Rural Health Update: Community Service Medical Officer Allocations 2017: Salt in an open wound
14 December 2016
The first round of community service (comserve) allocations of medical officers (MO) for 2017 was completed three weeks ago. The Rural Health Advocacy Project (RHAP) conducted a preliminary investigation into the two provinces (Eastern Cape and Northern Cape) of which it received the allocation data. We found that once again the majority of placements in these two provinces (EC, NC) favoured urban facilities. Various factors have led to this disappointing outcome at a time when the filling of posts to serve communities in rural areas is already under pressure due to hiring freezes and budget cuts. Based on the trends in previous years, we fear that the situation in other provinces is not much better.
History and purpose of community service
The one-year compulsory community service for health professionals was first introduced in 1998 with an amendment to the Health Professionals Act (Section 24:1998). Initially covering doctors, dentists and pharmacists, the scheme has since been extended to cover a further 7 professional groups including: physiotherapists, occupational and speech therapists, clinical psychologists, dieticians, radiographers and environmental health practitioners. The National Department of Health saw the introduction of community service as an opportunity to address the maldistribution of human resources within the South African health system by providing young professionals with an opportunity to develop skills, acquire knowledge and critical skills in diverse professional settings. Simultaneously the scheme would also introduce additional human resource capacity that would ensure improved provision of health services for all (1).
Allocations for 2017
The allocation of comserve officers usually takes place over three rounds. This year the National Department of Health introduced an online application platform to improve the management of the application and allocation process for community service applicants. Applicants are allowed up to 5 choices in order of preference, which must include posts in at least 3 provinces. In the case of provincial bursary holders these applicants must make 5 choices of facilities within the province that holds the bursary. In previous years the majority of applicants (85%) were placed during the first round with a further 10 % placed in the 2nd and 3rd rounds. The remaining 5% being placed at remaining facilities (2).
Feedback and analysis from this year’s first round of applications suggests that the process has faced a number of challenges. In the Eastern Cape with 153 comserve medical officer (MO) posts available, only 56 MO posts were filled after the first round. Of the filled posts, over 50% were allocated in larger urban centers such as the Buffalo City and Nelson Mandela metros (table 1). Deep rural facilities arguably with the greatest need were largely ignored. For example, Canzibe hospital, a 120 bed servicing 12 primary health care clinics catering to over 143 000 people was originally allocated 2 comserve posts yet no allocation has been made. The hospital is currently operating well below capacity and the additional capacity would have gone some way to alleviate this.
Table 1: Comserve MO allocations for 2017 after first round (refer to image at top of statement).
In the Northern Cape, of the 67 available posts, 60 posts were allocated to just one hospital in Kimberley, the provincial capital. These results give reason for great concern.
Making sense of the 2017 allocations
A possible explanation of the under-allocation of comserve MO’s during the first round in the Eastern Cape is the current bias to applicant choices within the system. For example, a comserve applicant could select 3 urban hospital posts in three different provinces and two slightly less urban locations in his preferred province. This way the applicant could completely avoid rural facilities resulting in the undersubscription of posts in the Eastern Cape. While it is unlikely that posts will not be filled there is a risk that facilities that receive reluctant comserve doctors may not get full value from the additional resource.
Secondly as in the case of the Northern Cape, applicant choices could also be informed by the availability of posts. Across 35 qualifying facilities, posts were only available in 6 facilities with the vast majority at Kimberly Hospital. With the large rural footprint of the Northern Cape the concentration of posts in Kimberley does not add to the goal of ensuring access to health care.
Thirdly the rural allowance that comes with rural posts may have acted as a disincentive for provinces to make more rural posts available. Using the Northern Cape example, by concentrating posts at Kimberly hospital which is an urban center instead of spreading these posts across the 26 facilities that qualify for a rural allowance the province has averted additional expenditure of over R3 million. The province may be performing on its commitment to absorb community service doctors, it is failing the intent of the policy by not equitably distributing the resource.
Finally, insufficient support due to existing staff shortages may be cited as reasons to prefer placements in the cities. It is important to note that the original intent of the policy was to facilitate the equitable distribution of health professional across the public sector. Accordingly every effort must be made to ensure that through the community service programme, young health professionals give at least one year of their professional life to communities that are underserved. In 2011 the KZN Department of Health adopted an exemplary rural-friendly comserve distribution, supervision and support policy to achieve exactly this. However it is unclear what the current status and practice of this policy is, nor are we aware of other provinces that have implemented such policies.
In conclusion, challenges remain, but these are not insurmountable. What is needed is bold decision-making and a deeper reflection on the values and processes that support the implementation of the policy. Political will and leadership is required at national, provincial and academic institutions to bring community service back to its original purpose. Provinces should keep the number of urban comserve facilities to an absolute minimum. A percentage should be agreed upon, for instance posts in urban areas should not exceed a maximum of 20% of total comserve allocations, and national should enforce the threshold. It is within the Minister of Health’s powers as determined in section 24b of the Health Professions Act to support this by ensuring that rural facilities feature strongly on all future comserve allocation lists.
Students need to be made aware when applying for medical schools that they will not have a choice but to do one year of community service in rural and underserved areas. If this is not acceptable to the student, the RHAP believes that he or she needs to be rather advised to choose another profession. Throughout the medical curriculum, rural exposure needs to be maintained.
Community service is one of the very few tools left to bringing additional human resources to underserved facilities and communities. We cannot ethically justify leaving deprived communities without doctors, while bolstering urban facilities. If we do, are we ready to explain our choices to the communities affected?
For more information:
RHAP: Deputy Director
Cellphone: 073 068 1359
Facebook: Rural Health Advocacy Project
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- Reid SJ, Community Service for Health Professionals, South African Health Review, HST, Durban, 2002
- National Department of Health, ICPS Frequently asked questions, June 2016