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According to the Minister of Health, Dr Zweli Mkhize, South Africa is currently facing a doctor and nurse shortage due to a lack of funding. Responding in a recent parliamentary session, Mkhize stated that the primary reason for this shortage is that the public health sector budget has not increased in real terms for the past 10 years. He mentions that the above matter has impacted on the number of staff that can be appointed. Mkhize added that the demand for health services in the country is increasing while there is no additional funding to address the change, which results primarily from immigration into the country and the increasing burden of disease.

Up to 17% of newly qualified doctors might be emigrating, while up to 80% of doctors prefer not to work for the state because of poor working conditions.

 

South Africa compares unfavourably with middle-income countries on the ratios of medical and dental professionals, and many districts have limited access to specialists and sub-specialists. Even South Africa’s private sector has fewer doctors per 100,000 people than most countries in the world.

 

According to Dr Zweli Mkhize the shortage of health professionals is a global phenomenon and is more pronounced in low and middle-income countries as health workers are more likely to migrate to upper-middle-income countries in search of better living and working conditions”. News24 reports that a comprehensive study produced by Econex after a request from the Hospital Association of SA paints a bleak picture, especially in light of the planned National Health Insurance (NHI) scheme. In 2013, there were just 25 state doctors and 92 private sector doctors per 100,000 people in South Africa. The average is 60 per 100,000, while the world average is 152. Even in India (70), Brazil (189) and China (194), there are more doctors per 100,000 people.

 

Statistics pertaining to our public health sector make even more grim reading.

Only about 30% of all our doctors work in the public sector. The rest earn their living caring for 16% of our population who are fortunate enough to be able to afford private medical insurance or pay for private healthcare when needed (Mail and Guardian, 2011). The above scenario is currently a reality in South Africa. The pressure on South Africa is growing because of HIV/AIDS, tuberculosis, violent crime, a high mortality rate among children younger than five, women who die during pregnancy, diabetes, heart disease and psychiatric illness (News24 report; HASA report – Full Bizcommunity report).

SAMA board member, Dr Rhulani Edward Ngwenya (2019) said the loss of these critical skills would prevent the national department of health from reaching its ambitious sustainable development goals by 2030, which include recruiting, training, and retaining healthcare professionals to curb epidemics such as AIDS, tuberculosis, and malaria. “We have an overwhelming shortage of qualified doctors and nurses, yet we are losing them to foreign countries because they can’t get jobs in public hospitals,” he said. “If they are trying to reach the sustainable development goals then they should be [creating] more posts because we simply don’t have enough doctors…”

High-quality health systems in the Sustainable Development Goals era: Time for a revolution

According to The Lancet Global Health Commission (2018), data from various countries and conditions show systematic deficits in quality of care. In lower and middle class (LMIC), mothers and children receive less than half of recommended clinical actions in a typical preventive or curative visit, less than half of suspected cases of tuberculosis are correctly managed, and fewer than one in ten people diagnosed with major depressive disorder receive minimally adequate treatment. Diagnoses are frequently incorrect for serious conditions, such as pneumonia, myocardial infarction, and newborn asphyxia. Care can also be too slow for conditions that require timely action, reducing chances of survival. At the system level, we found major gaps in safety, prevention, integration, and continuity, reflected by poor patient retention and insufficient coordination across platforms of care.

The report says greater participation by the private sector can thus play an important role in the provision of medical education. This study considers two possible avenues of participation: allowing the establishment and accreditation of private medical colleges; and encouraging greater participation by private hospitals and specialists in the clinical training of undergraduate students studying at South Africa’s public universities. Econex says that rather than posing a threat to the public sector, the private sector can strengthen South Africa’s medical workforce by helping government achieve many of its stated healthcare objectives. In the first instance, the accreditation of private medical colleges can allow a greater number of doctors to be trained at minimal cost to the public purse.

 

However, the report says, the perceived inequality in the distribution of resources between the private and public healthcare sectors creates the concern that private medical colleges will exacerbate current inequalities and give rise to elitist private training facilities. This history of antagonism in South Africa’s healthcare suggests that while private medical colleges provide a structural long-term solution, it will not be easy to implement in the short term.

In the second instance, private hospitals can play a greater participation in doctor training. There are already examples where the private health sector and public universities have collaborated effectively to lessen the training burden on public medical schools.

 

An initiative between Mediclinic South Africa (MCSA) and Stellenbosch University, where internal medicine students in mid-rotation complete a portion of their clinical training at a MCSA hospital, suggests that the private sector can contribute to the training capacity of public universities. It provides an easy and cost-effective way of increasing the number of doctors in South Africa, without skewing the distribution of healthcare resources. Netcare and Life Healthcare also contribute to lifting the training burden of the public sector through making funding and scholarships available for specialist and sub-specialist training. The report says greater involvement by the private sector in medical training should therefore be investigated and encouraged as a matter of priority, especially in light of the demand that the NHI will create for more doctors.

 

The private sector can also be used to help address the need for more healthcare resources in rural areas, where South Africa’s doctor shortage is especially acute. More doctors will be available for community service and internships in rural areas, if larger numbers of students are trained. Strategic agreements between (public or private) universities and rural clinics could also be tailored to increase the propensity of medical students to practice in these areas.

What should be done?

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. 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.

We are hopeful that the education system could 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 (Wildschut, senior researcher, Education and Skills Development programme, 2018: HSRC).