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SA nurses: Underfunded, stressed, overworked and abused

A lack of government healthcare spending is key to understanding the "bad rap" given to nurses in South Africa, writes a former Canadian nursing union economist in Daily Maverick.

South African nurses hold 81% of filled professional positions in the public healthcare sector and carry the bulk of responsibility of paid care in a country that in 2019 achieved “the most-unhealthy nation in the world” status in the Indigo Wellness Index. The index ranks countries according to measures of blood pressure, blood glucose, obesity, depression, happiness, alcohol use, tobacco use, exercise, healthy life expectancy and government spending on healthcare.

Salimah Valiani, the past economist of the Ontario Nurses’ Association, the largest nurses’ union in Canada, writes in the Daily Maverick that the last on this list — government spending on healthcare — is key to the bad rap given to nurses in South Africa.

Valiani writes in a recently published article in Academia that as a researcher studying public healthcare financing globally, it was surprising how the recent history of South Africa’s public healthcare spending is disputed terrain.

Valiani writes: “Though many health activists and workers know that government expenditure on public healthcare has been low in democratic South Africa, this is not the story told in current health systems literature. I graphed the latest World Health Organisation (WHO) data (graph below), to show that South Africa has consistently fallen below the 15% level of government expenditure on health (as a percentage of general government expenditure), agreed to by states in the 2001 Abuja Declaration on HIV/Aids, Tuberculosis and other Related Infectious Diseases. This despite South Africa’s relatively high status in Africa as a middle-income country and its exceptionally high levels of disability, and premature death caused by disease and violence.

“Looking at nursing labour supply, South Africa ranks much lower than several middle-income countries, at 49 nurses and midwives per 10,000 people. For instance, Libya’s ratio of nurses and midwives to population is 70 per 10,000 people, Brazil’s is 75 and Russia’s is 89, and all have higher life expectancy at birth than South Africa. Since 1998, South Africa’s ratio has risen only slightly, from 41 nurses and midwives per 10,000 people to 49.”

Valiani writes that added to this overall low supply of nurses is the filtering of nurses from the public to private sector.

“From 1995, the private health sector was permitted to grow rapidly in South Africa. Comparing workload, nurses in the public sector serve six times more patients than private-sector nurses – 17% of the population is covered by private medical schemes and associated private healthcare providers – representing about half of the country’s total health spending – while 83% rely on a dwindling number of nurses and the underfunded public healthcare sector that nurses sustain. The impact of all this on public sector nurses is immense. It includes staff shortages, excessive workload and workplace abuse.

“A 2015 study of mostly public sectors nurses in Gauteng and Free State showed how workplace constraints prevented nurses from upholding the International Code of Ethics for nurses and the South African Nurses Pledge of Service.

“A study of nurse managers in medical, surgical, paediatric and maternity units in nine Gauteng and Free State hospitals found that nurse managers were performing an average of 36 different tasks per hour, many unplanned, fragmented and of short duration.” Valiani writes that given such stressful working conditions, as in other countries, workplace abuse and violence are commonplace for nurses of all types in South Africa.

“In a 2017 study, undergraduate nurses of various levels in nine of 16 nursing schools in South Africa reported tolerating an average of 10.5 violent events over a 12-month period. Being treated differently due to undergraduate status, being subjected to nasty, rude or hostile behaviour, and being shouted at in rage are some of the forms of violent behaviour identified.

Valiani writes that nurses in South Africa get a bad rap. Nevertheless, she says, over the first 25 years of democracy, they have shouldered the bulk of the weight of massive inequality as it manifests in illness requiring professional care.

She writes: “If we can acknowledge massive inequality as readily as we do, it is time we acknowledge the necessarily grinding task and vital labour of nurse.”

[link url="https://www.dailymaverick.co.za/article/2020-02-16-poorly-behaved-nurses-and-the-bigger-picture-of-inequality-in-sas-healthcare-sector/"]Full Daily Maverick report[/link]

[link url="https://www.academia.edu/41929022/Public_Health_Care_Spending_in_South_Africa_and_the_Impact_on_Nurses_25_years_of_democracy"]Academia article[/link]

[link url="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4430685/"]Global Health Action 2015 study[/link]

[link url="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4430688/"]Global Health Action nurse manager study[/link]

[link url="https://repository.up.ac.za/handle/2263/66074"]University o Pretoria 2017 study[/link]

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