Compulsory community service for doctors in South Africa: A 15-year review

Abstract

Background. Compulsory community service (CS) for health professionals for 12 months was introduced in South Africa (SA) in 1998, starting with medical practitioners. Up to 2014, a total of 17 413 newly qualified doctors and ~44 000 health professionals had completed their year of service in public health facilities around the country. While a number of studies have described the experience and effects of CS qualitatively, none has looked at the programme longitudinally. Objectives. To describe the findings and analyse trends from surveys of CS doctors between 2000 and 2014, specifically with regard to their distribution, support, feedback and career plans. Methods. A consecutive cross-sectional descriptive study design was used based on annual national surveys of CS doctors. The study population of between 1 000 and 1 300 each year was surveyed with regard to their origins, allocations, experiences of the year and future career plans. Results. The total study population varied between 1 057 and 1 308 each year, with response rates of 20 -77%. The average turn-up rate of 89% showed a decreasing tendency, while 77% of respondents were satisfied with the allocation process. Over the 15-year period, the proportion of CS doctors who were black and received a study bursary, and who were allocated to rural areas and district hospitals, increased. The great majority believed that they had made a difference (91%) and developed professionally (81%) over the course of the year, but only about half felt adequately supported clinically and administratively. The attitude towards CS of the majority of respondents shifted significantly from neutral to positive over the course of the 15 years. In terms of future career plans, 50% hoped to specialise, a decreasing minority to go overseas or into private practice, and a constant 15% to work in rural or underserved areas.Conclusions. This study is the first to track the experience of compulsory CS over time in any country in order to describe the trends once it had become institutionalised. The SA experience of CS for doctors over the first 15 years appears to have been a successively positive one, and it has largely met its original objectives of redistribution of health professionals and professional development. Greater attention needs to be given to orientation, management support and clinical supervision, and focusing professional development opportunities on the important minority who are prepared to stay on longer than their obligatory year. CS still needs to be complemented by other interventions to capitalise on its potential.

Developing the health workforce for universal health coverage

“…The attraction of health workers to rural, isolated or otherwise underserved areas, and the retention of these workers once recruited, requires a range of strategies, including: targeted education admission policies to attract candidates from underserved zones; packages of financial, professional (mentorship, networking and continuing education) and qualityof-life incentives; regulatory reforms; and bonding contracts in exchange for educational support costs. 40 Specific policy interventions include: compulsory service in disadvantaged areas after the completion of studies, for example in South Africa; 41 development of a role intended to provide care in rural and/ or remote areas, for example in aged care nurse practitioner in Australia 42 and surgical technicians in Zambia; 43 an emphasis on rural experience in medical education provision; and the use of financial incentives to retain staff, for example in Cambodia, China and Viet Nam. 44…”

‘The Good Doctor’: the Making and Unmaking of the Physician Self in Contemporary South Africa

“…While there is insufficient data on the mobility of South African medical doctors, poor retention rates threaten the viability of the planned implementation of a National Health Insurance package, which purportedly rests on the availability of doctors with a commitment to the collective benefits of this scheme (Mahlathi and Dlamini 2017). A fifteen-year longitudinal study of the compulsory community service scheme shows that while the majority of doctors did think that they had 'made a difference' and learned as professionals, around half felt that administrative and clinical support had been inadequate (Reid et al 2018). In this fifteen-year cohort, expected rural retention remained constant with 15% of doctors indicating that they would continue to work in underserved and rural areas (Reid et al 2018).…”

“…A fifteen-year longitudinal study of the compulsory community service scheme shows that while the majority of doctors did think that they had 'made a difference' and learned as professionals, around half felt that administrative and clinical support had been inadequate (Reid et al 2018). In this fifteen-year cohort, expected rural retention remained constant with 15% of doctors indicating that they would continue to work in underserved and rural areas (Reid et al 2018). In sum, the government currently trains too few doctors; of those who graduate, a majority will move into private practice, emigrate, or switch professions, and rural retention rates remain low.…”

Reconceptualising Health Professions Education in South Africa

“…b To provide our young professionals with an opportunity to further develop their skills, acquire knowledge, behaviour patterns and critical thinking that will help them in their professional development and future careers (Reid, 2001).…”

“…It is significant that the two objectives were given equal importance, although, in practice, the former is regarded as the main purpose of the year. As the programme consisted of 'service not training', CS officers were allocated according to healthcare needs as determined by the DoH, rather than available supervision (Reid, 2001).…”