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Abstract
BACKGROUND. An aim of the Colleges of Medicine of South Africa (CMSA) project 'Strengthening Academic Medicine and Specialist Training' was to research the number and needs of specialists and subspecialists within South Africa. METHODS. Data were collected from several sources: Deans of the 8 Faculties of Health Sciences and the Presidents of the 27 constituent Colleges of the CMSA completed a survey; and the HPCSA's Register of Approved Registrar Posts for Faculties of Health Sciences was examined and the results tabulated. RESULTS. South Africa compares unfavourably with middle-income countries on the ratios of medical and dental professionals; many districts have limited access to specialists and subspecialists. The unacceptable ratio of doctors, dentists and other health professionals per capita needs to be remedied, given South Africa's impressive reputation for its output of health professionals, including the areas of medical training, clinical practice and clinical research. The existing output from South Africa's 8 medical schools of MB ChB and specialist graduates is not being absorbed into the public health system, and neither are other health professionals. CONCLUSION. Dynamic leadership and policy interventions are required to advocate and finance the planned increase of medical, dental and other health professionals in South Africa.
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... 8 In 2011, the World Bank report on human resources in health identified that there were 4.7 nurses, 0.8 doctors and 0.085 dentists per 1000 people. 8,9 The estimated need for palliative care using only mortality data is that 0.52% of the population requires palliative care in any year. There are currently eight hospital palliative care services (two dedicated children's palliative care services) and 150 hospices providing palliative care, about 40 of them also provide care for children. ...
... 27 A major challenge in providing oral palliative care in South Africa includes a lack of recognized and qualified dentists. 9 There is also an absence of curricula, limited formal training and resources, and no clear definition of roles and responsibilities of dentists in the palliative care team. Nurses and other health care workers within the multi-disciplinary team receive minimal training to enable them to recognize the needs of individuals seeking assistance for oral palliative care. ...
... Nurses and other health care workers within the multi-disciplinary team receive minimal training to enable them to recognize the needs of individuals seeking assistance for oral palliative care. Given the relative scarcity of dentists in South Africa (0.085 per 1000 population), 9 it has been argued that a health workforce should be developed for the provision of oral palliative care services. Graduate and Post Graduate dental students at the Institute of Palliative Medicine, day care, long term care facilities, tertiary cancer centres or centre for special needs, the availability of dental practitioners can be increased. ...
Palliative care is a global human right, to be provided in a systematic way. The dentist can help the patient right from the initial diagnosis of the condition up to the relief of pain in the terminal stages of the diseases. This inquiry into the oral physician‘s role on elderly care and specialneeds would be of benefit to researchers of PalliativeDentistry; particularly in multidisciplinary contexts. This textproposes to discussintegrated oral care, oral health caredelivery system, and a flow of educational actions, re-sources, research, conceptual framework, guidelines and dissemination of newer trends in oral palliative care.
... South Africa (SA) has an inadequate ratio of dentists per 1,000 population, and this together with a lack of access to oral health services, could be the driving forces in delayed diagnosis, untreated oral diseases and compromised health status [8,9]. Within SA, many provinces have limited or no access to dental services at all [8]. ...
... South Africa (SA) has an inadequate ratio of dentists per 1,000 population, and this together with a lack of access to oral health services, could be the driving forces in delayed diagnosis, untreated oral diseases and compromised health status [8,9]. Within SA, many provinces have limited or no access to dental services at all [8]. Bhayat et al. reported that in 2016 there were 6 125 general dental practitioners and 481 specialists [10]. ...
... Gap estimation. Based on the HPCSA database [27], and on the knowledge and experiences of two authors in the study, the number of dentists (including specialists) were assumed to be 95% of the total number of registrations (which are currently active and working) for the baseline year 2018 [8]. For subsequent years, we estimated net workforce as: ...
To manage the increasing burden of dental diseases, a robust health system is essential. In order to ensure the oral health system operates at an optimal level going into the future, a forecast of the national shortfall of dentists and dental specialists in South Africa (SA) was undertaken. There is currently a shortage of dentists and specialists in SA and given the huge burden of dental diseases, there is a dire need to increase the number of these health care workers. The aim was to determine the projected shortfall of dentists and specialists in each of the nine provinces in SA. The projected shortfall was calculated based on the SA Disability-Adjusted Life Years (DALYs) for each province. The estimate for the evaluation of the Global Burden of Disease (GBD) for SA was obtained from the Institute of Health Metrics and Evaluation (IHME) Global Burden of Disease website. For each province, age standardized DALYs were calculated with mid-year population estimates obtained from Statistics SA 2018. In order to reduce the existing human resources for health (HRH) inequity among the provinces of SA, three scenarios were created focussing on attaining horizontal equity. The best-case scenario estimates a shortfall of 430, 1252 and 1885 dentists and specialists in 2018, 2024 and 2030 respectively. In an optimistic scenario, the national shortfall was calculated at 733, 1540 and 2158 dentists and specialists for the years 2018, 2024 and 2030 respectively. In an aspirational scenario, shortfalls of 853 (2018), 1655 (2024) and 2267 (2030) dentists and specialists were forecasted. Access to oral health services should be ensured through the optimum supply of trained dentists and specialists and the delivery of appropriate oral health services. Thus, the roadmap provided for upscaling the oral health services recognizes the influence of both demand and supply factors on the pursuit of equity.
... In SA, there are 0.13 dentists per 1000 individuals, which is fewer than most other middle-income countries. 44 In addition, there are in-equities in the distribution of its oral health care workers (OHCW). 9,44 While 84-90% of the SA population is reliant on public oral health services, in 2009, only 25% of all South African dentists were employed by the public sector. ...
... 44 In addition, there are in-equities in the distribution of its oral health care workers (OHCW). 9,44 While 84-90% of the SA population is reliant on public oral health services, in 2009, only 25% of all South African dentists were employed by the public sector. 44 The SA National Department of Health has demonstrated that it has the ability to garner resources and undertake intense community screening as it has for SARS-CoV-2. ...
... 9,44 While 84-90% of the SA population is reliant on public oral health services, in 2009, only 25% of all South African dentists were employed by the public sector. 44 The SA National Department of Health has demonstrated that it has the ability to garner resources and undertake intense community screening as it has for SARS-CoV-2. If only such intense mobilisation could be done for the promotion of oral health screening and education in disadvantaged communities. ...
The global pandemic due to infection with the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV -2) causes the disease COVID-19 which is a mild, self-limiting disease in the majority of infected individuals.1 However, in many individuals, particularly the elderly, or those with comorbidities such as diabetes, pulmonary disease or cardiovascular conditions, infection with SARS-CoV-2 has resulted in more severe symptoms, and has proved fatal.2 Given that COVID-19 is a novel disease and that there is no vaccine or specific pharmacologic treatment for it, it is likely that its impact on an individual's general health will be protracted and is yet to unfold. Oral health is inextricably linked to general health and its neglect may have negative consequences on human and economic capital. The aim of this commentary is, therefore, to highlight the potential impact of SARS-CoV-2 on oral health in South Africa (SA).
... In SA, there are 0.13 dentists per 1000 individuals, which is fewer than most other middle-income countries. 44 In addition, there are in-equities in the distribution of its oral health care workers (OHCW). 9,44 While 84-90% of the SA population is reliant on public oral health services, in 2009, only 25% of all South African dentists were employed by the public sector. ...
... 44 In addition, there are in-equities in the distribution of its oral health care workers (OHCW). 9,44 While 84-90% of the SA population is reliant on public oral health services, in 2009, only 25% of all South African dentists were employed by the public sector. 44 The SA National Department of Health has demonstrated that it has the ability to garner resources and undertake intense community screening as it has for SARS-CoV-2. ...
... 9,44 While 84-90% of the SA population is reliant on public oral health services, in 2009, only 25% of all South African dentists were employed by the public sector. 44 The SA National Department of Health has demonstrated that it has the ability to garner resources and undertake intense community screening as it has for SARS-CoV-2. If only such intense mobilisation could be done for the promotion of oral health screening and education in disadvantaged communities. ...
INTRODUCTION: Anterior open bite (AOB) malocclusion presents as lack of vertical overlap of anterior teeth. It is viewed to be unaesthetic and may affect speech and mastication It develops due to the interaction of hereditary and environmental etiological factors and these usually affect the vertical growth of the face. This study describes the vertical changes of South African black people presenting with AOB. AIMS AND OBJECTIVES: The aim was to determine skeletal morphological features of patients with AOB malocclusion. DESIGN: The design was a retrospective, cross-sectional study. MATERIALS: Archived pre-treatment lateral cephalographs of 181 patients who consulted between 2007 and 2014 were divided into four groups: control group of 62 patients with skeletal Class I pattern without AOB; test groups of patients with AOB (119) divided into 35 Class I, 43 Class II, and 41 Class III malocclusions. Records of each group were divided according to gender. Descriptive statistics, the Pearson correlation coefficient, t-test and. Wilcoxon test were employed to analyze the data, and p values of <0.05 were considered statistically significant. RESULTS AND CONCLUSIONS: Patients with AOB had a larger vertical facial pattern in all classes of malocclusion. Males presented with larger Sn-GoGn angles than females. The PFH/AFH ratio was lower across all classes of malocclusion compared to the control group.
... The shortage and maldistribution of these professionals is a serious problem worldwide, 2,3,4,5,6,7 whereas the brain drain 8 and ageing of the workforce are additional problems exacerbating the situation. 9,10 In SA, the shortage and unequal distribution of medical doctors, with too few doctors servicing rural communities, is not a new phenomenon 11,12 and has been highlighted in the national media. 13,14,15,16,17 Several interventions such as training South Africans as doctors in Cuba, compulsory community service for graduate medical doctors, extension of internship to 2 years and the introduction of various financial incentives -such as scarce skills, rural allowances and the recruitment of Cuban doctors -have been tried in order to address shortage of doctors in remote and rural areas. ...
... This study explores the geographical distribution of medical doctors employed in the public sector hospitals of the Limpopo Province, SA. Recruitment and retention of a rural health workforce, particularly medical doctors, continues to be a national challenge 11,12 and a major constraint to the delivery of essential health services. 25 Despite comprehensive rural health workforce recruitment and retention strategies, 18,19 rural communities continue to face a greater health workforce shortage than do their urban counterparts. ...
... SA is below this minimum level; however, the country is much better placed than most African countries, 12,29 but undersupplied when compared with middleincome and high-income countries. 5,12 The national doctor-topopulation ratios hide internal disparities, 30 particularly between provinces. Evidently, in 2007, the doctor-to-population ratio in the Limpopo Province was far lower than in Western Cape and Gauteng provinces, 26,30 which makes it difficult for Limpopo to achieve certain health intervention goals. ...
Background
The shortage and unequal distribution of medical doctors in low- and middle-income countries continues to be a public health concern.
Objective
To establish the geographical distribution and demographic profile of medical doctors in public sector hospitals of the Limpopo Province, South Africa.
Method
The PERSAL system was used to obtain information on the number of medical doctors employed in public sector hospitals of the Limpopo Province. Data were exported from PERSAL’s database and then analysed using STATA version 9.0.
Result
The mean age of the 887 medical doctors was 40.1 ± 11.2 years (range 24–79 years). Sixty per cent of the doctors were male, 66% were aged ≤ 45 years and 84% were African. Most of the doctors (86%) were medical officers, of which 55% had < 5 years working experience. Overall, the doctor-to-population ratio for the five districts in the province was 16.4/100 000, with Capricorn (33.7/100 000) and Waterberg (20.2/100 000) recording the highest ratios. A large proportion (43%) of medical officers are employed in the Capricorn District, of which 71% were practising at the tertiary hospital.
Conclusion
This study demonstrated a shortage and maldistribution of medical doctors in the public sector hospitals of the Limpopo Province. This has a potentially negative effect on the delivery of an appropriate and efficient healthcare service to the population and requires urgent attention.
... SA has a major shortage of doctors in the public sector and faces concomitant epidemics of HIV and tuberculosis. [9] Due to high patient loads and limited supervision from specialists, it is important for students to be clinically competent on graduation. During their internship they will have to manage illnesses independently and often for prolonged periods under challenging circumstances. ...
... SA has a low physician-to-population ratio of only 36 doctors per 100 000 in the public sector and there is a need to increase the annual number of medical graduates. [9] By the time the curriculum was restructured at the NRMSM, it was globally recognised that teaching and learning in small groups requires more time, effort and resources. SA has a shortage of both resources and teaching staff. ...
... Clinical teaching staff at SA medical schools are mainly public sector specialists, but the number of specialists in this sector has declined. [9] Clinical teaching staff have large case loads and are salaried employees of the Department of Health, for whom patient care is a priority. Clinical teachers also face considerable pressure to publish. ...
p> Background. Medical education reformers must consider disease patterns, health system expectations and clearly specified outcomes to ensure that revised curricula are relevant. South Africa needs clinically competent doctors in adequate numbers to address the burden of psychiatric illnesses.
Objective. To evaluate the impact of a curricular reform, this study compared undergraduate students’ clinical competence in psychiatry following a change from a six-year traditional lecture-based (LB) curriculum to a five-year problem-based learning (PBL) curriculum.
Method. The psychiatry examination records of 936 students enrolled in a PBL curriculum were compared with those of 771 students enrolled in a LB curriculum, covering a nine-year period from 2001 to 2009. Records covered the long case, case vignette and oral examinations.
Results. Students in the PBL group performed significantly better in the problem-solving case vignette examination ( p <0.02). There were no statistically significant differences in the mean marks for the long case and the oral examination. Because the revised curriculum is shorter, one additional class of 200 students graduated during the duration of the study than would have been possible under the previous curriculum.
Conclusion. The new PBL curriculum produced more doctors, but there was no change in their psychiatric knowledge and skills compared with graduates from the old LB curriculum. Clinical teachers need to define outcomes prior to curriculum revision, because these are essential for evaluating the curriculum’s success.</p
... SA has a major shortage of doctors in the public sector and faces concomitant epidemics of HIV and tuberculosis. [9] Due to high patient loads and limited supervision from specialists, it is important for students to be clinically competent on graduation. During their internship they will have to manage illnesses independently and often for prolonged periods under challenging circumstances. ...
... SA has a low physician-to-population ratio of only 36 doctors per 100 000 in the public sector and there is a need to increase the annual number of medical graduates. [9] By the time the curriculum was restructured at the NRMSM, it was globally recognised that teaching and learning in small groups requires more time, effort and resources. SA has a shortage of both resources and teaching staff. ...
... Clinical teaching staff at SA medical schools are mainly public sector specialists, but the number of specialists in this sector has declined. [9] Clinical teaching staff have large case loads and are salaried employees of the Department of Health, for whom patient care is a priority. Clinical teachers also face considerable pressure to publish. ...
... SA has a major shortage of doctors in the public sector and faces concomitant epidemics of HIV and tuberculosis. [9] Due to high patient loads and limited supervision from specialists, it is important for students to be clinically competent on graduation. During their internship they will have to manage illnesses independently and often for prolonged periods under challenging circumstances. ...
... SA has a low physician-to-population ratio of only 36 doctors per 100 000 in the public sector and there is a need to increase the annual number of medical graduates. [9] By the time the curriculum was restructured at the NRMSM, it was globally recognised that teaching and learning in small groups requires more time, effort and resources. SA has a shortage of both resources and teaching staff. ...
... Clinical teaching staff at SA medical schools are mainly public sector specialists, but the number of specialists in this sector has declined. [9] Clinical teaching staff have large case loads and are salaried employees of the Department of Health, for whom patient care is a priority. Clinical teachers also face considerable pressure to publish. ...
Background. Medical education reformers must consider disease patterns, health system expectations and clearly specified outcomes to ensure that revised curricula are relevant. South Africa needs clinically competent doctors in adequate numbers to address the burden of psychiatric illnesses. Objective. To evaluate the impact of a curricular reform, this study compared undergraduate students' clinical competence in psychiatry following a change from a six-year traditional lecture-based (LB) curriculum to a five-year problem-based learning (PBL) curriculum. Method. The psychiatry examination records of 936 students enrolled in a PBL curriculum were compared with those of 771 students enrolled in a LB curriculum, covering a nine-year period from 2001 to 2009. Records covered the long case, case vignette and oral examinations. Results. Students in the PBL group performed significantly better in the problem-solving case vignette examination (p<0.02). There were no statistically significant differences in the mean marks for the long case and the oral examination. Because the revised curriculum is shorter, one additional class of 200 students graduated during the duration of the study than would have been possible under the previous curriculum. Conclusion. The new PBL curriculum produced more doctors, but there was no change in their psychiatric knowledge and skills compared with graduates from the old LB curriculum. Clinical teachers need to define outcomes prior to curriculum revision, because these are essential for evaluating the curriculum's success.
... South Africa's health care system, its HRH establishment and the supply of health professionals do not mirror the dire shortages and constraints found in other African countries. South Africa has strongly developed health professions, and in most categories a relative abundance of health professionals and of mid-level and auxiliary workers linked to the core professions [13][14][15][16]. With 4 doctors, nurses and midwives per 1000 population, South Africa's HRH provisioning falls well above the WHO 'critical' benchmark of 2.5 health workers per 1000, and also far above those of most other African countries [1,17]. ...
... Some time ago, it was estimated that health professionals leave South Africa at a rate of 25% per year [34] and that 37% of South Africa's medical practitioners and 7% of its nurses have migrated to other countries [44,48]. The reasons for this country-to-country migration hinge on the strength of various push/pull factors and stick/stay factors (material and non-material incentives/disincentives) within South Africa as a source country (and its health care sector) and in the recipient country (and its health care sector) [15][16][17]49]. ...
... Similarly, the two main forms of with in-country migration of health professionals, that is, rural to urban and public to private, are enduring problems in that these workforce flows constantly cause and aggravate existing imbalances and inequalities both in the distribution of HRH and also in access to care; they thus weaken both public and rural health services, while also negatively affecting the effectiveness of services [17]. This migration is generally explained in terms of the public health sector being fraught with push factors as over the strong pull factors that draw health professionals to an attractive private (both for profit and not for profit) health sector with its resource-rich environment, apparently better working conditions and career opportunities, attractive remuneration packages and reward/incentive schemes [15][16][17]44]. The trend is further fuelled by the as yet booming private hospital and health care industry, the expansion of the private hospital sector to countries abroad, the rise of private training institutions for nurses that supply nurses to the private sector, and the upsurge of private nurse agencies that contract nurses in the public sector for moonlighting, and, similarly, specialists for dual practice [17,50]. ...
The purpose of this contribution is to analyse and explain the South African HRH case, its historical evolution, and post-apartheid reform initiatives aimed at addressing deficiencies and shortfalls. HRH in South Africa not only mirrors the nature and diversity of challenges globally, but also the strategies pursued by countries to address these challenges. Although South Africa has strongly developed health professions, large numbers of professional and mid-level workers, and also well-established training institutions, it is experiencing serious workforce shortages and access constraints. This results from the unequal distribution of health workers between the well-resourced private sector over the poorly-resourced public sector, as well as from distributional disparities between urban and rural areas. During colonial and apartheid times, disparities were aggravated by policies of racial segregation and exclusion, remnants of which are today still visible in health-professional backlogs, unequal provincial HRH distribution, and differential access to health services for specific race and class groups.
Since 1994, South Africa’s transition to democracy deeply transformed the health system, health professions and HRH establishments. The introduction of free-health policies, the district health system and the prioritisation of PHC ensured more equal distribution of the workforce, as well as greater access to services for deprived groups. However, the HIV/AIDS epidemic brought about huge demands for care and massive patient loads in the public-sector. The emigration of health professionals to developed countries and to the private sector also undermines the strength and effectiveness of the public health sector. For the poor, access to care thus remains constrained and in perpetual shortfall.
The post-1994 government has introduced several HRH-specific strategies to recruit, distribute, motivate and retain health professionals to strengthen the public sector and to expand access and coverage. Of great significance among these is the NHI Plan that aims to bridge the structural divide and to redistribute material and human resources more equally. Its success largely hinges on HRH and the balanced deployment of the national workforce.
Low- and middle-income countries have much to learn from South African HRH experiences. In turn, South Africa has much to learn from other countries, as this case study shows.
... 3 In many parts of South Africa and Mexico, people have limited or no access to dental specialists. 9,10 There are 36 public and 3 non-governmental schools of dentistry in Iran. Resident training is offered in 10 specialized fields in 15 public and 2 non-governmental dentistry schools. ...
... 11 This unequal distribution is also a health system problem in some other countries. 3,[8][9][10] It appears that increasing the number of dental schools in Iran was not effective in solving this old problem. In Iran, the fields of endodontics, orthodontics, restorative dentistry, and dental prosthesis have the highest number of specialists, respectively, and maxillofacial surgeons are the least common dental specialists, while in Australia and the UK, orthodontics, maxillofacial surgery, and dental prosthesis have the highest percentage of dental specialties. ...
Background and aim
Dental specialists play an important role in dental care system. In some countries dental specialist comply with their workforce needs whereas in the developing countries it does not. It is necessary to plan for the training of professional human resources in accordance with the purpose of using specializations in health sector development programs. Although previous workforce reports of Iran’s dental human resources are available but there is no published document on the future prediction of this important sector. The aim of this study was to estimate the country's need for dental specialized human by 2025 and provides the possibility of proper planning of completion and distribution of specialized human workforce for senior managers.
Methods
This study employed an explanatory mixed method design at three stages. Supply analysis phase; collecting the status quo data and the process of changes in the admission and supply of specialized residents was done. Need assessment phase; the demand of the health system for specialized dental disciplines in both treatment and educational sectors in the country by 2025 was obtained. Gap analysis phase; the estimated supply and demand gap between specialized human resources was calculated by 2025, and the shortage or surplus was achieved.
Results
In the fields of orthodontics, pediatrics, maxillofacial surgery, prosthetics and restorative dentistry, we will still need 279, 292, 335, 216 and 229 specialists, respectively by 2025. In endodontics, periodontics and oral diseases, we will reach almost the desired situation. In oral pathology and radiology, we will have 87 and 59 specialists more than the defined standards, respectively.
Conclusion
Using the results of estimating required number of dental specialists by 2025, and considering the admission capacity of the country's universities, the national division of labor for the training of specialized dentists needed for the coming years can be done.
... South Africa also has the compounded problem of low nurse-and doctor-to-population ratios. 2,3 This means that many areas of the country not only have limited access to in-hospital medical care, but also that the current hospital system is overwhelmed. 2 These system limitations extend into the Emergency Department (ED). ...
... 2,3 This means that many areas of the country not only have limited access to in-hospital medical care, but also that the current hospital system is overwhelmed. 2 These system limitations extend into the Emergency Department (ED). Overcrowding, access and exit block have been linked to a range of adverse outcomes for both patients and staff. ...
Background: In South Africa, the national public health sector provides healthcare to the majority of the population, yet many hospitals are in a state of crisis. On-scene discharge or patient non-conveyance to hospital by Emergency Care Practitioners (ECP) may serve as a means for patients to access healthcare services while alleviating the burden on the hospitals. Aim: The aim of this study was to determine the number of patients being transported by ambulance to a public sector Emergency Department (ED) who could have potentially been managed and discharged on-scene by a South African pre-hospital ECP. Methods: This was a prospective, descriptive and quantitative study of patients brought to the ED by ambulance over a 72-hour weekend period. The medical care that was provided in the ED was compared to the existing ECP scope of practice. The patients’ disposition was also used as a surrogate to determine whether transportation to hospital was required. Results: A total of 118 patients were transported to the ED by ambulance, and 85 of these patients consented to participate in the study. Overall, 62.4% of these patients were ultimately discharged from the hospital (60.4% of discharged patients being trauma-related). Most of the treatment modalities prescribed for the discharged patients were within the ECP scope of practice. Conclusion: Pre-hospital on-scene discharge by ECPs may be a mechanism to alleviate hospital overcrowding in a failing public healthcare system. However, if an ambulance service condones the concept of on-scene discharge, they need to implement monitoring strategies to assess the subsequent outcomes for those patients discharged at the scene.
... In the South African context, the Econex work considered nurse, 28 general practitioner and specialist numbers separately, 17,29 while the CMSA work considered only specialists. 15 The national health workforce planning model was more comprehensive, covering 100 medical professions, including physicians, nurses, dental practitioners, allied health professions (such as occupational therapists and physiotherapists) and community health workers. 2 This was an appropriate approach given the multi-disciplinary team- based approach foreseen in the NHI Green 27 and White Papers. 4 ...
... All of the previous work done in South Africa falls into the first category of models. The aim of the 2008/09 project by the CMSA was to research the number of specialists and subspecialists within South Africa and to calculate whether these numbers are sufficient 27 by comparing South Africa's supply of specialists per 1 000 population with international benchmarks 15 (not taking cognisance of factors driving need or demand in South Africa). ...
The implementation of NHI amplifies the urgent need for coordinated, comprehensive health workforce planning in South Africa. Planning for and estimating the cost of adequate human resources for health (HRH) is of paramount importance to a well-functioning health system, and a central requirement for a strategic purchaser of health services tasked with matching healthcare needs with the supply of services.
National Health Insurance (NHI) is likely to alter health staffing requirements in South Africa as it strives to improve quality of and equitable access to health care. Increased health-seeking behaviour anticipated under NHI implies increased need for all cadres of healthcare workers, particularly specialists and general practitioners (GPs), who are currently drastically underrepresented in the public sector. The creation of the NHI Fund also provides the opportunity to do much-needed planning work on a more systematic and regular basis.
At present there is no ongoing process for HRH planning and no single, high-quality, integrated data source in South Africa to enable such planning. A review of the available data, together with the limitations of these data, is presented. There are no publicly available, audited and regularly updated statistics on the number and mix of health workers available and required for South Africa’s population.
This chapter considers both global best practice in health workforce planning and the South African context of critical shortages in order to recommend a way forward. The creation of a timely, accurate and integrated repository of human resources data is an essential first step. We recommend the creation of a multi-stakeholder structure tasked with the development of integrated plans that consider the health system as a whole, based on models that account for both supply-side dynamics and the need for services, and that explicitly model the interactions between cadres of healthcare workers.
... Research has demonstrated that South Africa has an extremely low number of dentists, as low as 0.13 per 1000 population ratio (Strachan et al., 2011). A survey conducted in 2009 placed the total best estimate of South African dentists working in the private sector to be only 3121 (Strachan et al., 2011). ...
... Research has demonstrated that South Africa has an extremely low number of dentists, as low as 0.13 per 1000 population ratio (Strachan et al., 2011). A survey conducted in 2009 placed the total best estimate of South African dentists working in the private sector to be only 3121 (Strachan et al., 2011). At the time of writing, an online database (Medpages, 2017) estimated the number of dentists in Pretoria to be 360. ...
Background:
The concept of single-use of endodontic files remains controversial in the published literature. The extent and attitudes concerning the single-use of endodontic hand files is currently unknown in many countries.
Aim:
The prevalence and perceptions regarding the single-use of endodontic files was investigated in this descriptive observational study.
Methods:
A questionnaire regarding the perceptions and usage protocols of endodontic files was developed. Twenty-seven South African dental practices were included in this study. Participation was voluntary.
Results:
None of the respondents reported single-use of endodontic hand files. Several decontamination methods were used by the respondents for reprocessing endodontic files.
Discussion:
Financial constraints were reported as the primary reason for the reuse of endodontic files. As no standardised method of reprocessing these instruments exists for South Africa, written guidelines on this subject should be developed.
... In SA, as in many other developing countries, health professionals often migrate to developed countries for financial security, education options for their children, health services, personal safety and other lifestyle factors 13 . Almost 25% of South African medical health-care workers have migrated over the past 10 years and this has placed a huge burden on the already limited health-care workforce 13,14 . Many dentists and DS who have migrated from SA may opt to continue being registered with the HPCSA and, as a result, the actual number of practicing oral health personnel could be much lower than the numbers currently reported. ...
... Dentists prefer working in the private sector as there are limited posts available in the public sector, the private sector is financially more lucrative, they have the freedom to be independent and offer a range of dental services and they have the flexibility to work according to their own time schedules 17 . Some of the reasons why medical personnel are not retained in the public sector include lack of finances, lack of employment opportunities, poor working environment and non-existent career prospects 14 . If the South African government wants to attract and retain dentists and DS in the public sector, they need to create more posts and try to address some of these issues. ...
Introduction:
It is essential to have regular audits of the number of oral health personnel so that planning, delivery of services and training can be addressed. There has not been such an audit in South Africa (SA) for more than 10 years.
Aim:
To determine the demographic profile of dentists and dental specialists (DS) between 2002 and 2015.
Methods:
A retrospective record-based study was used and all dentists and DS registered with the Health Professions Council of South Africa (HPCSA) from 2002 till 2015 were included. Demographic data, including gender, age, race, type of practice and geographical residence were recorded.
Results:
There were 6,125 dentists and 481 DS registered with the HPCSA in 2015. The younger dentists tended to be Black and Asian women while older dentists were mostly White males. The majority of DS with maxillo-facial surgeons (30%), orthodontists (30%) and prosthodontists (17%). The number of dentists increased at around 2% per annum and the majority of the dentists and DS resided in the most metropolitan provinces of SA. Over the 13-year period, the number of female dentists almost doubled and the number of Coloured, Black and Asian/Indian dentists and DS increased sharply.
Conclusion:
The population to dentist ratio was fairly low, with the majority of dentists and DS residing in the three metropolitan provinces of SA. There has been a relatively sharp increase in the number of Coloured, Black and female dentists, which could be a result of increased admission of previously disadvantaged students to dental schools.
... There is a shortage of qualified healthcare workers (HCWs) in South Africa (SA), [1,2] as well as a maldistribution between urban and rural areas. [3][4][5] Research has shown that health professionals of rural origin are more likely to live and work in rural areas than their urban colleagues. ...
Background. There is a shortage of qualified healthcare workers in South Africa (SA), as well as a maldistribution between urban and rural areas. Research has shown that health professionals of rural origin are more likely to live and work in rural areas than their urban colleagues. It has been recommended that student selection policies of higher education institutions should prioritise applicants from rural and remote areas to address the urban-rural maldistribution of graduates and to redress historical equity issues. However, university students in SA have high attrition and low graduation rates. The Umthombo Youth Development Foundation (UYDF) recruits and supports rural-origin health science students, who completed Grade 12 at a rural school, to address staff shortages in rural areas. Objectives. To report on the throughput rates (percentage of cohort who graduate) and time to completion (number of years taken to graduate) of eight cohorts of UYDF-supported rural-origin health science students. Methods. A total of 388 student records from the 2008 - 2015 cohorts, covering 17 different health science disciplines, were analysed, and throughput rates and time to completion for the different cohorts and health science disciplines were calculated. Throughput rates and time to completion were also calculated for 3-year, 4-year and 6-year qualifications. Results. Throughput for the 2008 - 2015 cohorts ranged between 82% (2010 cohort) and 100% (2009 cohort). For 3-year qualifications, five cohorts had 100% throughput and one cohort 50% throughput. For 4-year qualifications, throughput ranged from 75% (2010 cohort) to 100% (2009 cohort). For medical students (6-year qualification), throughput ranged from a low of 81% (2014 cohort) to 100% in two cohorts (2008 and 2009). More female students (n=29) were excluded than male students (n=14). With regard to time to completion, over the eight cohorts 68% of students completed in the minimum time, 23% needed 1 additional year, 6% an additional 2 years, 2% an additional 3 years, and 1% an additional 4 years. For 4-year qualifications, 58% of students completed in the minimum time, 28% needed 1 additional year, 9% needed 2 additional years, 4% needed 3 additional years, and 1% needed an additional 4 years. Of medical students, 76% completed in the minimum time, 19% needed 1 additional year, and 98% had completed after 2 additional years. Discussion. The UYDF students studying for 3-year and 4-year qualifications exceeded the national throughput rates in seven of eight cohorts. UYDF medical students exceeded the national statistics in four cohorts, had similar throughputs in two cohorts, and had lower throughputs than the national statistics in two cohorts. Overall, 91% of UYDF students across the eight cohorts completed in the minimum time plus 1 additional year, exceeding national statistics. Conclusion. The relatively high throughput rates compared with the national statistics highlight the academic ability of rural-origin health science students and provide hope that national shortages of healthcare workers may be addressed if there is an investment in such students..
... South Africa (SA) is a developing country with a high burden of oral health disease coupled with a severe shortage of healthcare professionals. 1 The SA healthcare system has two sectors: public and private. 2 Radiology services are primarily found in urban areas, with most radiologists in the private sector. 3 SA has 0.085 dentists per 1000 individuals. 4 In addition, only 10% of dentists are employed by the public sector, which treats 84% of the SA population. 2,5 The inequalities in oral healthcare access significantly burden the public sector to provide cost-effective, equitable, preventative and curative oral health services. ...
INTRODUCTION: South Africa is burdened by a high prevalence of dental pathology. It is common to encounter this dental pathology on computed tomography (CT) brain scans Aims and objectives: To determine the presence of dental pathology on CT brain scans performed in a tertiary hospital and to assess whether radiologists reported on the encountered pathology. The study aimed to raise awareness among radiologists on reporting dental pathology and highlight the impact this has on oral and general health. DESIGN: A retrospective observational study METHODS: Reports of CT brain scans performed between September 2019 and October 2019 were reviewed for dental findings. Two radiologists, Reader 1 and Reader 2, blinded to the reports' findings, reevaluated the corresponding CT images. Their findings were compared with the findings of the reports RESULTS: None of the 160 reports reviewed had dental findings. Reader 1 and Reader 2, respectively, reported dental pathology in 92% and 79% of the CT scans. The most common dental findings were dental caries (79% and 53%), followed by missing teeth (66% and 53%), periodontal disease (59% and 38%), periapical disease (54% and 29%), odontogenic sinusitis (19% and 3%), restorations (11% and 9%) and dental injuries (4% and 4% CONCLUSIONS: Radiologists do not report on dental pathology encountered on CT brain scans. Recognition of dental findings may alter patient management and reduce related morbidity and mortality
... 5 This inequitable distribution of healthcare workers poses a challenge to the health, including oral health of citizens as the majority (84%-90%) of the population rely on public oral health services, which have small numbers of health personnel. 8 According to Bhayat and Chikte, 2018, the ratio of dental practitioners to the population was 1:8817, 9 which is much lower than the recommended World Health Organization (WHO) dental personnel-patient ratio of one dental personnel for 1000 patients. 10 This low ratio of oral health professionals to the population may lead to limited access to basic oral health services. ...
Introduction
Dental therapists are mid-level oral healthcare providers introduced in 1977 to the South African health system to improve access to oral health services. There has, however, been anecdotal evidence of their unusually high rate of attrition that is cause for concern.
Aim and Objectives
This study aimed to determine the demographic profile and attrition rate among members of the South African Dental Therapy profession.
Methods
A retrospective time series review of records of all dental therapists who were previously registered and who are still registered with the Health Professions Council of South Africa (HPCSA) between 1977 and 2019 was conducted.
Results
A total of 1232 dental therapists were registered from 1977 to 2019. The majority (64%) were Africans. Most practicing dental therapists were based in KwaZulu-Natal (44%) and Gauteng (27%), which are the provinces where dental therapists are trained. The overall attrition rate between 1977 and 2019 was 40%, with a figure of 9% for the last 10 years of the study (2010 to 2019).
Conclusion
This study has provided the first evidence of the high attrition rate of dental therapists in South Africa. The high attrition warrants further investigation to address the loss of valuable human resources from an already overburdened and under-resourced public oral health sector.
... The shortage of health professionals-in particular medical doctors-is not being addressed adequately in South Africa [1,[4][5][6]. Prior to the COVID-19 pandemic, there were growing concerns in similar countries about the capacity, quality and productivity of the health workforce where the production of these medical doctors is costly, time-consuming and where curricula content has been informed historically [7][8][9][10]. The pandemic has exacerbated and accelerated the shortfall of frontline workers through multiple mechanisms, including the associated mortality rates, mental health impact and pressures to participate in task teams or assume managerial roles [11]. ...
The achievement of global and national health goals requires a health workforce that is sufficient and trained. Despite considerable steps in medical education, the teaching of management, health economics and research skills for medical doctors are often neglected in medical curricula. This study explored the opinions and experiences of medical doctors and academic educationalists on the inclusion of management, health economics and research in the medical curriculum. A qualitative study was undertaken at four medical schools in Southern Africa (February to April 2021). The study population was medical doctors and academic educationalists. Semi-structured interviews with purposively sampled participants were conducted. All interviews were recorded and professionally transcribed. Constructivist grounded theory guided the analysis with the use of ATLAS.ti version 9.1.7.0 software. In total, 21 academic educationalists and 28 medical doctors were interviewed. In the first theme We know, participants acknowledged the constraints of medical schools but were adamant that management needed to be taught intentionally and explicitly. The teaching and assessment of management and health economics was generally reported to be ad hoc and unstructured. There was a desire that graduates are able to use, but not necessarily do research. In comparison to management and research, support for the inclusion of health economics in the curriculum was insignificant. Under We hope, educationalists hoped that the formal clinical teaching will somehow instil values and best practices of management and that medical doctors would become health advocates. Most participants wished that research training could be optimised, especially in relation to the duration of allocated time; the timing in the curriculum and the learning outcomes. Despite acknowledgement that management and research are topics that need to be taught, educationalists appeared to rely on chance to teach and assess management in particular. These qualitative study findings will be used to develop a discrete choice experiment to inform optimal curricula design.
... 20,28 This reinforces the importance of quantitative and qualitative training of dentists and specialists trained to provide adequate dental services to ensure access to oral health services for the population. 6,26 In this study, no restored dental elements were found, either in the permanent or primary dentition, which could be a consequence of the limited availability and access to dental services. In the present study, the analysis of dental elements demonstrated that the maxillary and mandibular molars were the most affected by tooth decay, which was similar to the results of a study conducted in young people in the Kingdom of Lesotho, South Africa. ...
Purpose:
To analyse the epidemiological profile of dental caries in children aged 5 and 12 years in the city of Benguela, Angola.
Materials and methods:
This was an observational, analytical, cross-sectional study conducted in 2019 with 190 12-year-old schoolchildren and 240 5-year-old schoolchildren from the public education system in Benguela, Angola. The relationship between dental caries and dental characteristics, sociodemographic factors, access to dental services, oral hygiene practices, and eating habits was analysed. Dental condition was evaluated using the dmft and decayed, missing, and filled teeth (DMFT) indices.
Results:
It was found that 62.63% (n = 119) of 12-year-old students and 42.08% (n = 101) of 5-year-old students were free from dental caries. The average DMFT was 0.76 + 1.35 and dmft was 2.19 + 2.95. The majority of children (56.51%) had never been to the dentist, had no dental elements restored, and none of the students used dental floss. The proportion of students who consumed sweets every day was higher at 5 years of age (46.25%) than at 12 years of age (22.63%). There was a statistically significant association (P = 0.01) between the higher incidence of dental caries and peri-urban location among 5-year-old schoolchildren.
Conclusion:
This study showed that the prevalence of dental caries in the permanent dentition of schoolchildren in Benguela is very low; however, the situation is critical in the primary dentition, especially in the peri-urban area. The limited access to dental surgeons and lack of treatment for affected teeth highlight the need to implement and develop public policies to promote oral health.
... The provincial density of specialized MDs was 1.8 per 100,000 inhabitants. The study confirms that there is a general shortage of doctors, particularly specialists, in Limpopo [20], which correlates with earlier investigations stating there is a national shortage of doctors in SA [21,22]. In 2014, Ntuli and Ogunbanjo showed that Limpopo referral hospitals also lack midwives [23]. ...
Introduction:
as South Africa's maternal mortality ratio increased between 1990 and 2015, the country failed to reach the United Nations millennium development goal 5a. The maternal mortality ratio of Limpopo province is higher than the national average and previous studies report shortages of manpower and medical equipment in Limpopo province. The overall study aim was to elucidate views and experiences of medical doctors regarding maternal healthcare by identifying the challenges they experience and solutions they suggest.
Methods:
a qualitative interview-based study was performed with ten medical doctors as participants. Manifest content analysis was used to analyze the data.
Results:
the main findings were categorized as lack of material and human resources, feelings of experienced isolation and solution-focused expressions. The challenges identified included logistical issues, staffing issues, demographic characteristics of the patient population, poor interinstitutional communication and lack of support from the administration. The solutions included revision of resource allocation and improvement of the interinstitutional cooperation. For example, participants suggested that exchange programs between hospitals could be arranged, that the emergency medical service personnel could triage patients and that private practitioners could be contracted to work at public institutions.
Conclusion:
most identified challenges were related to a lack of resources. Based on their inside experience, the participants suggested several solutions. These firsthand accounts of the local medical doctors highlight the need for intervention and should be taken into account when it comes to improving the provincial healthcare and working toward achieving the healthcare-related sustainable development goals by 2030.
... Clinical associates are mid-level health professionals primarily intended to be employed in understaffed facilities in the public sector, thereby enabling government to achieve universal healthcare and allowing for the implementation of the National Health Insurance (NHI). 1 Clinical associates complete a Bachelor of Clinical Medical Practice (BCMP) degree, which is a three-year degree and is currently offered by three universities in South Africa: the Walter Sisulu University, the University of the Witwatersrand and the University of Pretoria (UP). The BCMP students spend the first semester primarily attending classes at a medical school, with regular patient contact. ...
Background:
A clinical associate (ClinA) is a mid-level health professional who may only practise under the supervision of a medical doctor. By extension, medical students need to be prepared for this responsibility. This study explored whether final-year medical students at one university were aware of this supervisory role, felt prepared and were knowledgeable about the ClinAs' scope of practice.
Methods:
A descriptive, cross-sectional study was conducted. The population included all final-year medical students who had completed their District Health and Community Obstetrics rotations (March to November 2017). After an end-of-rotation session, 151 students were given questionnaires to complete. A list of 20 treatments or procedures was extracted from the ClinAs' gazetted scope of practice for a 'knowledge test'. Data were analysed with Stata and Microsoft Excel. Ethical permission was granted.
Results:
The response rate was 77.4% (n/N = 117/151). The majority of participants (76.1%, n = 86) had worked with a qualified or student ClinA before and had a generally positive impression (81.4%; n = 70). Almost half (47.8%; n = 56) thought that the ClinAs' scope of work was similar to registered nurses rather than a doctor's (38.2%; n = 44). Most were unaware that they would be required to supervise ClinAs once qualified (65.8%; n = 77). On average, participants identified 12 out of 20 treatments or procedures that a ClinA could perform.
Conclusion:
Despite having worked with ClinAs, participants appeared largely unaware of their future legal obligation of supervision. Adequate clinical supervision is based on the knowledge of the scope of practice, which was variable. Formal training on the scope of the work of ClinAs is needed to prepare future doctors for their supervisory role. Medical schools have an obligation to adequately prepare their students in this regard as part of their transformative education with elements of interprofessional education.
... Access to high quality oral health care is of particular concern in low-income countries and resource-poor communities due to limited infrastructure and a shortage trained oral health providers serving the public sector. The South African health care system, for example, faces ongoing challenges with access to and utilization of care in the public sector, and high-quality oral health services are no exception [8][9][10][11]. Previous work by our group [12] and others [13] examined patient experiences accessing oral health care in township settings (resource-poor communities of low socioeconomic status) surrounding Cape Town; we found that common knowledge of care delivery among patients consisted almost entirely of tooth extractions, which dissuaded community members from seeking oral health care [12,13] Additionally, our study found that patients with oral health complaints may present late in disease progression to health centers that lack oral health services. Lack of patient knowledge of oral health care services, as well as lack of access to and availability of preventive care, contributed to this finding. ...
Introduction
The purpose of this study was to explore factors that impact patients’ ability to access high quality, expeditious oral health care by understanding medical professionals’ knowledge of oral health, the care they provide to patients presenting with oral health complaints, and their perceptions of potential interventions to improve oral health care delivery.
Methods
We conducted in depth qualitative interviews, which were analyzed using an inductive content analytical approach. The study was conducted in Gugulethu, a community located outside of Cape Town, South Africa. Local public sector health services provided free-of-charge are the main source of primary health and dental care for this population. Participants included the following medical providers: doctors, clinical nurse practitioners, professional nurses, and health promoters.
Results
Identified themes fell within the three broad subject areas: oral health knowledge, patient care, and potential interventions. Themes within oral health knowledge included (1) personal responsibility for hygiene, (2) routine oral health care, (3) lack of knowledge among medical professionals, (4) poverty, and (5) an oral-systemic connection. Participants cited both ‘clinical care knowledge’ and/or ‘uncertainty’ about patient care for oral health complaints. Participants independently suggested interventions in three broad areas: (1) education, (2) expanded provider roles, and (3) colocation of services.
Conclusions
Our findings suggest that a variety of interventions, ranging from high to low resource investment, may impact access to and utilization of oral health services and thereby result in improved patient care. Future studies should develop and evaluate the suggested interventions in a range of care settings.
... 25 These student responses also point to a disjunction between intentions and reality, and highlight the poor preparation of students for working life, with the 2009 statistics from the College of Medicine of South Africa and HPCSA indicating that 65% of doctors currently working in South Africa are practising as generalists (21 079 generalists vs. 10 229 specialists). 26 In the light of these statistics, it is of concern that 68% of students plan to specialise while medical schools should be preparing this proportion of graduates to work as generalists. These results also highlight the mismatch between student intentions and the human resource needs as documented in the HRH 2030 targets. ...
Background: While international experience suggests that well-trained primary care physicians improve the quality and cost effectiveness of health care, family medicine (FM) as the discipline of the specialist primary care physician appears to not be an attractive career for medical graduates in South Africa (SA). The aim of this study was to establish final-year medical students’ knowledge about FM and its relevance to the healthcare system, explore their perceptions of the discipline’s relevance, and identify their specialty preference.
Methods: This was a descriptive study conducted amongst final-year medical students at the University of KwaZulu-Natal (UKZN) in 2017 at the conclusion of their seven-week FM module. Data were collected using a self-administered questionnaire and results were analysed descriptively.
Results: The response rate of completed questionnaires was 80.2% (157/196). Students reported limited exposure to FM in their early undergraduate years and low levels of awareness about essential public health programmes. Students showed good awareness of the six roles of family physicians (FPs), but FM was only the sixth most popular choice for specialisation.
Conclusions: In general, students had favourable views concerning FM and its role in the future of healthcare delivery in SA, although their knowledge of essential health programmes was poor. The majority of students had limited interest in pursuing a career in FM. A key recommendation to address these issues is to introduce FM into the curriculum earlier, to cover the key roles of the FP, and provide teaching that highlights the relevance of FM to health system programmes.
... South Africa has been impacted by both outward migration of locally trained healthcare workers and increased workloads due to the country's HIV epidemic [11], which is one of the world's worst in terms of the number of people requiring care and treatment [12]. The country falls behind similarly developed countries in terms of the number of healthcare providers per capita [13,14]. In 2013, South Africa had 0.74 physicians per 1000 people; whereas Brazil had 1.85 and Mexico had 2.07 [14]. ...
Background:
Healthcare providers' skills and attitudes are both barriers and facilitators of contraceptive uptake. In South Africa, migration of healthcare workers and the demands of the HIV epidemic have also contributed to inequitable access to sexual and reproductive health (SRH) care. Yet, the country has committed to achieving universal access to SRH services. We explored healthcare provider's opinions and attitudes on provision of contraceptive services in public facilities, their personal use of methods, and their thoughts on the recent integration of new contraceptive methods in their facilities.
Methods:
We conducted a phenomenological, qualitative study in 2017 at an outpatient, public HIV treatment clinic and two primary healthcare clinics (PHCs) in Johannesburg, South Africa. We purposively selected providers who had worked at the facilities for at least six months and were seeing patients for HIV or SRH services. Trained study staff conducted semi-structured interviews. We conducted descriptive analyses for quantitative data, and used an iterative, thematic analysis approach for open-ended responses.
Results:
We interviewed 14 healthcare providers (HIV clinic - 5; PHCs - 9). One respondent was a man; all were nurses. All respondents reported having ever personally used a contraceptive method; half (7/14) were currently using a method. Responses on service provision were conflicting. Respondents felt that their clinics currently met the contraceptive needs of their female patients through on-site services or referrals. However, they noted that staff shortages, lack of training, and a limited contraceptive offering meant that women did not always get the counselling or method they wanted. Respondents noted that the 'best' contraceptive methods for women were those that fit with a woman's lifestyle and medical needs; however, providers also felt strongly that injectables were best for all women. Recent introduction of the implant at one PHC and injectable contraceptives at the HIV clinic was not overly challenging, though there were concerns about staffing and demand creation for the new methods.
Conclusions:
Respondents' conflicting responses revealed challenges with current service delivery, particularly contraceptive counselling. Addressing staff workloads and providing refresher training on contraception would contribute to increased contraceptive service capacity and quality in this setting.
... The pull factors in developed countries lay especially in the relatively stable work, economic, social and political environments that they have to offer, with opportunities for personal upward mobility and safe familial lifestyles. However implicit the ideological positions taken in each of the discourses cited above, their presentations are supported in the very clinical analyses by Strachan et al. (2011) titled as: More Doctors and Dentists are Needed in South Africa. Their statistics reveal that South Africa's doctor and dentist ratio per thousand people is generally lower than what is prescribed by the World Health Organisation (WHO). ...
... South Africa has a shortage of doctors [13,14], with a persistent ratio of less than one doctor per 1000 population between 1996 (0.59) and 2016 (0.8) [15]. This ratio compares favourably with the 2004 sub-Saharan average (0.214) but unfavourably with the Organisation for Economic Co-operation and Development (OECD) average (3.4), ranking SA as having the 16th worst doctor: patient ratio of 67 countries [16]. ...
Background:
Doctor emigration from low- and middle-income countries represents a financial loss and threatens the equitable delivery of healthcare. In response to government imperatives to produce more health professionals to meet the country's needs, South African medical schools increased their student intake and changed their selection criteria, but little is known about the impact of these changes. This paper reports on the retention and distribution of doctors who graduated from the University of the Witwatersrand, South Africa (SA), between 2007 and 2011.
Methods:
Data on 988 graduates were accessed from university databases. A cross-sectional descriptive email survey was used to gather information about graduates' demographics, work histories, and current work settings. Frequency and proportion counts and multiple logistic regressions of predictors of working in a rural area were conducted. Open-ended data were analysed using content analysis.
Results:
The survey response rate was 51.8%. Foreign nationals were excluded from the analysis because of restrictions on them working in SA. Of 497 South African respondents, 60% had completed their vocational training in underserved areas. At the time of the study, 89% (444) worked as doctors in SA, 6.8% (34) practised medicine outside the country, and 3.8% (19) no longer practised medicine. Eighty percent of the 444 doctors still in SA worked in the public sector. Only 33 respondents (6.6%) worked in rural areas, of which 20 (60.6%) were Black. Almost half (47.7%) of the 497 doctors still in SA were in specialist training appointments.
Conclusions:
Most of the graduates were still in the country, with an overwhelmingly urban and public sector bias to their distribution. Most doctors in the public sector were still in specialist training at the time of the study and may move to the private sector or leave the country. Black graduates, who were preferentially selected in this graduate cohort, constituted the majority of the doctors practising in rural areas. The study confirms the importance of selecting students with rural backgrounds to provide doctors for underserved areas. The study provides a baseline for future tracking studies to inform the training of doctors for underserved areas.
... In the South African context, the Econex work considered nurse, 28 general practitioner and specialist numbers separately, 17,29 while the CMSA work considered only specialists. 15 The national health workforce planning model was more comprehensive, covering 100 medical professions, including physicians, nurses, dental practitioners, allied health professions (such as occupational therapists and physiotherapists) and community health workers. 2 This was an appropriate approach given the multi-disciplinary teambased approach foreseen in the NHI Green 27 and White Papers. 4 These policy papers make it clear that the public PHC sector will remain a nurse-driven service, with doctors and specialists using hospitals as their base, but still doing outreach services. ...
The implementation of National Health Insurance (NHI) amplifies the urgent need
for coordinated, comprehensive health workforce planning in South Africa.
Planning for and estimating the cost of adequate human resources for health
(HRH) is of paramount importance to a well-functioning health system. Planning is
also a central requirement for a strategic purchaser of health services tasked with
matching healthcare needs with the supply of services.
The NHI is likely to alter health staffing requirements in South Africa as it strives
to improve quality of and equitable access to health care. Increased healthseeking
behaviour anticipated under NHI implies increased need for all cadres of
healthcare workers, particularly specialists and general practitioners (GPs), who are
underrepresented in the public sector. The creation of the NHI Fund also provides the
opportunity for much-needed HRH planning on a more systematic and regular basis.
At present there is no ongoing process for HRH planning and no single, high-quality,
integrated data source in South Africa to enable such planning. A review of the
available data, together with the limitations of these data, is presented. There are no
publicly available, audited and regularly updated statistics on the number and mix of
health workers available and required for South Africa’s population.
This chapter considers both global best practice in health workforce planning and the
South African context of critical shortages in order to recommend a way forward.
The creation of a timely, accurate and integrated repository of human resources data
is an essential first step. We recommend the creation of a multi-stakeholder structure
tasked with the development of integrated plans that consider the health system as
a whole, based on models that account for both supply-side dynamics and the need
for services, and that explicitly model the interactions between cadres of healthcare
workers.
... 25 These student responses also point to a disjunction between intentions and reality, and highlight the poor preparation of students for working life, with the 2009 statistics from the College of Medicine of South Africa and HPCSA indicating that 65% of doctors currently working in South Africa are practising as generalists (21 079 generalists vs. 10 229 specialists). 26 In the light of these statistics, it is of concern that 68% of students plan to specialise while medical schools should be preparing this proportion of graduates to work as generalists. These results also highlight the mismatch between student intentions and the human resource needs as documented in the HRH 2030 targets. ...
Background: While international experience suggests that well-trained primary care physicians improve the quality and cost effectiveness of health care, family medicine (FM) as the discipline of the specialist primary care physician appears to not be an attractive career for medical graduates in South Africa (SA). The aim of this study was to establish final-year medical students’ knowledge about FM and its relevance to the healthcare system, explore their perceptions of the discipline’s relevance, and identify their specialty preference.
Methods: This was a descriptive study conducted amongst final-year medical students at the University of KwaZulu-Natal (UKZN) in 2017 at the conclusion of their seven-week FM module. Data were collected using a self-administered questionnaire and results were analysed descriptively.
Results: The response rate of completed questionnaires was 80.2% (157/196). Students reported limited exposure to FM in their early undergraduate years and low levels of awareness about essential public health programmes. Students showed good awareness of the six roles of family physicians (FPs), but FM was only the sixth most popular choice for specialisation.
Conclusions: In general, students had favourable views concerning FM and its role in the future of healthcare delivery in SA, although their knowledge of essential health programmes was poor. The majority of students had limited interest in pursuing a career in FM. A key recommendation to address these issues is to introduce FM into the curriculum earlier, to cover the key roles of the FP, and provide teaching that highlights the relevance of FM to health system programmes.
... The stressful and 'inhumane' working conditions of SA junior physicians are widely reported [37], resulting in some 'exiting' public sector work [38]. Advocacy is being conducted to address difficult working conditions with policymakers [39]. ...
Background: South African physicians can specialise in public health through a four-year ‘registrar’ programme. Despite national health policies that seemingly value public health (PH) approaches, the Public Health Medicine (PHM) speciality is largely invisible in the health services. Nevertheless, many physicians enrol for specialist training.
Objectives: This study investigated physicians’ motivations for specialising in PHM, their intended career paths, perceptions of training, and perspectives about the future of the speciality.
Methods: Focus groups and in-depth interviews were conducted with specialists-in-training and newly qualified specialists, and thematic analysis of transcripts was performed.
Results: Motivations, often driven by difficult experiences as young physicians in poorly resourced clinical settings, stemmed from a commitment to improving communities’ health and desire to impact on perceived failing health systems. Rather than ‘exiting’ the South African health service, selecting PHM specialist training enacted participants’ ‘loyalty’ to population health. Participants anticipated carving out their own careers due to an absence of public sector career paths. They believed specialists’ contribution centred on providing ‘public health intelligence’ – finding and interpreting information; supporting services through management and leadership; and inputting into policymaking and planning.
Conclusions: Competencies of PHM specialists should be refined to inform and improve management of this scarce human resource for health. This is particularly important given the proposed major health reforms towards universal health coverage in South Africa presently. In addition, findings highlight the importance of physicians’ early work experiences where avenues for expressing ‘voice’, mediated by ‘loyalty’, could be utilised to improve public sector health systems.
... The literature generally attributes hypertension to be a risk factor in over 60% of stroke patients and as much as 86% among IC patients. 37,38 Access to Intermediate Care Close residential proximity to IC facilities and referral from a teaching hospital are 2 associations with admission described in literature 11,39 that were evident in the study findings. Most referrals (62%, n = 42) into IC in this study were from 2 nearby secondary and tertiary teaching hospitals situated in the same sub-district as the IC facility meaning there was relatively poor access for patients from other districts and sub-districts. ...
Background: A comprehensive primary healthcare (PHC) approach requires clear referral and continuity of care pathways. South Africa is a lower-middle income country (LMIC) that lacks data on the role of intermediate care (IC) services in the health system. This study described the model of service provision at one facility in Cape Town, including reason for admission, the mix of services and skills provided and needed, patient satisfaction, patient outcome and articulation with other services across the spectrum of care.
Methods: A multi-method design was used. Sixty-eight patients were recruited over one month in mid-2011 in a prospective cohort. Patient data were collected from clinical record review and an interviewer-administered questionnaire, administered shortly after admission to assess primary and secondary diagnosis, referring institution, knowledge of and previous use of home based care (HBC) services, reason for admission and demographics. A telephonic questionnaire at 9-weeks post-discharge recorded their vital status, use of HBC post-discharge and their satisfaction with care received. Staff members completed a self-administered questionnaire to describe demographics and skills. Cox regression was used to identify predictors of survival.
Results: Of the 68 participants, 38% and 24% were referred from a secondary and tertiary hospital, respectively. Stroke (35%) was the most common single reason for admission. The three most common reasons reported why care was better at the IC facility were staff attitude, the presence of physiotherapy and the wound care. Even though most patients reported admission to another health facility in the preceding year, only 13 patients (21%) had ever accessed HBC and only 25% (n=15) of discharged patients used HBC post-discharge. Of the 57 patients traced on follow-up, 21(37%) had died. The presence of a Care-plan was significantly associated with a 62% lower risk of death (hazard ratio: 0.38; CI 0.15–0.97). Notably, 46% of staff members reported performing roles that were outside their scope of practice and there was a mismatch between what staff reported doing and their actual tasks.
Conclusion: Clients understood this service as a caring environment primarily responsible for rehabilitation services. A Care-plan beyond admission could significantly reduce mortality. There was poor referral to and poor articulation with HBC services. IC services should be recognised as an integral part of the health system and should be accessible.
... Provision of dental services is unequal and there is a shortage of dentists working in the public setting; while more than 80% of the South African population (about 56 million) relies on public dental services, less than a quarter of dentists in the country work in the public sector. [5] In South Africa, poor access to care and low socio-economic status, among a variety of other determinants, contributes to oral disease such as dental caries. According to the National Children's Oral Health Survey, the Western Cape region has the population with the greatest need for dental care in South Africa (80% of children needed restorative care for treatment of caries) perhaps due to higher sugar intake in urban areas [6,7,8]. ...
Introduction
The purpose of this study is to understand engagement with and availability of dental services among people living with HIV in a low-income community of South Africa.
Methods
In depth qualitative interviewing was used to collect data, which was analyzed using an inductive content analytical approach. The study was conducted in Gugulethu, a township community located outside of Cape Town, South Africa. Local public sector health services provided free of charge are the main source of primary health and dental care for this population. Participants included South African adults (age 18–35) recently diagnosed with HIV who had a CD4 count >350 cells/mm³.
Results
Many participants had little to no experience with dental care, did not know which health care providers are appropriate to address oral health concerns, were not aware of available dental services, utilized home remedies to treat oral health problems, harbored many misperceptions of dental care, avoided dental services due to fear, and experienced poverty as a barrier to dental services.
Conclusions
Our findings suggest that integration of oral healthcare into medical care may increase patient knowledge about oral health and access to care. Leveraging the relatively robust HIV infrastructure to address oral disease may also be an effective approach to reaching these participants and those living in resource poor communities generally.
... In South Africa, 57% of health-care specialists are estimated to engage in private practice, which serves only 17% of the population. 7,10 Thus, the already disadvantaged 83% of the population who rely solely on public health care have access to disproportionately fewer health-care services. Oncology healthcare workers registered with the Health Professions Council of South Africa in 2014, distributed in both the public and private health-care system, are listed in the table. ...
... Another study conducted in South Africa [13] concluded that South Africa compares unfavorably with middle-income countries on the ratios of medical and dental professionals; many districts have limited access to specialists and subspecialists. The unacceptable ratio of doctors, dentists, and other health professionals per capita needs to be remedied, given South Africa's impressive reputation for its output of health professionals, including the areas of medical training, clinical practice, and clinical research. ...
To review uses of finance in dentistry. A search of 25 electronic databases and World Wide Web was conducted. Relevant journals were hand searched and further information was requested from authors. Inclusion criteria were a predefined hierarchy of evidence and objectives. Study validity was assessed with checklists. Two reviewers independently screened sources, extracted data, and assessed validity. Insurance has come of ages and has become the mainstay of payment in many developed countries. So much so that all the alternative forms of payment which originated as an alternative to fee for service now depend on insurance at one point or the other. Fee for service is still the major form of payment in many developing countries including India. It is preferred in many instances since the payment is made immediately.
Introduction:
South Africa has an inequitable distribution of health workers between the public and private sector, with rural areas being historically underserved. As rural background of health workers has been advocated as the strongest predictor of rural practice, the Umthombo Youth Development Foundation (UYDF) has invested in recruiting and training rural-origin health science students since 1999 as a way of addressing staff shortages at 15 district hospitals in northern KwaZulu-Natal Province, South Africa. UYDF's intervention is to support students to overcome their academic, social, and economic challenges and expose them annually to rural health practice. This study investigated the effects of various retention factors on the choice of where rural-origin UYDF graduates worked, namely in rural or urban, public or private settings.
Methods:
An online survey was developed containing questions relevant to the retention of health workers and included: personal satisfaction; hospital resources and employment factors; professional development and support; and community integration, as well as the reasons for working where they do. Of the 317 eligible health science graduates invited to participate, 139 (44%) responded. Descriptive statistics were compiled.
Results:
Forty-nine percent of graduates were working at a rural public healthcare facility (PHCF), followed by 34% at an urban PHCF, and 11% in the private sector. All the respondents, wherever they worked, reported positively on their work, management support, colleagues, and ability to practise their skills. Graduates working at rural PHCFs reported that patient care was sometimes compromised due to lack of equipment or medicines, with staff shortages being greater than at urban PHCFs. All the graduates reported that they had insufficient time to interact with peers regarding difficult cases, while those at rural PHCFs lacked access to senior staff or specialists compared to those working at urban PHCFs or urban private practice. Lack of professional development opportunities was reported by graduates at rural PHCFs as a reason they may leave, while those at urban PHCFs cited the intention to specialise. Graduates no longer working at a rural hospital reported that the lack of funded posts at rural PHCFs was the main reason (39%), followed by the desire to specialise (29.6%). Graduates working at rural PHCFs cited the 'ability to serve their community' and being 'close to family and friends' as the main reason for working where they do, whereas those working at urban PHCFs cited 'good work experience'.
Conclusion:
While nearly half of the rural-origin UYDF graduates surveyed continue to work in rural areas, this is considerably less than previously reported, indicating that rural-origin health workers are affected by retention factors. The lack of funded posts at rural PHCFs is a major barrier to the employment and retention of health workers, and to addressing the unequal distribution of health workers between urban and rural PHCFs. This requires commitment from government and other role players to increase the attraction and retention of health workers in rural areas. Focusing on the recruitment of rural students to become health workers, in the absence of adequate retention policies, is insufficient to adequately address shortages of staff at rural PHCFs, as rural-origin graduates will move from rural PHCFs to facilities where they can access these benefits.
The WHO Global Health Observatory Data Repository reports South Africa with 1.52 psychiatrists/100 000 of the population among other countries in Africa with 0.01 psychiatrists/100 000 (Chad, Burundi and Niger) to more than 30/100 000 for some countries in Europe. The overall situation, while being cognizant that mental health care is not only provided by specialist psychiatrists and that the current treatment gap may have to be addressed by strategies such as appropriate task sharing, suggests that there are actually too few psychiatrists to meet the country's mental health care needs. To address the need to develop a strategy to increase the local specialist training and examination capacity, a situational review of currently practicing psychiatrists was undertaken by the [BLINDED] and the [BLINDED], using the South African Society of Psychiatrists (SASOP) membership database. The number, distribution and attributes of practicing psychiatrists were compared with international figures on the ratio of psychiatrists/100 000 population. In April 2019 there were 850 qualified psychiatrists actively practicing in the country and based on the national population figure of 55.6 million people (2016 Census), the psychiatrists/100 000 ratio was 1.53. This indicates no improvement between 2016 to 2019. From the SASOP database, we determined that about 80% of psychiatrists are working in the private sector - a much higher proportion than is usually quoted. As the vast majority of psychiatrists are practicing in urban areas in two provinces, Gauteng (n=350) and Western Cape (n=292), the ratio of psychiatrists/100 000 in these areas is relatively higher, at 2.6 and 5.0 respectively. Whereas rural areas in South Africa are largely without specialist mental health expertise, at a rate of 0.03/100 000 population. This investigation provides a discipline-specific situational review of the attributes and distribution of the current workforce of specialists in the country.
This study aimed at assessing the causes and implications of brain drain and how it has affected South Africa’s socio-economic development with reference to the health and higher education sectors. The main research problem focused on what causes South Africans to migrate; the pull and push factors, and what has been the implications for South Africa’s socio-economic development.
The majority of the uninsured population in the Western Cape, estimated at about 4.5 million, is dependent on public dental clinics. Dental caries remains the most common chronic disease world-wide. Caries experience among 6-year-old children in the province increased from 82% to 84% in the period 2002 - 2015. Oral health programmes to promote good oral health at schools and clinics are very limited. A cross-sectional study investigated 128 dental clinics in the Western Cape to determine the availability of the basic oral health care package, which includes promotion of oral health, prevention of oral disease and basic oral health treatment. Less than a third (31.5%) offered the basic treatment package and slightly less than two thirds (65%) were offering only dental extractions. Despite clear policy guidelines, public dental care delivery in Western Cape is seen to be not adherent to the guidelines, norms and standards. There is an unavailability of dentists outside the main clinics and it appears there is a minimal focus on prevention of oral disease and promotion of good oral health. Dental caries must be recognized as an epidemic in the Western Cape, and basic oral health care should be made available.
The majority of the uninsured population in the Western Cape, estimated at about 4.5 million, are dependent on public dental clinics. Dental caries remains the most common chronic disease world-wide. Caries experience among 6-year-old children in the province increased from 82% to 84% in the period 2002 - 2015. Oral health programmes to promote good oral health at schools and clinics are very limited. A cross-sectional study investigated 128 dental clinics in the Western Cape to determine the availability of the basic oral health care package, which includes promotion of oral health, preventing oral disease and basic oral health treatment. Less than a third (31.5%) offered the basic treatment package and slightly less than two thirds (65%) were only offering dental extractions. Despite clear policy guidelines, public dental care delivery in Western Cape is seen to be not adherent to the guidelines, norms and standards. There is an unavailability of dentists outside the main clinics and it appears there is a minimal focus on oral disease prevention and promotion of good oral health. Dental caries must be recognized as an epidemic in the Western Cape, and basic oral health care should be made available.
This thesis is about promoting a sustainable National Health Insurance Scheme (NHIS) in Ghana through improved client-centred quality care and effective community engagement in quality care assessment.
The thesis comprises of two main parts. Part one reports on findings from baseline surveys conducted in 2012 among 324 health workers in 64 primary health facilities in the Greater Accra and Western regions of Ghana. Moreover, baseline household surveys were conducted in 1,903 households in the two regions. Baseline surveys explored health worker motivation levels and associations with healthcare quality efforts, efficiency in health service delivery, and comparison of perceived and technical quality healthcare. Part two of the thesis comprises of impact evaluation studies conducted in 2014, after implementing community engagement interventions in 2013. The interventions were designed to promote a more client-centred healthcare and insurance services. Positive impact of the interventions was observed on clinic staff motivation levels, perceptions on the NHIS, and efforts toward patient safety and risk reduction.
The thesis concludes that client and community engagement in healthcare quality improvement efforts could augment existing quality improvement strategies of the Ministry of Health and National Health Insurance Authority. This innovative approach will help increase trust in the NHIS and the healthcare system, needed to attain universal health coverage.
The report explores the role of dental public health specialists within the South African health system in curbing the increasing burden of oral diseases, most of which are preventable. Dental public health specialists globally play a vital role in addressing the oral health needs and well-being of the whole population through influencing policies and informing decisions thus improving the health of the public. The neglect of oral health in South Africa coupled with the curative and individually-focused management of oral diseases has led to exorbitant expenditure of public health funds due to the demand for care.
The expertise of these cadres of dental specialists places them in a suitable position to design, deliver and evaluate appropriate oral health interventions and preventive programmes to benefit the population as a whole. While there are 36 of these professionals registered with the Health Professions Council of South Africa, their skills seem to be largely under-utilized in the public health arena. The increasing prevalence of oral diseases and their unsuccessful management thus far necessitates for a critical review of alternative strategies for addressing oral health matters by exploring the role of these specialists and their effective utilization in the South African context.
INTRODUCTION: The University of Pretoria Oral Health Centre (UPOHC) is inundated by patients presenting with toothache, many requiring emergency pulpectomies (EPs). To date, the outcome of these procedures performed at this academic/public health facility, remains unknown. Aims and objectives: To determine the completion rate of treatment of teeth that had received EPs at the UPOHC. STUDY DESIGN: A retrospective survey of data obtained from electronic and paper records of 498 randomly selected teeth from the 1050 that had undergone EPs between 1 July 2012 and 30 June 2013 at the UPOHC, followed to 30 June 2014. METHODS: The outcome of treatment was recorded as "no treatment after initial pulpectomy", "pulpectomy repeated", "tooth was removed" or "root canal treatment (RCT) was completed by student or dentist". RESULTS: Of the 498 teeth included, 224 (44.98%) were obturated, 35 (7.03%) were retreated, forty two (8.43%) teeth were referred for extraction and 197 (39.56%) remained untreated. After 16.56 (SD 6.19) months, treatment remained incomplete in 46.58% (n=232) of cases CONCLUSIONS: The UPOHC lacked capacity to complete all RCTs that were started. A primary health care approach focussed on prevention combined with an integrated resource plan for oral health in the region is recommended.
Transnational physician migration has concerned states' health and migration policies for many years. Recent developments have increased attention to the outcomes of these flows in the global south, where physician emigration is undermining public health policies. Cuba's exporting of medical professionals presents an alternative dynamic, based upon both an ideology of humanitarian solidarity and a need to secure hard currency earnings. The benefits and challenges arising from a bilateral agreement between Cuba and South Africa to supply Cuban doctors to South Africa and training at the Latin American Medical School ( ELAM ) for South African medical students are addressed. The benefits of skills enhancement and professional development are noted, as well as the economic benefits for both the Cuban government and individual doctors, while concerns with the appropriateness of the medical training provided at ELAM for the South African health context and the sustainability of the current policy are discussed.
Policy Implications
Strategic bi‐lateral agreements offer a productive route towards more sustainable management of skilled migration.
When migration agreements include skills training, attention is needed to ensure the training provided is appropriate to the destination context: attention needs to be paid to the appropriateness of the medical training afforded to South African medical students in Cuba for health requirements in South Africa.
International migration agreements can form part of a broader policy suite aimed at realizing public health and other development priorities. However, attention must be paid to the suitability and sustainability of the outcomes of these practices.
Small numbers of graduates from few medical schools, and emigration of graduates to other countries, contribute to low physician presence in sub-Saharan Africa. The Sub-Saharan African Medical School Study examined the challenges, innovations, and emerging trends in medical education in the region. We identified 168 medical schools; of the 146 surveyed, 105 (72%) responded. Findings from the study showed that countries are prioritising medical education scale-up as part of health-system strengthening, and we identified many innovations in premedical preparation, team-based education, and creative use of scarce research support. The study also drew attention to ubiquitous faculty shortages in basic and clinical sciences, weak physical infrastructure, and little use of external accreditation. Patterns recorded include the growth of private medical schools, community-based education, and international partnerships, and the benefit of research for faculty development. Ten recommendations provide guidance for efforts to strengthen medical education in sub-Saharan Africa.