South Africa must drastically overhaul its current goals, budgets and thinking if it wants to train and produce more doctors and nurses, plug the medical brain drain, and boost the current abysmal public healthcare offerings.
In fact, to adequately care for the health of its future population, says a new study by a team from the World Bank, extracts of which were published in Daily Maverick, the country has to substantially invest in a skilled health workforce.
Courtney Price Ivins, Annie (Liying) Liang, Nicole Serfontein, Thulani Matsebula and Pia Schneider write that SA’s increasing population, changing demographics and growing middle class are just a few of the trends exerting pressure on the health system in the coming decades.
By 2050, South Africa is expected to grow by 15m: 77% of the population will be living in cities, and economic growth will help expand the middle class, especially in urban areas.
Simultaneously, life expectancy is projected to increase from the current 64 to about 73 years in 2040, if HIV/Aids can be controlled. However, many rural people will be both poor and elderly and facing chronic diseases, which are increasingly affecting the poor.
Technology will transform expectations for care, how care is provided, how providers are educated and how information is utilised. In 2019, more than 91% of South Africa’s population had access to a smartphone. This widespread availability to access information can increase people’s expectations for healthcare.
SA’s emerging market for the medical technology industry will reach $1.8bn in 2023 and will continue to grow and facilitate learning and medical work. Data systems will advance e-health, disease surveillance and communication with consumers and providers.
Preparing a health workforce for the future
South Africa is expected to become a high-income country within the next decade. With economic growth, the government will generate more domestic revenue that can be invested in medical education and the health workforce. Based on the analysis of the current context, six recommendations emerge from the World Bank study:
1. Invest in high-quality education and medical research
The quality of education must improve substantially to ensure the system produces enough qualified students for health professions. In 2017, only 55% of children finished secondary school. In international assessments, in 2015 and 2016, South African children ranked last among 49 countries in maths and reading. These outcomes need to improve to increase the number of qualified candidates for health studies.
In 2020, medical institutions here produced about 1,800 graduates, fewer than Chile, Colombia and Turkey. Universities should triple the number of medical graduates to about 5,500 annually to achieve the same output as Chile, and recruit faculty internationally, including among diaspora academics. However, the government’s plans are to increase the number to just 2,000 medical graduates annually by 2030. This is not enough.
The number of nursing schools and nurses must also be increased. About 47% of registered nurses and 29% of diploma nurses are older than 50, due to retire within the next decade. But SA trains fewer nurses than countries like Mexico and Turkey.
2. Reform education financing to train more medical and health graduates
Medical education is one of the most expensive fields of study. Training a medical doctor in SA costs about R900,000. To expand high-quality medical and nursing education, more resources are needed, and must be spent efficiently. However, education is already the government’s fastest-growing expenditure category. In 2020, it spent 19.5% of general expenditures on education, considerably higher than the average 11% of GDP spent by Organisation for Economic Co-operation and Development countries.
SA should increase tuition fees for its medical students, but offer them income-contingent loans (ICLs) to cover the cost. ICLs require students to start repaying their loans once they earn an income above a certain threshold.
3. Plan the health workforce based on future trends and within the resource context
The health workforce planning process should consider future trends and constraints. The Department of Health’s 2030 Human Resources for Health Strategy found a severe shortage of health workers to meet current needs and recommended hiring an additional 96,586 staff by 2025.
This would require recruiting among unemployed health workers, training substantially more health professionals and hiring foreign-trained health staff from countries with large diasporas (such as Ghana, Nigeria and Serbia), who could apply for a Critical Skills Work Visa. However, there are not enough unemployed health workers, training takes time and hiring foreign medical staff is almost impossible as the 2022 Critical Skills List includes only nurse educators.
High spending on wages currently limits any hiring into the sector: 35% of physician positions in the public sector are vacant.
Pay scales should be defined according to the objectives of the position, using factors like seniority, patient load and complexity, length and timing of shifts and location. The lack of jobs leads many health professionals to seek opportunities abroad. Since 2002, SA has experienced a net loss of physicians to OECD countries, reaching about 14,000 in 2010.
To reverse this trend, legislators will need to create more health positions; increase the attractiveness of the public health system as an employer and ramp up hiring.
4. Invest in health workforce management and modern technologies
Modern personnel management practices can increase the attractiveness of working in the public sector with employee promotion policies, better working conditions and opportunities for professional education.
Mental health services should be made widely available, including through virtual telemedicine.
Many South African students study abroad, but find it difficult to enter the health workforce at home. In 2020, a survey identified 458 foreign-trained medical graduates who were either unemployed or working in non-medical roles in SA because their registration with the Health Professions Council of South Africa (HPCSA) was still pending. The HPCSA could change hiring rules to allow foreign-trained graduates to work alongside certified physicians for up to two years, at which time they would have to pass the HPCSA exam.
5. Collect data and conduct analysis to inform strategies and policies
Data will be essential for health workforce planning and management and for determining medical and health education budgets. A centrally managed database could hold information on health sector performance, the health workforce, students and graduates, as well as on the unemployed. Statistics South Africa could expand its role to collect detailed health workforce data, including administrative and payroll data, and collect disaggregated health labour data for health workforce planning.
6. Expand collaboration with the private sector and an international workforce
The study recommends greater collaboration with the private sector and other countries to improve access to care. With a growing middle class, demand for private sector care in SA will continue to grow.
Policymakers should take advantage of opportunities to partner with the private sector, particularly in the provision of highly specialised care.
South Africa is fortunate in having an international health workforce, but harnessing the benefits requires measures to facilitate integration. Physicians and other health professionals should be added to the government’s Critical Skills List to prioritise their immigration to South Africa. Foreign medical staff could also be recruited through bilateral agreements with countries that already have a mobile health workforce, like Egypt, Ghana, Mexico, Nigeria and Serbia.
The World Bank report, The Future of Medical Work in Southern Africa, provides further analysis and more detail on how the country can best prepare for the coming changes.
Courtney Price Ivins is a health specialist with the World Bank’s East and Southern Africa Unit.
Annie (Liying) Liang is an operations analyst with the World Bank Group’s East and Southern Africa Unit.
Nicole Serfontein is a global health lawyer with 20 years’ experience working in the public and private health sectors on governance, finance, legislative and market strategies.
Thulani Matsebula is a senior economist with the World Bank Group’s East and Southern Africa Unit, based in Pretoria.
Pia Schneider is a lead economist with the World Bank Group, working on health reforms in Eastern and Southern Africa, Europe and the Middle East.
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