latter complaints category had been resolved while the health department was disputing the validity of 303 of the 565 complaints in the former category.
Over February and March she received 158 'electronic' complaints nation-wide with the national health department expecting SAMA to forward each one to the individual province concerned.
Worst performing OSD provinces were Gauteng and KwaZulu-Natal.
'It's the [health department's] wrong calculations that most people are offended by because it impacts on their back payments,' she said.