SA is facing a healthcare worker crisis – What to do?
Healthcare workers on the frontlines face many challenges, including a lack of personal protective equipment (PPE), essential medicines and at times, poor leadership and governance. However, South Africa’s new 2030 Human Resources for Health (HRH) Strategy, obtained by Spotlight and Maverick Citizen, reveals that South Africa’s healthcare workforce also faces worsening staff shortages, which will require billions of rands in additional investment to prevent.
Need for more support
“For me, what [the pandemic] revealed in a very stark way are the failures of leadership and management and adequate support to frontline healthcare workers,” says Professor Helen Schneider, a public health expert from the University of the Western Cape. “There needs to be a recognition of [systems that support] health workers in dealing with immense challenges in their work, so preventing burnout, debriefing, psychological and social support.”
Schneider explains that if a facility or province has poor managers and leadership, it directly impacts the morale of workers. She notes the Eastern Cape’s infamous Livingstone “hospital of horrors” as an example of this.
“What the pandemic has highlighted is all those pre-existing dynamics, so where you had good systems and some ability to hold things together in the past, then people have been able to navigate the immediate crisis,” she says. “You can see that where there is a really good manager at a facility, with a stable team that has public interest orientation, service oriented and people oriented, the frontline players are motivated, their absenteeism levels are low, they experience job fulfilment. It depends a lot on the nature of immediate support to frontline health professionals, but also the extent to which the system as a whole is supportive.”
Adding to this, she says that the crisis of access to PPE is a case in point that highlights pre-existing issues with supply chains that have lasting implications for frontline workers. “That is just an indicator of a wider set of issues, like chronic shortages of drugs or other kinds of equipment and supplies.”
Speaking to Spotlight, Simon Hlungwani, President of the Democratic Nursing Organisation of South Africa (DENOSA), says that the support for health workers is very poor, and stems from both systemic and leadership issues.
Questions we sent the National Department of Health about these issues were not responded to by the time of publication.
Addressing challenges with nursing
The new HRH Strategy, which has not yet been made public by the Department of Health (though you can find it here) projects that by 2025 an additional 97 000 health workers, with a third being community healthcare workers (CHWs), would be needed to bring staffing levels up to more equitable levels across provinces. Further projections estimate that the public primary healthcare (PHC) system alone would need almost 88 000 additional workers.
Nurses make up over half of the country’s health workforce, but pre-existing issues with nursing training have led to increased shortages, says Schneider. The Strategy models that over 16 000 additional professional nurses are needed across provinces by 2025.
“There’s been a lot of uncertainty as to the core cadres within the nursing profession. You’ve had an attempt to move away from sub-professional categories, in the name of professionalising nursing,” Hlungwani says. “So you’ve had the lengthening of professional nurse training and the phasing out of the enrolled nursing category, and replacing that with a staff nurse (which is a three-year trained nurse). You’ve got all these realignments happening in nursing education but endless delays, and an inability to finalise these things.”
Hlungwani adds that there needs to be a pointed focus on investing in the health workforce by improving the numbers of production, in other words, the number of workers that are trained each year. Echoing Schneider’s concerns, he emphasises that certain nursing colleges remain closed, and previous commitments to refurbish and reopen these facilities have not been honoured.
“The closure of these [colleges] soon after ushering in democracy has resulted in the shortage that we are continuing to see each year. Studies will show that the country needed 11 000 professional nurses in 2015, but all colleges and universities combined produced around 4 000,” he says.
Building and maintaining a rural health workforce
Maldistribution in the health workforce between urban and rural areas is noted in the Strategy, with significantly fewer specialists working in rural areas.
Schneider says that building up rural healthcare systems requires more people from rural areas to be trained.
“You get healthcare workers to work in rural areas if you train people from rural areas. That is the lesson here and everywhere else in the world. You get people to rural areas by selecting them from rural areas and perhaps even training them in rural areas,” she says.
The national Department of Health was also asked about their plan to build and retain a rural health workforce but, despite multiple attempts, no response was received.
NHI as a way to address public, private split
With a disproportionate percentage of the country’s specialist health workforce in the private sector, the question arises whether the proposed National Health Insurance (NHI) system could help to address these disparities.
Nicholas Crisp, who heads up the government’s NHI office, tells Spotlight that the aim of the NHI, regardless of whether the healthcare worker provider is in the public or private sector, is that the same fee for the same service is paid to all providers.
“The health system needs all the human resources it can muster. The challenge is to use the skills of [healthcare workers] effectively and efficiently. This is why the purchaser-provider split, with a single purchaser model, is attractive. It allows the consolidation of purchasing power, leverage through the purchasing power of the large pool of funds, and capacity for strategic purchasing to ensure that there is equitable, targeted purchasing of services from providers,” he explains.
Crisp notes that there are many HRH issues that need independent attention, including the need for a clear HRH strategy, plus education and training infrastructure to ensure skills are available at all times.
A way forward
While the 2030 HRH Strategy contains some recommendations, immediate steps are needed to ensure that the health workforce does not suffer further setbacks.
Previously, National Department of Health spokesperson, Popo Maja, told Spotlight that while the Strategy was not yet published, some recommendations had been acted upon in response to the COVID-19 pandemic. These include the filling of vacancies, recruitment of additional clinical staff, and the development of a Human Resources for Health Information System, to name a few.
“The maldistribution and shortages are well-known and have been established a long time ago,” says Schneider. “The issue is how you shift it and how do you develop a long-term strategy, [and] what are the concrete steps you do now to support that strategy. I think all those forecasts [and modelling] are valid, and we should aim for [those targets], but at the moment it reads like another wish-list.”
Schneider recommends that a strong focus be placed on PHC and district level services, specifically leadership and the role of CHWs. “This is a moment to really focus on addressing the long-standing set of issues in the ward based outreach team (WBOT) programme, [and] to regularise [CHW] positions [and] their training,” she says.
She also emphasises the need to strengthen district health services, which she calls the “building blocks of the formal healthcare system,” and pivotal to the functioning of NHI.
Adding to this, Hlungwani calls for government to review their staff retention strategy in the form of an Occupation-Specific Dispensation (OSD), noting that the current OSD should have been reviewed in 2012, and again in 2017.
“[A] staff retention strategy helps to keep talent and skills in [the country]. There is great potential to lose highly skilled staff to other countries as soon as we open the borders. Many nurses are greatly demoralised and there is absolutely nothing that the government can point to as a plan to [hold] on to greatly needed staff,” he says. “The shortage [of staff] is likely to worsen if nothing is put in place before it is too late.”