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1 Guy Stubbs chaptertwenty-three MEDICAL PRACTITIONERS AND NURSES Elsje Hall and Johan Erasmus In this chapter Introduction 523 Changes since Apartheid 524 The Demand for Medical Practitioners 526 The Supply of Medical Practitioners 532 The Demand for Nurses 537 The Supply of Nurses 542 Other Factors Influencing Supply 545 Recommendations 549 Access the data for this chapter at HRD REVIEW l 2003

2 abstract There are currently medical practitioners employed in South Africa at a rate of 65 physicians per of the population. Approximately 60 per cent of physicians are employed in the private health sector at a ratio of 255: The remainder work in the public health sector where they provide medical care to 84 per cent of the population at a ratio of 29: Shortages are created by the maldistribution of skills across sectors and provinces, and are aggravated by the outflow of skills from South Africa to other countries. Supply is restricted by limited resources, the limited availability of black candidates for higher education, high failure rates, and poor working conditions and remuneration in the public health sector. The number of nurses in employment is estimated at , at a nurse/population ratio of 343: , which compares favourably with the World Health Organisation s minimum norm of 200: The nurse/population ratio is expected to drop to 305: over the next ten years with a total of positions remaining unfilled. INTRODUCTION The government is committed to rectifying the racial, gender and regional disparities in the health system caused by the legacy of apartheid. The key policy drive is to promote and improve the quality of life of South Africans by ensuring that they all have equal access to healthcare services of a high standing. This is to be achieved through implementing an approach based on the principles of primary healthcare. A continuous supply of suitably qualified human resources for healthcare is needed to promote and maintain the health of the population. Challenges faced by planners in their efforts to ensure adequate skills in the health sector include inequalities in the distribution of human resources for healthcare, the migration of health personnel, and racial and gender imbalances. Planners also need to consider other factors impacting on the demand for health services, such as population growth and the incidence of communicable diseases. The shortage of health workers in the public health sector is highlighted in media reports which refer specifically to the impact of emigration on the number of medical practitioners and nurses in South Africa. These reports also question the future and quality of healthcare following the exodus of young physicians who have completed their year of community service l HRD REVIEW 523

3 It is against this background that we explore whether South Africa has enough medical practitioners and nurses to provide proper healthcare services to its citizens. This chapter will therefore focus on the demand for and supply of medical practitioners 1 and nurses 2 for the period 2001 to The chapter first aims to determine the current demand for medical practitioners and nurses. In the case of both professions, current demand is estimated by looking at the number of positions that are filled (total employment 3 ) as well as the number of positions that are currently vacant. 4 The register of the Health Professions Council of South Africa (HPCSA) and the Labour Force Survey (LFS) of September 2001 (Stats SA 2002) are used to determine the number of positions filled 5 in medicine and nursing respectively. Second, the chapter attempts to determine the number of medical practitioner and nursing positions that will be required until Factors that may influence growth in demand, such as growth in the population as well as the need that will arise from existing positions becoming vacant through death, emigration or retirement of health workers, are analysed. Third, we establish the expected output from higher education over the next ten years. In the case of physicians, only universities supply training. Data obtained from universities, the South African Post-Secondary Education (SAPSE) information system database and the Higher Education Management Information System (HEMIS) of the Department of Education (DoE) are used to establish output. Nursing output is obtained from the South African Nursing Council (SANC). 6 Finally, the estimated number of medical practitioners and nursing staff that will be needed for the period 2001 to 2011 is compared with the total output over the same period to arrive at the gap between demand and supply. Although the analyses of medical practitioners and nurses follow the same lines, the detail depends on the human resources data that are available on each profession. CHANGES SINCE APARTHEID The current government inherited a fragmented health system that was, among other things, characterised by racial, gender and geographic disparities in human resources. In striving for separate development, the apartheid government had established a homeland system in which each of the four black so-called independent states and six self-governing states had autonomous health departments. Health services were further fragmented by the introduction of three racially based Houses of Parliament in 1983, which resulted in 14 health ministers in the country, each administering an independent health service (Hunt 1991). Since the change of government in 1994, the emphasis has been on creating a unified health system and simpler regulatory systems. The objective, in terms of human resources, is to engage in a strategy that will ensure an adequate supply of people with the requisite knowledge and skills to give expression to the vision of an equitable, 524 HRD REVIEW l 2003

4 responsive health system guided by the primary healthcare approach (Pick, Nevhutalu, Cornwall & Masuku 2001). Action was taken and measures introduced to ensure a betterorganised, simplified health sector that would address the challenges associated with the provision of primary healthcare in South Africa. Here are some of the important interventions that have been put into motion so far: l l l Regulatory systems have been streamlined. During the years of apartheid, the nursing profession was characterised by fragmentation and racial separation. Currently, however, the nursing profession is regulated by only two bodies: the SANC and the Democratic Nursing Organisation of South Africa (DENOSA). The streamlining process has ensured the unification of the profession, which will benefit the planning and management of human resources for healthcare in the country. Regional imbalances are being addressed. The majority of health workers are still concentrated in urban areas, with government finding it difficult to recruit and retain professionals in rural areas. Running separate health departments during the years of apartheid wasted limited financial resources, which resulted in poor infrastructure, a lack of facilities, poor equipment and a shortage of personnel in the former homelands. Despite interventions such as the appointment of foreign practitioners and a compulsory year of community service, government still finds it difficult to recruit and retain health workers in rural areas. Promotion of equality, in terms of race and access to training. Apartheid impacted negatively on black education, especially on the mathematics and physical science output achieved by secondary schools. These subjects are requirements for accessing most training opportunities in healthcare. Various measures (such as upgrading the skills of mathematics and physical science teachers) have since been introduced to enhance the growth in output of black candidates. While limited access to quality training resulted in very small numbers of black people qualifying as professionals in the past, the change of government in 1994 resulted in academic institutions becoming accessible to all South Africans. In addition, training institutions have introduced various programmes such as bridging courses to address historical racial and gender imbalances. Poverty also makes it difficult for many black people to persevere with their studies over long periods, especially in the case of nurses (the training period for professional nurses is four years) who in many cases have financial obligations towards children or other family members. Apart from financial assistance, new admission procedures and multiple entry and exit points for nursing education and training have been recommended by the Human Resources for Health Task Team (Pick et al 2001), to increase the growth in output of professional nurses. l Training is focusing on the needs of primary healthcare. The current medical force is, generally speaking, not trained to address the needs of a health system that focuses on primary healthcare. Past training focused on cure rather than prevention. Physical symptoms were treated in isolation and little attention was paid to the relationship l HRD REVIEW

5 between people s health and their social and economic living conditions (De Beer 1984). Training is now being addressed in a holistic way that considers all aspects of the patient s circumstances. Emphasis is also being placed on South Africa s specific problems, such as HIV/AIDS, malnutrition, tuberculosis and poverty (Viall 2002). THE DEMAND FOR MEDICAL PRACTITIONERS This section offers insight into the current and future demand for medical practitioners in South Africa. First, current demand is addressed by determining total employment and the number of vacant positions in the public and private health sectors. Second, future demand is discussed in terms of the growth in the number of positions (new demand) as well as additional demand which arises when existing positions become vacant through retirement, death or emigration (replacement demand). Current demand In July 2002 there were registered medical practitioners on the Register of Medical Practitioners (RMP) including clinical assistants (specialists in training) whose registration fees are paid-up, but excluding interns (see Table 1). This figure includes a number of physicians who are, strictly speaking, not currently practising healthcare, for example, those who are temporarily working outside South Africa. Table 1 indicates that approximately 38 per cent or medical practitioners were employed in the public health sector in July Due to a lack of data on the private health sector, the number of physicians in the public health sector has been subtracted from total employment to arrive at an estimate for the number of practitioners in private health sector employment. The result indicates that more or less 62 per cent of physicians are employed in the private health service. However, a clear-cut distinction between the public and private health sectors in terms of employment is difficult to make, as some physicians employed by government also have part-time private practices, and vice versa. TABLE 1 Medical practitioners in employment, 2002 Total number of registered Total valid registrations Physicians employed in the Physicians employed in the physicians at the HPCSA (HPCSA) public health sector private health service (2002) (NDoH 2001) Number Number Percentage of Number Percentage of Number Percentage of total total total registrations registrations registrations a b Sources: HPCSA (2002); NDoH (2001) Notes: a This total includes active and inactive physicians (see endnote 5). b This figure represents paid-up registrations only (see endnote 5). 526 HRD REVIEW l 2003

6 Current demand cannot be determined accurately without taking into account the number of vacant positions. In the public health sector, the number of vacant positions are those posts provided for in the public health sector structure at national, provincial or local authority level, but which are unfilled. Total demand in the public health sector is estimated at : filled positions plus vacancies (NDoH 2001). As most physicians in the private health sector are self-employed, it is not possible to determine the number of vacancies in the sector. In the absence of information on vacant positions, however, one can still get an idea of the demand in the private health sector by establishing whether the sector can absorb new entrants. Physicians can either seek government employment or opt for employment in the private health sector. Adverse working conditions in the public health sector, lower remuneration, and the fact that many vacancies are in rural areas make the private health sector a more attractive employment option to most physicians. However, if the private health sector cannot absorb more physicians, these physicians will need to consider alternative employment. According to the National Department of Health (NDoH), there were public health sector vacancies in This is more than three times the number recorded for 1992, which indicates that physicians are increasingly being absorbed in employment outside the public health sector. This trend occurred in spite of an increase in the total number of registrations. Medical practitioner/total population ratios There are medical practitioners employed in South Africa. The Bureau of Market Research (Van Aardt, Van Tonder & Sadie 1999) projected the size of the South African population for 2001 at people. This means that there is one physician for every South Africans (medical practitioner/population ratio) or 65 physicians per of the population. This figure compares very favourably with similar medical practitioner/population ratios established by the World Health Organisation (WHO) for African countries such as Botswana (24), Namibia (30) and Nigeria (19), as well as certain developing countries like Malaysia (66). However, the ratio compares less favourably with the developing countries of Latin America such as Brazil (127) and Argentina (268) (WHO 2002). South Africa s situation, however, is not properly explained without taking cognisance of the imbalances in provision of medical practitioners in the public and private health sectors. According to the Council for Medical Schemes (2002), only 16 per cent of the South African population belonged to medical schemes in This group of people received their healthcare primarily from the private health sector, where approximately 63 per cent of medical skills are employed at a rate of 255: On the other hand, or 84 per cent of South Africans are not members of a medical fund, due to a lack of financial means, and depend wholly on public health care. This does not mean that members of medical funds do not use the public health sector as well. If members medical fund benefits are exhausted, they too must rely on public healthcare a situation that appears to be common due to the high cost of private medical care and the prevalence of diseases related to HIV/AIDS. Furthermore, more than one million members left the medical aid scheme industry between 1996 and l HRD REVIEW

7 This may be due to increases in medical costs and services, as well as rising unemployment. Some medical schemes also shifted patients back to the public health sector by limiting admissions to the private health sector (Van der Merwe 2001). A growing number of people therefore depend on the public health sector, in which only 37.7 per cent of South Africa s physicians are employed at a ratio of 29: Gender and race profile More than a quarter (26.7 per cent) of registered medical practitioners are female, while 73.3 per cent are male. In the public health sector more than a third (35.9 per cent) of general practitioners and 27.3 per cent of specialists are female, although there are provincial differences in female employment. For example, one-third of specialists in Gauteng are female, but only 6 per cent of specialists in Mpumalanga and the Northern Cape are female (NDoH 2001). The majority (61.3 per cent) of all registered practitioners are white. The situation differs somewhat in the public health sector, where 50 per cent of general practitioners and 29.3 per cent of specialists are black (NDoH 2001). The maldistribution of medical skills by province and region The most fundamental healthcare problem in South Africa is the imbalance between the relatively small group of people, concentrated in urban areas, who have access to firstworld healthcare services, and the majority of citizens who live mainly in rural areas and depend on primary healthcare. It is against this background that the distribution of medical skills should be considered. The provincial maldistribution of physicians is shown in Table 2, which is compiled from the register of the HPCSA. The Western Cape and Gauteng are the two provinces with the most favourable physician/population ratios in the country. Nearly 60 per cent of medical practitioners are employed in either of these provinces, providing healthcare services to approximately 28 per cent of the population. TABLE 2 Physicians per of the population, by province, 2001 Province Estimated Number of Number of physicians Proportion of Proportion of population physicians a per total population total number of of the population (percentage) physicians (percentage) Eastern Cape Free State Gauteng KwaZulu-Natal Mpumalanga North West Northern Cape Limpopo Western Cape Total Sources: HPCSA (2002); Stats SA (2002) Note: a This figure does not include foreign physicians. 528 HRD REVIEW l 2003

8 Provinces such as the Northern Province, North West and the Eastern Cape show far less favourable physician/population ratios than provinces like Gauteng (see Table 2). Existing vacancy rates of between 20 and 52 per cent in these provinces (NDoH 2001) is further proof of the shortage of medical practitioners in these areas. This is in spite of government s appointment of foreign qualified doctors in an attempt to rectify the situation. The balance between specialists and general practitioners Figure 1 shows that the number of specialists on the register has risen nearly twentyfold since 1943, the first year in which specialists were recorded on the register. Their share of the medical workforce grew from 11.4 per cent in 1943 to 25.8 per cent in The current specialist/general practitioner ratio is 1:2.9. Few specialists training is focused on primary healthcare or the health needs of communities in rural areas (HPCSA 2002); a situation which exacerbates the imbalance in the number and distribution of general practitioners and specialists. FIGURE 1 Number of registered general practitioners and specialists, Number Year Specialists General practitioners Source: HPCSA (2002) New and future demands This section looks at the number of physicians that will be needed until 2011 due to new demand and demand arising from replacement needs. Growth in the number of medical practitioners may be influenced by growth in the population, as well as changes in the healthcare needs of South Africans l HRD REVIEW

9 Population growth Forecasts predict a population increase from people in 2001 to people in 2011 (Van Aardt et al 1999). This amounts to 9 per cent growth over ten years. If the current overall ratio of 65 physicians per population were to be maintained, the country would require an extra medical practitioners by the year 2011 (see Table 3). However, the real dilemma that South Africa faces is the lack of physicians in the public sector. In this section, growth in demand will therefore be considered as the number of positions that need to be filled in order to maintain the current ratio of 65: for the period 2001 to TABLE 3 New demand for physicians due to population growth at a 65: ratio, Year Total population Number of positions New demand per year Growth in demand Number Number Number Percentage Total growth Sources: Van Aardt et al (1999) (data for total population); HPCSA (2002) (data for number of positions) Changes in healthcare needs Epidemics of communicable human diseases such as cholera last longer and have become more difficult to control in recent times (Girdler-Brown 2001). In a study on the impact of HIV, Quattek (1999) predicted that the rate of HIV infections will increase even further and will peak in 2006 (see Vass in Chapter 8 for more detail). This will, in turn, impact on the workload of health workers. If the current physician/population ratio can be maintained in future, it may have a mitigating effect on the situation. Replacement demand Demand may also arise from existing positions becoming vacant and needing to be filled. Positions may become vacant due to factors such as retirement, death, emigration, departure from the medical profession, as well as voluntary movement out of the labour force. Table 4 indicates that by 2011, positions will need to be filled because of retirement, positions because of death, and 630 positions because of emigration. 530 HRD REVIEW l 2003

10 TABLE 4 Replacement demand for medical practitioners, Year Total Retirement at 60 years Death Emigration Total Population Physicians Number Number Number Percentage Number Percentage Number Percentage a Number Total Sources: Van Aardt et al (1999) (data for population); ASSA (2000) (data for mortality); HPCSA (2002) (data for number of physicians); CSS ( ) (data for emigration); Stats SA ( ) (data for emigration) Note: a Average percentage of physicians that officially emigrated from 1988 to To estimate replacement demand arising from deaths, we used the race-, age- and genderspecific mortality rates for medical practitioners contained in the Actuarial Society of South Africa s AIDS demographic model 2000 (see Woolard, Kneebone & Lee in Chapter 20 for more detail). Various alternatives (Compernolle 2000; Dorrington cited in Van Aardt et al 1999; Quattek 1999; Van Aardt et al 1999; Whiteside & Sunter 2000) were explored before we decided to use this model. Figure 2 shows the number of medical practitioners emigrating from and immigrating to South Africa between 1988 and While there was a net gain to the country during the early 1990s, the situation changed after 1996 resulting in a net loss of medical practitioners to South Africa. It should also be noted that actual emigration is probably higher than is officially recorded (Brown, Kaplan & Meyer 2002; also see Bailey in Chapter 10 for more detail). Stats SA s emigration figures for physicians for the period 1988 to 2000 were compared with the total number of registrations so as to derive the percentage of physicians who emigrated annually. The average percentage over the 13-year period was used to determine the estimated effect of emigration on the projected number of physicians from 2002 to 2011 (see Table 4) l HRD REVIEW

11 FIGURE 2 Emigration and immigration of physicians, Number Year Immigration Emigration Net gain/loss Sources: CSS ( ); Stats SA ( ) Some professionals will temporarily move out of the labour force to obtain further qualifications, or because of pregnancy and other family-related commitments. A number of physicians will also move out of the South African labour force temporarily to practise in foreign countries for varying periods from a few months to a few years. THE SUPPLY OF MEDICAL PRACTITIONERS This section focuses on the annual output of physicians (general practitioners and specialists) and projects output up to Graduate output Table 5 indicates that total output of new graduates from South African universities medical schools increased from 936 in 1991 to in 2000, at an average annual rate of 2.9 per cent. The number of specialists graduating showed less growth, at a rate of 0.8 per cent per year for the same period (see Table 6). The growth rates for MBChB-degree graduates varied across universities, with the University of the Transkei and the Medical University of Southern Africa (MEDUNSA) showing the highest growth per annum at 29.5 per cent and 10.7 per cent respectively. The University of Natal and MEDUNSA contributed the highest number of black medical practitioners per year. For more information see the tables for Chapter 23 in the HSRC s HRD Data Warehouse at HRD REVIEW l 2003

12 TABLE 5 Number of medical practitioners qualifying at South African universities, Institution Total Average annual compounded growth, (percentage) University of Cape Town MEDUNSA University of Natal University of the Free State University of Pretoria University of Stellenbosch University of the Witwatersrand University of Transkei Total Sources: DoE ( ); DoE (2000); SA universities (Data gaps on SAPSE were supplemented with data directly obtained from universities if available) TABLE 6 Number of specialists qualifying at South African universities, Institution Average annual compounded growth, (percentage) University of Cape Town MEDUNSA University of Natal University of the Free State University of Pretoria University of Stellenbosch University of the Witwatersrand Total Sources: DoE ( ); DoE (2000); SA universities (Data gaps on SAPSE were supplemented with data directly obtained from universities if available) Note: Data could not be obtained from the University of the Transkei. Table 7 analyses the medical practitioners that qualified between 1991 and 1998 by gender and population group. The table shows that participation of females rose from 35.1 per cent in 1991 to 44.7 per cent in The participation of black South Africans also increased from 29.5 per cent in 1991 to 44.8 per cent in l HRD REVIEW

13 TABLE 7 General practitioners qualifying at South African universities, by population group and gender, Year Total male Total female Total white Total black Total Number Percentage Number Percentage Number Percentage Number Percentage Number Sources: DoE ( ); SA universities (Data gaps on SAPSE were supplemented with data directly obtained from universities if available) Table 8 sets out the number of general practitioners that qualified as specialists for the period 1991 to 1998, by gender and population group. The table reveals that considerably more men (1 272) than women (455) qualified as specialists; with male graduates accounting for 73.7 per cent of the total. Of the total number of specialists who qualified from 1991 to 1998, 87.4 per cent were white. TABLE 8 Specialists qualifying at South Africa universities, by population group and gender, Year Total male Total female Total white Total black Total Number Percentage Number Percentage Number Percentage Number Percentage Number Sources: DoE ( ); SA universities (Data gaps on SAPSE were supplemented with data directly obtained from universities if available) Note: Data could not be obtained from the University of the Transkei. Projected output of MBChB graduates, Table 9 sets out the projected output of general practitioners over the years 2001 to The base year of the projections is The average growth rate of 2.9 per cent for the period 1991 to 2000 was used to project growth in output by Table 9 shows that if the situation remains stable and no substantial changes to the number of candidates (such as the closure of a medical school) take place, the annual number of new practitioners will rise from in 2002 to in At an annual growth rate of 2.9 per cent, a total of medical practitioners will be produced by HRD REVIEW l 2003

14 TABLE 9 Projected output of MBChB graduates, Percentage (Base growth year) rate Source: Authors calculations A comparison of the demand for and supply of medical practitioners Shortages or surpluses within an occupation are difficult to forecast, as there is usually a lack of information about certain aspects that may impact on demand or supply. In the case of physicians, there is, for instance, a lack of data on human resources in the private health sector as well as on the exact size of the current workforce. Many physicians occupy positions in the private and public health sectors simultaneously, which makes it difficult to determine accurately the employment per sector. On the other hand, a register of all practising physicians is kept, and a fairly neat match exists between the qualification required to become a medical practitioner and the occupation itself. This makes the comparison between demand and supply easier. Table 10 compares the projected number of positions to be filled by new entrants into the labour market, and the projected number of new graduates that will be produced by universities between 2001 and TABLE 10 Comparison between the total number of positions that need to be filled and the output of new graduates, Scenario Total Growth in Demand due Total number New Percentage Surplus employed a demand to of positions graduates c supply replacement to be filled needs b Number Percentage A B C = B D E = C plus D minus A Scenario d Scenario e Scenario f Source: Notes: Compiled by the authors a Drawn from Table 3: New demand for physicians due to population growth. b Drawn from Table 4: Replacement demand for medical practitioners. c Drawn from Table 9: Projected future output of MBChB graduates. d Official emigration figures from CSS ( ) (data for emigration); Stats SA ( ) (data for emigration). e Official emigration figures + 65 per cent (Brown et al 2002). f Emigration: 5.5 per cent registered medical practitioners have foreign addresses (Erasmus 2001). In this chapter, growth in demand is calculated as the number of positions that need to be filled to maintain the current physician/population ratio of 65: Demand arising from replacement needs is based on retirement, death and emigration. Two l HRD REVIEW

15 factors that may well impact on future demand were not considered in the calculations: Changes in healthcare needs, and the impact of an increase in the number of vacant positions in the public health sector. According to Table 10 (Scenario 1), there will be more than sufficient new graduates to meet the demand resulting from the creation of new job opportunities, retirement, death and emigration. Scenario 1 shows that an oversupply of medical practitioners may develop over the next decade. However, such an oversupply is unlikely, for three reasons: l Lack of information on emigration. In Scenario 1, the official figures of CSS ( ) and Stats SA ( ) on emigration (see Table 4) were used in our calculations for replacement demand. If these figures are compared with other sources of information, it seems that there may be significant under-reporting of emigration. Brown et al (2002) came to the conclusion that only 35 per cent of emigrations are captured by official data, while Erasmus (2001) indicated that 5.5 per cent of medical practitioners registered with the Health Professions Council of South Africa had foreign addresses. Calculations of replacement needs in Scenarios 2 and 3 are based on the emigration figures that result from these views on lost skills. The scenarios show considerable differences in terms of future supply. l l Imbalances in the distribution of physicians. The main challenge in terms of supply and demand is the poor distribution of medical skills across provinces and between urban and rural communities. Table 2 shows that there are many provinces where the current physician/population ratio is far below the overall South African ratio of 65 physicians per An increased output of medical graduates from universities will not solve the shortages that are experienced in certain provinces and in rural areas. More physicians should be drawn to rural areas through appropriate incentives. However, at the same time, mechanisms should be put in place to ensure that such physicians are not performing tasks that could be carried out by other health workers. The impact of HIV/AIDS. The exact impact of HIV/AIDS on the demand and supply of medical practitioners is not known. While there is still uncertainty among experts in terms of the scope of the epidemic, the ING Barings study (2000) projected HIV prevalence rates to peak at 13.1 per cent for the highly skilled members of the South African labour force (see, for example, Vass in Chapter 8, who argues that HIV/ AIDS is likely to impact on all skills levels, including professional skills). 536 HRD REVIEW l 2003

16 THE DEMAND FOR NURSES Demand in 2001 All practising registered nurses and midwives, student nurses and student midwives, enrolled and trainee nurses, as well as enrolled nursing assistants are compelled by law to register with the South African Nursing Council (Pretorius, Marais & Martin 1997). Although the SANC register is a valuable source for determining the number of nurses in the health sector, it cannot be used to estimate total employment (see endnote 3). Instead, the 2001 Labour Force Survey (Stats SA 2002) was used to estimate the number of nurses that are currently employed in South Africa. There were registered nurses and midwives, student nurses and student midwives, enrolled and trainee nurses, as well as enrolled nursing assistants on the register of the SANC in 2001 (see Table 11). The Labour Force Survey, on the other hand, indicated a figure of The difference between the two data sources ( or 18.4 per cent) may be an indication of the number of nurses on the register that do not practise their profession anymore. This figure correlates with a study conducted in 1990 by Pim Goldby management consultants (cited in Brannigan 2000), which estimated the non-active component at 19 per cent. Table 11 reports that approximately 62.7 per cent or nurses are employed in the public health sector. Due to the lack of data on the private health sector, the number of nurses in the public health sector has been subtracted from total employment to arrive at an estimate for private sector employment. The result indicates that more or less 37.3 per cent of nurses are employed in the private health sector. Current demand cannot be estimated accurately without considering the number of vacant or unfilled nursing positions. In the public health sector there were vacant (unfilled) nursing positions in 2001 (NDoH 2001). This means that, in 2001, only 75 per cent of the available positions for nurses in the public health sector were filled. When compared with data from the past, this suggests that the situation is deteriorating. During the early 1990s, 80 per cent of all nursing posts in the public health sector were occupied (Pretorius et al 1997). The total demand for nurses in the public health sector is estimated at positions ( filled positions plus vacancies) in Due to the lack of private sector health service data, it is not possible to determine a vacancy rate in the private sector. TABLE 11 Total employment of nursing staff, 2001 Total registered at the Total estimated active Registered, but not Nurses employed in the Nurses employed in the SANC (2001)workforce active public health sector private health service (LFS Sept 2001)(NDoH 2001) Number Number Percentage Number Percentage Number Percentage Number Percentage of total of total of total of total registered registered workforce workforce a Sources: SANC (2001); Stats SA (2002); NDoH (2001) Note: a This figure includes active and inactive nurses (see endnote 5) l HRD REVIEW

17 Qualifications and distribution across nursing categories A distinction is drawn between registered and enrolled nurses. Registered nurses, who are also known as nursing professionals, are recorded on the registers of the SANC and require at least four years of post-matriculation training for entry on the registers. Enrolled nurses and nursing assistants (auxiliaries) are entered on the rolls of the SANC. To qualify as an enrolled nurse, a Grade 10 certificate and two years college training are required, while nursing auxiliaries require a Grade 10 certificate and one year of training to register with the Council. The SANC register indicates that 49.6 per cent of all nurses in South Africa are nursing professionals, 40.9 per cent nurses are enrolled nurses and nursing auxiliaries, and 9.5 per cent are students (see Table 12). Table 12 also shows the employment of nurses in the public health sector. The desired registered nurse/enrolled nurse ratio for hospitals is 1:3 (Pretorius et al 1997), yet in the public health sector the ratio is 1:1.2. This may imply that nursing professionals are not optimally used, as they perform tasks that could be accomplished by other health workers. TABLE 12 Occupational distribution of nursing staff, 2001 Nursing category SANC register, 2001 Public health sector Percentage of registered employment, 2001 nurses who are employed in the public health sector Number Percentage Number Percentage Registered Enrolled Nursing auxiliary Student Total Sources: SANC (2001); NDoH (2001) Nurse/total population ratios The World Health Organisation (WHO) sets the minimum norm of 200: for effective and adequate nursing services in developing countries (Pretorius et al 1997). Van Aardt et al (1999) projected the SA population figure for 2001 at If it is accepted that nurses were employed in 2001 (see Table 11), it means that there was one nurse for every 287 South Africans or 343 nurses per of the population. This figure compares favourably with the WHO ratios (2002) per of the population in African countries such as Botswana (219), Namibia (168) and Nigeria (66), as well as developing countries such as Brazil (41) and Argentina (77). Furthermore, the South African ratio compares favourably with the United Kingdom (497) and the United Arab Emirates (341), two of the countries to which South Africa loses nursing skills. 538 HRD REVIEW l 2003

18 Gender and race profile The majority of South African nurses are female. While less than half of all economically active people in South Africa are female (Stats SA 2002), 93 per cent of all practising and student nurses registered at the SANC, and 92 per cent of all nursing staff in the public health sector are female. However, more males are starting to enter the profession: the SANC register shows that in 2001, 15 per cent of all student nurses, and 9 per cent of pupil nurses, were male. Figure 3 captures the racial distribution of nurses and shows that most nurses (93 per cent) in South Africa are black, in contrast with the 1980s and early 1990s, when only 48 per cent and 54 per cent of nurses were black (Pretorius et al 1997). Changes in the racial composition of nurses can be ascribed to more training facilities becoming accessible to all races after The racial distribution of practising nurses reflects the demographic profile of South Africans. Africans constitute 77 per cent of South Africa s total population (Stats SA 2002) and 78 per cent of nursing staff in public health sector employment are African (see Figure 3). Although the data for 2001 exclude employment in the private health sector, in which the racial distribution of nurses may differ from the public health sector, it seems, nevertheless, that a proportional increase of black nurses (mainly African) relative to their white counterparts has occurred since FIGURE 3 Racial distribution of nursing staff by percentage, 1980, 1990 and Indian 2% Coloured 7% Indian and coloured 11 % Indian 2% Coloured 13% White 7% African 39% White 52% White 46% African 43% African 78% African Coloured Indian White Sources: Pretorius et al (1997) (data for 1980 & 1990); NDoH (2001) l HRD REVIEW

19 The sectoral and provincial distribution of nursing skills The demand for nurses in South Africa cannot be properly explained without taking cognisance of the sectoral and provincial imbalances in the provision of nurses. Earlier in the chapter it was indicated that in 2001, 62.7 per cent of all practising nurses were employed in the public health sector and 37.3 per cent in the private health sector (Table 11). In 1986, a total of 67 per cent of all nurses were employed in the public health sector (Pretorius et al 1997). The exodus of nurses from the public health sector thus seems to have been slower than may have been expected. There are also differences in the provincial nurse/population ratios. Although the provincial nurse/population ratio compares favourable with the WHO s standard, i.e. above the 200: nurse/population ratio, the data in Table 13 show that provinces with large rural areas such as the Northern Cape, Mpumalanga, Limpopo and Eastern Cape have a ratio below the current average ratio for South Africa (343 nurses per ). TABLE 13 Geographical distribution of nursing staff per of the population, 2001 Province Nurses per of the population Western Cape 418 Eastern Cape 261 Northern Cape 212 Free State 419 KwaZulu-Natal 393 North West 403 Gauteng 412 Mpumalanga 230 Limpopo 258 Total 343 Source: Stats SA (2002) Note: The calculation for each province was based on an estimated distribution (calculated from LFS figures) of nurses per of the provincial population. The nurse/population ratio for South Africa as a whole is a weighted average. New and future demands This section examines the number of nursing staff that will be needed until 2011, owing to new demand as well as replacement demand. The demand for nurses will be considered as the number of positions that need filling to maintain a nurse/population ratio of 343: for the period 2001 to New demand for nurses may be influenced by growth in the population as well as changes to the population s healthcare needs and the shortage of medical practitioners. Changes in healthcare needs. The South African population is expected to increase from people in 2001 to people in 2011 (Van Aardt et al 1999). If the current ratio of 343: is to be maintained, South Africa will need an additional nurses by the year 2011 to provide healthcare services to the population (see Table 14). Increased access to free healthcare and the extra burden caused by factors relating to increases in the prevalence of infectious diseases related to HIV/AIDS are expected to impact significantly on the workload of nurses. Sudden outbreaks of diseases such as 540 HRD REVIEW l 2003

20 cholera, or the increased prevalence of HIV/AIDS (see Chapter 8 for more detail) will require additional nurses to keep an already overloaded healthcare system functioning. Shortage of medical practitioners. Many nurses in rural areas have greater responsibilities and more work due to a shortage of physicians in these areas (Pick et al 2001). If the shortage of physicians in rural areas is to worsen, more nurses will be required to maintain health services. Replacement demand. Replacement demand refers to the demand that arises when existing job positions are vacated due to retirement, death and emigration. Table 14 indicates the projected demand for nurses that will occur due to replacement demand until Retirement. For the purposes of this study, 60 is considered to be retirement age. Table 14 shows the expected need for replacement of nurses due to retirement at 60. Total replacement demand due to retirement until 2011 is estimated at TABLE 14 New and replacement demand for nurses, Year Estimated Number of New demand Replacement demand due to: Total total positions a (population growth) Retirement at Death Emigration replacement population 60 years demand Number Number Percentage Number Percentage Number Percentage Number Percentage Number Total Sources: Van Aardt et al (1999) (total population data); ASSA (2000) (mortality data); SANC (2002) (emigration data); NDoH (2001) (data regarding number of positions); Stats SA (2000) (emigration data) Note: a Maintaining a 343: ratio. Death. According to Van Aardt et al (1999), it is difficult to formulate accurate mortality assumptions for the future as there are differences of opinion on the matter and little clarity on the likely impact of HIV/AIDS. As yet there are no published figures on the impact of HIV/AIDS on nurses, while estimations are contested. For example, during a presentation at the Nursing 2000 International Conference, Brannigan (2000) stated that about 20 per cent of South Africa s nurses were HIV positive. She expected that by 2005, at least 12 per cent of professional healthcare workers and 25 to 30 per cent of lower-paid workers in healthcare would be HIV positive. Professional bodies such as the SANC challenged these figures (Mzolo 2000). Furthermore, crude death rate figures for different occupations are not available. After considering various alternatives, the authors decided to base mortality calculations on the ASSA model (ASSA 2000). These suggest that, in order to maintain a ratio of 343: , positions need to be filled until 2011 due to mortality (see Table 14) l HRD REVIEW