Public Health and Health Systems

Bloated bureaucracy at HPCSA needs emergency surgery

Aaron Motsoaledi
Written by Kerry Cullinan

The HPCSA is notorious for its inefficiency, but the Health Minister finally has an opportunity to reform this Byzantine monster

Health Minister Dr Aaron Motsoaledi recently appointed a committee to look into the HPCSA

Health Minister Dr Aaron Motsoaledi recently appointed a committee to look into the HPCSA

When South African-trained doctors Tamara and Gideon Maresky returned to South Africa in August 2010 after specialising in the USA, they were excited. Both had double certifications – Tamara as an adult and child psychiatrist and Gideon as a general surgeon and plastic surgeon – and were keen to work in poor communities.

But after five exhausting years of battling with the Health Professions Council of SA (HPCSA) to get their qualifications recognised, they’re considering leaving the country.

“I am passionate about working with women and children in under-served communities, but I am heartsore that the HPCSA has made it so difficult,” says Tamara on the phone while driving back from Khayelitsha, where she currently works.

There are only 16 child psychiatrists in public health in the entire country, yet it took the HPCSA four-and-a half years to issue Harvard-trained Tamara with a certificate allowing her to practice as one. She had to do community service for a year, paid at the level of a newly qualified doctor not a specialist, while she waited.

But the council’s decision concerning Gideon, the family’s main breadwinner, was bizarre and punitive. Delivered after a four-year delay, it demanded that he complete a “self-funded “ year, working without pay as a registrar (trainee surgeon) before they would allow him to practice as a plastic surgeon because they were concerned that he didn’t have enough experience.

Recce to Australia

[quote float = right]There are only 16 child psychiatrists in public health in the entire country, yet it took the HPCSA four-and-a half years to issue Harvard-trained Tamara with a certificate allowing her to practice as one.”

Gideon consulted a lawyer who advised that the only way he could challenge the HPCSA decision was to go to the High Court but warned that there was no legal precedence for doing so and his chances of success were unclear. As the Mareskys have studied for many years and not amassed the kind of money that would allow them to engage in a court battle, they have decided to make a recce to Australia instead.

“We are resourceful and resilient, but we have really reached a dead end,” says Tamara. “After 15 years of studying, and five years waiting for the HCPSA, it is just not feasible for Gideon to work for a year as an unpaid registrar – especially as we don’t even know whether that will be enough. The HPCSA told us before we left the US that we would have not problem in registering.”

Sadly, the Mareskys’ case is not rare. The HPCSA, the body that regulates health professionals in the country and adjudicates the public’s complaints against health professionals, is notoriously dysfunctional –particularly when it comes to health workers with foreign qualifications.

“They act as if we have a glut of doctors in the country,” says Dr Mark Sonderup , vice-chairperson of the SA Medical Association (SAMA), a voluntary association representing doctors. SAMA is so disillusioned by the “inefficient and bloated” medical and dental board, one of 12 professional boards within the HPCSA that regulate different health professionals, that it wants doctors and dentists to have their own independent regulatory body.

Ministerial task team

“We want doctors and dentists to be afforded the same courtesy as pharmacists and nurses, by having our own independent regulatory authority,” said Sonderup. The nursing and pharmacy professions have their own independent regulatory authorities.

In March, Health Minister Aaron Motsoaledi appointed a task team to investigate the council, saying that he had “received a lot of complaints about governance, efficiency, effectiveness and sometimes even the competency of the management of the HPCSA”.

Task team chairperson Professor Bongani Mayosi confirmed that the task team had recently completed its work, which included public submissions, and handed a report to the Minister.

“I can’t tell you a thing about the report. The Minister is considering it, but my understanding is that there will be an announcement some time this month,” said Mayosi, who heads the University of Cape Town’s Department of Medicine, and is designated to be the next Dean of UCT’s medical School.

The task team was swamped with public submissions, including around 30 from staff and former staff, some of whom reported being sacked after trying to expose corruption and irregularities.

One of the irregularities considered by the task team concerned the council’s computer system, Oracle, which was initially due to cost R21-million but which had actually cost R43-million by 2012.

The HPCSA has a long history, dating back to 1928 when mandatory registration for doctors, nurses and pharmacists was introduced. In 1971, professional boards for physiotherapy, optometry, medical technology, chiropody, health inspectors, occupational therapy, psychology, radiography, speech therapy, audiology, dietetics, oral hygiene, opticians and clinical technology were set up.

Manto removed rights

Ironically, the health professionals’ right to nominate representatives to their respective boards was removed during the democratic post-apartheid era. In 2007, then Health Minister Manto Tshabalala-Msimang engineered a change to the Health Professions Act to ensure that representatives of the 12 boards would be appointed by the Department of Health, not their professions, despite the fact that members pay annual fees to the HPCSA. In doing so, she ensured that council representatives answered to government rather than the professionals that they are supposed to govern.

This partisan allegiance to government rather than its paid-up membership was clearly demonstrated in September 2013 when HPCSA President Professor Sam Mokogong joined forces with Health Minister Motsoaledi to try to prevent human rights organisation Section27 from revealing details of how health systems failures in an Eastern Cape hospital had led to the death of a one-year-old boy, Ikho.

“A day before the story was to be made public, the council’s president, Professor Sam Mokgokong, sent a letter to Mark Heywood, the director of Section27, warning him not to release details of Ikho’s story,” according to a GroundUp report.

[quote float= right]HPCSA President Professor Sam Mokogong joined forces with Health Minister Motsoaledi to try to prevent human rights organisation Section27 from revealing details of how health systems failures in an Eastern Cape hospital had led to the death of a one-year-old boy

“If it turn[s] out that any registered practitioners are complicit in this envisaged publication, the HPCSA would not hesitate to initiate professional conduct proceedings against such health practitioners,” warned Mokgokong.

But critics say that the biggest failing of the HPCSA is its inefficiency. Board members are mostly busy professionals who don’t have time to attend to day-to-day council business. Confusion exists about whether the part-time board committee chairpersons or council administrative staff are supposed to respond to professionals’ complaints and queries and as a result, professionals can wait many months for replies.

The waters are further muddied by a multitude of sub-committees under each of the 12 boards, with overlapping mandates and no clear terms of reference. In short, a bloated bureaucratic mess that is very hard to navigate.

HPCSA’s Occupational Therapy Board had passed a resolution agreeing in principle to register orientation and mobility practitioners, but said that “various other boards within the HPCSA would need to consider the application to ensure that there was no overlap with other registered professions”. But nothing had happened.

The practitioners help blind and partially sighted people to “understand and navigate his or her place in an environment, as well as basic tasks, such as cooking, hailing public transport and identifying money”, according to Section27 researcher Silomo Khumalo.

“Without orientation and mobility training, visually impaired learners do not acquire the skill of learning and adapting to environments, and risk injury when moving between places,” Khumalo told Health-e News.

But schools cannot establish posts for these practitioners until the HPCSA registers the Orientation and Mobility Association of South Africa (Omasa).

Overlapping mandates

“Despite repeated following up by Omasa, Section27 and other stakeholders, there has been no information whatsoever regarding the developments of the registration in the almost two years since the application was made,” said Khumalo.

“The Department of Basic Education must hold the HPCSA to account to ensure that visually impaired learners have equal access to their rights to a basic education.”

Somehow, Minister Motsoaledi has to find a way to cut through this Byzantine monster and establish the council as an efficient, credible regulator that has the confidence of professionals and the public. The solution is neither fast nor easy, and needs to include the option of an independent medical council, elected by members of the medical profession, given that, after emergency care practitioners, doctors are the largest group falling under the HPCSA. – Health-e News.

*Attempts to get comment from the HPCSA failed as Health-e News was told that the PR officer was out of the office on a road show and would not be available until next week. 

An edited version of this story also appeared in the Daily Maverick

About the author

Kerry Cullinan

Kerry Cullinan is the Managing Editor at Health-e News Service. Follow her on Twitter @kerrycullinan11

1 Comment

  • Hi all
    I face the very same issues.
    I am a HIV/TB specialist, started the first client on ART with MSF in Khayelitsha in 2001, supported about 30 countries in the fight against HIV, TB, and DRTB- amongst the countries, SA and the whole SA subregion. AT the time I was working in Khayelitsha, I was registered as a “volunteer” with the HPCSA, aand taught 4th year medical students at the UCT on ART.
    Since 2010 I have battled with the HPCSA:
    1. I have all my diplomas (Doctor i Medicine (Frand), HIV management, DTM&H, verified and recognized by SAQA- compulsory to get a work permit); but it took me 3 years to understand and have my diplomas verified by the ECMS in the States,dozens of phone calls to the US and to France to make people there understand what one needed from the other. I had to recurrently get certificates of Good Conduct from my council in France- although I had left in 1999 and explained that i had not returned to work there since…
    2. Then I met with the very useful guys from AHP some 2 years ago; they explained that i could apply under the category “Education” given my history here in SA; I had all the paperwork done (other documents of course!); at the time of submission the signatory of ? at the HPCSA had resigned and was not replaced for months.
    3. Finally this year, I was said that oh! by the way you have a permanent residence permit now, so I would go another way; the board meeting who would be looking at my case would take place in October (this was in June).
    4. At the end of July I called and was said that No! the board meeting would finally be in August; at this time i was be in France; oh by the way, you would have to also submit a…. Certificate of Good Standing from your council in France… the same that the tens I had already submitted before- I had not returned to work there since 1999, like for the previous ones I had submitted but no, it has to be not older than 3 months…..So new contacts, new people at my council, all these people contacted telephonically; then the plan was to have the certificate translated in France and authentified by the court here in SA; which might have taken more than 3 months from the time of being written….
    5. The latest contact: the board has been dissolved…

    The most stupid thing on Earth is that I have french diplomas…. I can work in the UK and in Belgium having them, without any step to be taken- countries from which the newest ex medical students can work with no hassle in SA.

    The country lack skill doctors………………….
    I am an extensively experienced specialist in fields where human resources is needed in this country; I have an “extraordinary skills” permanent residence permit.

    But I cannot work in SA as a MO because of all, because of the “legislation”.
    I have interviewed mounts of foreign doctors who are registered here and few (fortunately) are actually a danger for the patients when it comes to clinical skills.
    There is something here i really do not get…
    I am so empathetic with the SA doctors whose foreign diplomas are not recognized…

    A real nightmare….. with one wish: to go back to my country of origin, where i can be re registered in one week
    And I will do it, if nothing changes…

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