Human Resources, a persistent problem for the NHI

_{18 months into the initial phase of the National Health Insurance (NHI) scheme and South Africa is still short of 14 351 doctors, according to a recent survey conducted by the South African Institute for Race Relations (SAIRR).}

_{The current shortage of professional medical staff is likely to seriously hamper the government’s proposed National Health Insurance (NHI), medical experts say.}

_{The NHI is a system where universal health care coverage is proposed for every South African citizen however the transformation of the health system has been hindered by inadequate staff numbers and an inequitable distribution of health workers between the public and private sector.} 

_{The SAIRR survey found that staff shortages are not being adequately addressed by government and almost 56% of doctors’ posts are empty. Almost 46% of nursing posts also remain unfilled.} 

_{Lerato Moloi, a researcher at the SAIRR, says “these figures are alarming” and such high vacancies make NHI seem unachievable.}

_{“The two most critical aspects of the NHI are how are we going to fund it and how are we going to staff it” adds Doctor Mark Sonderup, a specialist at UCT Medical School.} 

_{The current health system is overwhelmed by very few resources that is compounded by the increasing population figures where both nurse-to-patient and doctor-to-patient ratios are excessively high,  says South African Medical Association’s (SAMA) public sector doctors' committee chairwoman, Dr Phophi Ramathuba.}

_{Despite these concerns the 2012/2013 South African Health Review states that “training of new doctors has been increased through increasing the intake in training institutions and sending 1000 medical students to Cuba to be trained”. In addition, since the launch of the National Human Resources for Health strategy in October 2011, an extra 40 doctors started training in South Africa in 2011/2012 and 125 in 2012/2013.}

_{In spite of this progress, numbers of doctors graduating from South African universities is decreasing. Between 2004 and 2008 there was a more 6%decline in medical graduates. Specialists who are being trained at the country’s eight medical schools are also not being properly absorbed into the public health sector. “To produce doctors and specialists, you need a functional academic sector. The capacity that we’ve had to train doctors has been under enormous pressure. The capacity to train doctors has been limited. What we need is more medical schools. Despite HIV/Aids, our population is growing. There is an increase in the number of immigrants. We have not kept up with that,” Sonderup says.}

_{In order for the NHI to be a success, the country needs to double the number of doctors it trains each year. The establishment of new medical schools and ensuring vacancies at existing schools are filled is critical to solving the problem and curbing the deficiency. The progress highlighted by the SAHR is insufficient to address the severe staff shortages currently plaguing the country’s health system. Health Minister Dr Aaron Motsoaledi told parliament he had asked deans of medial faculties to think innovative ways to increase student intake but the effects of this ‘request’ remain to be seen in the country’s production of medical graduates.}

_{The human resource problem also goes beyond higher education. A research report published in the South African Medical Journal in 2011 shows that at the time there were estimated 27 641 doctors practicing in South Africa, approximately 23 407 South African-born doctors were believed to be practicing overseas. It is clear that South Africa needs to ‘train and retain’ more doctors in order for the government’s proposed NHI to be a success.}

_{“While government's NHI plan has theoretical merit, in practice it will be exceedingly difficult to implement, particularly within the envisaged time frame of 14 years," Hospital workers union, HOSPERSA, said in a statement to News24 in 2010. The union also went on to say that foreign doctors will have to be recruited if NHI is to be successfully implemented. Sonderup also emphasises the need to recruit more doctors if NHI stands any chance of achieving success. “We have got to turn the tide of people who are still leaving. And we have got to go back and try to actively recruit those who have left. If we got just one-tenth back, we would have the equivalent of a year’s worth of graduates,” he says.}

_{However all is not doomed for the success of NHI. In April of this year the Mail and 
Guardian reported that 350 private doctors will start working part time for the country's NHI system this month at public health facilities. The clinics and hospitals are based at the NHI scheme's 11 pilot sites. Whether this will be enough to address the key challenge of providing and funding human resources within the envisaged timeframe of 14 years remains to be seen.}

Inequality and social stress: the missing element in understanding South Africa’s burden of disease?

Despite 18 years of democracy, inequalities in gender, race, income and geographical location still remain the key markers of poor health in South Africa  according to the 2012/2013 South African Health Review released on 2 April 2013.  

The Review contains commentary from a range of experts on topics such as the social determinants of health, non-communicable diseases, climate change and occupational health. It further states that overcoming these increasing inequities between the rich and the poor is necessary in order to reduce the country’s quadruple burden of disease and transform the public and private healthcare landscapes.

 South Africa is currently in the grips of 4 simultaneous epidemics referred to as the country’s ‘quadruple burden of disease’. This includes HIV and AIDS, diseases relating to poverty and under-development, chronic diseases, injuries and interpersonal violence.

The Review’s findings come amid a burgeoning volume of recent research which shows a direct correlation between social inequalities and poor health. Although there has been overall growth in the economy since 1994, South Africa still has one of the highest income inequalities in the world, with a Gini coefficient (the measure of inequality within a country) that has remained at 63.1.“Despite increased provision of social grants, extreme wealth inequalities and high unemployment likely play an important role in poor health outcomes” says Debbie Bradshaw, director of the Burden of Disease Research Unit at the South African Medical Research Council. Inequality is thus a far more useful determinant for assessing South Africa’s health status than material deprivation in the form of poverty.

An understanding of poverty in the form of material deprivation such as dirty water or poor nutrition is inadequate because relief of such material deprivation such as providing clean water can be reduced to merely a technical matter, asserts Michael Marmot, Professor of Epidemiology and Public Health at University College London. This understanding fails to take into account the socially determined nature and skewed allocation of these resources. “In fact, there are many examples of relatively poor populations with similar incomes but strikingly different health records,” Marmot further adds.

The Spirit Level: Why More Equal Societies Almost Always Do Better, published in 2009 by Richard Wilkinson and Kate Pickett argues that inequality is socially corrosive and leads to more violence, an erosion of trust, increased anxiety and illness, chronic stress and risky behaviour such as increased consumption of alcohol and smoking. These in turn lead to poor health outcomes in terms of physical and mental health, drug abuse, obesity, violence, infant mortality and lower average life expectancy.

According to the Review, violence, alcohol misuse and mental disorders are leading contributors to the burden of disease in South Africa. South African homicide rates are estimated at more than 8 times the global average among males and five times the global average among females. South African drinkers also rank in the top five riskiest drinkers in the world. These are all risk factors compounded by South Africa’s high levels of inequality and income disparities.

Government’s annual death report released on 10 April 2013 confirms that fewer South Africans are dying from HIV/AIDS-related diseases. This is likely a reflection of the success of the antiretroviral programme, says University of Cape Town (UCT) actuary and epidemiologist, Leigh Johnson, in an article for Health-e News Service.  However, more people are dying of non-communicable diseases (NCD’s) such as diabetes. The World Health survey shows that socio-economic inequalities are risk-factors for non-communicable and chronic diseases in low to middle income countries such as South Africa. This could explain the high contribution of NCD’s to the country’s disease burden.

However, the scale of whether a society’s income inequality is a determinant of population health still remains a controversial issue. Critics argue that measuring a nation’s health according to the level of inequality within that country is statistically flawed and does not explain homicide rates, women’s status, life expectancy or obesity.

In spite of this, South Africa has displayed a commitment to reducing the level of inequality within the country by signing the United Nations Millennium Declaration in 2000 which is a global attempt to address unacceptable inequalities within and between countries by the year 2015. These goals include eradicating poverty and hunger, promoting gender equality, reducing child mortality, improving maternal health, combating HIV and AIDS and ensuring environmental sustainability. Unfortunately with only 2 years to go, achieving these goals is proving to be elusive, and in many cases impossible for the country.

The implementation of the proposed National Health Insurance will also attempt to make inroads into reducing the level of inequality in the country’s health but whether this will be a success remains to be seen as many challenges still confront the planning committee.

The Review shows that more needs to be done to address the ‘causes of the causes’ of ill-health, namely those directly influenced by inequality and social stratification. After all, prevention is always better than cure.