Doctors in the public service TOO FEW FOR TOO MANY

In the global market for knowledge and the knowledgeable, health professionals are highly prized, leading to an international migration carousel – doctors offer their services or are actively recruited to countries that offer better conditions than their own. In South Africa, the migration of medical doctors has several dimensions, writes ANGELIQUE WILDSCHUT, illustrated by the ongoing inequality in distribution between the rural/urban divide and public/private sectors. 

This article draws on research conducted for two recent projects, one on professions and their professional education programmes, and the other, on skills shortages in selected professions in South Africa.

Do we have enough doctors?
   
   

In 2006 a total of 33 220 medical practitioners were registered with the Health Professions Council of South Africa (HPCSA), although the actual number of practising doctors is lower than the total number registered because the register includes those that might have retired, are out of the country or are just inactive.

The most commonly used measure employed to ascertain whether a country has enough doctors, is doctors per 10 000 population. With regard to our immediate neighbouring countries, South Africa is substantially better supplied with doctors (Table 1), but grossly undersupplied when compared to many developed countries, and even in relation to middle-income countries. South Africa ranks only slightly above those countries classified as low-income.

To illustrate further disparities in distribution within our country, we analysed the distribution and supply of registered doctors between provinces (Table 2). For instance, in the Western Cape and Gauteng, there are 14.7 and 12.6 physicians per 10 000 people respectively, ranking with middle-income countries, in contrast with the stark reality of Limpopo which has only 1.8 doctors per 10 000, placing this province only slightly above the average for sub-Saharan Africa.

Where are doctors needed most and where are they working?

The distribution of doctors between public and private sector practice exacerbates the inequality further. From numerous sources we know that 85% of the population do not have medical aid and are reliant on the public service. However, only about 41% of our medical doctors are working in the public sector. Conversely, 15% of the population do have medical aid and utilise the private sector, where approximately 59% of our medical doctors are working.

85% of the population do not have medical aid and are reliant on the public service. However, only about 41% of our medical doctors are working in the public sector.

South Africa’s high HIV/AIDS prevalence and associated high rate of TB requires additional health human resources, and thus impacts on the need for doctors and nurses as well. Based on the department of health’s Operational Plan for Comprehensive HIV/AIDS Care, Management and Treatment (2003), and the planned roll-out of antiretrovirals, it was estimated that a total of 21 824 new staff would have to be recruited between March 2004 and March 2008 – 975 doctors and 6 822 nurses.

Another factor impacting enormously on balancing the demand and supply of doctors is emigration – the extent of which is difficult to establish. It is widely recognised that the available data are largely incomplete and inaccurate, representing a severe under-count of emigration from South Africa for the following reasons:

  • Official figures are based on information provided by individuals leaving or entering the country, but compliance is not always enforced and not all individuals intending to emigrate indicate this.
  • South Africans who leave to travel and then stay abroad are not captured.
  • Only individuals leaving from the major South African airports are captured.
  • The system only recently started capturing disaggregated occupation data, and StatsSA categories have changed over the years, making it difficult to formulate trend analyses.

Using the available figures in an effort to establish a trend over time, we find that in the period 1988–1994 South Africa experienced a gain in doctors, peaking at 296 in 1992. By 2002, the country began to experience a net loss, beginning with 33 doctors in 1996 and increasing to a loss of 156 doctors in 2003 (Table 3). The most reliable calculations are probably those of Clemens and Petterson (2008), who use census data on African-born doctors who are actually working abroad and at home. Added together, these data show that South African-born doctors working in the eight countries specified (Australia, Belgium, Canada, France, Portugal, Spain, the UK and USA) constitute 21% of the total potential African-born workforce . Nevertheless, although South Africa is losing health professionals, it has over the years also benefitted from the services of foreign doctors.

Why are doctors leaving?

Salary levels were not the primary motivation for doctors to leave the country. They also left because of deteriorating work conditions, increase in workload due to wider access to healthcare, uneven distribution of resources between private and public sectors and between urban and rural contexts, exposure to AIDS and other endemic infectious diseases like TB, insecurity resulting from delinquency, the lack of suitable equipment, and social and racial factors.

Two studies show that the motivations for migration are very complicated, and although it is possible to have a list of reasons, it is difficult to ascertain in which circumstances each might carry more weight.

In four sub-Saharan Africa countries (Cameroon, South Africa, Uganda and Zimbabwe), according to the World Health Report, 2006, the main reasons for migration were better remuneration, followed by safer environment, living conditions, lack of facilities, lack of promotion, no future, heavy workload, to save money, work tempo, declining health service, economic decline, poor management, to upgrade qualifications. Two studies (OECD, 2004 and WHO, 2006) show that the motivations for migration are very complicated, and although it is possible to have a list of reasons, it is difficult to ascertain in which circumstances each might carry more weight.

What is government doing to address shortages?

Measures include allowances (scarce-skill and rural) and specific legislation designed to boost other forms of healthcare and to control the geographical distribution of newly registered doctors.

There has been a substantial decrease in the numbers of foreign doctors, which is not surprising given the department of health’s increasingly restrictive policies on the employment of foreign doctors.

The introduction of a 15% scarce-skill allowance recognises the shortage of doctors and tries to compensate accordingly. Additionally, the rural allowance of 18% and 22% was introduced in 2004 for doctors and specialists (and other selected health professionals) who work in rural and other ‘inhospitable’ areas within the public service.

A critical measure is legislation aimed at correcting the imbalance between the rural/urban divide and the public/private provision:

  • The Pharmacy Amendment Act (No. 88 of 1997), which extends ownership of pharmacies to ensure adequate distribution in rural and under-served areas.
  • The National Health Act (No. 61 of 2003), which specifies that private practitioners must obtain a certificate of need to practice in a particular area.
  • The Traditional Health Practitioners Act (No. 35 of 2004), which most importantly provides for registration, training and practices of traditional health practitioners.

Government-to-government importation of foreign doctors has been one of the measures put in place to alleviate shortages of doctors in various areas in South Africa. There has been a substantial decrease in the numbers of foreign doctors, which is not surprising given the department of health’s increasingly restrictive policies on the employment of foreign doctors. Given that most of these doctors work in the public service and many in rural areas, the effect on the rural public health service will be devastating.

Another measure is compulsory community service instituted in 1998, which requires that newly graduated medical practitioners, pharmacists and dentists who have completed their internship should undertake a year’s paid community service. This was put in place to alleviate staff shortages in rural and under-serviced areas, but whether it encourages young doctors to remain after completion is a moot point.

Attempts to double graduation numbers are further complicated by the pressure on medical schools to transform racially and to target not only black students, but those black students from disadvantaged or rural backgrounds.

What is the role of medical education?
   

The National Health Human Resources Plan (2006) recognises that ‘significant shortages and extreme mobility of medical doctors necessitate that production is increased’. The proposal is to double production from approximately 1 200 per year to 2 400 per year by 2012. This target may be unrealistic.

Attempts to double graduation numbers are further complicated by the pressure on medical schools to transform racially and to target not only black students, but those black students from disadvantaged or rural backgrounds.

Between 1999 and 2005, graduation numbers increased from 1 195 to 1 511, an average annual growth rate of 4%. Assuming this growth rate continues unchanged, the target of 2 400 doctors will only be reached in 2018. There is a serious question of infrastructure and human resources to be considered both in terms of maintaining, or improving this growth rate.

Attempts to double graduation numbers are further complicated by the pressure on medical schools to transform racially and to target not only black students, but those black students from disadvantaged or rural backgrounds. The strategy is not only driven by equity concerns, but also based on the premise that students from such backgrounds will be willing to go back to their communities to work. Indications are that this is not necessarily so. Transforming the intake of students is a challenge, given that the school system continues to produce insufficient Africans with the appropriate matriculation passes.

Much hope is being pinned on the education system to alleviate the shortage of doctors by producing more graduates who are likely to stay in the country and work where needed most, but there are constraints on what is possible in the short term.

What more can be done?

There is little doubt that there is a shortage of medical doctors in South Africa, concentrated mainly in the public and rural service. Nowhere in the country do we achieve the doctors-per-population norms of even middle-income countries internationally. We might compare favourably with our African neighbours but they are the most under-served countries in the world. Many thousands of our doctors are working abroad in countries classified as high-income, with physician-to-population ratios that are many times more favourable than ours.

Much hope is being pinned on the education system to alleviate the shortage of doctors by producing more graduates who are likely to stay in the country and work where needed most, but there are constraints on what is possible in the short term.

 

Key policy recommendations are:
  • Although it is understandable that government has a policy banning the recruitment of doctors from other African countries, other provisions to limit foreigners’ contracts and the total number of foreign doctors are misguided. This policy needs to be amended urgently to distinguish between countries that have more than enough doctors for their own needs and those that do not. This category of doctors should also be included in the department of labour’s scarce-skills list for immigration purposes.
  • Government-to-government agreements, which are already favoured but have so far produced very small numbers of doctors, should continue to be pursued.
  • There needs to be greater realisation that uncontained health threats in developing countries also have implications for the developed world (illustrated by the HIV/AIDS pandemic and global influenza outbreaks), and thus it is in the interest of the entire global community that the health workforces of poorer nations should be sustained.

Angelique Wildschut, senior researcher, Education and Skills Development programme, HSRC.