The number of doctors graduating from South African universities has dropped in recent years, despite a pressing need for more medical practitioners. A more than 6% decline in medical graduates between 2004 and 2008 - from 1,394 to 1,306 - has been blamed on lack of funds, staff shortages and poor facilities.
Another major problem is the control provincial governments have over medical schools, and deans are lobbying for the central government to play a more active role. A meeting is scheduled for 9 April in Durban where medical deans from across the country will air their grievances and follow up on issues raised at a similar meeting that took place last year.
The institutions with the biggest declines in graduates were the University of Limpopo, from 238 in 2004 to 150 in 2008, the University of the Free State from 167 to 109, and Walter Sisulu University from 119 to 103.
"It's a bit of a circus at the moment," said Professor Pieter Nel, programme director of health science at the University of the Free State medical school.
Nel told University World News the university generally had around 100 medical graduates a year. But in 2004, the number was much higher because of a cross-over of graduates after the school changed its programme from six to five years in 1999.
Still, the number is low, which Nel said was because of the poor state of health services in the Free State. Hospital wards and theatres had closed and training staff were in short supply. In 1999, there were around 2,000 hospital beds in the province, now there were fewer than 500.
"It's chaotic," he said. "The facilities they offer are terrible."
The universities of the Free State, Limpopo and Walter Sisulu are all in provinces with acute shortages of doctors. The number of vacancies for doctors grew by 4% from 2008 to 2009 in the five provinces where comparative data were available: from 4,376 to 4,557 - with 1,815 of those vacancies in Limpopo.
"There's been no forward thinking," said Mike Waters, opposition Democratic Alliance's shadow minister of health. Waters made the graduate numbers public after receiving a reply to a parliamentary question.
"The government hasn't been actively engaging with universities to encourage them to increase the intake. So we wait for a crisis to happen," he told University World News.
The government has proposed a three-scenario plan, from low-growth to high-growth, which involves increasing new intakes of medical students by 3% to 6% at some or all of the eight universities that offer the degree.
The low-growth plan would see an increase in graduates of only 175 (14%) from 2008 to 2020, while the high-growth scenario would achieve an increase of 800 graduates (63%).
Waters said even the projected high-growth scenario increase would be inadequate for South Africa's needs and did not take the capacity problems at some medical schools into account.
Nel agreed. "We can't do it with the current facilities and staff," he said.
The Ministry of Higher Education and Training admits in its proposal that the challenges are great. Costs of employing additional academics and expanding classroom space will be high, and the increase in clinical training will burden already struggling provincial hospitals.
Waters said the private sector was ready to step in to help, and had offered to train doctors and provide the technology and infrastructure so sorely needed. But this possibility was not mentioned in the government's three-scenario plan.
Some universities are faring better than others. The University of KwaZulu-Natal had the biggest jump in doctors qualifying, from 178 in 2004 to 224 in 2008, and the University of Pretoria increased from 180 to 200.
Some universities, such as KwaZulu-Natal, have maintained consistently high success rates despite similar funding problems and educational handicaps.
"Like other universities, 50% of our intake is from previously disadvantaged backgrounds," said Professor A Willem Sturm, Dean of the Nelson R Mandela School of Medicine. "We try to compensate for their lack of foundation as best we can."
But the problem goes beyond higher education. Fully 17% of doctors leave South Africa once they qualify and the reasons are diverse: the poor state of the nation's healthcare system, the soaring crime rate - and vastly more lucrative job opportunities abroad.
Taken together, the decline in doctor graduation numbers and the brain drain points to a growing health crisis.
Receive UWN's free weekly e-newsletters