SOUTH AFRICAN HEALTH SYSTEM - FROM BRAIN DRAIN TO BRAIN GAIN: UNDERSTANDING AND MANAGING THE MOVEMENT OF MEDICAL DOCTORS IN THE - World Health ...
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CASE STUDY | SOUTH AFRICA
FROM BRAIN DRAIN TO BRAIN GAIN:
UNDERSTANDING AND MANAGING THE
MOVEMENT OF MEDICAL DOCTORS IN THE
SOUTH AFRICAN
HEALTH SYSTEMContents
Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Figures
Figure 1a. Macro-organization of the
1. Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
South African health system . . . . . . . . . . . . . . . . . . . . . . . . . . 4
2. Health workforce context . . . . . . . . . . . . . . . . . . . . . . . . . 4
Figure 1b. Organization of the South African public
3. Practising medicine in South Africa . . . . . . . . . . . . . . . . . 4
health sector . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
4. Policy on the Recruitment and Employment of
Figure 2. Age profile of general practitioners, 2012–2015 . . . . . 14
Foreign Health Professionals in the South African
Acknowledgements Health Sector . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
4.1 Regulation of medical practitioners . . . . . . . . . . . . . . . 8
Figure 3. Health professions council of South Africa
registers 2010 to 2014 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
4.2 Registration requirements for expatriate Figure 4. Type of practice of respondents . . . . . . . . . . . . . . . . . . 18
The authors of this report are Percy Mahlathi and Jabu Dlamini (African Institute of Health & Leadership
qualified medical practitioners . . . . . . . . . . . . . . . . . . 8 Figure 5. Reasons for seeking employment overseas . . . . . . . . . 18
Development).
4.3 Registration of government-to-government Figure 6. Movements upon return from overseas employment . . 19
practitioners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
4.4 South Africa–Cuba Medical Training Programme . . . . . 9 Tables
4.5 Registration of South African-qualified
Table 1. 2015 mid-year population estimates for South Africa . . 3
medical practitioners . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Table 2. Cuban-trained South African medical doctors . . . . . . . . 4
5. Migration of the medical workforce . . . . . . . . . . . . . . . . 10 Table 3. Selected list of human resources for health policies . . . 5
6. Study objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Table 4. Register of medical practitioners,
7. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Medical and Dental Board . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
8. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Table 5. Medical training spaces on HPCSA system . . . . . . . . . . . 12
8.1 Minimum data sets . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Table 6. Total number of medical students (first to final year) . . 12
8.2 Stock of medical practitioners, 2016 . . . . . . . . . . . . . . 11
Table 7. Medical stock inflows (including both years
8.3 Regulation of medical training and new entrants . . . . . 11 of internship) from South African medical schools,
8.4 Expatriate medical workforce . . . . . . . . . . . . . . . . . . . . 12 2011–2015 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Table 8. HPCSA accredited and approved post numbers
9. Distribution of medical practitioners in South Africa . . 13 (inclusive of all teaching hospitals) . . . . . . . . . . . . . . . . . . . . . 12
10. Movements by government-employed medical doctors 20
Table 9. Percentage share of expatriate medical
11. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 workforce from main source countries . . . . . . . . . . . . . . . . . . 13
12. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Table 10. HPCSA medical officer register . . . . . . . . . . . . . . . . . 13
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Table 11. Age profile of female and male general
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 practitioners, Western Cape province . . . . . . . . . . . . . . . . . . . 14
Table 12. Age profile of female and male general
practitioners, Gauteng province . . . . . . . . . . . . . . . . . . . . . . . 15
Table 13. Age profile of expatriate medical practitioners . . . . . . 15
Funding for the development of this document was provided through the project “Brain Drain to Brain Gain - Supporting WHO
Code of practice on International Recruitment of Health personnel for Better Management of Health Worker Migration”, co-funded Table 14. Medical officer stock in government
by the European Union (DCI-MIGR/2013/282-931) and Norad, and coordinated by WHO. The contents of this document are the hospitals, 2011–2015 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
sole responsibility of the African Institute for Health and Leadership Development, and can under no circumstances be regarded Table 15. Provincial GP register at HPCSA,
as reflecting the position of the European Union or WHO. number and % of national total . . . . . . . . . . . . . . . . . . . . . . . . 17
Table 16. Medical officer resignations across five
© African Institute for Health and Leadership Development, all rights reserved. provinces (male and female), 2011–2015 . . . . . . . . . . . . . . . . 17
Table 17. Age profile of resignations from public health
March 2017 service in Eastern Cape and Western Cape provinces . . . . . . . . 17
UNDERSTANDING AND MANAGING THE MOVEMENT OF MEDICAL DOCTORS IN THE SOUTH AFRICAN HEALTH SYSTEM 1Abstract
Background. The provision of health services is largely dependent on the sufficiency of the health workforce in terms of
numbers, the quality of skills they possess, how and where they are deployed and how they are managed. With increasing
urbanization, the issue of migration (including immigration, emigration and movement between the public and private
sectors) of health personnel has become a critical factor in the debate about social justice in health, especially access and
UNDERSTANDING AND MANAGING THE
equity in the provision of health services. This case study seeks to better understand the patterns of movement of medical
doctors and the development of associated policies in order to help health authorities to put in place the necessary
MOVEMENT OF MEDICAL DOCTORS IN THE
systemic improvements for effective management of health workforce migration.
Objectives. The objectives of the study were (a) to assess the recorded movement of medical officers employed in
SOUTH AFRICAN HEALTH SYSTEM
the public health facilities; (b) to gain insight into the views and perspectives in South Africa of emigrant medical
practitioners; and (c) to identify existing policy instruments and practices in place to maximize benefits and mitigate 1. Background practitioners who run private surgeries or through private
negative consequences of the migration of medical doctors. hospitals, which tend to be located in urban areas. The
This study was undertaken as a follow-up to Minimum health care system consumed about 8.8% of the country’s
Method. Data were collected from the provincial Departments of Health, the Medical and Dental Board of the Health data sets for human resources for health and the surgical gross domestic product during 2012 (3).
Professions Council of South Africa, the South African Medical Association and individual medical practitioners workforce in South Africa’s health system: a rapid analysis
through a survey. The data utilized were derived from responses to a survey questionnaire. of stock and migration (1). The private sector serves about 16% of the population,
whilst the public sector serves 84% (4). The country’s
Results. Data analysis revealed that of the 754 respondents (South African-trained doctors) 37% had worked outside As at June 2016, South Africa was estimated to have a population distribution indicates that about 64.7% inhabit
South Africa, while 63% had not. The government keeps records of only those that it employs. Once medical doctors population of 54 956 900 (2). Most people access health the provinces, which are largely rural in nature. Table 1
resign from public service, there is no mechanism to provide data on their destination. About 57% of respondents services through the government’s public clinics and presents population statistics for South Africa.
believed that migration by medical doctors should be monitored, though there were variations in the reasons put hospitals, whilst approximately 16% access health services
forward as to why it should or should not be monitored. South Africa has in place policies that focus on the management through private health facilities, such as doctors’ private TABLE 1. 2015 MID-YEAR POPULATION ESTIMATES FOR
of the health workforce, including regarding statutory regulations, employment of medical doctors (junior to senior consulting rooms (surgeries) and private hospitals. SOUTH AFRICA
and specialist levels), and the employment benefits provided to foreign medical doctors employed in the public health There are instances where the State has a contractual
service. Some respondents are sceptical about management of migration, interpreting it as an attempt to victimise them relationship with private hospitals for the management Population % of total
Province Urban/rural
estimate population
through controlling their movement. of certain conditions that government health institutions
may not have the capacity to treat, for example in the case Eastern Cape 6 916 200 12.6 Rural
Discussion. The country needs to develop a mechanism to record and manage information regarding the mobility of its of outsourcing of radiological services due to specialist Free State 2 817 900 5.1 Rural
medical workforce. There are government initiatives to increase the training of medical doctors to boost the stock, though shortages in government hospitals. The public health Gauteng 13 200 300 24.0 Urban
fiscal challenges obstruct progress. The Policy on the Recruitment and Employment of Foreign Health Professionals in service is divided into primary, secondary and tertiary care Rural but has
the South African Health Sector is used to manage immigration, but requires review so that it is aligned with the new through health facilities that are located in, and managed KwaZulu-Natal 10 919 100 19.9 large urban
centres
immigration laws of the country. Refugees and asylum seekers who are professionals form a component of migration that by, the provincial Departments of Health. The provincial
Limpopo 5 726 800 10.4 Rural
is not often considered in the literature on migration of health workers. Given the broad and varying understanding of Departments of Health are thus the direct employers of the
Mpumalanga 4 282 900 7.8 Rural
general practitioners, the paper presents information on medical doctors as well as specifically on General Practitioners health workforce, whilst the national Ministry of Health is
Northern Cape 1 185 600 2.2 Rural
extracted from the HPCSA GP register, plus on Medical Officers from provincial level records. responsible for policy development and coordination.
North West 3 707 000 6.7 Rural
Key words. emigration, immigration, medical practitioners, experience, financial gain, expatriate medical workforce, South Africa’s Constitution guarantees every citizen Urban but has
refugee medical doctors, South Africa access to health services in accordance with section 27 of Western Cape 6 200 100 11.3 farming and rural
communities
the Bill of Rights. While all citizens can access both the
Total 54 956 900 100.0
public and private health services, access to private health
services depends on the patient’s ability to pay. The private
health sector provides health services through individual Source: Statistics South Africa (1).
2 FROM BRAIN DRAIN TO BRAIN GAIN: UNDERSTANDING AND MANAGING THE MOVEMENT OF MEDICAL DOCTORS IN THE SOUTH AFRICAN HEALTH SYSTEM 3
UNDERSTANDING AND MANAGING THE MOVEMENT OF MEDICAL DOCTORS IN THE SOUTH AFRICAN HEALTH SYSTEMFIGURE 1A. FIGURE 1B. doctor can have. There is also no application process for workforce. The Scarce Skills Allowance policy in the
MACRO-ORGANIZATION OF THE SOUTH AFRICAN ORGANIZATION OF THE SOUTH AFRICAN PUBLIC a medical doctor who wishes to establish private practice health sector ceased to operate as soon as the Policy on
HEALTH SYSTEM HEALTH SECTOR rooms, except obtaining a practice number from the Board Remuneration of Health Professionals Working in Public
of Healthcare Funders of Southern Africa. This enables Health Service (otherwise known as the Occupation
North West
Department doctors to receive payment from private medical insurance Specific Dispensation policy) came into effect. The Human
Northern of Health
Cape EC
Department
companies for services provided to their members. Resources for Health Planning Framework, 2006, was also
Public Health Private Health Department
Sector of Health of Health Medical doctors (generalists and specialists) who are in revised and updated as the Human Resources for Health
Sector
full-time employment by government can simultaneously Strategy, 2011.
Western
KZN manage their private practices subject to approval by a
Cape
Department
Department National Head of Department of Health in the province where that
4. Policy on the Recruitment
of Healeth
of Health Ministry of
Health practitioner is employed. This is in terms of the Policy on
National Health Remunerative Work Outside Public Service, which was and Employment of Foreign
System Free State
Department
Mpumalanga
Department
developed as a retention measure for doctors in the public Health Professionals in the
health service.
of Health of Health
South African Health Sector
Limpopo Guateng
Abbreviated Department Department Several policies have been adopted over the years aimed Since 2010 medical doctors from outside the Republic of
provinces: of Health of Health
EC = Eastern Cape at improved management of the medical workforce South Africa wishing to work in the country must comply
KZN = KwaZulu Natal
in South Africa. Table 3 presents a set of policy and with the Policy on the Recruitment and Employment of
There is a realization that the health workforce plays a the training of doctors in Cuba under a government-to- strategy documents relevant to the management of the Foreign Health Professionals in the South African Health
critical role in advancing the health system goals (5), government agreement. Table 2 shows the number of medical workforce that together contribute to improved Sector. This policy was introduced to improve the flow of
largely driven by a policy position of improving access Cuba-trained medical doctors appearing on the HPCSA distribution and retention of the workforce, and support health professionals into South Africa and expresses the
to health care for all citizens. Figures 1a and 1b present register for the period 2011–2015. implementation of the World Health Organization (WHO) following objectives:
a diagrammatic representation of how the South African Global Code of Practice on the International Recruitment
health system is organized. TABLE 2. CUBAN-TRAINED SOUTH AFRICAN of Health Personnel (6), with the Policy on the Recruitment • promote high standards of practice in the recruitment
MEDICAL DOCTORS and Employment of Foreign Health Professionals in the and employment of health professionals who are not
South African Health Sector being particularly notable. South African citizens or permanent residents;
2. Health workforce context
Year 2011 2012 2013 2014 2015 These policies are applied to management of the health
The mandate for health workforce policy lies with the national
Number 1 362 1 334 1 476 1 606 1 767
Ministry of Health in cooperation with the Department
of Higher Education and Training (for production) and TABLE 3. SELECTED LIST OF HUMAN RESOURCES FOR HEALTH POLICIES
the Department of Public Service and Administration (for Funding of higher education in South Africa has gained sharp
employment conditions). South Africa has a total of 23 focus through protests by university students demanding free Policy Year Focus / rationale
universities, of which eight have medical schools. A ninth higher education under the banner #Fees Must Fall Move- Human Resource Strategy 2001 Proposals on the definitions, entry requirements, and scope
medical school recently established at the University of ment. This will certainly put more demand on the financially of practice of all categories of health care professionals
Limpopo (in 2015) was meant to produce its first graduates underfunded medical training in South Africa. Scarce Skills Allowance 2003 Financial incentive to retain “scarce skills” in the public health service
in 2022. However, there have been serious compliance Remunerative Work Outside Public 2002 Incentive scheme allowing doctors to work in the private sector whilst
problems, leading to the Health Professions Council of Service fully employed by government
3. Practising medicine
South Africa (HPCSA) withdrawing accreditation until the Human Resources for Health 2006 Highlighting the need for systematic national health workforce
noncompliance issues are resolved. This would have been a
in South Africa Planning Framework planning
small addition to the number that is required to provide the Medical doctors have the freedom to set up their practice Policy on Remuneration of Health 2007 System of differentiated pay for health professionals employed in
Professionals Working in Public public health facilities with the objective of recruiting and retaining
much-needed medical services in the country. arrangements as they see fit as long as they are registered by Health Service professionals in the public health service
the Medical and Dental Board as eligible for independent
Policy on the Recruitment and 2008 Principles and practices in the employment of health professionals
Collectively, the medical schools have an annual production practice post-community service. They can remain Employment of Foreign Health (approved who are non-citizens aligned to the immigration processes of the
of medical graduates ranging between 1200 and 1300. This employed in government health facilities or by corporate Professionals in the South African in 2010) Department of Home Affairs
Health Sector
number has not changed significantly in the past 10 years bodies (for example, medical insurance schemes or mining
Human Resources for Health 2011 Focus on planning and staffing of health facilities in preparation for
and is viewed as a grossly inadequate production rate for companies), or can set up private practice wherever they
Strategy the introduction of the National Health Insurance. It built on the
a country with a population of approximately 55 million. wish. There is currently no limitation on either place of foundation laid by the 2001 Human Resource Strategy and the 2006
The production of medical doctors is supplemented by work or the number of surgeries (medical rooms) a medical Human Resources for Health Planning Framework
4 FROM BRAIN DRAIN TO BRAIN GAIN: UNDERSTANDING AND MANAGING THE MOVEMENT OF MEDICAL DOCTORS IN THE SOUTH AFRICAN HEALTH SYSTEM 5
UNDERSTANDING AND MANAGING THE MOVEMENT OF MEDICAL DOCTORS IN THE SOUTH AFRICAN HEALTH SYSTEM• preclude the active recruitment of health professionals council or board recognised by SAQA in terms BOX 1. AFRICA HEALTH PLACEMENTS: SUPPORT FOR REFUGEE DOCTORS IN SOUTH AFRICA
from developing countries unless there are specific of section 13(1)(i) of the National Qualifications
government-to-government agreements to allow and Framework Act; and
Africa Health Placements (AHP) is a South African NGO that was established in 2005 with the mission to help plan for,
support such recruitment.
find and retain the health workforce needed to provide access to health care in rural and underserved communities. A
c) proof of evaluation of the expatriate qualification major component of AHP’s work to date has been recruiting foreign-qualified doctors, mostly from the United Kingdom,
The policy was crafted such that it is complementary to by SAQA and translated by a sworn translator into to take up vacant salaried posts in rural government hospitals in South Africa. These doctors normally come for at least
the Immigration Act and other laws, and is consistent one of the official languages of the Republic (of a year, and so far AHP has recruited and placed over 2750 doctors to work there.
with the country’s Constitution. It lays out a recruitment South Africa). In recent years, doctors who have come to South Africa as refugees have become a sizeable percentage of the health
process that involves four stages: workers that AHP has placed. South Africa has a long history of providing asylum and in 2015 the country accepted
(6) A critical skills work visa shall be issued for a about 120 000 refugees (7). It is important to note that AHP does not actively recruit from countries with a critical
1. centralization of applications at the national period not exceeding five years. shortage of health workers (for example, the Group of 77 nations), and that the Government of South Africa also
prohibits this, although with some exceptions (8). AHP believes however that if doctors are already in South Africa as
ministry level (under an internal unit at the National
refugees then they have a right to live and work in the country. AHP’s role has been to support refugee doctors in their
Department of Health called the Foreign Workforce (7) A spouse and dependent children of a holder of
applications for professional registration and employment through active partnership with the national Department
Management Programme); a critical skills work visa shall be issued with an of Health and the HPCSA, thereby reinforcing the government’s rules. So far, AHP has supported the placement of
appropriate visa valid for a period not exceeding 430 refugee doctors from the Democratic Republic of the Congo, which is the most common source of refugee doctors
2. clearance to practise medicine in South Africa the period of validity of the applicant’s critical skills in South Africa.
processed by HPCSA; work visa. The placement and registration process for refugee doctors in South Africa is stringent and complex. Candidates must
first demonstrate that they have refugee status before obtaining professional registration from the HPCSA. This normally
3. issuance of endorsement letter by the Department of Section 18(3)(iii) of the Immigration Act also prescribes includes a requirement to pass an examination. Registration can be a challenge because it requires notarized copies of
Health enabling the expatriate health professional to that the salary and benefits of the applicant are not inferior their medical qualifications and contact with their medical school to verify their credentials. Many refugee doctors have
to go to great lengths to go back to the Democratic Republic of the Congo to get a certificate of good standing from their
be employed at a designated public health facility upon to the average salary and benefits of citizens or permanent
professional council. After registration, they get employed in salaried posts in public hospitals. That includes in most
fulfilment of requirements; residents occupying similar positions in the Republic. cases a two-year supervised internship programme and then a year of community service in an underserved area before
This is also in line with the provisions of the Occupational being able to practise independently in the public health sector.
4. appointment to a post to be open to fair competition Specific Dispensation policy, which regulates how health AHP provides support to refugee doctors by helping them to complete their application forms to the Foreign Workforce
by any deserving doctor. professionals in the public health service are remunerated. Management Directorate at the national Department of Health for permission to seek employment, as well as to the
HPCSA for professional registration. AHP checks that the forms are compliant with the regulations and helps to submit
A work permit finally gets issued by the Department of Whilst the Policy on the Recruitment and Employment of them on behalf of the refugee doctor and follows up on progress. Once these applications have been approved, AHP helps
Home Affairs. Once appointed to a post, all expatriate Foreign Health Professionals in the South African Health the refugee doctors to find a job by matching them with available posts in the public sector.
medical doctors are entitled to the same salary and Sector has been in operation since 2010, it requires urgent AHP believes that supporting refugee doctors to work in the health system in South Africa brings considerable benefits
benefits pertaining to the post as any South African review so that it is completely in line with the amended to both the country and to the refugee. These doctors are only allowed to work in public sector facilities, and must work
for at least one year in an underserved community. AHP has found that the foreign-qualified doctors who have come
counterpart who occupies a similar post. This is in line Immigration Act of 2014. In addition, prevalent health
as refugees stay longer in rural posts than those from high-income countries; for example, the doctors recruited from
with section 18 of the Immigration Act, which states workforce shortages have rendered some of the clauses of the Democratic Republic of the Congo have an average length of placement of 2.8 years compared to 1.3 years for their
that: the policy irrelevant, for example principle 5, which states counterparts from the United Kingdom, and many refugee doctors stay for life. Staying longer enables these doctors
that the employment of expatriate health professionals to adapt more to the local practice and culture and to be available to take on important clinical leadership roles in the
(5) An application for a critical skills work visa shall be shall only be allowed after they have been successful in facilities where they work. For the refugee, the ability to take up posts in the health system brings the obvious benefits
accompanied by proof that the applicant falls within competing for an advertised post and there is record of being able to work, support their families and continue in their careers.
the critical skills category in the form of – that no South African citizen or permanent resident The process for obtaining professional registration and a job offer is also a difficult one that can be slow and expensive
was available or found suitable to fill the particular post. to complete. There may therefore be opportunities to streamline the process further, for example by providing more
regular opportunities for candidates to undertake the HPCSA examinations or by offering bridging programmes (such as
a) a confirmation, in writing, from the professional When faced with critical shortages, this clause is unlikely
in language skills or medical practice) to help refugees to reach the required standards more quickly.
body, council or board recognised by South African to be adhered to.
Qualifications Authority (SAQA) in terms of section It is essential that due processes are followed to prevent active recruitment from critical shortage countries and to
ensure the professional competency of all doctors. If these are in place, the experience of South Africa demonstrates
13(1)(0) of the National Qualifications Framework In managing the employment of expatriate medical doctors,
that enabling and supporting refugees with medical qualifications to practise as doctors can provide mutual benefits for
Act, or any relevant government Department the Ministry of Health has struck partnerships with several both refugees and the host country.
confirming the skills or qualifications of the applicant nongovernmental organizations (NGOs), such as Africa
and appropriate post qualification experience; Health Placements (Box 1). These organizations offer
Source: Africa Health Placements.
advisory services that are broader than work placements,
b) if required by law, proof of application for a for example including facilitation of visa applications and
certificate of registration with the professional body, Medical and Dental Board examinations. The development
6 FROM BRAIN DRAIN TO BRAIN GAIN: UNDERSTANDING AND MANAGING THE MOVEMENT OF MEDICAL DOCTORS IN THE SOUTH AFRICAN HEALTH SYSTEM 7
UNDERSTANDING AND MANAGING THE MOVEMENT OF MEDICAL DOCTORS IN THE SOUTH AFRICAN HEALTH SYSTEMof the Policy on the Recruitment and Employment of to Cuba. For those who opt out of the agreement, their are then registered by the HPCSA to practise medicine in
BOX 2. CASE STUDY: DR S FROM THE DEMOCRATIC
Foreign Health Professionals, as well as the creation of REPUBLIC OF THE CONGO registration with HPCSA is cancelled, including the South Africa.
the Foreign Workforce Management Directorate within treaty visa with the Department of Home Affairs. Any
Dr S left his home country of the Democratic Republic of the
the national Department of Health, has provided the spouse who has not been identified in the government- There has been criticism of the programme over many
Congo aged 29 because he feared for his safety as conflict
framework for partnership and engagement with groups spread in his region. He had also started to experience to-government agreement is required to take the Board years, though the criticism has been focused on the cost
such as Africa Health Placements. Among those assisted in political interference in his work that went against his examination. of the programme rather than the quality of training in
finding work placements are refugee doctors, for example professional ethics. He came to Pretoria as a refugee in Cuba. With declining health budgets across the provinces,
from the Democratic Republic of the Congo (see Box 2 for 2009 and spent three years being supported financially Practitioners from the Islamic Republic of Iran and some provinces have been reluctant to fund the students
by friends and family, during which time he studied at the
a case study). Tunisia also register for a period of three years, which going into the programme. Universities have previously
local library, passed his English test and completed the
may be extended if the hospital still requires their argued that the money spent on the South Africa–Cuba
examinations and paperwork required by the Department
4.1 Regulation of medical of Home Affairs and the HPCSA. With the support of AHP he services. An endorsement by the Foreign Workforce Medical Training Programme could be diverted to South
practitioners was able to start working as a doctor in Durban in 2013 and Management Programme is also a requirement. They African universities to fund more medical undergraduate
Medical practitioners are regulated by the Medical and is now moving to take up a post as a medical officer in an can also opt out of the agreement but, unlike their Cuban spaces locally.
Dental Board of the HPCSA, pursuant to the provisions of underserved specialist hospital. He comments: counterparts, without any consequences from their
Health Professions Act No. 56 of 1974 (as amended). The “I initially experienced challenges being accepted by many country of origin. The basic documents that are required South Africa has firmly adopted a Health Sector Reform
patients and some of my colleagues because I didn’t speak
Medical and Dental Board has 17 professional categories for their registration include the duly completed Form Policy to implement National Health Insurance. Its own
Zulu, but I have worked hard to learn the language and
in its register that relate to the medical field, including 12, a notarized copy of a basic degree translated into predictions indicate that if the policy is to be successfully
things are much better for me now. I feel like South Africa
medical intern, medical practitioner, medical specialist has accepted and adopted me and I feel very grateful for English, and letters from both embassies confirming the implemented, there has to be a major boost in the
and clinical associate. Anyone wishing to practise that, and proud to work for people here and try to help.” government-to-government agreement. If the practitioner production of medical doctors. A major challenge is also
medicine in South Africa must register with the Medical has a speciality, they will submit a notarized copy of the ensuring a shift in mindset from a curative to a preventative
and Dental Board and keep their registration up to date certificate of registration with their country of origin as focus in health services – an approach, it is hoped, that will
through annual licensing by the Board. competence under the International English Language Test a specialist, after which they will register in the category be positively influenced by the Cuban-trained medical
System. A letter of support from the Foreign Workforce “public service government-to-government, restricted to doctors. However, some leaders in the medical field have
4.2 Registration requirements for Management Programme of the Ministry of Health is as ad- the field of medicine”. In these cases, no verification by commented that the Cuban medical training does not
expatriate qualified medical ditional requirement. This is to ensure that there is a post the Education Committee for Foreign Medical Graduates prepare doctors “for what is expected of a South African
practitioners available to accommodate the practitioner. All expatriate is required. Assessment is carried out by panels that are graduate who has to be competent to do a C-section and
All medical practitioners who have qualified outside medical practitioners must sit for the Medical and Dental assembled by the Ministry of Health. give a safe anaesthetic, and treat fractures and complicated
South Africa are categorized and subjected to specific Board examination, except for postgraduates, lecturers in TB and HIV patients during their community service” (9).
registration requirements. For the expatriate qualified the medical field and volunteers. The examination consists 4.4 South Africa–Cuba Medical Whilst the programme has made a constant contribution
medical practitioners, the registration requirements are of both written and practical elements. Once a practitioner Training Programme to annual medical graduate outputs – about 8% of the 1300
that they must produce verification of qualifications from passes the examination, he or she will be registered to work The training of South African students in Cuba to become graduates – debates continue about how successful the
the Education Committee for Foreign Medical Graduates, in the public health service. However, expatriate specialists medical doctors came to fruition in 1995 after the two gov- integration of its graduates is into the South African health
and among other requirements produce a notarized copy are required to pass the final examination of the Colleg- ernments signed a cooperation agreement on health mat- system. Some view the acceleration in Cuban training as
of a degree certificate (which, if not in English, is to be es of Medicine of South Africa, which comprises various ters. Prospective students are selected by panels that have a crisis intervention aimed at buying time to adjust and
translated and notarized). For specialists, notarized proof specialist colleges and is responsible for the maintenance been set up by provincial Departments of Health and get expand the local medical training platform so that it can
of postgraduate education and training or work experi- of specialization standards in its constituent fields. full support to study medicine in selected universities in increase local doctor output while continuing to better re-
ence must be produced. Submitting verification from the Cuba. Major criteria are that applicants must have passed orientate the Cuban “returnees” towards South Africa’s very
Education Committee for Foreign Medical Graduates is 4.3 Registration of government- matriculation (grade 12) with minimum medical uni- different disease profile (9). However, the major constraint
a prerequisite before applying for registration with the to-government practitioners versity entry requirements of level 4 in Physical Science, to any serious changes to the programme is political, as it is
HPCSA. South Africa has health cooperation agreements with Mathematics, Life Sciences and English, and must be South founded on deep political solidarity between South Africa
Cuba, the Islamic Republic of Iran and Tunisia. The African citizens and permanently residing in the respective and Cuba.
Fluency in English is mandatory to communicate with pa- Ministry of Health sends panels of South African province. They must also be aged between 18 and 25 years,
tients and to be able to engage meaningfully in the Medical specialists to these countries to assess practitioners based and priority is given to students with potential who come Integration of the Cuban graduates into the local health
and Dental Board’s examination. Candidates from Eng- on identified provincial needs. The practitioners who pass from poor households. These students undergo five years system is also a challenge to monitor. As noted in the
lish-speaking countries and candidates with English as a the assessment become registered with the HPCSA with a of medical studies and thereafter two years of medical stud- authors’ previous case study on the surgical workforce
first or second language qualification at secondary school clear indication that they are government-to-government ies at a South African university to complete a degree in (1), South Africa does not have a “live” workforce tracing
level qualify in terms of this standard. Candidates who practitioners. With effect from 2012, Cuban practitioners medicine. However, they receive a Cuban qualification at system or mechanism. It is therefore difficult to determine
do not qualify are requested to obtain graded academic register for a period of three years and must then return the university that they attended. These medical graduates where most graduates of the South Africa–Cuba Medical
8 FROM BRAIN DRAIN TO BRAIN GAIN: UNDERSTANDING AND MANAGING THE MOVEMENT OF MEDICAL DOCTORS IN THE SOUTH AFRICAN HEALTH SYSTEM 9
UNDERSTANDING AND MANAGING THE MOVEMENT OF MEDICAL DOCTORS IN THE SOUTH AFRICAN HEALTH SYSTEMTraining Programme finally settle. Do they end up being up to 35% vacancy rates for medical doctors. This relates an umbrella organization of medical doctors, including who have already qualified and are formally employed
swallowed in the predominantly curative practices or to approved posts for which a budget has been allocated specialists, in South Africa. in HPCSA accredited hospitals for internship training.
retain the basics of their training? How long do they stay in but which remain vacant due to the lack of medical doc- The category “clinical associate” was established as a
the public health service or do they also aspire to migrate tors to appoint. Several studies about the movement of Each respondent was sent a questionnaire to complete mechanism to curtail the shortages of medical services,
to the private sector? Do they also harbour ambitions of medical doctors focus on those employed by government and, based on the responses, telephonic follow-up inter- particularly in rural health facilities. It was created as a
specializing and if so, in what fields of medicine? These institutions, and very little or not at all on those working views were conducted for further explanations or closing mid-level practitioner in the field of medicine. These
are some of the questions that will need to be probed in in private practice. of gaps in the information supplied. Guiding the research cadres are trained by the family medicine units of medical
future studies. data-gathering process was a protocol developed by the schools. The “student intern” category comprises final year
Due to the difficulty of producing empirical evidence, Global Health Workforce Alliance that provided a list of medical students, who provide the bulk of stock inflows
4.5 Registration of South African- some studies have resorted to making deductions based minimum data sets against which to match responses. into the medical graduate field. They are placed at various
qualified medical practitioners on “intention to leave” of respondents (10). HPCSA-accredited government hospitals across the
All health care students are required to register with the country. Upon satisfactory completion of their internship,
8. Results
HPCSA within two months of commencement of their they must complete another one-year community service
6. Study objectives
studies. Some universities require students to regis- 8.1 Minimum data sets before being eligible for independent practice. This
ter as student interns for their sixth year by completing The objectives of the study were to: In relation to the minimum data sets, no data elements were community service category is thus included in the total
the relevant form and paying registration fees. Upon probed, as the previous study responses were deemed to be still number of medical practitioners.
completion of medical internship, they are registered (a) assess the recorded movement of medical officers em- relevant.
for independent practice. ployed in the public health facilities; 8.3 Regulation of medical training
8.2 Stock of medical practitioners, 2016 and new entrants
(b) gain insight into the views and perspectives in South The major data source was the HPCSA, which maintains The HPCSA, through its Undergraduate Committee,
5. Migration of the medical
Africa of emigrant medical practitioners; a register of all medical doctors that are licensed to approves the number of medical undergraduate training
workforce practise medicine in South Africa. The second source spaces to be made available for each year. This is based
The migration of South African medical professionals has (c) identify existing policy instruments and practices was the provincial Departments of Health, while the third on its planning processes and takes into consideration
been a subject of discussion for a considerable period. in place to maximize benefits and mitigate negative was individual practitioners who were surveyed through various factors, including the faculty–student ratio.
Many studies have been conducted and have advanced consequences of the migration of medical doctors. the South African Medical Association. The HPCSA has All medical schools undergo regular accreditation
varying estimates of emigration by health professionals in under its aegis 12 professional boards, with the Medical inspection by the HPCSA, which includes evaluation
the African continent (10–12). Several causes of migration The study also sought to identify whether any synergies and Dental Board the largest in terms of numbers. As of of the curriculum.
by health professionals have also been recorded. Measuring or gaps existed between the workforce data systems of 3 May 2016, the register of medical practitioners was as
the extent of emigration – particularly by South African provincial Departments of Health (the major employer indicated in Table 4. Once medical students graduate from a university, they
medical doctors – remains a challenge, as several research within the health sector), the HPCSA and the largest are required by law to register with the Medical and
studies have been based on incomplete data. This is partly medical professional association – the South African Student interns are those students who are in their final Dental Board of the HPCSA as a medical intern. The
because systematic data on international flows of health Medical Association. year of medical studies whilst medical interns are those internship, which is currently of two years duration, is
workers from South Africa, including to the rest of the performed at government hospitals that are preapproved
continent, have tended to rely on destination country data by the Internship Committee of the Medical and
7. Methods TABLE 4. REGISTER OF MEDICAL PRACTITIONERS,
systems to estimate the extent of emigration of medical Dental Board, in accordance with the provisions of the
MEDICAL AND DENTAL BOARD
doctors from South Africa. Clemens and Pettersson have A survey questionnaire was sent through the South Health Professions Act No. 56 of 1974 (as amended).
previously utilized destination country census data to make African Medical Association to its members. The nine pro- Upon completion of internship, the medical graduate
Number
such an estimation (13). vincial Departments of Health, the national Department Category on is statutorily required to serve an additional year of
of Health, the HPCSA and the South African Medical register community service before they can be sanctioned for
As reported in the authors’ previous study on the sur- Association were contacted for participation in the study. Student clinical associates 582 independent practice. This equates to three years of
gical workforce (1), South Africa still does not have a The nine provincial Departments of Health were included Clinical associates 572 statutory service commitment, which must be performed
systematized mechanism for measuring and monitor- in the study on the basis that they are the biggest direct in public health facilities.
Medical students 13 004
ing emigration of its medical doctors, even though the employing entity of medical doctors for the government.
country formalized its policy on migration of health The HPCSA was included on the basis that it carries the Student interns 1 549 The HPCSA is also responsible for accrediting academic
professionals in 2010 through the adoption of the Policy legislative mandate to maintain the registers of all medi- Medical interns 3 086 medical training programmes of universities. Upon
on the Recruitment and Employment of Foreign Health cal doctors in the country, including those in active prac- Medical practitioners (including specialists) 43 277 fulfilment of the statutory requirements of internship
Professionals in the South African Health Sector. The gov- tice and those no longer practising. The South African and community service, medical doctors practise as
Source: Summary of registered persons: HPCSA statistics (http://www.hpcsa.
ernment-run public health facilities report an average of Medical Association was included on the basis that it is co.za/Publications/Statistics). either general practitioners (GPs) (in the public or private
10 FROM BRAIN DRAIN TO BRAIN GAIN: UNDERSTANDING AND MANAGING THE MOVEMENT OF MEDICAL DOCTORS IN THE SOUTH AFRICAN HEALTH SYSTEM 11
UNDERSTANDING AND MANAGING THE MOVEMENT OF MEDICAL DOCTORS IN THE SOUTH AFRICAN HEALTH SYSTEMsector or both) or as specialists (in either the public or TABLE 7. MEDICAL STOCK INFLOWS (INCLUDING TABLE 9. PERCENTAGE SHARE OF EXPATRIATE MEDICAL WORKFORCE FROM MAIN SOURCE COUNTRIES
private sector or both). The term “general practitioner” BOTH YEARS OF INTERNSHIP) FROM SOUTH AFRICAN
tends to be used to refer to those medical doctors without MEDICAL SCHOOLS, 2011–2015 2011 2012 2013 2014 2015
specialist qualifications who are in private practice, Nigeria 7.39% 7.22% 7.49% 7.33% 7.47%
whilst their counterparts in public service are generally Year 2011 2012 2013 2014 2015 Britain 4.22% 4.90% 5.47% 6.05% 5.69%
referred to as “medical officers”. Previously, there
were medical practitioners who specialized in fields Number 3 862 3 338 3 396 3 280 3 215 Cuba 3.52% 3.77% 3.77% 4.75% 5.34%
such as family medicine but only practised as general Source: HPCSA, 2017. Democratic Republic of the Congo 4.96% 5.05% 5.03% 4.93% 5.00%
practitioners and not as specialists. This was because there Total expatriate medical workforce 5 004 5 066 5 046 5 238 5 164
was no register created for family medicine specialists through joint agreements between universities and the
% of total medical practitioner 20.62% 20.17% 19.50% 19.15% 18.47%
then. That situation has since changed with the formal provincial Departments of Health. These are salaried
workforce
establishment of a family practice register. posts that are the responsibility of the government to
fund. A relationship therefore exists between the HPCSA,
Table 5 shows the number of medical training spaces ap- medical schools and health authorities at provincial level. 9. Distribution of medical Some practitioners perform work overseas on a
proved for new entrants for the years 2011 to 2015. Table 8 shows the posts approved for the years 2011 to temporary basis and therefore see no need to change their
2015 (though numbers for 2011 and 2012 could not be
practitioners in South Africa registration details with the HPCSA. Table 10 shows the
TABLE 5. MEDICAL TRAINING SPACES ON HPCSA SYSTEM determined). One of the challenges that South Africa faces is provincial spread of medical doctors in terms of HPCSA
urbanization, which has consequences for the availability registration and government employment (five provincial
TABLE 8. HPCSA ACCREDITED AND APPROVED POST of services across the country. Registration statistics at Departments of Health).
Year 2011 2012 2013 2014 2015
NUMBERS (INCLUSIVE OF ALL TEACHING HOSPITALS) the HPCSA show that the rural provinces continue to
Number 550 440 550 640 910 be home to fewer medical doctors than urban provinces. Health workforce planning is a critical element of any
Year 2011 2012 2013 2014 2015 Caution must be placed on the reported number of health system planning and the age analysis of the
The undergraduate entrant training spaces are shared be- medical doctors practising in these provinces because workforce plays a major role in managing the workforce
Number No data No data 5 051 5 084 5 297
tween all eight medical schools. The HPCSA records in- it has previously been established that the registration stock inflows and outflows. In the South African
dicate variations in the total number of medical students address is not necessarily the same as the work address. environment, general practitioners ¬– medical doctors
registered over a period of five years (2011–2015) (Table 8.4 Expatriate medical workforce
6). There is still a practice whereby some students can en- South Africa is characterized as both a sending and
TABLE 10. HPCSA MEDICAL OFFICER REGISTER
ter medical training at second year provided they satisfy receiving country – there is an established trend of its
the admission requirements (for example having complet- medical doctors seeking employment overseas, whilst it
Eastern Cape* Western Cape* Gauteng Northern Cape Free State*
ed a science degree). also receives medical doctors to work in its health facili-
ties. All medical doctors wishing to work in South Africa Year Female Male Female Male Female Male Female Male Female Male
TABLE 6. TOTAL NUMBER OF MEDICAL STUDENTS
must abide by the regulations explained earlier. The 2011 459 916 1 451 2 081 2 483 3 578 86 181 278 529
(FIRST TO FINAL YEAR)
HPCSA has a legislative mandate to regulate their reg- 2012 456 883 1 450 2 066 2 434 3 477 84 176 264 522
istration and practice. On an annual basis, the HPCSA
Year 2011 2012 2013 2014 2015 2013 744 1 199 2 262 2 699 3 833 4 565 154 297 470 744
processes applications for registration by medical doc-
tors from over 60 countries from across the world. Table 2014 879 1 258 2 417 2 795 4 123 4 828 159 303 513 762
Number 9 406 10 009 10 719 11 678 12 238
9 shows the proportions of the expatriate medical work- 2015 897 1 259 2 566 2 864 4 242 4 807 165 312 506 770
Source: HPCSA, 2017. force in South Africa represented by medical practi-
tioners from the main identified source countries. The KwaZulu-Natal Mpumalanga Limpopo* North West*
For the corresponding period, the number of medical in- total number of expatriate medical practitioners over Year Female Male Female Male Female Male Female Male
terns on the HPCSA register were as indicated in Table 7. the five-year period studied stabilized at around 5000. 2011 1 135 2 136 354 960 215 499 127 307
A grave concern regarding this register is the percentage
2012 1 085 2 073 340 908 202 489 124 311
Any duly registered medical practitioner can study share of “unknown country of origin” – 2428 (48.52%)
further, depending on availability of specialist training in 2011, 2380 (46.98%) in 2012, 2238 (44.35%) in 2013, 2013 1 930 2 829 384 787 383 790 334 664
posts in the chosen field of study. The Medical and Dental 2530 (48.30%) in 2014 and 2394 (46.26%) in 2015. 2014 2 047 2 948 404 822 409 840 341 693
Board accredits and approves training posts that academic
2015 2 138 2 975 430 812 443 864 365 715
hospitals can have. All academic hospitals are linked
to a medical school. The training posts are regulated Note: Provinces marked (*) are those that responded to the survey.
12 FROM BRAIN DRAIN TO BRAIN GAIN: UNDERSTANDING AND MANAGING THE MOVEMENT OF MEDICAL DOCTORS IN THE SOUTH AFRICAN HEALTH SYSTEM 13
UNDERSTANDING AND MANAGING THE MOVEMENT OF MEDICAL DOCTORS IN THE SOUTH AFRICAN HEALTH SYSTEMFIGURE 2. TABLE 12. AGE PROFILE OF FEMALE AND MALE GENERAL PRACTITIONERS, GAUTENG PROVINCE
AGE PROFILE OF GENERAL PRACTITIONERS, 2012–2015
Age range Sex 2012 2013 2014 2015
5000
Female 280 734 787 982
Below 30
Male 153 385 440 539
4000
Female 1 000 1 584 1 631 1 587
31–40
Male 775 1 180 1 159 1 109
3000 Female 589 813 933 908
41–50
Male 874 1 048 1 132 1 094
2000 Female 330 427 462 462
51–60
Male 668 799 868 850
1000 Female 189 233 269 265
Above 60
Male 835 976 1 051 1 042
Female 46 42 41 38
0 Below 30 31-40 41-50 51-60 Above 60 No DOB
No DOB
Male 172 177 178 173
Female Male Female Male Female Male Female Male Female Male Female Male
Source: HPCSA.
DOB = date of birth 2012 2013 2014 2015
signify an exit from practise or a change in the form rather than the younger generation, that form the
with the basic medical qualification – form the front line of down to an average of about 2000 in the 41–50 age of medical practise. majority on the HPCSA register (Table 13). This may
medical services in both public and private health sectors. range. This contrasts with their male counterparts; be an indication that these practitioners have decided to
Figure 2 shows the age profile of general practitioners on whose numbers remain relatively stable for up to 60 The reason for greater female participation in the physician stay and work permanently in South Africa, an aspect
the HPCSA register for the years 2012 to 2015. No figures years and above. The marked fall in the numbers is workforce in these age ranges was not investigated. Such of importance to the “brain drain” in relation to their
were available for 2011. experienced mostly in the Western Cape and Gauteng an analysis is recommended for a further detailed study, countries of origin. Another finding is that there is an
provinces, as shown in Tables 11 and 12. The shaded perhaps following certain cohorts over a fixed period. increasing proportion of younger women expatriate
A major observation is the dramatic fall in the number figures indicate a greater female participation in the physicians on the register. Table 13 indicates lower
of female general practitioners from an average physician workforce than in any other female age range An analysis of the expatriate general practitioner numbers than appears on the HPCSA register, signifying
of about 4000 in the 31–40 age bracket category, for both Western Cape and Gauteng This could workforce for the same years shows that for both females missing data, consistent with the finding in the study on
and males, it is the age range 41 years to above 60 years, the surgical workforce.
TABLE 11. AGE PROFILE OF FEMALE AND MALE GENERAL PRACTITIONERS, WESTERN CAPE PROVINCE TABLE 13. AGE PROFILE OF EXPATRIATE MEDICAL PRACTITIONERS
Age range Sex 2012 2013 2014 2015 Age range Sex 2012 2013 2014 2015
Female 164 374 402 588 Female 280 734 787 982
Below 30 Below 30
Male 88 215 232 340 Male 153 385 440 539
Female 580 998 1 056 1 018 Female 1 000 1 584 1 631 1 587
31–40 31–40
Male 426 717 720 681 Male 775 1 180 1 159 1 109
Female 330 429 451 451 Female 589 813 933 908
41–50 41–50
Male 436 486 507 501 Male 874 1 048 1 132 1 094
Female 173 250 280 274 Female 330 427 462 462
51–60 51–60
Male 394 476 474 474 Male 668 799 868 850
Female 181 187 204 212 Female 189 233 269 265
Above 60 Above 60
Male 655 739 795 804 Male 835 976 1 051 1 042
Female 22 24 24 23 Female 46 42 41 38
No DOB No DOB
Male 67 66 67 64 Male 172 177 178 173
Source: HPCSA. Source: HPCSA.
14 FROM BRAIN DRAIN TO BRAIN GAIN: UNDERSTANDING AND MANAGING THE MOVEMENT OF MEDICAL DOCTORS IN THE SOUTH AFRICAN HEALTH SYSTEM 15
UNDERSTANDING AND MANAGING THE MOVEMENT OF MEDICAL DOCTORS IN THE SOUTH AFRICAN HEALTH SYSTEM10. Movements by government- The equivalent category of medical officer that practises TABLE 14. MEDICAL OFFICER STOCK IN GOVERNMENT HOSPITALS, 2011–2015
employed medical doctors in the private sector is referred to in the South African
environment as a “general practitioner” (GP). These are Province 2011 2012 2013 2014 2015
Of the nine provinces, five (45.56% of the total population) medical practitioners who own and manage their surger-
686 476 653 677 648
responded to the survey questionnaire. These were Eastern ies as self-employed professionals. The HPCSA register1 Eastern Cape
(2.83%) (1.90%) (2.52%) (2.48%) (2.32%)
Cape, Free State, Limpopo, North West and Western Cape for the corresponding years indicates a large number of 140 112 90 171 62
Free State
provinces. Their population sizes are as follows: Eastern GPs in the provinces (Table 15). (0.58%) (0.45%) (0.35%) (0.63%) (0.22%)
Cape 6 916 200 (12.6%), Free State 2 817 900 (5.1%), 697 652 709 735 776
Limpopo
Limpopo 5 726 800 (10.4%), North West 3 707 000 (6.7%) Whilst the Western Cape province had a large share of (2.87%) (2.60%) (2.74%) (2.69%) (2.78%)
and Western Cape 6 200 100 (11.3%). Several questions medical interns over the 2011 to 2015 period reviewed, 382 392 413 450 511
North West
(1.57%) (1.56%) (1.60%) (1.65%) (1.83%)
relating to placement, resignations, age profile and stock it also exhibited a high number of resignations (Table
903 881 895 860 817
of immigrant doctors were probed. The responses on the 16). This is explained by the fact that junior doctors who Western Cape
(3.72%) (3.51%) (3.46%) (3.14%) (2.92%)
matter of placements are shown in Figure 3. have completed their internship are free to move to other
provinces for their community service. Also, those who TABLE 15. PROVINCIAL GP REGISTER AT HPCSA, NUMBER AND % OF NATIONAL TOTAL
As can be seen, the Western Cape province consistently have just completed community service are free to move
Eastern Cape Free State Limpopo North West Western Cape
places a higher number of medical interns in its hospitals to other provinces, join the private health sector or seek
than any other responding province. Medical interns are work overseas. Year No. % No. % No. % No. % No. %
allocated posts in hospitals on an annual basis so that 2011 1 375 5.66 807 3.32 714 2.94 434 1.79 3 532 14.55
they can fulfil this two-year statutory requirement. Upon As indicated in the authors’ previous study on minimum 2012 1 339 5.33 786 3.13 691 2.75 435 1.73 3 516 14.00
completion of the internship period and community data sets, the South African medical doctors have liberty
2013 1 943 7.51 1 214 4.69 1 173 4.53 998 3.86 4 961 19.17
service, junior doctors join the ranks of medical officers by to work for both the public and private health sectors
either remaining in public health service or opting for the through either sessional contracts with provincial health 2014 2 137 7.81 1 275 4.66 1 249 4.57 1 034 3.78 5 212 19.06
private sector. Table 14 shows the stock in the five provinces departments or through the Policy on Remunerative 2015 2 156 7.71 1 276 4.56 1 307 4.67 1 080 3.86 5 430 19.42
for government-employed medical officers. Work outside Public Service. This policy was developed
TABLE 16. MEDICAL OFFICER RESIGNATIONS ACROSS FIVE PROVINCES (MALE AND FEMALE), 2011–2015
1. The register keeps only registered addresses of practitioners and is therefore
no guarantee that the medical doctor actually practises in that province.
Province 2011 2012 2013 2014 2015
299 255 244 288 342
Eastern Cape
FIGURE 3. (1.23%) (1.02%) (0.94%) (1.05%) (1.22%)
HEALTH PROFESSIONS COUNCIL OF SOUTH AFRICA REGISTERS 2010 TO 2014 50 43 52 68 61
Free State
(0.21%) (0.17%) (0.20%) (0.25%) (0.22%)
200 85 87 60 109 122
Limpopo
(0.35%) (0.35%) (0.23%) (0.40%) (0.44%)
31 19 39 44 30
North West
150 (0.13%) (0.08%) (0.15%) (0.16%) (0.11%)
811 821 807 798 729
Western Cape
(3.34%) (3.27%) (3.12%) (2.92%) (2.61%)
100
TABLE 17. AGE PROFILE OF RESIGNATIONS FROM PUBLIC HEALTH SERVICE IN EASTERN CAPE AND WESTERN
CAPE PROVINCES
50 Eastern Cape Western Cape
Year 2011 2012 2013 2014 2015 2011 2012 2013 2014 2015
0 30 and below 2 20 20 59 69 459 449 435 426 435
Eastern Cape Western Cape Limpopo Free State North West
31–40 134 111 102 94 105 268 318 302 319 276
2011 2012 2013 2014 2015
41–50 84 72 60 63 75 28 23 37 25 21
51–60 35 24 24 34 32 8 11 9 9 5
Above 60 51 41 38 42 60 12 20 24 19 12
16 FROM BRAIN DRAIN TO BRAIN GAIN: UNDERSTANDING AND MANAGING THE MOVEMENT OF MEDICAL DOCTORS IN THE SOUTH AFRICAN HEALTH SYSTEM 17
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