SOUTH AFRICAN HEALTH SYSTEM

Transcription

1 CASE STUDY SOUTH AFRICA FROM BRAIN DRAIN TO BRAIN GAIN: UNDERSTANDING AND MANAGING THE MOVEMENT OF MEDICAL DOCTORS IN THE SOUTH AFRICAN HEALTH SYSTEM

2 Contents Acknowledgements The authors of this report are Percy Mahlathi and Jabu Dlamini (African Institute & 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 personnel for Better Management Worker Migration, co-funded by the European Union (DCI-MIGR/2013/ ) 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. March 2017 Abstract Background Health workforce context Practising medicine in South Africa Policy on the Recruitment and Employment of Foreign Health Professionals in the South African Health Sector Regulation of medical practitioners Registration requirements for expatriate qualified medical practitioners Registration of government-to-government practitioners South Africa Cuba Medical Training Programme Registration of South African-qualified medical practitioners Migration of the medical workforce Study objectives Methods Results Minimum data sets Stock of medical practitioners, Regulation of medical training and new entrants Expatriate medical workforce Distribution of medical practitioners in South Africa Movements by government-employed medical doctors Discussion Conclusion...21 Acknowledgements...22 References...23 Figures Figure 1a. Macro-organization of the South African health system...4 Figure 1b. Organization of the South African public health sector...4 Figure 2. Age profile of general practitioners, Figure 3. Health professions council of South Africa registers 2010 to Figure 4. Type of practice of respondents...18 Figure 5. Reasons for seeking employment overseas Figure 6. Movements upon return from overseas employment. 19 Tables Table mid-year population estimates for South Africa..3 Table 2. Cuban-trained South African medical doctors...4 Table 3. Selected list of human resources for health policies...5 Table 4. Register of medical practitioners, Medical and Dental Board Table 5. Medical training spaces on HPCSA system...12 Table 6. Total number of medical students (first to final year). 12 Table 7. Medical stock inflows (including both years of internship) from South African medical schools, Table 8. HPCSA accredited and approved post numbers (inclusive of all teaching hospitals)...12 Table 9. Percentage share of expatriate medical workforce from main source countries...13 Table 10. HPCSA medical officer register...13 Table 11. Age profile of female and male general practitioners, Western Cape province...14 Table 12. Age profile of female and male general practitioners, Gauteng province Table 13. Age profile of expatriate medical practitioners...15 Table 14. Medical officer stock in government hospitals, Table 15. Provincial GP register at HPCSA, number and % of national total...17 Table 16. Medical officer resignations across five provinces (male and female), Table 17. Age profile of resignations from public health service in Eastern Cape and Western Cape provinces

3 Abstract Background. The provision of health services is largely dependent on the sufficiency of the health workforce in terms of numbers, the quality of skills they possess, how and where they are deployed and how they are managed. With increasing urbanization, the issue of migration (including immigration, emigration and movement between the public and private sectors) of health personnel has become a critical factor in the debate about social justice in health, especially access and equity in the provision of health services. This case study seeks to better understand the patterns of movement of medical doctors and the development of associated policies in order to help health authorities to put in place the necessary systemic improvements for effective management of health workforce migration. Objectives. The objectives of the study were (a) to assess the recorded movement of medical officers employed in the public health facilities; (b) to gain insight into the views and perspectives in South Africa of emigrant medical practitioners; and (c) to identify existing policy instruments and practices in place to maximize benefits and mitigate negative consequences of the migration of medical doctors. Method. Data were collected from the provincial s, the Medical and Dental Board of the Health Professions Council of South Africa, the South African Medical Association and individual medical practitioners through a survey. The data utilized were derived from responses to a survey questionnaire. Results. Data analysis revealed that of the 754 respondents (South African-trained doctors) 37% had worked outside South Africa, while 63% had not. The government keeps records of only those that it employs. Once medical doctors resign from public service, there is no mechanism to provide data on their destination. About 57% of respondents believed that migration by medical doctors should be monitored, though there were variations in the reasons put forward as to why it should or should not be monitored. South Africa has in place policies that focus on the management of the health workforce, including regarding statutory regulations, employment of medical doctors (junior to senior and specialist levels), and the employment benefits provided to foreign medical doctors employed in the public health service. Some respondents are sceptical about management of migration, interpreting it as an attempt to victimise them through controlling their movement. Discussion. The country needs to develop a mechanism to record and manage information regarding the mobility of its medical workforce. There are government initiatives to increase the training of medical doctors to boost the stock, though fiscal challenges obstruct progress. The Policy on the Recruitment and Employment of Foreign Health Professionals in the South African Health Sector is used to manage immigration, but requires review so that it is aligned with the new immigration laws of the country. Refugees and asylum seekers who are professionals form a component of migration that is not often considered in the literature on migration of health workers. Given the broad and varying understanding of general practitioners, the paper presents information on medical doctors as well as specifically on General Practitioners extracted from the HPCSA GP register, plus on Medical Officers from provincial level records. UNDERSTANDING AND MANAGING THE MOVEMENT OF MEDICAL DOCTORS IN THE SOUTH AFRICAN HEALTH SYSTEM 1. Background This study was undertaken as a follow-up to Minimum data sets for human resources for health and the surgical workforce in South Africa s health system: a rapid analysis of stock and migration (1). As at June 2016, South Africa was estimated to have a population of (2). Most people access health services through the government s public clinics and hospitals, whilst approximately 16% access health services through private health facilities, such as doctors private consulting rooms (surgeries) and private hospitals. There are instances where the State has a contractual relationship with private hospitals for the management of certain conditions that government health institutions may not have the capacity to treat, for example in the case of outsourcing of radiological services due to specialist shortages in government hospitals. The public health service is divided into primary, secondary and tertiary care through health facilities that are located in, and managed by, the provincial s. The provincial s are thus the direct employers of the health workforce, whilst the national Ministry is responsible for policy development and coordination. practitioners who run private surgeries or through private hospitals, which tend to be located in urban areas. The health care system consumed about 8.8% of the country s gross domestic product during 2012 (3). The private sector serves about 16% of the population, whilst the public sector serves 84% (4). The country s population distribution indicates that about 64.7% inhabit the provinces, which are largely rural in nature. Table 1 presents population statistics for South Africa. TABLE MID-YEAR POPULATION ESTIMATES FOR SOUTH AFRICA Province Population estimate % of total population Urban/rural Eastern Cape Rural Free State Rural Gauteng Urban KwaZulu-Natal Rural but has large urban centres Limpopo Rural Mpumalanga Rural Northern Cape Rural North West Rural Key words. emigration, immigration, medical practitioners, experience, financial gain, expatriate medical workforce, refugee medical doctors, South Africa South Africa s Constitution guarantees every citizen access to health services in accordance with section 27 of the Bill of Rights. While all citizens can access both the public and private health services, access to private health services depends on the patient s ability to pay. The private health sector provides health services through individual Western Cape Total Urban but has farming and rural communities Source: Statistics South Africa (1). 2 FROM BRAIN DRAIN TO BRAIN GAIN: 3

4 FIGURE 1A. MACRO-ORGANIZATION OF THE SOUTH AFRICAN HEALTH SYSTEM Public Health Sector National Health System Private Health Sector There is a realization that the health workforce plays a critical role in advancing the health system goals (5), largely driven by a policy position of improving access to health care for all citizens. Figures 1a and 1b present a diagrammatic representation of how the South African health system is organized. 2. Health workforce context The mandate for health workforce policy lies with the national Ministry in cooperation with the of Higher Education and Training (for production) and the of Public Service and Administration (for employment conditions). South Africa has a total of 23 universities, of which eight have medical schools. A ninth medical school recently established at the University of Limpopo (in 2015) was meant to produce its first graduates in However, there have been serious compliance problems, leading to the Health Professions Council of South Africa (HPCSA) withdrawing accreditation until the noncompliance issues are resolved. This would have been a small addition to the number that is required to provide the much-needed medical services in the country. Collectively, the medical schools have an annual production of medical graduates ranging between 1200 and This number has not changed significantly in the past 10 years and is viewed as a grossly inadequate production rate for a country with a population of approximately 55 million. The production of medical doctors is supplemented by FIGURE 1B. ORGANIZATION OF THE SOUTH AFRICAN PUBLIC HEALTH SECTOR Western Cape Free State Abbreviated provinces: EC = Eastern Cape KZN = KwaZulu Natal Northern Cape Limpopo North West National Ministry of Health Guateng the training of doctors in Cuba under a government-togovernment agreement. Table 2 shows the number of Cuba-trained medical doctors appearing on the HPCSA register for the period Funding of higher education in South Africa has gained sharp focus through protests by university students demanding free higher education under the banner #Fees Must Fall Movement. This will certainly put more demand on the financially underfunded medical training in South Africa. 3. Practising medicine in South Africa EC TABLE 2. CUBAN-TRAINED SOUTH AFRICAN MEDICAL DOCTORS KZN of Healeth Mpumalanga Year Number Medical doctors have the freedom to set up their practice arrangements as they see fit as long as they are registered by the Medical and Dental Board as eligible for independent practice post-community service. They can remain employed in government health facilities or by corporate bodies (for example, medical insurance schemes or mining companies), or can set up private practice wherever they wish. There is currently no limitation on either place of work or the number of surgeries (medical rooms) a medical doctor can have. There is also no application process for a medical doctor who wishes to establish private practice rooms, except obtaining a practice number from the Board care Funders of Southern Africa. This enables doctors to receive payment from private medical insurance companies for services provided to their members. Medical doctors (generalists and specialists) who are in full-time employment by government can simultaneously manage their private practices subject to approval by a Head of in the province where that practitioner is employed. This is in terms of the Policy on Remunerative Work Outside Public Service, which was developed as a retention measure for doctors in the public health service. Several policies have been adopted over the years aimed at improved management of the medical workforce in South Africa. Table 3 presents a set of policy and strategy documents relevant to the management of the medical workforce that together contribute to improved distribution and retention of the workforce, and support implementation of the World Health Organization (WHO) Global Code of Practice on the International Recruitment Personnel (6), with the Policy on the Recruitment and Employment of Foreign Health Professionals in the South African Health Sector being particularly notable. These policies are applied to management of the health TABLE 3. SELECTED LIST OF HUMAN RESOURCES FOR HEALTH POLICIES workforce. The Scarce Skills Allowance policy in the health sector ceased to operate as soon as the Policy on Remuneration Professionals Working in Public Health Service (otherwise known as the Occupation Specific Dispensation policy) came into effect. The Human Resources for Health Planning Framework, 2006, was also revised and updated as the Human Resources for Health Strategy, Policy on the Recruitment and Employment of Foreign Health Professionals in the South African Health Sector Since 2010 medical doctors from outside the Republic of South Africa wishing to work in the country must comply with the Policy on the Recruitment and Employment of Foreign Health Professionals in the South African Health Sector. This policy was introduced to improve the flow of health professionals into South Africa and expresses the following objectives: promote high standards of practice in the recruitment and employment of health professionals who are not South African citizens or permanent residents; 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 Service Human Resources for Health Planning Framework Policy on Remuneration Professionals Working in Public Health Service Policy on the Recruitment and Employment of Foreign Health Professionals in the South African Health Sector Human Resources for Health Strategy 2002 Incentive scheme allowing doctors to work in the private sector whilst fully employed by government 2006 Highlighting the need for systematic national health workforce planning 2007 System of differentiated pay for health professionals employed in public health facilities with the objective of recruiting and retaining professionals in the public health service 2008 (approved in 2010) Principles and practices in the employment of health professionals who are non-citizens aligned to the immigration processes of the of Home Affairs 2011 Focus on planning and staffing of health facilities in preparation for 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 4 FROM BRAIN DRAIN TO BRAIN GAIN: 5

5 preclude the active recruitment of health professionals from developing countries unless there are specific government-to-government agreements to allow and support such recruitment. The policy was crafted such that it is complementary to the Immigration Act and other laws, and is consistent with the country s Constitution. It lays out a recruitment process that involves four stages: 1. centralization of applications at the national ministry level (under an internal unit at the National called the Foreign Workforce Management Programme); 2. clearance to practise medicine in South Africa processed by HPCSA; 3. issuance of endorsement letter by the of Health enabling the expatriate health professional to be employed at a designated public health facility upon fulfilment of requirements; 4. appointment to a post to be open to fair competition by any deserving doctor. A work permit finally gets issued by the of Home Affairs. Once appointed to a post, all expatriate medical doctors are entitled to the same salary and benefits pertaining to the post as any South African counterpart who occupies a similar post. This is in line with section 18 of the Immigration Act, which states that: (5) An application for a critical skills work visa shall be accompanied by proof that the applicant falls within the critical skills category in the form of a) a confirmation, in writing, from the professional body, council or board recognised by South African Qualifications Authority (SAQA) in terms of section 13(1)(0) of the National Qualifications Framework Act, or any relevant government confirming the skills or qualifications of the applicant and appropriate post qualification experience; b) if required by law, proof of application for a certificate of registration with the professional body, council or board recognised by SAQA in terms of section 13(1)(i) of the National Qualifications Framework Act; and c) proof of evaluation of the expatriate qualification by SAQA and translated by a sworn translator into one of the official languages of the Republic (of South Africa). (6) A critical skills work visa shall be issued for a period not exceeding five years. (7) A spouse and dependent children of a holder of a critical skills work visa shall be issued with an appropriate visa valid for a period not exceeding the period of validity of the applicant s critical skills work visa. Section 18(3)(iii) of the Immigration Act also prescribes that the salary and benefits of the applicant are not inferior to the average salary and benefits of citizens or permanent residents occupying similar positions in the Republic. This is also in line with the provisions of the Occupational Specific Dispensation policy, which regulates how health professionals in the public health service are remunerated. Whilst the Policy on the Recruitment and Employment of Foreign Health Professionals in the South African Health Sector has been in operation since 2010, it requires urgent review so that it is completely in line with the amended Immigration Act of In addition, prevalent health workforce shortages have rendered some of the clauses of the policy irrelevant, for example principle 5, which states that the employment of expatriate health professionals shall only be allowed after they have been successful in competing for an advertised post and there is record that no South African citizen or permanent resident was available or found suitable to fill the particular post. When faced with critical shortages, this clause is unlikely to be adhered to. In managing the employment of expatriate medical doctors, the Ministry has struck partnerships with several nongovernmental organizations (NGOs), such as Africa Health Placements (Box 1). These organizations offer advisory services that are broader than work placements, for example including facilitation of visa applications and Medical and Dental Board examinations. The development BOX 1. AFRICA HEALTH PLACEMENTS: SUPPORT FOR REFUGEE DOCTORS IN SOUTH AFRICA Africa Health Placements (AHP) is a South African NGO that was established in 2005 with the mission to help plan for, find and retain the health workforce needed to provide access to health care in rural and underserved communities. A major component of AHP s work to date has been recruiting foreign-qualified doctors, mostly from the United Kingdom, to take up vacant salaried posts in rural government hospitals in South Africa. These doctors normally come for at least a year, and so far AHP has recruited and placed over 2750 doctors to work there. In recent years, doctors who have come to South Africa as refugees have become a sizeable percentage of the health workers that AHP has placed. South Africa has a long history of providing asylum and in 2015 the country accepted about refugees (7). It is important to note that AHP does not actively recruit from countries with a critical shortage of health workers (for example, the Group of 77 nations), and that the Government of South Africa also prohibits this, although with some exceptions (8). AHP believes however that if doctors are already in South Africa as refugees then they have a right to live and work in the country. AHP s role has been to support refugee doctors in their applications for professional registration and employment through active partnership with the national and the HPCSA, thereby reinforcing the government s rules. So far, AHP has supported the placement of 430 refugee doctors from the Democratic Republic of the Congo, which is the most common source of refugee doctors in South Africa. The placement and registration process for refugee doctors in South Africa is stringent and complex. Candidates must first demonstrate that they have refugee status before obtaining professional registration from the HPCSA. This normally includes a requirement to pass an examination. Registration can be a challenge because it requires notarized copies of their medical qualifications and contact with their medical school to verify their credentials. Many refugee doctors have to go to great lengths to go back to the Democratic Republic of the Congo to get a certificate of good standing from their professional council. After registration, they get employed in salaried posts in public hospitals. That includes in most cases a two-year supervised internship programme and then a year of community service in an underserved area before being able to practise independently in the public health sector. AHP provides support to refugee doctors by helping them to complete their application forms to the Foreign Workforce Management Directorate at the national for permission to seek employment, as well as to the HPCSA for professional registration. AHP checks that the forms are compliant with the regulations and helps to submit them on behalf of the refugee doctor and follows up on progress. Once these applications have been approved, AHP helps the refugee doctors to find a job by matching them with available posts in the public sector. AHP believes that supporting refugee doctors to work in the health system in South Africa brings considerable benefits to both the country and to the refugee. These doctors are only allowed to work in public sector facilities, and must work for at least one year in an underserved community. AHP has found that the foreign-qualified doctors who have come as refugees stay longer in rural posts than those from high-income countries; for example, the doctors recruited from the Democratic Republic of the Congo have an average length of placement of 2.8 years compared to 1.3 years for their counterparts from the United Kingdom, and many refugee doctors stay for life. Staying longer enables these doctors to adapt more to the local practice and culture and to be available to take on important clinical leadership roles in the facilities where they work. For the refugee, the ability to take up posts in the health system brings the obvious benefits of being able to work, support their families and continue in their careers. The process for obtaining professional registration and a job offer is also a difficult one that can be slow and expensive to complete. There may therefore be opportunities to streamline the process further, for example by providing more regular opportunities for candidates to undertake the HPCSA examinations or by offering bridging programmes (such as in language skills or medical practice) to help refugees to reach the required standards more quickly. It is essential that due processes are followed to prevent active recruitment from critical shortage countries and to ensure the professional competency of all doctors. If these are in place, the experience of South Africa demonstrates that enabling and supporting refugees with medical qualifications to practise as doctors can provide mutual benefits for both refugees and the host country. Source: Africa Health Placements. 6 FROM BRAIN DRAIN TO BRAIN GAIN: 7

6 of the Policy on the Recruitment and Employment of Foreign Health Professionals, as well as the creation of the Foreign Workforce Management Directorate within the national, has provided the framework for partnership and engagement with groups such as Africa Health Placements. Among those assisted in finding work placements are refugee doctors, for example from the Democratic Republic of the Congo (see Box 2 for a case study). 4.1 Regulation of medical practitioners Medical practitioners are regulated by the Medical and Dental Board of the HPCSA, pursuant to the provisions of Health Professions Act No. 56 of 1974 (as amended). The Medical and Dental Board has 17 professional categories in its register that relate to the medical field, including medical intern, medical practitioner, medical specialist and clinical associate. Anyone wishing to practise medicine in South Africa must register with the Medical BOX 2. CASE STUDY: DR S FROM THE DEMOCRATIC REPUBLIC OF THE CONGO Dr S left his home country of the Democratic Republic of the Congo aged 29 because he feared for his safety as conflict spread in his region. He had also started to experience political interference in his work that went against his professional ethics. He came to Pretoria as a refugee in 2009 and spent three years being supported financially by friends and family, during which time he studied at the local library, passed his English test and completed the examinations and paperwork required by the of Home Affairs and the HPCSA. With the support of AHP he was able to start working as a doctor in Durban in 2013 and is now moving to take up a post as a medical officer in an underserved specialist hospital. He comments: I initially experienced challenges being accepted by many patients and some of my colleagues because I didn t speak Zulu, but I have worked hard to learn the language and things are much better for me now. I feel like South Africa has accepted and adopted me and I feel very grateful for that, and proud to work for people here and try to help. to Cuba. For those who opt out of the agreement, their registration with HPCSA is cancelled, including the treaty visa with the of Home Affairs. Any spouse who has not been identified in the governmentto-government agreement is required to take the Board examination. Practitioners from the Islamic Republic of Iran and Tunisia also register for a period of three years, which may be extended if the hospital still requires their services. An endorsement by the Foreign Workforce Management Programme is also a requirement. They can also opt out of the agreement but, unlike their Cuban counterparts, without any consequences from their country of origin. The basic documents that are required for their registration include the duly completed Form 12, a notarized copy of a basic degree translated into English, and letters from both embassies confirming the government-to-government agreement. If the practitioner has a speciality, they will submit a notarized copy of the are then registered by the HPCSA to practise medicine in South Africa. There has been criticism of the programme over many years, though the criticism has been focused on the cost of the programme rather than the quality of training in Cuba. With declining health budgets across the provinces, some provinces have been reluctant to fund the students going into the programme. Universities have previously argued that the money spent on the South Africa Cuba Medical Training Programme could be diverted to South African universities to fund more medical undergraduate spaces locally. South Africa has firmly adopted a Health Sector Reform Policy to implement National Health Insurance. Its own predictions indicate that if the policy is to be successfully implemented, there has to be a major boost in the production of medical doctors. A major challenge is also ensuring a shift in mindset from a curative to a preventative and Dental Board and keep their registration up to date certificate of registration with their country of origin as focus in health services an approach, it is hoped, that will through annual licensing by the Board. competence under the International English Language Test a specialist, after which they will register in the category be positively influenced by the Cuban-trained medical 4.2 Registration requirements for expatriate qualified medical practitioners All medical practitioners who have qualified outside System. A letter of support from the Foreign Workforce Management Programme of the Ministry is as additional requirement. This is to ensure that there is a post available to accommodate the practitioner. All expatriate medical practitioners must sit for the Medical and Dental public service government-to-government, restricted to the field of medicine. In these cases, no verification by the Education Committee for Foreign Medical Graduates is required. Assessment is carried out by panels that are assembled by the Ministry. doctors. However, some leaders in the medical field have commented that the Cuban medical training does not prepare doctors for what is expected of a South African graduate who has to be competent to do a C-section and give a safe anaesthetic, and treat fractures and complicated South Africa are categorized and subjected to specific registration requirements. For the expatriate qualified medical practitioners, the registration requirements are that they must produce verification of qualifications from Board examination, except for postgraduates, lecturers in the medical field and volunteers. The examination consists of both written and practical elements. Once a practitioner passes the examination, he or she will be registered to work 4.4 South Africa Cuba Medical Training Programme The training of South African students in Cuba to become TB and HIV patients during their community service (9). Whilst the programme has made a constant contribution to annual medical graduate outputs about 8% of the 1300 graduates debates continue about how successful the the Education Committee for Foreign Medical Graduates, in the public health service. However, expatriate specialists medical doctors came to fruition in 1995 after the two gov- integration of its graduates is into the South African health and among other requirements produce a notarized copy are required to pass the final examination of the Colleg- ernments signed a cooperation agreement on health mat- system. Some view the acceleration in Cuban training as of a degree certificate (which, if not in English, is to be es of Medicine of South Africa, which comprises various ters. Prospective students are selected by panels that have a crisis intervention aimed at buying time to adjust and translated and notarized). For specialists, notarized proof specialist colleges and is responsible for the maintenance been set up by provincial s and get expand the local medical training platform so that it can of postgraduate education and training or work experi- of specialization standards in its constituent fields. full support to study medicine in selected universities in increase local doctor output while continuing to better re- ence must be produced. Submitting verification from the Education Committee for Foreign Medical Graduates is a prerequisite before applying for registration with the HPCSA. 4.3 Registration of governmentto-government practitioners South Africa has health cooperation agreements with Cuba. Major criteria are that applicants must have passed matriculation (grade 12) with minimum medical university entry requirements of level 4 in Physical Science, Mathematics, Life Sciences and English, and must be South orientate the Cuban returnees towards South Africa s very different disease profile (9). However, the major constraint to any serious changes to the programme is political, as it is founded on deep political solidarity between South Africa Cuba, the Islamic Republic of Iran and Tunisia. The African citizens and permanently residing in the respective and Cuba. Fluency in English is mandatory to communicate with pa- Ministry sends panels of South African province. They must also be aged between 18 and 25 years, tients and to be able to engage meaningfully in the Medical specialists to these countries to assess practitioners based and priority is given to students with potential who come Integration of the Cuban graduates into the local health and Dental Board s examination. Candidates from Eng- on identified provincial needs. The practitioners who pass from poor households. These students undergo five years system is also a challenge to monitor. As noted in the lish-speaking countries and candidates with English as a the assessment become registered with the HPCSA with a of medical studies and thereafter two years of medical stud- authors previous case study on the surgical workforce first or second language qualification at secondary school clear indication that they are government-to-government ies at a South African university to complete a degree in (1), South Africa does not have a live workforce tracing level qualify in terms of this standard. Candidates who practitioners. With effect from 2012, Cuban practitioners medicine. However, they receive a Cuban qualification at system or mechanism. It is therefore difficult to determine do not qualify are requested to obtain graded academic register for a period of three years and must then return the university that they attended. These medical graduates where most graduates of the South Africa Cuba Medical 8 FROM BRAIN DRAIN TO BRAIN GAIN: 9

7 Training Programme finally settle. Do they end up being up to 35% vacancy rates for medical doctors. This relates an umbrella organization of medical doctors, including who have already qualified and are formally employed swallowed in the predominantly curative practices or to approved posts for which a budget has been allocated specialists, in South Africa. in HPCSA accredited hospitals for internship training. retain the basics of their training? How long do they stay in but which remain vacant due to the lack of medical doc- The category clinical associate was established as a the public health service or do they also aspire to migrate tors to appoint. Several studies about the movement of Each respondent was sent a questionnaire to complete mechanism to curtail the shortages of medical services, to the private sector? Do they also harbour ambitions of medical doctors focus on those employed by government and, based on the responses, telephonic follow-up inter- particularly in rural health facilities. It was created as a specializing and if so, in what fields of medicine? These institutions, and very little or not at all on those working views were conducted for further explanations or closing mid-level practitioner in the field of medicine. These are some of the questions that will need to be probed in in private practice. of gaps in the information supplied. Guiding the research cadres are trained by the family medicine units of medical future studies. data-gathering process was a protocol developed by the schools. The student intern category comprises final year 4.5 Registration of South Africanqualified medical practitioners All health care students are required to register with the HPCSA within two months of commencement of their studies. Some universities require students to register as student interns for their sixth year by completing Due to the difficulty of producing empirical evidence, some studies have resorted to making deductions based on intention to leave of respondents (10). 6. Study objectives The objectives of the study were to: Global Health Workforce Alliance that provided a list of minimum data sets against which to match responses. 8. Results 8.1 Minimum data sets In relation to the minimum data sets, no data elements were medical students, who provide the bulk of stock inflows into the medical graduate field. They are placed at various HPCSA-accredited government hospitals across the country. Upon satisfactory completion of their internship, they must complete another one-year community service before being eligible for independent practice. This community service category is thus included in the total the relevant form and paying registration fees. Upon probed, as the previous study responses were deemed to be still number of medical practitioners. completion of medical internship, they are registered for independent practice. 5. Migration of the medical workforce (a) assess the recorded movement of medical officers employed in the public health facilities; (b) gain insight into the views and perspectives in South Africa of emigrant medical practitioners; relevant. 8.2 Stock of medical practitioners, 2016 The major data source was the HPCSA, which maintains a register of all medical doctors that are licensed to practise medicine in South Africa. The second source 8.3 Regulation of medical training and new entrants The HPCSA, through its Undergraduate Committee, approves the number of medical undergraduate training spaces to be made available for each year. This is based The migration of South African medical professionals has (c) identify existing policy instruments and practices was the provincial s, while the third on its planning processes and takes into consideration been a subject of discussion for a considerable period. in place to maximize benefits and mitigate negative was individual practitioners who were surveyed through various factors, including the faculty student ratio. Many studies have been conducted and have advanced consequences of the migration of medical doctors. the South African Medical Association. The HPCSA has All medical schools undergo regular accreditation varying estimates of emigration by health professionals in under its aegis 12 professional boards, with the Medical inspection by the HPCSA, which includes evaluation the African continent (10 12). Several causes of migration The study also sought to identify whether any synergies and Dental Board the largest in terms of numbers. As of of the curriculum. by health professionals have also been recorded. Measuring or gaps existed between the workforce data systems of 3 May 2016, the register of medical practitioners was as the extent of emigration particularly by South African provincial s (the major employer indicated in Table 4. Once medical students graduate from a university, they medical doctors remains a challenge, as several research within the health sector), the HPCSA and the largest are required by law to register with the Medical and studies have been based on incomplete data. This is partly medical professional association the South African Student interns are those students who are in their final Dental Board of the HPCSA as a medical intern. The because systematic data on international flows of health Medical Association. year of medical studies whilst medical interns are those internship, which is currently of two years duration, is workers from South Africa, including to the rest of the performed at government hospitals that are preapproved continent, have tended to rely on destination country data systems to estimate the extent of emigration of medical doctors from South Africa. Clemens and Pettersson have 7. Methods A survey questionnaire was sent through the South TABLE 4. REGISTER OF MEDICAL PRACTITIONERS, MEDICAL AND DENTAL BOARD by the Internship Committee of the Medical and Dental Board, in accordance with the provisions of the Health Professions Act No. 56 of 1974 (as amended). previously utilized destination country census data to make such an estimation (13). African Medical Association to its members. The nine provincial s, the national, the HPCSA and the South African Medical Category Number on register Upon completion of internship, the medical graduate is statutorily required to serve an additional year of community service before they can be sanctioned for As reported in the authors previous study on the surgical workforce (1), South Africa still does not have a systematized mechanism for measuring and monitoring emigration of its medical doctors, even though the country formalized its policy on migration of health professionals in 2010 through the adoption of the Policy Association were contacted for participation in the study. The nine provincial s were included in the study on the basis that they are the biggest direct employing entity of medical doctors for the government. The HPCSA was included on the basis that it carries the legislative mandate to maintain the registers of all medi- Student clinical associates 582 Clinical associates 572 Medical students Student interns Medical interns independent practice. This equates to three years of statutory service commitment, which must be performed in public health facilities. The HPCSA is also responsible for accrediting academic medical training programmes of universities. Upon on the Recruitment and Employment of Foreign Health Professionals in the South African Health Sector. The government-run public health facilities report an average of cal doctors in the country, including those in active practice and those no longer practising. The South African Medical Association was included on the basis that it is Medical practitioners (including specialists) Source: Summary of registered persons: HPCSA statistics ( co.za/publications/statistics). fulfilment of the statutory requirements of internship and community service, medical doctors practise as either general practitioners (GPs) (in the public or private 10 FROM BRAIN DRAIN TO BRAIN GAIN: 11

8 sector or both) or as specialists (in either the public or private sector or both). The term general practitioner tends to be used to refer to those medical doctors without specialist qualifications who are in private practice, whilst their counterparts in public service are generally referred to as medical officers. Previously, there were medical practitioners who specialized in fields such as family medicine but only practised as general practitioners and not as specialists. This was because there was no register created for family medicine specialists then. That situation has since changed with the formal establishment of a family practice register. Table 5 shows the number of medical training spaces approved for new entrants for the years 2011 to TABLE 5. MEDICAL TRAINING SPACES ON HPCSA SYSTEM Year Number The undergraduate entrant training spaces are shared between all eight medical schools. The HPCSA records indicate variations in the total number of medical students registered over a period of five years ( ) (Table 6). There is still a practice whereby some students can enter medical training at second year provided they satisfy the admission requirements (for example having completed a science degree). TABLE 6. TOTAL NUMBER OF MEDICAL STUDENTS (FIRST TO FINAL YEAR) Year Number Source: HPCSA, For the corresponding period, the number of medical interns on the HPCSA register were as indicated in Table 7. Any duly registered medical practitioner can study further, depending on availability of specialist training posts in the chosen field of study. The Medical and Dental Board accredits and approves training posts that academic hospitals can have. All academic hospitals are linked to a medical school. The training posts are regulated TABLE 7. MEDICAL STOCK INFLOWS (INCLUDING BOTH YEARS OF INTERNSHIP) FROM SOUTH AFRICAN MEDICAL SCHOOLS, Year Number Source: HPCSA, through joint agreements between universities and the provincial s. These are salaried posts that are the responsibility of the government to fund. A relationship therefore exists between the HPCSA, medical schools and health authorities at provincial level. Table 8 shows the posts approved for the years 2011 to 2015 (though numbers for 2011 and 2012 could not be determined). TABLE 8. HPCSA ACCREDITED AND APPROVED POST NUMBERS (INCLUSIVE OF ALL TEACHING HOSPITALS) Year Number No data No data Expatriate medical workforce South Africa is characterized as both a sending and receiving country there is an established trend of its medical doctors seeking employment overseas, whilst it also receives medical doctors to work in its health facilities. All medical doctors wishing to work in South Africa must abide by the regulations explained earlier. The HPCSA has a legislative mandate to regulate their registration and practice. On an annual basis, the HPCSA processes applications for registration by medical doctors from over 60 countries from across the world. Table 9 shows the proportions of the expatriate medical workforce in South Africa represented by medical practitioners from the main identified source countries. The total number of expatriate medical practitioners over the five-year period studied stabilized at around A grave concern regarding this register is the percentage share of unknown country of origin 2428 (48.52%) in 2011, 2380 (46.98%) in 2012, 2238 (44.35%) in 2013, 2530 (48.30%) in 2014 and 2394 (46.26%) in TABLE 9. PERCENTAGE SHARE OF EXPATRIATE MEDICAL WORKFORCE FROM MAIN SOURCE COUNTRIES 9. Distribution of medical practitioners in South Africa One of the challenges that South Africa faces is urbanization, which has consequences for the availability of services across the country. Registration statistics at the HPCSA show that the rural provinces continue to be home to fewer medical doctors than urban provinces. Caution must be placed on the reported number of medical doctors practising in these provinces because it has previously been established that the registration address is not necessarily the same as the work address Nigeria 7.39% 7.22% 7.49% 7.33% 7.47% Britain 4.22% 4.90% 5.47% 6.05% 5.69% Cuba 3.52% 3.77% 3.77% 4.75% 5.34% Democratic Republic of the Congo 4.96% 5.05% 5.03% 4.93% 5.00% Total expatriate medical workforce % of total medical practitioner workforce TABLE 10. HPCSA MEDICAL OFFICER REGISTER 20.62% 20.17% 19.50% 19.15% 18.47% Some practitioners perform work overseas on a temporary basis and therefore see no need to change their registration details with the HPCSA. Table 10 shows the provincial spread of medical doctors in terms of HPCSA registration and government employment (five provincial s ). Health workforce planning is a critical element of any health system planning and the age analysis of the workforce plays a major role in managing the workforce stock inflows and outflows. In the South African environment, general practitioners medical doctors Eastern Cape* Western Cape* Gauteng Northern Cape Free State* Year Female Male Female Male Female Male Female Male Female Male KwaZulu-Natal Mpumalanga Limpopo* North West* Year Female Male Female Male Female Male Female Male Note: Provinces marked (*) are those that responded to the survey. 12 FROM BRAIN DRAIN TO BRAIN GAIN: 13

9 FIGURE 2. AGE PROFILE OF GENERAL PRACTITIONERS, TABLE 12. AGE PROFILE OF FEMALE AND MALE GENERAL PRACTITIONERS, GAUTENG PROVINCE Age range Sex Below 30 Female Male Female Male Female Male Female Male Above 60 Female Male Below 30 Female Male Female Male Female Male Female Male Above 60 Female Male No DOB Female Male No DOB Female Male DOB = date of birth Source: HPCSA. signify an exit from practise or a change in the form rather than the younger generation, that form the with the basic medical qualification form the front line of down to an average of about 2000 in the age of medical practise. majority on the HPCSA register (Table 13). This may medical services in both public and private health sectors. range. This contrasts with their male counterparts; be an indication that these practitioners have decided to Figure 2 shows the age profile of general practitioners on whose numbers remain relatively stable for up to 60 The reason for greater female participation in the physician stay and work permanently in South Africa, an aspect the HPCSA register for the years 2012 to No figures years and above. The marked fall in the numbers is workforce in these age ranges was not investigated. Such of importance to the brain drain in relation to their were available for experienced mostly in the Western Cape and Gauteng an analysis is recommended for a further detailed study, countries of origin. Another finding is that there is an provinces, as shown in Tables 11 and 12. The shaded perhaps following certain cohorts over a fixed period. increasing proportion of younger women expatriate A major observation is the dramatic fall in the number figures indicate a greater female participation in the physicians on the register. Table 13 indicates lower of female general practitioners from an average physician workforce than in any other female age range An analysis of the expatriate general practitioner numbers than appears on the HPCSA register, signifying of about 4000 in the age bracket category, for both Western Cape and Gauteng This could workforce for the same years shows that for both females missing data, consistent with the finding in the study on and males, it is the age range 41 years to above 60 years, the surgical workforce. TABLE 11. AGE PROFILE OF FEMALE AND MALE GENERAL PRACTITIONERS, WESTERN CAPE PROVINCE TABLE 13. AGE PROFILE OF EXPATRIATE MEDICAL PRACTITIONERS Age range Sex Age range Sex Below 30 Female Male Below 30 Female Male Female Male Female Male Female Male Female Male Female Male Female Male Above 60 Female Male Above 60 Female Male No DOB Female Male No DOB Female Male Source: HPCSA. Source: HPCSA. 14 FROM BRAIN DRAIN TO BRAIN GAIN: 15

10 10. Movements by governmentemployed medical doctors Of the nine provinces, five (45.56% of the total population) responded to the survey questionnaire. These were Eastern Cape, Free State, Limpopo, North West and Western Cape provinces. Their population sizes are as follows: Eastern Cape (12.6%), Free State (5.1%), Limpopo (10.4%), North West (6.7%) and Western Cape (11.3%). Several questions relating to placement, resignations, age profile and stock of immigrant doctors were probed. The responses on the matter of placements are shown in Figure 3. As can be seen, the Western Cape province consistently places a higher number of medical interns in its hospitals than any other responding province. Medical interns are allocated posts in hospitals on an annual basis so that they can fulfil this two-year statutory requirement. Upon completion of the internship period and community service, junior doctors join the ranks of medical officers by either remaining in public health service or opting for the private sector. Table 14 shows the stock in the five provinces for government-employed medical officers. The equivalent category of medical officer that practises in the private sector is referred to in the South African environment as a general practitioner (GP). These are medical practitioners who own and manage their surgeries as self-employed professionals. The HPCSA register 1 for the corresponding years indicates a large number of GPs in the provinces (Table 15). Whilst the Western Cape province had a large share of medical interns over the 2011 to 2015 period reviewed, it also exhibited a high number of resignations (Table 16). This is explained by the fact that junior doctors who have completed their internship are free to move to other provinces for their community service. Also, those who have just completed community service are free to move to other provinces, join the private health sector or seek work overseas. As indicated in the authors previous study on minimum data sets, the South African medical doctors have liberty to work for both the public and private health sectors through either sessional contracts with provincial health departments or through the Policy on Remunerative Work outside Public Service. This policy was developed TABLE 14. MEDICAL OFFICER STOCK IN GOVERNMENT HOSPITALS, Province Eastern Cape Free State Limpopo North West Western Cape 686 (2.83%) 140 (0.58%) 697 (2.87%) 382 (1.57%) 903 (3.72%) 476 (1.90%) 112 (0.45%) 652 (2.60%) 392 (1.56%) 881 (3.51%) 653 (2.52%) 90 (0.35%) 709 (2.74%) 413 (1.60%) 895 (3.46%) TABLE 15. PROVINCIAL GP REGISTER AT HPCSA, NUMBER AND % OF NATIONAL TOTAL 677 (2.48%) 171 (0.63%) 735 (2.69%) 450 (1.65%) 860 (3.14%) TABLE 16. MEDICAL OFFICER RESIGNATIONS ACROSS FIVE PROVINCES (MALE AND FEMALE), (2.32%) 62 (0.22%) 776 (2.78%) 511 (1.83%) 817 (2.92%) Eastern Cape Free State Limpopo North West Western Cape Year No. % No. % No. % No. % No. % The register keeps only registered addresses of practitioners and is therefore no guarantee that the medical doctor actually practises in that province. Province FIGURE 3. HEALTH PROFESSIONS COUNCIL OF SOUTH AFRICA REGISTERS 2010 TO Eastern Cape Free State Limpopo North West Western Cape 299 (1.23%) 50 (0.21%) 85 (0.35%) 31 (0.13%) 811 (3.34%) 255 (1.02%) 43 (0.17%) 87 (0.35%) 19 (0.08%) 821 (3.27%) 244 (0.94%) 52 (0.20%) 60 (0.23%) 39 (0.15%) 807 (3.12%) 288 (1.05%) 68 (0.25%) 109 (0.40%) 44 (0.16%) 798 (2.92%) 342 (1.22%) 61 (0.22%) 122 (0.44%) 30 (0.11%) 729 (2.61%) TABLE 17. AGE PROFILE OF RESIGNATIONS FROM PUBLIC HEALTH SERVICE IN EASTERN CAPE AND WESTERN CAPE PROVINCES 50 Eastern Cape Western Cape 0 Eastern Cape Western Cape Limpopo Free State North West Year and below Above FROM BRAIN DRAIN TO BRAIN GAIN: 17

11 FIGURE 4. TYPE OF PRACTICE OF RESPONDENTS FIGURE 6. MOVEMENTS UPON RETURN FROM OVERSEAS EMPLOYMENT Public only Private only Dual (Public and Private Sector) (A3) Other No response Not completed or Not displayed 0 EC (1) FS (2) GP (3) KZN (4) LP (5) MP (6) NC (7) NW (8) WC (9) No Answer Providece before going Providence after coming back Not completed or Not displayed specifically as a retention measure for government- choices of less than one year, 1-3 years, 3-5 years, the On the question whether migration should be monitored, The number of doctors coming back with unique employed health professionals who wish to supplement most common response was a work period of three to most respondents (57.29%) felt that it should. However, experience and skills is more than can be believed. their income through limited work. It is important to five years. The respondents were asked to indicate the they differed on who should monitor it. Of these, Placing limits will negate the brain gain. Many doctors stress that once medical doctors resign from government reasons why they sought employment out of South 31.56% felt that it should be monitored by the HPCSA who go, will come back. Don t make it onerous, it health service, the s do not Africa. The main reasons advanced are shown in and 25.46% felt it should be monitored by the Ministry will only encourage them to stay away. Improve the currently have a mechanism for tracing where they go Figure 5. It could not be determined how many, whilst the rest were not sure who should take efficiency in registering expatriate doctors (e.g. UK- next. They remain registered with the HPCSA but that is South African medical doctors are currently working that responsibility. Each respondent was asked to provide trained with appropriate qualifications) with HPCSA. no guarantee that they are still working within the South outside South Africa. the name of the province where they had worked before African borders. going overseas and the province where they settled after It infringes on privacy and may impact on freedom coming back. The intention was to establish whether of movement if it leads to forcing people to work in The study was therefore extended to members of the South African Medical Association, mostly practising in the private sector, to establish the migratory history of FIGURE 5. REASONS FOR SEEKING EMPLOYMENT OVERSEAS South African migrant doctors change their preference of work location after a stint of working overseas. The responses indicate that there is minimal movement to certain areas, like the certificate of need required by GPs. Surveys like this are probably good, monitoring people s every move is not. respondents. A total of 754 medical doctors, approximately 10% all those registered as members with the South 250 a different province upon return except for the Western Cape and Gauteng, which appear to gain more doctors If working conditions in South Africa are poor with African Medical Association, responded to the survey. Of respondents, 65% were in the age group 40 years and 200 (Figure 6). little room for personal or professional growth, practitioners must be free to move. above, whilst 23% were in the years group; 77% of these respondents were married. The respondents 150 The following are selected quotations and excerpts on different aspects of the migration process and Conditions in our public health sector are nothing practice location or type was almost equally split between its management: These were gathered from medical short of terrible. The long hours and total disregard the public and private sectors (Figure 4), and 71% had postgraduate qualifications in the form of diplomas and 100 doctors that responded to the survey. by government about our working hours and conditions as well as remuneration makes us want to leave specialist degrees. 50 Freedom of movement, we are private individuals. They don t monitor accountants or lawyers. the country and seek employment abroad. It is unfair to try and force us to stay here. Rather, direct efforts to Of the total respondents, 37% had the experience of working outside South Africa. From a range of 0 Experience Monetary Training Humanitarian rebuilding and restoring our health care system. 18 FROM BRAIN DRAIN TO BRAIN GAIN: 19

12 South African doctors do not migrate on a whim the decision to migrate and the challenges along with it 11. Discussion factors in the health workforce planning processes. The excerpts quoted earlier provide an indication of the health manual verification of a practitioner s registration status. While the Medical and Dental Board of the HPCSA (writing of board exams etc.) occur when the doctors South African physicians are well qualified from a clinical system-wide challenges that contribute to the migration of may be responsive to the Ministry s call for in- are highly motivated to do so. The of and academic perspective; thus, they have little difficul- medical practitioners. creased numbers of practitioners, the Board is limited Health should focus more on improving working ty in being accepted in many countries across the world. by the number of training places that are available at any conditions, rather than monitoring and preventing They are esteemed for the high standard of training they It is difficult to state categorically how many doctors work given period. doctors from leaving. receive locally, a quality that renders them prime candi- in the public and private sectors because some doctors Whoever monitors it should do so to keep track of dates for employment (14). In a 2004 study, Hagopian et al. (15) reported that a total of 5334 physicians working work across both sectors a practice purported to help retain public health care workers in the public sectors of 12. Conclusion numbers and try and understand why. The global in the United States of America came from sub-saharan low- and middle-income countries through additional The policy context for improved management of the mi- village has become rather small and stopping migration Africa and of these, South Africa had contributed 35% wage incentives (17). Collaboration between all key stake- gration of health personnel in South Africa is compelling altogether is foolish and naive. Understanding the (1840/5334). Studies such as the Hagopian study are in- holders in the provision of health services is necessary and relevant. All human resources for health policies in reasons might allow solutions that enable cross- direct measurements of the scale of emigration from de- if the constitutional provisions (section 27 of the Bill of South Africa were developed with a central focus on re- pollination but more importantly the return to South veloping countries. Direct measurement should yield bet- Rights) are to be realized. taining health professionals in the public health service, Africa. ter data and information but there needs to be appropriate though there is no evidence that these policies were pur- systems in place to enable this. The challenge is a naming In South Africa, public health workers have been permit- posefully sequenced. Their implementation remains a Freedom of choice. Avoid becoming a nanny state. or definition convention. When is working outside your ted to work part-time in the private sector since the early challenge, despite the fact that the control of immigration We should rather monitor the movement of our country an exit or emigration? Do those who work for 1990s, initially through the Limited Private Practice Policy of health professionals appears to be well executed. The engineers who are economically more viable than 3 months or 1 year stints fall in the same category as and, since 2001, through the Policy on Remunerated Work emigration aspect of South African health professionals all the doctors and can contribute much more to our those who go permanently or go for 3 to 5 years? outside the Public Service (17). Because dual practice is a appears not to be on the radar for tighter control, presum- economic drive. Elon Musk is one South African sanctioned activity, the public service employer should be ably because of constitutional issues relating to freedom engineer that is changing the world energy landscape The HPCSA is the national custodian of data on the able to know who does what work and where. Accurate of movement and trade of citizens (section 22 of South but not as a South African. medical doctors in South Africa regarding registration records must thus be maintained across all employing Africa s Constitution). Several questions will need to be and licensure to practise. It is mandated by the Health agencies of government. In our study, it was difficult to considered, particularly when addressing the issue of It depends on what one means by monitor. Professions Act No. 56 of 1974 (as amended) to set up a determine how many medical practitioners work exclu- measuring the extent of migration Should the system Trends should be observed and incentives to stay medical board that regulates accreditation of medical ed- sively in the public or private health sectors. It was also also monitor the in-country movement of health profes- (and other non-coercive means) be used to retain ucation programmes and registration of medical students, difficult to determine how many of those appearing in the sionals? Should the system prioritize certain categories doctors. If monitoring includes more than just literal qualified medical staff and specialists, and to keep an an- HPCSA register have emigrated. This is the essence of the that are linked to specific priorities (for example, spe- monitoring, and involves placing restrictions on nual register of all these through the Medical and Dental Brain Drain to Brain Gain project 2 updating expatriate cialists in relation to management of maternal deaths)? travel or passport access or agreements with other Board. In the execution of its duties it must continue to policy, supporting entry/exit processes, and strengthen- Would management of emigration only relate to those countries not to employ South Africa doctors, then liaise with the national. ing links between HPCSA registration and employment who seek remunerative work in another country? What that should not happen. status of the physician workforce. about those who go on year-long sabbaticals or extended Whilst a relationship exists between the of holidays? South Africa being a Commonwealth country, it Health and the HPCSA, their workforce management sys- This requires strong coordination and leadership at should follow Commonwealth rules and regulations. tems are not synchronized. This creates a challenge for the the level of the national Ministry as the chief Clemens and Pettersson (13) pose the critical question Any doctor recruited from overseas should be given broader management of the health workforce, including steward of the health system in the country. It must in- of how long one must stay outside the country for that full registration automatically after a period of planning. Some respondents reported leaving for over- volve the public, private and nongovernmental or not- movement to be defined as emigration. The Brain Drain continuous work in a public hospital. Public sector seas countries only to return to the urban centres such as for-profit health sectors. The HPCSA is a critical player to Brain Gain study carried out by the Royal College of doctors should not be made hostages and made to Johannesburg and Cape Town, whilst a few returned to ru- in this process as it has the legislative responsibility to Surgeons in Ireland indicates that South African doctors slave in difficult circumstances. Absolute freedom ral provinces (see Figure 6). The shortage of medical doc- maintain the credibility of the register and ensure that on Ireland s register numbered 768 (13.6%), 672 (12.1%), to all doctors and no monitoring should be there. If tors in the rural public service globally has been document- only competent medical practitioners can practise med- 642 (10.8%) and 607 (9.1%) respectively for the years 2012, monitoring happens, doctors will always find ways to ed before (16). However, it is difficult to state categorically icine in the country. There is currently no link between 2013, 2014 and The College also notes that a signifi- leave this country. Instead of depending on Cuba and how many doctors work in rural areas, partly because of the HPCSA registration system and the government s cant number of these South Africans may just be retaining Tunisia, the government should create more medical the challenge of defining what qualifies as rural or not. In system. Any verification required is done manually, and their registration, annually, perhaps as an insurance policy schools and encourage doctors to specialize in the the South African context, the urban rural factors, whilst the HPCSA i-register on the website may be used for the to enable them to work in Ireland at a future point (18). subject of their choice. important in the distribution, recruitment and retention of health workers, must be considered together with other 2. Brain Drain to Brain Gain: Supporting the WHO Code of Practice on International Recruitment Personnel for Better Management of Health Worker Migration project. The results of the qualitative study identified that most respondents did not leave with the intention of emigrating 20 FROM BRAIN DRAIN TO BRAIN GAIN: 21

13 but rather for short-term employment in other countries with the most common response being 3-5 years. It seems therefore that the discourse should differentiate between emigration and short work stints outside the doctor s country of origin. The following recommendations are made: 1. There needs to be a system to monitor emigration without an intention to stop it but to formalize it (the present study suggests that many doctors leave for short periods). 2. The HPCSA needs to be the custodian of the migration monitoring system and collaborate with its counterparts in other counties. 3. Government-to-government agreements should be encouraged so that the migration numbers can be better managed without one party losing out. 4. The South African Medical Association should play a bigger role in monitoring, as doctors tend to trust the organization more than they trust governmental or health authorities. 5. The Ministry and the HPCSA should actively engage the medical profession on issues of migration to directly address their perceptions of being victimized. 6. The and the HPCSA should interact regularly to: (a) analyse the recorded movement of medical officers employed in the public health facilities; (b) gain insight into the views and perspectives in South Africa of emigrant medical practitioners; and (c) identify existing policy instruments and practices in place to maximize benefits and mitigate negative consequences of the migration of medical doctors 7. There needs to be intergovernmental discourse at country level regarding migration of professionals across the board, including for example engineers, medical doctors, physiotherapists, among many as these are trained at great expense to the country. A uniform approach will assist in removing perceptions of victimization prevalent in the medical workforce. 8. Increased focus should be placed on migration trends between rural and urban areas of the country. 9. HPCSA becomes the custodian migration monitoring body whose role should include the contextual relationship with the to meet the reporting requirements of the Code. Acknowledgements The African Institute and Leadership Development wishes to express its appreciation for the support given to this project by the Global Health Workforce Alliance through the funding provided by the European Commission in support of the implementation of the WHO Code of Practice on the International Recruitment Personnel. References 1. Mahlathi P, Dlamini J. Minimum data sets for human resources for health and the surgical workforce in South Africa s health system: a rapid analysis of stock and migration. African Institute and Leadership Development; Mid-year population estimates. Pretoria: Statistics SA; OECD health statistics 2014: how does South Africa compare? Paris: Organisation for Economic Co-operation and Development; Naidoo S. The South African National Health Insurance: a revolution in health care delivery! Journal of Public Health. 2012;34(1): Human Resources for Health Strategy. Pretoria: Ministry ; WHO Global Code of Practice on the International Recruitment Personnel. WHA Geneva: World Health Organization; 2010 ( gb/ebwha/pdf_files/wha63/a63_r16-en.pdf, accessed 1 June 2017). 7. Refugee population by country or territory of asylum. Washington (DC): World Bank ( org/indicator/sm.pop.refg?locations=za, accessed 31 May 2017). 8. Labonte R, Sanders D, Mathole T, Crush J, Chikanda A, Dambisya Y et al. Health worker migration from South Africa: causes, consequences and policy responses. Human Resources for Health. 2015;13: Bateman C. Doctor shortages: unpacking the Cuban solution. South African Medical Journal. 2013;103(9):603 5 ( samj/article/view/7323/5357, accessed 30 May 2017). doi: /samj Awases M, Gbary A, Nyoni J, Chatora R. Migration of health professionals in six countries: a synthesis report. Brazzaville: World Health Organization; Blaauw D, Ditlopo P, Maseko F, Chirwa M, Mwisongo A, Bidwell P et al. Comparing the job satisfaction and intention to leave of different categories of health workers in Tanzania, Malawi, and South Africa. Global Health Action. 2013;6: doi: /gha.v6i van Rensburg JC South Africa s protracted struggle for equal distribution and equitable access: still not there. Human Resources for Health. 2014;12:26 ( accessed 1 June 2017). doi: / Clemens MA, Pettersson G. New data on African health professionals abroad. Human Resources for Health. 2008;6:1. doi: / Bezuidenhout MM, Joubert G, Hiemstra LA, Struwig MC. Reasons for doctor migration from South Africa. South African Family Practice. 2009;51(3): Hagopian A, Thompson MJ, Fordyce M, Johnson KE, Hart LG. The migration of physicians from sub-saharan Africa to United States of America: measures of the African brain drain. Human Resources for Health. 2004;2(17):1 10. doi: / Benjamin TB, Degani N, Crichton T, Pong RW, Rourke JT, Goertzen J et al. Factors influencing family physicians to enter rural practice. Canadian Family Physician. 2005;51: Ashmore J, Gilson L Conceptualizing the impacts of dual practice on the retention of public sector specialists: evidence from South Africa. Human Resources for Health. 2015;13(1): Brugha R, Walsh A. Brain Drain to Brain Gain: Ireland s two-way flow of doctors. Ireland country case study, Year 2. Royal College of Surgeons in Ireland; FROM BRAIN DRAIN TO BRAIN GAIN: 23

14 For further information, please contact: African Institute and Leadership Development 181 Lancia Street, Lynnwood Ridge, 0081 Pretoria, South Africa