Train More Doctors To Lower Healthcare Costs
The solution isn’t to spend more money on healthcare; it’s to reduce the costs that go into delivering medical services.
South Africa’s healthcare costs will not be solved by a taxpayer funded universal healthcare system or the ill-thought National Health Insurance (NHI). As is the case with the majority of government run projects, any state-run healthcare initiative will soon collapse under the intense weight of corruption and incompetence that has seen our electricity grid come under threat and our infrastructure collapse.
Not to mention how, already, public hospitals have become a cesspool of wasted money and wasted lives, as we can notably see with the case of Tembisa hospital, where at least R2 billion was lost to corruption.
But, even if our institutions were to become magically impervious to corruption, there would still be a major problem with the affordability of healthcare. The expense would just shift from a combination of medical aid clients, private patients and taxpayers, as is the case now, to purely putting the weight of all medical expense on a rapidly diminishing taxbase.
Already, the public healthcare budget sits at R298.894 billion as of 2025/2026 (up from R277.229 billion), and is set to rise to R300 billion. Despite this, private spending still makes up 51.76% of healthcare spending.
The solution isn’t to spend more money on healthcare; it’s to reduce the costs that go into delivering medical services. There are many factors that determine healthcare costs, but the most notable factor, is of course, the supply of doctors.
South African doctors are notoriously overworked. In fact, our emergency rooms are considered some of the best in the world for training young doctors in becoming adaptable and resilient. Not because of the quality of the facilities, but because of sheer exposure to severe trauma and medical emergencies – much of it caused by violence.
Doctors, especially still in training, are expected to work ungodly hours under intense pressure. Burnout isn’t a risk, it’s a certainty. Despite producing some incredibly skilled doctors, this isn’t an optimal training environment. It is the result of understaffing and lack of resources.
While we can pretend that producing “battle-hardened” medical staff is a great side effect of institutional dysfunction, the fact of the matter is that we need more doctors. Not only will this take stress off existing doctors, it will also raise the supply of doctors, therefore causing competition to drive down prices.
Artificial barriers
Training to become a doctor is an intensive process that takes the better part of a decade, and very likely more when you account for specialists. Medical doctors are expected to be the best of the best and represent the peak of academic excellence.
It is the dream of many high achieving students to be accepted into medical school, with only 1 – 1.5% of these students being accepted. Of the 16,000+ applicants to Wits University’s medical programme, only around 257 applicants could be accepted.
Thousands, potentially tens of thousands of hard-working and intelligent students are not even given a chance to study medicine. This isn’t because of a lack of merit, or even because of racialised policies that attempts to regulate the demographics of medical students. The fact of the matter is that far too few students can even begin training to become doctors.
And even once they have finished training, their placement and career is put in the hands of the Health Professions Council of South Africa (HPCSA), which acts as a further gatekeeper. Their placement is restricted and regulated to only public health positions, many of which are chaotically run and leave medical students waiting months and even years for placement.
The HPCSA can act as a regulator not to just to bottleneck the training and placement of medical students and doctors, but to artificially restrict how many doctors enter the sector so to maintain the high salaries of existing doctors. Regardless of intent, HPCSA regulations suppress entry to a sector that drastically needs competition and manpower.
This may be all well and good for doctors, but no regulations or red tape should exist to protect the interests of a particular profession against competition. Especially one that needs to be made as cheap as possible to enable human flourishing.
Enable private colleges
The artificial restrictions imposed by the HPCSA is one thing. But there still exists a very real limited capacity for how many medical students can train simultaneously. While some training facilities are doubtlessly not accepting applicants at full capacity, many likely are.
In 2022, there were only 1900 positions available at South Africa’s ten medical schools. No wonder South Africa has the second lowest number of doctors proportionate to our population of the 36 countries measured by the Organisation for Economic Co-Operation & Development (OECD).
The OECD has found that the simplest way to enable high quality and affordable healthcare is to match healthcare supply with demand. It also found that enabling the free market to address the supply shortage of doctors raises the density of physicians in the populations far better than government-run initiatives.
Currently, the private sector is barred from starting medical schools. Aspiring doctors have to go to only ten schools in the country. This situation needs to end.
Laws barring private medical schools must be abolished, and the government must allow for the speedy creation of private medical schools. There are countless amazing students in this country who would make great doctors. We just need to expand capacity so that they can be trained.
The onus should shift from the public sector being solely responsible for training, to rather being a laissez-faire monitor to ensure quality of training. Other countries, like India, have utilised private medical schools to produce world-class doctors on mass.
On top of this, practical training must not be restricted to only public healthcare facilities. Any accredited healthcare facility, public or private, should be allowed for internships.
End mandatory community service
At the end of a gruelling six years of study and two years of internship, doctors are required to serve an additional year in mandatory community service, where they are placed by the government in a public healthcare sector role. This is often far from their home and families, and placement often only occurs months or even a year after the completion of their degree.
While these doctors await placement by an inefficient bureaucracy, they are not allowed to practice medicine. This is while a chronic manpower shortage assails our hospitals.
There is no logical reason why mandatory Community Service for doctors exists. They have done their time. They have done their training. All this creates is another arbitrary bottleneck for ensuring that as many doctors as possible enter the workplace.
This system needs to be abolished, allowing doctors to enter the market properly as soon as possible to provide a much-needed service to their community.
Conclusion
If we want healthcare to become more affordable, accessible, and humane, the solution is not further centralisation, but liberalisation. Remove the barriers to medical education. Allow private medical schools to operate. Open training to accredited private facilities. End mandatory community service that serves no clinical purpose.
Healthcare costs will fall when doctors are allowed to practise, compete, and serve their communities without bureaucratic obstruction. Human flourishing depends on it.
Nicholas Woode-Smith is the Managing Editor of the Rational Standard. He is a senior associate of the Free Market Foundation and writes in his personal capacity.
While everything the article says is valid, it does not get to the root problems:
The ANC inherited a fully functioning health system in 1994, albeit serving only a portion of the population; it should have expanded this system to provide health to all. This would have required at least trebling the existing infrastructure and providing the "warm bodies" to staff it — not only doctors, but administrators, pharmacists, nurses, radiographers, therapists, technicians and all the entire army of caregivers and support staff a fully functional health system involves.
This implies that every cohort of matrics arriving at university or college, is capable of optimum learning. It is superflous to point out the quality of state schools. Further, research has shown that education contributes to wellness in many ways, including being able to afford healthy lifestyles and to navigate the bureaucracy.
The current medical training system is complicated: the teaching hospitals are a hybrid of state (provincial) and medical schools, with senior staff being employed by one or the other or both. Rolling out more is not a simple matter.
One reform would be to amend the medical curriculum so that aspirant medics first study for a B.Sc (this can be at non-metro universities or colleges) and then transfer to medicine. (Some applicants who fail to get into medical school do use this route, hoping to transfer subsequently). (Bridging progammes at tertiary level are more expensive and less effective than preparing the student at school).
Bottom line:
All of this costs money, as will NHI or NHS in any form. The *only* way to provide this is to grow the economy. THAT is where reforms must begin.
There are other dimensions to this issue. Firstly the costs of being in practice. There are all sorts of registrations and credentialling costs s, then there are malpractice insurance costs, and then there is as a consequence of a hyper litigious culture defensive practices that add enormously to cost, then there is medical device costs , sahpra effectively creates a barrier to entry to the market which drives the costs of things up ( a knock off Chinese hip replacement can be made for 10 percent of the ones we use), then there is drug pricing policy. The entire system on the guise of patient safety adds enormously and excessively to costs. We have precisely the worst model all the worst of beauracracy.