Two Years Postgraduate Vocational Training for Medical Doctors Proposal

1. Background

At a recent meeting of the Interim Medical and Dental Council on 22 and 23 July 1996, the Council approved a proposal to introduce a system of postgraduate vocational training for medical practitioners as of 1 January 1998. This decision has created controversy among medical students and junior doctors who do not feel that they were consulted about this decision. There has been much speculation about how this proposal for additional vocational training relates to the Department of Health's proposed two years of mandatory service for medical practitioners before they could practice in the private sector.

2. The Proposal

The Interim Medical and Dental Council has not released many details about this proposal. They have circulated a one page press release announcing their decision with a brief motivation. Neither the precise implementation mechanisms of the proposal nor an impact analysis on the health system were presented with the original release. Subsequently, Dr Tim Wilson, Department of Health, has indicated that Department of Health and provincial departments will make the necessary posts available to accommodate the additional training. He also insisted that this proposal was separate from earlier Departmental proposals calling for two years of compulsory service.

The Council motivates that one of its responsibilities is to ensure in the public's interest that adequate standards of education and training of health professionals are in place. Vocational training is one of its primary mechanisms to ensure adequate levels of practical training.

Vocational medical training was introduced after graduation by the Medical and Dental Council in 1950. An undergraduate extension was introduced in the form of a student internship. The Interim Medical and Dental Council of South Africa is now proposing two further years of postgraduate training as a prerequisite for medical practitioners to enter private practice. It states that this training will structured according educational principles and will take place at approved hospitals/facilities under proper supervision.

The recommendations for the additional training will form part of broader amendments to the Medical Act that are expected to be tabled in Parliament during the first half of 1997. A special task team has been to examine the structure and implementation of additional vocational training. It is scheduled to report to the Council in October 1996. The Council is discussing the introduction of similar training with the other health profession that are within its jurisdiction.

3. Some Issues in the Debate

This decision has created an outcry from medical students and junior doctors that has been well covered in the media. Some of the major issues highlighted by students and other analysts are listed below.

• Does this proposal come from the IMD&C or is it the enactment of the Department's mandatory two year registrarship policy?

The two year additional vocational training proposal appears adopted by the Interim Medical and Dental Council of South Africa appears to be very similar to the mandatory two year service proposal contained in the Department of Health's official policy document released in January 1996. The Council presents a rather tepid motivation for its plan that South African medical students do not have sufficient vocational training. In fact, other countries recognise South Africa doctors as some of the most competent in the world. The Department has denied that these policies are related.

The similarity of the proposals and the categorical denial of the Department are troubling because they call into question the autonomy and independence of the Medical and Dental Council of South Africa. The Council was established as an independent body by an Act of Parliament in 1974 and is not directly accountable to the Minister or Department of Health.

• Should only doctors be subjected to this required extra vocational training or should other health professions and other professions also serve?

The press release mentions that the Interim Medical and Dental Council is in the midst of discussions with other health professions about similar vocational training. It is not clear at what stage these discussions are and what their motivation for additional training would be for these professions. Again, the Department of Health official policy is that other health professional graduates would also spend a defined period working in the public sector before being allowed to enter private practice.

• Will this proposal actually put more doctors in rural and underserved areas or will they leave the country to avoid additional service?

It is not clear that the proposal will actually put more doctors in rural and underserved areas. No impact analysis has been done on the number and distribution of doctors has been done as a result of this proposal.

There must be adequate supervision provided and the facilities have to approved by the Council for training. It would mean that senior doctors would need to be redeployed to supervise this training. Information on the geographic location of accrediting training facilities is needed to determine whether more junior doctors could be sent to remote rural and peri-urban areas. Lack of suitable accredited facilities might limit the scope of the additional practitioners. There is also some potential that doctors could emigrate rather than face additional training.

• Will this proposal positively or negatively impact the quality of care in rural areas?

According to official policy document of the Department, there is an acute shortage of approximately 1 000 doctors in the country currently to provide full access to PHC services. This shortage is expected to grow to 2 000 by 2000/2001. Thus, increasing the number of doctors working in the public sector should have a positive on the capacity of the public sector to deliver PHC services. It is estimated that this proposal would increase the number of doctors working in the public sector.

• What are the rights of the communities and patients in this regard?

One key factor that does not seem to have been considered is the impact on this policy on underserved communities in terms of quality of care. A high quality of care must be maintained through this proposal. It should not reduce the quality of care that patients are receiving in the public. Thus, adequate control and supervision are necessary to ensure quality of care. There is also a danger that certain communities will be continuously served by junior doctors meeting their obligations. Thought needs to be given to make sure that some poor communities are not permanently disadvantaged by this policy.

4. Consultation Process/Way Forward

The National Assembly Portfolio Committee on Health will conduct a hearing on this issue on Tuesday 17 September 1996. NPPHCN has been asked to make written and oral submissions at the hearing. The Committee will draft a formal report and make its recommendations to the Interim Medical and Dental Council. As mentioned above, the Council is still working out the details and expects to submit draft legislation early next year. The Committee will then formally consider, amend, and possibly enact the proposed legislation.

Last updated: 14/12/98
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