Instead of saving lives in hospital, 27-year-old Sherwin Prim, who spent 10 years qualifying as a doctor at the University of the Witwatersrand, is in jobless limbo.

This is Prim’s depressing lot since he finished his internship on April 30 in Cape Town. The Department of Health (DOH) told him there was a delay over the allocation of posts in community service and internship positions, the next stage in his career.

“Fortunately, my mom has taken me in and I still have my car,” he says.

Every day Prim hopes for a post before his life savings run out – a reality unimaginable when he moved down from Johannesburg to take up a bright future as an intern two years ago at the Tygerberg Hospital.

“I can’t practice as a doctor at the moment. It is illegal. It would be against our professional regulations… I can only do so once I have completed my community service,” says Prim.

The rules say doctors need to intern for two years, after graduation, plus complete a year of community service to be allowed to operate within the law. According to the DOH, posts open in two cycles. Once at the beginning of the year, to accommodate those who have qualified in the standard period, and in mid-year for those who qualify later.

Dr Sherwin Prim. (Photo supplied)

Prim hoped in vain for the second cycle, which would have meant a starting date of May 1.

“I have been waiting for the last three months without a salary. It is a serious administrative issue.

Doctors are being misinformed, they are not being allocated to positions.”

Mercy Or Monster?

It means Prim went from an average internship salary of R380,000 ($28,400) to moving back home to Johannesburg with his mother. These days all he can do is part-time work as a tutor at the university where he graduated.

“I have been doing some casual work through the university, invigilating and facilitating clinical skills with med students in the meantime. But most of this has been once or twice a week. I am not allowed to work more than 23 hours a month. It’s nowhere near my salary as an intern and works out to just R200 ($15) per hour.”

Prim isn’t alone. Other medical staff have found themselves scraping by as waiters in Spur, call center agents and estate agents.

Doctor Naira Langenbach works as a stand-in secretary in Johannesburg.

“The worst part is the unknown. The worst part is that you sit there and ask ‘when are they going to call me?’ I say to myself ‘just breathe, its fine, it’s going to be alright’,” says Langenbach.

“[At the reception desk] I try not to tell people I am a doctor, because I get very indignant, very quickly. I just want to be done with this. As soon as I am given my post I am going to go do my year of community service and then my degree will be worth something. I’ll probably do an MBA or maybe biomedical engineering. I am not going to do this anymore.”

Would You Carry A Child For Someone?

It is worse for Langenbach because she was born in Amsterdam, Netherlands. Despite being educated in South Africa since she was nine years old, she feels she is pushed to the back of the queue.

Dr Naira Langenbach (Photo supplied)

“What bugs me most about this is my degree is the same. It’s not that I have a dodgy degree. My degree is the same as the people from my year; exactly the same, 100 percent.”

It isn’t the first time she has had to work as a secretary either. When Langenbach graduated from university in 2015, she was forced to scrape for work for five-and-a-half months before her international work permit was issued.

“Last time [I was working for] one of my lecturers, I was helping them out with their accounts. That’s what I ended up doing. It’s not a good use of my skills. Now I’m back [where I started].”

It took a year for Langenbach to get word of a community service post, and when it came she missed it.

“On Saturday, because I am an orthodox Jew, my phone was off. On Monday morning I get a snotty email saying you didn’t pick up the phone and you will have to start work on the first of January 2018,” she says.

Langenbach tracked the caller down but was too late – her post had been given to someone else. The man on the phone promised to resolve the matter. Two days later, on July 11, Langenbach received an email saying she was awarded a post for a hospital in Mpumalanga; she didn’t even apply for it.

“I might have been allocated a spot, but I don’t trust it. There have been a lot of hoax emails going around and I can’t get hold of anybody to confirm it. I have no proof, no contract, no letter, no nothing.”

“I’m broken. I’m so defeated. Even when I tried to call Mpumalanga they hang up the phone after three rings.”

“You reach a point where you accept [the delay] and say okay I’m going to [give up], if I start work I start work. But in the meanwhile I think ‘am going to become a specimen cutter for Lancet?’ The same week that you resign your hopes, the same week, the national department says they are going to open up applications. This hope that you tucked away is suddenly the size of three houses. Then they crush your hope. And you are back to asking ‘am I doing this again?’” says Langenbach.

The Rat Race Against The Silent Killer

Zahid Badroodien, a doctor and chairperson of the Junior Doctor Association of South Africa (JUDASA), says four South African community service doctors, 20 international community service doctors,  139 South African interns and 63 international interns remain unlikely to receive any employment this year because of insufficient posts.

Dr Zahid Badroodien (Photo by Jay Caboz)

Badroodien works at the Site C Youth Centre in Khayelitsha, a township 30 kilometers south east of Cape Town, where he sees the cost of the shortage of doctors.

“This facility sees 200 people a day and we turn people away. We have three or four doctors here depending on the day. We need more people to come into the system.”

“As a community service doctor, who works in a clinic on an ordinary day, I am here from 8AM to 4PM every day. My call [at the hospital in Khayelitsha] then starts at 5PM and finishes at 7AM. I am then back at the clinic at 7AM until 12PM. Then I go home. Then I come back the next day and it starts all over again,” says Badroodien.

This dispute is just one of many complaints by junior doctors about an online system that came in August last year. The system places around 1,200 interns and 400 community service doctors a year.

“There have been many excuses as to what the problems are. Initially we were told there were technical difficulties with the online application system. Subsequent to that we were told the difficulties were with internship posts, specifically that there weren’t enough internship posts for the number of applicants that were applying,” says Prim.

In November, JUDASA cried foul that 307 (of about 1,700) medical students applying for internship had either not been placed or were placed inappropriately.  This included neglecting special circumstances because of a computer glitch which overlooked whether a student is married, pregnant or an owner of property.

The issue dates back to November 2015, when doctors got fed up with the manual paper application system that would regularly lose applications, says Badroodien.

“What I gauged at that stage was the [DOH] didn’t really understand the extent to which this impacts doctors’ personal lives, but also the people they needed to serve, the clinics where doctors needed to serve,” he says.

Beneath the surface there is also an internal battle between the DOH and provinces for the control of posts and placements. Provincial departments, that run the hospitals, make the final call. This means the DOH cannot guarantee whether a province accepts the doctor, once the posts are issued.

The process of acceptance can cause months of delay. Letters of employment are issued by the DOH according to vacancies supplied by provinces. The doctors then have to be interviewed by provinces and then issue contracts, which is the guarantee of employment. Then doctors must travel back to Pretoria to submit the contract of employment, along with the DOH’s letter of acceptance, to the Health Professions Council of South Africa (HPCSA).

“There is a lot of bias that comes in. When I was employed as an intern I was approached by a hospital to come and work for them, before I had even applied. That to me is problematic … We all have South African degrees, we all are South Africans, how are you choosing who is better placed for your hospital,” says Badroodien.

The DOH tells a different story. Aaron Motsoaledi, the Minister of Health, refutes claims that the system has been delayed and has denied the freezing of posts.

He claims that doctors are at fault, turning down positions.

“There are those who were placed in January and they declined those placements, saying they’d rather wait for the next cycle because they are not going to a certain hospital which is too rural or whatever. Others give religious reasons while others quote illness,” says Motsoaledi.

In a statement in January, Motsoaledi also addressed the concerns of JUDASA concerning the freezing of posts.

“Since the beginning of the year, we have been inundated with media queries about doctors and pharmacists who could not get employment in the public service because the government allegedly failed to place them into posts, or alternatively failed to create posts.”

“Despite trying very hard, the department is not always in a position to accommodate all the needs.”

South Africa needs every doctor it can get; a rising concern is when hospitals are forced to limit posts due to budget cuts.

In a 2016 announcement Motsoaledi said: “We want to put it on record that there are no medical posts frozen in this country. If there is freezing of posts by government departments, they have nothing to do with medical doctors as posts in the health sector are exempted. The country needs doctors to work in health facilities and therefore there is no way we can put moratorium on medical posts.”

Although the minister has denied there was a lack of posts, the DOH’s director-general, Malebona Precious Matsoso, told a parliamentary standing committee in March the DOH could not afford to hire the doctors they needed.

In Matsoso’s presentation she said the healthcare system had 45,733 vacant posts, and 351,925 filled posts. The vacancy number included frozen posts. The situation is so bad that two state-of-the-art buildings in the Free State cannot be opened because there are no health workers.

At the clinic in Khayelitsha, reality hits home. Badroodien says patients come as early as 4AM to queue and, due to the lack of doctors in other provinces, patients will travel more than 600 kilometers for treatment.

“When a patient from the Eastern Cape comes to our clinic with a broken neck to be seen by a doctor here, you need to say that is unacceptable,” says Badroodien.

“The national health department now finds itself at a tenuous junction: Find the money to open posts for medical interns or risk leaving dozens of graduates essentially unemployable,” says Badroodien.

South Africa’s dwindling economy and recent ratings downgrades could topple the country’s already fragile public health systems, experts have warned. So the next time you are sitting in the hospital and asking where the doctors are, they could be waiting on tables, answering phones or sitting at home.

Understaffed, Undersupplied, Unhappy

A 2015 study by research group Econex shows the extent of the health crisis. South Africa had 60 doctors per 100,000 citizens in 2013, while the world average was 152 doctors per 100,000 citizens.

The South African Medical Journal (SAMJ) in June released a report from 2,225 doctors that revealed the most significant reason doctors gave for leaving the public sector was dissatisfaction with working conditions.

The survey showed 60.73% of public sector doctors said the state of supplies was inadequate. Just over 66% of public sector doctors were concerned about the lack of equipment and infrastructure compared to 20.41% in the private sector. Around 38% of doctors in the public sector said hygiene and management was not of a good standard. In the private sector this was only 5.37%.

The report, conducted by the Colleges of Medicine of South Africa (CMSA) that included South African Medical Association (SAMA) members, found further underlying reasons for doctors leaving: immigration, better opportunities in private practice as well as being unable to apply for posts as they were frozen.