Research Report Establishing the Professional & Personal

Research Report

Establishing the Professional & Personal Needs of Community Service Doctors & Other Healthcare Professionals in South Africa.

Helen Strong - BSc (Natal) | Dip M Research & Advertising (UNISA) | MBA (Wits) +27 82 785 0256 | +27 11 268 6978 | [email protected]

Prepared for Dr G Wolvaardt; and Dr E Castleman. Foundation for Professional Development Castlewalk Office Park Erasmuskloof Extn 3 Pretoria

February

2008

i

acknowledgements

Foundation for

Professional Development

This research was made possible by the generous support of the American people through the United States Agency for International Development (USAID) and the Presidents Emergency Plan. The contents are the responsibility of FPD and do necessarily reflect the views of USAID or the United States Government.

This survey has also enjoyed the input and support of many generous people.

First and foremost thanks to all the Community Service Healthcare Professionals who took valuable time out of their busy schedules to complete the Survey. Their participation however would not have been possible without the tremendous assistance given to the study by their Clinical Superintendents, Medical and Hospital Managers in the distribution and return of questionnaires. Your concern and input was most appreciated!

Grateful thanks are extended to Ms P Zulu & Mr H Groenewald of the Directorate: Workforce Management, National Department of Health for their sound advice and helpful support in planning and implementation of this study.

The survey would also not have been possible without the help of the many Provincial Coordinators who cheerfully assisted with the distribution of the questionnaire in their areas. Particular thanks for the enthusiastic input from Mr Lourens van der Merwe and the Pharmaceutical Society for their steps taken to place a copy of the questionnaire on their web site and in encouraging their sector to respond. In this area, a special word of thanks to the Medical Doctors’ Provincial Coordinators who in the later stages of the fieldwork helped the author to make contact with their charges.

Finally I am indebted to Dr Elmie Castleman for her useful guidance and input as and when required; to Ms Monica Coetzee who worked against the clock to complete the analysis and provide her statistical insights, before departing for her own adventure; and to Prof Steve Reid whose research and involvement provided the foundation for this study.

Helen Strong January 2008

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contents

1. Acronyms 1

2. Executive Summary 2

3. Recommendations 3.1. Management 3.2. Work Environment 3.3. Emigration / Staffing Levels

8

4. Background 10

5. Prior Research 12

6. Research Aims & Objectives 6.1. Longitudinal 6.2. Recruitment & Placement Initiatives

14

7. Methodology 7.1. Sample Selection & Size vs. Return 7.2. Sample Demographics

15

8. Data Collection 18

9. Data Analysis 9.1. Editing & Coding 9.2. Statistical Evaluation 9.3. Presentation of Results

20

10. Community Service Environment 10.1. Level of Workplace Facilities 10.2. Community Service Allocation Process 10.3. Internship Facility 10.4. Financial Assistance 10.5. Community Service Experience

10.5.1. Overall Summary of Measured Factors 10.5.2. Satisfaction Clusters 10.5.3. Preparation & Growth 10.5.4. Supervision 10.5.5. Psychological and Attitudinal Factors 10.5.6. Overtime 10.5.7. Accommodation 10.5.8. Personal Safety Risk 10.5.9. Management Concerns

21

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11. Public Sector Motivators 42

12. Rural Intentions (Q28) 46

13. “Next Year” Work Intentions 13.1. Motivating Factors 13.2. Working Abroad 13.3. Same Institution

50

14. Professional Development Issues 14.1. Post-Graduate Studies During the CS Year 14.2. Intention to Study Further

14.2.1. Training Content & Timing 14.2.2. Intended Provider

58

15. Attitude to Career Environment 64

16. Emigration Issues 16.1. Environment Factors: Importance & Status 16.2. Drivers to Stay 16.3. Push / Pull Factors

16.3.1. Factors Disliked (Q34) 16.3.2. Attitude to Emigration 16.3.3. Top Factors 16.3.4. Stop Factors 16.3.5. Message to Colleagues Abroad

66

17. Conclusions 78

18. Appendices A: Questionnaire B: Covering Letter C: Sample Universe by Province D: Research Ethics and Team E: Statistical Analysis F: More Detailed Description G: Literature Review H: References I: Agencies and Organisations

80

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1.acronyms

CHC Community Health Centre

CS Community Service

CPD Continuing Professional Development

CSO / Cosmo Community Service Officer

DOH Department of Health

JUDASA Junior Doctors Association of South Africa

SAFP S A Family Practice

IDASA Institute for Democracy in South Africa

ILO International Labour Office

NEPAD New Partnership for African Development

NGO Non Governmental Organisations

ORSTOM French Institute of Scientific Research for Development and Cooperation

PMBs Prescribed Minimum Benefits

RWOPS Remuneration for Working Outside the Public Sector

SAMA South African Medical Association

S A MJ South African Medical Journal

SAMP Southern African Migration Project

SANSA South African network of Skills Abroad

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2. executive summary

2.1 Study Purpose and Methodology

This research is intended to provide comparative information for community service studies last conducted in 2003, and to identify the key forces in the emigration decisions of South African Healthcare professionals. The Universe of 3212 community service healthcare professionals formed the target respondents. Questionnaires were distributed in the first instance via personal delivery by Dept. of Health Provincial Co-ordinators. Where it was found that hospitals had not received copies then the covering letter and questionnaire were then either faxed or emailed to hospital managers for distribution. Ultimately it was also necessary to send copies of the questionnaire directly to individuals for response. Respondents had the option of remaining anonymous and of returning the questionnaire via the privacy of a sealed envelope, or to a private fax number, in order for ethical concerns to be addressed in the design of the study. The level of response was inhibited by the relatively slow distribution of questionnaires in some areas of the country and by the inefficiency of the free-post system. Some letters which were said to have been posted never reached the researcher and others took between 6 and 12 weeks to arrive back. The final return rate was 19% for medical professionals, with an overall response of 15%. This level of sample (491) has allowed a valid statistical analysis of difference between Doctors, Pharmacists and Allied Professionals; and examination of the overall results in 6 of the provinces.

2.2 Results

2.2.1 Satisfaction Clusters / Key Factors

• The study identified 3 clusters based on a statistical analysis of the responses to the community service experience questions. It is shown throughout the discussion that the cluster position of the individual is key in determining the attitudes and future actions of those individuals. Significantly:

• Least satisfied individuals are more likely to leave the country • Most satisfied are more likely to work in public service and rural areas

• When individual factors within the working environment are considered then “Managements’ ability”, “Professional behaviour” and “Availability of equipment” are the main significant determinants of respondents’ intention to leave.

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2.2.2 Community Service

2.2.2.1 Allocation

• The current allocation process resulted in the greater proportion of respondents (54.9%) receiving their first choice. It did, however appear flawed, in that significant differences were evident in the patterns of allocations of Allied Healthcare Professionals by provinces. Throughout the process fewer allocations were finalised for the Free State Province, prejudicing the chance of receiving people who really wanted to work within the province.

• Although respondents did not verbalise their attitude to the allocation process, we see that choice level was significantly related to overall level of satisfaction (61.5% of most satisfied cluster were in first choice facility)

2.2.2.2 Working Experience

• Province Significant differences occur by Province in the satisfaction levels (and therefore the working experience) of respondents. KwaZulu-Natal tops the provincial rating, with Mpumalanga and Free State at the other end of the scale.

• Preparation

• Tertiary education: was acknowledged as good preparation by 74.2% • Orientation: Still leaves a lot to be desired with only 56.2% agreeing that they were well oriented.

Agreement with this factor is positively related to high satisfaction levels within all professional groups.

• Support

• Good supervision is an important component in building a positive experience for community service personnel. As in prior research, this study has found that experiences are mixed. Overall levels are still not acceptable with only 39.1% agreeing that they had had a good level of supervision. Significantly:

• Negatively related to rural allowance (i.e. people working in rural areas did not agree that they received good supervision)

• Best rated in Western Cape • Best experienced by Allied professionals

• Availability of seniors has been shown to play a key role in changing the CS professionals’ attitude. In this survey seniors were significantly less available to doctors and more available for the Allied professionals.

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• Working Conditions

• On a spontaneous level the least liked factors are

• Work overload (hours / number of patients) • Lack of resources (working environment) • Poor Salaries • Feeling undervalued

• Differences coming through on the pre-determined factors were:

• Overtime: Doctors work significantly more overtime than the other professions. • Accommodation: Availability continues to be a problem with 17.5% of respondents indicating

that they did not have access to departmental accommodation. Significant differences exist in the pattern of satisfaction with accommodation by professional group, with pharmacists being the most indifferent (57.5% neutral). Condition of the premises (especially availability of running water and hygienic issues); and unsatisfactory sharing were the distinguishing factors for people rating their accommodation negatively.

• Personal safety: The results of the survey allow us to distinguish between “Safety in general” (as mentioned in Q34 and Q36) and “Safety within the work facility” (Q31). Safety in the workplace relates to having to deal with aggressive / drunk patients alone on night duty; treating mentally disturbed patients without adequate assistance; and walking back to residences in unlit / remote locations. For doctors “Safety in the workplace” is shown to be a significant determinant of their position in the satisfaction clusters, which in turn determines their attitudes and actions relative to public service / emigration. • Management: Only 24% of the respondents indicated that they were happy with the way in

which management handled their concerns. This factor is significantly associated with the CS satisfaction clusters and in its own right as a push factor for leaving public service or the country. 84% of the “reasons for dissatisfaction” lay in the attitudes and unavailability and/or unwillingness of management to address problems. As a result of this type of attitude, issues took too long to resolve, or in fact remained unsettled.

2.2.2.3 Attitudes

• The sense that one had “made a difference” was high (73%) and a defining factor in whether the professional had changed their attitude towards community service during the year

• Compared with prior research, changes were apparent in the “next year” working intentions, with more than half the respondents (56%) intending to spend at least some time in public service. However, the responses also indicate that there remains a critical shortage of staff which is contributing to the high stress levels within the facilities

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• Results indicated that:

• Respondents indicated that they had coped well during the year (60%) • Majority (59%) had ended with a positive attitude (significantly higher for Allied professionals) • The community service experience can affect long term plans either towards leaving, or staying.

Both the least and most satisfied indicating that they have had a change of plan during the year.

2.2.3 Workplace Imperatives

2.2.3.1 Next Year

• Family, career, and work experience emerge as equally strong forces in influencing the respondents’ “next year decision. (All around 30%)

• Quest for a “better salary”, “dissatisfaction with working conditions” and “management issues” are the major “drivers” out of public service.

• 17% of the sample indicates an intention to work abroad. Of these

• 46% had taken their decision in their CS year • 76% had organised their trip via a recruitment agency, but 19% was via the influence of “Friends” • UK, Canada, Australia and Ireland were the main destinations for the respondents (last three were

doctors main destinations) • Vast majority intended taking short trips.

2.2.4 Continuing Professional Development

• Study: Few respondents engaged in further studies during their community service year (only 20% yes). However, a significant number of the respondents intending to remain in public service expressed their intention to partake of further studies in the future

• Doctor’s who had not studied during the year fell (significantly) in the “least satisfied” and “medium satisfaction” clusters (80.4% and 82.5 vs. profile of 72.9%)

• Time and senior support were the main suggestions that would improve the ability of healthcare professionals to participate in CPD activities

• Access to study was mentioned as an inhibiting factor by 25% of Doctors and Allieds.

2.2.4.1 Rural Intentions

• 21% of respondents indicate a positive intention to work in rural areas in future, with 47% saying they would not

• It is not indiscriminate rural, but particular locations that 65% of “rural positive” people had in mind. Destinations included a variety of named towns or facilities where respondents had family ties or had enjoyed their working experience.

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• Key discriminators for “rural positive” respondents

• Interested / had identified projects for rural (healthcare) development (28%) • Saw opportunities for their own professional experience (25%)

• Key discriminators for “rural negative” respondents

• 62% of this group mentioned positive plans for alternative locations • The doctors’ position in the “least satisfied” cluster group was significantly related to a negative

intention to work in a rural area (i.e. CS experience influenced the decision) • Significant mention by Allieds that “More scope and professional challenges” exist in a non-rural

environment. This group of professionals point to a lack of available positions for their services in rural areas.

2.2.4.2 Emigration

2.2.4.2.1 Intention to Leave

• There are indications that the mass exodus of healthcare professionals has slowed down, compared with the atmosphere and trends evident at the turn of the century with only 17% of respondents expressing an immediate intention to leave

• Satisfaction with the overall CS experience is significantly related to emigration plans, and

• It is likely this goes down to an individual facility level since “intention to remain in CS facility” is also significantly related to plans for leaving

• Male respondents were more likely to have definite plans in place to go

• Doctors who are leaving for “Short Periods” are more likely to return to rural settings.

2.2.4.2.2 Push Factors

• At a conscious level push factors include:

• First mentions: Salary (36%), Crime (12%), General safety (7%), Experience (7%), Working conditions (6%)

• Total mention: Salary (73%) Experience (30%), Working conditions (27%), Travel (24%) and Career (23%) (mainly job opportunities)

• Using the “Importance” and “Status” ratings (Q37 & Q38) all the following factors are significant in emigration behaviour:

• Doctors

• “Management’s ability”, “Professional behaviour”, “Promotion prospects”: are all Important and have a low Status rating

• Status of “Being valued” and “Availability of equipment”

• Pharmacists:

• The status of “Management’s ability”, “Availability of equipment”, “Career path” and “Leadership”

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• Allieds:

• Importance of “Professional Behaviour”, “Promotion prospects”, “Being Valued” and “Availability of equipment”

• Status of “Working conditions”

2.2.4.2.3 Stop Factors

• On a spontaneous and first mention basis the factors of “Family”, “Salary”, “Better working environment”, “Career opportunities”, and “Safer / No crime” are the top factors

• On an all mention basis the impact of “Salary” jumps into prominence, with no other issue rising to the fore, and as such becomes a critical issue to be addressed

• It is obvious that respondents do not realise the reality of the relationship between “improving managements’ ability” and an overall improvement in systems and the working environment since management issues are only mentioned at a lower level.

2.2.4.2.4 Recall Appeals

When respondents were asked what they would say to their colleagues abroad to “bring them back”:

• Just over a quarter of respondents did not answer this question, and a further quarter indicated they would not enter into such an appeal.

• The top four appeals were based on “Gaining experience” (10%), “Being rewarding” (10%, but Allieds 20.3%), the “Extreme need” (9%) and “Professional obligation” (8%) to return and provide their countrymen with services.

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3. recommendations

Based on the outcomes of this survey there are a number of logical recommendations for actions which would improve the community service experience and the public service working environment. If the identified problems were addressed, it would also have the effect of reducing the negative factors giving rise to some healthcare professionals’ intentions to work in the private sector or emigrate.

3.1 Management

Management issues and availability of seniors are both shown to play an important role in staff attrition. It is therefore recommended that:

• Turnover statistics be compiled by individual facilities to identify problem facilities

• Attention should then be given to both the “people skills” and “technical skills” of hospital and clinical managers

3.2 Work Environment

All efforts should be made to address the factors shown to be key in leaving decisions. These include:

• Reduction in workload via

• Increase in staffing levels (salary adjustments at all professional levels would need to be significantly reviewed)

• Operating system review (This is necessary since a major source of frustration was identified as delays and inefficiencies in both managerial decision making and clinical referral systems.)

• Increase capacity of support staff via a skills audit and upgrade (Noting that “incompetent staff” would be a contributing factor to system inefficiency, and it is also directly mentioned (Q34) by 12.4% of respondents as a factor in the decision to leave the country.)

• Improvement of available resources (at 26.3% the top overall mention of factors disliked in Q34). This could be achieved via

• Improved supply chain management • Audit and review of the age and maintenance costs of equipment

• HR System Review (HR issues were 17.8% of the problems mentioned as management issues in Q32) Issues for attention include:

• Appointment and payment provisions for newly appointed staff • Identification and creation of clear career pathways for professionals • Guidelines for orientation in general, and by department / profession

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• Safety measures: It would seem that not only the safety systems themselves, but management’s reaction to safety issues that is important in addressing the needs of the professionals. When asked if there had been an increase in personal safety issues, 45% of respondents mention safety concerns in the working environment. Open ended responses in Q32 indicated that these problems were compounded by management apathy and the lack of response to safety issues. As tangible evidence of concern, it is suggested that there should be:

• Facility safety upgrade (via an audit, review and upgrade of protection systems) • Ongoing safety monitor of individual facilities (where statistic indicate a more severe problem) • Guidelines for handling crime / violence victims (to minimise trauma associated with incidents).

• Accommodation This issue is more pressing for community service personnel since their initial sojourn in an area is temporary and they do not have the time, inclination or resources to invest in property. 34% of the issues mentioned with regard to accommodation related to the condition. Hence:

• Apart from increasing availability, with managerial will, the Department can easily solve the problems of unhygienic quarters that are in a state of disrepair and that do not have basic utilities such as electricity and running water.

• Training: Continuing Professional Development (CPD) is an important part of a healthcare professional’s psyche. On a practical level it also enhances the level of service delivery performance. Hence in view of the CPD inhibiting factors raised by respondents, it is recommended that working time be allocated for CPD and formal programmes be developed for community service individuals. In particular consideration should be given to creating modules that would be delivered via distance learning and travelling workshops to district hospitals. For doctors this would include emergency medicine, and preparation for specialisation primaries in anaesthetics, paediatrics, and obstetrics & gynaecology

3.3 Retention The majority of the recommendations above will address emigration issues / retention of staff and improve the attraction of the South African public service work environment. In the interim staffing levels remain critical, so additional support strategies should be put in place to provide staff where needed. Measures could include:

• Continuation of recruitment initiatives

• Establishment of a team of specialist professionals who would be prepared to travel /conduct clinical workshops at facilities where CPD and an upgrade of skills is needed

• Development or coordination of support services for the skills audits and reviews recommended to address performance gaps, thus reducing workloads.

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4. background

Healthcare-worker migration is a global phenomenon. Throughout the world studies are conducted to try to provide employers, educators and policy makers with insights as to the underlying dynamics behind the perpetual mobility of the Professions. Traditionally (mid to late 20th century) South African qualified doctors took time out of the country to expand their professional horizons and obtain specialist qualifications that were either not available or perhaps not yet established in the country. Their absence was however usually not permanent. Newly qualified specialists returned to their home country to share and apply their international experience. South Africa suffers from a chronic shortage of healthcare workers in the public sector. This unfortunate situation has a spiralling effect as working conditions deteriorate for the remaining doctors’ and nurses’ trying to cope with increasing patient loads under difficult circumstances. Several factors underlie or compound the situation: Just prior to, and shortly after South Africa’s political transformation in 1994, the country witnessed a mass exodus of skilled and professional people who, for whatever reasons, decided that they would not remain in the country. A significant number of medical professionals were part of this migration. The graph below of registrations by qualification year clearly illustrates the extent of the loss of doctors during the period 1998 to 2003.

Market erosion 1998 to 2003

0

200

400

600

800

1,000

1,200

1,400

1,600

1954

1956

1958

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1968

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Year

Thou

sand

s of

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tors

2002 2001 1998 2003

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Historically salary levels of doctors in public service were considered grossly inadequate by the medical profession. While some advances were achieved in the 1990s, the manner of implementation often negated the positive increases. As a result public service was not an attractive career option for young medics who often had incurred significant debt to obtain their qualifications. Management restructuring in the late 1990’s created a position where doctors in public service complained of a lack of resources and a shortage of medicines. They also experienced that maintenance and replacement of equipment and technology was low on the budget agenda. In particular academic doctors were disillusioned, as they could no longer devote sufficient attention to their research obligations. Their academic interests were overshadowed by demands on their time to provide service delivery. Well-intentioned policy measures taken by the Department of Health in an attempt to resolve the staffing problems being experienced in public service did not have the desired effect in increasing availability of human resources. If anything, the introduction of community service seemed to trigger an avoidance of public service. S Reid’s chapter on Community Service published in The Health Systems Trust 2002 Review indicated that the programme had not yet had the desired effect of retaining young graduates. The number of doctors planning to work overseas had increased from 34% in 1999 to 43% in 2001. More recently, South Africa has been recognised as one of the worst affected nations by the HIV Aids pandemic. The 2006 UNAIDS Report indicated that 38.6million people were living with HIV worldwide, and approximately 5.5 million of these were in South Africa. The majority of these patients access their healthcare in the public service facilities.

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5. prior research

Following the passing of the necessary legislation and regulations, community service was first introduced in July 1998. The introduction of this new obligation had been met with heated resistance from the junior profession. They viewed the proposed system as unfair and unsafe. They felt that they were being required to complete compulsory service in conditions that they would not otherwise have chosen. Reid and Conco’s 1999 study of Community Service outcomes indicated that the scheme to distribute health personnel throughout the country in an equitable manner had been only partially successful. Only 25% of the community service doctors were placed in rural hospitals with 55% in regional, tertiary or specialised hospitals. The authors felt that the aim of improvement in provision of services had probably been met. They reported a mixed outcome with regard to providing an environment for professional development, where enhancement of skills had relied on the level of supervision available and the attitude of the individual CSO. The research into these initial years indicates that the attitudes of the CSO’s seemed to have improved as they felt positive that they had made a difference and had matured as a result of the experience. Supervision, support and the allocation process were however criticised. Conditions of service and social factors were highly dependent on individual postings. The major issues emerging at that time included the level of supervision and support. In teaching hospitals there was little opportunity for decision making, whilst sometimes the CSOs were the only doctors available in rural areas. A number of foreign qualified doctors in rural areas were hesitant to be supervisors. It would appear that the attitude and involvement of senior doctors in a province significantly improved the decision of CSOs to remain in an area. Clinical skills were only learnt where suitable supervision was available. i.e. future development depends on the strength of the healthcare system and availability of experienced personnel. It was also obvious that greater clarification was required regarding the role and responsibilities of CSOs Without a supportive environment doctors in isolated circumstances were said to have been frustrated and demoralized by the experience in view of their inability to contribute positively to the health status of people in their area. “Making a difference” as an important aspect in forming positive attitudes. As a result of the outcomes of this type of research and representations by JUDASA, the allocation system was reviewed and greater attention was given to trying to resolve individual issues. It was mentioned by the junior doctors that sometimes the number of people allocated to a hospital did not match the requirements. Conditions of service, communication problems and quality of accommodation were identified in the research as problematical at particular hospitals. In some instances availability of transport hindered clinic visits and there were concerns for personal safety. It was apparent that the availability of a social network is an essential feature in isolated rural situations. Positive impacts for the health system were obvious in the smaller hospitals where the higher staffing levels reduced stress and improved the patient flow through both casualty and wards. It also facilitated better service to outlying clinics. Transfers to other hospitals were said to increase (as a result of more diagnosis) and decrease as a result of competent resources at the rural hospital. In the 2002 Health Systems Review, a report was carried concerning the outcomes of continuing studies conducted by Prof. Reid. This time the research tracked the experiences of a range of other healthcare professionals, which had joined the community service process. The findings of the initial survey regarding an increase in maturity, but not (really) clinical skills were repeated here.

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Willingness of the young doctors to work in rural areas was again tested and Reid found that “… there are over 200 young doctors in the country each year that would willingly choose to work in rural and under-served areas, even at the end of their community service. Given the right incentives, this voluntary cohort could achieve the primary purpose of the whole programme of community service at a much lesser cost than coercing all medical graduates into grudgingly filling posts, most of which are in large urban hospitals.” The experiences of dental CSOs underlined the need for adequate facilities to be available throughout the healthcare system. Frustration was expressed at their inability to provide more than tooth extraction, when they had trained to deliver a different level of service. This dental cohort also reported a maldistribution of CSO’s as in some areas they were totally under-utilised, (Free State and Limpopo) and in others (KZN) they were kept constantly busy. Like the UK study on Vocational Training, Reid found that the experience of CS appeared to have no net effect on young professionals’ career plans, but merely delays them by a year. As mentioned elsewhere, at that time the intention of junior healthcare professionals to migrate continued unabated. One-fifth of the pharmacists, and just under half of the doctors and dentists surveyed intended to work outside of SA the following year. Reid debates the merits of the coercive nature of the scheme and its impacts. Rural hospitals are still without permanent staff, senior staff’s time is taken every year to train the CSOs in the hospital systems, and the participants develop an attitude that they have already “paid back society”. He concludes that the system could in fact be a contributor to the migration “push factors” in our country. A number of recommendations are made in the report to improve the community service planning, processes and implementation, with a review of the efficacy of the system in achieving its original objectives.

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6 research aim & objectives

Within the universe of community service doctors and other healthcare professionals, the research objectives were two-fold, these being “Longitudinal” and “Recruitment and Placement Imperatives”.

6.1 Longitudinal

Repeating the research conducted last in 2003 by Dr S Reid, to establish whether there has been a change in:

• Attitudes of community service doctors

• The placement process

• And working experiences.

6.1 Recruitment & Placement Imperatives

To facilitate efficient marketing and placement processes, in addition to the information obtain via the longitudinal study, to establish:

• Key factors influencing short and longer term career plans

• Drivers which cause community service doctors to

• Leave public service and / or • Emigrate

• Pull factors which retain or which could attract young doctors to return to public service

• Pull factors that would encourage prior emigrants to return to the country and take up positions in public hospitals, or “non-private” service delivery organisations.

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7. methodology

The research was based on all healthcare graduates who were currently completing their community service. The respondents were invited to express their views using a semi-structured, self-completion questionnaire, (see Appendix A), which was initially distributed via the Provincial Co-ordinators of the Department of Health.

7.1 Sample Selection and Size vs. Return

In view of the relatively small number of community service doctors, (just under 1200 individuals) and other healthcare professionals (a further 2000) it was agreed that the research would be distributed to the entire universe. Follow up measures were planned in an attempt to match the high levels achieved in prior studies. During the course of this activity it became obvious that it was taking an extended period of time for the questionnaires to reach the intended recipients. Due to the duty and holiday rosters, some healthcare professionals were also not present to receive a copy of the documents. To meet this challenge the telephone follow up was intensified, and lists obtained from Eastern Cape, Free State, Klerksdorp Complex, KwaZulu-Natal and Mpumalanga, for direct contact with doctors to encourage a higher rate of return. Returns were also compromised by the fact that the freepost licence facility was not operating smoothly. In a large number of cases individuals and hospital managers being contacted in November and December informed the researcher that the forms had been posted back 4 to 6 weeks previously. Due to the inadequate response levels being experienced, fieldwork was only closed off on 14th December. The final return rate was 19.5% for medical professionals, with an overall response of 15.3%. Since the study did not use a random sample, the results cannot be projected to the population. However, this level of return has allowed a valid statistical analysis of the differences between Doctors, Pharmacists and Allied Professionals; and examination of the overall results in 6 of the provinces.

Occupation #CSOs Sample % Return % Profile Doctors 1135 221 19.5 45.0 Dentists 197 13 6.6 2.6 Pharmacists 472* 81 17.2 16.5 Clinical psychologists 123 4 3.3 0.8 Dieticians 107 23 21.5 4.7 Environmental health 236 21 8.9 4.3 Occupational Therapists 230 35 15.2 7.1 Physiotherapists 319 55 17.2 11.2 Radiographers 268 21 7.8 4.3 Speech therapists 125 17 13.6 3.5 Total 3212 491 15.3 100.0 *Based on allocations, reporting level not fully available in Gauteng #CSOs = Community Service Officers reporting for duty

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Using the allocation list of interns to Community Service posts, (not exact, but reasonable guide to the final distribution) we see response levels were higher than expected from the Free State, Eastern Cape, KwaZulu-Natal and Western Cape.

Doctors / Province % of Allocation* % of Sample Ratio of

Response 1999 Prov. Allocation**

Base 1224 221 1084 Free State 4.7 11.3 2.4 9.0 Eastern Cape 12.1 23.5 1.9 11.6 KwaZulu-Natal 14.1 25.3 1.8 21.9 Western Cape 10.6 12.2 1.2 10.9 Mpumalanga 13.5 12.2 0.9 7.3 Gauteng 15.0 11.3 0.8 15.6 Limpopo 10.5 2.7 0.3 14.8 Northern Cape 6.3 0.9 0.1 1.6 North West 8.4 0.5 0.1 7.3 SAMHS 4.8 0 0.0 *List provided 2007 by SAMA’s Industrial Relations Unit **(11) Reid & Conco, 1999

A comparison with the allocation percentage of 1999 indicates that there has been a substantial change in distribution, with Mpumalanga being the largest beneficiary.

7.2 Sample Demographics

Note: Unless otherwise indicated, tables and percentages are based on positive responses and /or exclude missing replies. The sample consists of 71.5% female and 28.5% males. The higher female proportion is influenced by the responses from “female” occupations such as physiotherapy and occupational therapy. For doctors only, these percentages change to 57% / 43% females to males respectively. Just under a quarter of all respondents were married, (doctors 31%) with the average age of the total sample 25.6 years, but significant differences (probably as a function of the number of years in training) occurred between the ages of the various professions.

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Average Age Doctors 27.41 Pharmacists 25.43 Other 23.67

Group Percentages Racial Group Sample Doctors Pharmacists Allied Base count 489 216 81 184 Black 18.0 24.2 9.9 15.2 White 53.6 46.5 50.6 65.2 Indian 19.2 24.2 32.1 8.7 Coloured 7.6 5.1 7.4 10.9 Other 1.6 Total 100.0

Comparison of the “University of Origin” revealed that doctors from Stellenbosch and Walter Sisulu Universities are over-represented, whilst those from Medunsa/Limpopo and Wits are under-represented.

Just over half the sample was white, but the profile by professions indicates that transformation may have been more successful in the medical profession than in the others.

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8. data collection

Data collection took place using a semi-structured, self-completion questionnaire. The final version was based on the results on a pilot study conducted on ten respondents who were asked to complete the questionnaire prior to the main study. Objectives of the pilot study were to:

• Ensure the instructions are clear / understood

• Obtain respondent’s comments about

• Ease of completion of the questionnaire • Sensitivity or otherwise of the content • Areas that they believe should be covered or omitted.

It was evident that respondents easily handled the “complicated” rating question, and no issues were raised regarding the other areas. Hence the questionnaire was only marginally adjusted following the pilot study. In the main study, questionnaires were distributed in envelopes together with a covering letter and a reply paid envelope with the cooperation of Provincial Community Service coordinators. The expected distribution and return time (of 4 weeks) was underestimated. The envelope format was selected to ensure that all the elements reached the CSO’s, and that they would feel free to express themselves fully since their replies would be confidential. It also made the survey accessible to those healthcare professionals without electronic access to information. As mentioned previously, the postal return channel was heavily supplemented using mainly fax and email to distribute and then collect the questionnaires. In the event only one or two respondents elected to fax their replies via private lines, the rest used hospital fax facilities.

Return Method Number % Fax 323 65.8 Post (from 97 envelopes) 119 24.2 Email 49 10.0 Total 491 100.0

Activities to encourage returns included:

• Provincial CS coordinators

• Personal briefing of the Pharmaceutical and Allied Professions’ Coordinators by the researcher prior to distribution

• Email contact, by the researcher with all co-ordinators on list provided by DOH. The email included an electronic copy of the covering letter and questionnaire. A second email during the course of the follow-up period

• Telephone contact with several of the co-ordinators

• Two emails from Directorate of Workforce Management requesting additional effort in collecting questionnaires

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• Email distribution of questionnaires to hospitals and individuals where it was indicated they had not received copies

• Contact with the management and staff of the Rural Health Initiative

• Request to RUDASA members via the Mailadoc list, and to known individuals within rural hospitals

• Verbal and email request for assistance to JUDASA network (Initial and follow-up)

• Extensive telephone and fax exercise (approximately 1700 calls) to identified individuals within hospitals and from allocation lists. Complicating factors during this activity were:

• Large number of changed / non-existent hospital telephone numbers included on official lists • High level of personnel turnover • Unacceptably long waiting times before telephones were answered (could be as much as 5 minutes)

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9. data analysis

9.1 Editing and Coding

As questionnaires were returned they were reviewed for completeness, and if possible / necessary, respondents were contacted for clarification and expansion of replies. Extraction and coding of replies to open-ended questions was based on an initial 150 questionnaires. A running extract of “other” replies was maintained as the balance of questionnaires flowed in. This resulted in the addition of only one or two additional codes and a review to correct where necessary the “other” replies within the base 150 questionnaires.

9.2 Statistical Evaluation

All statistical analyses in the present study were computed using the SPSS statistical package for Windows version 14 (SPSS, 2005). SPSS stand for Statistical Package for the Social Sciences. The tests included the Chi-square goodness of fit and the Anova One-Way analysis of variance. (For more detail see Appendix E). Regression and cluster analyses were applied in some instances to more clearly understand the underlying combinations of factors. The analysis examined those elements which have been shown in previous work to be push, pull and “stick motivators.

9.3 Presentation of Results

Using the outcome of the cluster analysis we were able to identifying significant segments of the market with common attitudes, motivators and concerns. The so called “CS Satisfaction Clusters” provides considerable insight into the factors affecting the decisions of healthcare professionals. Comments have been provided with illustrative graphs and charts. A technical report is included which provides tables for the entire sample and for the various subgroups of the “Satisfaction Clusters”, “Migration Intentions”, and “Professional Group” (Doctors, Pharmacists and Allieds).

A CD is available incorporating the multiple cross tabulations and analyses carried out on based on other demographic factors. In the discussion, responses on the Community Service portion of the questionnaire have been compared against available results from prior research.

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10. outcomes: community service environment

10.1 Level of Workplace Facilities

Due to the structure of hospital complexes, duplication of response occurred in terms of the claimed main workplace facility. Only 15% of the total sample was working in central or specialised hospitals, with over 50% in district hospitals and CHC’s. The pattern for doctors was only marginally different (see bracketed figures below), being more concentrated in district hospitals. Compared with prior allocations (24%, Reid & Conco, 1999) this confirms the trend towards more rural facilities.

10.2 Community Service Allocation Process

Allocation issues were not probed, but did not emerge spontaneously as a problem or contentious issue More than half the sample (55%, doctors 52%) was allocated to their “first choice”, and a further 25% (doctors 29%) received their second choice of institution. Level of choice was significantly related to the total sample’s clusters of satisfaction, but this association was not evident by individual professions.

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The pattern of choice emerged as significantly different by gender, with females receiving relatively fewer first choice allocations, and even having “no choice” in some cases.

A graph of cumulative percentages for allocations clearly shows the significant difference within provinces for the allocation of the Allied healthcare respondents.

Three quarters of the respondents working in the Cape region were allocated in the first round.

Free State played catch-up through-out the allocation process.

The process of allocation needs to be assessed to establish where the delays are occurring.

0%10%20%30%40%50%60%70%80%90%

100%

Low Medium High

Overall Satisfaction Clusters

Q6: All: Level of Choice vs Satisfaction

First 2nd to 5th 6th to 10th >10 No choice

Q6 Pattern of Choice by Gender

0

10

20

30

40

50

60

70

Male Female

First 2nd to 5th 6th to 10th >10th No choice

Q6 Allieds Level of Choice by Province

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

120.00%

First + 2 to 5 +6 to 10 +>10

Choice

E Cape

Free S

Gauteng

KZN

Mpum'ga

W Cape

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From the pattern of “first round allocation by university” it is seen that graduates from KwaZulu-Natal, Wits and Free State universities received relatively fewer first round placements.

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10.3 Internship Facility

63.4% of Allied healthcare professionals and 36.3% of pharmacists either did not respond to Q7, or claimed that internship was “not applicable” to them. The majority of doctors completed internship in tertiary (51.1%) and regional institutions (37.1%).

10.4 Financial Assistance

In this sample, significantly more doctors (24.2%) receive bursary assistance than other healthcare professionals (pharmacists 11,5% Allied 6.6%).

As indicated by the significantly higher number of doctors receiving a “rural allowance” (doctors 60.0% / pharmacists 44.4% / Allied 33.7%) in combination with the “community service facility type”, we can conclude that Community Service Doctors are placed in more rural settings than their community service colleagues. This proportion also confirms that doctors are moving further into the community (Prior 1999 study put this figure at only 24%.)

Almost all the respondents claimed to receive a scarce skills allowance, with only 10% of the “Allied” healthcare professionals indicating that they were not included in this benefit.

0%

20%

40%

60%

80%

100%

Central Specialised Regional District Private Other Notapplicable

Intern Facility: Comparison by Profession

Doctors Pharmacists Allied

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10.5 Community Service Experience

10.5.1 Overall Summary of Measured Factors

Disagree Neutral Agree Count % Count % Count % My tertiary education equipped me well for this year 20 4.1% 106 21.7% 362 74.2%

I was well orientated to my job by the hospital staff when I arrived

91 18.7% 122 25.1% 273 56.2%

I have experienced significant professional development this year

80 16.3% 119 24.2% 292 59.5%

I have experienced good supervision 165 33.6% 134 27.3% 192 39.1%

My seniors have always been available when needed help 109 22.2% 126 25.7% 256 52.1%

I have coped well psychologically 61 12.5% 134 27.5% 293 60.0%

I have a positive attitude to community service 93 19.0% 106 21.7% 290 59.3%

My attitude changed for the positive over the course of this year

133 27.4% 169 34.8% 184 37.9%

The experience of this year has changed my long-term career plans

116 23.7% 127 25.9% 247 50.4%

I feel that I have personally made a difference this year 24 4.9% 107 21.9% 358 73.2%

I intend to stay working at the same institution next year 284 58.3% 72 14.8% 131 26.9%

10.5.2 Satisfaction Clusters

Analysis of the degree of satisfaction indicated in questions 11 to 21, led to the identification of three clusters. The largest was that of “Very Satisfied” (51%, referred to as the “High level”), 29% were “Moderately Satisfied”, (Medium level) and 20% were “Least Satisfied” (Low level).

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All the groups are similar in age, gender and marital status. Distinguishing features of the group profiles are:

• High level: Most Black or Coloured respondents fell in this category. Typically they were sent to their first choice of post; and felt that they had good orientation, were well supervised and enjoyed a high level of professional development. They intend working in the public sector “next year”.

• Medium level: Holds a greater percentage of Indian respondents than the other groups. They were sent to their second or even lower choice of facility. They are also more likely to be staying in public service, but are also contemplating their options for private and overseas.

• Low level: Consists of all race groups. Here again they were sent to second or lower levels of choice. They felt less well oriented and not well supervised. They are the least likely to intend staying in the same hospital and most likely to be going overseas.

The graph below clearly illustrates the significant differences for satisfaction ratings within these groups, and the impact of the perceived negative factors on the long term plans of those who generally rate the CS experience negatively.

1

1.5

2

2.5

3

Tertiaryeducation

GoodOrientation

Prof Dev GoodSupervision

Senior avail. CopedPsych.

+ve Attitude Attitudechanged

Long termplans

Made diff

3 High 1 Medium 2 Low

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Using these clusters we were able to identify that there is a significant difference in the level of satisfaction by province, with KwaZulu-Natal and Eastern Cape leading the other provinces. (See graph below.) It must be remembered, however, that insufficient replies were received from North West, Limpopo and Northern Cape to include these three provinces in this analysis.

10.5.3 Preparation and Growth By far the majority of respondents (74.2%) indicated that their academic training had prepared them well for their community service obligations. (No difference between professions.) Orientation practices could be improved, with only 56.2% of the sample claiming to have received a sound orientation on arrival at the hospital. (Figure reduced by pharmacists’ lack of satisfaction at 50.0%). Assessment of orientation is significantly related to the satisfaction clusters for all the professions. With an overall claim of 59.5% for “significant professional development” during the year, it is certain that this post internship year is one of growth for the healthcare professionals. It is likely that this growth is supported by the measure of clinical independence granted to these young professionals (see Q33).

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10.5.4 Supervision Supervision by seniors is an area of major concern. It is obvious that, even though they are being trained for independent practice, the healthcare professionals feel the need for more input in this area. These findings indicate that little progress has been made since Reid’s prior research. In the first instance only 39.1% of the sample agrees with the statement that they have “experienced good supervision this year”.

Q14: All: Rural vs. Quality ofSupervision

Disagree Neutral Agree

Allowance

No Allowance

The situation with supervision has not changed over time.

As in the prior studies, the perceived quality of supervision is significantly related to the presence / lack of a rural allowance, indicating that the quality of supervision deteriorates as community service professionals move further away from urban areas.

In this study significant differences occur when gender is taken into account, with males saying that they experienced a better level of input.

50% 40% 30% 20% 10% 0%

Q14: Good Supervision: Male vs Female

0

10

20

30

40

50


Male

Female

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Significant differences are noted between the professions. 44.4% of Allieds agreeing with the sentiment that they had had good supervision; 45.7% of pharmacists indicating they were “neutral” about the issue, with almost equal proportions of doctors voting for “agree” and “disagree” (36.2% and 37.6% respectively).

The level of supervision by Province is also significantly different, with respondents in Mpumalanga and KwaZulu-Natal indicating a lower level of supervision from seniors, and those in the Western Cape indicating that they have had a better experience than most in this area. (See table below.) One cannot tell from the study whether this is due to lack of interest or a shortage of supervisors in the various provinces.

Percentages Q14 Good Supervision E Cape F State Gauteng KZN Mpum W Cape Count 70 59 108 94 48 64 Disagree 32.9% 28.8% 35.2% 41.5% 47.9% 10.9% Neutral 24.3% 28.8% 31.5% 22.3% 27.1% 34.4% Agree 42.9% 42.4% 33.5% 36.2% 25.0% 54.7%

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When we consider the percentage of people who agree that they have experienced “Good Supervision” and “Availability of Seniors” within provinces, we see that a similar pattern emerges for these two factors, with availability moderately better than the level of supervision

If we then adjust the “agreement” percentages by deducting the “disagreement” percentages we note that the adjusted supervision and availability scores have a similar pattern by province, but indicate supervision could be unequally distributed. This is supported by the open-ended responses to Q32. We can also conclude that “availability” does not necessarily equate to “good supervision”.

Q14: Good Supervision: Rural Intentions

0%

10%

20%

40%

50%

Disagree Neutral AgreeGood Supervision

Not rural Neutral

Yes rural 30%

The importance of supervision also lies in the fact that it is significantly related to the respondents’ intentions to work in rural areas in the future. If the quality of supervision were to improve it would attract more applicants!

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10.5.5 Psychological and Attitudinal Factors Generally respondents claimed to have coped well psychologically with 60.0% agreeing with the statement and only 12.5% experiencing problems.

Many studies have shown that professional development is cherished by the majority of healthcare professionals. Overall 59.5% of the sample claimed to have had a positive experience in this regard.

Once again the role of having “good professional development” is confirmed in creating satisfaction with one’s community service experience.

The majority of respondents have ended they year with a positive attitude to community service. There are, however significant differences by both profession and province. Allied healthcare professionals are seen as the most positive, and pharmacists displaying higher negative sentiment.

One aspect that has not changed over time is the “lack” of professional development in rural areas. This study once more indicates that less development took place in rural settings since the presence of a rural allowance was significantly (negatively) related to agreement of respondents with the experience of good development.

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

Disagree Neutral AgreeGood Professional Development

Q13: All: Rural vs Prof Development

Rural allowance No rural

0.00%10.00%20.00%30.00%40.00%50.00%60.00%70.00%80.00%90.00%

Low Medium High

Q13: All: Prof Development by Satisfaction Clusters


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Mpumalanga is singled out as holding the least positive respondents, with Western Cape and Eastern Cape reflecting higher percentages than the rest. In the graphs below the adjusted percentages reflect the net figure for “Agree” less “Disagree”.

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Although an overall 37.9% claim that their attitude has “changed for the positive”, this effect is diluted by the large number (27.4%) who disagree with this statement.

73.2% of the total sample indicated that they felt they had personally “made a difference” during the year. This figure is close to the 76% positive levels measure in the prior research. (Different scales so significance test not applied.) We considered many of the factors (race / province / professional group etc) that could perhaps result in an observation of difference in this factor. The only grouping that was significant was “gender”, where the male / female percentages were significantly different (78.1% males vs. 71.6% of females); and the direct (but not significant) relationship between emigration intentions.

Make a difference: Yes

Leaving prolonged

Leaving for short period Undecided Staying Total

Base 89 142 155 84 491 Percent 67.4% 72.5% 73.5% 84.5% 73.2%

It has been shown (see regression analysis table Appendix E ) that there are three key factors influencing a change in a community service professionals’ attitude. These are:

• The feeling that “I have made a difference” (31% of the variance)

• The role of the availability (and hence support) of seniors which emerges as the second factor

• And finally the optimal model adding the belief that “I have experienced significant professional development.”

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The above analyses beg the question as to whether the community service experience has had any effect (positively or negatively) on the longer-term plans of the healthcare professionals. Just on half the sample indicated that indeed their future had been shaped by community service, but with no significant differences at professional or provincial level. As can be seen from the graphs below, the influence of community service year on long-term plans can go either way. The relationships are not significant, but if we consider the higher levels for “disagree” (that the year had changed long-term plans), the responses tend to suggest more Pharmacists and Allieds, had made up their minds about emigration / travel prior to community service.

0.010.020.030.040.050.060.070.0


Doctors: Long Term Plan Change vs Emigration Intention

Prolonged

Short

Undecided

Stay

0

10

20

30

40

50

60


Pharmacists: Long Term Plan Change vs Emigration Intention

Prolonged

Short

Undecided

Stay

0.010.020.030.040.050.060.0


Allieds: Long Term Plan Change vs Emigration Intention

Prolonged

Short

Undecided

Stay

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10.5.6 Overtime The graph below clearly illustrates the different pattern of overtime worked by each professional group, with doctors bearing the brunt of additional hours.

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10.5.7 Accommodation The experiences of the respondents can best be expressed in their own words:

“Drove 210Km per day because no accommodation was provided, no travel allowance, and was not allowed to work for extra petrol money!

“Live in a hospital ward

“No electricity or water for work-days of the week. Water is contaminated with e-coli. no proper living quarters

“It took me 4 months to be provided with accommodation. I had to share a bathroom with 3 other doctors initially and later had to share accommodation with another doctor, her fiancé, my family and doctors on call

__________

Just on one third of the respondents did not respond to this question or indicated that it was “not applicable”. A further 4.5% indicated that accommodation was “not available”. In fact if we combine all the balance of replies where respondents have linked an attitude to “not available”, we see that a total of 17.5% of the sample confirm that they did not have access to Departmental accommodation.

The condition of the accommodation appears to have been the distinguishing factor between being “unhappy” (34.0% of reasons) and feeling “neutral” (17.4%). However if the proportion of “neutral” respondents who refused to use the accommodation is taken into account, the 17.4% figures rises to 29%, so one must assume that that group of people was more forgiving.

Common Factors: % on number in group Unhappy Neutral

Condition / suitability/ poor / horrific / no water 34.0% 17.4% Availability / organising / delay in fixing 25.5% 31.9% Unsatisfactory Sharing 14.4% 13.0%

Male respondents were less happy with having to share (18.8% vs. 12.4% of female mention).

Unhappy respondents were the only ones to mention “cost” (6.5% of reasons) and “safety” (7.2%), whilst 4.3% of the accommodation “neutral” group complained about the lack of furniture.

“Happy” respondents described the accommodation as “nice / spacious” (30.2%), with good facilities (16.5%), clean (9.4%), safe (7.9%) in a suitable location (7.9%). Good maintenance was also mentioned in this group (5.8%).

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More complaints were registered by respondents in the Eastern Cape and Mpumalanga. The nature of these indicates that attention should be given to the condition of accommodation in Eastern Cape, Gauteng and Mpumalanga, and to availability in Eastern Cape, Mpumalanga, Free State, and KwaZulu-Natal. We cannot comment on accommodation issues in the low response provinces.

0%

50%

100%

150%

200%

Eastern Cape Free State Gauteng Kw aZuluNatal Mpumalanga Western Cape

Q30: Accommodation: Complaints by Province

Condition Availability Sharing

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10.5.8 Personal Safety Risk Only just over one third of respondents indicated that they felt that community service had not increased the risk to their personal safety. We note that the Department of Health could significantly reduce the stress (and “push”) factors for all healthcare professionals if workplace safety were to become a priority.

A higher proportion of males mentioned risk concerns but we cannot establish whether this is due to “task selection” or some other pre-disposing factors. Males were more concerned with “occupational injury” (mainly HIV), whilst the distinguishing factor for females is “having to deal with aggressive, abusive patients and their relatives”. Even environmental health officers mention the reaction from people whose livelihood is at risk because of their assessments.

Expression of concern was also evident at different levels by race (33.0% Black, 44.7%, White, 45.7% Indian and 21.6% Coloured respondents mentioned some aspect about factors that had increased their risk level.)

Q31 Risk Factors by Demographics Total Ma

le

Fema

le

Blac

k

Whit

e

Indian

Colou

red

Docto

rs

Parm

a-cis

ts

Othe

r

Base 202 66 134 29 117 43 8 117 25 60 Percentage mentioning risk 41.1% 47.8% 38.6% 33.0% 44.7% 45.7% 21.6% 52.9% 30.9% 31.7%

Safety concerns in working environment / accommodation /on call rooms (especially night)

45.0% 39.4% 47.0% 44.8% 43.6% 53.5% 37.5% 47.0% 44.0% 41.7%

Occupational injury / exposure / unhygienic 22.8% 31.8% 18.7% 17.2% 29.1% 16.3% 0.0% 23.1% 20.0% 23.3%

Hazardous / dangerous roads / driving / rural travel

22.3% 22.7% 20.9% 6.9% 23.9% 27.9% 25.0% 24.8% 20.0% 18.3%

Aggressive / abusive patients / relatives/ nurses/ colleagues/ on site workers

18.8% 9.1% 23.9% 6.9% 18.8% 16.3% 75.0% 14.5% 16.0% 28.3%

Strike related 14.9% 7.6% 18.7% 10.3% 18.8% 9.3% 0.0% 11.1% 24.0% 18.3% Crime / violence related 13.9% 19.7% 11.2% 13.8% 11.1% 18.6% 0.0% 19.7% 0.0% 8.3% Security service in hospital grounds or at gate: inadequate/ not performed/ poor/not respond

10.9% 10.6% 11.2% 37.9% 5.1% 7.0% 12.5% 15.4% 0.0% 6.7%

Other 10.4% 15.2% 8.2% 20.7% 12.0% 2.3% 0.0% 9.4% 16.0% 10.0%

158.9%

156.1%

159.7%

158.6%

162.4%

151.2%

150.0%

165.0%

140.0%

155.0%

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The relationship between personal risk and doctors’ “Satisfaction Clusters” confirms that this is one of the major contributors to that group’s assessment of their CS experience. It is possible that the working environment of CS doctors is inherently more dangerous since just over one half of the doctors (compared with just under one third of their colleagues) mentioned risk factors.

All Respondents

%s on Base 491

No 35.4%

Neutral 24.4%

Yes 38.5%

No reply/ na 1.6

Total 100.0

Personal safety issues are significantly related to the respondents’ emigration attitudes. 50% of those who say they are “staying” (vs. profile of 35.9%) did not experience safety issues during community service, while a similar proportion (47.7% vs. a profile of 38.5%) indicated that they did feel a threat to personal safety during the year, and they now intended emigrating for a prolonged period.

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10.5.9 Management Concerns Respondents reported mixed experiences, some indicating that the “immediate manager” was more responsive than those up the ranks:

‘They would promise to handle your query but never get back to you about it – you have to keep on enquiring which is annoying

“Medical manager was a lovely person who would listen and try to accommodate our needs. However there is politics between managers and often the department heads would disagree with her judgement and insist on the total opposite.

“Management handled NONE of our concern which is why 5 of the 6 Comm Serve due to leave are leaving. 1 is staying for bursary obligations. The clinical manager resigned end of November. TERRIBLE MANAGEMENT!

“Safe area to park cars / allowed to leave early on Fridays / seniors always prepared to help with problems e.g. breakdowns.

“Management is a myth. I think managers are not qualified or have a lack of vision and understanding when confronted with problems.

__________

Dissatisfaction with Management’s responsiveness and capability is one of the major and significant contributors to overall disenchantment with the CS experience and to some professionals’ decision to emigrate.

61.3% of Allieds in the least satisfied cluster (cf profile of 30.9%) were not happy with managements’ performance.

Did management handle concerns or problems satisfactorily?

% on Total Base 491

No 36.7

Neutral 37.7

Yes 24.0

Total 98.4

No reply/ na 1.6

100.0

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The reasons offered for dissatisfaction centred on the general unavailability of management, their unhelpful attitude, and inability to take action or achieve required change. Many times the lack of action would fail to secure resources. Management was criticised for being unsympathetic to clinical requirements. Inevitably the CSO’s working under this type of management suffered disillusionment and feel totally de-motivated.

Sheer frustration and disturbing outcomes are evident in some of the comments.

“Only 4 doctors in my hospital – 3 comm serve and 1 senior (by three years) – there was no superintendent or any other form of management present to assist us.

“Had severe problems with transport to clinics that was never handled. Doctors’ room for sleeping in terrible state, never fixed. The doctors are seen lower on the hierarchy than the cleaners, no support given in any regard. Our hospital is losing 9 out of 16 doctors now because we can take only so much abuse. Had to see between 60-120 / day in clinics after doing ward/theatre work. Total frustration.

“Our Occupational Health department seems to lose about 60% of post-needlestick injury blood samples, and couldn't be bothered when we complain about it.

“We did not have a supervisor for 6 to 7 months of the year. High management hear our problems but did not act on them

“With the end of the year coming XXXX cannot give me a definite reply on whether there will be posts next year or not. It’s not easy to organise your life on maybes

“Supervisors and seniors are ill equipped for their job description and do not perform their duties in terms of patient care and supervision

“Applied to stay on as a jnr physio at xxx hospital. Was told applied too early then re-applied but was told that comm. serves for next year had been allocated Therefore no available positions (too late to change / reject them) CEO prefers to use comm. serves on yearly basis – doesn’t matter to keep permanent staff therefore decrease in continuity of care. Public service doesn’t want to retain staff therefore will look to private / overseas for future jobs

“Definitely NO. They never had time for us, hence we didn’t have a supervisor, they were always busy with their “stuff” and attend to those people they favoured!

*CSO = Community Service Officer

Q32: Reasons for Dissatisfaction w Management

Attitude / not avail, 83.6%

Not prepare for CSOs*, 3.9%

HR issues, 17.8%Clinical apathy,

17.8%

Not respect CSOs*, 13.2%

Overtime issues, 3.3%

Corrupt, 5.9%

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11. public sector motivators

Work overload emanates from both lack of resources and from inefficiency of current resources. This is illustrated by respondents’ comments.

“Everyone in public sector try to do as little as possible. I hate working with people with this attitude – especially senior staff

“Too much frustration in the government sector, especially in the rural areas. E.g. No roadworthy cars to drive to clinics. Service area to big for one therapist. Have to drive 350-400km/week. Clinical supervisors not giving enough guidance and support. Skills deteriorating due to only seeing obese and arthritic patients at clinics. No stimulation. Most of the time only giving group classes. Lack of equipment. Hospital budget is usually finished when rehab can order. No job satisfaction.

“The procedures to order, dispense and to do all other activities will have to be a lot easier and a lot less time consuming – computerised systems will help

__________

0.0%5.0%

10.0%15.0%20.0%25.0%30.0%35.0%40.0%45.0%50.0%

Salary /Underpaid

Managementissues

Syst em / st ress St af f / hours No CareerProspect s

No JobSat isf act ion

Lack ofResources

Moving No Recognit ion

Q24:Professions Reasons for Leaving Public


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The study has proven that a (perceived) negative community service experience is directly related to the likelihood that doctors will not choose to work in public service.

0 20 40 60 80

Salary / Underpaid

No Career …

System / stress

No Job Satisfaction

Management …

Lack of Resources

Staff/hours

Moving

No Recognition

6755

4138

3023

2216

8

Q24a: Reasons for leaving Public Service

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0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0% 40.0% 45.0% 50.0%

Job Satisfaction

Everything must change

Lazy/incompetent people

Recognition / valued

No available posts

System stress

Opportunities prof. Dev.

Work fewer hours

Other

Management issues

Working conditions

Better salary

Q24b All Leaving Public: What would need to change

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The bar chart below reflects the ratio of male to female mention of the various factors. We see that twice as many men are concerned with staff shortages/work overload, with recognition and management issues being relatively more important for men. The relative rating for “career prospects” is reflecting the lack of jobs available for the Allied healthcare workers (majority of who are female).

Marital status also affects one’s view of workload. 22.9% of married respondents answering Q24, compared with 8.7% of their unmarried counterparts, mention staff shortages/workload as one of the factors driving them to leave the public sector.

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12. rural intentions

21% of all respondents indicated that they intended working in a rural area in future, with 46.6% saying they will not. Of the respondents who will “not work in rural” 61.6% mentioned a particular location where they intend working. The main reasons offered revolved around professional development (31.5% mentions) and working conditions being more favourable (21.9% mentions)

Respondents who rated their feelings as “Neutral” about working in rural areas had not yet decided whether they would or not (56.3% mention), fewer named locations (17.0% of this group) and concerns were expressed about resources (14.1% of mentions). Pharmacists in this “neutral” group were less decided than the other professions (Relative to doctors, only half named a chosen location, and 38% more were “undecided”.) Indecision in the “rural neutral” group was directly related to the CS satisfaction clusters, with the proportion of “least satisfied” expressing this sentiment being relatively higher (Least: 81.3%, Medium: 60.5% and Most: 51.8%) 71% of Allied professionals who are in the least satisfied cluster will not work in rural areas. It should be noted that while respondents have indicated they intend going into rural areas, the majority have a “particular” rural area in mind. 65.0% of this group naming their chosen location.

All: Not Work Rural Doctors Pharm acists Allied Married Un-

married Male Fe male

% within Subgroup: Base 36 8 29 20 41 16 55 More scope / professional challenges/ satisfaction in urban/ private/school

13.9% 37.5% 51.7% 20.0% 41.5% 12.5% 38.2%

Q28:All: Why Positive Rural Intention

Rural develoment

28.2%

Family 17.5%

Select location 65.0%

Current facility 11.7%

Other 26.2%Prof.

Experience 25.2%

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Respondents who are “rural positive” have apparently seen that professional development in a different environment (non-tertiary hospital) is available. (No pharmacists, but 36.5% of doctors and 16.7% of Allieds). More importantly, they have identified some aspect of the situation where they can contribute to the upliftment of rural people. Just on 24% of doctors firmly intend working in a rural situation. This is slightly higher than the “rural positive” intentions of the sample (21.5%). It is clear that the intention of medical professionals to work in rural areas is directly related to their rating of the CS experience. “Intern training facility”, “current CS facility” and” level of choice” do not seem to have affected the rural working intentions for doctors. An attitude change during the year has appears to be related to a “consideration” of working in rural areas, (see agree / neutral below) but a significant proportion of doctors have not changed their minds during the year, and do not intend working in rural areas. This observation is confirmed by the lack of relationship between a “change in long term plans” and the intention of doctors to work in rural areas.

Q28 Intend Working Rural Doctors

No Neutral Yes Total Disagree Count 45 12 11 68

(%s = within Q28) 45.5% 18.2% 21.2% 31.3%

Neutral Count 30 23 21 74

30.3% 34.8% 40.4% 34.1%

Agree Count 24 31 20 75

24.2% 47.0% 38.5% 34.6%

Q18

Attitude changed for positive during

the year

Total Count 99 66 52 217

100.0% 100.0% 100.0% 100.0%

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Exactly the same (significant) relationship of change of mind to rural intentions is observed within the full sample. What is different for the entire sample is the impact on long-term plans, with the experience of the year being significantly related to the overall positive intention to work in rural areas. Perhaps this relationship could be attributed to the indication by respondents that they feel that they have “Personally made a difference”. (Q20 81.6% vs. profile of 73.2%) The pattern of intention to work in rural areas is significantly related to “Coping psychologically” (Q16) and current “Positive Attitude to CS” (Q17). We see that doctors who have not coped well psychologically during the year are less likely to work in rural areas (20.0% vs. 13.8% profile), and those with a current positive attitude (68.6% vs. 56.2% profile) are more likely to have positive intentions. These significant relationships are repeated in the full sample of respondents (16.6% vs. 12.6% and 74.3% and 59.6% respectively) Within the whole sample, apart from the coping and attitudinal factors, we note that people are more likely to reject rural work depending on their experience of the “Orientation”, “Good supervision”, and “Availability of seniors”. These emerge as highly significant factors relative to rural intentions. Significantly different patterns exist in the distribution by

• Receipt of a rural allowance (taken to be an indicator of current “ruralness”)

• Doctors: 80.8% vs. profile of 54.4% positive for both allowance and intention to go rural, and 57.0% vs. 40.1% profile negative for both

• All respondents: 67.0% vs. 46.9% positive for both

• Race: proportionately fewer white doctors intending to work in a rural setting (53.6% of white doctors vs. profile of 46.0%)

• University of Origin:

• UCT doctors are positive (17.3% vs. profile of 11.1%).

• Medunsa/University of Limpopo who are “neutral” (21.2% vs. 13.4% profile)

• Doctors who indicate they will not be going to the rural areas include Wits (18.2% vs. profile 12.4%) and University of Pretoria (25.3% vs. 15.7% profile).

• Province:

• Doctors working in KwaZulu-Natal have positive intentions (42.3% vs. 25.7% profile), while those in Mpumalanga are less likely to work in rural areas. (16.0% 12.4% profile say “no”)

• Within the full sample KZN employees also positive (33.3% vs. 19.2% profile), and those in Gauteng less likely to consider rural work (31.0% vs. 22.5% ).

A significant force in the doctors’ decision to work in rural areas is the “personal safety” experience of during their CS year. 60.6% of those who will not work in rural areas express a negative safety experience (compared with profile of 49.5%). Intention to work in a rural area appears to be a “longer term” plan since none of the factors (travel / career / work experience / finance / family) mentioned in Q22 are related to rural intentions in the overall sample. What is significant, is the “next year’s workplace intention”, with those moving into private practice not ever intending to work in rural areas, (37.1% say yes for private and no for rural vs. profile of 28.1%), and those staying in public service more likely to be intending to go into rural areas (67.0% vs. profile 57.35).

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Some of the factors within doctors’ claimed attitudes towards immigration (Q35) are significantly related to the intention of working in rural areas. Those who are

• Undecided - are less likely to commit to rural work (41.0% vs. profile of 34.4%)

• Going for short periods – are more likely to intend working in rural (48.1% vs. 30.3% profile)

While the factors in questions 37 and 38 relate to “decision to emigrate”, we can see that they are also indicative of the overall attitudes of respondents. Doctors who indicate they are interested in rural work rate every factor mentioned in Q37 as of lesser importance than do their colleagues, with significant differences occurring for “Being valued”, “Availability of medicines”, “HIV Aids”, and “Promotion prospects”. Doctors who indicate they will not be working in rural areas rate the “Current Status” of all the factors less positively than their colleagues, with a significant difference for the status of “Promotion prospects”, and “Management’s ability”. Their rating of the status of “Professional Behaviour” also puts them apart from the doctors who have a more positive intention to work in rural areas. Defining “retention” as the intention of people to stay in their CS province, and based on the 247 respondents who indicated they were either “neutral” or “positive” regarding rural intentions, we note that amongst this group Mpumalanga, KwaZulu-Natal Eastern Cape and Western Cape have the higher retention levels. (Caution: small sub-sample sizes.) Of this group, 7.7% indicate an “academic intention”.

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13. “next year” work intentions

13.1. Motivating Factors

Salary scales obviously have some anomalies. As one respondent said:

“If I stay in public service next year I’ll be a junior OT. The pay is much less than I’m receiving now. Thus a step backwards not forwards.

__________ Significant differences are seen in the motivating factors between the professions in deciding where to work “next year”. Doctors are driven by “Career”, Pharmacists by “Finances” and Allieds by “Experience” Black respondents were significantly less likely than others to want to travel.

0% 20% 40% 60% 80% 100%

Career

Experience

Finances

Family

Travel

Next Year Motivators by Profession

Doctors Pharmacists Allieds

Q22: Next Year Factors by Race

0%5%

10%15%20%25%30%35%40%45%

Travel Career WorkExperience

Finance Family Other

BlackWhite

Indian

Coloured

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It has already been shown that the perceived community service experience is significantly related to the intentions of doctors to work in public service or go abroad. The cluster of least satisfied doctors has a significant intention in (Q35) to “definitely leave” (17.6% vs. profile of 7.4%) and to “Leave the Profession” (15.7% vs. profile of 4.7%) Respondents who indicate they intend going abroad for prolonged periods are significantly less likely to have responded to Q22 which investigates factors affecting the “next year” decision. Where “Travel” has been mentioned in Q22 as a factor influencing work selection for the following year, it is significantly related to respondents who intend leaving the country for a prolonged period. i.e. their departure could be imminent. Where “Family” issues have been selected this factor is seen also be significantly related to emigration intentions with a depressed level of intention to go abroad for prolonged periods.

Q22: Most Important factor Base 491 Q23: Intended Place of Work Base 491

Travel 11.4% Private sector SA 28.3% Career 29.3% Public sector SA 56.0% Work Experience 29.1% Overseas 17.1% Finance 21.8% NGO in SA 2.2% Family 30.3% Other 5.1% Other 6.7% No reply 1.0% No reply 0.2%

Over half the respondents intend spending some time in the public sector in 2009. Minor duplication of response exists within Q23 as some respondents will be biding their time waiting for academic posts to become available, or they intended working in one place (public say) for a while, then moving somewhere else. Although “Finance” is a relatively lower factor with regard to the immediate work plans of the majority of respondents, we will see later in the section regarding immigration that money issues are the major push factor driving that decision. These responses are very different from those measured in prior research as there has been a jump in the proportion claiming that they will work in the public sector “next year”. Whilst we cannot make statements with any confidence about the universe as a whole, this study demonstrates a difference by race in terms of work-place intentions, with Black respondents being significantly more likely to remain in public service, and less likely to move to private or go overseas.

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This trend is confirmed when we compare the overall emigration intentions over time. (Unpublished research conducted by S A Medical Association, “Out of Africa”, 2003) The same cautionary remarks apply as the SAMA sample included older respondents, but the patterns suggest that attitudes have markedly changed.

Due to the larger sample size and sampling method differences caution needs to be exercised in directly comparing the results from prior research. We also need to note that “less satisfied” individuals may not have responded to the 2007 study. That said, the responses suggest that the immediate plans of community service healthcare professions may have shifted to include the “Public Service” as the job destination of preference.

0% 20% 40% 60% 80% 100%

Black

White

Indian

Coloured

Q22: Next Year by Race

NGOOverseasPublicPrivate

0

1020

304050

60

PublicService

Overseas Not sure /Other (07)

Privatesector

Q23: Longitudinal Comparison

1999 2000 2001 2007 2007 (Dr)

Propensity to Leave

0%5%

10%15%20%25%30%35%40%45%50%

Stay Undecided Short Prolonged Def leave Leave prof No reply

2007 2003 Doctors Pharmacists Allieds

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13.2. Working Abroad

22.6% of the total sample responded to the questions regarding planning to work abroad. Within this group 36.4% expressed the view that they had “Always wanted to go”. However the decision seems to be one taken within the community service year, with 45.5% of people intending to work abroad having taken the decision in 2008. Unmarried respondents are significantly more likely to indicate that they will be going for “short periods” only, presumably to experience the adventure / world while they have fewer responsibilities.

% based on emigration subgroups

Leaving prolonged

Leaving for short period Un-decided Staying Total

Base 65 115 116 61 357 21-24 years 38.5% 48.7% 34.5% 41.0% 40.9% 25-30 years 50.8% 50.4% 57.8% 47.5% 52.4% 31+ years 10.8% 0.9% 7.8% 11.5% 6.7%

The above table illustrates the significant differences in intention to emigrate by age. 30 is the turning point for respondents to take short trips abroad, with a higher proportion indicating their intention to remain in the country. Significant differences also exist in the pattern of intention by race. White respondents are more likely to go abroad to work for “prolonged” periods 71.6% vs. profile of 54.8%), whilst Black respondents express their intention to “stay put” (31.0% vs. 18.2% profile) Destinations are almost totally confined to English speaking countries, with the traditional destinations of South African healthcare professionals again showing dominance. Due to their recent economic boom, Ireland had an aggressive programme to attract professionals, and this appears to be reflected in the figure below. Doctors have a different work destination pattern compared with the other respondents.

Q25c: Destination Countries (All /(Doctors)

Canada20% (28%)

UK/ England / Scotland

27% (13%)

Australia17% (20%)

Ireland12% (18%)

Other9%

New Zealand6%

Not sure4%

Not South Africa

1%

Europe3% (4%)Holland

1%

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There are positive indications that travel will be viewed as a temporary experience.

Total Sample % Travellers % Q25b Intention to return Base 491 Base 111

Definitely not 0.2 0.9 NO 1.0 4.5 Not sure 8.1 36.0 YES 7.5 33.3 Definitely yes 5.7 25.2 Total 22.6 100.0

Female respondents are less sure of their intentions, and indicate a shorter period abroad. (12.9% of male respondents vs. 20.5% of female respondents say will be away for only a year.) From Q35 we note that females are significantly more likely to be “staying put” than males.

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Consideration of the Satisfaction Clusters identified within the sample indicates that the CS experience has a significant impact on the decision of less satisfied doctors to work abroad.

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13.8% of all respondents intending to work abroad had already secured an overseas position, with a further 51.4% indicating that they are “in the process” of finalising a job. Recruitment agencies (76.1% of replies) remain the dominant exit channel, but the influence of friends abroad (at 19.3%) cannot be ignored. (Allieds are significantly influenced by friends.)

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13.3. Same Institution Within each group of professionals (doctors / pharmacists / Allied) the intention to work at the “same institution” is (significantly) related to the CS experience. As expected, for all the clusters expressing least satisfaction a greater proportion of them will not work at the same institution. Conversely, a greater proportion of the very satisfied clusters express the desire to stay at their institution.

0%10%20%30%40%50%60%70%80%90%


Q21:All: Intention to Remain at CS Facility

Low SatisfactionMediumHigh

0%

20%

40%

60%

80%

100%

Doctors Pharmacists Allieds

Q21 Intention to Remain at CS Facility

DisagreeNeutralAgree

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14. professional development issues

14.1. Post Graduate Studies during the CS Year

Coming immediately out of training or academic environments, respondents miss continuing professional development: “I love my work. I loved the patients. Working conditions are really tough, but me and the rest of our staff are always trying our best. What I like most is the academic side of medicine, but I never had any tutorials or ward round with other doctors this whole year.”

“From the day that I asked why we were not getting any academic teaching and was told by my senior that I am here to work, not to learn, I would never recommend that anyone come back to that kind of attitude in South Africa

__________

80.1% of respondents indicated that they had NOT undertaken any training during the year. Where respondents had been able to study these included:

Total mention Male Female Doctors Pharm-

acists Allied

Base 74 21 48 41 15 14 Masters / honours / Primaries 28.6% 42.9% 22.9% 29.3% 46.7% 7.1%

ATLS / ACLS/ PALS etc 18.6% 19.0% 16.7% 29.3% 6.7% 0.0%

Management 4.3% 4.8% 4.2% 0.0% 20.0% 0.0%

Diploma / certificate outside discipline 2.9% 0.0% 4.2% 4.9% 0.0% 0.0%

Diploma / certificate extending skills current scope of practice

34.3% 28.6% 37.5% 36.6% 6.7% 57.1%

Other 1.4% 0.0%

2.1% 0.0% 6.7% 0.0%

Under impression/ told were not allowed to study

15.7% 9.5%

18.8% 7.3% 20.0% 35.7%

105.7%

104.8%

106.3%

107.3%

106.7%

100.0%

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We see that males are more likely to have embarked on achieving their masters / a specialist degree, (47.1% of male doctors) whilst females have undertaken relatively more short courses (47.8% female doctors). Allied healthcare professionals appear to have been conscientious regarding their “within profession” development. Provinces were not equally discouraging about study. Within the group answering this question, no respondents from KwaZulu-Natal mentioned they believed they were not allowed to study, whilst half those from Gauteng were under this impression. Type of study during the year was also clearly related to the respondents’ intention to leave. This is illustrated via consideration of the intention of the doctors in the sample.

Doctors Leaving prolonged

Leaving short period Undecided Staying

Masters / honours / Primaries 0.0% 55.6% 40.0% 12.5% ATLS / ACLS/ PALS etc 55.6% 22.2% 13.3% 37.5% Diploma / certificate outside discipline 0.0% 0.0% 6.7% 12.5%

Diploma / certificate extending skills current scope of practice 44.4% 22.2% 40.0% 37.5%

Under impression/ told were not allowed to study 11.1% 11.1% 6.7% 0.0%

19.6% of the respondents suggested factors which would be of assistance. We see that time to study is the major problem, followed by “senior support”:

0.0% 5.0%10.0%15.0%20.0%25.0%30.0%35.0%40.0%

Time

Senior support

Money

Accessibility/ accredited env.

Other

Computers / libraries

Q26 All Assistance Factors

Doctors All

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Within doctors, money was mentioned relatively twice as frequently by male doctors (28.6% vs. female 11.9%). The graph below provides the pattern of suggestions by province.

0%

20%

40%

60%

80%

100%

Computers /libraries

Other Money Accessibility/accredited

env.

Seniorsupport

Time

Q26: Suggested Support by Province

Eastern Cape Free State Gauteng Kw aZuluNatal Mpumalanga Western Cape

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14.2. Intention to Study Further 14.2.1. Training Content and Timing 87.4% of the sample responded to this question, with 78.8% of this group indicating that they would be undertaking some form of further training. The greater proportion of the people intending to complete further training (36.5%), have firm and immediate plans as they claim they will begin studying “next year” 8.0% are not sure when they will start, with 35.6% not indicating an enrolment date. Allied healthcare professionals were not quite as likely as doctors and pharmacists to embark on further training immediately after their community service year. Doctors who completed their CS in the Free State (55.6% of them) and KwaZulu-Natal (51%) intend starting their further studies “next year” (2008). A higher proportion of female doctors indicate a next year start date (47.1% vs. 37.3% of male doctors).

Intended Training Area Total Mention

Specialising 33.9% Masters / honours/PHD 18.5% Diploma / certificate / degree extend skills current scope of practice 25.9%

ATLS / ACLS/ PALS / emergency medicine 5.4%

Management / MBA 4.8% Diploma / certificate/ Masters outside current discipline 2.6%

Change of direction 0.9%

Other 1.1% No reply not sure 13.4%

Where topics were indicated, doctors’ main interests for diploma subjects were emergency medicine, anaesthetics and HIV. Pharmacists were interested in management, Occupational Therapists in Sensory Integration, Physiotherapists in moving to a Masters degree. Environmental Health Officers intended completing a B Tech and Radiographers training for CT and MRI. It is likely that community service is seen as an impediment to academic development by some respondents. The speed with which respondents will start training is directly related to the CS satisfaction clusters, with intended next year start dates for 45.9% / 39.6% / 32.0% of least to most satisfied.

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%


42.7%32.4% 28.7%

13.0%

13.5% 16.3%

3.8%

0.0%10.1%

Q27: Further training timing

Next year One to two Longer

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Doctors: Intended Speciality Count Doctors: Diploma / Qualifications Count

Surgical 17 Emergency ATLS, APLS, D PEC, etc 20

Paediatrics 16 Anaesthetics 13 Anaesthetics 12 HIV 12 Obs & Gynae 10 Obs & Gynae 3 Internal medicine 8 Paediatrics 3 Psychiatry 7 Child Health 1 Ophthalmology 5 mplantology 2 Orthopaedics 4 Radiology 4 Family Medicine 4 Urology 3 Aviation 2 ENT 2 Neurology 2 Speciality not indicated 16 Not sure 7 Single mention 15 Single mentions 8

0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%

Black White Indian Coloured

32.7%43.8%

55.8%

20.0%

22.4% 6.3%

11.6%

20.0%

2.0%

6.3%10.0%

Q27: Doctors by Race

Next year One to two Longer

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14.2.2. Intended Provider At this stage the “provider” plans of 60% of the people intending to complete further training were not yet finalised. The balance often indicated “options” depending on their life plans, securing a post and acceptance by the various institutions.

29.7% Not indicated 8 The hospital I work in 10.0% Not sure / Depends where work 9 University W Cape 1 University of KZN 10 UNISA 2 University of Pretoria / Tuks/UP 11 Walter Sisulu University 3 University of Witwatersrand (Wits) 12 University of Free State 4 University of Cape Town 13 Professional Society / SAICI 5 Univ. of Stellenbosch / Tygerberg 14 CPUT 6 College of Medicine 15 Medunsa 7 Any SA university / top five/ selection of 16 University of Technology/ Durban / Tshwane

Current province of respondents appears to play a part in training institution choice. In

• KwaZulu-Natal: 34.7% of respondents in KZN, choose UKZN • Gauteng: 18.0% choosing Wits, same % University of Pretoria • M Mpumalanga: 30.3% UP, 18.2% Wits • Eastern Cape: 15.3% • Free State: 7.7%

0.0%2.0%4.0%6.0%8.0%

10.0%12.0%14.0%

1 2 3 4 5 6 7 8 9 10

Q27: Future Training:Top 10 Institutitons of Choice

All Doctors

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15. attitude to career environment

On a first as well as total mention basis, respondents claimed that “Helping people with a genuine need” was the most satisfying aspect of their work. (Open ended question 33). This was followed by the ability to “gain experience from a wide range of pathology”, and to “make a difference” in peoples’ lives. (For full description of attributes see Appendix F.) When racial demographics are brought into account, we see that a differentiating factor for black respondents is their awareness that they have of their “ability to make a difference” or affect the quality of their patients’ lives. (23.7% first mention vs. profile of 16.3%) Male respondents were more likely to first mention “experience” as a positive factor (25.6% vs. 14.5% of the females), but this difference disappears when considering all mentions. Overall, females were more aware of the “ability to make a difference” (31.2% vs. males’ 24.0%) and enjoyed the “educating and empowering role” (7.7% vs. 2.5% of males). Gender discrimination has not yet disappeared in the healthcare environment, with female respondents making more (total) mention of “inclusion” (8.0% vs. 4.1% of males)

0% 5% 10% 15% 20% 25% 30%

Percentage Mention

Job Security

Improve Access

Educating

Job Satisfaction

Prof Inclusion

Independence

Other

Rural experience

Appreciation

Difference

Experience

Help Needy

No reply

Q33: Satisfying Attributes in Healthcare

First Other

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The table below shows that there is also no doubt that doctors are driven by different factors compared with their healthcare professional colleagues. If gender differences are taken into account amongst doctors, then we see that female’s contribute slightly more to the lower factor of “ability to make a difference” and to the higher level of appreciation of clinical independence.

First Mention Doctors Pharmacists Allied Total

% within Profession Base: 190 72 175 437

Helping people in need / genuine need / underprivileged /great need working with patients 19.5% 41.7% 27.4% 26.3%

Ability to make a difference / in peoples lives / community / patients well being/quality of life 10.5% 20.8% 20.6% 16.2%

Opportunity to gain experience /skills / see wide variety of pathology /medical conditions 28.9% 5.6% 9.7% 17.4%

Clinical Independence / do different procedures and gain maturity. The challenge 6.8% 2.8% 3.4% 4.8%

Appreciative patients / gratitude/ response 5.8% 12.5% 12.6% 9.6%

Rural people / surroundings / experience/ benefits/ personal reward 8.9% 2.8% 6.9% 7.1%

Job satisfaction / love my work / emotional reward / motivational 5.8% 4.2% 0.6% 3.4%

Within Allied Professions the claimed level of enjoyment recorded for “ability to make a difference” and”Educating and empowering patients” are both directly related to the identified level / clusters of satisfaction for the CS experience.

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16. emigration issues

16.1. Environment Factors: Importance and Status Respondents replies to Q37 and Q38 in which they rate the importance and status of various factors provides a useful insight into the factors which cause healthcare professionals to leave or stay in the country. In the table below the ratings are considered relative to the intention of respondents to emigrate. Significant ratings are highlighted.

Q37 / Q38 Mean Ratings Importance and Status

Importance Mean

Status Mean

Importance Mean

Status Mean

Prolonged 4.74 3.10* Prolonged 4.10 3.80* Short 4.51 4.00 Short 3.97 4.59 Undecided 4.63 3.43 Undecided 4.02 4.11

Working Conditions

Staying 4.58 4.23

Leadership

Staying 4.00 5.22* Prolonged 4.20 3.01* Prolonged 4.44 3.87* Short 4.21 3.92 Short 4.30 4.45 Undecided 4.41 3.56 Undecided 4.40 4.11

Being valued/ appreciated

Staying 4.05 3.99

Availability of equipment

Staying 4.29 5.23* Prolonged 4.28 4.48 Prolonged 4.19 3.45* Short 4.16 4.91 Short 4.24 4.35 Undecided 4.40 4.61 Undecided 4.38 3.72

Availability of medicines

Staying 4.17 5.01

Promotion prospects

Staying 3.9* 4.66 Prolonged 3.91 4.02 Prolonged 4.47 3.89* Short 3.67 4.78 Short 4.30 4.51 Undecided 4.04 4.52 Undecided 4.41 4.02

HIV Aids issues

Staying 3.59* 4.76

Career path

Staying 4.12 4.85 Prolonged 4.20 3.25 Prolonged 4.6* 2.99* Short 4.15 3.93 Short 4.39 4.19 Undecided 4.26 3.81 Undecided 4.44 3.74

Work overload

Staying 4.21 4.30

Manage-ment's ability

Staying 4.16 4.77 Prolonged 4.50 2.69* Prolonged 4.42 4.31* Short 4.43 3.47 Short 4.33 5.14 Undecided 4.55 3.42 Undecided 4.40 4.85

Sufficient staff

Staying 4.42 3.70

Prof-essional behaviour

Staying 4.14 5.81 Prolonged 3.24 4.06 Short 3.22 4.77 Undecided 3.24 4.35

Private practice challenges : note lower level of importance

Staying 3.26 4.61

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Hence we can conclude that (overall) people who intend leaving for prolonged periods feel generally much less appreciated. Significantly they:

• Have a lower rating of leadership and managerial ability

• Have a lower perception of the status of working conditions (which includes lack of sufficient staff, availability of equipment);

• Feel that career development will be limited (career path and promotion prospects), and

• Are more critical of the level of professional behaviour in facilities.

The analysis of these factors by profession shows that different factors are significant in their emigration behaviour:

• Doctors

• “Management’s ability” , “Professional behaviour and “Promotion prospects”: are all “Important” and also have a low “Status” rating.

• “Status” of “Being valued” and “Availability of equipment”

• Pharmacists

• The “Status” of “Management’s ability”, “Availability of equipment”, “Career path” and “Leadership”

• Allieds

• “Importance” of “Professional Behaviour”, “Promotion prospects”, “Being Valued” and “Availability of equipment”

• “Status” of “Working conditions”

Respondents who intend staying are conversely less critical of the issues mentioned above. They:

• Rate “HIV issues” significantly less important,

• And are less ambitious in that “Promotion prospects” are less important and/or they view them in a more optimistic light.

As mentioned previously, the CS Satisfaction cluster position is a predictor of the emigration intentions of individuals. Hence recommendations to give attention to negative factors have been included in the executive summary of results. The ratings of factors affecting the emigration decision in Q37/38 also point to significant differences in the approach to the work environment by race.

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Importance Black White Indian Coloured HIV Aids issues 4.05 3.64 4.02 4.36 Work overload 4.43 4.02 4.56 4.33 Sufficient staff 4.42 4.40 4.65 4.75 Management's ability 4.11 4.45 4.58 4.47 Professional behaviour 4.10 4.27 4.63 4.67 Status Black White Indian Coloured HIV Aids issues 5.20 4.19 4.25 5.61 Leadership 4.51 4.15 4.10 6.33 Career path 4.58 4.08 4.16 5.42 Management's ability 4.32 3.63 3.58 5.77 Professional behaviour 5.40 4.80 4.71 6.17

16.2. Drivers to Stay

Q33 Satisfiers: First Mention Leaving prolonged

Leaving for short period Undecided Staying Total

% within Q35Crossview Base 77 133 135 77 422 Helping people in need / genuine need / underprivileged /great need working with patients

23.4% 24.8% 28.9% 29.9% 26.8%

Ability to make a difference / in peoples lives / community / patients well being/quality of life 15.6% 15.0% 18.5% 18.2% 16.8%

Opportunity to gain experience /skills / see wide variety of pathology /medical conditions 22.1% 18.0% 19.3% 10.4% 17.8%

Clinical Independence / do different procedures and gain maturity. The challenge 9.1% 2.3% 5.2% 3.9% 4.7%

Appreciative patients / gratitude/ response 10.4% 10.5% 9.6% 7.8% 9.7% Rural people / surroundings / experience/ benefits/ personal reward 2.6% 12.8% 3.0% 7.8% 6.9%

Job satisfaction / love my work / emotional reward / motivational 2.6% 3.8% 3.0% 5.2% 3.6%

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When satisfaction clusters are considered in conjunction with the open-ended response in Q33 we see that the “least satisfied” cluster has less mention of helping people; express a higher level of appreciation for clinical independence; is less concerned with educating patients and exhibit a lower level of job satisfaction.

Overall Satisfaction Clusters Q33 Satisfiers: Total Mention

Low Medium High

Helping people in need / genuine need / underprivileged /great need working with patients 26.3% 34.5% 32.4%

Clinical Independence / do different procedures and gain maturity. The challenge 17.5% 9.2% 11.1%

Educating and empowering (patients/clients/ co-workers) 1.3% 4.2% 8.0%

Job satisfaction / love my work / emotional reward / motivational 1.3% 6.7% 6.2%

When considered against work satisfiers, we see that doctors who say they are leaving for a prolonged period have a higher mention of enjoyment of “opportunities to gain skills” (37.55% vs. total doctor mention of 29.3%) and “clinical independence” (12.5% vs. 6.5% of total doctor mention). Doctors who are “Undecided” about leaving demonstrate a higher level of satisfaction for “Helping people in need” (26.2% vs. total doctor first mention of 20.1%). When total mention of things enjoyed about being a healthcare professional is taken into account, we see that doctors intending to leave for “Short Periods Only” are apparently torn between desire to “Obtain skills” (50.8% vs. 44.6% doctor total mention for this factor) and for their appreciation of the “Rural experience” (20.3% vs. 12.6% total doctor mention)

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16.3. Push / Pull Factors

16.3.1. Factors Disliked (Q34)

Whilst salaries play such a huge role in the workplace decisions of healthcare professionals, the impact of “Workload” and the “Lack or state of resources” emerge as the top of mind and overall mention factors which are disliked. It is not just the absolute amount of money that concerns the respondents. The concept of “Salary” needs to be understood in relation to the professional value of the individual plus the amount of work that is expected of him / her. In all these facets healthcare professionals feel underpaid, and by implication their worth or contribution is undervalued.

1 Patient and public abuse / insults / no respect/ interaction issues

7 Systems / frustrating / bureaucracy / time waste / constant battle

2 Cannot deliver. Standards: poor / inadequate / insufficient / lack professionalism

8 Burden of: disease (HIV) / crime / environment/ trauma

3 Incompetent /uncaring/ wrong referrals / unfriendly / unhelpful /lazy staff

9 Not appreciated or valued / not recognised / neglected / abused

4 Working conditions /environment / hospital conditions

10 Salaries / poor / underpaid/ pathetic / not enough poor conditions of service

5 Management: poor / incompetent / inefficient / discriminatory / don’t care

11 Lack of resources / medicines /equipment / facilities / Poor state of

6 Other 12 Work overload / stress / hours / overwhelming # patients/ staff shortage

0%

5%

10%

15%

20%

25%

30%

1 2 3 4 5 6 7 8 9 10 11 12

Q34: Total: Factors Disliked

Other MentionsFirst Mention

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16.3.2. Attitude to Emigration A highly significant relationship exists between the respondents’ attitude to community service (Q17) and the stated emigration intention. The less positive, the more likely a person is to intend leaving. Similarly, the more positive, the more likely the person is to stay. Since a change in attitude for the positive is also high significantly related to emigration intentions, we can probably conclude that a person’s experience of community service confirms his/her expectations. If they are negative to start they will not have a good CS experience, and if they are positive then these feelings will be magnified.

All: Attitude to CS vs. Emigration

Leaving prolonged


Base 89 142 154 85 470 Disagree 30.3% 9.2% 23.4% 10.6% 18.1% Neutral 19.1% 23.2% 27.3% 10.6% 21.5% Agree 50.6% 67.6% 49.4% 78.8% 60.4% 100.0% 100.0% 100.0% 100.0% 100.0%

All: Attitude: CS change vs. Emigration

Leaving prolonged



It is important to note that individual community service facilities could play a role in the decision of the CS professional to emigrate. We see that the intention to remain within the same institution is significantly related to emigration attitudes.

Intention to Stay in CS Facility

Leaving prolonged



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University of origin (and not province of community service) is a significant factor in the pattern of emigration intentions. Respondents from universities in the Western Cape are more likely to want to go for short periods, whilst the Gauteng based ones are more likely to consider prolonged absences.

0.0% 5.0% 10.0% 15.0% 20.0% 25.0%

Transkei / Walter Sisulu

Free State

Univ of NW /Potchefstroom

Medunsa/ Univ. of Limpopo

Cape Tow n

Kw aZuluNatal

Wits

Pretoria / Tshw ane

Stellenbosch / UWC

Q35: All: Emigration Attitude by University

Total in Sample Prolonged Short

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16.3.3. Top Factors Both positive and negative issues are raised by respondents: “The new affirmative action-based election of candidates for registrar posts. I don’t qualify because people less experienced than I have received registrar posts for 2008 above me.

“I want to explore the world whist young with resources at hand! Good pay cheque is a bonus

__________ On a first mention basis (35.8%) and overwhelmingly on all mention basis (72.5%), salary issues emerge as the principle driver for healthcare professionals to consider leaving the country. As mentioned above, the respondents’ view of their salary needs to be considered at an “absolute” level, as well as in relation to other professionals’ salaries. Again here they mention the lack of benefits and their feeling that salaries are totally out of proportion to their professional value and input (especially long hours by doctors) into the healthcare system. “Crime” (11.9%) and “Safety” (7.1%) usually mentioned in context of violence) were second and third on the list of first mention top factors. However, when all mentions were considered, these national issues took back seat to the personal interest of respondents to:

• Gain more professional experience (29.6%)

• Work in better and first world conditions (27.1%)

• Travel (23.9%), and

• Further their career (22.5%) (This factor related in many cases to the ability to find a job / registrar position.)

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0% 10% 20% 30% 40% 50% 60% 70% 80%

HIV issues

Valued

Job satisf 'n

Management

Educ'n

Std of care

Personal

Know ledge

Hours

Qlty Life

Resources

Politics

Career

Travel

Family

Work cond.

Experience

Safety

Crime

Salary

Q36: Total: Top Motivators

First Mention Other Mention

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16.3.4. Stop Factors Another respondent’s comment (taken in conjunction with the remarks with regard to leaving public service and management issues) emphasises that it is not salary alone, but the administration of salaries that give rise to despair. (We Need) “Health Department H R which is improved because it is not fair working without pay.

__________

“Family” is top of mind when considering what would make one stay in South Africa. However the importance of improving the financial situation and work environment comes through clearly. It would seem that availability of posts has hindered some individuals from working in the public sector. Doctors are more concerned with registrar / training posts, and Allieds with the sheer availability of posts in areas where they would like to work. On its own, the Department of Health cannot address the general issues of creation of a safer country, which is the fifth factor mentioned by respondents. Since workplace safety has been shown to play an important part in the community service experience, it would be constructive to take steps to reduce the level of safety risk in the immediate surroundings of healthcare professionals – i.e. the hospital facilities.

0% 5% 10% 15% 20% 25% 30% 35% 40% 45%

Suff icient staff ing

Immense need

Govt policy/attitude change

Improve management

Recognition / valued

Nothing stop me

RSA w eather/home

Safer /no crime

Career/job opportunities

Better w ork env.

Better salary

Family

Q39: All Stop Factors

First Mention Other Mentions

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16.3.5. Message to Colleagues Abroad The appeal of “home” and all that it stands for is uppermost in respondents’ replies. We also note a reluctance to be judgemental about departed colleagues. “I wouldn’t do that,(tell them to come back) only if things change dramatically for the better. They will also want to see before they believe. People who leave to work overseas have reasons enough to leave this beautiful country. “I would not persuade them to return. They are very happy abroad

“Difficult with the current status

“If crime comes down, then I would persuade them. And salaries don’t show our worth!

“Be proud of your roots

__________ 25.1% of the sample did not answer this question, and a further 27% said they had “Nothing” to say and another 6% said “Don’t Know”. The “strongest” positive message from this year’s community service professionals is that the people abroad should come “Home”, (17%) where the concept includes the presence of family; our beautiful country, fine weather and (in spite of comments in Q36) the good life enjoyed by South Africans. This sentiment is stronger from “unmarried” respondents (23.4%).

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A higher proportion of doctors feel there is “nothing to say” (32%), and “Don’t know” (8%). They appear less emotional in their appeal, as they mention “Home” (13%), and “Rewarding” (7%) less frequently than the respondents as a whole. 58.1% of the doctors who intend being away for a “Prolonged” period felt that there was “nothing to say”, as did 67.4% of the “least satisfied” cluster of doctors. Only 7.4% of Allied professionals in the group intending to be away for a “Prolonged” period mentioned the appeal “Rewarding”; compared with the 22.75% of “Short Period” and 30.4% of “Stayers” also in the allied professions. Within the Allied professions there is a direct relationship between the proportion making an appeal of “Rewarding” and the “Satisfaction Clusters” identified relative to the CS experience. Gender differences are seen in a higher female appeal to “Professional Obligation / Patriotism” (12.1%) and a male inability or unwillingness to even try (“Nothing” of 41.3%) On a provincial level Eastern Cape respondents were more likely to mention the incredible need (20.4%) and the rewarding aspect (18.5%) of services. Those in the Free State (34.1%) and Mpumalanga (30.8%) demonstrated a higher level of appeal to come “Home”.

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17. conclusions

This study measured the areas of the community service experience first suggested by Prof. Steven Reid’s initial research undertaken when community service was introduced. Via an analysis of the relationships of responses to those factors and to the intended actions of respondents, this study:

• Established the concept of “Satisfaction Clusters” and found that

• The “Most Satisfied” cluster consists of respondents who obtain their first choice of placement; who feel they have been well equipped and oriented; who have had the support and availability of their superiors; and feel that the experience is worthwhile because they have “made a difference”.

• In addition it was found that “Risk to personal safety” and the rating of “Management’s ability” are also significantly related to satisfaction levels

• Relates the intentions, or otherwise of healthcare professionals to remain in public service, to emigrate and / or to work in rural areas to their position in the satisfaction clusters

• Identifies “Salary” as the key push factor for all respondents, both out of public service, and out of the country. It should be noted that the dissatisfaction of the community service healthcare professionals is related not only to the absolute level of the salary, but to their inherent professional value and the high service levels / workloads expected of them.

• Shows that (other than salary)

• Doctors leaving public service are more likely to do so because of managerial issues and frustration with inefficient systems

• Pharmacists are the most conscious of salary inequities, and are more likely to leave because of the lack of career prospects and lack of job satisfaction

• Allied professionals identify a lack of job opportunities

• Relative to prior research suggests that:

• Supervision and CPD issues encountered in rural areas by prior community service healthcare professionals have not yet been resolved

• Working conditions and lack of resources also remain problematical

• There may currently be a higher level of intention to work in public service

• Identifies fundamental differences between the attitudes of people who intend emigrating and those who intend remaining in the country or simply exploring the world for professional and personal growth.

• Respondents who intend leaving the country feel less valued and are highly critical of management’s ability and rate the status of working conditions, the shortage of resources, work overload and professional behaviour lower than their colleagues. They appear to feel there is no place for them in South Africa as they also rate their promotion prospects and availability of a career path significantly lower.

• Respondents who indicated they were “Staying” consistently rate the workplace factors at a “better” level than their colleagues, especially their career path and promotion prospects. They also appear to have relatively more faith in the leadership and management’s ability

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• The ratings of respondents who were “Undecided” about their emigration intentions tended to be closer to those who intended departing.

• On a spontaneous (all mention) level, respondents name the top emigration motivators as:

• Salary • Experience • Working Conditions • Travel and • Career or job prospects

• And say that considerations for staying in the country include:

• Family • Better salary • Improved working environment • More career prospects / job opportunities and that it should be • Generally a safer environment with less crime

Essentially the results call for action to take note of the factors influencing young healthcare professionals workplace decisions and:

• Review the salary levels of healthcare professionals

• Improve managerial skills and personal skills, thereby improving the capacity of management to solve problems, be more available to their staff and provide better levels of supervision, and

• On behalf of community service healthcare professionals, improve working conditions with particular reference to

• Reviewing systems with a view to simplifying them and achieving more efficiency / fewer delays

• Reducing work overload through introduction of additional professional staff and skills upgrading of existing support staff

• Increasing workplace safety

• Increasing availability of resources and equipment that functions

• Provision of accommodation that is in a habitable condition. If the above was done there is no doubt that retention of personnel in the public healthcare system would be raised, as the environment would be more attractive and fulfilling of their professional and personal needs.

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18. appendices

Appendix A: Questionnaire

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JOINT VENTURE:

RURAL HEALTH INITIATIVE

&

THE PLACEMENT PROJECT

Appendix B: Covering Letter Dear Community Service Officer

Thank you for your contribution to the South African public health service this year. This is an independent survey of your experiences and feedback as community service officers, in order to better understand the challenges you have faced, and to improve the system. You can be assured that your responses will be confidential so that you can be as forthright as you feel necessary. We are also interested in understanding the career plans and the movement of health professionals such as yourselves, after community service. All your comments will be valued, including open-ended feedback in addition to the questionnaire. These will be incorporated into a report and presentations to various stakeholders including the national Department of Health and Provincial Coordinators. The report will be available on www.foundation.co.za. Should you want information on job offers in South Africa please provide us with contact information, as this would also allow us to keep you informed. With thanks for your cooperation in anticipation

Yours sincerely Prof S Reid University of KwaZulu-Natal

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Appendix C: Sample Universe by Province

Provinces Doctors Pharmacists Allieds Total in Province

Eastern Cape 140 35 123 298 Free State 53 39 115 207 Gauteng 181 151* 358 690

Kwazulu-Natal 159 61 260 480 Limpopo 122 20 125 267

Mpumalanga 142 33 181 356

Northern Cape 67 23 103 193

North West 100 37 116 253

Western Cape 127 53 139 319

SAMHS 44 20 85 149

TOTAL 1135 472 1605 3212 * Note based on allocations as number “reporting for duty” not confirmed

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Appendix D: Research Ethics and Team

Research Ethics To encourage a free flow of information, respondents were assured that their replies will remain confidential and (if quoted) anonymous. Identifying information will be removed from any questionnaires that are viewed by people other than the research team. Both Prof. S Reid and Ms H Strong are members (and therefore bound) by the Code of Ethics / Conduct of their respective professional bodies

Research Team Prof. Steve Reid Steve Reid is a Family Physician and Associate Professor at the Nelson R Mandela School of Medicine, University of KwaZulu-Natal, where he is the Director of the Centre for Rural Health. He has extensive experience in clinical practice, education and research in the field of rural health in South Africa. He teaches undergraduate and postgraduate students in public health, family medicine and health promotion, around the theme of Community-Oriented Primary Care (COPC). He has published extensively on the issue of compulsory community service, and is currently involved in numerous research projects in the field of rural health, including medical education, human resources for health, and HIV and AIDS.

Ms Helen Strong B.Sc (Natal), Dip M Research & Advertising (UNISA), MBA (Wits) Trained at Market Research Africa, a leading market research company, Helen Strong gained extensive experience as a research officer working in the fields of advertising, fast moving consumer goods, publications and as a marketing executive at S.A. Medical Association. She has been a full member of SAMRA (S.A. Marketing Research Association) for a period of nearly 40 years. She uses her business qualification to good effect in her ability to design research, which will deliver decision data and enable identification of strategic opportunities and threats.

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Appendix E Statistical Analysis

E1 Statistical Analysis Software All statistical analyses in the present study were computed using the SPSS statistical package for Windows version 14 (SPSS, 2005). SPSS stand for Statistical Package for the Social Sciences

Significance Testing The current study employed the following statistical tests to establish significant differences: Chi-Square The Chi-Square Test procedure tabulates a variable into categories and computes a chi-square statistic. This goodness-of-fit test compares the observed and expected frequencies in each category to test either that all categories contain the same proportion of values or that each category contains a user-specified proportion of values (SPSS 11.5:2004). This is the significance test used when making use of the cross-tabulation technique and is useful to determine significance difference amongst categorical variables. Anova Kazmier (2003: 116) describes the ANOVA test as “the one-way analysis of variance procedure is concerned with testing the difference among k sample means when the subjects are assigned randomly to each of the several groups”. The reference to k sample means refers to the number of groups for which means are compared and this test is therefore useful to compare two or more group means. Significance testing for all variables that were measured on interval scales, or for which means could be calculated, were done by means of this ANOVA test. Sources Kazmier L.J. Schaum’s Easy Outline of Business Statistics. 2003. McGraw-Hill Publishing: New York.

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E2 Regression Analysis for Attitude Change All statistical analyses in the present study were computed using the SPSS statistical package for Windows version 14 (SPSS

Predicting what influence the change in attitude for the positive (Q18) The analysis took into account responses to Q11,Q12,Q13,Q14,Q15,Q16, Q20

Stepwise regression model summary

Model R R Square Adjusted R

Square Std. Error of the

Estimate 1 .430(a) .185 .181 .736 2 .527(b) .278 .271 .694 3 .559(c) .312 .302 .679 4 .576(d) .331 .319 .671

a Predictors: (Constant), Q20 I feel that I have personally made a difference this year

b Predictors: (Constant), Q20 I feel that I have personally made a difference this year, Q15 My seniors have always been available when needed help

c Predictors: (Constant), Q20 I feel that I have personally made a difference this year, Q15 My seniors have always been available when needed help, Q13 I have experienced significant professional development this year

d Predictors: (Constant), Q20 I feel that I have personally made a difference this year, Q15 My seniors have always been available when needed help, Q13 I have experienced significant professional development this year, Q16 I have coped well psychologically

The first thing that influences attitudinal change for the positive is the feeling that they have been able to make a change. This factor explains 31% of the independent variable. Seniors also play a very important role as it is the second variable that enters into the equation. Model 4 explains only a small amount more variance then model 3 and therefore model 3 would be the optimal model. But this does present a picture of what variables are most important to drive a positive change in attitude.

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Appendix F: More Detailed Descriptions

Q33: What are the things that you enjoy / are most satisfying about being a healthcare professional in SA? Valid % on Base 437 Helping people in need / genuine need / underprivileged /great need working with patients 26.3

Opportunity to gain experience /skills / see wide variety of pathology /medical conditions 17.4

Ability to make a difference / in people’s lives / community / patients well being/quality of life 16.2

Appreciative patients / gratitude/ response 9.6 Rural people / surroundings / experience/ benefits/ personal reward 7.1 Other 6.6 Clinical Independence / do different procedures and gain maturity. The challenge 4.8 Professional inclusion / cooperation / guidance / acknowledgement/ colleagues 3.4 Job satisfaction / love my work / emotional reward / motivational 3.4 Educating and empowering (patients/clients/ coworkers) 2.1 Improving access / is a need to / many people need services 1.6 Job security 1.4 Total 100.0

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Q39: What things, if any, would stop you from leaving South Africa to emigrate or work abroad?

Valid % on Base 442 Family / parents/marriage 23.3 Better / increased salary benefits/package 20.4 Improved / better working environment / hours / resources 10.4 Career prospects / registrar post/ finding a job 8.8 Safer / crime free environment 8.1 South Africa s weather / beautiful country/ people/ its home /like it /no plans to leave 6.3 Other 5.7 Nothing would stop me from leaving 5.2 More recognition and appreciation / feel valued 3.8 Improved management and system / support 2.7 Govt Leadership and delivery / remove discrimination 2.5 Challenge of working in SA keeps me / massive need / commitment 2.0 Sufficient healthcare staffing 0.7 Total 100.0

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Q40 What would you say to your colleagues to persuade them to

come back to work in SA?

Leaving prolonged


% of total mentions on base 66 110 115 64 355 Nothing / can’t think of anything to convince them / prefer not lying to my friends/ personal decision

47.0% 22.7% 35.7% 35.9% 34.5%

Home / where the family is / Great people / weather and country / good life

19.7% 30.0% 19.1% 17.2% 21.5%

Gain excellent experience and exposure / Prof Challenge/ Research opportunities

12.1% 18.2% 10.4% 9.4% 12.8%

Rewarding / come make a difference/ part of the change for better

6.1% 17.3% 8.7% 17.2% 12.5%

Incredible need/ Such a great need 13.6% 10.0% 11.3% 15.6% 11.7%

Appeal to professional obligation / patriotism 4.5% 15.5% 8.7% 10.9% 10.3%

Don’t know / would not know what to say/not sure of what to say

1.5% 6.4% 13.0% 9.4% 8.4%

Salary and working conditions are improving/ good jobs available / being recognised/ things will get better

7.6% 9.1% 8.7% 6.3% 7.9%

Other 1.5% 7.3% 1.7% 6.3% 4.1% Public sector would need to improve/ treat doctors better/ motivate staff/ long way to reach potential

4.5% 2.7% 3.5% 1.6% 3.0%

Participate in the rural experience/ diversity of cultures 3.0% 3.6% 0.0% 1.6% 1.9%

Offer a financial incentive / private opportunity 1.5% 1.8% 1.7% 0.0% 1.4%

122.7% 144.5% 122.6% 131.3% 129.9%

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Appendix G: Literature Review

In 1978 Alfonso Mejía (1) provided the world with a benchmark publication, detailing migration patterns of physicians and nurses. In essence he set the parameters by which migration is researched today. Mejía illustrated the devastating effect of the losses by pointing out that “The number of physicians abroad is, in the case of numerous countries equal to several years output from the medical schools of these countries (five years in the case of Iran and the Philippines). In addition his estimate was that the major recipients would need 7 years to replace immigrants with their own graduates. His findings regarding factors affecting migration were that

• “Most physicians and nurses who migrate are seeking to improve their professional and financial situations”. This was accompanied by the caveat that migration had to be considered against the international as well as the national conditions.

• The income differential between physician income in donor and recipient countries was significant

• No discernable relationship was evident between migration levels and the split in allocation of expenditure between public and private health expenditure in the countries of origin.

• The proportion of doctors in the rural and urban areas was appeared to be related to affluence but was not established as a migration factor

• In the poorer countries the low ratio of nursing personnel to physicians appeared to be related to physician migration

• Same language (English to English) determined the destination of migration

• More physicians migrated to the USA when the donor countries had a higher proportion of specialists

• Physicians were lost to countries that had relatively high production rates of physicians, without the capacity to absorb them.

Mejía described active recruitment steps taken by a number of countries to foster migration. These included changes in immigration laws (USA) and training capacity enhancement (Republic of Korea and the Philippines). At that time governments trying to curb migration attempted to control the ability of the doctor to practice legally, or made it difficult to leave. These steps included: practice licences (France); admission examinations (USA, Canada and UK); travel documents and currency and a system of bonding (Sri Lanka). No comment could be made on the efficacy or impact of the various steps taken. Various incentives (not described) were offered by some countries in an attempt to induce their own migrants to return. Studies were conducted in the UK ((6) Neil Johnson et al, 1998) regarding career outcomes of doctors who had undergone “vocational training”. If we assume that young doctors all have similar needs, then the outcomes introduce some factors to be considered when recruiting doctors to return to the RSA. In particular, it was found that gender affects work priorities. Both sexes were concerned with “out of hours” work; men with availability of posts in a select area, but women doctors were more concerned with, children and family plus inflexibility of hours. The first major finding of the study was that the final careers pursued by doctors completing vocational training were not substantially different from previous cohorts. Another point of note was that of those working in general practice; just over half remained in the area in which they were trained.

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The 1997 / 98 situation in America illustrated that the view held about the “market for employment” by migrants and home graduates is different. JAMA carried a report on the outcome of focus groups held to discuss career management in the light of the pressures of managed healthcare measures being imposed on healthcare. At the same time, the USA remained on the list of destinations as a “preferred destination”, with the irony that local Americans were either not entering the profession, or were reportedly leaving it. Circumstances in the NHS in the late 1990’s were already such as to discourage the local doctors from remaining in service, thus opening the door to the need for importation of foreign graduates. Senior staff in the UK expressed their dismay at the growing dissatisfaction of juniors in the face of an environment that was growing more demanding, and less satisfying. In his letter to the Journal of the Royal Society of Medicine (7, October 1997) Davis enumerates how the NHS environment was less empathetic and supportive of their junior doctors. In another letter to the editor, John Black felt that non-clinical options for medically trained personnel were not adequately promoted. Recommendations for solutions to the problem of attracting general practitioners to return are informed by the experiences in the UK. Young and Leese (15, 1999) established four factors, which were positive for recruitment and retention. These were: 1. Varying time commitment across the working day and week 2. Offering a wider choice of long-term career paths 3. Fine-tuning education and training 4. Widening the scope of remuneration and contract conditions

They also argued that salaried options were almost “inevitable” given the needs of younger doctors for less risk and greater flexibility in a structured working environment. They noted that policy-makers were beginning to recognise these needs and incorporate them in proposed legislation. South Africa’s concern with migration promoted a number of studies in the late 1990’s. By that time the Southern African Migration Project (SAMP) had been established and had conducted a study in conjunction with IDASA. It was established that (at 41%) safety and security was the single most important push factor. An improvement in safety (28%), family ties (17%) and love of the country (9%) emerged as top factors that would cause doctors to stay. Whilst conditions may have changed since then, it would seem the task of attracting doctors to return to South Africa is a challenge. At that time two thirds of the potential migrants planned leaving for more than two years, with a possible return on retirement. In 1999 Ghana’s Ministry of Health (10) undertook an evaluation of the reasons for the shortage of doctors in the rural areas of the Volta region. The already established motivators emerged: seeking better remuneration and conditions of service; better postgraduate training opportunities and to be able to afford basic life amenities (housing / car / appliances

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Country specific reasons also surfaced and included:

• Lack of incentives for hard work in Ghana

• Frustration of junior doctors due to their senior colleagues

• Inadequate opportunities available for postgraduate training

• Ill defined and poorly structured local postgraduate programmes and

• Delayed promotions

This research raised the question concerning whether the content of training should be adjusted to the health needs of a country, rather than aspiring to the (traditional) western hi-tech approach. The authors also considered issues around augmenting the skills resource pool through training of medical assistants to perform specific skills normally reserved for doctors. A useful side-effect of this approach being that the new trainees would be unlikely to find employment opportunities outside of Ghana. The study noted that senior doctors’ concern with their ability to fund retirement might have contributed to the exodus of that level of practitioner. On the other end of the age scale, it was noted that prolonged periods of bonding may simply result in abuse of the system. The practice should also not disadvantage job and specialist training opportunities for those graduates required to pay back loans. The role of bureaucratic red tape was noted in dissuading doctors to return to the country. South Africa experienced specific challenges due to the political and social transformation wrought by the transfer of power in 1994. Five years on, the impacts were considered in the article by van Rensburg and van Rensburg of the University of the Free State. They attributed the exodus of health professionals to stress generated by change. The prime and obvious changes occurred in the redirection of financial allocations and training priorities. This had the effect that “Many provincial HR spokespeople complained about the continuous disruptive effects of restructuring on motivation, morale, relationships and staff turnover, resulting in overburdening of remaining staff. Similarly, “new” and “old” management styles and organizational cultures, and “friction” between these, had and still have adverse effects on staff and relationships between them” Staff discontent was said to result from administrative, managerial and grievance factors, especially where provinces were deprived of resources as a result of the chaos. In particular doctors were said to be suffering from burnout when trying to cope in this environment. In looking at doctors’ alternatives to migration, Paulo and van Lerberghe (2000) (18) consider the role of international development agencies and NGO’s in keeping doctors in a country. Whilst they are lost to public service, they are at least available to contribute to the well being of the underserved population. This solution in some part addresses the predicament faced by the doctor in an environment that does not support his / her high professional and material expectations. In part it also resolves the dilemma of public authorities without the resources to provide for salary increases.

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The authors found that incentives born of performance management are probably inappropriate for the public health sector of developing countries. As they say “it is academic and futile to evaluate the performance of public health staff when they do not have a minimum of supplies or equipment, nor a decent living wage.” 1 In this paper the authors express the view that development of a “professional ethos” together with fostering a sense of commitment to the public good would clearly contribute to an improved health personnel performance. The work of Bennett et al (2000) (16) concentrated on developing tools to measure health worker motivation, especially in developing countries. They described the symptoms which had been established by a number of authors (Gilson et al / Mutizwa-Mangiza / Haddad & Fournier)(3) as:

• Lack of courtesy to patients

• Failure to turn up at work on time and high levels of absenteeism

• Poor process quality such as failure to conduct proper patient examinations and failure to treat patients in a timely manner

The International Labour Office in Geneva in developing policy responses to the international mobility of skilled labour (Papers 44 and 45, 2001) (21), grouped the policies into 6 areas (return, restriction, recruitment, reparation, resourcing (diasporas) and retention. The authors believing that “grand policies of retention are likely to be the best long run response to a brain drain.”

1 Given the heterogeneous nature of South Africa’s hospitals in the public service, application of performance related incentives

would probably need to be adjusted by location.

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Whilst South Africa could do well to regard this advice, it is a long-term solution, and it is expedient for the country to attempt to embark on immediate action to regain lost ground w.r.t. its human resources. Further in the paper it is noted, “...policies that stimulate return may have the greatest immediate impact on offsetting brain drain”. The authors point out that both the initial investment in education and a contribution of global experience is brought back to the resource capital. The ILO papers recognised that the direct impact of a sizable brain drain could have the effect of reducing the economic growth of the sending country. It also discussed the issue of how loss of citizenship in the home country could undercut any connection to the source and decrease the likelihood of return. Another issue raised (Paper 45)(20) with respect to South Africa was the difficulty (at that time) of immigrants not being available to replace the country’s lost skills due to the complex work permit processes. The concept of a “brain exchange” was explored, with the authors supporting the view that increased education in the supply countries would in the longer term attract back the lost resources. The rise in the 1990’s of networks to connect expatriates was attributed to the growth in the number of migrants in combination with the availability of the internet. This type of network of contacts built up when abroad were viewed as invaluable sources of knowledge and new technologies for returning immigrants. In December 2001 a report on Incentives, Performance and Motivation prepared by Hicks and Adams for the Global Health Workforce Strategy Group was released in Geneva (22). The current survey should take note of the reminder in this report of the work by Schein. i.e. that different incentives are more effective and appropriate if consideration is given to the age / professional life-cycle of the individual. The role of non-financial incentives in retention strategies is again underlined. The World Bank and WHO collaborated to hold a consultative meeting in January 2002 (23). This was an attempt to bring about partnerships in education and health in Africa since the failure to address issues was now resulting in a human resource crisis. At the top of the agenda was the World Bank’s view that education and training should be appropriate to the needs of the served population. Other issues included the importance of involving health professionals in the process of role definition and policy development; the urgency of improving the work environment, with particular reference to managing the impact of HIV Aids. At a jointly sponsored workshop (SAMP / LHR / HSRC) held in Pretoria in April 2002 it was established that South Africa’s doctor skill shortage only started in 1994, where the major motivating factors were said to be levels of taxation, cost of living, personal and family security, and the political situation. The World Health Organisation (Wim van Lerberge et al, 2002) noted that the attempts of countries to retain and deploy professional staff in rural areas had had a mixed result. Such initiatives as decentralisation of training institutions, recruitment quotas for medical students and compulsory rural service were all mentioned. Recommendations from the World Bank in tying financial benefits to completion of work in underserved areas were noted. The Bulletin raised the problems associated with trying to force only one sector of public servants to complete rural service, while noting that an increase in salary would probably not be sufficient to eliminate moonlighting. The authors’ advice being that the improvement of working conditions is more than an adequate salary and decent equipment. It includes the development of career prospects and provision of perspectives for training. Writing in “Human Resources for Health” in 2003, Stilwell (30) et al defined and studied the current trends in migration. Quoting 2000 estimates they found that almost 175million or 2.9% of the world’s population were living outside their birth country, up from 1.8% in 1995.

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The difficulty of tracking these trends was noted and the unreliability of sources such as administrative registers, visas, work permits and census surveys were considered. South Africa’s health worker contribution to the UK was said to be of the order of 4400 between October 2000 and March 2001, or over 25% of all work permits granted to South Africans. The authors note that the most recent figures showed that restraining measures had only had a transitory effect on migration. May 2003 saw the adoption in Geneva of a Commonwealth Code of Practice (31) by the Health Ministers of Commonwealth countries. This Code was intended to provide a framework for recruitment. It was an attempt to address both the ethical issues and practical problems associated the flood of migrants leaving their own countries. Even though the right of countries to seek human resources was recognised, targeted recruitment from countries experiencing shortages was discouraged. The Code also tried to balance the responsibilities of physicians and nurses who were legally or morally obliged to provide services to their own healthcare systems, with their right to seek employment elsewhere. The growing cooperation of the international community with Africa is evident in meetings and publications generated by collaboration between such organisations as Equinet, Health Systems Trust and Medact. The Equinet discussion Paper #3 (32) critically reviews the literature and confronts the maldistribution and brain drain in the Southern African region. In the paper the authors quote the official estimated loss of 82 811 South African doctors between 1989 and 1997 and its associated cost of US$5 billion as more than sufficient reason for concern. This paper recognises the frequently cited endogenous and exogenous push factors which work with the pull factors in recipient countries. The authors point out that there appears to be a new policy momentum in response to the increasing scarcity of skilled workers, taking place as the migrants vote with their feet. Since it was easier to emigrate from South Africa, the rest of Africa’s workforce used to treat the country as a temporary posting station prior to moving to their final destination. South Africa’s attempt to eliminate this practice through implication of a moratorium on registrations was noted. The main problem identified is that there is “...while a host of factors influencing personnel flows are identified, there is inadequate specific assessment of the relative impact of these factors in different settings with different mixes of personnel; and of how different policy measures have impacted on them objectively and from the view of stakeholders relevant to the issue. The authors note the 2002 findings of Bhorat, Meyer and Mlatsheni (27) in which they found that a high crime rate was the major reason for emigration. South Africans claimed that they left the country due to “the declining quality of life; general dissatisfaction with the cost of living; taxation levels; affirmative action and the standard of public services.” They also mention SAMP sponsored research of McDonald and Crush, which indicated a challenging picture in that “12% of respondents indicated there was nothing that could make them stay; 25% said that an improvement in safety and security would make them less likely to leave the country; 12% suggested that patriotism would influence their decision to remain in South Africa.” Transformation measures that had been introduced to correct the profile of medical students were considered to have the possible effect of resulting in a lower proportion of doctors emigrating, since white medical graduates were more likely to leave the country. It is pointed out that in a country the size of South Africa migration can have significant effects such as the closure of a spinal injury centre and the loss of institutional memory as turnover takes its toll in duplication of work and wastage of resources. These costs are not always factored in to the estimated impacts.

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These findings were also included in the work of Bhorat et al when they described the deficiencies within training institutions in supervision of new graduates, thus affecting the future production of health personnel. The Equinet review found that such an exodus of skilled personnel might create the perception of political and economic stability. This in turn is said to be associated with a decline in national output measures. These aspects of the impacts of migration are beyond the scope of this survey. The review notes, but does not comment on the efficacy of strategies to improve the location of doctors in rural settings. These include continuing medical education; rural allowances; establishment of locum relief schemes; recognition of the need for family support such as spouse employment, improved accommodation and suitable arrangements for education for children. One pilot project (Netcare) enabled their staff to enjoy the benefits of temporary migration but coupled participation with performance based incentives and long service awards. It was not clear whether this type of initiatives to reduce loss of private institution personnel had had any significant effect. It was noted that research conducted by S Reid in 2001 indicated that the programme had not yet had the desired effect of retaining young graduates. The number of doctors planning to work overseas had increased from 34% in 1999 to 43% in 2001. The proposed study is intended to measure the current level of intention to leave, and test the push, stick and pull motivating factors. WHO Africa Regional Office published the outcomes in 2004, of a major study, which had been conducted on six African countries (Awases et al). They found that there had been no change in the leading factors (economic, declining health services, lack of professional development and political situations of crime and violence). The migration to private practice, or out of the country had impacted on the quality, effectiveness and equity of care.

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They found, in the absence of significant improvements in conditions, that the corrective measures had largely failed to retain and attract new staff to the public sectors. South Africa, with its problem of maldistribution was singled out as having particular circumstances and more complex patterns of migration. A number of reasons for the situation were provided such as the legacy of apartheid policies, continuing presence of compulsory service (military service replaced with community service) and the failure of the democratic government to advertise rural posts sufficiently. The restrictive registration policies and import of Cuban doctors to augment the healthcare services were reportedly defended as being necessary to provide an orderly process and adequately trained doctors. Doctors in the various countries displayed high levels of intent to migrate. In South Africa 52% of intended moving to the UK and only 43% respondents were looking for international experience (demonstrating the relatively higher level of available education still in the country). Gender and age differences were noted in the study, with men being more concerned with family safety, and older doctors less likely to mention the workload as factors, younger doctors the need to “save money quickly”. South Africa had a higher mention (38%) of respondents mentioning the general decline in healthcare services. Factors related to the motivation to stay were measured as:

• 77.5% better salaries • 67.8% healthy working environment • 66.4% better fringe benefits • 58.7% more reasonable workload

• 57.8% improved facilities and resources • 52.6% better quality professional education and training • 51.9% more accessible training facilities • 39.7% provision of day-care for children (possible impact of changing profile of doctors?)

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• 37.9% innovative training opportunities (distance education) • 26.1% better working relationships in public sector • 24.9% better leaders in public sector • 24.5% more peaceful social environment • 23.8% more competent health service managers

Indicators of care in South Africa were such as patient waiting time, respect for patients, respect for caregivers, quality of care and availability of medicines were all shown to be problematical. Again this study indicates that the “return factors” include better remuneration, a conducive working environment, better management of health service issues, and opportunities for CPD. The public sector in particular should provide incentives in the form of loans for housing and transport, medical assistance and better retirement benefits. Particular benefits were deemed appropriate to attract doctors to rural service. However this should be couples with an improved infrastructure (roads / electricity/ water / accommodation) The introduction in South Africa of rural allowances, the database of professionals living abroad, RWOPS, and twinning (exchange of personnel) were all mentioned, but not commented on, in the report. In considering the effect of migration on service delivery, no new symptoms appear in this study. What is worrying is that the tempo of migration was said to be increasing, especially of nurses.

Suggested remedies include

• Better salaries • Better management and policies (based on comprehensive HR information systems) • Improved conditions (comparable levels of salaries with other professionals in the same country),

sufficient accommodation, transport utilities and • Recognition of the professional priorities of the doctors (opportunities for education). • Allocation of donor funds towards improved remuneration • Establish links via new technology to health workers abroad • Encouragement of international exchange programmes

The authors recognise that a reduction in emigration is dependent on the level of socioeconomic development and political stability in the country. A local study reported in by M R de Villiers in April 2004 in the S A Family Practice journal covering rural areas in the Western Cape confirmed that working conditions remained difficult for these doctors. “This study provides evidence that substantial after-hour duties, an excessive workload and a perceived lack of management support impact negatively on doctors’ views of working in district hospitals.” de Villiers concluded that equity of access to health would be impossible in the absence of corrective measures. He quotes other authors whose work at that time supported these outcomes. The outcomes of de Villiers’ research were combined into 3 major themes, which are important since they confirm the measures that will need to be in place to attract doctors to return to RSA.

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1 Knowledge and skills 3 Support structures

1.1 Scope of knowledge and skills 3.1 Specialist support

1.2 Knowledge and skills gap 3.2 Regional & tertiary hospitals

1.3 Knowledge and skills development 3.3 District Health System

2 Situational factors 3.4 Nursing staff

2.1 Remoteness 3.5 Other support staff & services

2.2 Job satisfaction 3.6 Community service doctors

2.3 Job frustration 3.7 Management

2.4 Work-related stress 3.8 Public-private partnerships

2.5 Community issues

In the same issue of SAFP de Vries and Marincowitz highlighted the additional stresses faced by rural women doctors. Their paper reflects that “gender issues” are international in nature, with the need for a woman doctor to achieve a balance between her responsibilities as a woman and her work. Migration would be “complicated” by the need to consider opportunities for spousal employment. At a meeting organised by EQUINET and the Health Systems Trust (April 2004) the high number and cost to country of absent professionals was reiterated. It was said at that time about 20% of the medical workforce in Canada, Australia and the USA was made up of international medical graduates; with over 600 SA doctors working in New Zealand. Factors first described by Mejía were expanded to include “poor levels of remuneration and salaries, lack of job satisfaction, work associated risks including crime and HIV/AIDS, lack of opportunities for further education and career development, frustration with civil service and industrial relations systems that are overly bureaucratic and policy responses such as Community Service that are perceived to be unfair or undesirable.” Pull factors were identified as the converse of the above, and the presence of aggressive recruitment campaigns. Broader social factors causing general migration included poverty, unemployment, quality of life and crime, lack of business and economic opportunities, war, civil conflict and political repression, lack of education opportunities for children. The meeting identified opposing forces in the decision to migrate

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Diagram summarising the forces influencing the migration decision

In a submission to the Commission for Africa by Physicians for Human Rights (PHR) in January 2005 concern was expressed that healthcare workers in Africa were “all too often unable to meet their own needs or those of their patients”. The submission described a situation in which lack of resources and poor management resulted stress and the “unbearable” situation where they were unable to provide proper care to their patients. Here again the push factors are identified as a lack of:

• Living wages and decent benefits; • Effective infection prevention and control, including gloves and other gear to protect health workers from

HIV and other occupational infections; • Psychosocial support and health care, including confidential health services; • Better pre-service training and professional development opportunities and clearer career paths; • Better supervision and management, and; • The investments in basic infrastructure that will ensure that health care workers have the medicines,

supplies, and equipment needed to perform their jobs.

Migrant

PUSH FACTORS

Income; lack job satisfaction; work associated risks; crime; HIV / Aids; lack of further education; career development; frustration with civil service

STAY ABROAD

New social and cultural bonds; children’s education; new lifestyle; lack of awareness of jobs at home

HOME TIES and opportunities

PULL

All the push factors plus recruitment; high morale; able to deliver high quality care; valued personally and professionally; appropriate supervision; rewards; status; salaries training, joining family abroad

STICK: morale, delivery good care & valued by society

Barriers: cost re‐qu

alificatio

n & relocation /

differen

t clinical practice / immigratio

n proced

ures

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PHR appealed for governments to allocate sufficient funds to healthcare; that donor funding should be extended to support the remuneration of healthcare workers; and some action taken to prevent active recruitment. By 2004 it was recognised that “globalisation” of health labour markets had changed the migration environment. Stephen Bach (in the WHO Bulletin) pointed out that economic necessity was out-stripping historical cultural ties in the determination of migration pathways. He also expressed the opinion that increased migration would “form a central component of health policy analysis for the foreseeable future.” Stilwell et al identified the emerging threat of new communication technology and the way in which it is shaping the global labour market. Job advertisements and education are available via the Internet, which also facilitates easier access to visas and emigration processes. They also mention the work of Vujicic et al, which (applying economic theory) showed that the wage differential had grown to such an extent that wage adjustments are unlikely to affect migratory flow. This tends to indicate other factors (such as social networks and the involvement of the family in the decision) have grown in significance. Of relevance to the current project, and where answers need to be sought, Saravia and Miranda (also in the WHO Bulletin) suggested, “Creating opportunity, then, is a necessary and effective strategy for redirecting patterns of migration.” In particular they recommend that funds should be directed to research and development as an incentive to attract people to come home. Migrants’ interest should also be captured through innovative graduate education opportunities which would also facilitate technology transfer can take place. The authors recognise that these are also appropriate retention strategies. The April 2004 report of the WHO Secretariat confirmed the already established factors, and presented the outcomes of an analysis of the outcomes of data from 5 African countries. From the table below we see that South African doctors are more concerned with remuneration and working condition issues.

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At the end of 2004 Hamilton and Yau in a paper published by the Migration Policy Institute, commented that migration was a symptom, and not the cause of collapsing healthcare systems in the developing world. They reiterated that the prime consideration was not necessarily remuneration, but the unattractive, unhealthy and sometimes dangerous working environment. Suggestions for improving the situation from this quarter included regulation of active recruitment (in line with GATS), and the introduction of shorter-term “training visas” (so that the doctors were not cut off from professional development). However, the literature also indicates that a certain level of scepticism exists surrounding the workability of the General Agreement on Trade in Services since there is no accepted definition of “temporary” to support its recommendations. The Institute supported the principal of compensation for loss of their human resources. And finally an appeal was made for donors to direct their funds at capacity building and resources rather than focus on specific diseases. The 2002 studies of Martineau (24) et al had indicated the possibility of abuse of migrants in that their skills are under-utilised, and that their salaries are not at an equitable level compared with local doctors. By 2005 the international community was trying to reconcile the individual rights of healthcare professionals, with the devastation being wrought in the health systems of the developing countries, which had provided the migrant workers. In an analysis conducted by Beuno de Mesquita and Matt Gordon,(45), the authors discuss the possible contribution of migrants in terms of remittances and intellectual capital on their return “home”. To optimise the potential benefits they recommend that:

• The root cause of migration should be addressed

• Co-operation and dialogue between providing and recipient countries is essential

• There should be a process to facilitate reintegration of returning migrants.

They note the recognition given to the complex situation in the “Cairo Declaration and Programme of Action”, adopted by States at the International Conference on Population and Development (1994) It is said there that “The long-term manageability of international migration hinges on making the option to remain in one’s country a viable one for all people.” The analysis notes that it is often the most talented and experienced workers who are capable of migrating. The impact on academic resources, and the overload spiral were then said to combine with the abnormal pressure of the HIV pandemic and (what could be considered as) abuse in the work environment, resulting in further migration. The role of international recruiting agencies was again mentioned as an important factor in accelerating the pace of migration. Mention is made in the analysis of the potential abuse of migrants in recipient countries where misrepresentation about working conditions and lack of professional development are potential problems for the individuals. The concept of managed migration is dismissed by the authors who claim “There is little evidence that managed migration has been successfully applied to ameliorate the problem of health worker emigration in any country suffering a real shortage.” In fact, they point out, an increase in migration rates is associated with the attempts in the UK to implement such a code.

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They also claim that there is no consistent evidence that other measures to retain healthcare professionals (such as bonding) have worked. However, they concede that it is possible that in the shorter term there is no loss of quality of care when auxiliary workers (trained to a lower standard) are used as substitutes. The authors conclude that this type of solution does not address the fundamental problem of the abuse of workers’ rights in work and a right to a decent standard of working conditions. It is obvious that the problem of loss of healthcare human resources is not limited to Africa. As recently as March 2005 the Ministers of Health for the Pacific Island Countries held a meeting under the auspices of the WHO (46). Listed push and pull factors were consistent with all those mentioned above. The point was made, however that the “return factors” were poorly understood. The meeting concluded that migration will not disappear, so “comprehensive and sector wide” steps need to be taken to limit adverse outcomes. The negative picture painted for the outcomes in the Pacific area of the reduction in healthcare workers is echoed throughout Africa. Such factors as delays in delivery, closure of services, excessive workloads, demoralised and burnt out staff; cost and competency issues associated with foreign workers; and the possible loss of lives were all mentioned. While noting the Commonwealth Code’s existence, it was criticised by this meeting as having being ineffective due to its voluntary nature and lack of legal status. Some African Governments took heed of the debate and tried to adjust their systems accordingly. In particular the outline of an interesting Zambian Retention Scheme was included in The World Health Organisation’ Advocacy Toolkit in 2006 (52) for World Health Day. That programme included personal and professional incentives, and was designed to attract healthcare workers to rural and underserved areas. The principal of the need to protect healthcare workers from HIV infection, and workplace accidents and violence was reiterated in this publication. The toolkit reported on a study conducted in the United Republic of Tanzania, where productivity levels were significantly improved through the support management and deployment of motivated staff. The impact of aging populations in the developed countries was noted as one of the pull factors, which found little resistance from healthcare workers experiencing difficult working conditions.

An appeal is made to receiving countries to

• Adopt responsible recruitment policies

• Provide support to human resources in source countries

• Ensure the fair treatment of migrant workers

Advice from the WHO to source countries was to develop strategies around:

• Adjusting training to needs

• Improving local conditions

• Making it easy for health workers to return home after working abroad

Whilst doctors do not choose to work in inhospitable places in their own countries, they are often used to provide coverage of these areas when they migrate. Chen and Boufford in 2005 in the New England Journal of Medicine (47) use the description “Fatal Flows” as this characterises the impact of medical migration. They point out that the American system is dependent not on all levels of skilled workers to provide healthcare for disadvantaged Americans.

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They estimate by this time that African countries need the equivalent of at least 1 million additional healthcare workers to be in a position to offer basic services with the United Nations Millennium Development Goals. The report by the Secretariat at the 59th World Health Assembly (49) outlines the challenges being faced by healthcare systems in developing countries. It is claimed that knowledge about migratory flows had improved considerably, (hence the statement could be made that for every 100 doctors working in sub-Saharan Africa, 23 African-trained doctors are working in OECD countries!). In addition research support had been provided and a network of partners established to share information relating to migration. However the Secretariat held out little hope that these measures would stem the flow. Without legal standing, ethical initiatives and the GATS appeared transitory measures at best. More hope was held out for the impact of a global alliance, which was to be launched in 2006 – advocacy and supporting partnerships together with development of workforce strategies and better knowledge management were believed to offer a solution to the migration problem. The escalating position is evidenced in IDASA’s African Migration and Development Series No 2, published in 2006 (50). They show that the number of South African doctors practicing in Canada has reached over 1600, and say that nearly three times more South African nurses work in the country than from the next most represented group (Nigeria). This situation is attributed to the continuing push factors on the continent. The propensity of doctors to remain in their adopted countries was confirmed by the quoted immigration status statistics where 280 SSA region doctors gained permanent residence in Australia between 1993 and 2004 and 1232 were given temporary status in the same period, with over half remaining in the country. The authors note the concern of the South African government regarding the healthcare worker migration and their recognition of the factors involved (where financial issues included earning sufficient to build a nest-egg and the desire of recent graduates to pay off debts)

Table 3: Number of Physicians from Principal SSA Source Countries Practicing in Canada, 1993 - 2003

Sudan Zambia Zimbabwe Ghana Uganda Nigeria South Africa

1993 7 8 13 27 59 39 1060 1994 7 10 15 28 54 38 1136 1995 7 9 15 28 57 46 1139 1996 7 9 15 31 58 49 1163 1997 7 10 16 30 57 56 1197 1998 7 10 16 31 57 61 1318 1999 8 10 16 31 56 69 1433 2000 11 12 16 33 57 78 1473 2001 13 14 16 35 58 93 1628 2002 14 14 17 36 61 117 1750 2003 15 14 19 36 63 135 1679 Source: Canadian Institute for Health Information, Southern Medical Database, Statistics gathered at special request of authors and issued by HIHI on 12 August 2005

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American, Canadian and Commonwealth professional bodies reached common ground when they met in April 2005. New Principles were formulated, later referred to as the “London Declaration”. The key points were:

• All countries must strive to attain self-sufficiency in their health care workforce without generating adverse consequences for other countries;

• Developed countries must assist developing countries to expand their capacity to train and retain physicians and nurses, to enable them to become self-sufficient;

• All countries must ensure that their health care workers are educated, funded and supported to meet the health care needs of their populations; and

• Action to combat the skills drain in this area must balance the right to health of populations and other individual human rights.

Canada’s suggested that a voluntary (or mandatory) code for ethical recruitment should be adopted. This idea was supported, but dismissed since most of the delegates believed that individuals were not actively recruited but were self-migrating. An editorial carried in a newsletter of the International Centre on Nurse Migration (51) reported the concern of the international health community regarding migration. For the first time ever the UN General Assembly in September 2006 had met to discuss the challenges faced by member states with respect to healthcare worker migration and development. A singular lack of progress was evident from the closing statement of the President of the Assembly when he affirmed that:

• International migration is a growing phenomenon and a key component of development in both developing and developed countries;

• International migration can be a positive force for development in countries of origin and countries of destination, provided it is supported by the right set of policies;

• International cooperation on international migration, bilaterally, regionally and globally must be strengthened; respect for human rights is the necessary foundation for the beneficial effects of migration on development to accrue;

• The need to provide decent work and decent working conditions in countries of origin and countries of destination is paramount to alleviating the negative aspects of migration, including brain drain; and migration is no substitute for development

Small-scale studies conducted by Kotzee and Couper (54) in the Limpopo Province in South Africa indicated that any changes in conditions have not managed to influence attitudes materially. The themes emerging from the interviews were almost the same as the push factors first reported by Mejía (1) in the 70’s and included:

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• “Increasing salaries and rural allowances;

• Improving rural hospital accommodation;

• Ensuring career progression;

• Providing continuing medical education;

• Increasing support by specialist consultants;

• Improving the physical hospital infrastructure and rural referral systems;

• Ensuring the availability of essential medical equipment and medicines;

• Strengthening rural hospital management and increasing the role of doctors in management; improving the working conditions;

• Establishing private-public collaborations with private general practitioners;

• Increasing rural doctors' leave allocations;

• Ensuring adequate senior support for junior doctors;

• Improving rural hospital environments and providing recreational facilities;

• Assisting rural doctors' families, and providing recognition and appreciation for the work rural doctors do.

Figures released by WHO in 2006 (56) demonstrate the gravity for Africa of the current situation:

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More recently (July 2007) proceedings at the Roundtable discussions of the Global Forum on Migration and Development (55) illustrated that not much progress has been made with solving the issues. If anything professional migration has increased, not decreased in pace. “The proportion of foreign medical graduates practicing in the United States, for example, had risen from 18 percent in the 1970s to 25 percent in 2000 and over 30 percent of doctors in the UK and New Zealand around the same time were foreign-trained. Other estimates (The World Health Report 2006, Geneva,) have been made that suggest that some 18,556 doctors from 10 sub-Saharan countries were working in eight OECD countries around 2005, or an average of 23 percent of the total number of doctors in the home country” The report claims “Migration however is rarely the cause for a lack of development, even if it is often blamed for negative outcomes. Migration is part of a broader development picture, and is as much a consequence of a lack of development as it is a cause of that lack of development.” The participants indicated that rural healthcare delivery is not necessarily affected by migration because those leaving would not necessarily have been prepared to work there. Sectoral loses were said to also impact on the staffing situation, giving the example that in South Africa of some 32 000 public sector vacancies were available, but not filled by the (estimated) 35 000 registered but inactive nurses. It was commented that this situation called for broad-based civil service reform, as it was likely that there was an overall movement of talent. Policy recommendations for “countries of origin” (emanating from the forum and simply for noting as they are beyond the scope of this research) included measures regarding the expansion and nature of training services and opportunities; policies to impact on distribution of doctors; improvement in pay and conditions; and finally bonding (community service / payback for loans or scholarships) The Forum was agreed the current attempts to promote return and diaspora involvement had not yet proved effective. The Forum concluded that since migration was only one of several factors leading to the disintegration of health services, that the best hope for a solution lay in developing countries applying a multi-pronged approach which integrated human resource planning and policies.

Literature Review Conclusion

In spite of all the analyses, debates and agreements of the past forty-years we have not yet crafted a solution for developing countries regarding the loss of their medical human resources. We live in a global community where aging populations in the developed countries place growth demands on healthcare resources; where individual rights are recognised and where material, education and professional improvements are strong motivators for healthcare workers who, by their very nature tend to be the most mobile people in any population group. Whilst we continue to train medical professionals with skills for South Africa’s needs, there is a dire need to increase the availability of healthcare personnel in the shorter-term. It is hoped this study will provide the necessary insight to embark on a successful campaign to bring our South Africans home.

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Appendix H: References

1.

Mejía A. Migration of physicians and nurses: a worldwide picture. International Journal of Epidemiology 1978;7:207-15.

2 Schien EH. Organizational psychology, 3rd, ed. New Jersey: Prentice Hall, 1980.

3.

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Appendix I: Agencies and Organisations

A number of organisations, through their activities have expressed their interest and concern with healthcare professionals’ migration. These include (and are not limited to):

African Union American Medical Association American Nurses Association Belgium Government Bill and Melinda Gates Foundation

British Medical Association Commonwealth Medical Association Commonwealth Nurses Federation French Institute of Scientific Research for Development and Cooperation Fogarty International Centre (FIC) at the National Institutes of Health, USA

German Technical Cooperation Agency (GTZ) Health Canada International Organisation for Migration (IIOM) Institute for Democracy in South Africa (IDASA). Medical Council of Canada

New Partnership for African Development (NEPAD) Norwegian Agency for International Development (NORAD) Rockefeller Foundation Royal College of Nursing South African Medical Association

Southern African Migration Project (SAMP) South African network of Skills Abroad (SANSA) United Nations World Bank World Health Organization (WHO)

The World Medical Association (WMA) World Organisation of Family Doctors (WONCA)

technical reports

See accompanying document for the following:

19.1 Main Tables

19.2 Satisfaction Clusters

19.3 Emigration Intentions

19.4 Profession

19.5 Province

19.6 Open-Ended

19.7 Refer CD for the above and:

19.7.1 Intend Working in Rural

19.7.2 Rural Allowance

19.7.3 Gender Doctors Pharmacists Allieds

19.7.4 Professions by Province

19.7.5 Race

Documents

Research Report Establishing the Professional & Personal