Changes to overtime pay causes Gauteng state doctors to gear up for health department fight

Daily Maverick

11-05-2025

Trade unions, medical associations and universities are raising the alarm that Gauteng budget cuts at the cost of doctors' take-home pay will have dire consequences for public sector health. Meanwhile, the National Minister of Health has convened a committee to review the future of overtime for state doctors.
Dysfunction in the Gauteng Department of Health hit home hard for many public sector doctors on 29 April when their overtime payments due for the month went unpaid.
The non-payment came without notice and affected medical staff in facilities across the province, according to the South African Medical Association (SAMA). Only by Tuesday, 6 May did some doctors start to see payments reflect in their bank accounts. More payments are expected soon, given that, according to the Basic Conditions of Employment Act, the employer has seven days to settle, said SAMA.
As a fixed amount, commuted overtime is predictable supplemental income and for many doctors, it amounts to about a third of their take-home pay.
But tensions are rising as this payment blunder follows a protracted row over the department's unilateral decision to cut and change the terms of commuted overtime in the province. Proposals to cut down on commuted overtime come in the light of a very tight provincial health budget. As with most other provincial health departments, Gauteng's health budget has been shrinking in real terms for several years.
Threats of protests and legal action
The delayed payments and the ongoing review of cuts and changes to commuted overtime pay has led to threats of protests and legal action. SAMA says they will make civil claims for salaries owed, including for interest and legal costs. Registrars and medical officers at Dr George Mukhari Academic Hospital in Ga-Rankuwa collectively wrote to the hospital giving notice of withdrawal of overtime services until the non-payment issue is completely resolved. By 7 May, the head of anaesthesiology at Sefako Makgatho Health Sciences University wrote to the CEO of George Mukhari, informing him that no anaesthesia services would take place at the hospital starting Thursday, 8 May, given the decision by registrars and medical officers to down tools outside of regular work hours.
Those that Spotlight spoke to from the medical fraternity have set out a series of concerns. These include resignations; an exodus of doctors, especially specialists from the public sector; plummeting staff morale; negative impacts on the training of doctors as fewer consultants and seniors are available to supervise — which then puts universities' training accreditations at risk. Ultimately, several sources point out, it is the services offered to the public that suffer.
Committee appointed
By the beginning of April, there appeared to be some walking back by the Gauteng health department of its unilateral cutback proposals after meeting with the South African Medical Association Trade Union (SAMATU). In the same week, a circular was issued announcing that the national health department was conducting a review of its own, instructing provinces to hold off on their plans. Health Minister Dr Aaron Motsoaledi then set up a committee of experts to review certain human resource policies in the public healthcare sector. This includes a review of community service, commuted overtime, remunerative work outside the public service for health professionals, and rural and related allowances.
Commuted overtime is a pre-determined amount of overtime that doctors employed by provincial health departments are allowed to work. The amount is historically decided by hospital management and is based on an employee's role, seniority, the department they work in and the amount of overtime they are allowed to safely work. It's a fixed rate of 1.3 times the applicable hourly tariff for a specific work grade.
There are five contract options. A is no overtime worked; B is overtime of between four and eight hours a week; C is overtime between nine and 12 hours a week; D is overtime between 13 and 20 hours per week; and an option E is where, on approval, a doctor can be authorised to work more than 20 hours of overtime a week.
As a fixed amount, commuted overtime is predictable supplemental income and for many doctors, it amounts to about a third of their take-home pay.
The long rumblings to cut their overtime pay has seen doctors being required to motivate why they should remain on contracts that pay for more overtime hours, and junior doctors say they are being pressured to sign option C contracts, which will pay for fewer overtime hours. There are also proposals to change some of the terms relating to overtime, including scrapping overtime payments for doctors who are on call but not physically present at a facility.
Many doctors already exceed the maximum hours of their contracts because of the emergency nature of their work, gross understaffing and backlogs at their hospitals.
Costly, but essential?
The commuted overtime pay model has been contentious for years because it adds up to a sizable chunk of the healthcare budget. According to a spending review conducted in 2022 on behalf of National Treasury, the country's health departments spent R6.9-billion on commuted overtime in 2021. This made up about 70% of the total R9.9-billion spent on all types of overtime.
In an editorial published in the South African Medical Journal in April 2025, health sciences academics, associations, and unions slammed the Gauteng health department's handling of pay issues. They argue that the basic salaries of medical professionals in the public health sector are already much lower than what would be considered fair pay.
'COT [commuted overtime] has long served as a critical mechanism to ensure that doctors are available beyond the standard workday, safeguarding round-the-clock care in the public health system… The abrupt curtailment of this framework risks hollowing out the after-hours safety net, leaving emergency rooms, wards and clinics dangerously under-resourced,' they wrote.
A co-author of the editorial, SAMA CEO Dr Mzulungile Nodikida, told Spotlight: 'Medical doctors in South Africa's public sector are severely underpaid. A study by SAMA has shown that even the annual cost of living adjustments that have been made on the salaries have not matched inflation in the last five years. Commuted overtime has had the effect of masking a deficient salary.'
He said the Gauteng health department has shown itself to be an 'unreliable employer', adding that its relationship with doctors remains fractured as a loss of confidence in the department deepens.
'This breach of the most basic employment obligation: timely remuneration, has cascading effects. It jeopardises morale, compromises service delivery, and calls into question the department's commitment to its workforce. Doctors now operate under a cloud of uncertainty, unsure whether they will receive their salaries at month-end. This anxiety permeates every aspect of the employment relationship, from retention efforts to the willingness to engage in additional responsibilities,' said Nodikida.
View from the wards
Two doctors who spoke to Spotlight independently, from two different Gauteng hospitals, say the commuted overtime pay disaster is yet another symptom of weak human resources and poor management from the department of health. For them, proposals to cut commuted overtime is the department shirking from addressing the staffing crisis; the need to improve human resources systems; and rooting out corruption, maladministration and wasteful expenditure. Both doctors asked not to be named for fear of reprisals.
Dr A, who is based at Charlotte Maxeke Johannesburg Academic Hospital, said: 'Instead of having a system in place to record how many hours each doctor is actually working and what overtime that person should be paid, the department pays everyone this commuted overtime fixed sum…. [Y]ou could be a dermatologist or a psychologist and have very few overtime hours, or be a surgeon who is doing a lot of overtime. But you all get paid the same if you're on the same contract option,' she said. 'Right now, in my career, I'm working way more overtime hours than my contract, and I'm not being reimbursed for any of it.'
Dr A said the overtime pay cuts and proposed changes will impact her decision to stay in the public sector.
'It used to be the case that you were happy, once specialised, to stay because the overall lump sum of money from your salary and commuted overtime made up a decent pay — not comparable to what you could earn in private — but decent enough to stay,' she said.
She said she feels like doctors are now being under-valued and coming under attack by their own employer. 'The message we are getting is that 'if you're not happy, there's the door' — but what the department doesn't understand is that you can't just replace someone with 10 years' experience or someone who has 30 years' experience; it has a huge impact,' she said.
'Our patients are suffering; and every day it's like a game of Survivor. We run multiple clinics in one clinic space at Charlotte Maxeke, but you can't offer a functioning service like that. It's noisy, the computers don't work, and the intercom is going off the whole time.
'The other day, I had a 90-year-old patient have a panic attack in the waiting room. He had been waiting for a while and left his wife, who is blind, in the car. He had to park far from the hospital building because the parking lot from the hospital fire [in April 2021] is still not properly repaired and he was overcome with worry,' she said.
Dr B works at Chris Hani Baragwanath Hospital and he said the debacle over doctors' overtime pay has pushed him to the edge. He said doctors are already overworked and disheartened from working within a failing system. He sent photos to Spotlight of theatres and wards in darkness, as power went off at the Soweto hospital for days at the end of April.
He said staff bring in their own toilet paper because they're told there's none. Most alarming, he said 'doctors are not getting the training and supervision they need' and regularly perform surgeries and procedures without adequate experience and with no supervision.
'They are overwhelmed, overworked and doing way too many overtime hours that they're not being paid for. Then they go home overtired, eat a pizza and crash, sleep a few hours then do it all over again the next day, and the next day,' he said.
'We, doctors, are literally the ones putting patients' lives at risk,' he said, adding that he is 'surviving on anti-depressants' and has sometimes shut himself away in hospital storerooms crying tears of sheer frustration, exhaustion and exasperation.
Dr B does still count the wins though. It's on the days when he clears an impossibly long patient list of children who need procedures done. It's when he and his colleagues decide to push through to make sure no child's procedure gets cancelled.
'Those are the good days — they're just few and far between. And now the department is coming for us by cutting our overtime pay and forcing us to sign contracts to downgrade our overtime pay,' he said.
Resignations and impact on training
Professor Shabir Madhi is dean of the faculty of Health Sciences at the University of Witwatersrand. He said the proposed cuts and freezing of posts and changes to commuted overtime pay has already resulted in resignations of some senior staff at state hospitals.
'If we don't have the proper consultant staff complement in these hospitals who can provide supervision throughout the day, it compromises our training of specialists as well as of undergraduate students.
'If the Health Professions Council of South Africa were to do an audit and find that there isn't adequate consultant cover and supervision, they could remove the accreditation of the training programmes offered by the universities.
'The medical schools are completely dependent on the Gauteng Department of Health to retain consultants and other categories of staff, and to ensure that staff are allocated time for supervision and training of future medical doctors, including specialists, as well as other academic activities.
'It means decision-making around cuts to overtime pay need to be cognisant of the overall impact that it would have, and not only in how it would assess budget constraints. This situation needs meaningful and informed decision-making,' he said.
Dr Phuti Ratshabedi, Gauteng chairperson of SAMATU, said the non-payment of commuted overtime pay in April was a slap in the face from the provincial health department, as the union had a meeting with the department that month and left with the department agreeing to uphold their contractual agreements to leave contracts terms for commuted overtime pay unchanged at least till the end of March 2026 — the end of the financial year.
'What we saw is that the department will promise one thing, and do another. But we will be holding them to what they stated in their own circular or we will look to legal action.
'What we want to see in this review period is that they go after departments [where overtime is not being performed but being paid for] but leave other departments alone — they cannot put everyone under the same blanket.
'If the government is able to bail out over and over things like Eskom and Transnet, how can they not prioritise healthcare — this sets our country way back, and we doctors will no longer be silent about this,' said Ratshabedi.
Spotlight sent questions to the Gauteng Department of Health, including on how the payment delay happened; the number of people affected; how the department is addressing the widespread knock-on effects of their proposed commuted overtime cuts; and what amendments they hope will come out of the national review. Despite several reminders, the department did not respond to our questions. DM