Healthcare skills shortage a global phenomenon
The shortage of healthcare professionals in South Africa is one of the biggest threats to the country’s ambition to eventually roll-out equitable universal access to healthcare for all its citizens.
But the dearth of suitably qualified and experienced healthcare professionals is one of the biggest challenges facing the healthcare industry worldwide, not just in South Africa or in other developing countries.
The root cause of the shortage is the same that is helping push up healthcare costs. Ageing populations in developed countries, and improving life expectancy in emerging markets and developing economies, drive the increase in demand for healthcare services.
The United States has an estimated shortage of about 16 000 primary healthcare doctors, while half of the 830 000 who are currently in practice are over 50 and approaching retirement, which suggests a looming crunch.
The United Kingdom, a key destination for South African nurses, had an estimated shortage of 40 000 nurses in 2012.
In Africa, about 36 countries have inadequate staff and facilities to deliver even the most basic immunisation and maternal health services, with the greatest need being in sub-Saharan Africa, where a 140% increase in the health workforce is required to meet the population’s needs.
The health worker density in most sub-Saharan countries is well below the WHO threshold of 2.3 physicians, nurses and midwives for every 1,000 people. This is considered to be the minimum number of healthcare workers required to deliver essential health services.
Although South Africa has a higher ratio of healthcare workers per 10 000 population, at 4,85 - which is considered to be as critical as the shortage experienced by most other African countries - the country still lags its BRICS peers, all of whom have much larger populations on this measure.
The rural urban divide in South Africa is an ever present reality. Some 43.6% of the South African population live in rural areas but are only served by 12% of the doctors and 19% of nurses; this is according to the Department of Health. Some parts of rural South Africa have 14 times fewer doctors than the national average. In addition, they suffer a higher infant mortality rate of 52.6 per 1,000 live births versus 32.6 in urban areas.
The migration of healthcare workers is another challenge contributing to South Africa’s shortage of healthcare workers. Many African, Caribbean and Asian countries are unwilling exporters of health workers. Their migratory streams are not necessarily supported by national health policy and are driven largely by global labour market forces.
But the international mobility of health workers is not a recent phenomenon. Migration is generally attributed to a combination of “push” from within the sender countries, as well as “pull” from the host countries. The challenge for South Africa is to make the country attractive for healthcare workers to want to stay - because staff shortage translates into both a decline in the quality of care and poor health outcomes.
South Africa, which is affected by migration of health workers, is not the worst hit. India, Nigeria and Pakistan are three countries with critical healthcare staff shortages yet occupy the Top 25 of countries whose doctors, nurses and pharmacists migrate to other countries.
The loss of healthcare workers is acutely felt in a country like South Africa. In health facilities already faced with staff shortages and unfilled vacancies, the migration of existing staff adds to the workload of those who remain, increasing their caseloads and leading to fatigue, loss of motivation and eventual burnout. These pressures provide an impetus for remaining workers to themselves migrate out, extending the vicious spiral.
South Africa is one of the countries that have the means and an opportunity to retain its healthcare professionals within the system and stem the brain drain. The country can take a number of steps to improve the supply of healthcare workers and motivate the professionals to stay in the industry, especially the public health system, and develop their careers.
The attraction and retention of professionals into any sector is driven by the investment the sector can attract, and healthcare is no exception. The sector needs to attract local and foreign investment to hold onto its brightest and best. Otherwise doctors simply pursue MBAs and move into business instead of treating patients.
The maxim that nursing is not a profession, but a calling may be true, but passion alone will not keep nurses, neither will a frequently rising pay that is not matched by improving working conditions.
Healthcare professionals are also motivated by hygiene factors: the ability to do their jobs well using the latest equipment and best practices, exposure to research and development and working with the best minds in their chosen fields - whether a renowned expert spends time at a local facility or a small group is sponsored to travel to a centre of excellence elsewhere In the world.
A short term measure that can help remedy the shortage is the reform of the immigration system which allows hospitals to bring in skilled foreign workers. The process is currently cumbersome and reform is politically unpalatable in the face of high unemployment.
But that view is dangerous and mistaken. Unemployment currently affects the semi-skilled and unskilled while senior and specialist posts have an acute shortage. The two have to be separated.
The next step is to improve the professional’s value proposition and deploy professionals effectively. For example the work of pharmacists can be aided by improvement of disease management protocol and freeing them from administration such as counting pills, to allow pharmacists to spend more time consulting with patients. Pharmacists can also benefit from the use of technology such as robotic dispensers, which again frees them up to offer advice and face-time with patients.
The long term intervention is the improvement of the education system, specifically maths and sciences, as well training institutions. The sector also needs to maintain it’s on-the-job training programme that offers accelerated growth.
There is no panacea to cure the ills of skills shortage, but a series of short and long term measures can help to address the problem.
Rudish is the Global Head of Healthcare at Deloitte, based in the United Sates. Adao is the Head of Healthcare and Life Sciences at Deloitte in South Africa. Varndell is a Senior Manager in Deloitte Healthcare and Life Sciences.