The ambiguity of multiple job holding regulation in South Africa: Stakeholder perspectives on the implementation of the Remunerative Work Outside the Public Service Policy
1
Dual Practice Project, Health Economics and Epidemiology Research Office (HE²RO), Wits Health Consortium, Parktown, Johannesburg, South Africa
2
Centre of Health Policy, School of Public Health, University of the Witwatersrand, Parktown, Johannesburg, South Africa
3
Centre of Health Policy & South African Research Chairs Initiative (SARChI), School Public Health, University of the Witwatersrand, Parktown, Johannesburg, South Africa
Popul. Med. 2026;8(Supplement Supplement 1):A3525
ABSTRACT
BACKGROUND:
Multiple job holding (MJH), or holding two paid jobs simultaneously, is widespread among public sector health professionals in mixed health systems. Countries regulate MJH to balance potential benefits such as health professional retention with the likely negative effects on public service availability and quality of care. In South Africa, MJH is regulated by the Remunerative Work Outside the Public Sector (RWOPS) policy. This study used Sutinen and Kuperan’s socio-economic theory of regulatory compliance to explore the implementation of the RWOPS policy in South Africa.
METHODS:
This qualitative study combined 33 semi-structured key informant interviews and 30 in-depth interviews with public sector health professionals. The key informants were selected purposively from different levels of government, health profession regulators, professional associations, civil society and academia. Doctors, nurses and therapists engaged in MJH were purposively selected from public hospitals in two provinces. The interviews focused on the understanding of the RWOPS policy, its implementation in hospitals, and compliance by health professionals. Sutinen and Kuperan’s framework informed the thematic analysis of the data.
RESULTS:
Implementation weaknesses undermined compliance with the RWOPS policy with many health professionals engaging in MJH during working hours or neglecting their public hospital duties. There was significant ambiguity about the policy - stakeholders frequently characterised it as a ‘necessary evil’. Uncertainty about RWOPS restrictions, slow and inconsistent approval processes, and perceived unfairness in implementation further weakened the policy’s legitimacy. Managerial failures and uneven enforcement resulted in ineffective deterrence to non-compliance. Alleged transgressions by senior specialists eroded the social and professional norms that should have supported compliance. However, visible and robust hospital management in some settings served as a deterrent to unauthorised MJH.
CONCLUSIONS:
Clarity on RWOPS policy provisions, improved management, procedural fairness and efficiency, and consistent enforcement will improve MJH regulatory compliance and reduce potential adverse effects.
Multiple job holding (MJH), or holding two paid jobs simultaneously, is widespread among public sector health professionals in mixed health systems. Countries regulate MJH to balance potential benefits such as health professional retention with the likely negative effects on public service availability and quality of care. In South Africa, MJH is regulated by the Remunerative Work Outside the Public Sector (RWOPS) policy. This study used Sutinen and Kuperan’s socio-economic theory of regulatory compliance to explore the implementation of the RWOPS policy in South Africa.
METHODS:
This qualitative study combined 33 semi-structured key informant interviews and 30 in-depth interviews with public sector health professionals. The key informants were selected purposively from different levels of government, health profession regulators, professional associations, civil society and academia. Doctors, nurses and therapists engaged in MJH were purposively selected from public hospitals in two provinces. The interviews focused on the understanding of the RWOPS policy, its implementation in hospitals, and compliance by health professionals. Sutinen and Kuperan’s framework informed the thematic analysis of the data.
RESULTS:
Implementation weaknesses undermined compliance with the RWOPS policy with many health professionals engaging in MJH during working hours or neglecting their public hospital duties. There was significant ambiguity about the policy - stakeholders frequently characterised it as a ‘necessary evil’. Uncertainty about RWOPS restrictions, slow and inconsistent approval processes, and perceived unfairness in implementation further weakened the policy’s legitimacy. Managerial failures and uneven enforcement resulted in ineffective deterrence to non-compliance. Alleged transgressions by senior specialists eroded the social and professional norms that should have supported compliance. However, visible and robust hospital management in some settings served as a deterrent to unauthorised MJH.
CONCLUSIONS:
Clarity on RWOPS policy provisions, improved management, procedural fairness and efficiency, and consistent enforcement will improve MJH regulatory compliance and reduce potential adverse effects.
| eISSN: | 2654-1459 |
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