SOUTH AFRICAN HEALTH SYSTEM - NURSING AND MIDWIFERY MIGRATION TRENDS IN THE FROM BRAIN DRAIN TO BRAIN GAIN
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CASE STUDY | SOUTH AFRICA
FROM BRAIN DRAIN TO BRAIN GAIN:
NURSING AND MIDWIFERY
MIGRATION TRENDS IN THE
SOUTH AFRICAN
HEALTH SYSTEM
Acknowledgements The authors of this report are Percy Mahlathi and Jabu Dlamini (African Institute of Health & Leadership Development). 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 by the European Union (DCI-MIGR/2013/282-931) and Norad, and coordinated by WHO. The contents of this document are the sole responsibility of the African Institute for Health and Leadership Development, and can under no circumstances be regarded as reflecting the position of the European Union or WHO. © African Institute for Health and Leadership Development, all rights reserved. October 2017
Contents
Abbreviations.......................................................................................................................... 3
Abstract................................................................................................................................. 4
1. Background...................................................................................................................... 5
2. Policy context of nursing in South Africa.............................................................................. 6
3. Nursing workforce context.................................................................................................. 8
4. Education and training of nurses in South Africa................................................................... 9
5. Registration requirements for foreign nurses.......................................................................10
6. Migration of the South African nursing workforce.................................................................12
7. Study objectives...............................................................................................................13
8. Methods..........................................................................................................................13
9. Results...........................................................................................................................13
9.1 Minimum data sets…....................................................................................................13
9.2 Stock of nurses, 2016....................................................................................................13
10. Distribution of nurse practitioners in South Africa................................................................18
11. Movements by South African nurses....................................................................................19
12. Discussion..................................................................................................................... 22
13. Conclusion..................................................................................................................... 25
Acknowledgements..................................................................................................................26
References.............................................................................................................................27
Figure
Figure 1. Organization of nursing leadership: public health service.................................................... 7
Tables
Table 1. Mid-year population estimates by province, 2017................................................................. 5
Table 2. Demographic indicators, 2002–2017................................................................................. 6
Table 3. Selected list of human resources for health policies.............................................................. 8
Table 4. Categories of nursing p6ractitioners ................................................................................. 9
Table 5. Numbers in nurse training categories...............................................................................14
Table 6. Outputs from all SANC...................................................................................................14
Table 7. Outputs from public nursing education institutions.............................................................15
NURSING AND MIDWIFERY MIGRATION TRENDS IN THE SOUTH AFRICAN HEALTH SYSTEM 1Contents (continued) Table 8. Outputs from universities, 2012–2016 (four-year programme)...............................................15 Table 9. Increase in the registers of nurse practitioners, 2012–2016..................................................16 Table 10. Age comparison of new entrants, 2011 and 2016...............................................................16 Table 11. Output of pupil nurses: private nursing institutions, by province, 2012–2016.........................17 Table 12. Output of pupil nurses: public nursing institutions............................................................17 Table 13. SANC registrations by provincial distribution...................................................................18 Table 14. Requests for letters of verification.................................................................................20 Table 15. Foreign nurses registered by SANC.................................................................................20 Table 16. Strategies to mitigate health worker migration.................................................................21 Table 17. Nurse/midwife resignations across provinces, 2012–2016...................................................23 2 FROM BRAIN DRAIN TO BRAIN GAIN:
Abbreviations
CNO Chief Nursing Officer
DENOSA Democratic Nursing Organisation of South Africa
EM Enrolled Midwife
EN Enrolled Nurse
ENA Enrolled Nursing Auxiliary
ESMOE Essential Steps in the Management of Obstetric Emergencies
NQF National Qualifications Framework
OECD Organisation for Economic Co-operation and Development
PHC Primary Health Care
RN/RM Registered Nurse/Midwife
SANC South African Nursing Council
SAQA South African Qualifications Authority
SRN/M Specialist Registered Nurse/Midwife
WHO World Health Organization
NURSING AND MIDWIFERY MIGRATION TRENDS IN THE SOUTH AFRICAN HEALTH SYSTEM 3Abstract 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 equity in the provision of health services. This case study seeks to better understand the patterns of movement of nurses and midwives and the development of associated policies in order to help health authorities to put in place the necessary systemic improvements for effective management of health workforce migration. Objectives. The objectives of the study were (a) to assess the recorded movement of nurses and midwives employed in the public health facilities; and (b) to identify existing policy instruments and practices in place to maximize benefits and mitigate negative consequences of the migration of nurses. Method. Data were collected from the provincial Departments of Health, the South African Nursing Council (SANC), the Democratic Nursing Organisation of South Africa and nursing education institutions through a survey. Follow-up telephonic or face-to-face interviews were conducted where a need was felt for verbal discussion. The data utilized were derived from responses to a survey questionnaire, published data from the SANC website and responses from oral interviews. Results. Data analysis revealed that registered nurses and registered midwives form 34.45% (138 335) of 401 543 nurses appearing on the 2016 SANC register are employed by the provincial Departments of Health. Evidence of widespread migration by South African nurses is difficult to prove empirically despite several previous research studies. Over a five- year period, only 2158 registered nurses requested verification letters from SANC, either directly or through recruitment agencies. Nursing qualifications have undergone a major review and will be implemented in 2020. South African qualified nurses are trained to be generalists with grounded skills in midwifery. When nurses seek work in other countries, they do so utilizing their generalist nursing skills and experience rather than midwifery skills. There is variance between SANC registration data and provincial employment data for nurses. Discussion. The country needs to develop a proactive mechanism to record and manage information regarding the mobility of its nursing workforce. SANC keeps records of nurses but cannot differentiate those in active practice from those in retirement or working overseas. SANC’s policy on foreign-trained nurses, based on the Department of Health’s Policy on the Recruitment and Employment of Foreign Health Professionals in the South African Health Sector, also requires review to align it with the new immigration laws of the country. Refugees and asylum seekers who are nurses form a component of migration but are not often considered in the literature on nurse migration. Given the long- standing interest in the international mobility of South African nurses, this paper advances an argument that migration by South African nurses is not as high as claimed in some studies. The most reliable indicator available currently is the record of requests for letters of verification, which are only issued by SANC. However, data from the Organisation for Economic Co-operation and Development appear to be at odds with SANC data. Key words. emigration, immigration, nurses, midwives, experience, financial gain, foreign-trained nurses, South Africa, SANC 4 FROM BRAIN DRAIN TO BRAIN GAIN:
NURSING AND MIDWIFERY
MIGRATION TRENDS IN THE
SOUTH AFRICAN HEALTH SYSTEM
1. Background hospitals, whilst approximately 16% access health services
through private health facilities. The vast majority of health
This study was undertaken as a follow-up to Minimum professionals that work in public health facilities are nurses.
data sets for human resources for health and the surgical Stand-alone private nursing practices are not a common
workforce in South Africa’s health system: a rapid analysis feature in the South African health system. The South
of stock and migration (1) and From Brain Drain to Brain African Nursing Council (SANC) register shows that as of
Gain: understanding and managing the movement of 17 January 2017 there were 401 543 nurses and midwives
medical doctors in the South African health system (2). eligible to practise nursing in South Africa (4), compared
to 391 517 in 2015.
The South African health system is premised on primary
health care (PHC) services that are delivered through a TABLE 1. MID-YEAR POPULATION ESTIMATES BY PROVINCE, 2017
District Health System. The system is designed to ensure
easy access to health services by every citizen in line with Urban/rural/
Population % of total
the Bill of Rights as enshrined in the Constitution of the nature of
estimate population
Republic of South Africa. With effect from 1996, the gov- province
ernment endeavoured to extend access through a massive Eastern Cape 6 498 700 11.5 Rural
clinic building programme and revitalization of hospitals Free State 2 866 700 5.1 Rural
across the country. The public health service is divided Gauteng 14 278 700 25.3 Urban
into primary, secondary and tertiary care through health Rural but has
facilities that are located in, and managed by, the provin- KwaZulu-Natal 11 074 800 19.6 large urban
centres
cial Departments of Health. The provincial Departments
Limpopo 5 778 400 10.2 Rural
of Health are thus the direct employers of the health
Mpumalanga 4 444 200 7.9 Rural
workforce, including nurses, whilst the national Ministry
of Health is responsible for policy development and Northern Cape 1 214 000 2.1 Rural
coordination. North West 3 856 200 6.8 Rural
Urban but has
Between June 2016 and June 2017, the South African Western Cape 6 510 300 11.5 farming and rural
communities
population is estimated to have grown by 2.85% from
Total 56 521 900 100.0
54 956 900 to 56 521 900 (3). Most people access health
services through the government’s public clinics and Source: Statistics South Africa, 2017.
NURSING AND MIDWIFERY MIGRATION TRENDS IN THE SOUTH AFRICAN HEALTH SYSTEM 5TABLE 2. DEMOGRAPHIC INDICATORS, 2002–2017
Infant Under-5
Crude mortality mortality Crude Rate of
birth rate Life expectancy (years) rate rate death rate natural
(per 1000 (per 1000 (per 1000 (per 1000 increase
Year pop.) Male Female Total pop.) pop.) pop.) (%)
2002 21.7 52.9 56.6 54.9 48.1 71.3 13.4 0.83
2003 21.7 52.5 55.8 54.2 48.1 71.6 14.0 0.77
2004 22.7 52.2 55.3 53.8 48.7 71.8 14.4 0.83
2005 23.4 52.1 54.8 53.5 49.1 72.5 14.8 0.86
2006 24.1 52.3 54.7 53.5 48.7 71.7 14.8 0.93
2007 24.8 53.3 56.1 54.7 47.8 70.1 14.0 1.08
2008 24.8 54.3 57.9 56.1 46.6 67.6 13.0 1.18
2009 24.4 55.0 58.7 56.9 42.8 63.3 12.6 1.18
2010 23.9 56.4 60.6 58.5 41.1 58.4 11.6 1.23
2011 23.5 57.6 62.7 60.2 39.9 54.4 10.7 1.28
2012 23.3 58.5 63.6 61.1 38.8 51.5 10.2 1.31
2013 23.0 59.2 64.6 61.9 37.4 49.1 9.8 1.32
2014 22.7 59.7 65.1 62.5 36.0 47.1 9.6 1.31
2015 22.2 60.0 65.5 62.8 34.0 44.7 9.5 1.27
2016 21.7 60.6 66.1 63.4 33.5 43.6 9.2 1.25
2017 21.3 61.2 66.7 64.0 32.8 42.4 9.0 1.23
Source: Statistics South Africa, 2017.
The health care system consumed about 8.8% of the would be dedicated to nursing issues. The driving force
country’s gross domestic product during 2012 (5). The was a realization and acknowledgement that nursing,
private sector serves about 16% of the population, whilst being the largest component of the health care professions,
the public sector serves 84% (6). The country’s population needed coordination at the highest policy level. Whilst the
distribution indicates that about 64.7% inhabit the crude birth rate has remained fairly constant from 2002
provinces, which are largely rural in nature. Table 2 and (21.7) to 2017 (21.3), there has been a noticeable rate of
Table 3 present population and demographic statistics for natural increase requiring a steady provision of health
South Africa. workers.
There is a realization that the health workforce plays a
2. Policy context of nursing in
critical role in advancing the health system goals (7),
largely driven by a policy position of improving access
South Africa
to health care for all citizens. In the mid-2000s, the The nursing profession is regulated through an act of
nursing profession, through their national association, Parliament – the Nursing Act No. 33 of 2005. This act
the Democratic Nursing Organisation of South Africa replaced the previous Nursing Act No. 50 of 1978. The
(DENOSA), made several representations to the Ministry purpose of the act was to regulate the nursing profession,
of Health for the creation of a post at national level that and to provide for matters connected therewith. It thus
6 FROM BRAIN DRAIN TO BRAIN GAIN:enabled the establishment of the South African Nursing The CNO is supported at provincial level by a director for
Council (SANC) to regulate such matters and spelled nursing practice, whose functions relate to operational
out clear functions that the council must regulate and policy implementation. The director is required to advise
adjudicate upon. the members of the Executive Council for Health and the
head of the Department of Health on all matters relating
Some of SANC’s key objects are (a) to serve and protect to the planning, organization and deployment of nursing
the public in matters involving health services generally services in public clinics and hospitals across the province.
and nursing services in particular; (b) to perform its func- Their counterparts are the principals of the public
tions in the best interests of the public and in accordance nursing colleges, which are located within the provincial
with national health policy as determined by the Minister Departments of Health. The next layer of nursing leadership
of Health; (c) to establish, improve, and control the con- is at health service delivery level, namely hospitals and
ditions, standards, and quality of nursing education and clinics, as depicted in Figure 1.
training within the ambit of the act and any other appli-
cable laws; and (d) to maintain professional conduct and
practice standards for practitioners within the ambit of any FIGURE 1. ORGANIZATION OF NURSING LEADERSHIP:
applicable law. PUBLIC HEALTH SERVICE
SANC is therefore the custodian of nursing education,
training and practice standards. It is required to work in Chief Nursing Officer
concert with the Ministry of Health in matters related to (located at Ministry of Health)
nursing. In that context, the Ministry of Health established
the office of the Chief Nursing Officer (CNO) in 2014
after considering representations from DENOSA. The
major role of the CNO is to provide advice to the Minister
of Health and the members of the Executive Council for
Health in the nine provinces on technical and policy Provincial nursing directors (x9)
matters regarding nursing and health services generally.
The establishment of this office has served to reinforce
the central role that nursing plays in the provision of
health services in South Africa. The location of the office Principals of nursing colleges (x9) and
Nursing managers (hospitals and clinics)
within the Ministry of Health is strategic, as it places
nursing at the centre of health policy development and
coordination at national and global level. The CNO is part
of the country delegation to the World Health Assemblies,
which are held on an annual basis. The CNO therefore A number of policies have been adopted over the years
participates in the global CNO meetings that serve to aimed at improved management of the health workforce
advance the nursing agenda on the global health stage. in South Africa (1, 2). Table 3 presents a set of policy
Positive results have emanated from the establishment and strategy documents relevant to the management of
of CNOs in many WHO Member States, for example the the health workforce, including nursing, that together
inclusion of a chapter on nursing in the Global Strategy on contribute to improved distribution and retention of the
Human Resources for Health: Workforce 2030. workforce, and support implementation of the World
Health Organization (WHO) Global Code of Practice on
At national level, the CNO policy focus areas include the International Recruitment of Health Personnel (8),
placing major emphasis on the centrality of nursing in with the Policy on the Recruitment and Employment of
PHC, for example in the areas of school health, ward-based Foreign Health Professionals in the South African Health
PHC services, and maternal and child health services. Sector being particularly notable.
NURSING AND MIDWIFERY MIGRATION TRENDS IN THE SOUTH AFRICAN HEALTH SYSTEM 7TABLE 3. SELECTED LIST OF HUMAN RESOURCES FOR HEALTH POLICIES
Policy Year Focus/rationale
Human Resource Strategy 2001 Proposals on the definitions, entry requirements, and scope of practice
of all categories of health care professionals
Scarce Skills Allowance 2003 Financial incentive to retain “scarce skills” in the public health service
Remunerative Work outside Public 2002 Incentive scheme allowing public servants to work in the private sector
Service whilst fully employed by government
Human Resources for Health 2006 Highlighting the need for systematic national health workforce
Planning Framework planning
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
Health Service professionals in the public health service
Nursing Strategy 2008 Articulates how nursing education and training, practice, resources,
social positioning, regulation and leadership are planned and linked
together with prescripts of professionalism to support the nation’s
health system
Policy on the Recruitment and 2010 Principles and practices in the employment of health professionals
Employment of Foreign Health who are non-citizens aligned to the immigration processes of the
Professionals in the South African Department of Home Affairs
Health Sector
Human Resources for Health 2011 Focus on planning and staffing of health facilities in preparation for
Strategy the introduction of the National Health Insurance. It built on the
foundation laid by the 2001 Human Resource Strategy and the 2006
Human Resources for Health Planning Framework
National Strategic Plan for Nurse 2012 Develop, reconstruct and revitalize the profession to ensure that
Education, Training and Practice nursing and midwifery practitioners are equipped to address the
disease burden and population health needs within a revitalized
health care system in South Africa
These policies are intended to work in harmony and extend to influence the operations of statutory health councils such as
SANC and education institutions.
3. Nursing workforce context nursing departments located within universities. Nursing
constitutes the largest cadre of the South African health
In recent years, nursing education and training has come workforce.
under the spotlight due to the split mandate between the
National Department of Health and the Department of When the health system was being transformed from 1996
Higher Education and Training. The National Department onwards, the government took a decision to adopt PHC as
of Health is responsible for nursing service provision whilst the preferred system for making health services accessible to
the Department of Higher Education and Training is citizens. The White paper for the transformation of the health
responsible for the education aspects through the Council system (1997) articulated the values that would be pursued
on Higher Education. Nursing education and training in line with the Bill of Rights enshrined in the country’s
takes place at three types of facilities – nursing colleges, Constitution. Nursing is widely regarded as a critical
which are located within provincial Departments of component of the provision of health services. In 2009, a
Health; private nursing schools, which either are attached process for improving PHC, termed the Re-engineering of
to private hospitals or are independent; and university Primary Health Care, was introduced by the Ministry of
8 FROM BRAIN DRAIN TO BRAIN GAIN:Health. It has three strands, namely establishment of ward- According to the current education qualifications
based PHC outreach teams, expansion and strengthening framework (9), four categories of nurses are recognized:
of school health services, and establishment of district enrolled nursing auxiliary (ENA), enrolled nurse (EN),
clinical specialist teams. Nurses play a key role in all these registered nurse/midwife (RN/M), and specialist registered
strands. nurse/midwife (SRN/M). Table 4 indicates the length of
training for each category.
TABLE 4. CATEGORIES OF NURSING PRACTITIONERS (BASED ON CURRENT QUALIFICATIONS)
AND LENGTH OF TRAINING
Qualification category Length of education and training
Enrolled nursing auxiliary (ENA) 1 year
Enrolled nurse (EN) 2 years
Registered nurse/midwife (RN/M) 4 years
Specialist registered nurse/midwife (SRN/M) 1 or 2 years post RN/M training depending, on the post-basic
programme
A nurse who holds any of these qualifications can provide health services in any environment as long as their scope of practice
permits. Thus, nurses are found in every health facility – public and private – where health services are required.
4. Education and training of (c) recommending qualifications or part qualifications to
SAQA for registration.
nurses in South Africa
Education and training of nurses in South Africa is regu- The repeal of the Nursing Act No. 50 of 1978 necessi-
lated by SANC through the Nursing Act No. 33 of 2005. tated a review of nursing qualifications. The unintend-
For a person to be admitted to an academic programme ed consequence of the introduction of the four-year
leading to qualification as a nurse, they need to have suc- Comprehensive Diploma in Nursing through Government
cessfully achieved a grade 12 school pass. This pass is at Notice No. R425 of 22 February 1985 (as amended) was
level 4 of the National Qualifications Framework (NQF) the perception that the programme offered four qualifica-
as defined by the South African Qualifications Authority tions in one, namely general nursing, community health
(SAQA). The NQF is set up in terms of the National nursing, psychiatric nursing and midwifery. In addition,
Qualifications Framework Act No. 67 of 2008, as amend- the registration of a qualified nurse in the current SANC
ed. In terms of the NQF Act, SANC is designated as a register is registered nurse/midwife (RN/M). This also
Quality Council, with responsibilities including (a) devel- gives a perception that the RN/M is a double qualifica-
oping and implementing policy and criteria, taking into tion. The policy intention of the Comprehensive Diploma
account the policy and criteria contemplated in section in Nursing was the production of a generalist nurse with
13(1)(h)(i) of the act, for the development, registration a wide range of relatively superficial competence in order
and publication of qualifications; (b) ensuring the devel- to render a generalist level of care (10). Thus, the mid-
opment of such qualifications or part qualifications as are wifery aspect of the four-year diploma is not a stand-alone
necessary for the sector, which may include appropriate qualification but rather a designation to indicate training
measures for the assessment of learning achievement; and in midwifery. A South African nurse with a four-year
NURSING AND MIDWIFERY MIGRATION TRENDS IN THE SOUTH AFRICAN HEALTH SYSTEM 9Diploma in Nursing (under the current system) is there- planning and implementation of basic nursing care; and
fore expected to possess competencies that can be applied (d) develop writing and oral communication skills.
in the practice of midwifery under general conditions of
nursing practice. These nurses operate at any level of the Diploma in Nursing: Staff Nurse. This diploma will ap-
health service and are not confined to obstetric care. ply evidence-based nursing practice, based on research
or established practices that have proven to be effective
With the enactment of the Nursing Act No. 33 of 2005, both nationally and internationally within the profession.
it became imperative that all nursing qualifications be It will also equip diplomates with a developed sense of eq-
reviewed so that each could be streamlined and operate uity, justice and service ethics that will ensure that they
in harmony with the relevant scopes of practice. These work in an accountable manner, irrespective of their cho-
have now been configured such that the new Diploma in sen workplace.
Nursing will be completed over a three-year period and
confined to the PHC environment where the comprehen- Bachelor’s Degree in Nursing and Midwifery. The
sive generalist competencies will be required (11). A new graduate who completes this qualification will be able
register of specialist nurses will be established and is due to, inter alia, (a) apply knowledge of theory of biological
to come into operation in 2020. The register with the cur- and natural sciences, psychosocial sciences and pharma-
rent (legacy) qualifications will cease to exist at the end cology in the provision of comprehensive nursing and
of 2019. There is therefore heightened activity in prepa- midwifery care; (b) develop, implement and evaluate
ration for the transformation of nursing education and population-based health care; and (c) utilize research in
training in South Africa. nursing and health-related problems to improve health
care outcomes.
The policy imperative is articulated by SANC as follows:
Nursing education and training across South Advanced Diploma in Midwifery. The primary purpose
Africa is responding to changing needs, develop- of this qualification is to produce competent, independent
ments, priorities and expectations in health and and critically thinking midwives who will provide scien-
healthcare. Nurses who acquire the knowledge, tific, safe and comprehensive quality midwifery care to in-
skills and behaviours that meet our standards will dividuals, families and communities within the legal and
be equipped to meet these present and future chal- ethical framework.
lenges, improve health and wellbeing and drive
up standards and quality, working in a range of These academic programmes can be offered at any post-
roles including practitioner, educator, leader and school level – nursing college, technical and vocational
researcher. education training institution, or university – as long as
such an institution has satisfied the accreditation criteria
The review of nursing qualifications was also necessitat- set by SANC.
ed in part by an increasingly complex burden of disease
requiring new competencies among nurses, and by the 5. Registration requirements for
changing post-schooling education landscape as articu- foreign nurses
lated by the NQF. The qualifications are now organized in
the following manner (11): Since 2010 all health professionals from outside South
Africa wishing to work in the country must comply with
Higher Certificate: Auxiliary Nursing. This qualifica- the Policy on the Recruitment and Employment of Foreign
tion aims to (a) produce nurses that will provide basic Health Professionals in the South African Health Sector.
nursing care in all spheres of health care service delivery; This policy was introduced to improve the flow of health
(b) provide the nurse with a wide range of cognitive, affec- professionals into South Africa and expresses the following
tive and psychomotor skills; (c) hone skills in assessment, objectives:
10 FROM BRAIN DRAIN TO BRAIN GAIN:• promote high standards of practice in the recruitment professional bodies must be submitted in order for
and employment of health professionals who are not SANC to conduct a fair and authentic evaluation of a
South African citizens or permanent residents; foreign qualification.
• preclude the active recruitment of health professionals • Complete verification of a foreign qualification is
from developing countries unless there are specific required before it is recognized as authentic.
government-to-government agreements to allow and
support such recruitment. The categories that are envisaged in the policy are applicants
who:
The policy was crafted such that it is complementary to the
Immigration Act and other laws, and is consistent with the • hold a foreign qualification and wish to undergo basic/
country’s Constitution. SANC has in turn developed and undergraduate nurse training and education in South
adopted policy guidelines regarding registration of inter- Africa;
nationally qualified nurses and midwives and/or foreign
qualifications with SANC. The policy emphasizes the fact • hold a foreign qualification and wish to pursue
that SANC is responsible for the regulation of the nurs- postgraduate studies in South Africa;
ing profession in South Africa. In executing the function
of registration of foreign nurses and qualifications from • wish to do elective practicums in South Africa in order
foreign countries, SANC takes cognizance of the Policy to gain experience in a specific area of practice;
on the Recruitment and Employment of Foreign Health
Professionals in the South African Health Sector (12). In • wish to do voluntary work or research in South Africa;
pursuit of this function, SANC processes applications from
foreign nurses and midwives who hold qualifications from • wish to be registered for employment after successful
a foreign country as well as South Africans who hold qual- completion of postgraduate studies in South Africa.
ifications from a foreign country.
Foreign nationals who wish to be employed in South Africa
The fundamental principle is that “the evaluation of for- as nurses must submit to SANC the following documents:
eign qualifications by SANC considers all South African
National Qualifications Framework related legislation, • letter of intent/application;
regulations and policies”. The policy guidelines further em-
phasize that “where substantial difference exists and can be • letter of support from the National Department of
demonstrated between foreign and local qualification, it re- Health’s Foreign Workforce Management Programme;
mains SANC’s decision (prerogative) to recognize a foreign
qualification at the designated NQF level”. Furthermore, • certificate of English language proficiency from an
SANC reserves the right to revoke a certificate of profes- accredited institution (applicable only to applicants
sional registration should any evidence come to light that whose nursing education was not done in English);
compromises its integrity and validity (12).
• evaluation certificate of foreign educational qualification
The guidelines advance the following requirements for a by SAQA;
nurse affected by this policy:
• certified copy of registration by the regulatory body
• Applicants must provide SANC with a complete and from the country of origin;
credible set of documents to enable evaluation.
• certified copy of qualification certificate;
• Relevant information from foreign institutions and
NURSING AND MIDWIFERY MIGRATION TRENDS IN THE SOUTH AFRICAN HEALTH SYSTEM 11• valid licence to practise as a nurse from the nurse’s reg- council or board recognized by SAQA in terms
ulatory body where the applicant’s nursing qualification of section 13(1)(i) of the National Qualifications
was registered; Framework Act; and
• record of education and training (transcript) from the c) proof of evaluation of the expatriate qualification
nursing education institution in the country of origin; by SAQA and translated by a sworn translator into
one of the official languages of the Republic (of
• verification certificate from the regulatory body of South Africa).
the country of origin confirming that the applicant is
in good professional standing and has no professional (6) A critical skills work visa shall be issued for a period not
misconduct cases pending against her/him (except for exceeding five years.
refugees);
(7) A spouse and dependent children of a holder of a crit-
• letter of competence from the last employer; ical skills work visa shall be issued with an appropriate
visa valid for a period not exceeding the period of valid-
• police clearance letter from the country of origin (ex- ity of the applicant’s critical skills work visa.
cept for refugees).
Section 18(3)(iii) of the Immigration Act also prescribes
The exclusion of refugees from some of these requirements that the salary and benefits of the applicant are not inferi-
is based on the provisions of South Africa’s Refugees Act or to the average salary and benefits of citizens or perma-
No. 130 of 1998, as amended, which aims to protect those nent residents occupying similar positions in South Africa.
who come to South Africa because of persecution in their This is also in line with the provisions of the Occupation-
countries. However, a work permit or formal recognition of Specific Dispensation policy, which regulates how health
refugee status issued by the Department of Home Affairs professionals in the public health service are remunerated.
must be produced. In the case of employment, once all con-
ditions set by SANC have been satisfied, and once appoint- There is acknowledgment that the National Department
ed to a post, an expatriate nurse is entitled to the same sala- of Health’s Policy on the Recruitment and Employment of
ry and benefits pertaining to the post as any South African Foreign Health Professionals in the South African Health
counterpart who occupies a similar post. This is in line with Sector requires urgent review so that it is completely in line
section 18 of the Immigration Act, which states that: with the amended Immigration Act of 2014. In addition,
prevalent health workforce shortages have rendered some
(5) An application for a critical skills work visa shall be ac- of the clauses of the policy irrelevant, for example princi-
companied by proof that the applicant falls within the ple 5, which states that the employment of expatriate health
critical skills category in the form of – professionals shall only be allowed after they have been
successful in competing for an advertised post and there is
a) a confirmation, in writing, from the profession- record that no South African citizen or permanent resident
al body, council or board recognized by South was available or found suitable to fill the particular post.
African Qualifications Authority (SAQA) in terms When faced with critical shortages, this clause is unlikely
of section 13(1)(0) of the National Qualifications to be adhered to.
Framework Act, or any relevant government
Department confirming the skills or qualifications
6. Migration of the South African
of the applicant and appropriate post qualification
experience;
nursing workforce
The migration of South African medical professionals has
b) if required by law, proof of application for a cer- been a subject of discussion for a considerable period.
tificate of registration with the professional body, Many studies have been conducted and have advanced
12 FROM BRAIN DRAIN TO BRAIN GAIN:varying estimates of emigration by health professionals 8. Methods
in the African continent (13–15). Several causes of
migration by health professionals have also been recorded. A survey questionnaire was sent through SANC, the
Measuring the extent of emigration – particularly by South nursing directors of the nine provincial Departments
African nurses – remains a challenge, as several research of Health, the principals of the nursing colleges locat-
studies have been based on incomplete data. Previously, ed within the provincial Departments of Health, and
challenges have been reported relating to collection of DENOSA. The nine provincial Departments of Health
systematic data on international flows of health workers were included in the study on the basis that they are the
from South Africa, including to the rest of the continent, biggest direct employing entity of nurses. SANC was in-
resulting in a tendency to rely on destination country data cluded on the basis that it carries the legislative mandate
systems to estimate the extent of emigration of medical to maintain the registers of all nurses in the country,
doctors from South Africa (2). Clemens and Pettersson including those in active practice and those no longer
have previously utilized destination country census data practising. DENOSA was included on the basis that it is
to make such an estimation (15). an umbrella organization of nurses, and the nursing col-
leges and universities on the basis that they are respon-
As reported in the authors’ previous study on the sible for the training of nurses. The Society of Midwives
surgical workforce and management of migration by of South Africa was also included in the study. A face-
medical doctors (1, 2), South Africa still does not have a to-face interview was held with the CNO to discuss and
systematized mechanism for measuring and monitoring explore various policy issues relating to nursing and the
emigration of its health professionals. SANC has a system role of her office.
of issuing verification letters for nurses who request
these for purposes of seeking employment overseas. Each respondent was sent a questionnaire to complete
However, even this method does not accurately estimate and, based on the responses, telephonic follow-up in-
the number of nurses who end up taking employment in terviews were conducted for further explanations or
other countries. closure of gaps in the information supplied. Guiding
the research data-gathering process was a protocol de-
Due to the difficulty of producing empirical evidence, veloped by the Global Health Workforce Alliance that
some studies have resorted to making deductions based provided a list of minimum data sets against which to
on “intention to leave” of respondents (16, 17). match responses.
7. Study objectives 9. Results
The objectives of the study were to: 9.1 Minimum data sets
In relation to the minimum data sets, no data elements
(a) assess the recorded movement of nurses employed in were probed, as the previous study responses (1) were
the public health facilities; deemed to be still relevant.
(b) identify existing policy instruments and practices in 9.2 Stock of nurses, 2016
place to maximize benefits and mitigate negative con- The major data source was SANC, which maintains a
sequences of the migration of nurses. register of all student nurses and qualified nurses that
are licensed to practise in South Africa. The second
The study also sought to identify whether any synergies source was the provincial Departments of Health.
or gaps existed between the workforce data systems of
provincial Departments of Health (the major employer As of 31 January 2017, the register of individuals
within the health sector), SANC and the national nursing undergoing training to be nurses as student nurses, pupil
association – DENOSA. nurses, or pupil nursing auxiliaries was as indicated in
NURSING AND MIDWIFERY MIGRATION TRENDS IN THE SOUTH AFRICAN HEALTH SYSTEM 13Table 5. These students are admitted for training at any time and does not include those who are in bridging
of the nursing education institutions – public nursing programmes or supplementary basic programmes.
college, private nursing school or university. Whilst all
nursing education institutions are in the post-schooling Tables 6, 7 and 8 present data on outputs from
system, admission criteria are not necessarily the same. various types of training institutions for the period
All universities utilize a point system for admission 2012–2016.
into their academic programmes. However, the point
requirements differ for each programme. Upon qualification as a nurse/midwife, these
professionals must maintain their names in the register
The table reflects the number of persons entering the by paying an annual registration fee. SANC is the
nursing profession (as students or pupils) for the first statutory body responsible for maintaining the integrity
TABLE 5. NUMBERS IN NURSE TRAINING CATEGORIES, 2012–2016
Category 2012 2013 2014 2015 2016
Student nurses and midwives 20 920 20 956 21 303 20 549 21 339
Pupil nurses 16 424 15 337 18 767 18 846 10 773
Pupil nursing auxiliaries 5 910 6 747 8 549 9 312 2 990
TABLE 6. OUTPUTS FROM ALL SANC ACCREDITED NURSING EDUCATION INSTITUTIONS, 2012–2016 (FOUR-YEAR
PROGRAMME)
Province 2012 2013 2014 2015 2016
Eastern Cape 502 549 558 542 558
Free State 147 174 153 228 236
Gauteng 757 793 842 806 774
KwaZulu Natal 604 586 630 486 515
Limpopo 339 220 271 312 343
Mpumalanga 120 197 145 36 322
Northern Cape 3 0 0 24 25
North West 297 322 230 350 347
Western Cape 456 420 392 507 408
Yearly totals 3 225 3 261 3 221 3 291 3 528
14 FROM BRAIN DRAIN TO BRAIN GAIN:TABLE 7. OUTPUTS FROM PUBLIC NURSING EDUCATION INSTITUTIONS, 2012–2016 (FOUR-YEAR PROGRAMME)
Category 2012 2013 2014 2015 2016
Eastern Cape 375 407 411 367 358
Free State 98 139 121 169 165
Gauteng 647 680 742 670 681
KwaZulu Natal 534 524 506 370 316
Limpopo 230 148 177 196 218
Mpumalanga 120 197 145 36 322
Northern Cape 62 56 3 24 25
North West 237 265 166 259 275
Western Cape 229 250 213 301 243
TABLE 8. OUTPUTS FROM UNIVERSITIES, 2012–2016 (FOUR-YEAR PROGRAMME)
Province 2012 2013 2014 2015 2016
Eastern Cape 127 142 147 175 200
Free State 49 35 32 59 71
Gauteng 110 113 100 136 93
KwaZulu Natal 70 62 124 116 199
Limpopo 109 72 94 116 125
Mpumalanga No university-based programme
Northern Cape No university-based programme
North West 297 322 230 350 347
Western Cape 456 420 392 507 408
of the register. Table 9 shows the increase in numbers of Over the same comparable period, the population of
various registered categories. South Africa increased from approximately 47.850
million in 2007 to 55.909 million in 2016, an increase
The age analysis of students entering nurse training of 16% (Statistics South Africa, midyear estimate).
for the first time indicates the continued popularity of SANC compiles and publishes its statistics annually on
the profession to South Africans. A contributing factor 31 December. Upon completion of training nurses have
may be that it remains one of the few professions that to perform community service, which amounts to one
the government still takes responsibility for in terms year working in the public health service. This system
of providing funding for studies. Table 10 shows the commenced with medical interns and was extended to
comparative ages of new entrants to various courses. nurses as from 2006. This is performed in terms of section
NURSING AND MIDWIFERY MIGRATION TRENDS IN THE SOUTH AFRICAN HEALTH SYSTEM 1540(1) of the Nursing Act, 2005, which states: “A person Health workforce planning is a critical element of any
who is a citizen of South Africa intending to register health system planning, and the age analysis of the
for the first time to practise a profession in a prescribed workforce plays a major role in managing the workforce
category must perform remunerated community service stock inflows and outflows. Nurses form the front line
for a period of one year at a public health facility.” The of health services in the public health sector. Evidence
associated Regulation 2.1 of the Regulations Relating to shows that the private nursing schools contribute
Performance of Community Service states: “Any person significant numbers of nurses to the health system
who is a citizen of South Africa intending to register for through the training of current staff nurses. Table 11
the first time as a professional nurse in terms of the Act, shows the output of pupil nurses from private nursing
as having met the prescribed requirements to qualify as institutions by province, 2012–2016, while Table 12
such, must perform remunerated community service for shows the output of pupil nurses from public nursing
a period of one year.” These regulations pertain to South institutions for the same period.
African citizens and permanent residents. Exemption
will be granted to persons who may have performed a
similar service elsewhere (12).
TABLE 9. INCREASE IN THE REGISTERS OF NURSE PRACTITIONERS, 2012–2016
Category 2012 2013 2014 2015 2016
RN/RM 124 045 129 015 133 127 136 854 140 598
EN/EM 58 722 63 788 66 891 70 300 73 558
ENA 65 969 67 895 70 419 71 463 73 302
RN/RM = registered nurses and registered midwives; EN/EM = enrolled nurses and enrolled midwives; ENA = enrolled nursing auxiliaries.
TABLE 10. AGE COMPARISON OF NEW ENTRANTS, 2011 AND 2016
Average age Minimum age Maximum age No.
Course 2011 2016 2011 2016 2011 2016 2011 2016
4-Yr Diploma 25 23 15 15 57 56 4 649 4 922
Bridging 36 36 20 21 61 62 3 051 5 131
Psychiatry 46 45 27 30 60 60 111 114
Midwifery 44 43 25 24 66 62 1 108 1 506
EN-Gen 30 34 17 18 60 60 7 622 845
EN-Comm 37 37 26 24 61 58 142 55
EN-Aged Care – 34 – 20 – 45 – 4
EN-Psy 39 38 27 38 53 38 41 2
AN 29 32 20 18 61 55 4 374 518
CHATC (PHC) 41 41 24 24 64 63 314 789
EN-Gen = enrolled nurse general; EN-Comm = enrolled nurse community health; EN-Psy = enrolled nurse psychiatry; AN = assistant nurse; CHATC = clinical nursing
science, health assessment, treatment and care.
16 FROM BRAIN DRAIN TO BRAIN GAIN:TABLE 11. OUTPUT OF PUPIL NURSES: PRIVATE NURSING INSTITUTIONS, BY PROVINCE, 2012–2016
Province 2012 2013 2014 2015 2016
Eastern Cape 195 211 246 406 271
Free State 41 62 57 66 65
Gauteng 1 978 2 345 1 998 2 848 2 414
KwaZulu-Natal 2 448 2 951 2 301 2 633 2 332
Limpopo 99 120 132 108 99
Mpumalanga 34 46 25 32 24
Northern Cape 0 0 0 0 0
North West 103 183 153 126 141
Western Cape 345 387 260 478 426
Yearly totals 5 243 6 305 5 172 6 697 5 772
TABLE 12. OUTPUT OF PUPIL NURSES: PUBLIC NURSING INSTITUTIONS, BY PROVINCE, 2012–2016
Province 2012 2013 2014 2015 2016
Eastern Cape 501 416 377 582 593
Free State 173 129 154 191 192
Gauteng 540 802 394 333 435
KwaZulu-Natal 536 634 297 199 8
Limpopo 409 162 134 237 246
Mpumalanga 211 271 216 262 399
Northern Cape 0 0 0 0 0
North West 1 23 41 71 82
Western Cape 119 212 164 184 152
Yearly totals 2 490 2 649 1 777 2 059 2 107
Note: Pupil nurses are those nurses who study towards the registration qualifications of enrolled nurse and enrolled nurse assistant.
NURSING AND MIDWIFERY MIGRATION TRENDS IN THE SOUTH AFRICAN HEALTH SYSTEM 1710. Distribution of nurse The figures in Table 13 indicate that the provinces of
Gauteng, KwaZulu-Natal and Western Cape share be-
practitioners in South Africa tween them more than 60% of the country’s RN/RM reg-
One of the challenges that South Africa faces is urbaniza- istrations. Similarly, these provinces share about 52% of
tion, which has consequences for the availability of ser- the student nurse population amongst them. These pro-
vices across the country. Registration statistics at SANC vincial distribution figures are based on registration data
show that the highest number of registrations is in three at SANC and do not reflect accurately the place of em-
out of nine provinces. This does not necessarily mean that ployment of each nurse. SANC also does not keep a regis-
all those nurses are working in those provinces, as the ter based on the employment status of anyone appearing
SANC database is not linked to the employee databases in its register.
of the Departments of Health in the provinces. Table 13
shows the provincial spread of nurses in terms of SANC
registration, but not necessarily employment.
TABLE 13. SANC REGISTRATIONS BY PROVINCIAL DISTRIBUTION, AS AT 31 DECEMBER 2016
Registered Enrolled Auxiliary
Province Sex nurses nurses nurses Total Students Pupils Pupil NAs
Eastern Cape
Female 13 975 5 244 6 563 25 782 2 596 911 351
Male 1 588 873 1 216 3 677 1 160 289 136
Total 15 563 6 117 7 779 29 459 3 756 1 200 487
(11.07%) (8.32%) (10.61%) (10.25%) (17.6%) (11.14%) (16.29%)
Free State
Female 7 103 2 066 2 828 11 997 971 151 63
Male 1 102 416 359 1 877 242 25 16
Total 8 205 2 482 3 187 13 874 1 213 176 79
(5.84%) (3.37%) (4.35%) (4.83%) (5.68%) (1.63%) (2.64%)
Gauteng
Female 34 024 17 263 18 553 69 840 3 829 3 583 1 055
Male 2 579 1 471 1 214 5 264 908 350 95
Total 36 603 18 734 19 767 75 104 4 737 3 933 1 146
(26.03%) (25.47%) (26.97%) (26.12%) (22.2%) (36.51%) (38.33%)
KwaZulu Natal
Female 28 609 22 755 12 759 64 123 2 650 3 459 522
Male 2 999 2 537 1 302 6 838 981 546 84
Total 31 608 25 292 14 061 70 961 3 631 4 005 606
(22.48%) (34.38%) (19.18%) (24.68%) (17.02%) (37.17%) (20.27%)
Limpopo
Female 10 355 5 965 9 224 25 544 1 376 119 85
Male 1 498 652 838 2 988 519 27 11
Total 11 853 6 617 10 062 28 532 1 895 146 96
(8.43%) (9%) (13.73%) (9.93%) (8.88%) (1.36%) (3.21%)
(continued)
18 FROM BRAIN DRAIN TO BRAIN GAIN:TABLE 13. (continued)
Registered Enrolled Auxiliary
Province Sex nurses nurses nurses Total Students Pupils Pupil NAs
Mpumalanga
Female 6 621 3 179 3 579 13 379 650 119 74
Male 881 310 245 1 436 341 20 26
Total 7 502 3 489 3 824 14 815 991 139 100
(5.34%) (4.74%) (5.22%) (5.15%) (4.64%) (1.29%) (3.34%)
Northern Cape
Female 2 085 407 978 3 470 196 - 74
Male 199 45 97 341 68 - 43
Total 2 284 452 1 075 3 811 264 - 117
(1.62%) (0.61%) (1.47%) (1.33%) (1.24%) (0%) (3.91%)
North West
Female 8 555 3 095 4 430 16 080 1 585 329 67
Male 1 290 329 579 2 198 486 37 17
Total 9 845 3 424 5 009 18 278 2 071 366 84
(7.00%) (4.66%) (6.83%) (6.36%) (9.71%) (3.4%) (2.81%)
Western Cape
Female 15 841 6 516 7 967 30 324 2 229 704 246
Male 1 294 435 571 2 300 552 104 29
Total 17 135 6 951 8 538 32 624 2 781 808 275
(12.19%) (9.45%) (11.64%) (11.35%) (13.03%) (7.5%) (9.2%)
100% of workforce 140 598 73 558 73 302 287 458 21 339 (7.5%) 2 990
(%) of national nursing workforce in each column.
11. Movements by South interest irrespective of the accuracy or inaccuracy of reports
about it. The issue that evokes most public emotions is per-
African nurses ceived emigration by highly skilled nurses. On 2 February
The majority of South African nurses are employed in 2016, a local newspaper published the following story with
the public health service, with the provinces of Gauteng, the headline “Nurses leaving SA in droves”:
KwaZulu-Natal and Western Cape taking the bulk of More and more South African nurses are taking
these. Up to 1994 it was not easy for nurses to seek work their skills and knowledge abroad for the promise
overseas. However, this changed when the country elected of more pay and better working conditions. This
a democratic government. This enabled all citizens to has plunged the country’s healthcare sector and
have freedom of movement and work, as enshrined in the nursing profession deep into crisis, the Pretoria
Constitution of the Republic of South Africa, section 22 News learnt on Monday. The hardest-hit victims of
of the Bill of Rights, which states: “Every citizen has the the exodus are children, the sick, poor and elderly
right to choose their trade, occupation or profession freely. and those who live in areas where healthcare
The practice of a trade, occupation or profession may be was already scarce, stakeholders said. Hundreds
regulated by law.” of thousands of well-trained and highly skilled
professional nurses were working in countries
The movement of South African nurses has remained a such as the UK, Canada and Arab countries. (18)
sensitive topic since 1995. It is a matter that evokes public
NURSING AND MIDWIFERY MIGRATION TRENDS IN THE SOUTH AFRICAN HEALTH SYSTEM 19However, close scrutiny of SANC records (letters of veri- nursing stock were 488 (0.378%) for 2013, 501 (0.376%)
fication) revealed the opposite. Over the past five years, for 2014, 388 (0.284%) for 2015, and 501 (0.356%) for
only 2158 requests for letters of verification were processed 2016. These have been calculated for categories 1 to 5
by SANC. Table 14 provides a breakdown of numbers by and 8 to 9 of table 16 and fall within the RN/RM regis-
country. tration category of SANC. Some of these foreign nurses
are recruited under special permit conditions to work
The numbers of foreign nurses in South Africa (as regis- in private hospitals, such as those operated by Netcare.
tered by SANC) and percentages of total South African Zimbabwe also contributes to the pool of foreign nurses.
TABLE 14. REQUESTS FOR LETTERS OF VERIFICATION WITH COUNTRY DESTINATIONS, 2012–2016
Country 2012 2013 2014 2015 2016 5-year totals
Abu Dhabi 25 13 31 7 12 88
Australia 106 43 66 54 75 344
Bahrain – 9 2 3 3 17
Botswana 7 – – – – 7
Canada 33 21 33 1 1 89
Ireland 3 4 11 10 15 43
Namibia 17 7 15 5 10 54
New Zealand 41 10 20 26 37 134
Qatar 12 – – – – 12
United Kingdom 45 21 59 81 132 338
United States of America 59 23 18 62 78 240
Zimbabwe – – – – 7 7
Other countries 30 14 101 127 98 370
Agencies – – 230 83 102 415
Totals 378 165 586 459 570 2 158
Source: SANC, 2017.
TABLE 15. FOREIGN NURSES REGISTERED BY SANC, BY CATEGORY, 2012–2016
Programme 2012 2013 2014 2015 2016 5-year Totals
1. General nurse – 373 426 313 419 1 531
2. General nurse and psychiatry – 4 4 6 4 18
3. General nurse and midwifery/accoucheur – 102 62 50 71 285
4. Psychiatric nursing science – 3 – 2 1 6
5. Midwifery – 4 8 17 6 35
6. Enrolled nurse – 3 5 4 2 14
7. Enrolment as a nursing auxiliary – 2 1 4 – 7
8. General nurse, psychiatric nurse and midwife – 1 1 – – 2
9. General nurse, midwife community health – 1 – – – 1
20 FROM BRAIN DRAIN TO BRAIN GAIN:The fact that a nurse has requested that a verification skilled health workers primarily use migratory routes for
be sent to a potential employer or a recruitment agency professional development, suggesting that health worker
does not necessarily mean that she or he has taken up the shortages as a result of permanent migration no longer
offer of a position in another country. The news report pertain to South Africa. Temporary migration of South
cited above (18) is also contradicted by other empirical African health professionals motivated by professional
studies that have been conducted on health worker mi- development and short-term financial reasons is an es-
gration in South Africa. Based on their study, Labonté et tablished phenomenon (2).
al. concluded that even though in the recent past South
Africa’s health worker shortages as a result of emigration Recent research suggests that “moonlighting” (having a
were viewed as significant and harmful, currently domes- second job in addition to a primary job) is a predictor
tic policies to improve health care and the health work- of nurses’ intention to leave South Africa (19). This re-
force, including such innovations as new skilled health search is also inconclusive about the real migration of
worker cadres and Occupation-Specific Dispensation nurses out of South Africa, either on a temporary or on
policies, appear to have served to decrease skilled health a long-term basis. However, the most promising initi-
worker shortages to some extent (17). They further atives to mitigate health worker migration and associ-
observed that there are indications that South African ated shortages of health workers are those undertaken
TABLE 16. STRATEGIES TO MITIGATE HEALTH WORKER MIGRATION AND ADDRESS HEALTH WORKER
SHORTAGES IN SOUTH AFRICA
Scope Strategy
Global agreements Commonwealth Code (2003)
Health Worker Migration Initiative (2007)
WHO Global Code of Practice on the International Recruitment of
Health Personnel (2010)
Domestic policy statements on migration South Africa’s policy statements on health worker immigration (2001,
2006)
Bilateral agreements United Kingdom/South Africa memorandum of understanding (2003)
Cuba (1996)
Germany
Tunisia (1999 and 2007 technical agreements)
Islamic Republic of Iran (2004)
United States PEPFAR/Medical and Nursing Education Partnership
Initiative (2013)
Destination country agreements with potential to United Kingdom Code of Practice for the Ethical Recruitment of
impact South African migrants International Healthcare Professionals (2004)
South African initiatives to prevent migration Examples include:
by improving health system human resources • increasing skilled health worker production
for health and living and working conditions for
• student sponsorship programmes
health workers
• community service programme
• new skilled health worker cadres
• task shifting
• African health placements
• Occupation-Specific Dispensation
Source: Labonté et al. (17).
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