As a healthcare professional whose experience is rooted in the public healthcare sector of South Africa, I can sympathize with healthcare professionals who choose to leave the continent, in order to pursue their career overseas. The phenomenon of ‘brain drain’ which is the emigration of highly skilled professional, from their home country to another, has been a significant concern for many developing nations, including South Africa. According to an article by Health Policy Watch, fifteen of the world’s richest countries have over 55 000 African doctors in their healthcare systems.
A report by the World Health Organization (WHO) which was published last year in the British Medical Journal Global Health and which surveyed 47 African countries, found that “the region has a ratio of 1.55 health workers (physicians, nurses and midwives) per 1000 people. This is below the WHO threshold density of 4.45 health workers per 1000 people needed to deliver essential health services and achieve universal health coverage.” The report goes on to say that there will be a shortage of ‘6.1 million’ health workers by 2030.
The consequences for the continent is that the burden of providing quality healthcare for the masses rests on the shoulders of a handful of men and women who remain behind to serve the local population. The most popular emigration destinations are the UK followed by the US France and then Canada. It is not uncommon for wealthier countries to exploit the desperate working conditions faced by health workers on the African continent, in order to recruit them to beef up the gaps in their own health workforce. Some might say this is another example of colonial plunder because Western Capitalists are looting human capital from formerly colonized regions, to benefit themselves.
South Africa is no exception. The working conditions in public healthcare institutions are shocking to say the least. The average gross package of a registered nurse in South Africa is less than R25 000 per month, (approximately $1334.59 U.S. dollars). For those who are employed through labor brokers or temporary contracts, it is even less. Healthcare workers who are exploited through labor brokers are unable to afford housing, vehicle financing and other credit facilities. Workers are also extremely demoralized because they work in buildings which are old and falling apart. They are forced to work overtime a lot because of severe staff shortages. They often have to endure verbal abuse from frustrated members of the community who have to wait extremely long hours to get treatment. Therefore, it is unsurprising that every year, thousands of healthcare workers leave our shores in order to chase better opportunities. However, in addressing this serious crisis, it is important to understand where the problem started.
At the center of the healthcare crisis in South Africa is the full scale implementation of neoliberal economic policies and more recently, the implementation of austerity measures. Neoliberalism is characterized by policies such as privatization, de-regulation, free trade, and most importantly, austerity policies through reducing government budget deficits through either through spending cuts or tax increases. In some cases, it is a combination of both. Either way, when these policies are applied, the impact on the healthcare system is devastating.
The implementation of neoliberalism and austerity measures has had a significant impact on South Africa’s healthcare system. These policies have led to budget cuts resulting in a lack of resources, inadequate infrastructure, and poor working conditions, and therefore the public healthcare sector is suffocating because of a lack of resources. The privatization of healthcare has led to the creation of a two-tier healthcare system where there is an efficient, well-resourced private sector health care system which caters only to a tiny wealthy elite and is very expensive. The masses, meanwhile, are forced to depend on a crumbling healthcare system which is under-resourced and understaffed, and is unable to adequately take care of the health needs of the majority of the people.
The budget cuts which have been implemented by National Treasury have resulted in the health sector being grossly underfunded for many years. The freezing of posts and the inability of the Health Department to fill vacant posts means we have vacancy rates as high as 20% in some cases. South Africa has a critical shortage of doctors, with less than one doctor to treat 1 000 patients. The Global Economy reported in 2020 that the average ratio of nurses to patients in South Africa was 1.03 nurses per 1,000 people. In comparison, the world average for nurse to patient ratio is “8.71 nurses per 1,000 people”.
The non-filling of critical posts leads to dangerously long hours, which means there is a higher likelihood of negligence, thus leading to increased lawsuits and negligence claims against the Department of Health. It also means poor service because the current staff is collapsing under extremely high patient loads. This is exacerbated by frequent power cuts and load shedding which makes the difficult job of saving lives almost impossible. The link between the brain drain and the implementation of neoliberalism and austerity measures in South Africa’s healthcare system is clear. These policies have led to a deterioration of the healthcare system, prompting many healthcare professionals to emigrate, thus exacerbating the healthcare crisis even further.
To reinforce the health system, it is critical to address the persistent shortages and poor distribution of the health workforce. South Africa must significantly increase investments in building the health workforce to meet its current and future needs. Strong measures are also needed to boost training and the recruitment of health workers as well as to improve their deployment and measures must be implemented to retain these skills. These measures must include increasing spending for the healthcare sector and an end to austerity. Any attempt to improve service delivery without increasing spending is futile. Such a plan is bound to fail because it is based on the naïve idea that quality service is possible in the absence of resources. It is comparable to buying a car, but refusing to pay for petrol in order to save costs, but somehow, the car must still move. It is an absurd idea which is not rooted in reality.
Healthcare is a necessity, not a luxury. The right to healthcare is enshrined in the South African constitution. There is a lot of research that links total health expenditure, public health expenditure, and private health expenditure to positive economic growth. From an economic perspective, being healthy is not only a matter of not having any disease but also having the potential to do productive activities. Workers with better health will be able to perform at a higher level and are less likely to be absent. Healthy individuals also indirectly impact economic growth by raising healthy families which may subsequently create healthier future generations. Besides physical health, mental health is an important part of human well-being as an improvement in individual’s mental state can give an increase in social and economic participation, engagement and connectedness, and work productivity.
A healthy population is able to acquire more education and skills. This translates into economic growth directly by increasing labor productivity and decreasing the costs of illnesses. Therefore, the increase in public health expenditures is positively related to economic performance. Spending on health should be seen as investing in the overall positive development of society. The spinoffs are that there are economic benefits because a health society is a society which can contribute meaningfully to economic growth.
So now that we have established that spending on healthcare is a no-brainer and we should do it, why is it that our government is refusing to act accordingly? One of the biggest challenges we face is that we must accept that South Africa is not a sovereign nation. The governing party is owned and controlled by the banks and international finance institutions who are dictating economic policy. The same countries which are looting us for our human capital are offering us loans which have conditions that place restrictions on the state on how to prioritize public spending.
A report published by the National Library of Medicine in June 2019 found that, “The privatization and buying out of African hospitals by foreign companies in an attempt to “help and rescue them” is a capitalist response that undercuts universal healthcare for Africans by appropriating the language of care and inclusion. In reality, this “white saviour approach” is layered with nothing but racism, disempowerment, exploitation of people, and exclusion of those who cannot afford those “privatized” services. Access to health services, therefore, remains both a political as well as a human rights issue that’s closely tied to social justice (Braveman and Gruskin 2003b); but Africa’s colonial history, fueled by Western greed for her resources, promotes discriminatory policies that continue to impact Africans and their well being.”
So what this tells you is that the ultimate cure to the disease which has paralyzed our healthcare system is for the state to have the courage to act in the interests of the majority of people, and to stop implementing policies that benefit the banks and the private sector. At the same time, we must abolish private healthcare and fast track the implementation of the National Health Insurance. The NHI will deal with gross shortage of staff, gross shortage of medicine and it will mean that our health care facilities and the standards will drastically improve. This is a call which the Health and Allied workers Indaba Trade Union (HAITU) has consistently made. We must abolish the private healthcare system which promotes inequality. One system for all means that all our resources will be channeled to benefit every citizen equally and ensure that no one is left behind.
Lerato Mthunzi is the General Secretary of Health and Allied workers Indaba Trade Union, a health care workers union in South Africa representing over 23,000 workers.
