Kerry Cullinan and Anso Thom
Although Health Minister Dr Manto Tshabalala-Mimang promised
that a national human resource plan to address the critical
shortage of health workers would be released by the end of
March, there is still no sign of it. In addition, key
stakeholders, the Democratic Nurses Organisation of SA (Denosa)
and the National Education, Health and Allied Workers Union (Nehawu)
say that they have not been consulted about the plan. However,
the South African Medical Association (SAMA) which represents
doctors has been consulted, fueling fears from the other unions
that the plan will be doctor-oriented.
SAMA president Dr Kgosi Letlape said his organization had
been involved in workshops with the health department and was
optimistic that the [plan] will address working
conditions. We were very encouraged by the process and was
waiting for the final plan to be tabled, said Letlape.
However, Denosas general secretary, Thembeka Gwagwa, said her
organization had not been consulted about the plan. By the
time they are willing to negotiate with us, there may not be any
nurses left in the public sector, said Gwagwa. Moloantoa
Molabe, national spokesperson for Nehawu, said that his union
had not been consulted on the plan, and cautioned that human
resources in the health sector was not a matter that could be
decided technocractically. There are many stakeholders
who have views based on their experience in the sector and have
a lot to contribute. To not include us would be inappropriate
and could undermine whatever is produced, said Molabe.
The Health departments chief director for human resources,
Dr Percy Mahlati, is the driving force behind the plan. A former
chief of SAMA, Mahlati joined the department a year ago and was
handed the hot potato of salvaging the human resource sector
which is widely acknowledged to be in crisis. Sometimes it
feels like it is all too much, but we have one chance to get
this right. We cant get it wrong. We now need to correct
those things that have been overlooked for many decades, says
Mahlati. Despite Health-e having been promised a copy of the
plan more than two weeks ago, at the time of going to press the
health department simply said: The HR plan is in the process
of being developed.
A source close to the process said that the release of the
plan had been delayed as the Health Minister had yet to sign it
off. The biggest frustration is that things are desperately
urgent, but the process is proceeding at a pace of business as
usual even though it has got worse over the past two to three
years, said Dr Uta Lehman, a human resources expert based at
the University of the Western Cape. Speaking from his sparsely
furnished Pretoria office, Mahlati was not prepared to be drawn
on the contents of the plan until it has been seen and signed by
the Minister of Health (Formulating) the human resources plan
is a daunting task. But I see it as a challenge. On a personal
level it is an opportunity to correct the things that I saw in
the early eighties and nineties while working as a GP in
Khayelitsha, Mahlati said during an interview last month.
One of the things the plan is supposed to do is set norms and
standards for doctor-patient and nurse-patient ratios.
Tshabalala-Msimang acknowledged in her Budget speech earlier
this year that the single most critical resource in our
ability to deliver on our health objectives is the availability
and capacity of health personnel. She went on to say that
various interventions were being made to address particularly
the supply and distribution of health personnel in the country
and mitigate the impact of outwards migration of health skills.
Figures from 2001 show that as many as 3 500 South African
health professionals were working in Australia, 2 360 in Canada,
1 600 in New Zealand, 9 000 in the United Kingdom and 7 000 in
the United States. Vacancy figures for 2003 in the public health
sector compiled by the Health Systems Trust reveal a bleak
picture in most of the provinces.
A staggering 67% of posts in Mpumalanga were vacant, 41% in
the Free State, 33% in the NorthWest, 32% in Gauteng, 28% in the
Eastern Cape, 27% in the Northern Cape, 25% in KwaZulu-Natal,
13% in Limpopo and 14% in the Western Cape. Indications are that
the situation has worsened with reports that posts advertised in
provinces such as the Eastern Cape receiving zero applications.
Mahlati acknowledged that he was worried about all the provinces
for different reasons. In the rural provinces we are finding
it difficult to attract professionals, while Gauteng and the
Western Cape are losing high end skills. However Nehawus
secretary general Fikile Majola says part of the reason why
people are not going to rural areas is because working
conditions are unattractive.
We need to ensure that in the rural areas we dont only
have staff, but there is equipment and medicines, said
Majola. Wed need to create working conditions that can
retain and attract health personnel in those areas. I dont
think theres an aggressive enough strategy to address that at
the moment. Mahlati pointed out that the plan would enable
the department to develop a system which would in turn inform
them whether enough health professionals are being produced by
the academic institutions and other training facilities. He
acknowledged that the bi-lateral agreement with the United
Kingdom around poaching of personnel could not be implemented
fully until details in the Human Resources Plan are released.
Mahlati said it was too early to produce firm evidence whether
the scarce skills and rural allowances introduced in 2004 were
having the desired impact.
However, preliminary research conducted by the University of
KwaZulu-Natals Professor Steve Reid soon after the allowances
were introduced indicated that they had made an impact. Almost
one-third of health professionals in rural areas said that they
had changed their career plans the following year as a result of
the new allowance. Senior advisor at the Health Systems Trust Dr
Peter Barron predicted further problems with the introduction of
the district health system which will see provinces having to
pick up salary tabs previously paid by the metros. Metros
have been paying higher salaries and provinces will not be able
to continue, he pointed out. Barron said nurses were taking
the brunt of the confusion around the district health system,
further compounded by the burden of HIV.
Lehman and Professor David Sanders, also of the University of
the Western Cape, say that while there has always been
recognition that human resources play an important role in the
transformation of the health system, some would argue that human
resource development has not received the attention it deserves
and requires. Historically, the distribution of health personnel
in the country has been highly inequitable, skewed in favour of
the private sector, the richest provinces and urban areas.
Access to educational opportunities to train as health
professionals is equally inequitable, while education and
training are inadequate and often inappropriate
Ten things that can be done in the short term to improve
the human resources situation in the public sector.
- Move urgently to convene a health sector summit to ensure
that all the role-players agree on a Human Resources plan
that everybody can buy into.
- Review the remuneration of health personnel, especially
nurses, bringing it up to a reasonably competitive level.
- Strengthen bi-lateral agreements with countries such as
the United Kingdom to try and stem the migration of
- Allow senior nurses who have been working overseas to
return to South Africa and enter the public sector at the
same level. Currently, returning senior nurses have to start
at the bottom and work as juniors.
- Strengthen the training and support for the lower level
workers, relieving the pressure on professional staff. At
the same time speed up the introduction of new mid-level
- Care for the carers. Put good supervision and support
systems in place that will give frontline staff a sense of
being looked after.
- Intensify the training around HIV and AIDS at primary
health care level where staff feel overwhelmed and not
competent to deal with some of the issues related to the
- Urgently put structures in place to strengthen the
interface between the departments of health and education,
both centrally involved in health personnel education.
- Sharpen the primary health care skills of general
practitioners in the private sector, encouraging them to
work on a sessional basis in the public sector, especially
in the rural areas.
- Urgently address the upgrading of infrastructure at
(Source: Health-e, May 18, 2005)