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Tables
Table 2.1: HIV prevalence among respondents aged two years and older by sex and
age group, 2005 10
Table 2.2: Medical practitioners per 10 000 population in South Africa and
neighbouring countries, various years 14
Table 2.3: Medical practitioners per 10 000 population in high-, middle- and low-
income countries 14
Table 2.4: Number of medical practitioners by region, 2002 to 2004 15
Table 2.5: Number of medical practitioners per 10 000 population by province, 2004 15
Table 2.6: Number of practising medical practitioners per 10 000 population, OECD
countries, 2002 16
Table 2.7: Distribution of public sector medical practitioners per 10 000 public sector-
dependent population by province, 2000 to 2003 17
Table 2.8: Number of South African-born practitioners in certain OECD countries,
2001 18
Table 2.9: Total additional staff to be recruited by DoH 19
Table 3.1: Headcount enrolments at SA medical schools, 1988(89) and 2002 23
Table 3.2: Total enrolments in numbers and percentages at SA medical schools
by institution, 1999 to 2003 24
Table 3.3: Total graduates from SA medical schools in numbers and percentages
by institution, 1999 to 2003 25
Table 3.4: Total enrolments at all eight medical schools by race, 1999 to 2003 25
Table 3.5: Medical school enrolments at individual medical schools by race, numbers
and percentages, 2003 26
Table 3.6: Total graduates from SA medical schools in numbers and percentages
by race, 1999 to 2003 28
Table 3.7: Medical school graduations at individual institutions by race, numbers
and percentages, 2003 29
Table 3.8: Number of medical practitioners by gender, 2002 to 2004 30
Table 3.9: Total enrolments at all SA medical schools by gender, in numbers and
percentages, 1999 to 2003 31
Table 3.10: Total graduates at all SA medical schools by gender, in numbers and
percentages, 1999 to 2003 31
Table 4.1: MBChB enrolments at UCT by race, 1999 to 2003 47
Table 4.2: MBChB graduates at UCT by race, 1999 to 2003 48
Table 4.3: The MBChB at UCT: First-time entering students in the six-year programme,
all cohorts, 1993 to 1998 49
Table 4.4: The MBChB at UCT: First-time entering students in the seven-year
programme, all cohorts, 1992 to 1997 49
Table 4.5: MBChB enrolments at UCT by gender, 1999 to 2002 51
Table 4.6: MBChB graduates at UCT by gender, numbers and percentages of total,
1999 to 2003 52
LIST OF TABLES AND FIGURES
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Table 4.7: MBChB enrolments at UCT Medical School by race and gender, numbers
and percentages of total, 1999 to 2003 53
Table 4.8: MBChB graduates at UCT Medical School by race and gender, numbers and
percentages of total, 1999 to 2003 54
Table 4.9: UCT MBChB and M Med enrolments, percentage of black students,
1999 to 2003 56
Table 4.10: UCT MBChB and M Med enrolments, percentage of female students,
1999 to 2003 57
Table 4.11: UCT M Med enrolments by race and gender, 1999 to 2005 58
Table 4.12: Specialisations with the highest number of enrolments by race,
1999 to 2005 58
Table 4.13: M Med enrolments for all surgical disciplines by race, 1999 to 2005 60
Table 4.14: M Med enrolments for surgical disciplines by race and gender, 1999 to 2005
(percentages) 61
Table 6.1: Numbers of enrolments and graduates at WSU Medical School, 1999 to 2003
(percentages) 78
Table 6.2: Enrolments at WSU Medical School by race, numbers and percentages
of total, 1999 to 2003 79
Table 6.3: Graduates at WSU by race, numbers and percentages of total, 1999
to 2003 79
Table 6.4: Headcount enrolments at WSU by gender, numbers and percentages of total,
1999 to 2003 80
Table 6.5: Graduates at WSU by gender, numbers and percentages of total,
1999 to 2003 80
Figures
Figure 1.1: A model for the analysis of a profession and professional education,
applied to the medical profession and the education of doctors 5
Figure 2.1: Macro organisation of the National Health System in South Africa 13

Doctors in a Divided Society
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Many of the hopes and aspirations of South Africa’s new democracy depend upon the
production of professionals who not only have globally competitive knowledge and skills,
but are also ‘socially responsible and conscious of their role in contributing to the national
development effort and social transformation’ (Ministry of Education 2001: 5). Furthermore,
there is a dire need for more black and female professionals, not only to redress the
inequities of the past, but also to broaden the consciousness of social formations that
tend to be conservative everywhere in the world. In South Africa under apartheid, the
professions reflected race and gender hierarchies, and to varying extents they still do.
Whether the professions and their education programmes are managing to achieve these
ideals is a moot point which the HSRC hopes to address with a series of studies on
professions and professional education, of which this is the first. The studies are intended
to explore the policy concerns stated above and also to raise issues that have not yet
entered policy discourse. They will examine each profession through two theoretical
lenses; the first being professional labour markets, both national and international, as
well as the wider general labour market in South Africa, while the second focuses on
the national and international professional milieu. By this expression, we mean the
multiple socio-economic and political conditions, structural arrangements and professional
and educational discourses which shape what it means to be a professional, behaving
professionally, at a particular juncture in history. Each profession will examine itself
through both these lenses and identify key issues of concern which will form the focus of
each study and be explored at multiple levels. Studies will also include sub-case studies –
micro-level explorations of these issues in professional education settings.
This first case study concerns the profession and education of medical practitioners and
has been selected for two main reasons. First, medicine is one of the oldest and most
highly esteemed professions both locally and internationally and is often regarded as a
prototype for other professions. Secondly, in South Africa, at the start of the 21
st
century,
it is arguably one of the most controversial, with articles appearing daily in the media
on issues relevant to government’s policy aim of global competence/local conscience.
Underlying all the controversies are the deep divides within the health system, between
rich and poor, private and public, urban and rural.
PREFACE
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viii
This research would not have been possible without the help of a number of people.
We would like to thank:
• Professor Michael Young, Dr Heather Jacklin, Professor Chris Rogerson and Professor
Aslam Fataar for their incisive comments on the original proposal;
• Our colleagues, Dr Andre Kraak, Dr Glenda Kruss, Dr Jeanne Gamble, and the late
Charlton Koen for their valuable insights and encouragement as the project progressed;
• Priscilla Barnes for her indispensable administrative support;
• Carin Favero for her excellent transcriptions;
• Dr Heather Jacklin and Dr Peter Barron for their very valuable review of an early
draft of the monograph; and
• Jean Skene of the Department of Education, for providing the statistics that underpin
the quantitative analyses of medical school enrolments and graduations.
Most of all we would like to thank the interviewees who made time to speak to us and in
some cases helped us to revise chapters. In connection with the University of Cape Town
(UCT) case study, we are particularly grateful to Professor Gonda Perez, Professor Janet
Seggie, Nadia Hartman, Professor Leslie London, Brenda Klingenberg and Jane Hendry
(all of UCT). A special vote of thanks is due to Adri Winckler, who collated the data that
informs our analysis of postgraduate enrolments at UCT. Others who provided valuable
insights for the UCT study include: Professor Nicky Padayachee (former dean and head of
the Health Professions Council of South Africa [HPCSA] at the time of our interview); Dr
Beth Engelbrecht (Western Cape Department of Health [DoH]); Dr Saadiq Kariem (chief
operations officer, Groote Schuur Hospital) Maureen Ross (assistant director, nursing, Groote
Schuur Hospital) and several other interviewees who asked to remain anonymous.
In connection with the Walter Sisulu University (WSU) study, we owe many thanks to
Dr Parimalarani Yogeswaran, Professor JA Aguirre, Professor Orlando Alonso-Betancourt,
Dr KO Awotedu, Professor Jehu Iputo, Dr S Vasaiker, Dr Lungelwa Linda-Mafanya,
Dr R Jayakrishnan, and Professor Lech Banach, as well as to many others who requested
anonymity. A special vote of thanks to Charlene Schoeman who set up the interviews.
We are also very grateful to the students who allowed observation of their participation
in problem-based learning (PBL) sessions and who participated in a focus group at the
Nelson Mandela Academic Hospital.
For managing the production of this monograph, we would like to thank Inga Norenius of
HSRC Press. Finally, thank you to Independent Newspapers for permission to reproduce
the photographs on page 20 (top and bottom) and page 63 (top).
ACKNOWLEDGEMENTS
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AA Alcoholics Anonymous
ANC African National Congress
ART antiretroviral therapy
ARV antiretroviral
BMA British Medical Association
CS community service
DoE Department of Education (South Africa)
DoH Department of Health (South Africa)
FHS Faculty of Health Sciences (UCT)
HEMIS Higher Education Management Information System
HEQC Higher Education Quality Committee
HPCSA Health Professions Council of South Africa
HSRC Human Sciences Research Council
HST Health Systems Trust
INMDC Interim National Medical and Dental Council
IT Information technology
KZN KwaZulu-Natal
Medunsa Medical University of South Africa
NPHE National Plan for Higher Education
OECD Organisation for Economic Co-operation and Development
PBL problem-based learning
RWOPS Remunerative Work Outside Public Service
SAMA South African Medical Association
SAMDC South African Medical and Dental Council
UCHPP Unitra Community Health Partnership Project
UCT University of Cape Town
UFS University of the Free State
UKZN University of KwaZulu-Natal
UN University of Natal
Unitra University of Transkei
Wits University of the Witwatersrand
WSU Walter Sisulu University
ABBREVIATIONS AND ACRONYMS
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CHAPTER 1
Towards an understanding of
the profession and education
of medical doctors
Becoming a doctor in South Africa today is a long and expensive business, starting with
intense competition to gain access to one of the country’s eight medical schools. There
can be as many as 20 times the number of applicants as places available and the criteria
for selection are increasingly complex as universities struggle to meet a number of policy
requirements. In particular they must attract more students from previously disadvantaged
groups and more students who will fill the gaps in the current workforce, primarily in the
public service and rural areas.
Once they have gained their places, the students’ long haul begins. Until recently, the
MBChB was a six-year degree, followed by one year’s internship. Since 1998, new
graduates have also been required to do one year’s community service. Now, medical
schools can offer the degree in five years, but the internship period has been extended
to two years. Some universities, such as the University of Cape Town (UCT) and the
University of the Witwatersrand (Wits), have retained the six-year curriculum, so a degree
at these institutions currently takes eight years to complete, with a further year’s community
service. At the end of it all, students become doctors, permitted to work in general
practice, or as registrars in an academic hospital if they wish to study further and become
specialists. Whatever they choose, they will have embarked on a demanding, though often
financially rewarding, career that presents many morally difficult choices along the way.
Despite numerous reforms since 1994, the South African health system remains divided:
first-world private care that ranks with middle-income countries internationally
1
at the one
end, and at the other extreme, in the rural public sector in particular, conditions that are
superior only to the poorest of African countries.
New doctors must decide either now or later which world they wish to enter. Some
will seek out the profession only because of status and monetary implications. Others
might start out with idealistic views but end up disillusioned and pragmatic. Many will
emigrate at this point or later – only a very few will take the difficult road of the public
service; even fewer will veer from the beaten track and into the harsh world of rural
public practice.
Although the profile of these young doctors will differ vastly from cohorts under the
apartheid dispensation – with a clear majority of them black (African, coloured and
Indian) and more than half of them women, it is not clear yet whether their choices will
be substantially different.
In this study, we consider the multiple worlds of medical practice in South Africa ten
years into democracy from a number of perspectives. Firstly, we present the major
problem facing government – the skewed distribution of medical doctors across public/
private, rural/urban divides – and consider its recent attempts to rectify the imbalances.
Secondly, we present the universities’ responses to the equity and redress demands
1 In some fields it ranks with the best internationally, as the current popularity of ‘medical safaris’ suggests.
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Doctors in a Divided Society
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of government policy: changing profiles of medical students and graduates and new
curricula to meet the profile of the ‘basic’ doctor who is willing and able to serve the
needs of a transformed South Africa. Finally, we focus on two medical schools to explore
these issues in greater depth. At UCT, we explore the travails of transformation at a long-
established medical school and discover some interesting implications in the field of
gender. At the University of the Transkei (now Walter Sisulu University), we explore what
is arguably the most concerted attempt in the country to produce rural doctors and raise
questions about the success of this initiative and the survival of the medical school. The
final chapter concludes that there has been progress in the admission of black students
to formerly white institutions although Africans are still underrepresented. Gender
transformation has been so significant that women students are generally in the majority,
but whether the universities are managing to graduate more doctors who are prepared to
work in the public and rural service, remains a moot point.
Methodology
The Human Sciences Research Council’s (HSRC’s) broader project on the professions
is essentially a review of the state of certain professions and occupations and their
education programmes after a decade of democracy. Each profession is viewed in relation
to labour market supply and demand issues and to the changing local and international
discourses of professionalism and professional education, which include policy discourses
and goals.
In taking this approach, it was tempting to concentrate only on the policy goals set out
in the preface, given the urgency of the issues that underlie them. In the context of the
medical profession, this would have required us to find out how many black and women
doctors are being produced, whether medical graduates are achieving internationally
acceptable standards and whether they are also contributing to national development and
social transformation. Such an inquiry is essential but is limited to those factors which
government has already deemed to be important. It is not broad enough to capture
unforeseen questions and the kind of contextual detail which could illuminate old issues.
To widen our enquiry, we explored the way in which professions are being researched
and written about in national and international literature.
Firstly, we noted the international obsession with the appropriate definition of the term
‘profession’, the criteria for counting an occupation as a profession or semi-profession,
the increasing numbers of occupations that wish to be called ‘professions’ and their
reasons for doing so (Abbott 1988; Eraut 1994; Evetts 2003). A focus on these issues in
the South African context might lead one to consider the power of certain key professions
such as medicine and law in relation to fields deemed to be ‘occupations’ rather than
‘professions’. Secondly, there are studies on the process of professionalisation (Wilensky
1964, quoted in Brint 1994), the consolidation of professional authority (Johnson 1972;
Larson 1977), and the histories of professions, both generally and as they developed
in particular countries (Torstendahl & Burrage 1990; Kimball 1992). A focus on these
issues would invite one to consider the history of a profession in South Africa and
the manner in which it consolidated its power, particularly under the conditions of
apartheid. One might also extend this to consider changing views of professionalism,
the bureaucratisation and proletarianisation of professionals and the sociology of the
professions generally (Parsons 1939; Brint 1994; MacDonald 1995; Bourner et al. 2000;
Friedson 2001).
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Thirdly, there have been many studies of professional labour markets, including a
number of important South African studies. These include various reports that have been
published by the Health Systems Trust (HST), a study by the HSRC (Hall & Erasmus 2003)
and international studies on the migration of health professionals (Lehman & Sanders
2002, 2004; Meeus 2003; Joint Learning Initiative on Human Resources 2004; OECD
2004a). These studies have placed great emphasis on the shortages of health professionals
and the impact of the brain drain. Recent international studies in the health professions
field include numerous studies of the nursing labour market (Skatun, Antonazzo, Scott &
Elliot 2005), remuneration in the medical labour markets (Hoff 2004; Bhattacharya 2005),
immigration of medical doctors (Raghuram & Kofman 2002) and studies on the medical
specialities (Thornton 2000).
Fourthly, there have been studies about the relationship between professions and
class (Brint 1994) and the gendered nature of professions and professional education
(Dedobbeleer et al. 1995; Davies 1996, 2003; De Vos 2004). These studies from the US
and UK respectively are important for South Africans who have tended to use the
concept of race as the major tool of categorisation. The concept of gender is gaining
prominence but class remains on the outskirts of policy and academic discourse about
the professions here.
Fifthly, there have been studies by educationists on, among other topics, the process of
professional learning (Kolb 1984), the micro-dynamics of professional education (Becker
et al. 1961), the nature and sociology of professional knowledge (Eraut 1994, 2000, 2004;
Eraut et al. 1998; Young 2004; Guile & Young 2004; Jensen & Lahn 2004), changing
academic and professional identities (Beckett & Gough 2004; Beck & Young 2005)
and the quite recent international shift to problem-based learning in the education of
professionals (Boud & Feletti 1997; Bligh 2000).
Out of these multiple foci – the international debates as well as the local policy
perspective – we arrived at a method which requires one to view professions and their
professional education programmes from two broad perspectives:
• The professional milieu, which encompasses the socio-economic and political
conditions that affect the practice of the profession, as well as the discourses
of professionalism that determine what it means to be a ‘professional’ behaving
‘professionally’ in the particular profession concerned. An examination of the
professional milieu starts with a consideration of the structural arrangements that
underpin the practice of the profession: what it takes to become a professional and
what rules, bodies and professional associations govern practice.
• The current state of the professional labour market requires a consideration of
the extent to which the supply of professionals from the institutions that produce
them meets or exceeds demand. The concern here is with the local professional
market, but international conditions can also be very significant. The broader local
labour market is also relevant to the extent that it includes other supporting or
competing professions.
The relationship between these dimensions is depicted in Figure 1.1. At the heart of the
enquiry is the professional education sector with its students and academics, seen in the
context of the immediate professional labour market. This is divided into urban/rural,
and public/private. These divisions are pertinent in any professional enquiry but are
particularly so when considering the health professions in South Africa, where 63 per cent
of doctors work in the private sector. The lines within the professional labour market orb
an understanding of the profession and education of medical doctors
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Doctors in a Divided Society
4
indicate the proportion of medical practitioners that practise in that sector – a relatively
large number in the urban private sector, a much smaller number in the rural private
sector and very small concentrations in the public sector, urban as well as rural. Note
that the proportions referred to concern jobs, not population, which would show reverse
trends – a large population dependent on public sector medicine (84 per cent of total
population) and a much smaller one which uses the private sector. The overlap between
the professional education oval and the professional labour market shows the position of
academics and students in relation to these sectors. Students are trained in public facilities
which are primarily located in urban areas, but with rural outreach facilities. Academics
may also work in the private sector, which is primarily based in the cities, but can also be
found in some small towns.
The national professional milieu – the broader environment in which practitioners
find themselves – is created to a large extent by the Department of Health (DoH),
health legislation and the Health Professions Council of South Africa (HPCSA), which
is meant to protect the public and has an important say in the education of health
professionals. The South African Medical Association (SAMA) and other medical
associations (such as the Junior Doctors’ Association) represent the interests of doctors.
The national professional milieu is also profoundly affected by the general state of
health of the nation, which in South Africa is very poor, in view of the prevalence of
HIV/AIDS and the fact that average life expectancy at birth is only 51.4 years (HST 2005:
15). Conditions in the public sector have improved somewhat since 1994 but remain
unsatisfactory, particularly in the rural areas where they are affected by the impoverished
environments in which they operate (there may be no running water or electricity, for
example) or the shortage of staff prepared to work there. Private practice ranges from
overcrowded small rooms in high-traffic, working-class areas where patients receive
relatively cheap service, with medication included in the consultation fee. At the other
extreme is the plush world of the medical specialist – luxurious consulting rooms and
world-class service at SAMA rates. These rates are far higher than many medical aid
schemes will pay and medical aid members must cover the difference between medical
aid rates and what the doctors charge.
The national general labour market is potentially of interest to any professional
enquiry, primarily because of the competing professions which it contains. For example,
if there is a boom in the status and monetary rewards in the information technologies
(IT) industry and room for new entrants, it will not be surprising if some people abandon
their original training to go in this direction, or avoid less rewarding professions in the
first place. This study does not explore this problem, which could be considered one of
its weaknesses. An exploration of the reasons why fewer males are choosing to study
medicine (see Chapters 3 and 4) might well lead to the doors of the IT industry or to
those of big business in general.
The international professional labour market is of particular interest to the health
professions because of the heavy demand for professionals by developed countries with
increasingly long-lived populations. Active recruitment by the UK, United States and
New Zealand, for example, has led to the exodus of thousands of health professionals
from African countries, including South Africa. Other countries with great demand, but
less attractive living conditions, such as Saudi Arabia, offer highly-paid, if temporary,
opportunities. There are a few exceptions, like Cuba, which has the highest doctor/
population ratio in the world and exports its physicians by the thousands, as a form of
political currency. South Africa has benefited from several hundred of these doctors, but
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