CASE STUDY | SOUTH AFRICA
FROM BRAIN DRAIN TO BRAIN GAIN: NURSING AND MIDWIFERY MIGRATION TRENDS IN THE SOUTH AFRICAN HEALTH SYSTEM Acknowledgements
The authors of this report are Percy Mahlathi and Jabu Dlamini (African Institute of Health & Leadership Development).
Funding for the development of this document was provided through the project “Brain Drain to Brain Gain - Supporting WHO Code of practice on International Recruitment of Health personnel for Better Management of Health Worker Migration”, co-funded by the European Union (DCI-MIGR/2013/282-931) and Norad, and coordinated by WHO. The contents of this document are the sole responsibility of the African Institute for Health and Leadership Development, and can under no circumstances be regarded as reflecting the position of the European Union or WHO.
© African Institute for Health and Leadership Development, all rights reserved.
October 2017 Contents
Abbreviations...... 3
Abstract...... 4
1. Background...... 5 2. Policy context of nursing in South Africa...... 6 3. Nursing workforce context...... 8 4. Education and training of nurses in South Africa...... 9 5. Registration requirements for foreign nurses...... 10 6. Migration of the South African nursing workforce...... 12 7. Study objectives...... 13 8. Methods...... 13 9. Results...... 13 9.1 Minimum data sets…...... 13 9.2 Stock of nurses, 2016...... 13
10. Distribution of nurse practitioners in South Africa...... 18
11. Movements by South African nurses...... 19
12. Discussion...... 22
13. Conclusion...... 25
Acknowledgements...... 26
References...... 27
Figure Figure 1. Organization of nursing leadership: public health service...... 7
Tables Table 1. Mid-year population estimates by province, 2017...... 5
Table 2. Demographic indicators, 2002–2017...... 6
Table 3. Selected list of human resources for health policies...... 8
Table 4. Categories of nursing p6ractitioners ...... 9
Table 5. Numbers in nurse training categories...... 14
Table 6. Outputs from all SANC...... 14
Table 7. Outputs from public nursing education institutions...... 15
NURSING AND MIDWIFERY MIGRATION TRENDS IN THE SOUTH AFRICAN HEALTH SYSTEM 1 Contents (continued)
Table 8. Outputs from universities, 2012–2016 (four-year programme)...... 15
Table 9. Increase in the registers of nurse practitioners, 2012–2016...... 16
Table 10. Age comparison of new entrants, 2011 and 2016...... 16
Table 11. Output of pupil nurses: private nursing institutions, by province, 2012–2016...... 17
Table 12. Output of pupil nurses: public nursing institutions...... 17
Table 13. SANC registrations by provincial distribution...... 18
Table 14. Requests for letters of verification...... 20
Table 15. Foreign nurses registered by SANC...... 20
Table 16. Strategies to mitigate health worker migration...... 21
Table 17. Nurse/midwife resignations across provinces, 2012–2016...... 23
2 FROM BRAIN DRAIN TO BRAIN GAIN: Abbreviations
CNO Chief Nursing Officer DENOSA Democratic Nursing Organisation of South Africa EM Enrolled Midwife EN Enrolled Nurse ENA Enrolled Nursing Auxiliary ESMOE Essential Steps in the Management of Obstetric Emergencies NQF National Qualifications Framework OECD Organisation for Economic Co-operation and Development PHC Primary Health Care RN/RM Registered Nurse/Midwife SANC South African Nursing Council SAQA South African Qualifications Authority SRN/M Specialist Registered Nurse/Midwife WHO World Health Organization
NURSING AND MIDWIFERY MIGRATION TRENDS IN THE SOUTH AFRICAN HEALTH SYSTEM 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 nurses and midwives and the development of associated policies in order to help health authorities to put in place the necessary systemic improvements for effective management of health workforce migration.
Objectives. The objectives of the study were (a) to assess the recorded movement of nurses and midwives employed in the public health facilities; and (b) to identify existing policy instruments and practices in place to maximize benefits and mitigate negative consequences of the migration of nurses.
Method. Data were collected from the provincial Departments of Health, the South African Nursing Council (SANC), the Democratic Nursing Organisation of South Africa and nursing education institutions through a survey. Follow-up telephonic or face-to-face interviews were conducted where a need was felt for verbal discussion. The data utilized were derived from responses to a survey questionnaire, published data from the SANC website and responses from oral interviews.
Results. Data analysis revealed that registered nurses and registered midwives form 34.45% (138 335) of 401 543 nurses appearing on the 2016 SANC register are employed by the provincial Departments of Health. Evidence of widespread migration by South African nurses is difficult to prove empirically despite several previous research studies. Over a five- year period, only 2158 registered nurses requested verification letters from SANC, either directly or through recruitment agencies. Nursing qualifications have undergone a major review and will be implemented in 2020. South African qualified nurses are trained to be generalists with grounded skills in midwifery. When nurses seek work in other countries, they do so utilizing their generalist nursing skills and experience rather than midwifery skills. There is variance between SANC registration data and provincial employment data for nurses.
Discussion. The country needs to develop a proactive mechanism to record and manage information regarding the mobility of its nursing workforce. SANC keeps records of nurses but cannot differentiate those in active practice from those in retirement or working overseas. SANC’s policy on foreign-trained nurses, based on the Department of Health’s Policy on the Recruitment and Employment of Foreign Health Professionals in the South African Health Sector, also requires review to align it with the new immigration laws of the country. Refugees and asylum seekers who are nurses form a component of migration but are not often considered in the literature on nurse migration. Given the long- standing interest in the international mobility of South African nurses, this paper advances an argument that migration by South African nurses is not as high as claimed in some studies. The most reliable indicator available currently is the record of requests for letters of verification, which are only issued by SANC. However, data from the Organisation for Economic Co-operation and Development appear to be at odds with SANC data.
Key words. emigration, immigration, nurses, midwives, experience, financial gain, foreign-trained nurses, South Africa, SANC
4 FROM BRAIN DRAIN TO BRAIN GAIN: NURSING AND MIDWIFERY MIGRATION TRENDS IN THE SOUTH AFRICAN HEALTH SYSTEM
1. Background hospitals, whilst approximately 16% access health services through private health facilities. The vast majority of health This study was undertaken as a follow-up to Minimum professionals that work in public health facilities are nurses. data sets for human resources for health and the surgical Stand-alone private nursing practices are not a common workforce in South Africa’s health system: a rapid analysis feature in the South African health system. The South of stock and migration (1) and From Brain Drain to Brain African Nursing Council (SANC) register shows that as of Gain: understanding and managing the movement of 17 January 2017 there were 401 543 nurses and midwives medical doctors in the South African health system (2). eligible to practise nursing in South Africa (4), compared to 391 517 in 2015. The South African health system is premised on primary health care (PHC) services that are delivered through a TABLE 1. MID-YEAR POPULATION ESTIMATES BY PROVINCE, 2017 District Health System. The system is designed to ensure easy access to health services by every citizen in line with Urban/rural/ Population % of total nature of the Bill of Rights as enshrined in the Constitution of the estimate population Republic of South Africa. With effect from 1996, the gov- province ernment endeavoured to extend access through a massive Eastern Cape 6 498 700 11.5 Rural clinic building programme and revitalization of hospitals Free State 2 866 700 5.1 Rural across the country. The public health service is divided Gauteng 14 278 700 25.3 Urban into primary, secondary and tertiary care through health Rural but has facilities that are located in, and managed by, the provin- KwaZulu-Natal 11 074 800 19.6 large urban centres cial Departments of Health. The provincial Departments Limpopo 5 778 400 10.2 Rural of Health are thus the direct employers of the health Mpumalanga 4 444 200 7.9 Rural workforce, including nurses, whilst the national Ministry Northern Cape 1 214 000 2.1 Rural of Health is responsible for policy development and coordination. North West 3 856 200 6.8 Rural Urban but has Between June 2016 and June 2017, the South African Western Cape 6 510 300 11.5 farming and rural communities population is estimated to have grown by 2.85% from Total 56 521 900 100.0 54 956 900 to 56 521 900 (3). Most people access health services through the government’s public clinics and Source: Statistics South Africa, 2017.
NURSING AND MIDWIFERY MIGRATION TRENDS IN THE SOUTH AFRICAN HEALTH SYSTEM 5 TABLE 2. DEMOGRAPHIC INDICATORS, 2002–2017
Infant Under-5 Crude mortality mortality Crude Rate of birth rate Life expectancy (years) rate rate death rate natural (per 1000 (per 1000 (per 1000 (per 1000 increase Year pop.) Male Female Total pop.) pop.) pop.) (%) 2002 21.7 52.9 56.6 54.9 48.1 71.3 13.4 0.83 2003 21.7 52.5 55.8 54.2 48.1 71.6 14.0 0.77 2004 22.7 52.2 55.3 53.8 48.7 71.8 14.4 0.83 2005 23.4 52.1 54.8 53.5 49.1 72.5 14.8 0.86 2006 24.1 52.3 54.7 53.5 48.7 71.7 14.8 0.93 2007 24.8 53.3 56.1 54.7 47.8 70.1 14.0 1.08 2008 24.8 54.3 57.9 56.1 46.6 67.6 13.0 1.18 2009 24.4 55.0 58.7 56.9 42.8 63.3 12.6 1.18 2010 23.9 56.4 60.6 58.5 41.1 58.4 11.6 1.23 2011 23.5 57.6 62.7 60.2 39.9 54.4 10.7 1.28 2012 23.3 58.5 63.6 61.1 38.8 51.5 10.2 1.31 2013 23.0 59.2 64.6 61.9 37.4 49.1 9.8 1.32 2014 22.7 59.7 65.1 62.5 36.0 47.1 9.6 1.31
2015 22.2 60.0 65.5 62.8 34.0 44.7 9.5 1.27
2016 21.7 60.6 66.1 63.4 33.5 43.6 9.2 1.25 2017 21.3 61.2 66.7 64.0 32.8 42.4 9.0 1.23
Source: Statistics South Africa, 2017.
The health care system consumed about 8.8% of the would be dedicated to nursing issues. The driving force country’s gross domestic product during 2012 (5). The was a realization and acknowledgement that nursing, private sector serves about 16% of the population, whilst being the largest component of the health care professions, the public sector serves 84% (6). The country’s population needed coordination at the highest policy level. Whilst the distribution indicates that about 64.7% inhabit the crude birth rate has remained fairly constant from 2002 provinces, which are largely rural in nature. Table 2 and (21.7) to 2017 (21.3), there has been a noticeable rate of Table 3 present population and demographic statistics for natural increase requiring a steady provision of health South Africa. workers.
There is a realization that the health workforce plays a 2. Policy context of nursing in critical role in advancing the health system goals (7), largely driven by a policy position of improving access South Africa to health care for all citizens. In the mid-2000s, the The nursing profession is regulated through an act of nursing profession, through their national association, Parliament – the Nursing Act No. 33 of 2005. This act the Democratic Nursing Organisation of South Africa replaced the previous Nursing Act No. 50 of 1978. The (DENOSA), made several representations to the Ministry purpose of the act was to regulate the nursing profession, of Health for the creation of a post at national level that and to provide for matters connected therewith. It thus
6 FROM BRAIN DRAIN TO BRAIN GAIN: enabled the establishment of the South African Nursing The CNO is supported at provincial level by a director for Council (SANC) to regulate such matters and spelled nursing practice, whose functions relate to operational out clear functions that the council must regulate and policy implementation. The director is required to advise adjudicate upon. the members of the Executive Council for Health and the head of the Department of Health on all matters relating Some of SANC’s key objects are (a) to serve and protect to the planning, organization and deployment of nursing the public in matters involving health services generally services in public clinics and hospitals across the province. and nursing services in particular; (b) to perform its func- Their counterparts are the principals of the public tions in the best interests of the public and in accordance nursing colleges, which are located within the provincial with national health policy as determined by the Minister Departments of Health. The next layer of nursing leadership of Health; (c) to establish, improve, and control the con- is at health service delivery level, namely hospitals and ditions, standards, and quality of nursing education and clinics, as depicted in Figure 1. training within the ambit of the act and any other appli- cable laws; and (d) to maintain professional conduct and practice standards for practitioners within the ambit of any FIGURE 1. ORGANIZATION OF NURSING LEADERSHIP: applicable law. PUBLIC HEALTH SERVICE
SANC is therefore the custodian of nursing education, training and practice standards. It is required to work in Chief Nursing Officer concert with the Ministry of Health in matters related to (located at Ministry of Health) nursing. In that context, the Ministry of Health established the office of the Chief Nursing Officer (CNO) in 2014 after considering representations from DENOSA. The major role of the CNO is to provide advice to the Minister of Health and the members of the Executive Council for Health in the nine provinces on technical and policy Provincial nursing directors (x9) matters regarding nursing and health services generally. The establishment of this office has served to reinforce the central role that nursing plays in the provision of health services in South Africa. The location of the office Principals of nursing colleges (x9) and Nursing managers (hospitals and clinics) within the Ministry of Health is strategic, as it places nursing at the centre of health policy development and coordination at national and global level. The CNO is part of the country delegation to the World Health Assemblies, which are held on an annual basis. The CNO therefore A number of policies have been adopted over the years participates in the global CNO meetings that serve to aimed at improved management of the health workforce advance the nursing agenda on the global health stage. in South Africa (1, 2). Table 3 presents a set of policy Positive results have emanated from the establishment and strategy documents relevant to the management of of CNOs in many WHO Member States, for example the the health workforce, including nursing, that together inclusion of a chapter on nursing in the Global Strategy on contribute to improved distribution and retention of the Human Resources for Health: Workforce 2030. workforce, and support implementation of the World Health Organization (WHO) Global Code of Practice on At national level, the CNO policy focus areas include the International Recruitment of Health Personnel (8), placing major emphasis on the centrality of nursing in with the Policy on the Recruitment and Employment of PHC, for example in the areas of school health, ward-based Foreign Health Professionals in the South African Health PHC services, and maternal and child health services. Sector being particularly notable.
NURSING AND MIDWIFERY MIGRATION TRENDS IN THE SOUTH AFRICAN HEALTH SYSTEM 7 TABLE 3. SELECTED LIST OF HUMAN RESOURCES FOR HEALTH POLICIES
Policy Year Focus/rationale Human Resource Strategy 2001 Proposals on the definitions, entry requirements, and scope of practice of all categories of health care professionals Scarce Skills Allowance 2003 Financial incentive to retain “scarce skills” in the public health service Remunerative Work outside Public 2002 Incentive scheme allowing public servants to work in the private sector Service whilst fully employed by government Human Resources for Health 2006 Highlighting the need for systematic national health workforce Planning Framework planning Policy on Remuneration of Health 2007 System of differentiated pay for health professionals employed in Professionals Working in Public public health facilities with the objective of recruiting and retaining Health Service professionals in the public health service Nursing Strategy 2008 Articulates how nursing education and training, practice, resources, social positioning, regulation and leadership are planned and linked together with prescripts of professionalism to support the nation’s health system Policy on the Recruitment and 2010 Principles and practices in the employment of health professionals Employment of Foreign Health who are non-citizens aligned to the immigration processes of the Professionals in the South African Department of Home Affairs Health Sector Human Resources for Health 2011 Focus on planning and staffing of health facilities in preparation for Strategy the introduction of the National Health Insurance. It built on the foundation laid by the 2001 Human Resource Strategy and the 2006 Human Resources for Health Planning Framework National Strategic Plan for Nurse 2012 Develop, reconstruct and revitalize the profession to ensure that Education, Training and Practice nursing and midwifery practitioners are equipped to address the disease burden and population health needs within a revitalized health care system in South Africa
These policies are intended to work in harmony and extend to influence the operations of statutory health councils such as SANC and education institutions.
3. Nursing workforce context nursing departments located within universities. Nursing constitutes the largest cadre of the South African health In recent years, nursing education and training has come workforce. under the spotlight due to the split mandate between the National Department of Health and the Department of When the health system was being transformed from 1996 Higher Education and Training. The National Department onwards, the government took a decision to adopt PHC as of Health is responsible for nursing service provision whilst the preferred system for making health services accessible to the Department of Higher Education and Training is citizens. The White paper for the transformation of the health responsible for the education aspects through the Council system (1997) articulated the values that would be pursued on Higher Education. Nursing education and training in line with the Bill of Rights enshrined in the country’s takes place at three types of facilities – nursing colleges, Constitution. Nursing is widely regarded as a critical which are located within provincial Departments of component of the provision of health services. In 2009, a Health; private nursing schools, which either are attached process for improving PHC, termed the Re-engineering of to private hospitals or are independent; and university Primary Health Care, was introduced by the Ministry of
8 FROM BRAIN DRAIN TO BRAIN GAIN: Health. It has three strands, namely establishment of ward- According to the current education qualifications based PHC outreach teams, expansion and strengthening framework (9), four categories of nurses are recognized: of school health services, and establishment of district enrolled nursing auxiliary (ENA), enrolled nurse (EN), clinical specialist teams. Nurses play a key role in all these registered nurse/midwife (RN/M), and specialist registered strands. nurse/midwife (SRN/M). Table 4 indicates the length of training for each category.
TABLE 4. CATEGORIES OF NURSING PRACTITIONERS (BASED ON CURRENT QUALIFICATIONS) AND LENGTH OF TRAINING
Qualification category Length of education and training Enrolled nursing auxiliary (ENA) 1 year
Enrolled nurse (EN) 2 years Registered nurse/midwife (RN/M) 4 years
Specialist registered nurse/midwife (SRN/M) 1 or 2 years post RN/M training depending, on the post-basic programme
A nurse who holds any of these qualifications can provide health services in any environment as long as their scope of practice permits. Thus, nurses are found in every health facility – public and private – where health services are required.
4. Education and training of (c) recommending qualifications or part qualifications to nurses in South Africa SAQA for registration.
Education and training of nurses in South Africa is regu- The repeal of the Nursing Act No. 50 of 1978 necessi- lated by SANC through the Nursing Act No. 33 of 2005. tated a review of nursing qualifications. The unintend- For a person to be admitted to an academic programme ed consequence of the introduction of the four-year leading to qualification as a nurse, they need to have suc- Comprehensive Diploma in Nursing through Government cessfully achieved a grade 12 school pass. This pass is at Notice No. R425 of 22 February 1985 (as amended) was level 4 of the National Qualifications Framework (NQF) the perception that the programme offered four qualifica- as defined by the South African Qualifications Authority tions in one, namely general nursing, community health (SAQA). The NQF is set up in terms of the National nursing, psychiatric nursing and midwifery. In addition, Qualifications Framework Act No. 67 of 2008, as amend- the registration of a qualified nurse in the current SANC ed. In terms of the NQF Act, SANC is designated as a register is registered nurse/midwife (RN/M). This also Quality Council, with responsibilities including (a) devel- gives a perception that the RN/M is a double qualifica- oping and implementing policy and criteria, taking into tion. The policy intention of the Comprehensive Diploma account the policy and criteria contemplated in section in Nursing was the production of a generalist nurse with 13(1)(h)(i) of the act, for the development, registration a wide range of relatively superficial competence in order and publication of qualifications; (b) ensuring the devel- to render a generalist level of care (10). Thus, the mid- opment of such qualifications or part qualifications as are wifery aspect of the four-year diploma is not a stand-alone necessary for the sector, which may include appropriate qualification but rather a designation to indicate training measures for the assessment of learning achievement; and in midwifery. A South African nurse with a four-year
NURSING AND MIDWIFERY MIGRATION TRENDS IN THE SOUTH AFRICAN HEALTH SYSTEM 9 Diploma in Nursing (under the current system) is there- planning and implementation of basic nursing care; and fore expected to possess competencies that can be applied (d) develop writing and oral communication skills. in the practice of midwifery under general conditions of nursing practice. These nurses operate at any level of the Diploma in Nursing: Staff Nurse. This diploma will ap- health service and are not confined to obstetric care. ply evidence-based nursing practice, based on research or established practices that have proven to be effective With the enactment of the Nursing Act No. 33 of 2005, both nationally and internationally within the profession. it became imperative that all nursing qualifications be It will also equip diplomates with a developed sense of eq- reviewed so that each could be streamlined and operate uity, justice and service ethics that will ensure that they in harmony with the relevant scopes of practice. These work in an accountable manner, irrespective of their cho- have now been configured such that the new Diploma in sen workplace. Nursing will be completed over a three-year period and confined to the PHC environment where the comprehen- Bachelor’s Degree in Nursing and Midwifery. The sive generalist competencies will be required (11). A new graduate who completes this qualification will be able register of specialist nurses will be established and is due to, inter alia, (a) apply knowledge of theory of biological to come into operation in 2020. The register with the cur- and natural sciences, psychosocial sciences and pharma- rent (legacy) qualifications will cease to exist at the end cology in the provision of comprehensive nursing and of 2019. There is therefore heightened activity in prepa- midwifery care; (b) develop, implement and evaluate ration for the transformation of nursing education and population-based health care; and (c) utilize research in training in South Africa. nursing and health-related problems to improve health care outcomes. The policy imperative is articulated by SANC as follows: Nursing education and training across South Advanced Diploma in Midwifery. The primary purpose Africa is responding to changing needs, develop- of this qualification is to produce competent, independent ments, priorities and expectations in health and and critically thinking midwives who will provide scien- healthcare. Nurses who acquire the knowledge, tific, safe and comprehensive quality midwifery care to in- skills and behaviours that meet our standards will dividuals, families and communities within the legal and be equipped to meet these present and future chal- ethical framework. lenges, improve health and wellbeing and drive up standards and quality, working in a range of These academic programmes can be offered at any post- roles including practitioner, educator, leader and school level – nursing college, technical and vocational researcher. education training institution, or university – as long as such an institution has satisfied the accreditation criteria The review of nursing qualifications was also necessitat- set by SANC. ed in part by an increasingly complex burden of disease requiring new competencies among nurses, and by the 5. Registration requirements for changing post-schooling education landscape as articu- foreign nurses lated by the NQF. The qualifications are now organized in the following manner (11): Since 2010 all health professionals from outside South Africa wishing to work in the country must comply with Higher Certificate: Auxiliary Nursing. This qualifica- the Policy on the Recruitment and Employment of Foreign tion aims to (a) produce nurses that will provide basic Health Professionals in the South African Health Sector. nursing care in all spheres of health care service delivery; This policy was introduced to improve the flow of health (b) provide the nurse with a wide range of cognitive, affec- professionals into South Africa and expresses the following tive and psychomotor skills; (c) hone skills in assessment, objectives:
10 FROM BRAIN DRAIN TO BRAIN GAIN: • promote high standards of practice in the recruitment professional bodies must be submitted in order for and employment of health professionals who are not SANC to conduct a fair and authentic evaluation of a South African citizens or permanent residents; foreign qualification.
• preclude the active recruitment of health professionals • Complete verification of a foreign qualification is from developing countries unless there are specific required before it is recognized as authentic. government-to-government agreements to allow and support such recruitment. The categories that are envisaged in the policy are applicants who: The policy was crafted such that it is complementary to the Immigration Act and other laws, and is consistent with the • hold a foreign qualification and wish to undergo basic/ country’s Constitution. SANC has in turn developed and undergraduate nurse training and education in South adopted policy guidelines regarding registration of inter- Africa; nationally qualified nurses and midwives and/or foreign qualifications with SANC. The policy emphasizes the fact • hold a foreign qualification and wish to pursue that SANC is responsible for the regulation of the nurs- postgraduate studies in South Africa; ing profession in South Africa. In executing the function of registration of foreign nurses and qualifications from • wish to do elective practicums in South Africa in order foreign countries, SANC takes cognizance of the Policy to gain experience in a specific area of practice; on the Recruitment and Employment of Foreign Health Professionals in the South African Health Sector (12). In • wish to do voluntary work or research in South Africa; pursuit of this function, SANC processes applications from foreign nurses and midwives who hold qualifications from • wish to be registered for employment after successful a foreign country as well as South Africans who hold qual- completion of postgraduate studies in South Africa. ifications from a foreign country. Foreign nationals who wish to be employed in South Africa The fundamental principle is that “the evaluation of for- as nurses must submit to SANC the following documents: eign qualifications by SANC considers all South African National Qualifications Framework related legislation, • letter of intent/application; regulations and policies”. The policy guidelines further em- phasize that “where substantial difference exists and can be • letter of support from the National Department of demonstrated between foreign and local qualification, it re- Health’s Foreign Workforce Management Programme; mains SANC’s decision (prerogative) to recognize a foreign qualification at the designated NQF level”. Furthermore, • certificate of English language proficiency from an SANC reserves the right to revoke a certificate of profes- accredited institution (applicable only to applicants sional registration should any evidence come to light that whose nursing education was not done in English); compromises its integrity and validity (12). • evaluation certificate of foreign educational qualification The guidelines advance the following requirements for a by SAQA; nurse affected by this policy: • certified copy of registration by the regulatory body • Applicants must provide SANC with a complete and from the country of origin; credible set of documents to enable evaluation. • certified copy of qualification certificate; • Relevant information from foreign institutions and
NURSING AND MIDWIFERY MIGRATION TRENDS IN THE SOUTH AFRICAN HEALTH SYSTEM 11 • valid licence to practise as a nurse from the nurse’s reg- council or board recognized by SAQA in terms ulatory body where the applicant’s nursing qualification of section 13(1)(i) of the National Qualifications was registered; Framework Act; and
• record of education and training (transcript) from the c) proof of evaluation of the expatriate qualification nursing education institution in the country of origin; by SAQA and translated by a sworn translator into one of the official languages of the Republic (of • verification certificate from the regulatory body of South Africa). the country of origin confirming that the applicant is in good professional standing and has no professional (6) A critical skills work visa shall be issued for a period not misconduct cases pending against her/him (except for exceeding five years. refugees); (7) A spouse and dependent children of a holder of a crit- • letter of competence from the last employer; ical skills work visa shall be issued with an appropriate visa valid for a period not exceeding the period of valid- • police clearance letter from the country of origin (ex- ity of the applicant’s critical skills work visa. cept for refugees). Section 18(3)(iii) of the Immigration Act also prescribes The exclusion of refugees from some of these requirements that the salary and benefits of the applicant are not inferi- is based on the provisions of South Africa’s Refugees Act or to the average salary and benefits of citizens or perma- No. 130 of 1998, as amended, which aims to protect those nent residents occupying similar positions in South Africa. who come to South Africa because of persecution in their This is also in line with the provisions of the Occupation- countries. However, a work permit or formal recognition of Specific Dispensation policy, which regulates how health refugee status issued by the Department of Home Affairs professionals in the public health service are remunerated. must be produced. In the case of employment, once all con- ditions set by SANC have been satisfied, and once appoint- There is acknowledgment that the National Department ed to a post, an expatriate nurse is entitled to the same sala- of Health’s Policy on the Recruitment and Employment of ry and benefits pertaining to the post as any South African Foreign Health Professionals in the South African Health counterpart who occupies a similar post. This is in line with Sector requires urgent review so that it is completely in line section 18 of the Immigration Act, which states that: with the amended Immigration Act of 2014. In addition, prevalent health workforce shortages have rendered some (5) An application for a critical skills work visa shall be ac- of the clauses of the policy irrelevant, for example princi- companied by proof that the applicant falls within the ple 5, which states that the employment of expatriate health critical skills category in the form of – professionals shall only be allowed after they have been successful in competing for an advertised post and there is a) a confirmation, in writing, from the profession- record that no South African citizen or permanent resident al body, council or board recognized by South was available or found suitable to fill the particular post. African Qualifications Authority (SAQA) in terms When faced with critical shortages, this clause is unlikely of section 13(1)(0) of the National Qualifications to be adhered to. Framework Act, or any relevant government Department confirming the skills or qualifications 6. Migration of the South African of the applicant and appropriate post qualification experience; nursing workforce The migration of South African medical professionals has b) if required by law, proof of application for a cer- been a subject of discussion for a considerable period. tificate of registration with the professional body, Many studies have been conducted and have advanced
12 FROM BRAIN DRAIN TO BRAIN GAIN: varying estimates of emigration by health professionals 8. Methods in the African continent (13–15). Several causes of migration by health professionals have also been recorded. A survey questionnaire was sent through SANC, the Measuring the extent of emigration – particularly by South nursing directors of the nine provincial Departments African nurses – remains a challenge, as several research of Health, the principals of the nursing colleges locat- studies have been based on incomplete data. Previously, ed within the provincial Departments of Health, and challenges have been reported relating to collection of DENOSA. The nine provincial Departments of Health systematic data on international flows of health workers were included in the study on the basis that they are the from South Africa, including to the rest of the continent, biggest direct employing entity of nurses. SANC was in- resulting in a tendency to rely on destination country data cluded on the basis that it carries the legislative mandate systems to estimate the extent of emigration of medical to maintain the registers of all nurses in the country, doctors from South Africa (2). Clemens and Pettersson including those in active practice and those no longer have previously utilized destination country census data practising. DENOSA was included on the basis that it is to make such an estimation (15). an umbrella organization of nurses, and the nursing col- leges and universities on the basis that they are respon- As reported in the authors’ previous study on the sible for the training of nurses. The Society of Midwives surgical workforce and management of migration by of South Africa was also included in the study. A face- medical doctors (1, 2), South Africa still does not have a to-face interview was held with the CNO to discuss and systematized mechanism for measuring and monitoring explore various policy issues relating to nursing and the emigration of its health professionals. SANC has a system role of her office. of issuing verification letters for nurses who request these for purposes of seeking employment overseas. Each respondent was sent a questionnaire to complete However, even this method does not accurately estimate and, based on the responses, telephonic follow-up in- the number of nurses who end up taking employment in terviews were conducted for further explanations or other countries. closure of gaps in the information supplied. Guiding the research data-gathering process was a protocol de- Due to the difficulty of producing empirical evidence, veloped by the Global Health Workforce Alliance that some studies have resorted to making deductions based provided a list of minimum data sets against which to on “intention to leave” of respondents (16, 17). match responses.
7. Study objectives 9. Results
The objectives of the study were to: 9.1 Minimum data sets In relation to the minimum data sets, no data elements (a) assess the recorded movement of nurses employed in were probed, as the previous study responses (1) were the public health facilities; deemed to be still relevant.
(b) identify existing policy instruments and practices in 9.2 Stock of nurses, 2016 place to maximize benefits and mitigate negative con- The major data source was SANC, which maintains a sequences of the migration of nurses. register of all student nurses and qualified nurses that are licensed to practise in South Africa. The second The study also sought to identify whether any synergies source was the provincial Departments of Health. or gaps existed between the workforce data systems of provincial Departments of Health (the major employer As of 31 January 2017, the register of individuals within the health sector), SANC and the national nursing undergoing training to be nurses as student nurses, pupil association – DENOSA. nurses, or pupil nursing auxiliaries was as indicated in
NURSING AND MIDWIFERY MIGRATION TRENDS IN THE SOUTH AFRICAN HEALTH SYSTEM 13 Table 5. These students are admitted for training at any time and does not include those who are in bridging of the nursing education institutions – public nursing programmes or supplementary basic programmes. college, private nursing school or university. Whilst all nursing education institutions are in the post-schooling Tables 6, 7 and 8 present data on outputs from system, admission criteria are not necessarily the same. various types of training institutions for the period All universities utilize a point system for admission 2012–2016. into their academic programmes. However, the point requirements differ for each programme. Upon qualification as a nurse/midwife, these professionals must maintain their names in the register The table reflects the number of persons entering the by paying an annual registration fee. SANC is the nursing profession (as students or pupils) for the first statutory body responsible for maintaining the integrity
TABLE 5. NUMBERS IN NURSE TRAINING CATEGORIES, 2012–2016
Category 2012 2013 2014 2015 2016 Student nurses and midwives 20 920 20 956 21 303 20 549 21 339
Pupil nurses 16 424 15 337 18 767 18 846 10 773
Pupil nursing auxiliaries 5 910 6 747 8 549 9 312 2 990
TABLE 6. OUTPUTS FROM ALL SANC ACCREDITED NURSING EDUCATION INSTITUTIONS, 2012–2016 (FOUR-YEAR PROGRAMME)
Province 2012 2013 2014 2015 2016 Eastern Cape 502 549 558 542 558 Free State 147 174 153 228 236 Gauteng 757 793 842 806 774 KwaZulu Natal 604 586 630 486 515 Limpopo 339 220 271 312 343 Mpumalanga 120 197 145 36 322 Northern Cape 3 0 0 24 25
North West 297 322 230 350 347 Western Cape 456 420 392 507 408 Yearly totals 3 225 3 261 3 221 3 291 3 528
14 FROM BRAIN DRAIN TO BRAIN GAIN: TABLE 7. OUTPUTS FROM PUBLIC NURSING EDUCATION INSTITUTIONS, 2012–2016 (FOUR-YEAR PROGRAMME)
Category 2012 2013 2014 2015 2016 Eastern Cape 375 407 411 367 358 Free State 98 139 121 169 165 Gauteng 647 680 742 670 681 KwaZulu Natal 534 524 506 370 316 Limpopo 230 148 177 196 218 Mpumalanga 120 197 145 36 322 Northern Cape 62 56 3 24 25 North West 237 265 166 259 275 Western Cape 229 250 213 301 243
TABLE 8. OUTPUTS FROM UNIVERSITIES, 2012–2016 (FOUR-YEAR PROGRAMME)
Province 2012 2013 2014 2015 2016 Eastern Cape 127 142 147 175 200 Free State 49 35 32 59 71 Gauteng 110 113 100 136 93 KwaZulu Natal 70 62 124 116 199 Limpopo 109 72 94 116 125 Mpumalanga No university-based programme Northern Cape No university-based programme North West 297 322 230 350 347 Western Cape 456 420 392 507 408
of the register. Table 9 shows the increase in numbers of Over the same comparable period, the population of various registered categories. South Africa increased from approximately 47.850 million in 2007 to 55.909 million in 2016, an increase The age analysis of students entering nurse training of 16% (Statistics South Africa, midyear estimate). for the first time indicates the continued popularity of SANC compiles and publishes its statistics annually on the profession to South Africans. A contributing factor 31 December. Upon completion of training nurses have may be that it remains one of the few professions that to perform community service, which amounts to one the government still takes responsibility for in terms year working in the public health service. This system of providing funding for studies. Table 10 shows the commenced with medical interns and was extended to comparative ages of new entrants to various courses. nurses as from 2006. This is performed in terms of section
NURSING AND MIDWIFERY MIGRATION TRENDS IN THE SOUTH AFRICAN HEALTH SYSTEM 15 40(1) of the Nursing Act, 2005, which states: “A person Health workforce planning is a critical element of any who is a citizen of South Africa intending to register health system planning, and the age analysis of the for the first time to practise a profession in a prescribed workforce plays a major role in managing the workforce category must perform remunerated community service stock inflows and outflows. Nurses form the front line for a period of one year at a public health facility.” The of health services in the public health sector. Evidence associated Regulation 2.1 of the Regulations Relating to shows that the private nursing schools contribute Performance of Community Service states: “Any person significant numbers of nurses to the health system who is a citizen of South Africa intending to register for through the training of current staff nurses. Table 11 the first time as a professional nurse in terms of the Act, shows the output of pupil nurses from private nursing as having met the prescribed requirements to qualify as institutions by province, 2012–2016, while Table 12 such, must perform remunerated community service for shows the output of pupil nurses from public nursing a period of one year.” These regulations pertain to South institutions for the same period. African citizens and permanent residents. Exemption will be granted to persons who may have performed a similar service elsewhere (12).
TABLE 9. INCREASE IN THE REGISTERS OF NURSE PRACTITIONERS, 2012–2016
Category 2012 2013 2014 2015 2016 RN/RM 124 045 129 015 133 127 136 854 140 598 EN/EM 58 722 63 788 66 891 70 300 73 558 ENA 65 969 67 895 70 419 71 463 73 302
RN/RM = registered nurses and registered midwives; EN/EM = enrolled nurses and enrolled midwives; ENA = enrolled nursing auxiliaries.
TABLE 10. AGE COMPARISON OF NEW ENTRANTS, 2011 AND 2016
Average age Minimum age Maximum age No.
Course 2011 2016 2011 2016 2011 2016 2011 2016 4-Yr Diploma 25 23 15 15 57 56 4 649 4 922 Bridging 36 36 20 21 61 62 3 051 5 131 Psychiatry 46 45 27 30 60 60 111 114 Midwifery 44 43 25 24 66 62 1 108 1 506 EN-Gen 30 34 17 18 60 60 7 622 845 EN-Comm 37 37 26 24 61 58 142 55 EN-Aged Care – 34 – 20 – 45 – 4 EN-Psy 39 38 27 38 53 38 41 2 AN 29 32 20 18 61 55 4 374 518 CHATC (PHC) 41 41 24 24 64 63 314 789
EN-Gen = enrolled nurse general; EN-Comm = enrolled nurse community health; EN-Psy = enrolled nurse psychiatry; AN = assistant nurse; CHATC = clinical nursing science, health assessment, treatment and care.
16 FROM BRAIN DRAIN TO BRAIN GAIN: TABLE 11. OUTPUT OF PUPIL NURSES: PRIVATE NURSING INSTITUTIONS, BY PROVINCE, 2012–2016
Province 2012 2013 2014 2015 2016 Eastern Cape 195 211 246 406 271 Free State 41 62 57 66 65 Gauteng 1 978 2 345 1 998 2 848 2 414 KwaZulu-Natal 2 448 2 951 2 301 2 633 2 332 Limpopo 99 120 132 108 99 Mpumalanga 34 46 25 32 24 Northern Cape 0 0 0 0 0 North West 103 183 153 126 141 Western Cape 345 387 260 478 426 Yearly totals 5 243 6 305 5 172 6 697 5 772
TABLE 12. OUTPUT OF PUPIL NURSES: PUBLIC NURSING INSTITUTIONS, BY PROVINCE, 2012–2016
Province 2012 2013 2014 2015 2016 Eastern Cape 501 416 377 582 593 Free State 173 129 154 191 192 Gauteng 540 802 394 333 435 KwaZulu-Natal 536 634 297 199 8 Limpopo 409 162 134 237 246 Mpumalanga 211 271 216 262 399 Northern Cape 0 0 0 0 0 North West 1 23 41 71 82 Western Cape 119 212 164 184 152 Yearly totals 2 490 2 649 1 777 2 059 2 107
Note: Pupil nurses are those nurses who study towards the registration qualifications of enrolled nurse and enrolled nurse assistant.
NURSING AND MIDWIFERY MIGRATION TRENDS IN THE SOUTH AFRICAN HEALTH SYSTEM 17 10. Distribution of nurse The figures in Table 13 indicate that the provinces of practitioners in South Africa Gauteng, KwaZulu-Natal and Western Cape share be- tween them more than 60% of the country’s RN/RM reg- One of the challenges that South Africa faces is urbaniza- istrations. Similarly, these provinces share about 52% of tion, which has consequences for the availability of ser- the student nurse population amongst them. These pro- vices across the country. Registration statistics at SANC vincial distribution figures are based on registration data show that the highest number of registrations is in three at SANC and do not reflect accurately the place of em- out of nine provinces. This does not necessarily mean that ployment of each nurse. SANC also does not keep a regis- all those nurses are working in those provinces, as the ter based on the employment status of anyone appearing SANC database is not linked to the employee databases in its register. of the Departments of Health in the provinces. Table 13 shows the provincial spread of nurses in terms of SANC registration, but not necessarily employment.
TABLE 13. SANC REGISTRATIONS BY PROVINCIAL DISTRIBUTION, AS AT 31 DECEMBER 2016
Registered Enrolled Auxiliary Province Sex nurses nurses nurses Total Students Pupils Pupil NAs Eastern Cape Female 13 975 5 244 6 563 25 782 2 596 911 351 Male 1 588 873 1 216 3 677 1 160 289 136 Total 15 563 6 117 7 779 29 459 3 756 1 200 487 (11.07%) (8.32%) (10.61%) (10.25%) (17.6%) (11.14%) (16.29%) Free State Female 7 103 2 066 2 828 11 997 971 151 63 Male 1 102 416 359 1 877 242 25 16 Total 8 205 2 482 3 187 13 874 1 213 176 79 (5.84%) (3.37%) (4.35%) (4.83%) (5.68%) (1.63%) (2.64%) Gauteng Female 34 024 17 263 18 553 69 840 3 829 3 583 1 055 Male 2 579 1 471 1 214 5 264 908 350 95 Total 36 603 18 734 19 767 75 104 4 737 3 933 1 146 (26.03%) (25.47%) (26.97%) (26.12%) (22.2%) (36.51%) (38.33%) KwaZulu Natal Female 28 609 22 755 12 759 64 123 2 650 3 459 522 Male 2 999 2 537 1 302 6 838 981 546 84 Total 31 608 25 292 14 061 70 961 3 631 4 005 606 (22.48%) (34.38%) (19.18%) (24.68%) (17.02%) (37.17%) (20.27%) Limpopo Female 10 355 5 965 9 224 25 544 1 376 119 85 Male 1 498 652 838 2 988 519 27 11 Total 11 853 6 617 10 062 28 532 1 895 146 96 (8.43%) (9%) (13.73%) (9.93%) (8.88%) (1.36%) (3.21%)
(continued)
18 FROM BRAIN DRAIN TO BRAIN GAIN: TABLE 13. (continued)
Registered Enrolled Auxiliary Province Sex nurses nurses nurses Total Students Pupils Pupil NAs Mpumalanga Female 6 621 3 179 3 579 13 379 650 119 74 Male 881 310 245 1 436 341 20 26 Total 7 502 3 489 3 824 14 815 991 139 100 (5.34%) (4.74%) (5.22%) (5.15%) (4.64%) (1.29%) (3.34%) Northern Cape Female 2 085 407 978 3 470 196 - 74 Male 199 45 97 341 68 - 43 Total 2 284 452 1 075 3 811 264 - 117 (1.62%) (0.61%) (1.47%) (1.33%) (1.24%) (0%) (3.91%) North West Female 8 555 3 095 4 430 16 080 1 585 329 67 Male 1 290 329 579 2 198 486 37 17 Total 9 845 3 424 5 009 18 278 2 071 366 84 (7.00%) (4.66%) (6.83%) (6.36%) (9.71%) (3.4%) (2.81%) Western Cape Female 15 841 6 516 7 967 30 324 2 229 704 246 Male 1 294 435 571 2 300 552 104 29 Total 17 135 6 951 8 538 32 624 2 781 808 275 (12.19%) (9.45%) (11.64%) (11.35%) (13.03%) (7.5%) (9.2%) 100% of workforce 140 598 73 558 73 302 287 458 21 339 (7.5%) 2 990
(%) of national nursing workforce in each column.
11. Movements by South interest irrespective of the accuracy or inaccuracy of reports African nurses about it. The issue that evokes most public emotions is per- ceived emigration by highly skilled nurses. On 2 February The majority of South African nurses are employed in 2016, a local newspaper published the following story with the public health service, with the provinces of Gauteng, the headline “Nurses leaving SA in droves”: KwaZulu-Natal and Western Cape taking the bulk of More and more South African nurses are taking these. Up to 1994 it was not easy for nurses to seek work their skills and knowledge abroad for the promise overseas. However, this changed when the country elected of more pay and better working conditions. This a democratic government. This enabled all citizens to has plunged the country’s healthcare sector and have freedom of movement and work, as enshrined in the nursing profession deep into crisis, the Pretoria Constitution of the Republic of South Africa, section 22 News learnt on Monday. The hardest-hit victims of of the Bill of Rights, which states: “Every citizen has the the exodus are children, the sick, poor and elderly right to choose their trade, occupation or profession freely. and those who live in areas where healthcare The practice of a trade, occupation or profession may be was already scarce, stakeholders said. Hundreds regulated by law.” of thousands of well-trained and highly skilled professional nurses were working in countries The movement of South African nurses has remained a such as the UK, Canada and Arab countries. (18) sensitive topic since 1995. It is a matter that evokes public
NURSING AND MIDWIFERY MIGRATION TRENDS IN THE SOUTH AFRICAN HEALTH SYSTEM 19 However, close scrutiny of SANC records (letters of veri- nursing stock were 488 (0.378%) for 2013, 501 (0.376%) fication) revealed the opposite. Over the past five years, for 2014, 388 (0.284%) for 2015, and 501 (0.356%) for only 2158 requests for letters of verification were processed 2016. These have been calculated for categories 1 to 5 by SANC. Table 14 provides a breakdown of numbers by and 8 to 9 of table 16 and fall within the RN/RM regis- country. tration category of SANC. Some of these foreign nurses are recruited under special permit conditions to work The numbers of foreign nurses in South Africa (as regis- in private hospitals, such as those operated by Netcare. tered by SANC) and percentages of total South African Zimbabwe also contributes to the pool of foreign nurses.
TABLE 14. REQUESTS FOR LETTERS OF VERIFICATION WITH COUNTRY DESTINATIONS, 2012–2016
Country 2012 2013 2014 2015 2016 5-year totals Abu Dhabi 25 13 31 7 12 88 Australia 106 43 66 54 75 344 Bahrain – 9 2 3 3 17 Botswana 7 – – – – 7 Canada 33 21 33 1 1 89 Ireland 3 4 11 10 15 43 Namibia 17 7 15 5 10 54 New Zealand 41 10 20 26 37 134 Qatar 12 – – – – 12 United Kingdom 45 21 59 81 132 338 United States of America 59 23 18 62 78 240 Zimbabwe – – – – 7 7 Other countries 30 14 101 127 98 370 Agencies – – 230 83 102 415 Totals 378 165 586 459 570 2 158
Source: SANC, 2017.
TABLE 15. FOREIGN NURSES REGISTERED BY SANC, BY CATEGORY, 2012–2016
Programme 2012 2013 2014 2015 2016 5-year Totals 1. General nurse – 373 426 313 419 1 531 2. General nurse and psychiatry – 4 4 6 4 18 3. General nurse and midwifery/accoucheur – 102 62 50 71 285 4. Psychiatric nursing science – 3 – 2 1 6 5. Midwifery – 4 8 17 6 35 6. Enrolled nurse – 3 5 4 2 14 7. Enrolment as a nursing auxiliary – 2 1 4 – 7 8. General nurse, psychiatric nurse and midwife – 1 1 – – 2 9. General nurse, midwife community health – 1 – – – 1
20 FROM BRAIN DRAIN TO BRAIN GAIN: The fact that a nurse has requested that a verification skilled health workers primarily use migratory routes for be sent to a potential employer or a recruitment agency professional development, suggesting that health worker does not necessarily mean that she or he has taken up the shortages as a result of permanent migration no longer offer of a position in another country. The news report pertain to South Africa. Temporary migration of South cited above (18) is also contradicted by other empirical African health professionals motivated by professional studies that have been conducted on health worker mi- development and short-term financial reasons is an es- gration in South Africa. Based on their study, Labonté et tablished phenomenon (2). al. concluded that even though in the recent past South Africa’s health worker shortages as a result of emigration Recent research suggests that “moonlighting” (having a were viewed as significant and harmful, currently domes- second job in addition to a primary job) is a predictor tic policies to improve health care and the health work- of nurses’ intention to leave South Africa (19). This re- force, including such innovations as new skilled health search is also inconclusive about the real migration of worker cadres and Occupation-Specific Dispensation nurses out of South Africa, either on a temporary or on policies, appear to have served to decrease skilled health a long-term basis. However, the most promising initi- worker shortages to some extent (17). They further atives to mitigate health worker migration and associ- observed that there are indications that South African ated shortages of health workers are those undertaken
TABLE 16. STRATEGIES TO MITIGATE HEALTH WORKER MIGRATION AND ADDRESS HEALTH WORKER SHORTAGES IN SOUTH AFRICA
Scope Strategy Global agreements Commonwealth Code (2003) Health Worker Migration Initiative (2007) WHO Global Code of Practice on the International Recruitment of Health Personnel (2010) Domestic policy statements on migration South Africa’s policy statements on health worker immigration (2001, 2006) Bilateral agreements United Kingdom/South Africa memorandum of understanding (2003) Cuba (1996) Germany Tunisia (1999 and 2007 technical agreements) Islamic Republic of Iran (2004) United States PEPFAR/Medical and Nursing Education Partnership Initiative (2013) Destination country agreements with potential to United Kingdom Code of Practice for the Ethical Recruitment of impact South African migrants International Healthcare Professionals (2004) South African initiatives to prevent migration Examples include: by improving health system human resources • increasing skilled health worker production for health and living and working conditions for • student sponsorship programmes health workers • community service programme • new skilled health worker cadres • task shifting • African health placements • Occupation-Specific Dispensation
Source: Labonté et al. (17).
NURSING AND MIDWIFERY MIGRATION TRENDS IN THE SOUTH AFRICAN HEALTH SYSTEM 21 within South Africa itself through the improvement of 12. Discussion health system human resources for health and living and working conditions for health workers (17). Several ac- South African nurse training is esteemed for the high tions have been undertaken internally and are reported standard of training it offers its practitioners, a quality to have led to a decline in the numbers of nurses wishing that renders them prime candidates for recruitment to work overseas. Table 16 summarizes strategies to mit- (22). The nursing profession, in common with the igate health worker migration and address health worker teaching profession and police training, has for a long shortages in South Africa. time been easier to access by ordinary South Africans than other fields of study, such as law, engineering, One of the key retention strategies was the introduction medicine, pharmacy, and dentistry. Nursing has over of the Occupation-Specific Dispensation, which was de- the years been the first point of contact that patients vised as an incentive strategy to attract and retain health have with a health system. Nurses are found in every professionals within the public health service. Whilst health facility across the country and play a vital role many researchers and professionals alike regarded it in the delivery of health services, from PHC to highly as purely a financial incentive, it was meant to address specialized medical interventions. Their training is other aspects beyond salary, for example by encouraging extensive, in line with the demanding accreditation new career paths, helping to manage career progression criteria set by SANC for nursing education institutions. and contributing to performance management. The first SANC has recently revised the competencies of nurse professional group to benefit from this strategy was the educators to include the following key elements: (a) nurses. It is reported to have stemmed, but not halted, scholarship of teaching and learning; (b) academic and the tide of unmanaged movement of nurses into and out student management; (c) curriculum development; (d) of South Africa. From a purely financial perspective, the management and leadership; (e) personal development movement of nurses has not been dented and the system of the nurse educator; and (f) research and knowledge has its critics (20). Criticism of the system can be part- creation (23). ly attributed to an interpretation of policy interventions only in terms of the financial gain for individual prac- These are some of the criteria being utilized when titioners. It has been reported in literature that salary nursing education institutions are accredited for nurse alone is a poor retention incentive for health profession- training. Nursing education takes place in a complex als. Good working conditions, including availability of institutional environment, which includes 20 out of 23 medicines and other tools of trade, are key measures to public universities, 12 public sector nursing colleges retaining health professionals. (with numerous satellite training campuses) that are the responsibility of the nine provincial health departments, The practice whereby individual nurses seek extra in- a nursing college run by the defence force, private come by holding a second, temporary job, termed nursing colleges run by the three major private hospital moonlighting, has been reported as prevalent in South groups in South Africa, and private nursing schools Africa (19, 20). This is despite the OSD appearing to that are run for profit (24). These education institutions have lowered the risk of health workers migrating due to provide the nursing workforce, the majority of whom are low salaries (21). Moonlighting is defined as occurring employed in public health facilities. Their employment when no permission has been granted by the employing is linked to the bursary agreements wherein nurses who department for a professional to engage in private remu- received government funding assistance are required nerative work. In the survey, all the employer partici- to serve the public through employment by provincial pants reported that they allowed nurses to engage in pri- Departments of Health. Such bondage assists in reducing vate work on condition that the criteria were fulfilled as the unemployment of nurses. legislated by section 30 of the Public Service Act No. 103 of 1994, as amended. This section allows government Despite the high level of training of midwives, the letters employees to engage in remunerative work outside pub- of verification are requested for confirmation of the lic service provided that there is no conflict of interest. nurse’s competence as a general nurse, not as a midwife.
22 FROM BRAIN DRAIN TO BRAIN GAIN: TABLE 18. NURSE/MIDWIFE RESIGNATIONS ACROSS PROVINCES, 2012–2016
Province 2012 2013 2014 2015 2016 Eastern Cape 1 121 1 069 1 562 1 226 (19 432) (19 051) (19 067) (18 330) (19 226) [%] [5.88%] [5.61%] [8.52%] [6.38%]
Free State 309 410 469 446 (6 820) (6 900) (7 138) (5 166) (6 737) [%] [4.48%] [5.74%] [9.08%] [6.62%]
Gauteng 1 106 1 302 1 925 1 649 (27 245) (24 784) (24 909) (25 017) (26 173) [%] [4.46%] [5.23%] [7.69%] [6.30%]
KwaZulu Natal 1 738 1 418 2 649 1 902 (34 419) (30 846) (32 782) (33 186) (33 585) [%] [5.63%] [4.33%] [7.98%] [5.66%]
Limpopo 407 329 422 825 (18 675) (18 321) (18 245) (18 164) (18 192) [%] [2.22%] [1.80%] [2.32%] [4.53%]
Mpumalanga 302 409 660 432 (8 523) (7 862) (7 850) (8 272) (8 327) [%] [3.84%] [5.21%] [7.99%] [5.19%]
Northern Cape 124 187 362 228 (2 558) (2 496) (2 474) (2 478) (2 439) [%] [4.97%] [7.56%] [14.61%] [9.34%]
Western Cape 882 871 1 513 1 272 (12 867) (12 044) (12 321) (11 531) (12 583) [%] [7.32%] [7.07%] [13.12%] [10.11%]
Numbers in parentheses ( ) represent total numbers employed; numbers in brackets [ ] represent percentage resignations. No data on resignations retrieved for 2016. Source: Vulindlela 10/2017.
Consequently, it can be assumed that nurses’ movements it is the moonlighting phenomenon that must be are based on their basic nursing competencies, except addressed. The number of persons registered by SANC those of highly specialized categories such as critical care, forms the largest proportion of all those registered by intensive care unit and theatre nursing. The prevalence all three statutory health councils – SANC, 401 543 of the moonlighting phenomenon can be attributed to a (57.93%); Health Professions Council of South Africa, desire by health professionals generally to augment their 249 827 (36.05%); and the South African Pharmacy salaries. This practice also exists in other professions, Council, 41 745 (6.02%). This indicates the need for the such as medicine, where it is termed “remunerative work implementation of the National Health Insurance system outside public service”. All provincial nursing directors to be heavily reliant on (a) the continued production reported that this practice is officially allowed on of highly qualified nurses; (b) equitable distribution condition that the services provided in the private health of qualified nurses between urban and rural public facilities do not conflict with the nurse’s normal duties. health facilities; and (c) ensuring that effective retention They however concede that it is a practice that is very strategies for nurse practitioners are in place, especially difficult to control or monitor. for rural hospitals and clinics.
Whilst the movement of nurses to other countries Another notable finding is the variance between appears insignificant in terms of recorded verifications, registration of nurses by SANC per province versus the
NURSING AND MIDWIFERY MIGRATION TRENDS IN THE SOUTH AFRICAN HEALTH SYSTEM 23 total employment numbers as supplied by the Vulindlela Migration patterns between the public and private human resource system in public service. Vulindlela, a health nursing sectors are difficult to quantify. The derivative of the payroll system in public service, provides moonlighting practice, even though not officially employment figures relating to financial years. Table 18 sanctioned, enables nurses to work in both sectors shows a number of data gaps that were experienced when without losing their formal employment. However, extracting figures for the present study; for example, for those who officially leave the public health service, the North West province did not show any resignation several reasons have been advanced. The most prevalent record for the years 2012 to 2016. This is most likely reasons provided for resignation from the public health due to a system glitch. The 2016/2017 figures could also service by nurses relate to (a) increasing workloads, with not be reliably extracted. The option would therefore be midwives reporting inability to cope with the increasing to do a headcount at provincial level to obtain accurate pressure of work, especially where there is a shortage of figures. However, provincial Departments of Health also medical doctors, thus placing more pressure on their rely on the Vulindlela system, which does not make a practice; (b) financial constraints attributed to inability separation between a registered nurse and a midwife. to manage finances, including payments for housing This is one aspect that the nursing profession has to work loans, school fees and other necessities; (c) accessing on and clarify because not every nurse is a midwife, even pension funds, whereby some nurses resign with the though many have midwifery skills. The employment intention of accessing their pension and applying for system records a nurse generically as “registered nurse” re-employment; (d) negative practice environments and does not separate that from a midwife. This will compounded by lawsuits, especially in the obstetric hopefully be addressed through the new nursing units, which is again linked to the shortage of medical qualifications and creation of a nurse specialist register. doctors who would normally shoulder responsibility; There is also a need to devise a mechanism for matching and (e) moving to the private health sector with a belief data between SANC, provincial Departments of Health that private hospitals have lighter workloads, fewer and private sector employers. patients and more doctors to support in the clinical management of patients. Direct measurement of the movement between the public and private sectors, and in and out of the country, will There are variations in the requirements for nurses that require good cooperation between the government and wish to return to the public health service. One province SANC. This should yield better data and information, but reported requiring the returning nurse to provide a discussions regarding such attempts should include the certificate of service, whilst two other reported no leadership of health professional associations. This is to requirement to prove competencies. Instead, midwives are allay fears of perceived victimization by the professionals oriented on assuming duties in the relevant department. (2). From a nursing perspective, there is an urgent need The midwife has to attend in-service training, including to address leadership in all respects, building on the in such activities as fire drills and essential steps in the successful establishment of the post of Chief Nursing management of obstetric emergencies (ESMOE), in Officer. A lack of emphasis on leadership development order to raise their professional competencies. There is in nursing education and its professional associations, no prescribed format through which nurses returning meaning that not enough nurses have the background to the public health service are assessed to establish to assume prominent roles in addressing South Africa’s whether they still have the requisite competencies. health care policy issues, is a serious concern (25). In the long run, addressing nursing leadership development South Africa needs to improve the involvement of will address the problem reported in a previous study nursing education institutions and nursing directorates by Ditlopo et al. that nurses’ participation in policy- in nursing workforce planning. Production of nurses making is both contested and complex, and that there is without involvement of these critical organs hampers a disjuncture between nursing leadership and front-line the equitable distribution of nursing services across the nurses in their levels of awareness of nursing policies country. Only the Western Cape nursing directorate (26). reported a purposeful participation in nursing workforce
24 FROM BRAIN DRAIN TO BRAIN GAIN: planning, whilst others, such as KwaZulu-Natal and move and explore other working environments may North West, reported no participation. This lack of interpret the effort as aimed at curbing their freedom of uniformity has implications for the prioritization of movement – a constitutional guarantee in South Africa. financial resources to fund nursing in the country. The Attempts at getting South African expatriate nurses in private nursing schools continue to produce significantly both the United Arab Emirates and the United Kingdom higher numbers of nurses in the EN and ENA categories, to participate in the survey for this study failed. The which are largely utilized in the private hospitals. There reasons advanced included scepticism about a possible is a view in health policy circles that the high production unintended consequence of the survey results, namely a of nurses in those categories is driven by commercial reduction in the freedom of movement of professionals. interests rather than a linkage to health service delivery This was despite the aims of the Global Code being made needs. clear to potential participants. This fear has roots in the political history of South Africa where, before 1994, On the issue of migration trends, all provinces reported freedom of movement, especially of black professionals, that when a nurse decides to resign, there is no was severely curtailed. Indirect measures of movements mechanism by which the employer is informed where the by South African nurses and other health professionals, nurse has sought employment. The only entity that has including doctors, pharmacists and physiotherapists, the ability to establish that is SANC, though the method have not provided the health policy-makers with better applied also has its limitations. The actual numbers of information and understanding of the magnitude of nurses requesting letters of good standing, which enable migration trends. New mechanisms have to be devised nurses to obtain employment overseas, do not portray to achieve the objective. a serious exodus of South African nurses. However, the Organisation for Economic Co-operation and 13. Conclusion Development (OECD) has recently reported an increase in the expatriation rate for nurses in South Africa from Measuring the migration trends of nurses is critical for 12.6% in 2000/2001 to 16.5% in 2010/2011 (27). Whilst the provision of health services in South Africa from a the OECD figures were for a decade prior to the decade workforce planning and human resource deployment measured for this study, it points to disjuncture between perspective. Over the years indirect measures have been OECD and SANC data. The expatriation rate of South attempted, particularly for medical doctors and nurses. African nurses as observed in OECD countries could However, these remain inaccurate, as some professionals be a result of several factors, among them circulation choose to keep their registrations active in some overseas within these countries following initial exit from South countries to facilitate temporary work stints, as revealed Africa. Previous studies have alluded to a decrease in the by the Royal College of Surgeons in Ireland study on movement of South African nurses out of the country medical doctors (28). Migration, whether temporary or due in part to certain policy successes (17). An argument permanent, has an impact on resource planning of the against the expatriation rate increase is another national health system, impacting the production of observation that the economic crisis that started in nurses (education and training numbers) and service 2007/2008 had varying effects on international flows of provision (number and skills base of nurses deployed migrant health workers, in that some countries recruited at health facilities). The funding of nursing education fewer international health care professionals as they and training within the public nursing colleges is in line set limits on their health systems’ financial resources with the country’s policy thrust on access to education (27). This necessitates efforts at direct measurement of and attempts at alleviating poverty. The provision of migration trends from source countries rather than at bursaries to nursing students assists them and their the host country. families by reducing the burden of training fees.
This will have its own limitations, especially in the Whilst the government is providing funding for nurse South African environment, where those who wish to training at college level, the area of nursing workforce
NURSING AND MIDWIFERY MIGRATION TRENDS IN THE SOUTH AFRICAN HEALTH SYSTEM 25 planning requires attention. Only one nursing college, 5. A collaboration to be set up with other statutory located within a Department of Health, reported being health councils for mapping out accurately where actively engaged in workforce planning. Other public registered practitioners are employed. nursing colleges seem not to be involved, calling into question the role of directors of nursing in the respective 6. A mechanism to be devised for matching nursing provincial departments. Data accuracy remains a workforce data between SANC, provincial problem for the regulatory bodies, despite the critical Departments of Health and private sector employers. role that the deployment of health professionals will play in the health sector reform initiatives of the Ministry 7. Active engagement to be practised between SANC, of Health. The National Health Insurance scheme is nursing education institutions and provincial predicated on appropriate staffing of public health Departments of Health for nursing workforce facilities with highly qualified health professionals, planning. with nurses playing a leading role. The current Re- engineering of Primary Health Care is heavily reliant 8. SANC to become the custodian migration monitoring on the nursing profession to make its three pillars body for nurses, whose role should include the functional. Observing, measuring and managing the contextual relationship with the Department of migration trends of nurses is of major relevance to how Health to meet the reporting requirements of the the South African health system undertakes nursing Global Code. workforce planning. 9. SANC to regularly interact with nursing regulators The following recommendations are made: in countries where most South African nurses regularly seek employment for the purpose of 1. SANC to establish a register of nurses who work comparing statistics on requests for verification overseas. This could be achieved through collaboration letters and actual employment. This will provide a with sister nursing regulatory bodies in countries such better measure of actual migration than indirect as Australia, New Zealand and the United Kingdom estimates. by matching data on an annual basis. 10. SANC and the Ministry of Health to engage nursing 2. A mechanism for monitoring migration trends of professional associations to impress on them the nurses to be established through the involvement of need for monitoring migration trends as one of the SANC, the Ministry of Health and the Department mechanisms to positively influence nursing planning of Home Affairs. The Department of Home Affairs and eventually education, training and deployment. already has a mechanism for determining priority skills among immigrants that seek employment in 11. SANC to engage the recruitment agencies to South Africa. improve the request form for letters of good standing (verification letters) so that the intended destination 3. A separate register for nurses who are not in active country or countries are declared in the form. practice to be established at SANC. Calculating the attrition rate due to retirement and death is Acknowledgements important for workforce planning. The African Institute of Health and Leadership 4. The registration categories to be aligned to the Development wishes to express its appreciation for new nursing qualifications such that it is easy to the support given to this project by the Global Health distinguish midwives from those who may possess Workforce Alliance through the funding provided by the midwifery skills but are not applying those skills European Commission in support of the implementation in their daily work environment, for example in a of the WHO Global Code of Practice on the International mental health facility. Recruitment of Health Personnel.
26 FROM BRAIN DRAIN TO BRAIN GAIN: References
1. Mahlathi P, Dlamini J. Minimum data sets for hu- 13. Blaauw D, Ditlopo P, Maseko F, Chirwa M, Mwisongo man resources for health and the surgical workforce A, Bidwell P et al. Comparing the job satisfaction in South Africa’s health system: a rapid analysis of and intention to leave of different categories of health stock and migration. African Institute of Health and workers in Tanzania, Malawi, and South Africa. Leadership Development; 2015. Global Health Action. 2013;6:19287. doi:10.3402/gha. v6i0.19287. 2. Mahlathi P, Dlamini J. From Brain Drain to Brain Gain: understanding and managing the movement 14. van Rensburg JC. South Africa’s protracted strug- of medical doctors in the South African health gle for equal distribution and equitable access: system. African Institute of Health and Leadership still not there. Human Resources for Health. Development; 2016. 2014;12:26 (http://www.human-resources-health. com/content/12/1/26, accessed 24 October 2017). 3. Mid-year population estimates. Pretoria: Statistics doi:10.1186/1478-4491-12-26. South Africa; 2017. 15. Clemens MA, Pettersson G. New data on African 4. Growth in registers of the SANC 2016. South health professionals abroad. Human Resources for African Nursing Council (www.sanc.co.za, accessed Health. 2008;6:1. doi:10.1186/1478-4491-6-1. 24 October 2017). 16. Awases M, Gbary A, Nyoni J, Chatora R. Migration 5. OECD health statistics 2014: how does South Africa of health professionals in six countries: a synthesis compare? Paris: Organisation for Economic Co- report. Brazzaville: World Health Organization; operation and Development; 2014. 2004. 6. Naidoo S. The South African National Health 17. Labonté R, Sanders D, Mathole T, Crush J, Chikanda Insurance: a revolution in health care delivery! A, Dambisya Y et al. Health worker migration from Journal of Public Health. 2012;34(1):149–50. South Africa: causes, consequences and policy 7. Human Resources for Health Strategy. Pretoria: responses. Human Resources for Health. 2015;13:92. Ministry of Health; 2011. doi:10.1186/s12960-015-0093-4. 8. WHO Global Code of Practice on the International 18. Makhubu N. Nurses leaving SA in droves. IOL Recruitment of Health Personnel. WHA63.16. news, 2 February 2016 (https://www.iol.co.za/ Geneva: World Health Organization; 2010 (http:// news/south-africa/gauteng/nurses-leaving-sa-in- apps.who.int/gb/ebwha/pdf_files/WHA63/A63_ droves-1978572, accessed 25 October 2017). R16-en.pdf, accessed 24 October 2017). 19. Rispel LC, Blaauw D. The health system consequenc- 9. National Qualifications Framework Act No. 67 of es of agency nursing and moonlighting in South 2008, as amended. Government of South Africa. Africa. Global Health Action. 2015;8:26683. 10. Uys LR, Klopper HC. What is the ideal ratio of 20. Ditlopo P, Blaauw D, Rispel L, Thomas S, Bidwell categories of nurses for the South African public P. Policy implementation and financial incentives health system? South African Journal of Science. for nurses in South Africa: a case study on the 2013;109(5/6): Art. a0015. http://dx.doi.org/10.1590/ Occupation Specific Dispensation. Global Health sajs.2013/a0015, accessed 24 October 2017). Action. 2013;6:138–46. 11. Nursing education and training standards. South 21. George G, Atujuna M, Gow J. Migration of South African Nursing Council; 2016 (www.sanc.co.za, African health workers: the extent to which financial accessed 24 October 2017). considerations influence internal flows and exter- 12. Policy guidelines regarding registration of inter- nal movements. BMC Health Services Research. nationally qualified nurses and midwives and/or 2013;13:297. foreign qualifications with South African Nursing Council. South African Nursing Council; 2016.
NURSING AND MIDWIFERY MIGRATION TRENDS IN THE SOUTH AFRICAN HEALTH SYSTEM 27 22. Xaba J, Phillips G. Understanding nurse recruit- 26. Ditlopo P, Blaauw D, Penn-Kekana L, Rispel LC. ment: fi nal report. Pretoria: Democratic Nursing Contestations and complexities of nurses’ participa- Organization of South Africa (DENOSA); 2001. tion in policy-making in South Africa. Global Health 23. Competencies for a nurse educator. South African Action. 2014;7:25327 (http://dx.doi.org/10.3402/gha. Nursing Council (www.sanc.co.za, accessed 25 October v7.25327, accessed 25 October 2017). 2017). 27. International migration outlook 2015. Paris: 24. Rispel LC. Transforming nursing policy, practice Organisation for Economic Co-operation and and management in South Africa. Global Health Development; 2015 (http://dx.doi.org/10.1787/migr_ Action. 2015;8:28005 (http://dx.doi.org/10.3402/gha. outlook-2015-en, accessed 25 October 2017). v8.28005, accessed 25 October 2017). 28. Brugha R, Walsh A. Brain Drain to Brain Gain: 25. Transforming health care in South Africa: a summary Ireland’s two-way flow of doctors. Ireland country evaluation of the Atlantic Philanthropies’ Nursing case study, Year 2. Royal College of Surgeons in Programme. Atlantic Philanthropies; 2014. Ireland; 2017.
28 FROM BRAIN DRAIN TO BRAIN GAIN:
For further information, please contact: African Institute of Health and Leadership Development 181 Lancia Street, Lynnwood Ridge, 0081 Pretoria, South Africa www.selizwe.co.za