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

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

3 HRH Crisis in Africa, 2006

The health system in South Africa 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 The number of enrolled nurses has dropped from 60 per to 52 per and the number of professional nurses has dropped from 120 per to 109 per 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

Overview of HR in Africa

Current landscape in Africa 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%)

Crisis in Africa’s Health Workforce 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)

Countries Nurses per population Physicians per population South Africa Swaziland Botswana Zimbabwe 5415 Zambia Malawi 251 Mozambique 202 Belgium UK USA Source: WHO, 2004 (last update 26 Oct 2004) HRH shortages

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

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

Major Characteristics of BD  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

African Diaspora in the US Source: 2002 Yearbook of Immigration Statistics Nigeria7,892 Ethiopia6,643 Ghana4,416 Egypt3,355 Kenya3,216 Morocco3,141 Somalia2,448 South Africa2,220 Sudan1,886 Liberia1,768 Sierra Leone 1,496 Togo1,188 Immigrants Admitted in the US in 2003

 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 expatriates 1 Development paradox Reduction of job & wealth creation capacity Slowdown of research & technological innovations Impacts of BD 1 Selassie and Weiss, 2002

HIGH HIV Prev. Countries

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

PLWHAs per medical doctor PLWHAs per nurse Malawi7, Mozambique3, Zimbabwe2, Tanzania2, Rwanda1, Zambia1,21675 Swaziland1,13564 Botswana67681 Uganda39737 South Africa17130 Cambodia7520 Thailand306 Brazil27

Death from HIV – largest cause of attrition Zambia: : 2 nurses out of 1000 died : 27 nurses out of 1000 died Botswana: : 17% of health workforce died : 40% of health workforce will die (projection if no action) HIV prevalence = 15% up to 33 % loss of health workers in 10 years Source: WHO (2006). The World Health Report 2006 – Working Together for Health. Geneva, World Health Organization

AIDS  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

Main HR Challenges 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 …

The HRH Crisis  two problems Lack of HRH production (pre-service) – Lack of infrastructure – Need  ~$200- million* Home/Work environment leads to high attrition – Lack of Proper Housing – Need  ~$ million* * Within the SADC region, not including RSA 21

Huge Regional Disparities in Medical Schools and Graduates

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

Contact Details Gavin George

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?