Backgrounder No. 31
In 2006, the World Health Organization (WHO) reported that 57 countries, most of them in Africa and Asia, face a severe health workforce crisis. They estimate that over 2 million health service providers and 1.8 million management support workers are needed to fill the gap (WHO, 2009). Meanwhile, the availability of human resources for health (HRH) has been positively correlated to improved health outcomes — as detailed in a study of 68 middle to low-income countries — and is especially paramount in the context of countries with a high-HIV burden, such as South Africa (Gupta, 2011: 1452). With HRH costs representing 65 to 70 percent of recurrent health expenditures in these countries (DOH, 2011:13), adequate planning and mitigating the impact of the HRH shortage is critical to meet the needs of the population.
Factors influencing the global health worker shortage echo the HRH situation in South Africa. Global skill imbalances, poor distribution of health workers and undesirable work environments are major impediments to appropriate service delivery (Chen, 2004: 1984-1990). With respect to skill imbalances, an emphasis on training of physicians rather than nurses, auxiliary health workers and community health workers (CHWS) has created dramatic shortages of staff. In South Africa, the closure of nursing colleges during the 1990s has led to a reduced number of nurses (Coovadia, 2009: 830).
There is also a poor distribution of resources between private and public sector health workers, and within the public sector. Physicians working in the private sector of South Africa’s health system rose from 40 percent (1980) to 79 percent (2007) leaving many clinics in the public sector without direct supervision from physicians (Coovadia, 2009: 830). The unbalanced distribution between urban and rural areas leaves South Africa’s rural dwellers (44 percent of total population) with only 19 percent of the country’s physicians and 12 percent of its nurses (Department of Health, 2011: 30). Large variations also exist in the distribution of HRH in the public sector with significant variation within and between sub-districts (Daviaud and Chopra, 2008: 48). The country’s health workforce is identified as having a weak knowledge base, as acknowledged in the national report “Human Resources for Health South Africa: Strategy for the Health Sector 2012/13-2016/17” (herein referred to as HRH SA 2012/13-2016/17) noting large inconsistencies between databases on number of public health sector employees with the margin of error being as high as 30 percent (Department of Health, 2011: 21).
Health worker migration is an issue which has gained international recognition in recent years. At the World Health Assembly in 2010, the “WHO Global Code of Practice on the International Recruitment of Health Personnel” was established in reaction to the issue. This document encourages ethical recruitment of health workers by member states “taking into account the right to the highest attainable standard of health of the population of source countries” with a focus on sustainability of health systems in developing countries (WHO, 2010). Migration of health workers is a major challenge for the South African health system. As noted by Pendelton et al (2007), “lack of posts in the public sector, HIV/AIDS, working conditions, workload in the public sector, workplace security, relationship with management, morale in the workplace, risk of contracting TB, and personal safety” are all factors affecting the attrition of South African health workers. Staff turnover rates are as high as 80 percent per year in some provinces (Department of Health, 2011: 59).
High rates of HIV/AIDS in South Africa has the effect of aggravating the human resource crisis by further depleting the workforce and causing increased demand for health services. The World Bank estimates that a country with 15 percent adult HIV prevalence can expect to lose up to 3.3 percent of its healthcare providers from HIV-related illness annually (Dreesch, 2005: 267). As of 2008 South Africa had approximately 5.7 million people living with HIV/AIDS, or nearly 12 percent of the population (WHO, 2008: 7). With 75 to 80 percent of the South African population dependent on public health care facilities (South African Health Review, 2010: 5), this sector must be strengthened to provide for the needs of the entire population.
The South African National Department of Health has released the 2012/13-2016/17 strategic plan that includes a balancing of short and long term goals, including the re-engineering of primary health care. Aspects of the plan include the provision of effective, evidence-based care; a supportive regulatory environment for HRH; equitable staffing; health workforce development; recruitment and retention of HRH; and, fostering an environment for clinical research. The part of the plan that addresses the re-engineering of primary health care (PHC) calls for attention on “maternal, child and women’s health, maintaining the HIV and AIDS focus and an emphasis on community-based and preventative health care” (Department of Health, 2011: 65).
The health workforce strategies to accomplish the re-engineering of PHC, as discussed in the strategic plan, include task shifting and the defining of new roles of HRH, such as enrolled nurses and pharmacy assistants. Under these new role definitions, the 65,000 community-based health workers currently in the country will now be formally recognized as part of the PHC team. Additional graduates are still needed in the nursing profession with an emphasis on training professionals and advanced midwives, as well as reorienting existing nurses towards PHC. With respect to the clinical specialist teams, there are insufficient numbers of trained staff and, of those available, there is a need to re-orient their work within a multi-level, PHC team. Pharmacy assistants, lay counselors, health promoters and rehabilitation assistants all need to be identified and trained. The government has created the National Department of Health Workforce Model to estimate the HRH needs for this strategy. Although the quality of the data entered in the model must be verified for accuracy, it predicts that the gap in the HRH shortage can be mitigated within the next 15 to 25 years and benchmarks have been set to reach this goal.
The 2012/13-2016/17 policy is ambitious and addresses many of the pressing health needs of the South African population. Balancing short-term plans with long-term strategies for training more health workers is a welcome and essential approach to addressing HRH shortages. Referral systems among PHC teams and managers with those in other areas of the health system will be important in the success of the policy. Concerted efforts between the ministries of education and health will be necessary to develop the workforce required to implement the strategy. An accurate tracking system will be needed to quantify the number and geographic distribution of employees within the system. Finally, taking steps to making the health workplace a safer and more inviting work environment will assist in the retention of the current workforce. Actors in other health systems, especially those in high HIV-burden, low-resource countries, may be able to learn from the forthcoming experience of implementing the strategy in South Africa.
Biesma, R.G. et al (2009). “The effects of global health initiatives on country health systems: a review of the evidence from HIV/AIDS control.” Health policy and planning 24 (4): 239.
Chen L, Evans T, Anand S, Boufford JI, Brown H, Chowdhury M, et al (2004). “Human resources for health: overcoming the crisis.” The Lancet. 364, 1984–1990.
Chopra M, Daviaud E, Pattinson R, Fonn S, Lawn JE (2009). “Saving the lives of South Africa’s mothers, babies, and children: can the health system deliver?” 2009: Lancet 374: 835–846.
Chopra M, Lawn JE, Sanders D, et al (2009). “Achieving the health Millennium Development Goals for South Africa: challenges and priorities.” The Lancet 374: 1023-1031.
Coovadia, H, Jewkes R, Barron p, Sanders D, Mc Intyre D (2009). The health and the health system of South Africa: historical roots of current public health challenges. The Lancet 374: 835–846
Daviaud E, Chopra M (2008). “How much is not enough? Human resources requirements for primary health care: a case study from South Africa.” Bulletin of the World Health Organization 86:46–51.
Department of Health, South Africa (2011). Human Resources for Health South Africa: Strategy for the Health Sector 2012/13-2016/17. Available at: www.rhap.org.za/wp.../Abridged_Final_HRH_Strategy-2011.pdf
Dreesch, N. et al (2005). “An approach to estimating human resource requirements to achieve the Millennium Development Goals.” Health policy and planning 20: 267.
Gupta N, Maliqi B, França A, Nyonator F, Pate MA, Sanders D, et al (2011). “Human resources for maternal, newborn and child health: from measurement and planning to performance for improved health outcomes.” Human Resources for Health 9: 16.
McCoy D, Chopra M, Loewenson R, Aitken JM, Ngulube T, Muula A, et al (2005). “Expanding access to antiretroviral therapy in sub-Saharan Africa: avoiding the pitfalls and dangers, capitalizing on the opportunities.” American Journal of Public Health 95: 18.
Pendelton W and Crush, J (2007). The Haemmorrhage of Health Professionals from South Africa: Medical Opinions. Available at: www.idasa.org/media/uploads/outputs/files/samp47prelimsweb.pdf
Pillay, Yogan, Barron P (2011). The implementation of PHC re-engineering in South Africa Available from: http://www.phasa.org.za/wp-content/uploads/2011/11/Pillay-The-implementa...
Scheffler, R.M. et al. “Forecasting the global shortage of physicians: an economic-and needs-based approach.” Bulletin of the World Health Organization 86: 516-523.
Schneider H, Blaauw D, Gilson L, Chabikuli N, Goudge J (2006). “Health systems and access to antiretroviral drugs for HIV in Southern Africa: service delivery and human resources challenges.” Reproductive Health Matters 14: 12–23.
Tobi P, George G, Schmidt E, Renton A (2008). “Antiretroviral treatment and the health workforce in South Africa: how have ART workers been affected by scaling up?” Tropical Medicine & International Health 13: 1452–8.
World Health Organization (2009). Towards Universal Access: Scaling up priority HIV/AIDS interventions in the health sector: progress report 2009. WHO Press.
UNAIDS/WHO (2008). Epidemiological fact sheets on HIV and AIDS: Core data on epidemiology and response, South Africa. Available at: http://apps.who.int/globalatlas/predefinedReports/EFS2008/full/EFS2008_Z....
Wouters E, Heunis C, Ponnet K, et al (2010). “Who is accessing public-sector anti-retroviral treatment in the Free State, South Africa? An exploratory study of the first three years of programme implementation.” BMC Public Health 10: 387.