Understanding and managing Health Worker migration and retention in South Africa

1. Understanding and managing Health Worker migration and retention in South Africa Gavin George Senior Researcher HEARD March 2012

2. Overview of the HR situation Brain Drain Role of HIV/AIDS Main HR Challenges Presentation Roadmap

3. HRH Crisis in Africa, 2006

4. 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 The health system in South Africa

5. Overview of HR in Africa

6. 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%) Current landscape in Africa

7. 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) Crisis in Africa’s Health Workforce

8. HRH shortages Source: WHO, 2004 (last update 26 Oct 2004)

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

11. Main Factors in the BD Process 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 • Migration within and outside Africa: Brain Drain • Insufficient capacity for policy planning, formulation & project implementation to achieve sustainable development • Lack of qualified professionals • Under utilization of skills

12. Traditional vs. Modern paths Traditional: 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 Major Characteristics of BD

13. Immigrants Admitted in the US in 2003 Nigeria 7,892 Kenya 3,216 Sudan 1,886 Ethiopia 6,643 Morocco 3,141 Liberia 1,768 Ghana 4,416 Somalia 2,448 Sierra Leone 1,496 Egypt 3,355 South Africa 2,220 Togo 1,188 African Diaspora in the US Source: 2002 Yearbook of Immigration Statistics

14. In countries of destination Additional manpower Partly offsets domestic shortages of professionals In countries of origin Loss of skills significant for development Dependency on foreign expertise Ex. African countries spend an estimated US$4 billion every year to employ about 100,000 non-African expatriates1 Development paradox Reduction of job & wealth creation capacity Slowdown of research & technological innovations Impacts of BD 1Selassie and Weiss, 2002

15. HIGH HIV Prev. Countries

16. Increased disease burden (OIs, incl. TB, Malaria?)  Increased demand for care More consultations More hospitalisations Longer hospital stays “crowding-out effects” Impact of AIDS on HRH

18. 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 Death from HIV – largest cause of attrition Source: WHO (2006). The World Health Report 2006 – Working Together for Health. Geneva, World Health Organization

19. 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 AIDS

20. 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 … Main HR Challenges

21. 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

22. Huge Regional Disparities in Medical Schools and Graduates

23. 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

24. Contact Details Gavin George georgeg@ukzn.ac.za

25. 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?