The 2003/4 South African Health Review shows that the exodus of skilled health personnel has been substantial – 600 South African doctors are registered to practice in New Zealand while 10% of Canada’€™s hospital based physicians and 6% of hospital-based doctors in the United Kingdom are South African.

The SA Health Review is an annual report on the state of the nation’s health produced by the non-governmental organisation Health Systems Trust. The report was launched by the Health Minister, Dr Manto Tshabalala-Msimang, in Cape Town last night (28 July).

By far the most significant component of any health system is its health personnel. Without a foundation of skilled human resources, healthcare systems cannot function adequately or effectively, particularly in the public sector and at the primary level of care.

South Africa faces a number of health personnel problems. These include an overall lack of staff in key areas of the health sector; an inequitable distribution of those health personnel who are available and a significant erosion of trained personnel from the health sector and from the country.

Head of the School of Public Health at the University of the Western Cape, Professor David Saunders has stated on several occasions that the biggest problem in the South African healthcare system was implementing the good policies that have been formulated over the years.

‘€œThe reason why there is this huge gap (between policy and implementation) is the lack of capacity of human resources at all levels. When we say the health systems are not functioning it is because the human resources are not functioning,’€ says Saunders.

The human resources factor is even more critical in the face of the local AIDS epidemic. South Africa’€™s Operational Plan for Comprehensive HIV and AIDS Care, Management and Treatment will continue to come unstuck unless this crucial element is addressed and professionals are attracted into the health system.

The Review also cautions that AIDS related mortality, burnout and work overload will result in the continued loss of health staff.

Nationally, the percentage of vacant public sector posts was reduced from 57 percent in 2001 to 31 percent in 2003. However, during this same period, the actual number of public sector posts was reduced from 268 122 to 169 121, of which 116 547 were filled in 2003.

According to the Health Review, only the Western Cape and Limpopo have less than 20 percent of their posts vacant. The situation in Mpumalanga is described as dire with more than two thirds of posts empty.

Ashnie Padarath, Antoinette Ntuli and Lee Berthiaume, authors of the Human Resources chapter in the Health Review, point out that there are some good news stories from southern Africa of health systems improving their performance. This has happened when there have been improvements in the deployment and orientation of health personnel to deal with major health problems as well as improving the effective use of staff time.

South Africa is often used as an example of a country with stark inequities between the haves and the have nots and nowhere is it more clear than in the healthcare sector and more specifically in the distribution of health personnel.

In South Africa, the greatest imbalance in personnel distribution is between the private and public sectors. Private health services consume 58 percent of total health expenditure and capture a higher proportion of all types of personnel (except nurses) than the public sector.

In 1998, 52,7 percent of all general practitioners and 76 percent of all specialists worked in the private sector. By 1999, 73 percent of all general practitioners were estimated to be working in the private sector in SA, despite the fact that this sector catered for less than 20 percent of the population.

There is also a significant imbalance between rural and urban areas. Compounding factors such as poor infrastructure, inadequate facilities and lack of appropriate housing and schooling in rural areas exacerbate this.

Despite its critical importance, the Health Review reveals that human resources for health in SA has been a relatively under-resourced and understudied area within the National Department of Health.

Although the shortages are across the board, the most critical is in the nursing sector. It is estimated that even with recruitment to address the 25 percent vacancy rate in the public sector, there will be a shortfall of almost 19 000 nurses by 2011.

Government has taken several policy measures to try and turn the tide in the health personnel sector.

One option, that of recruiting health professionals from outside South Africa, is complicated. The country’€™s official policy on the recruitment and employment of foreign health professionals expressly states that such initiatives are designed to recruit workers to underserved, mostly rural areas where there are little if any schools and houses for the professional.

The health department policy also states that no doctors may be recruited from developing countries, especially the Southern African Development Community.

The department has implemented community service as well as rural and scarce skills allowances in the hope of attracting staff to under-resourced areas. Community service for doctors was introduced six years ago and was subsequently extended to dentists, pharmacists, physiotherapists, occupational and speech therapists, clinical psychologists, dieticians, radiographers and environmental health practitioners. The new Nursing Bill makes provision for the introduction of community service for nurses for a period of one year before they can be registered with the SA Nursing Council.

According to the Health Review community service has had limited success in increasing the supply of personnel in under-served areas. Various problems have arisen including students opting for urban rather than rural placements where there is greatest need. The absence of supervision has also been a problem ‘€“ in some hospitals the community service doctor reportedly ends up as the only doctor. One study found that between 20 and 45% of all community service practitioners were planning on working overseas after completion of their time.

The objective of the recently introduced rural and scarce skills allowances is to attract and retain health professionals in the public health sector. However, several of the most under resourced provinces have complained that they have not received their fair share of the budget cake (R500-m set aside for 2004 and R750-m for 2005).

The National Health Bill goes some way towards creating an enabling framework within which to address the production, retention and distribution of human resources in the health sector. However, the authors caution that care must be taken to ensure that policies do not simply reinforce existing inequities, especially between rural and urban areas.

The proposed Act also makes provision for a certificate of need to be issued before any health establishment (ranging from a large hospital to a private medical practice) is opened, extended or expanded. There has been resistance to implementing the certificate in South Africa, but it is a tool that has been successfully implemented in many countries.

Those opposed to the move claim that the certificate will have the effect of driving doctors away and will aggravate the existing brain drain in the country.

However, all these actions are by enlarge piecemeal interventions and the Health Review calls for a ‘€œcomprehensive human resources for health strategy’€ that would address the wide spectrum of issues that impact on the production, retention and distribution of human resources.

E-mail Anso Thom