Updated 20 October 2015

Will doctors be told where they can work?

The controversial 'certificate of need', which can deny doctors an operating license in a bid to address the inequalities in medical services, is yet again up for discussion.


After an outcry in mid-2014 about the introduction of the so-called certificate of need (CoN) and stated intentions to withdraw this proposal, it seems to be back on the cards.

Health Minister Aaron Motsoaledi indicated at a conference in September that the CoN was again included in the National Health Insurance (NHI) White Paper, which is set to be discussed soon.

Read: White paper on NHI to be tabled 'shortly'

In May 2014, long-dormant sections of the National Health Act were signed into law according to which the director general of health would have the power to deny doctors an operating license if they wanted to open a practice in areas with existing sufficient medical services.

What exactly does the law say?

A CoN will be needed by anyone who is:

(i)    establishing, constructing, modifying or acquiring a health establishment or agency;
(ii)    increasing the number of beds in, or acquiring prescribed health technology at, a health establishment or health agency;
(iii)    providing 'prescribed' health services; or
(iv)    continuing to operate a health establishment or health agency after the expiration of 24 months from the date at which the relevant addition to the Act took effect (1 April 2014).

Other considerations taken into account before issuing a licence include ‘from consistency of health services development, equitable distribution and rationalisation of services and resources, and correcting racial, gender, economic and geographical imbalances, to taking into account the demographic and epidemiological characteristics of the population to be served, according to an article published in the South African Medical Journal in July 2014.

Read: SA doctors need not panic over 'certificates of need'

In effect, it comes down to government having the power to give (or deny) doctors permission to work in certain areas. The original purpose of this would have been to address the inequalities in medical services between rural and urban areas and to improve access to healthcare, the Minister of Health, Dr Aaron Motsoaledi, said at the time.

A paucity of skilled professionals in rural areas is not a South African phenomenon, but a worldwide problem, as many professionals are drawn to urban areas, where they have greater access to a large variety of amenities and services, which are often absent in remote areas. In many countries extra ‘rural allowances’ are paid to attract professionals to non-urban areas where their skills are needed.

In mid-2014, after consultation with doctors and health professionals, the proclamation was withdrawn. In January 2015, the Constitutional Court declared the provisions of the proclamation invalid.

The CoN resurfaces

But it has now resurfaced, much to the chagrin of many doctors, of whom 87% said in a survey conducted by PPS (Professional Provident Society) that its implementation would have a negative effect on the medical profession. In 2014, various bodies representing medical professionals (SAMA, SADA and the SAPPF) spoke of ‘unintended consequences for the private sector’ and warned that implementing these provisions could make access to healthcare in underserviced areas even worse.

In September 2015 Motsoaledi said at a conference of the Hospital Association of South Africa that the CoN was again included in the NHI White Paper. Its withdrawal, he said, was because it was badly written, and not because it was being permanently shelved.

Read: SA urged not to adopt American NHI model

The private health sector has been at the receiving end of harsh criticism from the government in recent years and they have been blamed, among other things, for the sharp rise in medical inflation and a perceived unwillingness to be of service to the 84% of the SA population who do not have medical cover.

When asked by Health24 why many medical professionals were unhappy with the proposed NHI scheme he said that many doctors were uncertain that the NHI would succeed while the public healthcare sector public healthcare sector remains beset with various issues including inadequate staffing levels, heavy patient loads, aging infrastructure and stock-outs.

“The CoN in its original form will disregard the medical professionals’ right to choose their place of work,” according to Dr Mark Sonderup, Vice-Chairperson of the South African Medical Association (SAMA).

The Minister is to brief the Cabinet on the NHI White Paper when he is invited to do so. The redirecting of health resources to areas of need is a fundamental aspect of the proposed NHI.

In June Health Department spokesperson Joe Maila assured doctors that no decision, regarding the regulations of the CoN, will be made without full consultation.

He added at the time that that the director general started the process of consulting with all affected parties.

Also read:

The Devil and the NHI

Motsoaledi will make the HPCSA findings public

Female doctors are better


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