523-528.html

Original Articles

More doctors and dentists are needed in South Africa

B Strachan, T Zabow, Z M van der Spuy


Background. An aim of the Colleges of Medicine of South Africa (CMSA) project ‘Strengthening Academic Medicine and Specialist Training’ was to research the number and needs of specialists and subspecialists within South Africa.

Methods. Data were collected from several sources: Deans of the 8 Faculties of Health Sciences and the Presidents of the 27 constituent Colleges of the CMSA completed a survey; and the HPCSA’s Register of Approved Registrar Posts for Faculties of Health Sciences was examined and the results tabulated.

Results. South Africa compares unfavourably with middle-income countries on the ratios of medical and dental professionals; many districts have limited access to specialists and subspecialists. The unacceptable ratio of doctors, dentists and other health professionals per capita needs to be remedied, given South Africa’s impressive reputation for its output of health professionals, including the areas of medical training, clinical practice and clinical research. The existing output from South Africa’s 8 medical schools of MB ChB and specialist graduates is not being absorbed into the public health system, and neither are other health professionals.

Conclusion. Dynamic leadership and policy interventions are required to advocate and finance the planned increase of medical, dental and other health professionals in South Africa.

S Afr Med J 2011;101:523-528.


In 2008, the Colleges of Medicine of South Africa (CMSA) initiated a project entitled ‘Strengthening Academic Medicine and Specialist Training’ as a response to the concern among medical and dental professionals about increasing challenges in the academic training environment and issues relating to the output and retention of specialists and sub-specialists in the public health services. These challenges significantly affect the capacity of the public and private health sectors to provide South Africa’s required quality of health care and to ensure the output of sufficient health professionals to meet its needs.

A prime aim of the CMSA project was to research the need for, and numbers of, specialists and subspecialists within South Africa; this is ongoing, and the initial results are presented herein.


Objectives

The objectives of the CMSA project were to:

compare South Africa internationally regarding the number of doctors and dentists per 1 000 population

establish the number of specialists and subspecialists in South Africa

establish whether these numbers meet South Africa’s healthcare requirements

identify the cost of registrar training should finances be needed to increase the output

develop an Excel model and database to capture and monitor data on specialists and subspecialists by discipline and Faculty.


Methods

Data were collected from the following sources:

World Health Organization (WHO) country data on medical doctors and dental personnel.

Public and private sources of data in South Africa on health professionals included the National Department of Health (DOH), CMSA, National Treasury, Health Professions Council of South Africa (HPCSA), a large private funder, Board of Healthcare Funders (BHF), South African Medical Association (SAMA) and Medpages.

The deans of the eight faculties of health sciences were asked to complete a survey in 2009. The objectives were to determine:

existing figures for filled HPCSA specialist and subspecialist training posts

why HPCSA training numbers have not been translated into filled posts e.g. because of unfunded or inadequate recruitment

what additional specialist registrar training numbers are needed, and what increase is recommended for specialists, sub-specialists and dental specialists

capacity and staffing requirements to train specialists, sub- specialists and dental specialists, and how to meet future staffing needs.

The Presidents of the then 27 constituent colleges of the CMSA in 2009 were sent the available data and asked to complete a survey. They were informed that the outcome of the exercise was a practicable and pragmatic plan to increase the output of specialists and sub-specialists and that the survey was the first step. They were asked to:

agree or disagree with the figures provided (and make adjustments)

suggest an ideal staffing situation, and a pragmatic increase which would address, in part, health care needs

motivate the reasons for the increase

make any other suggestions about staffing requirements.

The HPCSA’s Register of Approved Registrar Posts for health sciences faculties was examined and results tabulated. This register is based on HPCSA accreditation site visits and includes approved training numbers for specialists and sub-specialists.


Results


WHO data

South Africa compares unfavourably with other middle-income countries in terms of medical and dental professionals per 1 000 population. In 2008,1 South Africa had 0.77 physicians (medical professionals) per 1 000 population, compared with Brazil (1.85), Mexico (1.8), the UK (2.47) and Australia (2.3) (Table I). The UK has 120 000 doctors for a population of 60 million; South Africa, with a population of 48 million, has 27 000 doctors. South Africa compares very unfavourably with other countries in terms of dentistry personnel (only 0.13 per 1 000 population) (Table I), compared with Brazil (1.16) and Mexico (1.42).


South African figures for doctors and dentists per 1 000 population

Several data sources were studied to establish the number of doctors and dentists in South Africa (Tables II - V). A ‘best guess’ estimate involved reviewing and collating data from various sources. This once-off effort is a useful exercise, but is limited as data quickly become outdated.

In 2009 there were about 9 765 medical specialists in the South African health sector – 5 532 in the private and 4 233 in the public sector. There are an estimated 14 814 medical professionals in the public sector (0.36 per 1 000 population) and 12 827 in the private sector (1.70 per 1 000 population), giving a total of 27 641 (0.57 per 1 000 population). This is a lower ratio than the WHO data in Table I (0.77 per 1 000).

Tables II and III show the results of data searching on numbers of doctors in South Africa in 2009.

A ‘best guess’ of dentists in South Africa revealed extremely low numbers of dentists and a low ratio per 1 000 population. There were 4 153 dentists (0.085 per 1 000 population) and few or no posts available to them in the public sector. The Community Dentistry speciality is a particular concern, with only 8 posts identified in South Africa (personal communication: Medpages 2011; Dr Barrie, UWC School of Dentistry, January 2011).


Survey of Deans of Faculties of Health Sciences 2009

The 2009 CMSA survey results of Deans of Faculties of Health Sciences are reported in Tables V - VII; 72.43% of HPCSA-approved registrar posts were filled, and only 53% of sub-specialist training posts were filled. Deans prioritised the funding and filling of existing posts before considering plans for expansion, but nevertheless proposed an increase of 8% for specialist trainees and 22% for subspecialist trainees. Deans provided motivation by speciality and sub-specialty for the proposed increases, and identified matters for consideration that affect expansion of specialist and sub-specialist output (Table V).

The numerical results of the deans’ survey are summarised in Tables VI and VII. Table VII presents the results of the survey of dental deans. Despite the significant shortage of dental specialists, only 62% of dental specialist registrar training posts are filled.


Survey of Presidents of Constituent Colleges of the CMSA 2009

Table VIII summarises the responses to the survey of the Presidents of the constituent colleges of the CMSA. They recommended that a pragmatic increase would be from 8 743 to 13 614 specialists (56% increase). The Presidents suggested that the total number of specialists in the public and private sectors was 8 743, which differs from the figures in Table III that show a ‘best guess’ of 9 765 – or 10 229 according to HPCSA data. The difference is possibly due to double counting of specialists working in the public and private sectors, non-practising/retired specialists, and emigrants.


Review of the HPCSA ‘Register of Approved Registrar Posts’

The HPCSA ‘Register of Approved Registrar Posts’ was analysed in 2010. Tables IX and X show data from HPCSA reports of site visits that recorded the total number of accredited registrar and sub-specialist training posts, and unfilled training posts; 38% of specialist and 75% sub-specialist training posts were unfilled. The HPCSA register numbers differ from the Deans’ survey in Tables VI and VII, which could be due to the year in which the Faculty was visited by the HPCSA, and other factors. To implement a plan for the filling of training posts, Faculty and HPCSA data must be reconciled.


Costs of filling unfilled HPCSA training posts

The costs of filling unfilled HPCSA training posts were calculated (personal communication: Dr Mark Blecher, Social Sector National Treasury). Table XI shows the total cost of filling unfilled specialist and sub-specialist training posts over 5 years. Costs were calculated using only the costs of the registrar salary for a training period of 4 years for registrars and 2 years for sub-specialists (with a 6% cumulative annual increase for inflation). The costs of the service sites where they are trained are not included as they are assumed to be academic site health-service costs and not part of the dedicated financing required for specialist and sub-specialist trainee salaries.

These costs must be taken into account but through a different funding stream. Academic clinician costs were also calculated for each speciality and sub-specialty. Not all newly filled registrar and sub-specialist training posts will require academic clinician appointments. The academic supervision cost per trainee based on 2009 salaries, and over 4 years, is R1 million to R1.5 million, depending on the speciality. Funds for registrar training posts should be ring-fenced to protect their training in line with national needs for medical and dental practitioners.


Discussion

Our study demonstrates that South Africa has a poor ratio of doctors and dentists per 1 000 population, and many districts have limited or no access to specialist medical and dental services. The situation should never have developed. South Africa employs relatively few of its doctors and dentists in the public sector, and loses many to emigration.

From 1997 to 2006, there was a significant decline of 854 (25%) specialists and sub-specialists in the public sector (from 3 782 to 2 928). The number of medical practitioners (non-specialist) on the public sector payroll increased in the same period from 9 184 to 9 958, an increase of only 774 in 10 years (personal communication: Dr Nicholas Crisp, Benguela Health, 2010). The decline in specialists and sub-specialists, and limited increase in medical professionals in the public sector over 10 years, must be seen against the output of MB ChB and specialist graduates in South Africa. Table XII shows the graduates produced during the period 1998 - 2006, when specialist and generalist numbers on the public sector payroll were declining and stagnating. Over 9 years, 14 145 MB ChB and specialist graduates were produced.

These graduates are not being recruited into the public sector system; the reasons include: lack of policy to expand the number of medical professionals in the public sector; lack of planning; lack of finance and posts; poor working environment and working conditions; and very limited – to non-existent – career prospects in the public health services.2

A significant contributor to low retention has been lack of positive reinforcement for 15 years from DoH authorities to doctors. Doctors often feel undervalued, and some policy and financing incentives support this perception. The South African health and education system has, by omission and commission, implemented ‘push factors’ which send doctors away (Table XIII).3

The first step to improve management of staff needs for the South African health sector is to have a reliable database that supplies the numbers of health professionals, and trends in output and retention. The present study showed that there is no accurate and reliable database of health professionals, with information on location and type of employment, active or inactive, emigrated, etc. Therefore, trends are not monitored. Key trends are that the number of public sector specialists is declining despite an annual output of about 500, and only a tenth of medical graduates are absorbed into the public sector.

A central data source on medical, dental and other health professionals, which is monitored and updated annually, is urgently needed. It should be used to ensure planning and development of specialists, monitor placement and emigration, plan recruitment, and review specialist service activity. Such a database should be developed by collaboration between the parties who provided data for this research, and be publicly available. Examples of international electronic databases include the UK’s www.specialistinfo.com and the Australian www.healthdirectory.com.au/medicalspecialists.

Table XIV details the data sources reviewed and their strengths and weaknesses. No single source is adequate for providing comprehensive data on health professionals.


Conclusion

Dynamic leadership and policy interventions are required to advocate and finance the planned growth of medical, dental and other health professionals, including specialists and sub-specialists. This effort must be accompanied by a strategy to retain doctors, careful assessment of working conditions, and active recruitment of doctors who have left the country and of foreign doctors who can contribute to South African health care development.5,6 The policy priority should be to consolidate training capacity by planning and funding the existing recommended HPCSA training posts within faculties of health sciences, and to send a positive message to South African doctors and dentists that the country values and needs them.

Postscript. As a result of the CMSA’s project work in 2010, National Treasury agreed this year to allocate funds for filling unfilled registrar training posts over 5 years, as detailed and costed in this article.

Acknowledgement

The CMSA expresses its appreciation to funders for supporting this research that was part of its project ‘Strengthening Academic Medicine and Specialist Training’. Funding was initiated through the CMSA Foundation (new Board of Trustees). The Discovery Foundation funding allowed development of the project and significant research. Other funders were the Medi-Clinic Hospital Group, Netcare Hospital Group, Metropolitan Health Group, Medscheme Health Risk Management, Old Mutual Health Risk Management, and Medical Advisors Groups of SAMA.




Table III. Total general practitioners and medical specialists in the public and private sectors, South Africa 2009

Public sector

Private sector

Total

Medpages

3 568

12 775

16 756

Large private sector funder

0

12 827

12 827

BHF

0

4 178

not complete

HPCSA and CMSA

0

0

31 308

SAMA

0

0

24 503

Persal public sector

14 814

14 814

Best guess

14 814

12 827

27 641

Population

41 127 928

7 552 820

48 680 749

Per 10 000 population

3.6

17

5.7

Per 1 000 population

0.36

1.70

0.57


Table I. Comparison of practising physicians and dental personnel, GNP per capita and health expenditure (WHO 2008)

Country

Physicians per 1 000

Dental personnel per 1 000

GNP per capita in $

Health exp as % total exp

Lesotho

0.05

0.01

1 810

6.7

South Africa

0.77

0.13

8 900

8.6

Brazil

1.85

1.16

8 700

7.5

Mexico

1.98

1.42

11 990

6.2

USA

2.56

1.63

44 070

15.3

Greece

5

1.32

30 870

9.9

UK

2.3

0.52

33 650

8.4

Australia

2.47

0.69

33 940

8.7

Exp=expenditure.

Dentistry personnel includes dentists, dental assistants, dental technicians and related
occupations.


Table II. Medical specialists and general practitioners, South Africa 2009

General practitioners

Medical specialists

Data source

Public sector

Private sector

Total

Public sector

Private sector

Total

Medpages

1 780

8 461

10 568

1 788

4 314

6 188

Large private sector funder

7 295

7 295

5 532

5 532

BHF

4 178

4 178

HPCSA and CMSA

21 079

10 229

SAMA members

18 165

6 338

Persal public sector

10 581

4 233

Best guess

10 581

7 295

17 876

4 233

5 532

9 765



Table IV. General practitioner dentists and specialists in the public and private sectors, South Africa 2009

Public sector

Private sector

Total

GP dentists

Medpages

2 881

NDoH unpublished Persal payroll

1 086

Best guess

1 086

2 881

3 767

Per 1 000 population

0.026

0.381

0.077

Specialist dentists

Medpages

28

240

CMSA survey 2009

146

240

386

Best guess

146

240

386

Per 1 000 population

0.004

0.032

0.008

Total best guess

1 032

3 121

4 153

Total per 1 000 population

0.025

0.413

0.085




Table V. CMSA 2009 survey of Deans of Faculties of Health Sciences: Issues that affect growth in specialist and sub-specialist training

Lack of funds for registrar, sub-specialist and consultant posts

Staffing issues: Need for better staff remuneration and career planning; slow staff appointments must be facilitated; posts and filling of posts are the problem, not staff availability; various strategies must be used for staff recruitment; staff shortages owing to the shrinkage of academic clinical staff and job opportunities; improve faculty staffing partly with more private sessions

Provincial departments of health have too much control over the appointment of academic staff

Health service providers and provincial departments of health could be more accommodating of the needs for clinical specialist training

Lack of retention of young doctors

Trainees must be allowed to rotate through the private sector, honorary consultant posts be established for private sector specialists, and ‘academic chairs’ should be sponsored by the private sector

The public and private sectors should work together as a partnership with training in both sectors

Training is threatened in the public sector owing to infrastructure, staff issues and reduced theatre time

Faculties of health sciences should collaborate and circulate professors who head centres of excellence, or rotate registrars through centres of excellence across the country

There is a need for a national forum and transparent national process which allows discussion and decision making, and that has access to ring-fenced funding and information


Table VI. CMSA deans’ survey: Filled and vacant HPCSA medical training post figures, and proposed increase, by faculty, 2009

UCT

US

Wits

UP

UKZN

FS

UL

WSU

Total

Vacant

116

80

173

97

293

63

126

89

1 037

Filled

368

308

673

309

611

226

167

63

2 725

Total

484

388

846

406

904

289

293

152

3 762

% filled

76%

79.4%

79.6%

76.1%

67.6%

78.2%

57%

41.5%

72.4%

Increase

100

30

161

22

4

39

0

0

356

% increase

20.7%

7.7%

19%

5.4%

0.4%

13.5%

0%

0%

9.5%


Table VII. CMSA deans’ survey: Filled and vacant HPCSA dental training post numbers and proposed increase by faculty, 2009

Registrar posts

Totals

Vacant

Filled

Total

% filled

Increase

% increase

Community dentistry

10

7

17

41.2%

0

0%

Maxillo-facial and oral surgery

4

23

27

85.2%

1

3.7%

Oral medicine and periodontics

8

8

16

50%

2

12.5%

Oral pathology

5

6

11

55%

0

0%

Orthodontics

12

16

28

57.1%

0

0%

Prosthodontics

6

16

22

72.7%

2

9.1%

Totals

45

76

121

62.8%

5

4.1%


Table VIII. CMSA survey 2009: Total number of specialists in the public and private sectors and a recommended pragmatic increase to meet healthcare requirements

EC

FS

GA

KZ

LI

MP

NC

NW

WC

Totals

Public and private

533

494

3 560

1 312

149

202

72

218

2 203

8 743

Public

249

262

1 289

604

85

60

27

46

1 015

3 637

Private

284

232

2 271

708

64

142

45

172

1 188

5 106

Ratio/10 000 population 2008

0.81

1.72

3.41

1.30

0.28

0.56

0.64

0.64

4.19

1.50

Ratio/population pragmatic

2.00

2.41

4.46

2.47

1.35

1.41

1.54

1.58

4.79

2.44

Actual numbers pragmatic

1 317

694

4 657

2 498

713

506

173

540

2 518

13 614

EC = Eastern Cape; FS = Free State; GA = Gauteng; KZ = KwaZulu-Natal; LI = Limpopo; MP = Mpumalanga; NC = Northern Cape; NW = North West; WC = Western Cape.


Table IX. Number of HPCSA-approved registrar training posts

Faculty

UCT

US

Wits

UP

UKZN

FS

UL

WSU

Total

Vacant

148

63

210

126

433

56

148

169

1 353

Filled

299

287

568

260

436

214

159

6

2 229

Total

447

350

778

386

872

270

307

175

3 582

% filled

67%

82%

73%

67%

50%

79%

52%

3%

62%

Note: HPCSA sites visits were undertaken between 2008 and 2010.


Table X. Number of HPCSA-approved sub-specialist training posts

UCT

US

Wits

UP

UKZN

FS

UL

WSU

Total

Vacant

49

62

59

69

42

29

43

27

380

Filled

29

24

53

0

8

2

0

0

116

Total

78

86

112

69

50

31

43

27

496

% filled

37%

28%

53%

0%

16%

6%

0%

0%

25%

HPCSA sites visits were undertaken between 2008 and 2010.



Table XII. Specialist and MB ChB graduates 1998 - 2006

Graduate specialists

Graduate MB ChBs

Total

1998

263

1 131

1 394

1999

304

1 131

2 829

2000

298 

1 131

4 258

2001

285

1 229

5 772

2002

306

1 212

7 290

2003

324

1 296

8 910

2004

335

1 394

10 639

2005

321

1 511

12 471

2006

308

1 366

14 145

Source: Personal communication DHET and CMSA, 2010.




Table XIII. Main push and pull factors in migration and international recruitment of health workers4

Push factors

Pull factors

Low pay (absolute and/or relative)

Higher pay and opportunities for remittances

Poor working conditions

Better working conditions

Lack of resources to work effectively

Better-resourced health systems

Limited career opportunities

Career opportunities

Limited educational opportunities

Provision of post-basic education

Impact of HIV and AIDS

Political stability

Unstable/dangerous working environment

Travel opportunities

Economic instability

Aid work


Table XI. Cost of filling unfilled trainee specialist and sub-specialist training posts, 2010

Year

1

2

3

4

5

Trainees

305

645

985

1 330

1 382

Total annual costs

R198 468 623

R462 805 132

R683 058 919

R934 763 254

R1 018 901 474

Sub-specialist trainees are paid at specialist rates, unless sub-specialty is studied in registrar years 3 and 4. Overtime and the 2010/2011 salary increase are included.



Table XIV. Sources of South African data on medical and dental specialists, and medical practitioners (non specialist)

Data source

Quality of data

Persal public sector payroll

Persal system from National Treasury is an accurate source of data on existing medical professionals on the public sector payroll, but only records job category and broad profession. Its lack of recording the type of medical or dental specialist can be corrected by the DoH requesting provincial health departments to use a standard set of job titles in existing job categories. Data are captured inconsistently by existing fields for geographical and workplace location and employer. Provincial departments of health could be required annually to submit this refined data on medical, dental and other health professionals, in a standard format to the DoH or other central source.

HPCSA

The HPCSA records the registration of specialist medical personnel and other health professionals in specific disciplines so that they can practise, but does not monitor numbers of health professionals in the health system. Therefore, its database has limitations as an accurate source of numbers of individual specialists in the health system, and has no available data by practitioner and their work location in the public or private sector. Registrars are registered separately. The data are an overestimate as there is double counting of specialists who are on 2 or more registers. HPCSA data duplicate public and private sector figures, include people who have emigrated and who no longer practise, and does not record individual and practice details. The utility of HPCSA data could be improved by refining the annual registration form and ensuring that the data can be analysed annually in a relevant format. Extending the current HPCSA database capture has resource implications.

CMSA

The CMSA database includes only members of the CMSA and not specialists who are not members. CMSA data do not include details of where specialists work. This research checked CMSA and HPCSA data against each other and used a single figure for the results.

Medpages

Medpages (www.medpages.co.za) is a live database that is regularly updated and maintained by a private service provider. It was developed to service private sector suppliers such as pharmaceutical companies. Medpages data on private sector providers and practitioners are accurate to within 95%. It records speciality and sub-speciality and area/s of interest. Medpages separates non-practising and emigrated practitioners and public, private and limited private practice; and identifies physical location of practices and academics in the public and private sectors. As Medpages had no access to information on medical professionals working in the public sector at the time of the research, their data are less accurate than their data on the private sector.

BHF

BHF data did not have the relevant data required.

SAMA

SAMA data records only medical practitioners who are members, but includes non-practising practitioners.

Large private sector administrator/funder

A large private sector administrator/funder that has an accurate data base of types of specialists and the specialists’ practice address was used to establish numbers of private sector specialists. Their data on types of private sector specialists, and specialists in the public sector who do private work, were similar to Medpages’.

DoH

The DoH does not have a live database on practising medical and dental professionals in the public and private sectors, or information on other health professionals. To plan and finance the health workforce, and manage need, demand and supply, the DoH requires an accurate database of health professionals, which it could develop or outsource.




Colleges of Medicine of South Africa, Cape Town

B Strachan, BSc Hons, MA, PhD, MSc

T Zabow, MB ChB, DPM, FCPsych (SA), MRCPsych (UK)

Immediate Past President of Colleges of Medicine of South Africa; Department of Obstetrics and Gynaecology, University of Cape Town

Z M van der Spuy, PhD, MB ChB, FRCOG, FCOG (SA)

Corresponding author: B Strachan (bstrachan@telkomsa.net)


References
1 World Health Organization. WHO Statistical Information System (WHOSIS). http://www.who.int/whosis/indicators/compendium/2008/4mrn/en/index.html (accessed 15 March 2010).

2. Pendleton W, Crush J, Lefko-Everett K. The Haemorrhage of Health Professionals from South Africa: Medical Opinions. Cape Town: IDASA, 2007:2,6.

3. Ibid.:17.

4. Buchan J. Migration of Health Workers in Europe: Policy Problem or Policy Solution. In: Du Bois C, McKee M, Nolte E, eds. Human Resources for Health in Europe. Maidenhead, Berks., UK: Open University Press, 2006:44-52.

5. Mullan F, Frehyot S, Omaswa F, et al. Medical schools in sub-Saharan Africa. Lancet 2011;377(9771):1113-1121.

6. Collins FS, Glass RI, Whitescarver J, Wakefield M, Goosby E. Developing health workforce capacity in Africa. Science 2010;330(6009):1324-1325.

Accepted 17 June 2011.


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