This Draft Human Resources for Health (HRH) Strategy for South Africa was developed through reviewing policy and research reports and consolidating them in consultation with key informants. It addresses a range of issues affecting HRH in South Africa including: sectoral analysis by professional category and the costs; skills mix; level of human resources; equity and maldistribution; factors affecting shortages; provincial HR and Service Transformation (STP) plans and their use in workforce planning, the re-engineered primary health care (PHC) approach and its impact on HRH, retention and recruitment issues, and management and leadership. The draft strategy also provides projections on future staffing needs, how these quotas will be filled and projected training and educational requirements.
Human Resources
This paper discusses gender issues manifested within health occupations and across them. It examines gender dynamics in medicine, nursing, community health workers and home carers and explores from a gender perspective issues concerning delegation, migration and violence, which cut across these categories of health workers. Gender plays a critical role in determining the structural location of women and men in the health labour force and their subjective experience of that location. The paper shows that woman are overrepresented in caring, informal, part-time, unskilled and unpaid work and within occupations there are significant gender differences in terms of employment security, promotion, remuneration.
This desk review notes a lack of sex-disaggregated data, which hides the presence of women in the health workforce or misrepresents their work. Gender also influences the structural location of women and men in health occupations, resulting in significant gender differences in terms of employment security, promotion, remuneration etc. These differences are neither static nor universal, so they need to be analysed and monitored in changing national contexts, specific health system circumstances and by other social determinants. Recommendations include monitoring delegation, implementing strategies to address gender inequalities (such as affirmative action and training), halting the gender bias that questions the personal and professional prestige of women health workers and recognising home-based care efforts, which are mostly shouldered by women. Source and recipient countries must do more to retain local nursing staff, and recognise violence in the health work place. Individual efforts by women and men must be constructively and collectively amplified through policy and programme efforts at higher and broader levels in health systems.
According to this article, health worker density/100,000 population is substantially lower in South Africa compared to the vast majority of countries against which South Africa is benchmarked, including the BRIC (Brazil, Russia, India and China) countries. The existing higher education sector is unable to meet the graduate output required by the health sector while foreign recruitment is constrained by current legislation on the registration and practice of foreign healthcare professionals by the Professional Councils and the WHO Global Code of Practice on the International Recruitment of Health Personnel. Existing and future health workforce production is not commensurate with the healthcare needs of the country. A number of challenges are identified: health challenges have outpaced curriculum reform; fragmented, outdated, static curricula produce ill-equipped health graduates; there are episodic encounters as opposed to a continuum of care; healthcare is hospi-centric as opposed to primary healthcare based; there is narrow technical focus without contextual understanding; there exists a mismatch of competencies and patient/population needs; and there is poor teamwork. Solutions to barriers related to the quantitative aspect of health workforce production in South Africa are presented in the article.
This report presents the findings and recommendations of the Joint Learning Initiative (JLI). The report highlights major global challenges in human resources for health. These include: global shortages of skilled workers; skill imbalances in existing workers; poor distribution of services worsened by increased migration; poor work environments; and a weak knowledge base. The findings show that effective workforce strategies, including community action and country leadership, enhance the performance of health systems even under difficult circumstances. The authors call for immediate action to harness the power of health workers, which must be country based and led.
The World Health Organization defines a “critical shortage” of health workers as being fewer than 2.28 health workers per 1000 population and failing to attain 80% coverage for deliveries by skilled birth attendants. The authors aimed to quantify the number of health workers in five African countries and the proportion of these currently working in primary health care facilities, to compare this to estimates of numbers needed and to assess how the situation has changed in recent years. This study is a review of published and unpublished “grey” literature on human resources for health in Mali, Sudan, Uganda, Botswana and South Africa. Health worker density has increased steadily since 2000 in South Africa and Botswana which already meet WHO targets but has not significantly increased since 2004 in Sudan, Mali and Uganda which have a critical shortage of health workers. In all five countries, a minority of doctors, nurses and midwives are working in primary health care, and shortages of qualified staff are greatest in rural areas. In Uganda, shortages are greater in primary health care settings than at higher levels. Even South Africa has a shortage of doctors in primary health care in poorer districts. Although most countries recognize village health workers, traditional healers and traditional birth attendants, there are insufficient data on their numbers. There is an “inverse primary health care law” in the countries studied: staffing is inversely related to poverty and level of need, and health worker density is not increasing in the lowest income countries. Unless there is money to recruit and retain staff in these areas, training programmes will not improve health worker density because the trained staff will simply leave to work elsewhere. The author argues that information systems need to be improved in a way that informs policy on the health workforce. It may be possible to use existing resources more cost-effectively by involving skilled staff to supervise and support lower level health care workers who currently provide the front line of primary health care in most of Africa.
Many decision-makers readily point to human resource problems as the chief bottleneck they face in attempting to scale up health systems. Yet time and again the reform agenda neatly skirts around the sensitive and difficult issues involved—not least because there are major gaps in the knowledge base required for a realistic workforce strategy. This editorial of the World Health Organisation Bulletin provides an overview of the role of human resources within the health sector, regardless of whether it is public or private. The editorial discusses the importance of human resources management within the health sector, and suggests that policy-makers and donors concerned with human resources problems may want to request those proposing a major new project or policy to make a systematic and formal ‘human resource impact assessment’ during its preparation. Such assessments would examine the likely effects of the proposed project or policy on the health workforce.
In this study, the authors quantify the number of HIV health workers (HHWs) required to be added to the current HIV workforce to achieve universal access to HIV treatment in South Africa, under different eligibility criteria. They performed a time and motion study in three HIV clinics in a rural, primary care-based HIV treatment program in KwaZulu-Natal, South Africa, to estimate the average time per patient visit for doctors, nurses, and counselors. They estimated that, for universal access to HIV treatment for all patients with a CD4 cell count of less than or equal to 350 cells/muL, an additional 2,200 nurses, 3,800 counselors, and 300 doctors would be required, at additional annual salary cost of R929 million, equivalent to US$ 141 million. For universal treatment ('treatment as prevention'), an additional 6,000 nurses, 11,000 counselors, and 800 doctors would be required, at an additional annual salary cost of R2.6 billion (US$ 400 million). Universal access to HIV treatment for patients with a CD4 cell count of less than or equal to 350 cells/mul in South Africa may be affordable, but the number of HHWs available for HIV will need to be substantially increased. Unfortunately, treatment as prevention strategies will require considerable additional financial and human resource commitments.
Twelve percent of the adult population in Malawi is estimated to be HIV infected. The country has a public sector-led antiretroviral treatment program both in the private and public health sectors. Estimation of the clinical human resources needs is required to inform the planning and distribution of health professionals. HAART provision is a labour intensive exercise. Although data in this paper is insufficient to determine whether HAART scale-up has resulted in the weakening or strengthening of the health systems in Malawi, the human resources requirements for HAART scale-up are significant. Malawi is using far less human resources than would be estimated based on the literature from other settings.
This presentation was given at the First Forum on Human Resources for Health in Kampala. It discusses the Zambia Health Workers Retention Scheme, an incentive program targeting key health worker cadres primarily in rural district to decrease attrition rates of critical service providers.