SA healthcare sector plagued by dire staffing crisis across the board

[Nat Quinn]

By now, the dire shortage of nurses in the South African healthcare workforce is reasonably well known. ​​ In 2015, 70% of South African nurses admitted to ‘moonlighting’ or working overtime due to a massive skills shortage in this under-resourced sector. However, this is only one part of a way bigger crisis plaguing South Africa’s healthcare workforce. This article by veteran health journalist Chris Bateman details the chronic issue – involving grim vacancy rates across health professions, huge underfunding, critical misplacement of healthcare professionals and an enormous shortage of specialists – faced by the SA healthcare sector. Never mind that reform is vital for successful implementation of the proposed National Health Insurance, reform is beyond necessary right now. This article first appeared on Med Brief Africa. – Nadya Swart

Poor planning to blame for SA’s healthcare staffing crisis – experts

By Chris Bateman

A chronic lack of investment in effective structures, capacity and specialised technical and planning skills lies at the heart of South Africa’s healthcare workforce crisis.

Interviews by Medbrief Africa with the two leading government health workforce advisors, an outspoken provincial Health MEC and alarming official numbers of vacant State healthcare posts reveal a disparate, often chaotic, hugely underfunded system. While more medical officers than ever are coming on-stream, public sector post vacancy rates remain high, administration dysfunctional and workload and skills-appropriate mix and placement of healthcare professionals grossly lacking.

According to Wits University based Professor Laetitia Rispel, South African Research Chair on the Health Workforce, implementation of the hard won 2020 -2030 National Workforce Strategy¹ remains ‘largely absent.”

“We do not need piecemeal solutions. The solution lies in investing in the health workforce through the creation of a strong technical unit with skills and capacity in the National Department of Health (NDOH) to lead and steer these reforms and implement the strategy recommendations,” she says.

She highlighted some of the ongoing problems white-anting the reform critical for implementation of a successful NHI.

While Covid has exacerbated the chronic lack of investment in suitable structures, capacity, and specialised technical and planning skills, the NDOH continues to have an unacceptably high turnover of senior managers, she says.

This was coupled with a lack of technical knowledge, a lack of credible information, resistance to change or an inability to manage change, and public sector budgets that had failed to keep in step with inflation, let alone growing demand.

Rispel says, “When I chaired the 2030 Human Resources for Health strategy¹, we stressed that the budget would need to increase just to maintain the current ratios of health professionals-to-population, but even more if we want to address the gross inequities, both between the public and private health sectors, and within the public health sector.”.

The 2030 strategy paper she led warns that the inequity between the public and private health sectors will worsen without ‘concerted policy intervention’.

The overall ratio of medical specialists is calculated as 16.5 per 100,000 population. Yet, there are an estimated 7 specialists per 100,000 population in the public sector and 69 per 100,000 in the private health sector.

Within the public health sector, rural provinces have significantly lower numbers of more skilled health professionals, while the inequities for medical specialists, nurses, and community healthcare workers (CHW’s) are the most marked. For example, the Western Cape has 25.8 medical specialists per 100,000 public sector population compared to only 1.4 per 100,000 in Limpopo.

Limpopo’s Health MEC, Dr Pophi Ramathuba, took exception to local DA health spokesperson Risham Maharaj quoting extremely high vacancy rates in critical medical personnel posts for her province.

Citing her department’s latest annual report, Maharaj said vacancy rates stood at 52,1% in health administration, 73,7% in health sciences training, 54,6% in provincial hospital services, 53,3% in district health services, 55,5% in central hospital services and 43,7% in emergency medical services. Just 130 of the 561 specialist posts were filled (a 76,83% vacancy rate), while medical officer and professional nurse vacancy rates stood at 54,57 % and 40,71% respectively.

Maharaj said most posts were vacant due to budget constraints, historically poor financial management and poor working conditions. The upshot was ‘an overworked healthcare cadre and a contingent liability bill of R15 billion due to litigation,’ he said.

However, Ramathuba said these figures were misleading and based on a hugely faulty structure that failed to consider workload indicators of staffing needs. This was something she had rectified with a new needs-based staffing mix structure currently before the Department of Public Service and Administration and the Office of the Premier for approval.

“They want to play politics because we inherited a non-evidence-based structure which skews the figures. You’ll see shortages of nurses at hospitals but an oversupply at our clinics. There are very few enrolled nurses at hospitals for much-needed care and wound dressing, and you’ll find too many professional nurses at the clinics,” she said.

She said identifying shortages where staff were appropriately deployed was the correct approach. “Instead, they just advertise without doing this work beforehand and the problem gets out of hand. You have to deal with the root cause which is putting the right people in the right places. For example, those 140 vacant medical officer posts Maharaj cites – well they’re all now filled because we advertised based on the correct structure,” she added.

Enthusiastically endorsing many of Rispel’s recommendations, Ramathuba said she inherited eight deputy director’s general whom she had since cut down to four. Each district manager had five directors which she had since cut down to two.

“People wake up in the morning and create posts for their comrades,” she quipped.

She said her most difficult problem was dealing with unions while trying to rationalise.

“For example, you find maternity wards very busy but very few midwives there. Many of them are sitting in the male medical wards doing nothing. As an employer I have to look after the interests of the patient. I constantly tell the unions I also have their interests at heart because a satisfied workforce brings results – but I won’t entertain a selfish approach; we’re all in Health because of patients,” she adds.

She agrees staff shortages are dire, “but not in the way they’re portraying it”. With R8,8 billion allocated to the NHI, many observers are questioning why this money is not being used to deal with (for example), the shortage of 21,000 specialist medical posts nationally.

Rispel said both the Discovery Health “Percept” actuarial report on human resources for health² and the 2030 strategy she helped craft singled out the “time bomb” of an ageing nurse cohort and the Remuneration for Work Outside of the Public Sector (RWOPS) as priorities.

RWOPS, an attempt to even out the gross income disparities between public and private sector specialists and subspecialists, was poorly managed and often abused. A full 35% of specialists work in both sectors, the Percept report found.

Observed Rispel, “Many senior specialists in the public sector spend a considerable proportion of their time in private practice, adding pressure on junior staff and making shortages worse.”

A PhD student of hers was studying this multiple job holding among doctors, professional nurses, and rehabilitation therapists. Her preliminary impression of the research was that “the chaos in public sector hospitals is mind boggling”. “It saddens me a great deal to see what’s happening – we don’t have to be in such a situation,” she added.

Former Health Minister Dr Aaron Motsoaledi had insisted on increasing the medical student intake (i.e., the Cuban training program), “but no one planned for what will happen when those young people completed their training and need two-year intern posts plus one year of community service posts”.

Rispel stressed, “We need strong national leadership, the use of evidence, good human resource information systems, building of coalitions (given the diversity of stakeholders-from regulators to training institutions), learning from our mistakes, but also learning lessons from past successes. And we need stability. One cannot drive changes when there is such instability in senior leadership.”

Professor Eric Buch, CEO of the Colleges of Medicine of SA and Rispel’s deputy on the strategic workforce task team, told Medbrief Africa that there was simply not enough money.

“The reality is that the health budget as it stands is not sufficient to meet all aspirations in terms of a package of services and quality of care. Complex choices have to be made around staffing and resources. You have to apply what you have.”

“Before convincing Treasury to put more resources into health you first want to be sure you’re using existing resources to maximum capacity,” he said, adding that corruption in the sector and systemic weaknesses were failing to deliver “bang for buck.”.

Buch says there is sufficient data on the various patient conditions and “we know roughly how many different kinds of surgeries there are, and what physician and specialist care is needed. For example, a proportion of women in childbirth can be cared for by a midwife and physicians with C-section training. We also know how many patients need referral to an obstetrician/gynaecologist, so a needs framework is possible”.

Using the state sector Persal salary system, one of his task teams had come up with the innovative concept of using the third best performing province in each discipline as the national staffing benchmark.

“But you have to spend 14 years from the start of medical school training to become a specialist and 16 years to become a sub specialist, and we can only produce as many specialists as there are specialist training posts. There are simply not enough registrar training posts to meet the shortage of specialists in the country. There needs to be a dedicated fund to bridge that gap,” he asserted.

He warned that unless quick action was taken, the NHI would falter due to a lack of specialists. “It’s critical. But every bit as critical is creating a positive practice environment with sufficient nurses and high care capability,” he added.

He said RWOPS needed careful monitoring and evaluation to retain specialists in the public sector while ensuring they met their teaching and patient care responsibilities. Specialists in South Africa were prime targets for overseas recruitment.

“We need a national plan to deal with specialities into the future – some kind of body that brings together the Minister of Health, Higher Education and others, with a clear priority on how to bridge this gap, including broadening post graduate diplomas, active tuition and online learning,” he added.

The proposed WHO sustainable development goal threshold is 44.5 doctors, nurses, and midwives per 10,000 population. In Africa, the comparable average ratio is around 14 per 10,000. South Africa’s comparable average ratio tracks at slightly below 60 per 10,000.

This staffing ratio comes in the context of SA’s triple challenge of poverty, inequality, and unemployment, exacerbated by a quadruple burden of disease: the HIV & AIDS epidemic alongside a high burden of tuberculosis (TB); high maternal and child mortality; high levels of violence and injuries; and a growing burden of non-communicable diseases (NCDs).

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