EDITORIAL

 

Cost-cutting at the expense of care and training: The predictable consequences of attempts at austerity by the Gauteng Department of Health

 

 

The Gauteng Department of Health (GDoH) has recently initiated drastic austerity measures, including the unilateral downgrading of commuted overtime (COT) tiers, the termination of sessional contracts, and non-filling of posts following resignations and retirement. These actions were taken without meaningful engagement with affected stakeholders, and have sent shockwaves through Gauteng Province's public healthcare system. At stake are not only overtime contracts and working hours, but the very foundations of patient care, professional training for medical students and specialist training, and the future sustainability of healthcare delivery in South Africa (SA)'s most populous province.

Remuneration packages for doctors should not be split between standard working hours and after-hours services, and must be comprehensive, owing to the very nature of services rendered. Furthermore, they should not discriminate among specialties and between specialists and generalists. The European Working Time Directive (EWTD)^[1,2] offers an integrated model for working hours and compensation. SA should consider a similar approach.

In the current system, the remuneration of doctors in the public sector consists of a basic salary (standard working hours) and COT (after-hours remuneration). COT has long served as a critical mechanism to ensure that doctors are available beyond the standard workday, safeguarding round-the-clock care in the public health system. SA doctors routinely work 60 hours per week, with 40 hours serving as a normal work week and 20 hours forming part of overtime services.^[3] The proposed change in COT will restrict these hours.

The basic salaries for medical professionals in the public health sector in SA fall well below a 'fair remuneration' for the skills and expertise rendered. The abrupt curtailment of this framework risks hollowing out the after-hours safety net, leaving emergency rooms, wards and clinics dangerously under-resourced. In addition, the unilateral removal of sessional contracts compounds this issue, particularly in departments already grappling with unfilled posts and a defacto hiring freeze since October 2024.

A study by the South African Medical Association^[4] showed a significant salary deficit for public sector medical practitioners in SA between 2012 and 2022, with all categories of doctors' salaries increasingly losing their real value. Between 2019 and 2020, public sector doctors' salaries reduced by 20% when compared against inflation. COT, which is critical in ensuring 24-hour access to healthcare services in the public sector, has also significantly supplemented doctors' salaries, contributing as much as 40% of some doctors' total income. COT has therefore had the unintended consequence of masking the inadequacy of base salaries. The study revealed the need for urgent reform to establish parity in remuneration, reduce reliance on overtime and align salaries with inflation, professional responsibilities, disease complexities and the value and social impact contributed by doctors, to ensure fair and sustainable compensation for all public sector doctors.

Three of the largest medical schools in the country fall within Gauteng Province. These universities produce ~25% of the medical graduates in SA, and are major contributors to medical research in the country. Beyond the immediate impact on patient services, these decisions by GDoH strike at the heart of training for future healthcare professionals. Clinical instruction does not pause at 16h00. Junior doctors, interns and registrars require hands-on mentorship throughout the 24-hour cycle. Without adequate senior supervision, training will be compromised, and so too will patient safety.

Additionally, modern technology allows for both medical care and supervision of junior doctors virtually, telephonically and over platforms such as WhatsApp. Telemedicine now constitutes an integral part of the SA health system, and should be embraced by the GDoH and implemented in all health facilities.^[5] On-call professionals providing essential life-saving cover and advice should be fairly remunerated, and should not be penalised for not being 'on site'. The erosion of training environments threatens the long-term resilience of the public health system itself.

While the GDoH might argue that fiscal constraints necessitate such measures, the method of implementation - unilateral, non-transparent and seemingly disconnected from on-the-ground realities - reflects a profound misjudgement. Healthcare professionals are not commodities that can simply be recalibrated to balance a budget spreadsheet. They are the core of the healthcare system, and their presence, particularly for after-hours calls, is non-negotiable when it comes to ensuring patient safety and quality care. This could have a profound effect on the plans for providing universal healthcare and implementation of National Health Insurance.

There is a risk that this decision, if left unchallenged, could trigger a cascading effect: loss of morale, flight of talent to the private sector or overseas, de-accreditation of undergraduate and postgraduate training and a further entrenchment of the inequities between public and private care in SA. The uncertainty of future salary packages is already creating significant anxiety among healthcare workers, and some doctors have already resigned to take up offers in the private sector.

The GDoH needs to immediately rescind the proposed austerity measures and engage meaningfully with all relevant stakeholders -including academic institutions, unions and professional councils. Fiscal prudence must not come at the cost of lives, dignity and the future of our healthcare system. Collaboration, transparency and respect for the profession must be the cornerstone of any meaningful reform.

Let us be clear: austerity should not be a blunt instrument swung in desperation. It must be a carefully wielded scalpel, guided by evidence, compassion and consultation. Anything less is not only reckless, it is unethical.

Flavia Senkubuge

University of Pretoria

Priya Soma-Pillay

University of Pretoria

priya.somapillay@up.ac.za

Debashis Basu

University of Pretoria

Shabir Madhi

University of the Witwatersrand

Feroza Motara

University of the Witwatersrand

Patrick Lekgwara

Sefako Makgatho Health Sciences University

Pagollang Motloba

Sefako Makgatho Health Sciences University

Willy Vangu

University of the Witwatersrand

Mzulungile Nodikida

South African Medical Association

Simon Madini

South African Medical Association Trade Union (SAMATU)

Mike Sathekge

University of Pretoria

Mhlengi Ncube

South African Medical Association (Health Policy)

Lawrence Chauke

University of the Witwatersrand

Ruhann Botha

Junior Doctors Association of South Africa

Tladi Ledibane

Sefako Makgatho Health Sciences University

Ashraf Coovadia

University of the Witwatersrand

Ndlela Dhlodhlo

Sefako Makgatho Health Sciences University

Shakeera Holland

University of the Witwatersrand

Cedric Sihlangu

South African Medical Association Trade Union (SAMATU)

Zaheer Bayat

University of the Witwatersrand

Risenga Chauke

Sefako Makgatho Health Sciences University

William Oosthuizen

South African Medical Association (Legal)

Langanani Mbodi

South African Medical Association Trade Union (SAMATU)

 

References

1. European Commission. Working time directive. European Commission, 2003. https://employment-social-affairs.ec.europa.eu/policies-and-activities/rights-work/labour-law/working-conditions/working-time-directive_en (accessed 6 April 2025).         [ Links ]

2. British Medical Association. Doctors and the European working time directive (EWTD). BMA, 2024. https://www.bma.org.uk/pay-and-contracts/working-hours/european-working-time-directive-ewtd/doctors-and-the-european-working-time-directive (accessed 6 April 2025).         [ Links ]

3. Bhekisisa Team. Budget 2025: Jobs for only 800 of 1 800 unemployed doctors. Bhekisisa, 2025. https://bhekisisa.org/health-news-south-africa/2025-03-12-update-budget-2025-jobs-for-only-800-of-1-800-unemployed-doctors/ (accessed 6 April 2025).         [ Links ]

4. Sobuwa Y. Salaries are down at 2015 levels, and doctors may simply up and leave, says SAMA. News 24, 14 February 2024. https://www.news24.com/news24/southafrica/news/salaries-are-down-at-2015-levels-and-doctors-may-simply-up-and-leave-says-sama-20240214 (accessed 7 April 2025).         [ Links ]

5. Health Professions Council of South Africa. HPCSA Telehealth Guidelines. HPCSA, 2022. https://www.hpcsa-blogs.co.za/hpcsa-telehealth-guidelines/ (accessed 6 April 2025).         [ Links ]