MINIMUM DATA SETS FOR HUMAN RESOURCES FOR HEALTH
CASE STUDY SOUTH AFRICAMINIMUM DATA SETS FOR HUMANRESOURCES FOR HEALTH AND THESURGICAL WORKFORCE INSOUTH AFRICA’SHEALTH SYSTEMA rapid analysis of stockand migration
AcknowledgementsThe authors of this report are Percy Mahlathi and Jabu Dlamini (African Institute of Health & LeadershipDevelopment).Comments on an earlier draft were provided by James Buchan (University of Technology, Sidney) andGiorgio Cometto (WHO).This document is an unedited draft, not to be referenced, published or disseminated without priorpermission of the African Institute for Health and Leadership Development and WHO.Funding for the development of this document was provided through the project “Brain Drain to Brain Gain - Supporting WHOCode of practice on International Recruitment of Health personnel for Better Management of Health Worker Migration”, co-fundedby the European Union (DCI-MIGR/2013/282-931) and Norad, and coordinated by WHO. The contents of this document are thesole responsibility of the African Institute for Health and Leadership Development, and can under no circumstances be regardedas reflecting the position of the European Union or WHO. African Institute for Health and Leadership Development, all rights reserved.September 2015
ContentsAbstract. 21. Background.31.1 Constitutional and organizational context of South African health system. 31.2 Health workforce context. 41.3 Migration of the health workforce. 52. Objectives and Methods.62.1 Study objectives. 62.2 Methods. 63. Results.63.1 Minimum data sets. 63.2 Stock inflows (production). 83.3 Stock in existence. 83.4 Surgical stock. 94. Discussion. 105. Conclusions. CEMIGRATIONWHAT THE STATE OF KERALA TELLS US ABOUT THE PRODUCTION, STOCK AANDMIGRATIONHEALTH1
AbstractBackground. The provision of health services is largely dependent on the sufficiency of the health workforce in termsof numbers, the quality of skills they possess, how and where they are deployed and how they are managed. Withincreasing urbanization, the issue of migration (in all forms) of health personnel has become a critical factor in thedebate about social justice in health, especially access and equity in the provision of health services. This case studyseeks to establish the existence of a system that is necessary if health authorities are to improve the management ofhealth workforce migration.Objectives. The objectives of the study were to determine the minimum data sets that are recorded by government,statutory health councils and professional associations in their management systems; determine the stock of healthprofessionals involved in surgical care; and establish the existence of data and systems to manage the emigration ofSouth African health professionals.Method. Data were collected from the National Ministry of Health, provincial departments of health, statutory healthcouncils (Health Professions Council of South Africa, South African Nursing Council and South African PharmacyCouncil) and the South African Society of Anaesthesiologists. The data sources that were utilized fell into the followingcategories: policies (health policies that relate to the health workforce); status report from a payroll system (specificfocus on the workforce); and statutory health council annual reports and responses to a survey questionnaire.Results. Data analysis revealed that the provincial departments of health do not collect information on employees ina uniform manner. There is no distinct national register of categories making up the surgical workforce. However, thescopes of practice that are developed by the statutory health councils dictate who can offer surgical care. Consequentlythe surgical workforce is mostly made up of medical specialties and medical officers. There is however no quantifiableinformation relating to numbers of medical officers offering surgical care at health facilities.Conclusion. The country needs to improve collaboration between stakeholders that have human resources for healthdata management systems; modify and strengthen the use of the current public service-wide human resources system(Vulindlela) to cater for health-specific human resources data; and strengthen its workforce planning capability byensuring the existence of an appropriate national health workforce information system. This should straddle bothpublic and private health sectors, including the statutory health councils. The National Ministry of Health andMinistry of Home Affairs need to improve their collaboration on the measurement and monitoring of emigrationby South African health professionals.Key words: emigration, immigration, minimum data sets, health professionals, South Africa2MINIMUM DATA SETS FOR HUMAN RESOURCES FOR HEALTH AND THE SURGICAL WORKFORCE IN SOUTH AFRICA’S HEALTH SYSTEM
MINIMUM DATA SETS FOR HUMAN RESOURCESFOR HEALTH AND THE SURGICAL WORKFORCE INSOUTH AFRICA’S HEALTH SYSTEMA rapid analysis of stock and migration1. Background1.1 Constitutional and organizationalcontext of South African health systemSouth Africa has an estimated population of 54 956 900(1), the majority of whom access health services throughgovernment-run public clinics and hospitals. The healthsystem comprises the public sector (run by the government) and the private sector. The public health servicesare divided into primary, secondary and tertiary throughhealth facilities that are located in and managed by theprovincial departments of health. The provincial departments are thus the direct employers of the health workforce while the National Ministry of Health is responsiblefor policy development and coordination.South Africa’s Constitution guarantees every citizen access to health services (section 27 of the Bill of Rights).However, everyone can access both public and privatehealth services, with access to private health servicesdepending on an individual’s ability to pay. The privatehealth sector provides health services through individual practitioners who run private surgeries or throughprivate hospitals, which tend to be located in urbanareas. The health care system consumed about 8.8% ofthe country’s gross domestic product during 2012 (2).The majority of patients access health services throughthe public sector District Health System, which is thepreferred government mechanism for health provisionwithin a primary health care approach. The privatesector serves 16% of the population while the public sector serves 84% (3). The country’s population distributionindicates that about 64.7% inhabit the provinces that arelargely rural in nature. Some of these provinces containlarge cities, though the bulk of the population lives inrural communities. Table 1 shows population estimatesand distribution by province.There is realization that the health workforce plays acritical role in advancing the health system goals, largelydriven by a policy position of improving access to healthTABLE 1. SOUTH AFRICA: POPULATION TOTALS ANDDISTRIBUTION BY PROVINCE (MIDYEAR 2015)ProvincePopulationestimate% of totalpopulationEastern Cape6 916 20012.6Free State2 817 9005.1Gauteng13 200 30024.0KwaZulu-Natal10 919 10019.9Limpopo5 726 80010.4Mpumalanga4 282 9007.8Northern Cape1 185 6002.2North West3 707 0006.7Western Cape6 200 10011.3Total54 956 900100.0Source: Statistics South Africa (1).A RAPID ANALYSIS OF STOCK AND MIGRATION3
FIGURE 1. ORGANIZATION OF THE SOUTH AFRICAN HEALTH SYSTEM1a. Macro-organization of the South Africanhealth systemPublic HealthSectorPrivate HealthSector1b. Organization of the South African public healthsectorNorthernCapeDepartmentof HealthWesternCapeDepartmentof HealthNational HealthSystemNorth WestDepartmentof HealthNationalMinistry ofHealthFree StateDepartmentof Health1.2 Health workforce contextThe mandate for health workforce policy lies with theNational Ministry of Health in cooperation with theDepartment of Higher Education and Training (foroutput of trained personnel) and Department of PublicService and Administration (for employment conditions). South Africa has a total of 23 universities andeight schools of health sciences; a ninth medical schoolis being established. In addition there are nine provincial nursing colleges and a number of private nursingschools. Collectively, the medical schools have an annualoutput of medical graduates ranging between 1200 and1300. This is viewed as grossly inadequate for a countrywith a population size of approximately 55 million. Theproduction of medical doctors is supplemented by thetraining of doctors in Cuba under a government-togovernment agreement.Once health science students graduate from universityor college, they are required by law to register with arelevant professional health council, namely the NursingCouncil in the case of nurses, the Pharmacy Council inthe case of pharmacists and one of the 12 professionalboards for those professions that are governed by theHealth Professions Council. These professional councilsare referred to as statutory health councils because they4KZNDepartmentof HealethMpumalangaDepartmentof HealthLimpopoDepartmentof Healthcare for all citizens (4). Figure 1 shows how the SouthAfrican health system is organized.ECDepartmentof HealthGuatengDepartmentof Healthwere set up by various acts of Parliament, for examplethe South African Nursing Act No. 33 of 2005, the SouthAfrican Pharmacy Act No. 53 of 1974 and the HealthProfessions Act No. 56 of 1974. These acts and associatedregulations get amended from time to time.Graduates in the health sciences are required by lawto perform community service before they can besanctioned for independent practice by the relevantprofessional council. This is in addition to the periodof internship for categories such as medical graduates.The professional councils are also responsible foraccrediting the academic programmes of traininginstitutions. In the case of the medical profession, anexamining body – the Colleges of Medicine of SouthAfrica – conducts specialist examinations. This is inaddition to the specialist examinations conducted byindividual universities.The employment of health professionals is either throughgovernment institutions or through self-employment inthe private sector. Some become employed by corporatebodies, for example medical insurance entities or miningcompanies. The management of the health workforce isguided by a number of policies that were adopted by thegovernment over a number of years following the 1995White Paper on Transformation of Health Services.Table 2 lists those policies and indicates their focus.MINIMUM DATA SETS FOR HUMAN RESOURCES FOR HEALTH AND THE SURGICAL WORKFORCE IN SOUTH AFRICA’S HEALTH SYSTEM
TABLE 2. HUMAN RESOURCES FOR HEALTH POLICIES AND THEIR FOCUSPolicyYearFocus / rationaleHuman Resource Strategy2001Proposals on the definitions, entry requirementsand scope of practice of all categories of health careprofessionalsScarce Skills Allowance2003Financial incentive to retain “scarce skills” in the publichealth servicePolicy on Remunerative Work outside PublicService2002An incentive scheme allowing doctors to work in theprivate sector while fully employed by the governmentHuman Resources for Health PlanningFramework2006Highlighting the need for systematic national healthworkforce planningPolicy on Remuneration of Health ProfessionalsWorking in Public Health Service2007System of differentiated pay for health professionalsemployed in public health facilities with the objectiveof recruiting and retaining professionals in the publichealth serviceNursing Strategy2008Focus on nursing as the backbone of health services byadvancing six key strategies for stabilization of nursingPolicy on Employment of Foreign HealthProfessionals in the Public Health Sector2008Principles and practices in the employment of healthprofessionals who are non-citizens aligned to theimmigration processes of the Department of HomeAffairsHuman Resources for Health Strategy SouthAfrica2011Focus on planning and staffing of health facilities inpreparation for the introduction of National HealthInsurance. The strategy builds on the foundation laid bythe 2001 Human Resource Strategy and the 2006 HumanResources for Health Planning Framework1.3 Migration of the health workforceThe migration of South African health professionals hasbeen a subject of discussion for a considerable periodof time. Many studies have been conducted and haveadvanced varying estimates of emigration by health professionals (5–7), and several causes of migration of healthprofessionals have been identified. Internal migration ofnurses within the South African health care sector andemigration to other countries are two major factors thathave contributed to the high turnover rate of South African professional nurses (8). Measuring the extent of emigration of South African health professionals remains achallenge. Many research studies have been based on incomplete data, as systematic data on international flowsof health workers from South Africa, and indeed fromthe whole of the African continent, have generally beenabsent, leading to untested hypotheses (9). As a result,some studies utilize destination country data systems toestimate the extent of emigration of health workers fromdeveloping countries (9).South Africa still does not have a systematized mechanismfor measuring and monitoring emigration of its healthprofessionals. However, it does have a mechanism formanaging the immigration of those who wish to work inthe South African health system. The country formalizedits policy on migration of health professionals in 2008through the adoption of the Policy on Employment ofForeign Health Professionals in the Public Health Sector.During the height of emigration of South African nurses,mostly to the United Kingdom in the late 1990s and early2000s, the South African Ministry of Health engaged withits counterpart in the United Kingdom to explore cooperation in the health field. This resulted in the developmentand adoption of a bilateral agreement between the twocountries – the Memorandum of Understanding on theReciprocal Educational Exchange of Healthcare ConceptsA RAPID ANALYSIS OF STOCK AND MIGRATION5
and Personnel (2003). While it did not seek to stop emigration by South African health professionals, its thrustwas to influence it. Due to the lack of a policy explicitlyaddressing the emigration of South African health professionals, no systems have yet been developed to monitortheir movement out of the country. Even internal movements appear not to be closely recorded, as evidenced bythe survey responses of provincial departments of health.Due to the difficulty of producing empirical evidence,some studies have resorted to making deductions basedon “intention to leave” of respondents (5).2. Objectives and methods2.1 Study objectivesThe objectives of the study were threefold:1.determine the minimum data sets that are recorded by government, statutory health councils andprofessional associations in their managementsystems;2.determine the stock of health professionalsinvolved in surgical care;3.establish the existence of data and systems tomanage the emigration of South African healthprofessionals.In addition, the study sought to identify what synergiesexisted between the workforce data systems of majorentities such as the provincial departments of health,which are the major employers within the health sector,and what data gaps needed to be filled.2.2 MethodsIn 2015 the study group contacted the nine provincial departments of health, the National Department of Health,the three statutory health councils and one umbrella professional organization for surgical societies. The nine provincial departments of health were included in the studyas they are the biggest direct employing entity of healthprofessionals for the government; that is, they constitutethe public health service employer. The statutory healthcouncils – the Health Professions Council of South Africa,the South African Nursing Council and the South African6Pharmacy Council – were included on the basis that theycarry a legislative mandate to maintain the registers of allhealth professionals in the country. The South AfricanSociety of Anaesthesiologists was included as it is an umbrella organization of specialists involved in surgical care.Each respondent was sent a questionnaire to complete and,based on the responses, telephone follow-up interviewswere conducted to obtain further explanations or to closeany gaps in the information supplied. The research datagathering process was guided by a protocol developed by theGlobal Health Workforce Alliance, which provided a list ofminimum data sets against which to match responses.3. Results3.1 Minimum data setsThe following data elements were included in theminimum data sets: full names, identity number, date ofbirth, citizenship, country of residence, language, address,contact information, qualifications, professional registration status, employment status, employment address,previous employer and number of years as a professional.Respondents were asked to add any other relevant field tothe above. There were small variations in what respondents provided for the minimum data sets but nothingadditional to the list provided in the research protocol andquestionnaire.The provincial departments of health utilize the governmentwide human resources data system – “Vulindlela”– to collect information on human resources for healthbut do not perform this task uniformly. Table 3 indicatesthe fields that are recorded by the provincial departmentsof health.Limited recording relates to a situation where only theprimary academic qualification that is a basic requirement for the post or job is recorded. That then excludesthe recording of any other academic qualificationsthat may have been obtained additional to the primaryqualification.The statutory health councils and the South African Society of Anaesthesiologists responded to the minimumdata sets section, as shown in Table 4.MINIMUM DATA SETS FOR HUMAN RESOURCES FOR HEALTH AND THE SURGICAL WORKFORCE IN SOUTH AFRICA’S HEALTH SYSTEM
TABLE 3. DATA FIELDS RECORDED BY PROVINCIAL DEPARTMENTS OF HEALTHData elementECFSGAKZNLPMPNCNWWCNDoHFull namesYesYesYesYesYesNRYesYesYesYesIdentification numberYesYesYesYesYesNRYesYesYesYesDate of sYesYesYesNRYesYesYesYesCountry of YesYesYesContact ionsYesYesYesLRYesNRYesYesYesYesProf. regis
South African health professionals. Method. Data were collected from the National Ministry of Health, provincial departments of health, statutory health councils (Health Professions Council of South Africa, South African Nursing Council and South African Pharmacy Council) and the
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