South Africa needs a new way to address the doctor shortage

There is a skewed distribution of skilled staff and an imbalance of skills. Andreea Campeanu/Reuters

Millions of South Africans are missing out on basic health care because of a skewed system that fails to make use of all the country’s skilled health professionals.

It is public knowledge that there are not enough doctors in the South African public health system. For every 1000 people, the country has less than one doctor available. Brazil, with a similar gross national product per capital to South Africa, has nearly two physicians for every 1000 people.

What is less well known is that if South Africa’s complete health workforce is tallied, there is not a critical shortage of human resources. The combined national average is 2.9 doctors, nurses and midwives for every 1000 people. This is similar to Thailand, which has a comparable economic environment and counts [2.7 doctors and nurses]((http://ac.els-cdn.com/S0140673610620351/1-s2.0-S0140673610620351-main.pdf?_tid=1ae4c7a0-f97c-11e4-a5e9-00000aacb35d&acdnat=1431527395_8cdf39618458d792383e4b6cb7deb151) for same number of people. Both figures are well above the World Health Organisation’s suggested 2.28 doctors and nurses for every 1000 people as the critical shortage threshold.

So what’s the problem?

The challenge with the health workforce in South Africa is two fold: the skewed distribution of skilled staff and an imbalance of skills. Doctors are mostly in private practice located in urban areas and the skills imbalance means that there is limited use of the mid-level health workforce.

Distribution needs urgent intervention. Even if the number of health care workers increases, the urban-rural imbalance may be worsened, particularly with doctors.

There is also a need to shift some tasks from doctors to nurses. This can be done without having a detrimental effect on quality. For every doctor in South Africa, there are just under five nurses, which is higher that the global average of 2.1 nurses for each doctor. This suggests a potential for some efficiency gains in health workforce.

If less reliance is placed on doctors for health care delivery and nurses are given the responsibilities, there would be less shortages in under-serviced areas.

Why so few doctors

One of the most common reasons for the shortage of doctors is the fact that not enough are produced annually by the country’s medical schools. South Africa’s eight medical schools each produce about [200 doctors a year]((http://www.samj.org.za/index.php/samj/article/view/7323/5357) - but its not enough to serve a population of just over 50 million people.

Cuba, in comparison, with a population of about 11 million people, has 22 medical schools.

The stumbling block is in the production line. The country’s institutions are unable to produce more doctors.

The government has established a ninth medical school in Limpopo province, which should have its first intake in 2016. It has also continuously encouraged medical schools to increase their intakes. But a significant increase in the intake of medical students would require clearing a number of hurdles.

Medical schools are accredited by the Health Professions Council of South Africa to train only the number of students that their existing infrastructure can accommodate. Any increase in student intake needs the council’s approval. The council will give the nod only if faculty can guarantee quality training. This would involve expanding facilities such as staff, lecture room seats and hospital facilities.

Approval would also require public hospitals to increase the number of posts for two-year intern training so that there are enough senior staff to supervise.

Universities are caught in a double bind. Expanding teaching facilities requires a significant cash injection. But between 60% - 80% of their funding comes in the form of a major block grant based on the number of full time students they take in two years earlier. This means that even if they increased their student now, the increase in subsidies would only be realised in 2017.

Institutions also need to rethink their admission policies which are skewed towards students from better-off urban areas. Refining the admission criteria to attract more students from rural and under-serviced areas would go some way to lessening this imbalance as doctors in rural areas would be more likely to return home after graduation. The latest medical training curriculum adopted by the council emphasises this social accountability back home.

Medical school tuition would also have to become cheaper to enable rural students to afford the cost of a medical degree. This remains a challenge despite the government’s intervention through the National Student Financial Aid Scheme (NSFAS).

Changing the way the system works

It has been suggested that the shortage of doctors poses a challenge to the South African government’s ambitious plan to create universal access to health care which is to be rolled-out over the next 10 years.

This does not need to be the case. More doctors are needed and sending 1000 students to Cuba for medical training every year is helping to fill the gap.

But this needs to be accompanied by a re-engineering of the primary health care system to focus on preventive care. Ward-based teams could be deployed to communities, assigned to a number of households. The teams would be made up of a several community health workers and led by a nurse coordinating the regular visits. This would ensure the maintenance of health, and care would be provided before it requires a doctor’s intervention.

Improving the availability of the health workforce and not just doctors would go a long way, particularly in rural areas. This would require training more mid-level clinicians such as the clinical associates and the providing a policy that reduces the over reliance on doctors and shifting some of the clinical functions and responsibilities to lower cadre of clinical staff.