• A Written Submission
    by
    The National Progressive Primary Health Care Network
    on
    A Proposal to Introduce Additional Postgraduate Vocational Training for Medical Doctors
    to
    The National Assembly Portfolio Committee on Health
    on
    16 September 1996

    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 additional 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.

    The National Progressive Primary Health Care Network (NPPHCN) would like to thank the National Assembly Portfolio Committee on Health for the opportunity to share its views on this important issue. NPPHCN is a national non-government organisation founded in 1987 to advocate for the implementation of a national health system based on the principles of the Primary Health Care (PHC) approach. NPPHCN has a membership of more than 1,100 health and development programmes, projects, and individuals. We have offices in eight of the nine provinces and our national office is based in Johannesburg.

    2. The Constitutional Context


    Chapter two of the New Constitution contains the Bill of Rights, the most fundamental rights of citizens by which all levels of government and other individuals are sometimes bound. The "Bill of Rights is the cornerstone of democracy in South Africa. It enshrines the rights of all people in our country and affirms the democratic values of human dignity; equality and freedom. The state must respect, protect, promote, and fulfil the rights in the Bill of Rights."

    Specific health care rights also have been included. "Every person has the right to have access to:

    • (a) health care services, including reproductive health care;

      (b) sufficient food and clean water; and

      (c) a social security system including, if they are unable to support themselves and their dependants, appropriate social assistance."

    Further, "the state must take reasonable legislative and other measures, within its available resources, to achieve the progressive realisation of each of these rights." This places the burden on the government to take measures to provide health care services, food, water, and social security to all South Africans. Finally, no one may be refused emergency medical treatment. The Constitution must be the benchmark against which all health policies, regulations, and legislation are measured.

    3. NPPHCN's Positions


    3.1 Greater Clarity on the Proposal

    • The origin of and motivation for the proposal must be clarified before further planning is done.

    Based on recent media reports, it is not clear whether this proposal originates from the Interim South African Medical and Dental Council (SAMDC) or the Department of Health. The two years of additional vocational training endorsed by the SAMDC appears to be similar to the mandatory two-year community service proposal contained in the Department of Health's official policy document released in January 1996. Department of Health officials have denied that the proposals are similar and insisted that this proposal reflects the views of the SAMDC. SAMDC spokespersons have not been clear on this point in the media. Community service and additional vocational training are two different endeavours with very different implications that must be considered separately.

    The similarity of the two proposals is potentially troubling because it calls into question the autonomy and independence of the SAMDC. The Council was established as an independent body by an Act of Parliament and is not directly accountable to the Minister or Department of Health. NPPHCN urges the SAMDC to provide clarity on the origin of and the motivation for this proposal. Given the confusion surrounding this issue, the role and functions of the SAMDC and its relationship to the Department of Health may need to be further clarified by the Portfolio Committee in the future.

    3.2 Additional Vocational Training

    • Given the hospicentric, curative nature of medical training currently, South African medical graduates could benefit from additional primary care training before entering private practice.

    The proposed new National Health System presents a major challenge to medical educators to better prepare young doctors to work in primary health care settings. While it is true that South African medical graduates receive many offers to practice internationally in the United States, Canada, and Great Britain, which reflect the quality of their education and training, they may not be properly equipped for the transformed health system where the emphasis will change from hospital care to primary care. NPPHCN agrees with the Council's findings that additional training conducted outside the hospital setting may be necessary to supplement current training and to address any deficiencies.

    It is not clear, however, that simply adding two years of additional training without broader medical curriculum reform is the best long-term solution for the nation. More research is urgently needed to identify the specific skills medical graduates are lacking and the shortcomings of the current medical education system. NPPHCN supports a comprehensive approach to medical education and training reforms. This comprehensive approach also would include a reexamination of the selection process and criteria for admission to medical schools to redress the imbalances of the past. We are concerned about simply adding vocational training without broader medical educational reforms.

    The SAMDC said that it was discussing similar vocational training with other health professions. It is not clear how these discussions are progressing. NPPHCN supports and encourages these discussions. Similarly, NPPHCN recommends that additional training for other health professionals takes place within the context of broader health professions education reforms.

    • Efforts should be made to conduct additional vocational training in rural and underserved urban areas where possible.

    To properly prepare young doctors for the new health system and broader changes in the country, some of the additional training should be conducted in underserved urban and rural areas. To accommodate this proposal, sufficient senior doctors would need to be redeployed to supervise them. We recognise that the limited number of accredited facilities currently will limit the geographic scope of these practitioners, and suggest that more information on the geographic location of accrediting training facilities is needed to address this issue in the future.

    • If after research and consultation the SAMDC believes that it is necessary, additional vocational training should be mandatory for all health workers and begin in the short-term.

    Currently, the Department of Health is engaged in many activities and initiatives addressing the need for changes in health curricula. NPPHCN supports these changes and hopes that they will inform the deliberations of the SAMDC. As medical education reforms will take a long time to fully implement, preparation for these changes should begin as soon as possible and initiatives should be implemented as soon as consensus is reached..

    3.3 Community Service

    • NPPHCN wants to restate its support for the Department of Health's proposal to institute a two-year period of community service for all doctors in underserved areas.

    Although the SAMDC and the Department have stated that this proposal primarily addresses vocational training, NPPHCN reasserts its support for mandatory community service for doctors. We believe that as these students receive significant state subsidies for their education, medical graduates have a responsibility to the people of this country to provide health services in underserved areas.

    • Further NPPHCN recommends that other health professionals and other professionals be required to perform two years of community service.

    Again, NPPHCN agrees with the Department of Health's policy calling for mandatary community service to be implemented for all graduates whose education is substantially subsidised by the government. We recognise that this policy must be discussed within the context of the new National Qualifications Framework and addressed by the South African Qualifications Authority (SAQA). We also recognise that it is very ambitious and will take some time to fully implement, but we believe that it is important to redress the imbalances of the past.

    • Community service should be done on a mandatory basis with the option to repay the cost of their education.

    Although NPPHCN believes that community service proposals should be structured so that the majority students choose to perform service, students should be given the option to buy out of their service. Further, a reasonable salary and benefits should be paid to those professionals while they are doing community service.

    3.4 Prerequisites for Both Proposals

    • Whether additional training or community service for young doctors is implemented, they must be properly supervised.

    NPPHCN reiterates the need for adequate supervision and training facilities approved by the Council for those purposes. Additional vocational training should not be an opportunity for young doctors to practice on poor, marginalised people before they begin working to the private sector. Thus, adequate control and supervision are necessary to ensure a high quality of care.

    • The potential for emigration should be addressed in proposals for additional training or community service.

    There is a potential danger that doctors could emigrate rather than face additional training or community service. This danger needs to be fully explored and addressed in future legislation. For example, provisional medical degrees could be awarded until either training or community service has been completed. Additionally, changing the selection criteria of entering medical students to more closely reflect the population should help to address this issue.

    4. Consultation Process

    NPPHCN wants to express its concern about the lack of community input on this issue compared to the many submissions made to the Committee yesterday on the dispensing of medicines. NPPHCN, therefore, encourages the SAMDC to consult widely with all of the major stakeholders, including poor communities, as they flesh out this proposal and draft legislation for introduction in Parliament next year. Additionally, we expect that the National Assembly Portfolio Committee on Health will closely monitor the development of this proposal to ensure that it has broad-based support by the time that legislation is introduced.

    5. Recommendations to the SAMDC


    1. The SAMDC should provide clarity on this proposal and explain how it relates to broader changes in health professions education contemplated by the Department.

    2. As the proposal is developed, the SAMDC should provide analysis of the impact of this proposal on underserved urban and rural communities.

    3. Throughout this process, the SAMDC should conduct appropriate public consultations with all of the relevant stakeholders on this issue, in particular poor communities.

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