SA’s missing doctors

Maleboho Senior Secondary School, in the Limpopo bushveld, is five hours’ drive from St Stithians College, in the heart of Joburg's northern suburbs.  But the historical and social distance between the two schools couldn’t be greater: the one private; the other state-run.

Edwin Molele and Alexandra Walker’s journeys to join SA’s new medical generation as bachelors of medicine & surgery (MBChB) are as different as the schools they come from. 

Molele’s high marks at Maleboho put him in contention for the Nelson Mandela/Fidel Castro medical programme, and he left SA for Havana in November 2012. There he had to learn Spanish, and deal with cultural differences and high internet costs that made communication with home difficult.

In July 2018 he completed his Cuban studies and returned to SA for an 18-month integration programme at the University of Limpopo. The 29-year-old is now finishing his year of community service at Tshwane’s Mamelodi Hospital. Once fully qualified, he’ll need to pay off his studies by working for the state.

Walker took the more conventional route into medicine. Her parents could afford the extra lessons that would help her achieve the marks required for acceptance to medical school at the University of Cape Town (UCT). But she also undertook community service before applying, which she believes helped secure her place in the competitive programme (though she acknowledges that suturing wounds and dealing with sexual assault victims took an emotional toll).

Now 25, Walker is in the first year of a two-year internship at George Hospital, in the Western Cape. Once she’s done, she’ll need to complete a year of community service to fully qualify as a doctor.

Both Molele and Walker are products of a deliberate attempt by SA medical schools to make the profession more diverse. And both recognise the benefits of that. Molele believes the Cuban programme opens doors for many more South Africans to study medicine; Walker says current medical school admission criteria are necessary, as they favour women and people of colour.

But while the two doctors are happy just to get on with their work, a dispute is raging in their field over who gets to be a doctor in SA. Driving the debate is the scarcity of opportunity: just 1,900 first-year places are available at SA’s 10 medical schools. Because medical schools judge applicants on race and socioeconomic status (see box below), some applicants with top academic results find themselves excluded, and are aggrieved as a result.

At the same time, SA is facing a severe shortage of doctors. In 2015, a study by consulting firm Econex for the Hospital Association of SA found the country had just 60 doctors per 100,000 people in 2013, against a world average of 152. More recent figures from the Organisation for Economic Co-operation & Development (OECD) put SA’s average at 80 doctors for 100,000 people — the second lowest of 36 countries measured. Austria tops the ranking, with 540 per 100,000.

When it comes to specialists, the situation is even more dire. According to a 2019 study by health-care consultancy Percept, there are just seven full-time specialists in the public sector for every 100,000 people. The SA private sector has an average 69 specialists per 100,000 people. Taken together, the local public and private sectors provide 17 specialists for every 100,000 people — woefully below the OECD average of 274. It also suggests a vast mismatch in needs between the public and private sectors.

In part, as Econex found, the emigration of health-care professionals and restrictions on foreign doctors working in SA contributed to the shortage of qualified professionals. But the critical factor limiting the supply of local doctors was the constraint on the number of doctors being trained in the first place.

Any attempt to ease the shortage is circumscribed by the limited places available in SA medical schools. That, in turn, has focused attention on the criteria that determine selection to those few places — in particular, on academic merit against race and demographic factors.

Nine of SA’s 10 medical schools responded to the FM’s requests for details about admission criteria. Outside of basic entry requirements, all say their selection criteria include taking into account academic merit, race, gender and socioeconomic background. Most use the school quintile system as a determinant, where quintile 1 schools are those that receive the highest state subsidies, and quintile 5 the least lowest.

Universities also split classes between school leavers and students with relevant degrees.

The diversity criteria the schools use can be summarised as follows:

Nelson Mandela University: The university selects 60% of its students from the top three quintile schools (non-fee-paying). It favours students from the Eastern Cape and then elsewhere in SA.

Sefako Makgatho Health Sciences University: 80.2% of places are allocated to black applicants, 8.8% to coloureds, 8.5% to whites and 2.5% to Indians or Asians. A  foundational medicine programme is reserved for black students from schools in the top two quintiles.

Stellenbosch University: 120 of the 290 places available are reserved for top-ranked applicants. The remaining 170 slots are allocated to ensure diversity, taking into account race and socioeconomic factors. The university tries to ensure that the gender profile of selected candidates reflects that of the pool of applicants who satisfy the minimum requirements.

University of Cape Town: Applicants who meet the basic requirements for the 240 available places are categorised in three bands based on matric marks and national benchmark tests. Band A is guaranteed acceptance; for Band B uses a weighted-point score is used that calculates a disadvantage factor, considering the school quintile school, the family’s educational profile, income and the like. For Band C, UCT ranks applicants according to a “faculty point score”. No Band C candidates were accepted in 2022 because applicants in bands A and B filled the available spaces.

University of the Free State: The university requires a minimum male or female representation of 40% for its 180 available places. At least 70% must be black, and the selection takes regional demography into account. The university allocates 30% of its places to white students, and gives five places to students from Lesotho, and. It accepts 20% of places go to students who already have a relevant degree.

University of KwaZulu-Natal: Of the 250 available places, 69% are reserved for black students, 19% for Indians, 9% for coloureds, 2% for whites and 1% for “other people”. The university favours top-performing applicants from the first three quintiles, and requires “sufficient applicants from SA rural areas”.

University of Pretoria: Of 300 available places, at least 128 are filled to satisfy diversity factors. Ten of the remaining 187 places are reserved for applicants sponsored by the SA National Defence Force.

Wits University: The available 200 places are awarded to top-performing applicants as follows: 40% on academic merit, 20% to rural applicants, 20% from schools in the top three quintiles; and 20% to black and coloured applicants falling outside the other categories.

Walter Sisulu University: Of 120 places, 80% are reserved for black applicants, 8% for coloureds, 7% for whites, 3% for Indians and 2% for “other”. Applicants are selected on academic merit and socioeconomic status, with most successful applicants taken from schools in the top three quintiles. The university doesn’t apply gender screening.

Note: The University of Limpopo did not respond to the FM’s request for admission criteria

—  How SA universities choose medical students

A controversial issue

The issue boiled over in January, when Dr Angelique Coetzee, then the chair of the SA Medical Association (Sama), told CapeTalk that the selection process for SA medical schools was “highly political” and “racially biased”, and that it reduced the focus on academic achievement.

“Someone who has a D in maths, a C in science and a C in biology gets into med school,” she said in an interview with the radio station.

Coetzee’s remarks were considered incendiary in a country where issues of race remain fraught. And it brought her into conflict with the medical association. When she stepped down as chair of the organisation in February, Sama released a statement saying she had “apologised unreservedly for any emotional hurt this statement may have caused”.

As she tells it, Sama threatened her with a disciplinary hearing, but dropped that when she resigned from the board. “I’m still a Sama member, and I serve on Sama committees,” she tells the FM.

Coetzee says Sama accused her of being tone-deaf following her comments to CapeTalk, saying she didn’t understand the country’s history. “It is just politics,” she says. “I would rather walk away. I will not be accused of being a racist, which I am not.”

As for her supposed backtrack, she tells the FM she didn’t write an “apology” letter. “It is signed in my name, but I didn’t write the letter,” she says. “Sama wrote the letter.”

Months later, her position hasn’t changed. She tells the FM she has proof that a medical school accepted a student with the marks she mentioned on CapeTalk. “I don’t want to name that university because I still work with them, but I know exactly which university,” she says. “I have documentary proof. It is not Wits, UCT, Stellenbosch, the University of Pretoria or the Free State University. So I will not put that doctor’s name out there.”

When asked for comment about Coetzee’s latest remarks, Sama chair Dr Mvuyisi Mzukwa, says: “We [Sama] no longer speak about Angelique and her views. Instead, we are seized with the association’s objectives.”

But it’s not only Sama that was up in arms. Prof Lionel Green-Thompson, chair of SA’s committee of medical deans and dean of health sciences at UCT, tells the FM he, too, was offended by Coetzee’s remarks.

“Nobody is admitting students with science [marks] below 60%. The maths marks are much higher than that,” he says, speaking in his capacity as deans’ committee chair. “Even if people get in with differential performances, this kind of comment — that you can get in [to a local medical school] with a D in maths ­— is offensive because it suggests that candidates in the programme are unworthy.”

Green-Thompson has previously told CapeTalk he wants to dispel the notion that the black students selected by local medical schools are so far below the required performance bar that their selection amounts to preferential admission. As he explains it, most SA medical schools have pass rates of more than 90%.

Whatever criticisms of their admission criteria might be, the pass rates at SA universities’ medical schools do seem up to scratch.

University of KwaZulu-Natal spokesperson Normah Zondo, for example, says the university’s medical school has a pass rate of about 96%, with some students carrying over modules to the next year. Stellenbosch University spokesperson Martin Viljoen says 97% of the 289-strong first-year cohort pass, while the rate at the second-year level is 94%. And Sefako Makgatho Health Sciences University (SMU) spokesperson Lusani Netshitomboni says the university’s pass rate for the 149 students it accepted into its first-year MBChB programme last year was 97.5%; the second-year pass rate was 97.3%.

The University of Limpopo has been less stellar. It’s the newest of SA’s medical schools, having opened its doors to students in 2016. Of its original cohort of 60 students, 47 have now graduated — a 78% throughput rate.

There are programmes in place to lift throughput rates. SMU, for example, runs a strong foundation programme to help aspiring medical students, particularly those from poor schools. “Everybody has robust support structures for the [MBChB] basic degree,” says Green-Thompson.

While he estimates that fewer than 10% of students repeat a year, and some take an extra year to complete their studies, “the people who repeat come from across the spectrum; it is not just poor black students. The reasons for repeating include cognitive capacity and mental adjustment.”

More than academic results

For Coetzee, admission on the basis of race is simply not fair on students. “That is when they think they are not good enough,” she says.

In her view, students should be placed on merit. Or at the least, there needs to be transparency around student placement, so parents have clarity when they ask why their children have not been accepted, despite obtaining numerous matric distinctions. And there should be some kind of standardisation across universities. “You need to be open and honest with parents who ask these questions about admission criteria,” she says.

It’s a point with which Green-Thompson would take issue.  “We are open and honest,” he says. “All the universities’ criteria are on their websites. However, I’m deeply mindful that students who performed well at school may not get in based on the [admission] criteria. Each candidate needs to be dealt with individually, and universities have an extensive system of dealing with the appeals and providing parents with explanations.”

As he notes: “Medical school places are a scarce resource. Therefore, all of us have redress in our criteria.”

In 2016, Green-Thompson co-authored an article in the SA Medical Journal that looked at local medical school admissions criteria. The authors found that 39% of undergraduate medical school students were black, against a general population that was 80% black; 33% were white (against a national demographic of 9%); 14% were Indian or Asian (national: 2.5%); and almost 14% were coloured (national: 9%). So, relative to the national population, black medical students were severely underrepresented, while other race groups were overrepresented.

The study also found that 62% of local medical students were female.

“Selection policies for undergraduate medical programmes aimed at redress should be continued and refined, along with the provision of support to ensure student success,” the authors recommended.

But the article also found that stronger evidence was needed to link medical school throughput, academic success and future career paths to selection criteria. And, it said, an emerging black middle class complicated the definition of disadvantage by race.

Six years on, Green-Thompson believes issues around redress in student selection are a reflection of SA’s socioeconomic realities.

“Increasingly, medical schools will introduce measures so matric performance may be a smaller part of the selection process. We are looking for proven selection methods beyond pure academic performance that will ensure an adaptive graduate can manage the complexities of health care from a cognitive and humanistic perspective,” he says.

It does raise questions about the kind of prerequisites that make a good doctor. A cursory online search will tell you that, in addition to excelling academically, doctors need to be excellent communicators, empathetic, organised and able to manage stress, and to work well in teams. They need to be curious, detail-orientated and committed. This is why top international schools require applicants to satisfy a number of requirements — including, in some cases, a contribution to diversity (see box below).

Top medical schools in the US, UK and Asia require academic excellence from applicants, and competition for places is fierce.

The FM looked at the admission criteria on the websites of Harvard Medical School, Stanford University School of Medicine, Oxford University Medical School, the All India Institute of Medical Sciences, the National University of Singapore (NUS) Yong Loo Lin School of Medicine and the University of Cambridge School of Clinical Medicine.

Harvard notes that it seeks “students of integrity and maturity who have a concern for others, leadership potential, and an aptitude for working with people”. Its selection is based on a range of factors, including academic record, application essay, admissions test, and letters of motivation, as well as life experience and extracurricular activities.

Stanford recruits medical applicants with proven excellence, but also takes into account “behavioural and social determinants of health”. It evaluates candidates’ competence across four categories: interpersonal, intrapersonal, reasoning and science, and also notes the importance of diversity in the profession.

Cambridge says it looks holistically at each applicant based on an extensive list of medical admission requirements, including critical qualities, scientific competencies, personal attributes, and professional and career considerations.

Top academic performance in medical subjects, particularly biology, chemistry, physics and mathematics, but also English, is required by these medical schools.

Admission tests form part of the screening process for all six international schools.

NUS’s school ranks candidates according to their scores for “focused skills assessment and situational judgment test, and the top 280 candidates will be offered a place”.

The All India Institute allocates places, in part, based on a reservation system: 27% go goes to applicants from “backward classes”, 15% to applicants from a “scheduled caste”, 7.5% to “scheduled tribes”, 10% to applicants from an “economically weaker section”, and 5% to applicants with disabilities.

—  International comparisons

Perhaps, Coetzee suggests, local schools need to reconsider if marks alone are enough. “Would a combination of good marks with [high] emotional IQ make a better doctor?” she asks. “Great marks are no guarantee that you will handle the pressure.”

Says Green-Thompson: “I don’t think any deans believe that matric performance is the best way to select doctors. But because fairness and justice are big issues, we have defaulted to the [academic] numbers because it is tough to justify subjective measures. But medical schools are introducing situational judgment tests to their selection processes. These tests show how students react to certain situations.”

Similarly, Sama’s Mzukwa said in an interview with eNCA that matric distinctions are not the only criteria used by local medical schools: while they consider applicants’ academic performance, they also put candidates through national benchmark tests. And they take into account nonacademic attributes including leadership, community engagement and applicants’ socioeconomic backgrounds.

“There is nothing wrong with the [medical school] admission criteria,” he said. “However, they [the medical schools] are responsible for dealing with transformation and accommodating redress policies.”

According to Prof Shabir Madhi, health sciences dean at Wits, the university’s medical school tries to be objective with admissions. “We try to remove any subjectivity. That is why we focus on academic performance,” he recently told CapeTalk. “It [admission] is not a political issue, but to redress the inequity of the past.”

Still, Madhi said SA medical schools could not expect students from poorly resourced schools to compete with students from private schools. To suggest that admission criteria are political, he added, “shows complete naiveté”.

In search of a solution

Given the high throughput rate of SA’s medical schools — and the stiff competition for placement — it would seem a no-brainer that the solution to the doctor shortage is to increase training opportunities.

This, in part, is Coetzee’s view: open up medical schools and make more spaces available. In other words, spend more on tertiary education.

It’s a point with which Green-Thompson agrees, as he acknowledges the need for “many more doctors”. But, he adds, it’s a “vexing problem”.

“Some of us feel doctors are the answer to the problem; others think a realignment of the professional tasks is the way to go. Some universities work on very constrained clinical training platforms. That is the limitation.”

Of course, there’s the perennial issue of the shortage of resources. “The government subsidies are shrinking because of the fiscus tightening up,” Green-Thompson says. “For many universities’ budgets, subsidies form a smaller part of their income.”

Frikkie Booysen, professor of health economics at Wits, says if SA is to increase the number of locally registered doctors, it needs more medical schools. But he acknowledges that that’s a long-term solution: “Building infrastructure takes time, and training facilities need to be appropriately resourced.”

In large part, the expansion of existing medical schools — or the construction of new ones — needs to be funded by the state through investments “via earmarked conditional grants from the Treasury”, says Booysen. However, he adds, “the private sector’s role in co-funding medical schools should be explored”.

There are, of course, other, more immediate ways to ensure SA has a sufficient supply of doctors to meet its growing demand. The government could bring additional foreign doctors into the country. But, importantly, Booysen says the government could also work harder to keep its doctors, and stop them from emigrating by improving their working conditions.

Karabo Kobue is well-acquainted with SA’s doctor shortage. “There were only a few doctors where I come from,” the 23-year-old, fifth-year Wits MBChB student tells the FM. “I have been sick and know how it feels to use a public hospital.”

Kobue grew up in the North West town of Brits. He attended Hartbeespoort High School on an SA National Roads Agency mathematics and science scholarship before being accepted into medical school.

“The application process is the hardest thing when getting into medical school. Fortunately, I knew people who attended my high school and med school, so they guided me,” he says.

His grandmother, a pensioner, tried to help pay for his university fees during his first year, but she didn’t have enough money. “It was very tough. However, I performed well academically and later got funding from the National Student Financial Aid Scheme for my studies,” he says.

Kobue takes issue with those who oppose diversity measures for medical school admission. “A particular population thinks it is their birthright to study medicine,” he says. “Universities shouldn’t have to implement [diversity measures], but medical schools should reflect the country’s demographics.

“You can’t have a medical school where the minority holds most places. That makes little sense. Those doctors won’t serve the population where they are needed the most.”

Those who fail to get into medical school in SA can always look to study abroad — if they can afford it.

The World Directory of Medical Schools checked website lists about foreign 3,600 foreign medical schools, most priced out of the reach of ordinary South Africans.

SA medical student, Alicia* is studying at an Italian private university dedicated to the medical sciences. She tells the FM that she had a matric average of about 90% and had completed many hours of community service. However, neither the University of Cape Town (UCT) nor Stellenbosch accepted her into their medical programmes.

“I don’t know why I wasn’t accepted,” Alicia tells the FM. “I didn’t ask. Getting into medical school in SA is super-competitive because so many people apply.”

Still, while she says the selection criteria “aren’t perfect”, she understands why they are there.

When Alicia arrived in Italy, she couldn’t speak a word of Italian, “so it was a bit of an adventure”. But English is acceptable for exams, written and oral, and the classes and textbooks are in English.

She estimates it’s three or four times more expensive to study medicine in Italy than at UCT (R93,210 for first-year MBChB) or Stellenbosch (R78,910). (University search site Gyanberry puts fees at Italian medical schools at R313,000-R468,000 a year.)

Medical studies in the UK and the US are among the most expensive in the world. In the UK, fees for international students run vary from R526,299 a year at the University of Manchester (local students pay about R181,000), to R830,000 at Queen Mary University of London. While top US medical schools could cost upwards of R900,000 a year.

According to the world directory and other sources, cheaper options are available in Eastern Europe, as well as in France, India, Spain, Australia, Canada, Georgia, Grenada, Ireland and Hungary.

Alicia says she has come across other South Africans who have gone overseas to study medicine — about half of them black, by her estimate. She believes the number of South Africans studying medicine abroad and the shortage of doctors in SA points to the need for more local training opportunities.

* Not her real name

—  Offshore options

State cash crunch for interns

Before practising as doctors, medical graduates must complete two years of internship and a year of community service. But in recent years, the government and the medical profession have been at loggerheads over a lack of money and inadequate places for interns and community service doctors.

According to SA Medical Association (Sama) chair Dr Mvuyisi Mzukwa, in some years about 600 of the about 1,500 medical interns who qualify from local medical schools (2,000-2,500 if graduates from Cuban schools are included) cannot find posts. This year, all graduates and interns were placed, he adds — but only after a fight with the government.

“It is mere incompetence,” Mzukwa says, blaming the national department of health. “They should be in a position where they can do this smoothly now.”

Prof Steve Reid, director of the primary health-care unit at the University of Cape Town, says placing medical graduates in internships and community service has been a problem for the past five years. “There is an annual showdown between the doctors and the government,” he tells the FM.

According to health department spokesperson Foster Mohale, “issues” arose back in 2019 when it came to funding medical interns and doctors doing community service. This was a result of an increase in the number of students studying medicine in SA and Cuba, and the National Treasury cutting costs.

Victor Khanyile, director of human resources management at the department of health, says it costs about R10bn a year to cover 4,800 first- and second-year interns, and about 2,300 community service doctors. That figure also includes the cost of health-care professionals from 16 categories required to complete a year of community service (pharmacists, nurses and psychologists, for example).