The medical-specialist skills shortage is already having a major impact on the South African health landscape and indications are that it will only get worse in the long term, with enormous cost implications for the country.
“We’re facing a massive skills shortage in South Africa, as never seen before. The lack of specialist skills costs the country both in terms of the negative impact on people’s health and the price of health provision,” says Natalie Zimmelman, chief executive officer of the South African Society of Anaesthesiologists.
The situation is one of causality, a never-ending loop of cause and effect. Insufficient investment in the training of specialists leads to insufficient specialist skills, which in turn results in an overburdened and underperforming health industry. This then leads to further shortages in specialist skills, as there are not enough skilled specialists to offer training; nor are there adequate facilities and resources to equip specialist training and treat patients appropriately.
South Africa has an average of one doctor and one nurse per 1 000 patients, according to figures released by the World Health Organization (WHO) in 2014. This is appallingly low when compared to countries such as Australia, for instance, which averages four doctors and 12 nurses per 1 000 patients. These statistics are for general practitioners – the figures for specialists would be significantly lower.
Says Zimmelman, “South Africa’s doctors-to-nurses ratio is especially telling of the scarcity we face when it comes to skilled healthcare professionals, and the crushing pressure this has put on our healthcare system.”
Skills development for medical practitioners is currently primarily focused on undergraduates, which is a good start, but insufficient.
Given the dire straits that South Africa’s health industry is in, SASA believes a substantial budget should be set aside for training to address the increasing skills shortages, especially in specialist fields.
However, there are two major challenges. The first relates to numbers – not only does the number of medical students at universities need to increase, but more posts should be made available at teaching hospitals. This issue affects both registrars who need to be trained in their chosen specialist fields and consultants who provide the specialist training.
The second issue is the on-going tension between the needs of the Department of Health with regards to service delivery and those of the Department of Higher Education and Training. There is a memorandum of understanding between the two bodies, outlining the terms of service delivery at the teaching hospitals and the academic training that must take place at these institutions.
The memorandum stipulates that both departments and their employees need to understand and agree to its terms, but it has been ineffective. This is because the immediate need to treat patients in this resource-constrained environment is overriding the less immediate, but no less important, need to develop more skills.
“The problem is that we need more people for service delivery, to train and to be trained for the future. There are simply not enough posts and insufficient planning,” says Zimmelman.
“With the universities already under so much pressure, they feel they can’t do more. But for us to increase pass rates and transform, we must, somehow, do more. Every party, from the Colleges of Medicine of South Africa and the universities to the national and provincial departments of health and the professional societies, will have to help if we are to address this problem.”
As an example, Zimmelman cites the accounting sector, where the South African Institute of Chartered Accountants took significant responsibility for training and transformation as early as 2000, preventing similar issues in that profession.
Dr Zane Farina, an anaesthesiologist and head of SASA’s public sector business unit, has noted that one of the issues compounding South Africa’s medical-training problems is the loss of academic accreditation.
He stated in a presentation to SASA that the Health Professions Council of South Africa had withdrawn the accreditation of certain departments in Durban and institutions such as the University of Limpopo, and questioned the future of healthcare in KwaZulu-Natal and Limpopo – and, by extension, the country – in a situation where specialist training could not be sustained.
Farina elaborated, “A junior doctor who has easy access to a supervising specialist can provide excellent safe health care. An unsupervised junior doctor can easily slip into simple pitfalls, harming patients and exposing the Department of Health to significant medico-legal risk.”
The lack of oncologists and impact this has had on oncology services, especially in KwaZulu-Natal, is a case in point. Recent media reports have stated that there are no oncologists left in Durban’s public hospitals, resulting in a collapse in oncology services in the province.
The collapse of other departments can have a further knock-on effect. In 2014, the Free State experienced a setback with the collapse of the cardiology department at the Universitas Academic Hospital. This affected training of cardiothoracic surgeons and anaesthetists for cardiac surgery. Urgent intervention to appoint appropriate personnel improved the situation. Recovery is slow, but it does show that intervention can make a difference.
SASA believes a clear government directive is required to ensure a systemic focus on specialist skills development and training, coupled with workforce planning. These need to be addressed with the imminent roll-out of the National Health Insurance system.
Zimmelman concludes that South Africa has to take a long-term strategic view with regards to medical specialist skills and training and that the numbers must be addressed at national level.
“There must be a separate budget for specialist training. Failing this, the medical-specialist skills shortage is going to be immensely costly in terms of our population’s health and the monetary cost of health services and facilities.”