Risk 1: Failure to retain HOCUs in DCSTs may bring about human resource and financial imbalances in the public health system
Despite HOCUs being successfully recruited in some districts, doubts have been expressed about the length of their retention.
Risk 2: HOCUs will ultimately perform their commuted overtime duties in district facilities if the regional or tertiary hospital is too far away from their district-based location
PHC costs will increase since all HOCUs (except FPs) will require the support of a medical officer while performing commuted overtime, to deal with generalist cases that fall outside the specialist's scope of practice.
According to the Commuted Overtime Policy in Gauteng,  HOCUs are restricted to 12 hours of commuted overtime per week; in exceptional cases, 16-20 hours may be granted.
Risk 3: HOCUs (the FP excepted) will be restricted in their scope of practice, especially in rural districts, resulting in skills loss
All managers must be made aware of the potential movement of HOCUs within the health system.
In future, instead of appointing HOCUs at the district level, FPs, entry level specialists or medical officers with specialist diplomas (diplomates) should be appointed within district hospitals.