Self-Regulation of Doctors and Health Professions Council of South Africa (HPCSA): South African Medical Association briefing

Meeting report

Opening Statement
The Chairperson noted that the Committee was meeting the South African Medical Association (SAMA) at a time when recent news articles reported on people arrested for pretending to be doctors. This was a matter that the Committee had to focus on. SAMA was a union for medical doctors. The Committee would also be calling on other medical unions. He welcomed officials from SAMA and the Department of Health (DoH).

South African Medical Association briefing
Dr Fazel Randera, Chairperson of the Health Policy Committee of SAMA, told Members that the South African Medical and Dental Act and the SA Medical and Dental Council existed prior to 1994. After the first democratic elections, the Interim Health Professional Council was established in keeping with the need to transform health professional bodies. The nursing profession and the pharmacy profession were allowed to retain their respective legislation and professional bodies. At this time SAMA expressed its reservations about a Health Professional Council representing so many professional bodies and continued to support professional autonomy.

In 2007, the Health Professional Amendment Bill was released for public comment and SAMA made a comprehensive submission to the Health Portfolio Committee. SAMA’s submission requested a significant change from the legislation and it proposed a council that represented doctors and dentists so that professional autonomy could be respected. They also suggested that the majority of members serving on the professional boards should be elected by the Minister instead of using the elected representation method as previously applied. The World Medical Association promoted professional autonomy and self-regulation saying that the medical profession had a continuing responsibility to be self-regulatory. The ultimate control and decision-making authority had to rest with physicians, based on their specific medical training, knowledge, experience and expertise. A SAMA survey showed that there were profession-specific regulators in most countries.

SAMA conducted a comparative survey amongst Medical Councils and Dental Councils of other countries. They found that in many countries, the majority of council members were from the respective profession the council sought to regulate. In South Africa, the Nursing Council members and the Pharmacy Council members were registered nurses and pharmacists respectively. In the amended respective Acts that have taken place since 1994, a number of members sitting on the respective councils were appointed by the Minister.

SAMA has experienced challenges with the Health Professions Council of South Africa (HPCSA). The first challenge had to do with the structural relationship between HPCSA and the Medical and Dental Board (MDB). The general environment and the functioning of HPCSA undermined representation of the medical profession by the MDB. HPCSA prevented the MDB from having a direct audience with the Minister of Health, even when necessary. The multi-profession representation by HPCSA resulted in the dilution of the medical voice and marginalisation of the professional interests of doctors and dentists. Doctors paid disproportionably high annual registration fees to HPCSA. There was also a lack of guidance, delays in response and correspondence from HPCSA. SAMA participated in many interventions and engagements to do with legislation and constitutional structures. SAMA made a comprehensive written submission to the Health Portfolio Committee on the Health Professions Act. They had several interactions with HPCSA and the MDB and more recently, discussions were held with the Minister and a submission was made on Professional Autonomy. The SAMA Board indicated a strong approval for a campaign towards the establishment of a standalone council for medical and dental professions.

Doctors and dentists continued to feel marginalised by the HPCSA structure and the authorities that regulated them. HPCSA’s structure contradicted the principle of self-regulation, and professional and clinical autonomy had been eroded. There was increasing mistrust with the current regulator and doctors and dentists were increasingly dissatisfied and frustrated in South Africa.

The understanding was that HPCSA’s primary objective was to protect the public and to regulate the profession of doctors with respect to training, establishing standards, providing for ethical and human rights and promoting professional autonomy. SAMA appealed to the Health Portfolio Committee to re-evaluate the existing legislation for doctors and to consider the establishment of a separate, independent regulatory body for doctors. This would allow the profession to directly run affairs that affected them, and it would enable members of the doctor profession to have professional autonomy over important issues of professional misconduct and clinical negligence.

Discussion
The Chairperson told SAMA that he knew how many challenges doctors in the country faced such as security problems and salary structures. He thought the problem started with regulations where there was no autonomy. He noted that there were people pretending to be doctors and he did not know how many people these “doctors” had killed. It meant that someone somewhere was not doing his/her job. It was someone's fault for not educating the community about proper health care and proper doctors. The point at which the government had to start was to look at the regulation of doctors.

Dr Randera replied that there had been many reports of “bogus” doctors working in hospitals and clinics. Somewhere along the chain, the system had not worked. Every doctor had to register with the Health Professions Council of South Africa (HPCSA). The question was whether HPCSA had enough oversight mechanisms in place so that sufficient verification of certificates could take place. In the last several months an amendment was gazetted to say that every member of the doctor profession had to have medical insurance. This seemed to be another form of oversight.

Mr M Waters (DA) addressed the issue of rights being taken away from professionals to choose their own boards. He thought SAMA was alluding to the fact that the boards were not representative of the country. For example, the majority of nurses were black and their right to select their own board was taken away. This had a lot to do with the centralisation of power by the Minister at the time and because the Ministry at the time wanted certain people on the board to get their own agenda through. It was a different time in those days, that is, 1997, and there was a lot of tension. He focused on the Membership of Association. He noted that SAMA did not have enough members to represent itself independently on the Bargaining Council. This implied that SAMA's voice was not heard. He asked if this was something SAMA wanted the Committee to look into. He noted that SAMA had said there were only a few members of the Health Professions Council of South Africa (HPCSA) that were doctors or dentists. He asked if they could give the Committee an indication of how many board members there were and how many of them were doctors and dentists. He noted that SAMA said that doctors paid disproportionate amounts of fees to HPCSA. What did SAMA expect them to pay?

Dr Randera replied that when 1994 came around, there was unequal representation in terms of black versus white groupings. The history of Apartheid was very clear; the majority of doctors in 1994 came from the white community. In the Interim Medical and Dental Council's first election after 1994, the criticism was that doctors seemed to be voting according to the groupings from which they came. There was only one doctor of colour elected onto the Council. The Interim Medical and Dental Council soon learned that a change in environment was needed and at the next election they changed the rules - stating that almost 60% of the people on the Council had to be from black groupings of South Africa.

Dr Randera said the HPCSA was made up of a number of representative groupings. Within these groupings, there were one or two doctors. The rest were from universities, the public, the legal fraternity and representatives for the Minister. He did not have the exact number of doctors on the board. He would send this information to the Committee.

He answered that SAMA was an association of doctors in independent practices and in the public sector. It was the public sector doctors that needed a voice when it came to the Bargaining Council. If SAMA was going to take part in the negotiating process, then they needed to have a voice in the Bargaining Council.

On the disproportionate fees that doctors paid to HPCSA, physicians paid much more than general practitioners. An obstetrician paid even higher fees. There was no “one size fits all” for the entire medical profession. HPCSA was setting the fees according to the risk that came with what particular doctors did.

Ms T Kenye (ANC) noted that different professions had different ethical codes. She asked if there would be a conflict of interest with ethical codes if there is one body for all professions. She addressed the false certification of doctors. Did SAMA think it necessary for the National Intelligence Agency (NIA) to scrutinise doctors in the interest of their patients?

Dr Randera answered that there were many issues within the health fraternity that spoke to the ethical codes applied. He thought that ethical codes should be common to the whole sector. But there were times when certain difficult decisions had to be made. For example, who made the decision to take a brain dead person off life support? There were particular issues that doctors had to grapple with on a daily basis.

Mr D Kganare (COPE) told SAMA that he was very interested in their definition of self-regulation. To him, it meant that there were no external structures or individuals involved. Usually with the self-regulatory approach, matters could not be taken to court. He asked for an explanation on professional autonomy and how it would impact on the need to be regulated.

Dr Randera explained that it could seem that self-regulation meant that SAMA wanted an independent regulatory body for doctors and that they did not want to work within societal rules and regulations. This was not what SAMA wanted. There would always be an over-arching legislative body to oversee regulation. SAMA meant that there should be co-regulation rather than self-regulation or self-autonomy. SAMA was talking about whether the “dilution” that had taken place within the structure the legislation had created should have been allowed. They had come to Parliament to ask if this discussion could be opened up again.

Ms M Segale-Diswai (ANC) stated that she was a little concerned about self-regulation. She wondered who had to be held accountable for doctors at the end of the day. Her opinion was that the Minister had to account for what the doctors were doing and if there were appointments of unqualified doctors. She asked if the self-regulation of doctors was possible. Was it possible to be a “referee and a player at the same time”?

Ms E More (ANC) addressed the physical safety of doctors at hospitals. She asked if there had been any meetings between SAMA and the DoH to discuss the matter. What was the current situation? 

Dr Randera answered that the safety of doctors continued to be a concern in the country. He was not asking for doctors to be given special protection but safety was a problem.

Mr G Lekgetho (ANC) noted that SAMA had met with many entities to try and resolve some of the problems they were facing. Discussions were even held with the Minister. He wanted to know what the outcome of the meeting was. SAMA spoke of their dissatisfaction and frustration with certain issues. He agreed that when doctors were so unhappy that they had put their frustrations to paper, then this meeting was long overdue. The Committee had to take cognisance of this.

Dr Randera replied that SAMA had spoken to many entities. Prior to this meeting, the Minister had shown interest in the matter and said that it should be discussed again. SAMA would be following up with the Minister as they had not received a response from his offices yet.

Ms M Dube (ANC) asked for a gender breakdown of the board and if there were any civilians on the board. She wondered if dentists, doctors and pharmacists had joint meetings to discuss patient care. Did SAMA know if there was a mechanism for recruiting doctors in the country?

Dr Randera explained that over the years, post 1994, the number of doctors to graduate from universities had not increased. There was the same number of medical schools as there was then, yet the country was faced with four major epidemics. The epidemics included HIV, trauma, chronic diseases and TB. The number of doctors and dentists has not increased since 1994. SAMA knew that the country's resources were limited so the government was unable to build medical schools. Unfortunately, the country needed a doctor-based health care service. The government had to find ways or interim measures of bringing more doctors in.

Ms L Makhubele-Mashele (ANC) noted that doctors and dentists felt marginalised by HPCSA, which was the regulatory body. She asked if doctors wanted to define themselves outside of HPCSA. This told her that there were doctors that felt they were superior to all the other health professionals in the country - wanting a regulatory body outside of HPCSA. She thought this was going to be a problem. Were doctors dissatisfied and frustrated because they wanted their own regulatory body outside of HPCSA?

Dr Randera replied that doctors did not want to project the image that they were superior to other health professionals. This was not the intention because since1971 there was already a Medical and Dental Council in place that had included other groupings. Doctors in the country were not just frustrated because of HPCSA. There were also other reasons for the dissatisfaction. SAMA was a member-based organisation and had to take into consideration what its members said. The members of SAMA wanted to see a body that represented the views and interests of doctors in the country, rather than being in a body with a number of organisations. 

Ms B Ngcobo (ANC) asked if the exodus of doctors from the country was because of the way they were being regulated or if there were other underlying causes. If doctors wanted self-regulation, who would keep an eye on them?

Dr Randera answered that doctors were leaving South African shores for a number of reasons such as safety and security, the conditions doctors encountered on a daily basis, accreditation of hospitals, and lack of oversight, facilities and equipment.

Dr Randera explained that SAMA was not saying that doctors did not want oversight, as it was very important in every aspect of society. SAMA was not saying that there should not be oversight; they were saying that oversight comes from within the profession as well as from outside of the profession.

The Chairperson said he understood from what SAMA was saying that HPCSA was a regulatory body that encompassed all health professionals. This was a good thing but the “technicalities” of doctors in the regulatory process were neglected. He understood that self-regulation did not mean that doctors were going to “do their own thing”. They just did not want to belong to a large body. It raised the question of who checked doctors’ surgeries to see if they were qualified or not. He thought that HPCSA had probably not done its work in ensuring that all doctors were qualified.

The Chairperson noted that the DoH officials present would not be able to respond to questions concerning legislation.

Mr Mahlane Phalane, National Chair of the Junior Doctors Association of South Africa (JUDASA), informed the Committee that the security of doctors was a serious issue, as doctors were being raped and robbed at gunpoint in hospitals. If a doctor’s environment was unsafe, then it meant that the patients' environment was also unsafe. There was many times where junior doctors were left alone without support. HPCSA had to focus on this problem as well as staff shortages, a lack of recruitment and retention of doctors, the unavailability of resources such as ambulances, and the lack of opportunities for doctors to further their studies. There was no funding for doctors to be able to specialise in certain fields. He also complained that there was a gross abuse of emergency services by certain communities. The public had to be educated about emergency services. There were people that used the ambulance as a form of public transport. The accreditation of hospitals was also a problem. There were some hospitals that did not deserve to be accredited, as they compromised the training of interns and young doctors.

Mr Hennie Groenewald, Director: Workforce Management (DoH), replied that he could not speak for HPCSA, but as far as he knew, the Medical and Dental Board looked into the accreditation of health facilities. So, when interns are placed at these facilities, they ensure there is adequate supervision. Interns could only be placed at places that were accredited with the Medical and Dental Board.

He said the recruitment and retention of doctors was a very serious concern for the DoH which had had a number of engagements with SAMA on this. The DoH was trying to increase the number of doctors in the rural areas. Special incentives were given for doctors working in rural areas. This was put in place in 1994. Doctors in rural areas were also eligible for a rural allowance. With the introduction of the new remuneration dispensation in 2009, it had seen some improvement in the overall dispensation for young doctors coming in to the system. The DoH was also focused on recruiting foreign health professionals. Currently, the Minister had agreements with Cuba, Tunisia and Iran to bring some of their doctors into country.

Mr Groenewald said he did not know that the country's emergency services were being abused by the community and that the ambulances were used to like public transport to bring people to hospitals. He would convey this to senior DoH officials.

Mr Waters commented that the Committee should hold a meeting with HPCSA as well as the Medical and Dental Board to discuss the accreditation of hospitals and the maintenance of the accreditation. The DoH also had to be summoned to Parliament to explain their plan to increase the number of doctors in the country. He noted that South Africa had arrangements to bring doctors into the country from Cuba, Iran and Tunisia. None of these countries spoke English as a first language and they were being sent to rural areas where very little English was spoken and understood. The government was not training its own doctors. He wanted to see a comprehensive plan on how many more medical students the DoH planned on recruiting and how many more medical practices were going to be opened.

Ms Ngcobo added that the government had to educate the public about the importance of ambulances and emergency services. This was not only the DoH's responsibility; it was everybody's responsibility.

Ms More stated that it was her opinion that a council for doctors and dentists was needed urgently. This had to be discussed with the DoH.

Mr Lekgetho noted that the Committee had a right to legislate certain things if they felt the need for it. SAMA had held several meetings with a number of entities; however, nothing had come from the discussions. The Committee had to do something to help SAMA.

The Chairperson agreed that the legislation had to be looked at. The problems that doctors experienced seemed to have stemmed from the Health Professional Amendment Act. The Committee would hold a meeting with the DoH, HPCSA and the deans of health sciences faculties at universities to discuss ways of recruiting and retaining doctors.

The meeting was adjourned.