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HEALTH PORTFOLIO COMMITTEE
19 June 2007
HUMAN RESOURCES FOR HEALTH (HRH) PLAN & NURSING STRATEGY
Chairperson: Mr LV Ngculu (ANC)
Documents handed out:
Implementation of the Human Resources for Health (HRH) Plan presentation
Nursing Strategy for South Africa presentation
Audio recording of the Meeting
The Department discussed the work and dialogue taking place in the extensive implementation of the HRH Plan, which although not yet complete, was in the process of addressing issues ranging from immediate, medium term to long term. The shortage of nurses, the drop in the standards of nursing and the training of nurses were confronted, as well as the drain of health workers to developed countries for more lucrative remuneration and better working conditions. Creating a more attractive image of the nursing profession was imperative as was raising salaries, in order to not only train but retain the staff that formed the backbone of healthcare services.
Questions around the employment of foreign doctors and nurses were raised, as well as the time it was taking to address matters which had arisen over several years. A further follow-up presentation will be made, for the purposes of mapping out progress made in the implementation of the plan, as well as the medium to long term goals for addressing shortages in human and fiscal resources in health care services.
Human Resources for Health (HRH) Plan: Department of Health briefing
Prof Ronnie Green-Thompson, special advisor to the Health Minister, and Ms Carol Nuga-Deliwe (Human Resources: Policy Research and Planning) presented. The implementation of the HRH Plan was geared to strengthen education and training in the health sciences, facilitating the increased production of health professionals. The strategic framework was still subject to extensive consultations with relevant stakeholders. The Department was also in consultation with faculties and higher education institutions in facilitating health sciences academic and research development.
Implementation of the Plan was divided into three phases: HRH Production, which included addressing specialist training, the nursing strategy and development of mid-level worker policy. HRH Development would require harmonization of training needs and the development of hospital management and leadership. The Hospital Management programme was currently under review. The successful programme was being funded by France.
The policy regarding the recruitment of foreign health professionals involved the consolidation of various pieces of legislation, facilitating a more consistent approach. Remuneration was under review, especially those of nurses. Further implementation included development of provincial plans, the development of plans for various statutory councils and the development of HRH performance indicators. There was strong regional support and engagement with SADC, WHO Afro and the African Union Ministers of Health. The National Health Information System was integrated with the new HR Information System.
Finally, Ms Nuga-Deliwe raised the issue of norms, which were difficult to calculate, since context had to be a factor in order to make these norms relevant. Increasing student nurse intake was also being approached in the context of support, improving conditions for the completion of those studies.
Prof Green-Thompson said that the present state of healthcare services had to be informed by the fact that globally this field was suffering major shortages and that developed countries were not producing nearly enough of these professionals for their own needs. They were therefore poaching them from developing countries because they could offer better remuneration and working conditions. This had caused a significant drain on their health care professionals. Canada was losing these professionals to America. Agreements between countries could control this trend to some extent. The Department had a policy of not poaching health professionals from any sub-Saharan country. He said that a solution was to increase the number of tertiary institutions offering training in these fields. The need for an immediate remedy meant that they were recruiting doctors from Iran, Tunisia and for a while now from Cuba.
A separate bargaining council for health workers had been recommended. Nurses were set to earn up to 50% more in certain areas. These increases were to take effect from 1 July were it not for the recent developments, which would hold up implementation of increases. He said that health workers had to be recognised for their work and that the training of CEOs was essential. Furthermore the refurbishment of hospitals should continue with greater alacrity, which required more funding.
The Nursing Strategy for South Africa was a critical aspect of the implementation of the HRH Plan, since nursing was considered a tracer profession, which meant that the deficiencies being encountered in this profession were impacting on the entire standard of healthcare services being provided in South Africa. The strategy recognised the importance of this profession and the need to strengthen it, by aligning education and training, practice, resources, social positioning, regulation and leadership in support of the national health system. Each stakeholder would be involved in addressing issues that affected their core business.
Ms Nuga-Deliwe said it was crucial that good quality education and training was provided across the board. A nursing audit had been undertaken, highlighting major issues of concern with regard to infrastructure, curriculum, training and learning resources. The current dynamics in the Nursing Council was also symptomatic of the state of nursing at present and good leadership in nursing had to be restored. Fundamental issues which were being addressed were: Nursing in a changing health system, Nursing as a career choice, regulating nursing, educational qualifications, scopes of practice, managing the nursing workforce and international influences. Strategic focus areas included values in nursing which spoke to reinvigorating professionalism and values in nursing.
Prof Green-Thomson said it was essential to improve remuneration and retention of nurses. They did not have the financial resources to increase remuneration sufficiently and working conditions also needed improvement. In addition to these internal factors, there were extrinsic factors which had also affected health care services. A wellness programme had been launched by the Department in a bid to raise health awareness and to reduce the number of sick people. Social services would have to increase access to basic services such as fresh water and sanitation. Anti-smoking legislation might go some way towards increasing the awareness of the health risks of smoking. The country was also struggling with the illnesses of obesity and diabetes and more children than ever were suffering from Type II diabetes, as a result of obesity, bad eating habits and a general lack of exercise. These phenomena were placing considerable increased burden on the health care system. This did not even begin to take into consideration the impact of HIV and AIDS on the system. It was imperative that everything possible be done to reduce the disease burden in the country. Another disease they were struggling with was TB and some 34% of those cured were being re-infected because of compromising living conditions in places such as Khayelitsha. Reducing this burden was the responsibility of all and only an inter-sectoral approach could possibly address these needs.
Mr A Madella (ANC) said that currently the Public Services Bargaining Council included Health and Welfare. He did not understand why there was need for a separate bargaining council. He welcomed the implementation of preventative measures to reduce the burden of disease. Currently tertiary institutions were producing some 1200 doctors a year. He asked if this was enough to fulfil the needs of the country. He also questioned if there was enough infrastructure to meet public healthcare needs and whether technology at hospitals was sufficiently up to date. He said that in previous years there had been an oversupply of teachers and nurses. He agreed that an incentive needed to be created in order to encourage people to seek out these professions. He said in his constituency only one out of six high schools offered Maths up to matric.
Ms M Madumise (ANC) asked what the status of the programme launched in 2001 was, which had also sought to train and retain health workers. She asked if South Africa was also engaged in recruiting nurses from other countries. She asked how many students had applied for bursaries.
Mr G Morgan (DA) asked for elaboration of the statement that norms had to be placed in context. He said that unless the requirements were known, goals could not be set or achieved. He referred to the status of pharmacy technicians and said that, since there was a patent shortage of pharmacists, a new level of worker might be introduced that needed only minimum supervision. Only 20% of the 9000 pharmacists in the country were employed in the public sector.
Ms Nuga-Deliwe replied that they were very aware of the shortage of pharmacists in the country and that they had established a clear career path for technicians. The need was especially critical in rural areas, but also in urban areas, especially with regard to the ARV roll-out. Norms had to be viewed in context and looking simply at vacancies would not be sufficient to quantify supply and demand. Since the disease burden had changed considerably over the last few years, facility levels could not remain constant and norms could not be applied consistently since needs differed considerably between urban, peri-urban and rural communities. The National Health Resources Committee was looking at facilities that were well run and well equipped, in order to establish requirements. Essentially norms had to be established with the purpose of providing equitable health care to all and this often meant providing more in less favourable social-economic areas.
Prof Green-Thompson said that the pharmacy practice was being looked at similar to the process of trying to chisel nursing practice, separating non-nursing duties from those that have to be performed by a qualified nurse. The issue of determining norms could not be approached simplistically. Even the UK had not established their norms. Since there were not a sufficient number of pharmacists and doctors in the country they were in the process of trying to increase the numbers of people qualifying in these professions. They were engaged with the Minister, educational institutions, as well as the African Ministers of Health on this. He said he could not speak on behalf of other departments that were responsible for improving basic services.
Ms F Batyi (ID) asked why there were no more tertiary hospitals available in the Western Cape for the training of nurses. People could not afford to go to university. She asked what the requirements were for entering the course and whether nurses were still being paid a stipend.
Ms C Dudley (ACDP) asked about the policy for the recruitment of foreign health workers and on what basis countries were chosen for this recruitment. She asked what the blockages were to recruiting from sub-Saharan countries. She asked what the obstacles were in the labour law regarding the treatment of those nurses or staff that did not uphold a professional standard. She asked whether research opportunities were being provided in furthering the careers of researchers. What was being done to provide basic services, water sanitation and child protection in coordination with other departments and what marketing would the department be engaging in to inspire people to enter these careers.
Ms M Matsemela (ANC) asked what still needed to be done to implement the nursing strategy.
Ms R Mashigo (ANC) asked for more information about the hospital management training programme which was funded by France, but which was in the process of being evaluated. Did South Africa engage with other developing countries that had similar challenges?
Mr M Sibuyana (ANC) commented that nurses were leaving the country because of being overworked and underpaid.
Ms Nuga-Deliwe said there was a career guidance booklet available which provided information on subject requirements, although perhaps a booklet focusing specifically on health professions could be produced. She said they were looking at countries with similar profiles to find solutions. Job evaluation processes were looking at the best possible ways of attracting and retaining people. HR processes included performance management tools, which measured clinical outcomes and dealt with lack of performance within this system. The legislative framework was in place already. The challenge was to continually improve training and education, including the promotion of research. The existing Hospital Management Programme was of a high standard, but continued evaluation would ensure that it remained relevant. The nursing strategy would take up to ten years or longer to fully implement and that a meeting with the National Health Council (NHC) had been interrupted by the recent flow of events. However, pressing issues like remuneration had been reviewed already. The plan would be evaluated early 2008 for progress made since its launch last year.
Ms R Mdlalose (HR Stakeholder Relations and Management) replied they were far in the process of re-opening nursing hospitals, as highlighted as a priority by the President himself. The necessary audit had been done, infrastructure developments needs had been determined and they had doubled the intake of student nurses. Students required a matric pass, with English, especially Biology, and Natural Sciences preferably as subjects for entrance into the training. Nurses were still receiving a stipend. Some universities had converted these stipends into bursaries. She said they did not recruit nurses from other countries since their standards were still not as high as those in South Africa and many of them only qualified as staff nurses, which caused difficulties in registration. A hospital management programme had been initiated by France and was funded by them and the EU. It was based on a similar programme in France, where employment in the public health sector held much more prestige than here. The universities of the Witwatersrand and Kwa-Zulu Natal offered these courses, which were three year programmes. It had started in 2006 and they were targeting the 400 CEOs in the country.
Mr Morgan asked if the protocols for prescribing powers of nurses would be consolidated among the provinces, especially since there was such a need for these in the ARV roll-out and in pain relief. He said only a certain percentage of the population received palliative care. He suggested that the private sector be involved in relieving shortages in the public sector and that private pharmacies be used as points of delivery for medications.
Mr B Mashile (ANC) asked whether the five-year contracts that CEOs were employed under were long enough to gain from their experience and knowledge.
Ms Dudley suggested that the current policy on employment of health professionals from SADC countries could be regarded as an obstacle, whereas dealing with foreigners who were already in the country, might be solved by giving them short-term contracts.
Ms Mdlalose explained they were already engaging the private sector in hospitals and they especially used specialists in this regard. She said pharmacists were one of scarcest resources in the country. Mid-level health workers were being used to fill the gap wherever possible. The SADC policy on foreign professionals was stringent. South Africa did not want to create the impression that they were poaching as this could have a chain effect of attracting people into the country who were more desperately needed in their home countries. Employing these people would only place more pressure on health systems in neighbouring countries, which would then spill over into South Africa.
Prof Green-Thompson said the national social cluster was engaged in the question of provision of basic services, together with the Departments of Water Affairs and Forestry and the provincial government. He said we could not appeal to the likes of the UK and Canada in asking them not to employ our professionals if we were engaged in exactly the same act closer to home. He said New Zealand had many South African professionals and so also in America. It raised the question whether we were recruiting the right kind of people into the profession. People needed to identify with their communities and be willing to go back into those communities after qualification.
He said the hospital revitalization programme was addressing the issue of modernising technology and equipment. However, it had been estimated that this process could cost up to R1,5 billion, in order to fully upgrade all hospitals. He said assessments in this regard had to be discerning as not all upgrading of technology was always a necessity. He said the problem with pharmacies was that they were usually located in high density or built up areas, where there was not need and they were not usually found in rural areas. Clinics had largely taken over the tasks of dispensing medications, but unfortunately patients were still very doctor-centric and did not always trust nurses. Hospitals tended to have long cues of patients, who could usually be served just as efficiently at clinics. Patients needed to be made aware of the facilities provided by clinics. Certain areas, such as the Cape Flats, were in dire need of hospitals, in order to serve places like Khayelitsha, Langa and Mitchells Plain.
Ms Madumise asked whether foreign doctors were still required to complete an entrance examination and whether they had to be able to speak English.
Ms Mdlalose said that this was so and that candidates were only considered if they were fully fluent in English. The exam was not needed where bilateral agreements with other countries existed. She said CEOs were bonded.
Mr Ngculu asked whether the Nursing Bill of 2005 had been signed and where it fitted into the HRH Plan. He said that in view of immediate needs in the sector it was of some concern to him that the plan would take so long to roll out. He questioned whether it was not possible to address many of the issues of remuneration and vacancies sooner, especially with regard to rural allowances and scarce skills allowances. He said there still seemed to be a barrier preventing more blacks from becoming specialists. It seemed to him that this plan had been too long in the pipeline and the completion of it too far into the future to address immediate and urgent needs in the sector.
Prof Green-Thompson said that specifics on what had been achieved to date and what was being achieved in the foreseeable future could be presented to the members in order to gain clarification on this matter, He suggested that should be done as soon as possible. He said a separate bargaining council would add value to the process of improving nurses’ remuneration once the current situation had normalised. The comments regarding demographic were accepted, but that here other players would have to enter the process and perhaps more regulation would provide a solution. He said that allowances were non-pensionable and therefore did not provide sufficient incentive to professionals who were concerned about their income after retirement. Therefore these incentives were not viewed as viable long-term options. Additional funding was needed in this regard and in meeting other remunerative needs.
Mr Ngculu asked if members were amenable to having another meeting in addressing these issues in greater detail. Members agreed and the meeting was adjourned.
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