Section B!!

Section B Part A a In 2004 one of the most important measures introduced to combat the problem was the Scarce Skills Allowance. This consists of a 15% allowance for healthcare workers. Furthermore, an additional allowance of 18-22% was given to doctors working in the public sector. This allowance acknowledges the presence of shortage and acts as a deterrent against emigration of health professionals. Since 1998, doctors, pharmacists and dentists having just finished their internship must carry out a paid year of community service. Health systems in rural areas depend greatly upon the intake of young doctors. A 3-year training period was imposed as well as the internship in whatever district the student has matriculated in. This, in addition to passing a medical exam and approval by a supervising doctor, must be completed to be a certified physician.(1) The department of Health has been using

another approach to try meeting the need for healthcare workers: Bring in practitioners from Cuba. Cuba is known to have a high rate of doctor-to-population (about 59 to 10,000 compared to 6.7 to 10,000 in South Africa). The Government has also financed the South African Network of Skills Abroad’s (SANSA) project to help expatriates returning to South Africa. Scholarship plans are being explored by the Government to decrease brain drain. In this plan, graduates are given financial support for their education but will need to work in their country after they graduate(2). b) The HIV pandemic contributes to the problem. It is estimated that 16% of the health worker force is HIV positive(3). Late detection of HIV due to inadequate facilities often eventually leads to death. Barriers such as stigmatization and confidentiality in health service provision must be taken into consideration. Nonetheless, there are some exemplary staff care programs being initiated such as at McCord Hospital in Durban and Mseleni Hospital in northern KwaZulu-

Natal. In McCord Hospital, free healthcare is provided for the staff (4). Staff morale is also increased via support groups addressing emotional burden of caring for dying patients(4). As for the Mseleni Hospital, Antiretroviral therapy (ART) for staff has been free since 2005(2). A self-declared HIV positive lay counselor receiving ART is involved in counseling and testing of staff. These hospitals have shown good initiatives in providing well-managed in-house programs for medical staff. However, the implementation of such programs faces challenges, as the prevalence of HIV among health workers is not well known. The health system must take measures to protect health workers from occupational exposure to HIV and TB to improve health worker retention and job satisfaction (5). Non-governmental, faith-based and communitybased organizations stepped up to combat the shortage, too. As well as employees, volunteers are recruited from for-profit business employee volunteer programs, developed recently (6). Approximately 60 000 to 80 000 non-profit organizations have projects in South Africa today (6). Unfortunately, some areas rely predominantly on such organizations. Examples include the role of nonprofit organizations in palliative care, and faith based organizations, like the Salvation Army, in the care of people infected with HIV and AIDS. Supplementing this, the Catholic Church, operate three hospitals, 32 public health care clinics, and many hospices and

day centers (6). In addition, 200,000 traditional healers participate in the country's healthcare; playing an important role in the field of psychology and mental well-being. Moreover, there are selfemployed health care providers in all fields of medicine that meet the primary care needs of 7.1 million South Africans for a fee (6). The African Health Placements is a donor and corporate-funded project aimed at addressing health worker shortages in the public sector. This project recruits foreign healthcare workers from developed countries and South African qualified workers moving from private to public sectors (6).

SECTION B PART 2 A study by the Centre of Rural Health, University of Kwazulu-Natal collected two sets of data from 159 hospitals on November 2003, and May 2004, two months after implementation of the Rural Allowance and Scarce Skills Allowance. The majority of respondents (51%) stated that the new RA influenced them to work in rural areas (7). The findings suggest that the allowances attracted more health personnel to work in a rural setting, combating shortages in rural areas. In the first survey, finance was the primary factor for respondents’ choice of site of practice; however, in the second survey it

was the third considered factor behind career opportunities and job satisfaction.

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Many communities in South Africa have become dependant on the one-year compulsory community work of doctors. Although they compensate somewhat for the shortage of HCW’s, there is sometimes no supervision and support of junior doctors, and due to inexperience they rely too much on tests rather than diagnostic skills.8 Although the plan was introduced to consolidate social solidarity and decrease brain drain, the number of doctors planning to work overseas increased from 34% in 1999 (when the compulsory community service was introduced) to 43% in 2001, showing the limited success of the scheme.9 Forcing prospective doctors to stay an additional year does not solve the problem underlying the shortage in their numbers. It merely prolongs the inexorable. To eradicate this national affliction, short term, temporary solutions must be disregarded and replaced by a focus on making long-term changes. (1) The World Organization of Family Doctors (WONCA) in 2002 recommended recipient

countries of health care emigration pay compensation, a “brain drain tax” to the country of origin, making recruitment more costly, thereby discouraging it. Compensation received could then be ploughed back into the health system, into the recruitment of more homegrown doctors and medical equipment. Problems with this theory would be distribution of compensation and administrative problems, accused of corruption (10) Strenghts1-Scarce Skills Allowance and Rural Allowance, financial incentive to remain in the country 2-Compulsory Community Service and Scholarships, prevent graduates from leaving the country early. 3-Recruitment of Foreign Workers Weakness1-Compulsory Community Service, workers education undermined. 2-Technologically, infrastructural, and salary-wise. South Africa is still not on par with Western healthcare systems. 3. 1. Tshabalala-Msimang, Manto. Programme to Address Shortage of Doctors. 2004 April 1. [cited 09 October 27]. Available from: http://www.healthlink.org.za/news/20040330

2. Department of labour South Africa. The shortage of medical doctors in South Africa [Internet]. South Africa; 2007 [cited 2009 Nov 19]. Available from: http://www.uif.gov.za/downloads/documents/researchdocuments/Medical%20Doctors_DoL_Report.pdf 1 3. Health Gap, UGCH, AMSA [document on the Internet]. Healthcare Worker Shortage Crisis in Africa: Fact Sheet [updated 2007, cited 9/10/2009] Available from http://www.healthgap.org/hcw/documents/HealthcareWorker ShortageFact_Sheet_UCGH.pdf 4. Uebel KE, Nash J, Avalos A. Caring for the Caregivers: Models of HIV/AIDS Care and Treatment Provision for Health Care Workers in Southern Africa. The Journal of Infectious Diseases. 2007; 196, S3. 5. The World Bank [webpage]. Where HIV/AIDS and Africa’s Health Worker Shortage Meet. [updated 2009, cited 1 Nov 2009]. Available from http://web.worldbank.org/WBSITE/EXTERNAL/NEWS/0,,conten tMDK:21861007~menuPK:34457~pagePK:34370~piPK:3442 4~theSitePK:4607,00.html

6. Schaay N, Sanders D. International Perspective on Primary Health Care Over the Past 30 Years. In: Barron P, Roma-Reardon J, editors. South African health review 2008. Durban: Health Systems Trust; 2008. p. 223-36 Available from: http://www.hst.org.za/publications/841 Reid S. “Monitoring the effect of the new rural allowance for health professionals” Durban: Healh Systems Trust; 11/2004; Cited 13/11/2009 Available from: http://www.healthlink.org.za/publications/643 7

Anthony Zabarowski “Community Service in an urban hospital” Durban: Health Systems Trust. 11/2000; Cited 13/11/2009 8

Reid S ‘Community Service for Health Professionals’ In P Ijumba, A Ntuli, P Barron (editors), South African Health Review 2002. Health Systems Trust, Durban Cited 16/11/2009 9

Padarath, Ashnie ‘Health Personnel in South Africa: Confronting maldistribution and brain drain’ EQUINET. 2003. Cited 16/10/2009 10