An Econex study for the Hospital Association of SA paints a bleak picture of the lack of medical professionals, especially in light of the planned National Health Insurance scheme. Up to 17% of newly qualified doctors might be emigrating, while up to 80% 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.
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.
This is while pressure on South Africa is growing as a result 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.
The standard practice is that people visit their general practitioner three times a year. If that was done locally, there would be a shortage of 4,100 doctors in the country, according to the study. A constant increase in the number of trained doctors is necessary to meet the needs of the populace, which is growing at a rate of 1.58% a year.
The report says it is uncertain how many doctors have emigrated, but between 2004 and 2009, 17% of doctors who qualified did not report for community service. To be registered with the Health Professions Council of SA, you have to complete a year’s community service. This could mean these doctors are leaving the country. Most South African doctors go to Canada, New Zealand, Australia, the US and the UK.
Between 70% and 80% of doctors also prefer not to work for the state but, the report says, the main reason for this is not poor pay, but poor working conditions. Other reasons include a lack of equipment and medical provisions, a heavy workload, and insufficient protection against HIV and tuberculosis infections.
Foreign doctors, on the other hand, are eager to work in South Africa, but bureaucratic red tape prevents that. In the report, this is referred to as “severe delays and inefficiency by the Foreign Workforce Management Programme”.
The report says in 2006, the department of health indicated that it wanted to increase the number of doctors who were being trained annually from about 1,300 to about 2,400, but nothing came of that. In the meantime, Health Minister Aaron Motsoaledi said it was going to be increased to 3,600 in anticipation of the NHI scheme.
The plan is to train doctors in Cuba and China but according to the study, money is needed locally to train specialists. It costs about R3.1m per specialist and a post has to be available at one of the eight academic hospitals.
If private hospitals that serve as colleges also get accreditation for this, it would lighten the load considerably, the report says. In India and Brazil, the model of private colleges has helped. In Brazil, training from the state is free, but students have to pay at private colleges.
The most significant factor that limits the supply of doctors from meeting demand, is the number of doctors being trained at the moment at the eight faculties of medicine at South Africa’s public universities, says a Bizcommunity report. These medical schools carry the full responsibility for training doctors, but cannot deliver enough doctors to respond to the country’s demand and large disease burden.
The report quotes Econex as saying: “The prohibition on establishing private medical colleges in South Africa limits the private sector’s ability to help lift this burden, and leaves training in the public sector constrained by limited funding and resources. “National or provincial governments, universities and the private sector have tried different approaches to address the lack of training capacity for healthcare professionals in South Africa. One such policy is to send students to countries like Cuba and China for medical training.
“We argue that the long-term effectiveness of such policies needs to be weighed against counterfactual scenarios and the quality and suitability of medical education received.
“Training doctors abroad is at best a temporary solution to doctor shortages in South Africa. Instead, partnerships between universities and provincial governments, as well as (limited) partnerships between universities and the private sector have been proven to help lift the burden, albeit only marginally, and should be further encouraged. The structural shortage of doctor training capacity will best be solved through a combination of initiatives.”
According to the report, the rise of private medical schools in India, for example, has retained medical students who might otherwise have studied abroad. Brazil relies on both public and private medical schools to provide training, and uses both of these platforms to provide healthcare services to communities while students are in training.
Indeed, research shows that private medical schools are common internationally and as a rule provide high quality education. Other important lessons can be drawn from African countries like Malawi, which has increased its training capacity with the help of international volunteer doctors. Zambia’s experience illustrates that exposure to rural areas during training needs to be complemented by adequate mentoring in order to provide healthcare practitioners in these areas with the necessary skills.
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, the role that greater participation by private hospitals can play 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 practise in these areas.