The fiscal cost of 24-hour clinical coverage: Commuted overtime v. shift-based models in a South African regional hospital

Background. South Africa (SA)’s public health system relies on commuted overtime (COT) to provide 24-hour medical cover in hospitals. Persistent concerns about excessive working hours, fatigue and patient safety have renewed interest in shift-based staffing models. Local evidence on the workforce and fiscal implications of such a transition remains limited. Objectives. To determine the staffing complement required to deliver continuous 24-hour surgical coverage under a shift-based system, and to model the personnel cost implications across three staffing configurations compared with the current COT arrangement. Clinical outcomes and optimal staffing levels were not assessed. Methods. We conducted a retrospective cost analysis from a health-system perspective at a regional hospital in eThekwini District, KwaZulu-Natal Province, SA, using the Department of General Surgery as the case study. Three staffing models were compared: the current COT model; a hybrid model with medical officers (MOs) on 12-hour shifts and specialists retained on COT; and an expanded hybrid model with additional specialist posts. Annual personnel costs were calculated using 2024/25 occupation-specific dispensation salary notches under grade 1 and mixed-grade assumptions. Sensitivity analyses examined variations in specialist salaries, workload estimates and absence allowances. Results. The baseline complement comprised eight MOs and four specialists. Delivering continuous shift-based coverage required scaling the MO complement to 22, a 175% increase. On a base-salary-only comparison, annual costs rose from ZAR13.54 million (all grade 1) to ZAR27.56 million under hybrid model A (+103.7%) and to ZAR31.71 million under hybrid model B (+134.3%). When estimated COT payments are incorporated into the current model baseline – using group 3 parameters and a 1.3 × ordinary hourly rate multiplier applied to 16 contracted overtime hours per week – total estimated annual remuneration rises to ZAR20.58 million (all grade 1) and ZAR23.21 million (mixed grades). Under this COT-inclusive comparison, hybrid model A represents a cost increase of ~48% and hybrid model B ~79%. Shift-based models increase total personnel expenditure under both costing approaches; the COT-inclusive figures are the primary policy- relevant comparator. Sensitivity analyses confirmed robustness across all scenarios tested. Conclusion. Replacing COT with a 12-hour shift system requires a substantially greater number of MOs, and increases total personnel costs by 48 - 79% when estimated overtime is included in the baseline. Hybrid models reduce but do not eliminate this impact. Any transition should be phased, locally costed using verified payroll data and aligned with national workforce planning priorities.