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 SYSTEM
Contents
                                                                                                                                 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                                                 1
Abstract
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).

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    UNDERSTANDING AND MANAGING THE MOVEMENT OF MEDICAL DOCTORS IN THE SOUTH AFRICAN HEALTH SYSTEM
FIGURE 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

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    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 SYSTEM
of 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 SYSTEM
Training 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 SYSTEM
sector 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 SYSTEM
FIGURE 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 SYSTEM
10. 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
   UNDERSTANDING AND MANAGING THE MOVEMENT OF MEDICAL DOCTORS IN THE SOUTH AFRICAN HEALTH SYSTEM
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