Understanding and managing Health Worker migration and

retention in South Africa

Gavin GeorgeSenior Researcher

HEARDMarch 2012

Presentation Roadmap

• Overview of the HR situation • Brain Drain• Role of HIV/AIDS• Main HR Challenges

3

HRH Crisis in Africa, 2006

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

BrainDrain

MD ratio

The health system in South Africa• South Africa’s private sector employs half of the country’s nurses and 2/3rds of its

doctors. The shortage of nurses has grown substantially worse between 2000 and 2005. The number of enrolled nurses has dropped from 60 per 100 000 to 52 per 100 000 and the number of professional nurses has dropped from 120 per 100 000 to 109 per 100 000.

• Although the supply of health care workers in South Africa is arguably not an acute problem, unequal distribution between the private and public sectors and between urban and rural areas- due to low salaries and poor working conditions- combine to create a crisis.

• South Africa is both a destination and source of skilled workers. While an estimated 5,000 doctors have moved from South Africa to the US, UK, Canada, and Australia, South Africa has become a destination for health professionals in its own right

• Migration is not solely responsible for the shortages but it is an active factor with 35,000 registered nurses inactive or unemployed, despite 32,000 vacancies in the public sector

• Rural areas account for 46 percent of the population, but only 12 percent of doctors and 19 percent of nurses

Overview of HR in Africa

Current landscape in Africa

• Africa's share of the world's population (13.8%)

• Africa's share of the world's disease burden (25%)

• Africa's share of the world's health workforce (1.3%)

Crisis in Africa’s Health Workforce

• Africa has 25% of the world’s disease burden, 13.8% of the world’s population, but only 1.3 % of the world’s health workforce (Source: WHO)

• Joint Learning Initiative estimate: 600,000 doctors, nurses, and midwives now; 1 million more needed to achieve Millennium Development Goals– This is needed to achieve a health worker density of 250

doctors, nurses, and midwives per 100,000 population– In contrast, the U.S. and Europe have more than 1,000

doctors, nurses, and midwives per 100,000 population (Source: WHO)

Countries Nurses per 100 000 population

Physicians per 100 000 population

South Africa 388 69Swaziland 320 17Botswana 241 28Zimbabwe 54 15Zambia 113 7Malawi 25 1Mozambique 20 2Belgium 1074 418UK 496 166USA 772 549

Source: WHO, 2004 (last update 26 Oct 2004)

HRH shortages

Causes to the Health Workforce Crisis – Brain Drain (BD)

Training institutions

Public sector

Private-not-for-profit sector:NGOs - missions

Private-for-profit sector

Attritiondue to illness, death, retirement,

work in other sectors ...

Abroadpublic & private health facilities

Rural facilities

Management & Admin

MoH

Urban facilities

Flows in health labour market(using a country-perspective)

International organisations

OverallHRH shortages

Internal brain drain

Externalbrain drain

Maldistribution

Main Factors in the BD Process

Insufficient capacity for policy

planning, formulation &

project implementation to

achieve sustainable

development

Migration within and outside Africa:

Brain Drain

Push Factors Poverty

Lack of opportunity Unemployment Bad governance

Political instability Conflicts

Pull Factors Higher salaries

Higher Education Professional career

dev’t Higher standard of

living Fewer bureaucratic

controls

Lack of qualified professionals

Under utilization of skills

Major Characteristics of BD

Traditional vs. Modern pathsTraditional: From Africa to former colonial powers

Ex: West & North Africa to France, Anglophone Africa to UK, Great Lakes region to Belgium

Modern: Intra-Africa, to Middle East, Asia or Latin America

African Diaspora in the US

Source: 2002 Yearbook of Immigration Statistics

Nigeria 7,892

Ethiopia 6,643

Ghana 4,416

Egypt 3,355

Kenya 3,216

Morocco 3,141

Somalia 2,448

South Africa 2,220

Sudan 1,886

Liberia 1,768

Sierra Leone 1,496

Togo 1,188

Immigrants Admitted in the US in 2003

In countries of destinationAdditional manpowerPartly offsets domestic shortages of professionals

In countries of originLoss of skills significant for developmentDependency on foreign expertise

Ex. African countries spend an estimated US$4 billion every year to employ about 100,000 non-African expatriates1

Development paradoxReduction of job & wealth creation capacitySlowdown of research & technological innovations

Impacts of BD

1Selassie and Weiss, 2002

HIGH HIV Prev. Countries

Impact of AIDS on HRH

Increased disease burden (OIs, incl. TB, Malaria?)

Increased demand for careMore consultations More hospitalisationsLonger hospital stays

“crowding-out effects”

PLWHAs per medical doctor

PLWHAs per nurse

Malawi 7,435 286Mozambique 3,446 328Zimbabwe 2,337 260Tanzania 2,164 117Rwanda 1,490 142Zambia 1,216 75Swaziland 1,135 64Botswana 676 81Uganda 397 37South Africa 171 30Cambodia 75 20Thailand 30 6Brazil 2 7

Death from HIV – largest cause of attrition

• Death from HIV – largest cause of attrition• Zambia:

- 1980: 2 nurses out of 1000 died- 2001: 27 nurses out of 1000 died

• Botswana:- 1999-2005: 17% of health workforce died- 1999-2010: 40% of health workforce will die (projection if no action)

• HIV prevalence = 15% up to 33 % loss of health workers in 10 years

Source: WHO (2006). The World Health Report 2006 – Working Together for Health. Geneva, World Health Organization

AIDS Increased health worker

attrition & absenteeism Health workers our dying

from AIDS

Increased absenteeism due to own illness

illness of family members

funerals

Consequences for the remaining carers

• Increased workload• Compelled to work longer

hours, see more patients, assume more tasks “Burn-out”

• Workplace security (perceived?) risk of HIV infection

Main HR Challenges• Insufficient quantity,• Inadequate quality,• Uneven distribution,• Poor salaries,• Harsh working conditions,• HIV/AIDS,• Poor supervision capacity,• Low motivation,• High absenteeism,

• High attrition rates,• Low enrollment,• Brain-drain,• Inadequate training• Lengthy training,• Health Sect. reform,• Vertical programmes,• Inadequate HR intelligence,• Low HR planning capacity,• Low HR management capacity …

The HRH Crisis two problems

• Lack of HRH production (pre-service)– Lack of infrastructure– Need~$200- million*

• Home/Work environment leads to high attrition– Lack of Proper Housing– Need ~$300-600 million*

* Within the SADC region, not including RSA

21

Huge Regional Disparities inMedical Schools and Graduates

Summing Up• Muddle through with MDs, bet on nurses and

midwives• Foreign Assistance can help to bridge the

funding gap for pre-service training and retention/housing of current work force

• African countries need an investment plan– How to mobilize resources for the construction to

meet infrastructure gap

23

Contact DetailsGavin George

georgeg@ukzn.ac.za

1) What initiatives are effective in stemming the Brain Drain? 2) Does the production of health workers meet the need? What is

required to increase the production of health workers? Will the Fiscus allow for the absorption of these health workers into the public health sector?

3) Which HWs do we really need? Which cadres of HWs should we

therefore be investing in? Which tasks/functions can be shifted to available HWs?