Monitoring the implementation of community service

Conclusions
Community service for doctors in South Africa was conceived amid controversy, but has emerged as
a symbol of the commitment of the health department and the medical establishment to equity in the
health system. Unclear policy guidelines in this first year of implementation (not unexpected in the light of
the pressure to start) lead to the highly variable community service placements. Only 259 (less than 25%)
of the community service doctors are placed in rural hospitals (as designated by the rural allowance), while
55% are working in regional, tertiary and specialised hospitals. Thus, the aim “to distribute health personnel
throughout the country in an equitable manner” has only been partially addressed by this policy so far.
Preliminary findings indicate that the aim of ensuring “improved provision of health services to all
the citizens of our country” has probably been met. All the health facilities that received community
service doctors reported positive impacts, except for one tertiary hospital that regarded them as a “nuisance”.
The interpretation of the policy as meaning that community service doctors should work primarily in the
community health services of districts, has resulted in many of them visiting outlying clinics regularly, with
surprisingly beneficial results for the district health system as well as the community service doctors themselves.
The secondary aim of “providing our young professionals with an opportunity to develop skills,
acquire knowledge, behaviour patterns and critical thinking that will help them in their professional
development”, has been successfully met by some but not all of the community service placements. This
depends on the level of supervision available, as well as the attitude with which the individual approached
the year. In general, the response of community service doctors to the challenges and difficulties in public
service hospitals around the country has been encouragingly positive, as they have found meaning in
“making a difference” in their situations. In the words of one community service doctor placed in a rural
hospital: “My perspective has totally changed from the Stellenbosch Afrikaans way of understanding things”
A minority found the environment demoralising, and felt resentful at the unfairness of the allocation
process that placed them there. The exact proportion of negative and positive experiences will be determined
in the quantitative survey planned for the end of 1999. This will also give an indication of the number of
community service doctors who are prepared to remain in the public service in areas of need in the longer
term.
It is important to remember that “health manpower planning is an integral part of comprehensive
health planning and should not become an independent activity”, and that “planning, production and
management of human resources must be brought into closer and more functional relationship with each
other”. As we proceed to the next round of community service placements, it is imperative that the
experiences and lessons of the first year of implementation are taken into account, and used as the basis of
ongoing planning. Universities need to supply graduates with the appropriate knowledge, skills and attitudes,
and provincial health departments need to manage their human resources in an equitable manner.
A comprehensive policy on human resources for medically under-served areas in South Africa is
needed, of which obligatory community service for doctors is only a part. Judging by the initial feedback
of this first year, and the willingness of all those involved, there is a solid basis from which to work.
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