Spotlight

South Africa is facing a healthcare worker crisis – thousands more nurses will be needed

By Kathryn Cleary for Spotlight 24 September 2020

A volunteer-enrolled nurse, Precious Ntozakhe, helps to feed a patient at the Nasrec Field Hospital. The care requirements for patients at the hospital are constant and varied and require all nursing skill levels. (Photo: Chris Collingridge)

Many healthcare workers are rightly identified as heroes of South Africa’s Covid-19 response. Yet, these same workers are given very little support in the public healthcare system, something that may get worse as staff shortages become more acute in the coming years. Kathryn Cleary investigates.

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.”

Health workers experience the system around them, explains Schneider, and if a facility or province has poor managers and leadership, it directly impacts the morale of workers – she points to the Eastern Cape’s infamous Livingstone “hospital of horrors” as an example of this.

“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, Schneider says the crisis of access to PPE highlights pre-existing issues with supply chains. “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 support for health workers is very poor and stems from both systemic and leadership issues.

Questions sent to 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 health department (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 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 predicts that over 16,000 additional professional nurses will be needed across provinces by 2025.

“There’s been a lot of uncertainty regarding the core cadres within the nursing profession,” says Hlungwani. “You’ve had an attempt to move away from sub-professional categories in the name of professionalising nursing, 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 says the focus needs to be on investing in the health workforce by increasing the number of staff who are trained each year. Echoing Schneider’s concerns, he emphasises that certain nursing colleges remain closed, and that 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 shortages that we continue to see each year. Studies showed that the country needed 11,000 professional nurses in 2015, but all colleges and universities combined produced only around 4,000,” he says.

Building 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 asked about their plans to build 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 being 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 for the same fee, for the same service, to be 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 numerous 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 doesn’t suffer further setbacks.

Previously, health department spokesperson Popo Maja told Spotlight that while the strategy was not yet published, some of the 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,” says Schneider. “The issue is how you begin to shift it, and how you develop a long-term strategy, [and] what are the concrete steps you do now in support of that strategy. 

“I think all those forecasts [and modelling] are valid, and we should be aiming for [those targets], but at the moment it reads like another wishlist.”

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’s] positions and their training,” she says.

She also emphasises the need to strengthen district health services – the “building blocks of the formal healthcare system” – which are pivotal to the functioning of NHI.

Adding to this, Hlungwani also wants government to review its 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 within 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 onto greatly needed staff,” he says. 

“The shortage of staff is likely to worsen if nothing is put in place.” DM/MC

Maverick Citizen will from tomorrow (Saturday 26 September) publish a series of images and interviews with healthcare workers at the frontline of the Covid-19 epidemic. Photojournalist Thom Pierce and Journalist Nomatter Ndebele travelled to all nine provinces during the lockdown and interviewed doctors, nurses, porters, cleaners and more. The stories are the human stories of South Africa’s Covid-19 epidemic. Some of the stories and images will also appear in the Daily Maverick print publication 168.

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