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HEALTH PORTFOLIO COMMITTEE
24 May 2005
HUMAN RESOURCES PLAN: DEPARTMENT BRIEFING
Documents handed out:
Department presentation on National Human Resources Health Plan
The Health Department briefed the Committee about the framework, guidelines and principles of a new policy to develop national healthcare human resources (HR). This proposed radical policy shift had not yet been approved by the Minister or the National Health Commission (NHC) or been subject to public input. The ensuing comments by Members became quite heated and raised issues such as doctors training in Cuba, admissions requirements for medical programmes, the exclusion of the Committee from conferences, and the omission of details in the report on human resources were raised.
Dr P Mahlathi, Department Deputy Director-General: Human Resources, reported on the need for a unified national plan that would be effective in the medium- to long-term. The Department had to integrate the needs of public, private and non-governmental organisation (NGO) healthcare providers with regards to all healthcare professionals, as there was no coherent national policy. This policy shift, which had yet to be approved by the Minister or the NHC, was based on the World Health Organisation (WHO) Human Resources Toolkit for Developing Countries, and could be used as a template by neighbouring countries, particularly those in the Southern African Development Community (SADC).
Education was a strong emphasis, with the focus on quality, skills mix, and geographical concentrations of health professionals, rather than strictly on numbers of healthcare workers trained. International trends in healthcare, particularly migration, were also considered. Other international trends discussed were the changing patterns of diseases, the importance of technology in health education and care, and some social, economic and political factors contributing to the difficulty of retaining professionals.
The guiding principles of the HR policy included better distribution of professionals, national self-sufficiency, the ‘up-skilling’ of workers, and improving their work environments. Expected areas of debate when the policy was opened to public comment, included new categories of health workers (such as community care providers); changing targets of training; internal and global migration; and healthcare education and training. They required integration of the new policy with existing policies; a clear approach to the development and management of professionals, and to deal with the expectations of the national and provincial government and the public.
Mr S Njikelana (ANC) warned that caution and a solid long-term policy plan were more important than haste. He was glad that the Committee had finally received an update. The Department needed to urgently release the document for public scrutiny by NGOs, civil service and individuals. The new policy should take into account changes in the healthcare system, including district health systems and the possibility of a single public service, as well as the general tendency towards an intersectoral approach between departments.
He asked that the Department consider the distinction between helping other nations and ‘commercialising’ professionals by ‘exporting’ skilled healthcare workers. He stressed the benefits of self-sufficiency and focussig on regional and continental capacity. Improvement of working environments would also include improving primary health nursing. Other concerns were the training and skills enrichment of managers, administrators and clinicians; the relationship between doctors and patients; and the role of mid-level and community healthworkers.
Mr Njikelana asked about the impact of foreign healthcare professionals in South Africa, particularly when they repatriated. He requested that the Committee receive copies of the WHO 2003 report.
Dr Mahlathi said the policy document would be released when the Ministry had approved it, with public debates to follow, particularly on health education. The policy would impact on district and primary healthcare as it outlined a plan for basic care for all. The governance of health institutions and co-operation between the public and private sectors should also be improved. The Deans of medical schools met once or twice a year with their counterparts in other countries, and the exchange of teachers would contribute to the developmental regional capacity-building approach envisioned in the new policy.
Commercialisation of ‘exported’ heathcare workers, though principally a human resources issue, was also a function of economics. South Africa produced high quality healthcare professionals and other countries hired them. The goal of the policy was to prevent the net loss of professionals by encouraging repatriation, allowing healthcare workers to re-enter the skills and experience hierarchy - rather than them starting again at the bottom as had been the case to date. Dr Mahlathi also cited the examples of India and the Philippines, which overproduced healthcare professionals ‘for export’, and noted the role remittances from healthcare workers abroad played in the national Gross Domestic Product (GDP).
Ms B Ngcobo (ANC) asked why recently grauated doctors left South Africa. Dr Mahlathi explained that there were no legal restriction on young doctors leaving the country as long as they had no bursary obligations after they had completed their two-year internship and one year of community service. Many who completed community service had enjoyed a very positive experience and ask to remain posted in that area. One successful mechanism for retaining doctors in rural areas of the Northern Cape and the Free State had been for hospitals to pay off young doctors’ debts in return for a three or four year commitment. As many recent graduates went oversees to pay off loans, they were happy to stay if these obligations were removed.
Dr R Rabinowitz (IFP) asked whether it would be advantageous to pay student nurses and about the impact of long shifts on nurses’ morale and family lives.
Dr Mahlathi said that stipends for student nurses were being considered, along with changes to the nurse’s curriculum. There had to be robust debate around these issues to ensure good training and quality of care. Nurse training was primarily conducted at the provincial level, where the bursary system was more common than stipends. Awaiting the public debates, the Department had not yet examined the ‘nitty-gritty’ details.
Ms D Kohler-Barnarrd (DA) enquired when the proposed policy would be released to the public, noting the already long delay. She also asked which students should be targetted for medical programmes. This past year, only black students had been accepted in Kwa-Zulu Natal universities. Some of these black students had all B and C grades for their subjects, while Indian students with six or seven A, and other coloured and white students were rejected. She noted the difficulty of the course and the high number of drop-outs after two years. She thought such admissions policies were "social engineering gone mad."
Dr Mahlathi couldn’t specify the precise date of the documents public release, as the proposed policy had to be approved by the Ministry of Health and the NHC, but it would preferably be by the end of June 2005. The revision of the standards for admission of medical students was intended to accelerate transformation of the profession and eliminate privileges based on good schooling. Although the competition for admittance was intense, it would be unfair to exclude those who had had no prior expose to science. Furthermore, students with poor matric scores could make excellent doctors who were likely to stay in the country, as a very successful medical college in the former Transkei had shown. The emphasis was on providing for the needs of the healthcare system while redressing past discrimination. The issue of support remained very important and would be discussed with the universities.
Ms Ngcobo asked about the mechanisms to work with other departments on a national strategy for rural development and service provision, and the possibility of lucrative job offers to attract doctors to rural areas.
Dr Mahlathi stated that the Department was working on intersectoral integration. He noted co-operation with the Department of Education in situating nurses’ training colleges and the merger of universities. The Ministry was also active within the Social Services cluster and was debating with various Directors-General. Regarding rural issues, rapid urbanisation in the past ten years had led to a strategy of poverty relief for rural areas. Each small town or village had a clinic and the Department had to utilise these better.
The Chairperson asked why the Committee was not invited to national and international health conferences. Dr Rabinowitz also commented that the Committee was left out of international conferences by the Department.
Dr Mahlathi replied that the Department organised very few conferences, but conferences organised by civil society should invite the Committee as well as the Department. Such invitations could be passed along by the Parliamentary Officer of the Department.
Dr Rabinowitz strongly asserted that the Committee wanted to be useful and deal with the ‘nitty-gritty’, rather than the ‘fluffy ideals’ with which they had been presented. Several years ago they had been told by universities that government support for ‘bridging programmes’ was crucial.
Dr Mahlathi responded that the process had actually moved very quickly. He reiterated the need for consultation with other departments now, in order to prevent having to constantly fix flaws later.
Dr Rabinowitz asked about the financial figures of government subsidy of training for doctors and nurses. It was unclear how many had received bursaries. The bursary system tended to be ‘nebulous’ and based on ‘power and pull’ rather than on credentials, leading to a lack of pride in the system. She further questioned the benefit of South Africa paying Cuba to train some of its doctors.
Dr Mahlathi responded that KwaZulu-Natal felt that the Cuban programme was beneficial, as their 19 Cuban-trained doctors were all as competent as South African-trained doctors. The cost should be considered separately from the issue of skills acquirement.
Dr Rabinowitz asked how much autonomy the district level heath systems would have. Their development was a priority and they were not up and running in KZN. Lower level innovations were important ‘pilots’ for national change implementation.
Dr Mahlathi responded that the district health system was the main provider of primary care, although it had not been easy to establish and still needed coherent national guidelines. The proposed policy had to both provide a framework for implementation as well as numerous options. Dr Mahlathi personally did not currently know the ‘nitty-gritty’ requested by Dr Rabinowitz.
Mr Njikelana strenuously objected to KZN medical admissions criteria being referred to as "social engineering gone mad." The universities could not admit students based simply on grades, as historical inequities and patriotism also needed to be taken into account. Most Admissions Departments were dealing with this issue in a transparent manner.
On the subject of Cuban doctors, Mr Njikelana stated that he was Deputy Chairperson of the Friends of Cuba Society. Cuba had a ‘culture of healthcare’ that changed the attitudes of students who studied there. He also re-emphasised the role of primary healthcare and asked about the inclusion of complementary or other forms of health practices in the HR framework.
Ms Kohler-Barnard took exception to Mr Njikelana’s statement that patriotism should be a determining criterion for admission to medical school. If this were the case, how would patriotism be measured? This criterion was ‘crazy’ - were Indian, coloured and white South Africans in KZN considered less patriotic than black applicants?
Ms M Manana (ANC) felt this political topic should be discussed privately. Ms Kohler-Barnarrd countered that the issue should be discussed publicly due to the presence of the press and the implications for student admissions.
Mr Njikelana agreed that the issue should be sorted out during this meeting. The use of patriotism as an admission criterion was a personal position rather than policy. Ms Kohler-Barnard stated that there would be many questions on this topic later.
The meeting was adjourned.
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