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A new human resources plan by the Department of Health could potentially halve the number of foreign medical doctors in South Africa with serious consequences for the public health service, warns Dr Mignonne Breier, a chief research specialist at the Human Sciences Research Council. Policy plans to reduce the number of foreign doctors are particularly difficult to understand when one considers South Africa has less than 7 doctors per 10 000 people whereas the UK has around 21, the United States around 24 and many European countries more than 30. Our own doctors emigrate in significant numbers (estimated at 150 per year) and, of those who stay, more than 60% work in the private sector, where they serve less than 20% of the population. With the majority of these doctors opting to work in urban centres, rural areas have been heavily reliant on foreign doctors. Research by the HSRC – published in a monograph entitled Doctors in a Divided Society: The Profession and Education of Medical Practitioners in South Africa – gives an account of the role of foreign doctors in and around Mthatha in the Eastern Cape. In Mthatha it is not uncommon for ten people to live off a single old age or disability pension, in other words, about R82 each per month. HIV/AIDS is rife and the area’s exceptionally high suicide rate is thought to be closely linked. Health services in the area are crippled by a shortage of nurses and doctors. There is a state-of-the-art academic hospital in Mthatha, but it has only about half the medical staff it needs. The surgical department is particularly understaffed with only 40% of the specialists and 30% of the surgical nursing staff required, according to a senior surgeon. In the Eastern Cape as a whole, there are fewer than 3 doctors per 10 000 people. And barely one of these is in the public sector. The medical services that do exist in this area are being provided largely by foreign doctors, many of whom are attached to the medical school at the Walter Sisulu University (formerly the University of Transkei). Their countries of origin include India, Sri Lanka, Bangladesh, Nigeria, Uganda and Zimbabwe. The greatest number is from Cuba, which produces the highest numbers of doctors in the world: around 59 per 10 000 people. In interviews, the foreign doctors gave many different reasons why they came to this country: to escape political violence or worsening professional conditions, to earn more money, to acquire specialist training, or to link up with family who emigrated earlier. Several spoke of their desire to serve the poor and ‘make a difference’. The Cubans came under the conditions of a government-to-government agreement in the mid-90s. Others have worked in the area for decades. Several questionable assumptions underlie the Department of Health’s new policy. Firstly, the department claims that the restrictions will limit the brain drain from other countries in Africa, where there are even fewer doctors: less than 1 per 10 000 people in Lesotho, Malawi, Mozambique, Zambia, Uganda and Tanzania, for example. It is true that many of the doctors who have come to this country are from elsewhere in Africa and that they fill the gaps caused by those of our doctors who emigrate to countries like the US, UK, Canada and New Zealand. And, understandably, the South African government does not want to deplete the health resources of its neighbours any further. But there is no guarantee their doctors will stay at home just because South Africa closes its doors. Of the medical practitioners in America who had received their medical training abroad, a study found that 5 334 had trained in Africa, of whom 1 943 (36%) were from South Africa and the rest from other African countries. The biggest number (2 158, or 40%) were from Nigeria. Secondly, there is the assumption that South Africa can make up the shortfall by rapidly increasing its output from medical schools. The aim is to double the number of graduates from 1 200 to 2 400 per year by 2014. How this is to be achieved is difficult to understand, given that the plan also provides statistics showing that the number of graduates from the eight medical schools has only increased by 32% in the 12 years between 1994 and 2005. Most of the growth has been in the historically black medical schools, which produced 737 doctors in 2005, compared to 231 in 1994. The Walter Sisulu University showed the biggest growth, albeit from a low base, quadrupling its graduates from 18 to 78. Nevertheless, it is difficult to imagine how the medical school can maintain this trajectory, as it is almost totally reliant on foreigners for its academic staff. In contrast, the historically white medical schools produced only 8% more doctors in 2005 than in 1994 (840 compared with 779). A third assumption is that a change in recruitment strategy to target students from ‘rural and under-serviced’ areas will help to produce doctors who are more likely to return to those deprived areas to work than students from urban and less disadvantaged backgrounds. This assumption suggests that the post-1994 changes in admissions criteria and curricula have failed to produce sufficient numbers of this kind of doctor. ‘It is clear that the government will have to invest a great deal of money in the education of medical doctors if it wants to double numbers in the next eight years’ It is clear that the government will have to invest a great deal of money in the education of medical doctors if it wants to double numbers in the next eight years. Learner-centred teaching methodologies found in community- and problem-based curricula are expensive to implement because students have to be transported to community centres. In addition, the problem-based curricula are labour intensive. In the past, one lecturer would address a group of 200. Now 20 staff members are required to facilitate groups of 10 or less. The universities will need more staff, facilities and hospital posts. If a sizeable proportion of students are to come from rural backgrounds in the hope that they will return there to work, then there will also have to be sizeable investment in rural education to produce the maths and science passes needed to gain access to a medical school. In the meantime, we need to take note of the reasons why health professionals leave this country. A study by the Organisation for Economic Co-operation and Development (OECD) found primary concerns were crime, affirmative action, the deteriorating state of public education and uncertainties about the future. The Global Commission for International Migration advised countries that are losing professionals to be ‘good employers’. Doctors who work in the Mthatha area complained not only of poor salaries, but also of impossible workloads, inefficient administrations and an inhospitable social environment. They say the roads are neglected and the drivers unlicensed and dangerous, the schools are of poor standard, and that the town offers little entertainment. At the university where they teach, students are often without hot water or electricity and there is only one sports field. The medical school is renowned for problem-based learning, but the rooms in which it offers the small group sessions are windowless cubicles in a converted library with crumbling paint and lifts that do not work. There is clearly a need for a multi-faceted approach to the human resource problems in the health sector. Such an approach would not only involve more government departments than just the Department of Health, but would be long term as well. Restricting the number of foreign doctors in the short term would certainly not be a feature. A copy of the report, Doctors in a Divided Society: The Profession and Education of Medical Practitioners in South Africa, by Mignonne Breier, can be ordered or downloaded free from http://www.hsrcpress.ac.za/full_title_info.asp?id=2146
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