It's the age of austerity and it's bad news for doctors, nurses and patients alike -- unless the state can do more with less.
Almost 200 posts for doctors and specialists remain unfilled at Gauteng's four academic hospitals - and many of these posts are likely to remain empty, the health department says.
Gauteng hospitals can only fill half of its critical medical staff vacancies - positions that normally go to doctors, specialists and nurses, Gauteng health department deputy director general for clinical services Richard Lebethe says. Hospitals were first informed about this via an April circular sent to hospitals.
Doctors at Chris Hani-Baragwanath Academic Hospital say they are feeling the strain of almost 80 vacant posts, according to the facility's head of psychiatry Wendy Friedlander.
"Doctors [now] have a much greater doctor to patient ratio. If you have more patients, what you can give in in terms of time, facilities and resources to each patient is much less", she says.
"Every patient is getting less care than they should be getting, less care than what they are entitled to", Friedlander explains.
"The quality of care has plummeted."
Friedlander is part of a committee of hospital doctors who have asked the provincial health department to unfreeze these posts. The Gauteng health department disputes these figures, saying that their records show 60 vacancies for doctors and specialists at the hospital south of Johannesburg.
The hospital was told to stop recruiting for these positions in July, doctors say.
South Africa requires newly graduated doctors to complete two-year internships before beginning one year of community service in order to practice in South Africa. Most other medical professionals including nurses must also complete a mandatory year of community service.
But in the past few years, stories of unplaced medical interns and community service applicants have become regular features. In 2017, Health Minister Aaron Motsoaledi told Bhekisisa he would sue provinces if they didn't make money for more than 100 positions available from provincial purses.
"[The provinces] must go and create these posts. That is where the problem is because provincial governments just don't do it. Some of them just decide they don't have money and that is why I have been impressing on them that it's not your choice - it's something that you have got to do", he said.
Just days before the minister's statement, more than 300 healthcare graduates were still waiting to be placed, sparking a national online campaign by junior doctors hoping to put pressure on officials.
Director of the Rural Health Advocacy Project (Rhap) Russell Rensburg says to expect more of the same in years to come.
Rensburg says that annual increases to health budgets are dwarfed by provinces' unpaid debt and spiralling bills from medical malpractice claims.
"In reality, our health budget has actually been declining for the past eight years, and our capacity to implement stuff becomes weaker and weaker", he says.
The Democratic Nursing Organisation of South Africa says the failure to hire more nurses following their community will jeopardise the country's move to universal healthcare under the National Health Insurance (NHI). The union is appealing to the government to hire more nurses.
"Not employing nurses will also work against the realisation of NHI because nurses are supposed to play a pivotal role in strengthening the provision of primary healthcare services," the union said in a statement earlier this month.
However, the national health department's spokesperson Popo Maja says the state is only responsible for placing health workers for internships and community service and that it is not obligated to hire nurses after.
He explains: "Internship and community service do not automatically translate into a guaranteed, permanent employment. Such employment is subject to normal recruitment practices that any other graduate belonging to any profession is subjected to".
"Imagine what would happen to the country if any other graduate in the country started demanding placement for jobs within the state and the state must make a budget available for that," he says.
"Such a situation will be extremely untenable."
The union also wants the provincial health departments to use President Cyril Ramaphosa's "stimulus package", first announced in September, to hire nurses.
"To address some of the shortages in our hospitals, funding is being made available immediately to buy beds and linen, while the Minister of Health and the National Health Council will immediately fill 2 200 critical medical posts, including nurses and interns," Ramaphosa announced.
But the medium term budget revealed this wasn't new money being allocated to the health budget. Rather, R350-million was diverted from NHI to pay for employing more health workers, according to the Division of Revenue Amendment Bill.
The South African Medical Association (Sama) has welcomed proposals to shorten medical internships from two years to one year to ease the strain on provincial budgets, according to a TimesLIVE report. But, some caution that transitioning to such a system would result in at least one year in which provinces would have to do a double intake, meaning that they would receive a new crop of one-year interns while the previous year's interns completed their second year.
This could have major financial implications.
Rensburg says that this strategy may save money in the long term but argues junior doctors will lose out on an additional year of supervision under which to sharpen their skills.
Maja admits that the health budget is taking strain.
"[The] public health has lost R9-billion in the past three years, and the hardest hit was, unfortunately, the human resources budget as well as infrastructure and equipment budget", he says.
"This situation pains us as the department; we do not enjoy it at all. We will try our utmost to make sure that the country gets out of this situation as speedily as possible."
To cope, Rhap says the government should try to evaluate where it can save money, including changes in the way it procures medicines, equipment and services.
In a 2016 working paper, the NGO also recommends the health department should continue to try to protect important posts, helping provinces to define what a "critical post" is in facilities, which the NGO says will change from community-to-community. Rhap says districts should be developing costed human resources plans to allow them to make local decisions about how to prioritise health spending.
Rensburg says: "Provinces should come together and discuss shared problems with aim of finding shared solutions."