Amanda Jitsing and Fouche Venter

It’s 09h00 and the queue outside the district hospital stretches for about 500 metres and grows as each new patient arrives. There is only one doctor on call and he is expected to treat hundreds of patients. Many of these patients won’t get to see him and will have to make the arduous trip tomorrow and wait patiently for their turn.

South Africa, like many developing countries, faces severe shortages in doctors. In 2010, the country had only 55 physicians for every 100000 people[1], against the average of 180 amongst similar middle-income countries[2]. When compared to its BRIC counterparts, South Africa also fares poorly. Russia has almost eight times more physicians per 100000 people than South Africa.

In a country confronted with a quadruple burden of disease – HIV/AIDS and TB, maternal and child mortality, non-communicable diseases and violence and injuries– this statistic is worrying. The situation becomes even more concerning if one considers that many of these physicians work exclusively in the private sector, which serves the approximately 8 million South Africans who have medical aid.

One of the main reasons for this shortage is because the country’s capacity to train physicians is limited. The last time South Africa built a new medical school was in 1976. Since then, there have been only 8 medical schools to train doctors. These institutions, together with our bilateral training agreement with Cuba, produce about 1200 doctors per year, and about a quarter of these are lost through attribution, retirement and emigration.[3]

South Africa’s shortage of doctors, particularly in the public sector, poses a substantial risk to its goal of achieving universal coverage through the rollout of the National Health Insurance Scheme (NHI). By 2025, the target year for full implementation of the NHI, our calculations reveal that South Africa’s physicians per 100000 population will increase to 64.3 if population and the net number of doctors produced grows roughly in line with the past five years.[4]

However, this marginal increase will still not be enough to achieve the health outcomes set out in the National Development Plan. If South Africa were to pursue the benchmark provided by similar middle income countries, it should target a ratio of 180 physicians per 100000 population. This means that we will need 111885 physicians by 2025. Yet, at current growth rates, the country will likely fall short of this target by a massive 71899. Our analysis estimates that South Africa will have to add 6834 doctors to its stock annually – this is a big ask in a country that currently produces only 920 doctors per year.

South Africa’s government is on the right track. In 2015, two new medical schools will open and the government has committed to increasing number of doctors being trained in Cuba and Russia. But this will still not be enough to meet the demand for doctors under the NHI.

What else might be done to address this shortfall?

South Africa could reduce the barriers that prevent foreign health professionals from practising in the country. Enticing doctors from developing countries has worked well for developed countries. In Great Britain, one in every ten doctors comes from India.[5] To achieve this, South Africa will have to compete with the salaries and incentives offered by developed countries. We would also need to revise current immigration and health regulations, which make it extremely onerous for foreign doctors to obtain accreditation and work in South Africa.

And if we cannot recruit doctors from abroad, then we will simply need to raise the number we produce at home. Recently, a group of South African doctors proposed an alternative means to do so – the establishment of private medical schools. These school would run on a strictly commercial basis and would not require any support or subsidy from Government. Unfortunately, this proposal has not found favour with government. The National Department of Health has argued that a private medical school would make medicine unaffordable to learners from historically disadvantaged backgrounds.

This proposal deserves further consideration. In many countries, doctors leave universities with debt. For banks, lending to medical students is an opportunity to secure high-earning future clients with stable income streams. So, for the fast growing middle class in South Africa, who are able to secure loans for their studies, private medical schools may not in fact be unaffordable. Moreover, the entry of private schools would create additional space (and budget) for government to subsidise the cost of medical training for those learners that most need financial support. There are also regional benefits of allowing private medical schools to operate in South Africa. They could be used to train aspiring doctors from neighbouring countries, while minimising the costs to South African government.

The idea of private medical training is not new and other African countries have already made good progress in this direction. For instance, the SSR Medical College is a private medical school in Mauritius. Since its inception in 1999, this school has trained over 775 doctors or an average of 50 doctors a year. Fees for the 5 year degree cost aUSD 39,000 (R 401,700). And, although this represents a 38% increase over the fees at a South African university for a Bachelor of Medicine and Bachelor of Surgery (MBChB), it is not beyond the reach of those learners who qualify for student loans.

Undoubtedly, the quality of training at any private school will have to be closely monitored. South Africa already has a well-developed education and training quality assurance system in place. Specifically, in the health sector, the Democratic Nursing Organisation of South Africa (DENOSA) monitors the quality of nursing training by private providers. There are other ways of assuring the quality of private medical training. For instance, the National Department of Health could impose additional conditions on any private training provider by requiring it to obtain and maintain accreditation from medical boards or affiliate itself with a university.

Arguably, any initiative that increases the number of doctors in South Africa is likely to improve health outcomes. The NHI will increase the demand for doctors considerably and South Africa ought to consider a wide range of policy interventions and solutions to bolster supply. This should include the potential contribution of private medical schools. Rather than dismiss this proposal outright, the Government should be encouraged to work with the private sector to find a mutually beneficial solution to this impending crisis – lest there is no doctor to answer when the NHI call comes!