South Africa’s healthcare staffing crisis is far from new. In 2015, 70% of South African nurses admitted ‘part-time’ or overtime due to the massive skills shortage in this under-resourced sector. This is an alarming statistic, given the fact that the effectiveness of any health care system directly depends on the quality of care provided by these health workers. The impact of Covid-19 on the health sector has exacerbated staffing shortages with unprecedented pressure on nurses and professionals, pushing them to the very limits of their professional and human capacity to do their jobs. This crisis, together with the growing burden of disease – itself a crisis that is projected to grow to catastrophic levels by 2040 – presents a dual and alarming threat to South Africa’s health sector. This article first appeared on Medical certificate.– Nadia Swart

South African healthcare is facing a staffing crisis and a growing burden of disease

With a quarter of South Africans over the age of 50 conservatively projected to suffer from one or more non-communicable diseases (NCDs) by 2040, the country is “going blind”.

That’s according to Professor Shivani Ranchod, senior lecturer in actuarial science at the University of Cape Town, who says the confluence of NCDs and health workforce crises, particularly the shortage of professionals coupled with population growth, is deeply worrying.

Chris Bateman, author for MedicalBriefreports that at the Hospital Association of South Africa (HASA) annual conference in Century City in Cape Town this month, she looked at SA’s workforce crisis and its quadrupling of disease burden.

She says more than 18% of South Africans over the age of 50 currently suffer from NCD co-morbidities: (8.2%) depression; (11.7%) diabetes mellitus; (8.9%) heart disease (2.3%) or hypertension (25.3%).

“The crises we face are a call to action, especially given the impact of Covid and burnout among healthcare providers. It’s time to connect to our hearts and get out of our brains – it’s personal, not abstract,” she told delegates.

Due to the maldistribution of physicians geographically and between the public and private sectors, as well as the “demarcation” between training platforms and service delivery platforms, the data were alarming.

A terrible shortage of specialists

There were only seven full-time professionals in the public health sector per 100,000 of South Africa’s population, compared to 69 in the private sector. The number of SA professionals was 16.5 professionals per 100,000 people (2019 figures); compared to Chile’s 110 (2015 figures) and 274 (2015 figures) in the Organization for Economic Co-operation and Development (OECD) (37 member countries).

“So you can see how serious the situation is. The second crisis from the point of view of NCDs is the epidemiological transition. NCDs are lifelong and there is a disproportionately high and interconnected burden in South Africa,” she said.

Ranchod says diabetes is the biggest killer of women in South Africa, ahead of all other African countries, compounded by the complex relationship between HIV and NCDs. “It has to do with the impact on the metabolic system – plus a huge percentage of South Africans have no idea they have diabetes,” she explained.

On top of this is the burden of intergenerational trauma from SA’s history of violence and repression, which research suggests can persist for 14 generations. “We need to work to cure this because mental health affects other illnesses, becoming a risk factor through alcohol and drug abuse.”

While there were “excellent” predictions for HIV and TB, there was “almost no data” on NCDs, and she warned that her scenario was “unrealistically positive” because it assumed that the burden of disease in an age-peer group was not get worse.

The human resources “vortex” for healthcare began with an aging cohort of nurses and specialists due to insufficient entry into training, while ProfMed figures showed that clinicians are not necessarily emigrating but leaving the profession.

“Every day I get CVs on my desk from clinicians who want to retire from clinical work. Then you have enormous political uncertainty in the country. People respond by going elsewhere, even though this country has universal health care coverage and practice regulations. It’s not so much about the details, but about the feeling of insecurity and physical risk,” she added.

RWOPS requires addressing

Another contributing factor is that 36% of public sector professionals appear to be using RWOPS (paid work outside the public service), where the amount of time they spend in the private sector remains unknown. “It’s a huge problem, but we keep allowing it to happen,” she said.

If South Africans contributed “just a little”, things could change, “but polarization prevents us from solving problems. If we stay in polar camps, it is difficult to act and move forward. We need to start solving real problems on the ground,” she urged.

The NHI can be seen as a panacea or a crisis – but a ‘middle ground’ needs to be found.

Most people tend to view NCDs as individual patterns of behavior related to tobacco or alcohol use, unhealthy diet, physical activity, environment, or childhood adversity. However, “systemic” should be combined with “individual”.

“There are major drivers at the system level. People live in food deserts with no access to healthy food – women don’t exercise as much because of safety concerns. You have the intersection of environment with lifestyle, the intersection with socioeconomic conditions,” she said.

Some suggested solutions

Ranchod, a strong proponent of value-based solutions, explained that “value” is about optimizing patient outcomes within a financial package. “It involves a population health perspective – optimizing patient outcomes not for individual patients but for the entire system as a whole – which in turn involves a focus on equity and access.”

Placing values ​​”at the center” provided an alternative sequence of reforms, starting with measurement, then focusing on delivery, and only then addressing the payment mechanisms of care. This “caring for care” approach was designed with low- and middle-income countries in mind.

Among her decisions are the creation of a separate health workforce planning agency and the involvement of key stakeholders and experts in creating a centralized database for all health workers. She said such a database would detail workforce type, sector, effort level and demographics for planning.

A simple initial change that would facilitate health resource planning would be to capture more health worker data in the state’s PERSAL (payroll) system.

Other innovations include encouraging patient self-management to decongest the system, transferring successful private sector health promotion programs to the public sector, and home delivery of medicines supported by community health workers. Ranchod said that Covid has highlighted the ability of telemedicine to improve outcomes and access to care.

She warned that the current medical malpractice litigation (over 70 billion rand in the public sector at the latest estimates) could bring the health system to its knees, not to mention disincentivize professionals. Gynecologists pay 1.2 million rand a year in risk coverage, but a value-based approach with patient-based outcome measurement would reduce the risk. “We have the opportunity to think differently, build inclusive solutions, focus on values ​​and ignite innovation. What are we waiting for?” she asked.

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