The shortage of healthcare professionals in South Africa is one of the biggest threats to the country's ambition to eventually roll out equitable universal access to healthcare for all its citizens.
But the dearth of suitably qualified and experienced healthcare professionals is one of the biggest challenges facing the healthcare industry worldwide, not just in South Africa or in other developing countries.
The root cause of the shortage is the same that is helping push up healthcare costs. Ageing populations in developed countries and improving life expectancy in emerging markets and developing economies, drive the increase in demand for healthcare services.
The United States has an estimated shortage of about 16 000 primary healthcare doctors, while half of the 830 000 who are currently in practice are over 50 years old and are approaching retirement.
The United Kingdom, a key destination for South African nurses, had an estimated shortage of 40 000 nurses in 2012.
In Africa, about 36 countries have inadequate staff and facilities to deliver even the most basic immunisation and maternal health services, with the greatest need being in sub-Saharan Africa, where a 140% increase in the workforce is required to meet the population's needs.
The health worker density in most sub-Saharan countries is well below the World Health Organisation threshold of 2.3 physicians, nurses and midwives for every 1 000 people. This is considered to be the minimum number of healthcare workers required to deliver essential services.
SA falling behind Brics
Although South Africa has a higher ratio of healthcare workers for every 10 000 people, at 4.85 – which is considered to be as critical as the shortage experienced by most other African countries – the country still lags behind its peers in the Brazil, Russia, India, China and South Africa (Brics) grouping, all of whom have much larger populations on this measure.
The rural-urban divide in South Africa is an ever-present reality. According to the department of health, about 43.6% of the South African population lives in rural areas but is only served by 12% of the doctors and 19% of nurses.
Some parts of rural South Africa have 14 times fewer doctors than the national average. In addition, they suffer a higher infant mortality rate of 52.6 for 1 000 live births, versus 32.6 in urban areas.
The migration of healthcare workers is another challenge. Many African, Caribbean and Asian countries are unwilling exporters of health workers. Their migratory streams are not necessarily supported by national health policy and are driven largely by global labour market forces.
But the international mobility of health workers is not a recent phenomenon.
Migration is generally attributed to a combination of "push" from within the sender countries and "pull" from the host countries. The challenge for South Africa is to make the healthcare environment attractive enough for healthcare workers to want to stay.
South Africa is not the worst hit. India, Nigeria and Pakistan are three countries with critical healthcare staff shortages yet are among the top-25 countries whose doctors, nurses and pharmacists emigrate.
Migration a "vicious spiral"
The loss of healthcare workers is acutely felt in a country like South Africa. With health facilities already facing staff shortages and unfilled vacancies, the migration of existing staff adds to the workload of those who remain, increasing their case loads and leading to fatigue, loss of motivation and eventual burnout. These pressures provide an impetus for remaining workers to migrate, extending the vicious spiral.
South Africa has the means and the opportunity to retain its healthcare professionals within the system and stem the brain drain. The country can take a number of steps to improve the supply of healthcare workers and motivate professionals to stay in the industry, especially the public health system, and develop their careers.
The attraction and retention of professionals in any sector is driven by the investment the sector can attract, and healthcare is no exception. The sector needs to attract local and foreign investment to hold on to its brightest and best. Otherwise, doctors simply pursue MBAs and move into business instead of treating patients.
The maxim that nursing is not a profession but a calling may be true, but passion alone will not keep nurses, neither will a frequently increased salary that is not matched by improving working conditions.
Improve working conditions
Healthcare professionals are also motivated by hygiene factors: the ability to do their jobs well using the latest equipment and best practices, exposure to research and development and working with the best minds in their chosen fields – whether a renowned expert spends time at a local facility or a small group is sponsored to travel to a centre of excellence elsewhere in the world.
A short-term measure that can help remedy the shortage is the reform of the immigration system to allow hospitals to bring in skilled foreign workers. The process is currently cumbersome and reform is politically unpalatable in the face of high unemployment.
But that view is dangerous and mistaken. Unemployment currently affects the semi-skilled and unskilled, while there is an acute shortage of people to fill senior and specialist posts. The two have to be separated.
The next step is to inculcate a belief in the value of a professional and deploy professionals effectively.
For example, the work of pharmacists can be aided by improving disease management protocol and freeing them from administration such as counting pills, to allow pharmacists to spend more time consulting with patients. Pharmacists can also benefit from the use of technology such as robotic dispensers, which again frees them to offer advice and face-time to patients.
Invest in education
The long-term intervention is the improvement of the education system, specifically maths and sciences, as well training institutions. The sector also needs to maintain its on-the-job training programme, which offers accelerated growth.
There is no panacea for the ills of skills shortage, but a series of short- and long-term measures can help to address the problem.
Russ Rudish is the global head of healthcare at Deloitte, based in the United Sates. Valter Adao is the head of healthcare and life sciences at Deloitte in South Africa. Judy Varndell is a senior manager in Deloitte's healthcare and life sciences team.