Inequalities in public-private sector employment of early career health professionals in the WiSDOM cohort study in South Africa

Inclusive and sustainable health systems depend on an equitably-distributed health workforce. South Africa continues to grapple with the persistent maldistribution of health professionals between the public and private sectors. This study is novel in examining the revealed preferences of early career health professionals for public or private sector employment in South Africa, and the factors influencing these preferences. The aim of the study was to examine and compare the distribution of early career health professionals in the WiSDOM cohort study in the public or private health sectors, and the factors influencing choice of employment sector. WiSDOM, a 2017 prospective longitudinal cohort study, consists of eight health professions: clinical associates, dentists, doctors, nurses, occupational therapists, oral hygienists, pharmacists, and physiotherapists. Every year we collect information on sector of employment, and the reasons for working in the private health sector. We used Stata ® 19 for analysis, and multiple multinomial logistic regression to investigate factors associated with sector choice across the eight professions in 2025. In 2025, the mean age of the cohort was 31.9 (± 2.1), and the majority were female (74.3%). Overall, 49.2% [95%CI: 43.6% − 54.6%] of the cohort were employed in the public sector, with marked variations across professions. Public sector employment ranged from 0.0% among oral hygienists and dentists to 76.2% among medical doctors, with other professional groups concentrated mostly in the private-for-profit sector. The top reasons for private sector employment were opportunities for professional advancement (23.0%), lack of public sector posts (23.0%), and better working conditions (16.8%). The predictors of private-for-profit sector employment compared to working in the public sector were health professional category, increased age, urban location, and whether financial benefits were cited as a reason for the choice of profession at baseline in 2017. The WiSDOM study highlights significant inequalities in sectoral employment across health professions, shaped by public sector absorptive capacity, professional aspirations, and working conditions. Expanding public sector career opportunities and improving working conditions are essential to promote more equitable health workforce distribution and ensure an inclusive health system in South Africa.