The government has seized control over health care professionals.

There’s an interesting debate going on in the world of medicine. It involves the Health Professions Council South Africa (HPCSA),  the over-arching body that comprises 12 professional boards, including the Medical and Dental Professions Board, and those of professional optometrists, physiotherapists and audiologists.

The HPCSA is there to set and maintain educational and professional standards, and it is, says their website, “an entirely autonomous organisation”, which “does not receive grants or subsidies from government or any other source, and is funded entirely by the health care professions it represents”.

Autonomous se moer, says the editor of the South African Medical Journal (SAMJ), Dr JP van Niekerk. In its April 2009 issue, Van Niekerk wrote an editorial castigating changes that have been made to the HPCSA. The main thrust of his attack is that the Department of Health has taken complete control of the HPCSA – in the same way that it has taken over bodies like the Medical Research Council and the Medicines Control Council.

Autonomous se moer…
The Department of Health has taken complete control of the HPCSA

This process by which government has gained control of these bodies, says Van Niekerk, was initiated and vigorously pursued by former President Thabo Mbeki and his never-to-be-forgotten health minister, Manto Tshabalala-Msimang, and is now just about complete. According to Van Niekerk, the Medical and Dental Professions’ Board – the largest and most important of the boards comprising the HPCSA – has vigorously opposed the changes, but its views were completely ignored. Van Niekerk also claims that the HPCSA president, Dr Nicky Padayachee, and HPCSA registrar and CEO, advocate Boyce Mkhize, rammed these changes through Parliament (see footnote).

Van Niekerk has a further gripe: changes that the government proposes making to the composition of disciplinary boards means that they will in future be chaired by laymen rather than doctors.

So how has the government obtained control over a body that is funded by its own members? Simple: it changed the rules so that the quaint old system of health professionals electing the members of their professional boards has been replaced with one whereby Big Brother, in the guise of the minister of Health, appoints the members of the various boards from names nominated by health professionals, and so is able to appoint the “right” people.

This control over the medical profession is a great shame, according to Van Niekerk, because one of the very reasons why the HPCSA came into being was because of the perception that the old South African Medical and Dental Council (SAMDC) – which did not represent black doctors properly and failed to distinguish itself during the Steve Biko affair – had been under the thumb of the old regime.

HPCSA CEO advocate Boyce Mkhize disagrees. In a furious response published in the July edition of the SAMJ, he refers to Van Niekerk’s comments as “wild, libellous and unsubstantiated”, saying there is no evidence of any attempt to politicise the HPCSA. As regards the objections of the Medical and Dental Professions’ Board, Mkhize says that the HPCSA “carefully considered their protestations and ruled them to be without basis”. He goes on to say that the HPCSA is much more than doctors and dentists, and the “overwhelming majority” of the members supported the changes. Mkhize denies “that democracy will be eroded”, and claims that the new system is “certainly not a dictatorship but a form of democracy that perhaps Dr Van Niekerk does not like; but the fact that he does not like it does not make it something other than democracy. Election is only one form of democracy and there are many other forms”.

Apparently tiring of arguing the matter on the merits, Mkhize then moves to safer territory: “Dr van Niekerk”, he says, “omits to advise the readership that the process of appointments by government is not something unique to developing countries such as South Africa, or something of the so-called ‘dark continent’ but a practice in force in many developed countries and so-called civilised democracies of the world. A number of States in America and Commonwealth countries with established democracies use this model of appointments.” Ho hum.

Mkhize goes on to deny that he or Padayachee played an improper role in getting the legislation passed, or that the system of lay chairmen will adversely affect disciplinary proceedings, pointing out that there will always be medical assessors. And then it’s on to the personal stuff, describing the editorial as “a foul cry lamenting what Dr Van Niekerk may have perceived or experienced as a glorious past in which he played an active part and the new order in which he has no part to play and hence his conclusion that the HPCSA has become or is becoming a sorry mess”.

…the appointment system is an improvement, because “in the past, this organisation reflected a very skewed representation of the country’s demographics…”

Time to see what this is really all about. Noseweek asked Mkhize to explain exactly how the new appointment system works, and he supplied the following example: The Professional Board for Physiotherapy, Podiatry and Biokinetics will now comprise 13 members, including physiotherapists, podiatrists, biokineticists, as well as persons from the Department of Health, the world of higher education, and “the community”. Of these 13, all but one will be appointed by the Minister of Health. He sees the appointment system as an improvement because “in the past, this organisation (and the previous Medical and Dental Board) reflected a very skewed representation of the country’s demographics; the HPCSA therefore needed to transform into an organisation with members who represent the broader population and not a limited minority”.

Ah, so that’s what it’s about.

A long-serving Medical and Dental Professions Board member, who wishes to remain anonymous, put it more bluntly – democracy’s nice, but only if you’re winning. In the old days, practitioners elected the people they wanted on the board. The government didn’t much like this because the doctors and dentists tended to elect white board members, possibly because most of the practitioners were white. So a system whereby certain members were elected and others were designated by the minister was introduced – in other words a quota system, a bit like they have in rugby and cricket.

But that wasn’t good enough, so elections were done away with altogether. And now the system is this: every registered practitioner can nominate people they want on their board; every person who gets two or more nominations goes on to a very long short list, and the minister then appoints board members from that list. Mkhize is right, says the source: it is a different form of democracy – the version you might find in, say, North Korea.

Regarding the disciplinary panels, Mkhize told Noseweek that in the past the HPCSA was seen as an old boys’ club that protected its own, so having laymen with doctors adds fairness and transparency. Fair enough, but how exactly does it work? Well, said Mkhize, every disciplinary panel will consist of six members – two doctors specialising in the field, two community representatives (one of whom will be the chair), one board member, and one legal assessor who will simply guide the panel, but have no vote.

So who are these community representatives? Well, it seems that if the complaint involves alleged negligence by a doctor in Pretoria, two people from Pretoria will serve. And what if there’s disagreement between the laymen and the experts? Oh that won’t happen said Mkize, there’ll always be consensus. So why bother with laymen?

… the government is keen to ensure that doctors agree with the policy of the day, be it the prescribing of garlic or simply making sure it isn’t so damn hard to get a medical degree…

Why, then, does government want so much control over doctors? And does it matter? The ANC is, of course, obsessive about centralising power, but doctors have a real concern about what this means for the profession, because one of the main functions of the professional boards is to set standards and register professionals. And that’s why the government is so keen to ensure that doctors agree with the policy of the day, be it the prescribing of garlic, the recognition of Cuban medical qualifications, or simply making sure that it isn’t so damm hard to get a medical degree – Noseweek understands that there’s already a Medicine Lite qualification available, a so-called “medical associate”.

Yes, the real concern is that the medical professionals we will be consulting in the future may be a far cry from the ones we’re consulting now.

Everything that’s wrong

HPCSA PRESIDENT Dr Nicky Padayachee epitomises everything that’s wrong with affirmative action. A once highly-regarded doctor who succumbed to well-documented psychiatric and substance abuse problems, Padayachee was controversially appointed dean of the UCT Medical School, only to be relieved of his duties after slurring and being unable to stand straight at a graduation ceremony. He then went on to become executive director of research at the Medical Research Council (MRC) and president of the HPCSA – but resigned his position at the MRC after embarrassing himself and his country at a medical conference in Switzerland, once again by slurring and being unable to stand straight.

He did, however manage to resist calls by the Medical and Dental Professions Board to resign his HPCSA presidency, primarily because ministerially-appointed HPCSA board members supported him. Padayachee is close to former Health Minister Manto Tshabalala-Msimang (who also contrived to embarrass her country). Advocate Boyce Mkhize, registrar and CEO of the HPCSA, has been there a long time. Some think he suffers from “Founder’s Syndrome”, an unofficial term referring to the autocratic behaviour of those who have been in a position of power for a long time. Doctors claim that, although he’s simply an administrator, he rules the HPCSA like a dictator.

Taken from the December 2010 edition of Noseweek.