By Motalatale Modiba, Siyabonga Jikwana and Dr. Adiel Chikobvu

Recent criticism of the Gauteng Department of Health’s (GDoH) Commuted Overtime
(CoT) policy enforcement, as articulated in the South African Medical Journal (SAMJ)
editorial of April 2025, has ignited an important discussion about the management of
health systems. This response is a humble attempt, not to silence professional voices,
but to place the issue in proper administrative, financial, and constitutional context.

The SAMJ editorial, like some of the views that have been emerging in the public
discourse, unfortunately misses the purpose of Circular 6 and overlooks the deeply
entrenched abuses it aims to resolve.

The Problem: Chronic Abuse of Commuted Overtime

Commuted Overtime (CoT) was introduced as a mechanism to ensure after-hours
service continuity, especially in specialist-dependent disciplines. Over time, however,
it became riddled with operational inconsistencies, poor contract management, lack of
accountability, and abuse, raising ethical and moral questions.

Research by Munyadziwa Kwinda, submitted to fulfil the requirements for a master’s
degree in medicine, Bioethics and Health Law focusing on Remunerative Work
Outside the Public Service (RWOPS), highlighted that poor enforcement of policy
instruments and reluctance to comply has resulted in professionals undermining their
legal and ethical obligations. This has contributed to remuneration for duties not
performed, contravening the Public Service Act and other regulations and to a large
extend contributed to the eroding of trust in the public health system.

Circular 6: A Targeted Administrative and Policy Remedy

Circular 6 of 2025 as issued by the GDoH recently is not a blunt instrument of austerity,
as some describe it, but a carefully structured and constitutionally sound tool. It is a
corrective policy measure that aims to align service delivery with remuneration, ensure
contract enforcement, and enable verifiable accountability mechanisms.

Key corrective functions of Circular 6

The directive provides for contractual clarity and performance accountability. It
mandates time-defined, auditable CoT agreements. This ends the era of ambiguous
and assumed overtime privileges.

It furthermore ensures that there is equity and budget stabilization. This
standardization advocates for CoT to be allocated according to health facility needs,
not historical entitlements or personal lobbying, thus promoting fairer access to limited
resources.

It operationalizes Section 31 of the Public Service Act, making it enforceable to recover
unauthorized remuneration and institute disciplinary action where necessary.

In terms of transparent oversight, facilities are now compelled to track hours through
biometric attendance, shift logs, and supervisor validation. This means that claims can
be linked to verifiable delivery.

Rebutting the SAMJ Editorial: Conflicts, Omissions, and Procedural Missteps

The SAMJ editorial, while emotionally persuasive, is procedurally flawed and
selectively reasoned. Its key failings include:

The failure by its authors at a principle level to disclose a conflict-of-interest. Several
signatories to the opinion piece are, or have been, recipients of CoT and are currently
employed by the GDoH. The absence of conflict-of-interest disclaimer undermines the
article’s academic integrity and possibly objectivity.

There is clear selective legal interpretation as the the editorial does not engage with
Circular 6’s basis in Treasury regulations, PFMA compliance, or prior collective
agreements such as the 2009 PSCBC ruling abolishing Limited Private Practice (LPP).

Patient interests is sidelined as the focus is largely on professional monetary
dissatisfaction. There is little regard for the public right to quality and uninterrupted
care which is a right enshrined in Section 27 of the Constitution.

The piece seems to endorse the obstruction of public sector governance by calling for
an unconditional reversal of Circular 6, thus implicitly condoning an erroneous practice
of unmonitored spending and undermines efforts toward financial accountability.

Circular 6 addresses four critical challenges in the public health sector. Firstly,
escalating compensation costs are concerning, with CoT in some institutions
accounting for up to 40% of individual doctor earnings without proportional service
output. Secondly, inadequate human resource controls have resulted in multiple
facilities failing to implement basic duty rosters, leaving departments vulnerable to
fraud. Thirdly, the lack of training and mentorship is evident, as junior doctors
frequently lack supervision while senior colleagues pursue remunerative work outside
the public service, violating GDoH’s teaching mandates. Lastly, poor governance of
overtime has been flagged by the Auditor-General, jeopardizing clean audit objectives
and damaging the department’s reputation.

The Fiscal Case: Preparing the Ground for National Health Insurance

South Africa is on the cusp of a profound shift in healthcare delivery. The
implementation of National Health Insurance (NHI) will demand not only expanded
services but transparent governance, performance-based spending, and a zerotolerance approach to waste.

Value for money is not optional it is foundational. If public funds are spent on overtime
and RWOPS-enabled practitioners who are absent from duty, then public confidence
in NHI will collapse. There can be no talk of universal coverage when service platforms
are hollowed out by neglect and unchecked privilege.

NHI demands coherence, not chaos. Circular 6 introduces enforceable governance in
the very spaces where waste has festered. It ensures that taxpayers, patients, and
oversight institutions can trust the numbers on the page. A rules-based culture must
precede system-wide expansion

It is critical that in the deliberation we do not lose sight of the point that austerity cannot be the goal but sustainability is. Circular 6 is not about cutting doctors’ pay
indiscriminately. It is about protecting the fiscal space to expand hiring, reduce
vacancy rates, upgrade infrastructure, and widen access – all of which are impossible
if the bulk of budgets are absorbed by unchecked CoT allocations.

A Call for Constructive Partnership

Given the tight resources envelope for public health, this calls for the recalibration of
engagement values for improvement of patient care. We recognise different roles that
have to be played by various stakeholders in the provision of quality care.
Certainly the department has got a major role to play in developing policies and
creating an enabling environment for healthcare workers to perform their function even
within limited resources.

All clinical staff employed by GDoH remain central to the health system
transformation. Under the current leadership, the department has identified
programmes that are major cost drivers, where waste and abuse have been clear. The
expertise, commitment, and sacrifice of our clinicians and all healthcare workers
deserve protection. This must be within a framework that is just, lawful, and financially
responsible.

Circular 6 offers a platform for honest engagement. Stakeholders should not reject it
outright but rather contribute to its refinement and rollout. This is the only way to
balance professional fairness with the public interest, which must always come first.
We hope that employees of the department, in particular, will take advantage of the
opportunity provided for by the Circular to deposit their inputs with the view to continue to advance transformation and better management which is geared towards improved patient care. This responsibility also entails protecting the shrinking resources envelop to render adequate care to patients in Gauteng province.

Modiba is the Chief Director: Communication
Jikwana is the Chief Director: Health Economics and Finance
Dr. Chikobvu is the Director: Strategic Operations and NHI

The trio are Senior Managers in the Gauteng Department of Health and this opinion
is shared in their personal capacities.