- Doctors at government hospitals are legally allowed to do extra work in the private sector as long as they do it outside their normal work hours.
- This is called dual-practice or moonlighting. Evidence, though, suggests that many senior and specialist doctors abuse the system by working both jobs at the same time.
- Experts say this causes "artificial shortages" of specialists at government hospitals, and erodes the quality of training that would-be-specialists get.
There were 20 babies screaming for attention in the dilapidated paediatric ward of a state hospital in a small South African town.
Just down the road, at a buzzing taxi rank next to a school, children were getting out of white minibuses to start their day of learning.
Emily Benson, not her real name, was growing anxious inside the children's ward. It was 08:45 on an icy Monday morning, her first rotation in that department.
One of the infants was having a seizure. Blood tests showed at least two of his organs were failing.
Benson knew she had to treat this baby first — but didn't know how.
She was a second-year intern doctor. That means she had graduated from medical school, but still needed to complete her last internship year and a year of community service before she could work without supervision.
There was a medical officer — a general practitioner (GP) at a government hospital or clinic — on duty.
It wasn't enough.
The intern and GP needed the help of a child health specialist. But the hospital's only full-time paediatrician had left the facility to work at her private practice.
Benson hastily put the infant on a drip, but she and the GP were out of their depth.
"I didn't know what to do to save this child," she recalls. "I was terrified."
There's little room for mistakes when treating babies, and even tiny errors can have devastating effects on a body so small.
But the person who could save the baby, and had been appointed full-time by the hospital, was busy treating kids with much wealthier parents just a few kilometres away.
The fact that the hospital's paediatrician also works in the private sector is not illegal.
Doctors (and many other state employees) in South Africa are allowed to work for both the public and private sectors. "Dual practice" or "moonlighting" is what it's often called.
Government health workers can apply to work a limited amount of time in the private sector – as long as it's outside of their government working hours and doesn't compromise their state patients' care.
State health staff have to get written permission for dual practice with their supervisor, who sends a recommendation that goes to the provincial health MEC — or someone who they've delegated the job to, often the hospital's ethics officer — to make the final decision about whether private work would interfere with a doctor's government job.
The call must be made within 30 days. If not, health workers are allowed to assume the request has been approved.
But a 2015 study found that a quarter of doctors interviewed moonlight without ever applying for permission.
And even when they do get approval, not all of them follow the rules.
The specialist Emily Benson was waiting for is one of them: "She works full-time at this hospital, but full-time in private as well."
So she's being paid a full salary by taxpayers to work in state hospitals, and then private sector patients pay her again.
And the baby boy that Benson's looking after is running out of time.
Benson recalls: "I was so out of my depth. Every minute that this baby was without the right medicine increased [his] chance of dying."
When it comes to paediatricians, the country only has 818.
South Africa's specialist-patients ratio is much lower than in many other middle-income countries. Take Brazil. That country has nearly twice the number of specialists for every 100 000 people as South Africa. In Mexico, the number of specialists per 100 000 people outstrip South Africa's count nine to one.
And in government facilities? Only seven.
And Benson's story suggests that things are worse than they appear on paper.
Because while the government may be paying for seven specialists for every 100 000 people, many aren't showing up to work.
When Benson and the GP called their hospital's paediatrician at her private practice to find out when she would come to the baby's aid at the state facility, her response was, "I'm quite busy at the private hospital".
All Emily could do, in between monitoring all the other sick babies in her care, was to run back to the dying boy to resuscitate him after each fit.
About a third of South Africa's state specialists make extra money at private facilities. But it's unclear how many are exploiting the system.
"It's probably about a quarter of doctors [who abuse dual practice], but that places a burden on everyone else and compromises the entire system," says Shabir Madhi, who heads up the University of the Witwatersrand's medical school.
Research in Gauteng in 2004 showed the abuse of the dual practice concession was so widespread in that province that "the majority of doctors work only for four hours [per day] on average before leaving to consult private patients in their private clinics".
For this story, Bhekisisa spoke to 11 medical professionals — from practising doctors to public health researchers, the head of a medical school and a senior government official.
Almost all either had a story about the abuse of dual practice, or said it was common.
Madhi says that when moonlighting is left unchecked, the result is an "artificial shortage" of specialists at government hospitals.
What happens then?
The quality of specialist care at state facilities drops.
What specialists-in-training lose when there are no seniors
The NHI is a plan to make the same quality of health services available to everyone, regardless of how much they can pay for it.
But for the system to work, we need enough professionals — and the workforce to train them.
Specialists-in-training are called registrars, who do a combination of theoretical and practical training.
Theory can be learned from books, but practical training requires supervision.
Nicholas Crisp, a trained doctor and the deputy director-general at the health department, who is heading up the implementation of the NHI, says: "As doctors, we learn not just from what's written in a book, but also when someone watches you while you're putting in stitches and drains. If that senior person isn't there, how much are you really going to learn as a registrar?"
The dearth of mentoring won't just affect those training to be specialists, Crisp says.
"If the registrars aren't around because they're tired from doing the consultant's work, and say there are no senior medical officers around, what are the junior doctors going to learn?"
'It's white collar crime'
So, if dual practice is potentially bad for both patients and doctors, why do managers allow it?
Because, in many cases, they're abusing the system too, according to three of those interviewed.
One medical intern, who was often abandoned by her moonlighting superiors, told Bhekisisa that it was hard to lodge complaints because her department heads, to whom she's supposed to report this, were doing the same thing.
That culture trickles down to juniors, a clinical manager said, who then copy it when they become supervisors.
Crisp says there's no real shame about abuse of the system.
"We have senior clinicians at government hospitals who brag that they have not been in the public hospital for weeks."
For Madhi, however the abuse happens, the bottom line is clear: "It's white collar crime."
And the weak suffer what they must
Back in Benson's small-town hospital's children's ward, it's 15:00. There's still no sign of the paediatrician that she called six hours earlier.
The little boy's mom is waiting by his cot.
Benson tries to explain to her what is happening, but her isiXhosa is broken and there's no translator around.
The parent is confused and worried. She's been by her child's side, plastered to a cheap plastic chair for days.
It's people like her who bear the brunt of doctors' greed, which is encouraged by a badly managed system.
Moonlighting was originally supposed to compensate for low salaries offered by the public health sector. The idea was that the government could prevent underpaid doctors from leaving state hospitals, by allowing them to earn extra from private work.
But government doctors' pay has ballooned since 2009.
A new wage policy was implemented then, which meant that in a single year medical officers saw their salaries increase by up to 68%, and specialists' pay rose by up to 50%, with the annual salaries of chief specialists rising to R1.2 million.
As a result, medical officers in South African government hospitals were earning more than their peers in the United Kingdom and Australia (when considering the actual purchasing power of their wages).
For instance, a medical officer at a South African government hospital, with 5-9 years of experience, earned R423 846 a year in 2009 following the salary adjustment. Their peers in the UK and Australia were earning R385 314 and R327 127 respectively (when their wages are converted to rands and then adjusted for their actual purchasing power).
The NHI might, however, make it harder to moonlight.
There will be far fewer opportunities for dual practice under the state-funded medical aid because private medical insurers will not be able to cover the services that the NHI provides. This will make it more difficult for specialist doctors to open a private practice separate from the scheme.
But Crisp reasons that rather than relying on the NHI to stop moonlighting, the principle of dual practice should be scrapped for the healthcare sector altogether.
"The clinical department head in a provincial hospital now earns millions a year, with overtime, and then still does [dual practice], sometimes during public sector time. Why would you allow that?"
Is there an upside?
The silhouette of Devil's Peak dwarfs Cape Town's Groote Schuur Hospital, the teaching facility where Allan Taylor has just come out of surgery. He's the specialist who runs the unit that operates on people's brains, spines and nerves.
Taylor works long, long days, but he runs a tight ship. His team does dual-practice by the book.
"Banning the practice wouldn't solve the problems with moonlighting," he says.
"It will erase some of the benefits of the practice."
State doctors can gain skills from working in the private sector, which they can bring back into government hospitals. "They can take the management lessons they learn in the fast and efficient private sector back to state facilities."
Moreover, spending time in private practice gives doctors the chance to do procedures that they would not have the resources to perform in government hospitals, a 2015 paper shows.
John Ashmore, a public health researcher, also warns that changing the rules that allow for moonlighting may not actually stop the practice; it would simply push it underground.
And there could be bad consequences.
Staff, who are already angry at the department, could feel vilified, Ashmore says.
In June, paediatrician Tim de Maayer was suspended from his post at Rahima Moosa Mother and Child Hospital in Johannesburg for speaking out in the media about the dire conditions doctors and patients face there.
He was reinstated soon afterwards, likely only because of public pressure, including a petition that has since garnered nearly 70 000 signatures.
The move provoked an open letter to the Gauteng provincial health department, signed by more than 130 prominent public health figures, among them HIV researcher Linda-Gail Bekker, and Boitumele Semete, who heads up the country's medicine regulator, the South African Health Products Regulatory Authority.
Moonlighting, however, remains shrouded in mystery.
Sources quoted anonymously in this story asked Bhekisisa to hide their identities because they feared speaking out against powerful senior staff.
What happened when the paediatrician returned?
In the small town where Benson works, hundreds of kilometres from Rahima Moosa, the day's shadows are getting longer. The only full-time paediatrician at the state facility is finally back at her post.
She orders a seizing baby boy to be rushed to the intensive care unit (ICU).
The paediatrician is livid. She says the GP, who supervised Benson, should have known to admit the infant to the ICU far sooner. "This should have been done this morning already," she scolds.
But Benson and the medical officer had kept the baby alive for seven hours — not without potential consequences.
He's doing alright — for now — but doctors couldn't rule out the possibility that he'll show signs of brain damage.
– Additional reporting by Regan Boden.