The backdrop to the participation of nurses in particular in the strike needs to be considered. Since the early 1990s several policies have impacted on nursing in South Africa. Firstly the move towards rendering primary health care relies more extensively on nurses as the main service provider, and has resulted in nurses taking on more responsibility for managing and providing health services. Increased access and utilisation of health services as a result of the provision of free health care for pregnant women and children and other improvements in access, has in some areas also increased the workload of nurses.
The increasing burden of disease due to HIV and TB, and the range of new interventions to prevent and treat HIV and AIDS have further impacted on nurses' work. The new HIV & AIDS and STI Strategic Plan for South Africa 2007 -2011, will further rely on task shifting of functions of other health professionals in short supply (doctors, pharmacists) to nurses in order to ensure that the health system is able to meet the demands for prevention and care. The policy and regulatory framework for this is, however, still to be finalised.
Nurses also increasingly have to manage new categories of lay health workers and mid level health workers. These categories are intended to relieve the pressure on nurses, but also present new responsibilities and challenges in terms of the management and supervisory roles of nurses.
Whilst the scope of work and levels of responsibility of nurses has expanded, the availability of nurses to undertake these new roles and work load has diminished. Firstly, the rationalisation of nursing colleges during the 1990s resulted in a reduced intake and production of new nurses (graph).
Figure 1: Number of professional nurses trained per year by nursing colleges and universities
Source: South African Nursing Council Register
The drop in new recruits over the decade has resulted in an aging nursing population, with more than 70% of nurses registered in South Africa already over 40 years of age. As this older generation of nurses retires, there are concerns that insufficient numbers of experienced younger nurses will be available to fill their places. Steps have recently been taken to increase the enrolment and training of nurses, and current intakes of nursing trainees at 12% increase per annum is catching up with the population growth.
With a current nursing vacancy rate of 36% in the public sector, the immediate backlog remains to be addressed. Attempts to create interim solutions by recruiting foreign nurses, has been impeded by the difficulties of their obtaining registration to work in South Africa. Only 78 foreign nurses were successfully registered to work in South Africa in 2006, whilst 639 local nurses applied to have their certification sent to a foreign country during the first four months of 2006 (SAMJ, Feb 2007).
Although empirical data is hard to obtain for this migration of nurses, a recent study found that 5% of South African born professional nurses are working in 9 other countries which are the main recipients of African health workers (Clemens M, 2007). In addition to migration to countries which offer more lucrative packages and favorable working conditions, the private sector has also attracted a large number of public sector nurses for similar reasons.
The South African Nursing Council records also show that only 31.5% of nurses trained in the previous decade remained on the Council register to work as nurses in South Africa in 2004 (Subedar H, SAHR, 2005). The 68.5% of trained nurses no longer registered to work in South Africa includes natural attrition through retirement and death, and those that have migrated. However, extensive movement of nurses out of the profession also appears to have contributed to this loss of registered nurses.
Several factors influence the decisions of nurses to leave the profession, the public sector and the country. These include low salaries, but also job satisfaction, working conditions, career opportunities, governance and management, and safety factors. Salaries are the key issue under the spotlight with the current industrial action, but much also needs to be done to address the other factors resulting in a loss of nursing professionals.
Further compounding these challenges is evidence that of the nurses who remain within the public health system, between 13% and 16% are infected by HIV (HSRC 2005, Connelly D 2007). Many of these nurses were already eligible for antiretroviral treatment but were not accessing treatment. Unless provided with the care they require, the attrition of nurses due to HIV and AIDS will further impact on the health system in the near future.
The Department of Health adopted a national Human Resources Plan for Health in 2006, which has focused attention and action around the human resources crisis in the health sector. Steps are being taken to re-open nursing colleges to increase the numbers of nurses trained. There is also an expressed intention by government to increase funding for nursing posts and provision to be made for an occupation specific dispensation which would address nurses salaries amongst others.
The extent of the crisis in the nursing profession and the health system, as well as the frustration of nurses who are now on strike, suggests that much more is needed to address issues of remuneration, retention of staff, management, support and career-pathing for nurses. The current industrial action, brings this into clearer focus and warrants a concerted and comprehensive response.
Dr Lilian Dudley, CEO
Health Systems Trust