1. IMPACT OF NURSE MIGRATION ON SOUTHERN AFRICA Christine Zondagh GROUP INDUSTRIAL RELATIONS MANAGER NETCARE

2. Human Resources for health "The most critical issue facing health care systems is the shortage of people who make them work" WHO 2003:110

3. Catastrophic effect The loss of health nurses from SSA – is having a catastrophic effect on these countries. Movement of nurses towards more wealthy regions is nothing new - the current situation is more problematic than in the past – HIV/AIDS crisis in developing countries is rapidly depleting current workforces and increasing the overall workload, and the recent sharp rise in the sheer number of people leaving has led to a staffing crisis. Africa reported a nurse vacancy rate of 30% in 2002.

4. Sub-Sahara Africa WHO estimates: SSA has 25% of the worlds diseases burden but only 1.3% of the trained health workforce and 1% of world financial resources – even with loans and grants from abroad. Recent estimate is that SSA countries have a shortfall of more than 600 000 nurses needed to meet the MDGs of improving the health and wellbeing of the population Buchanan and Calman, 2004:19 Total nurse to population in SSA - reported to be 135 nurses per 100 000 population – worst in world..

5. Migration Impact -Africa Africa lost 1/3 of health professionals- costing $ 4 billion to replace – about 23 000 African health professionals migrate to developed countries every year. Malawi losing more nurses through migration than it can train. A main hospital in Malawi has half its nursing posts vacant, and only two nurses were available to staff a maternity ward with 40 births a day Anderson, 2004. Almost 50% of Zimbabwe RNs & 80% of doctors left the country.

6. Impact – Southern Africa Ghana reported 10 000 nurses taking care of population of about 19 million. Zambia: 100 and Uganda 6 nurse / 100 000 population Buchanan and Calman, 2004:19. In contrast - UK reported one nurse / 110 population.

7. Impact – Southern Africa Misdistribution between public and private and rural and urban areas major concern. Tanzania – Average nurse/population ratio is 160/100,000 but 6/100,000 in rural districts.

8. South Africa South Africa also reported a serious nurse shortage and brain drain. Nearly 250 000 skilled health personnel people left the country for Australia, Canada, New Zealand, UK and the US between 1989 and 1997. More than 25 000 nurses requested the SA Nursing Council to verify their qualifications between 1994 and 2004.

9. South Africa Reported 42 000 vacant nursing positions in the public service Padarath et al, 2003: 307 We only have around 2 500 ICU trained and 2 800 theatre trained RNs in the country– estimated that up to 50% of them might have migrated or inactive. There is a critical shortage of nurse tutors and educators, which will constrain any attempts to increase the numbers of nurses being educated.

10. Impact – Southern Africa RN ratio in SA declined from 120 /100 000 population in 2000 to 109 in 2005. In contrast - the U.S. - has almost 1000 RNs for every 100 000 Americans. Nurses in SSA are expected to accept unreasonable workloads, to work outside their scope of practice and are increasingly been put at risk of professional negligence due shortage of nurses.

11. Impact of HIV SSA is home to more than 60% of all people living with HIV and AIDS although this region contains little more than 10% of the world's population. Almost 53% of all deaths in Government employees in Africa due to HIV/AIDS. Tawfik & Kinoti 2001. Student nurse HIV related deaths: –Malawi is 40% –Zambia is 38%.

12. Impact of HIV – South Africa SA accounts for 13% of all people living with HIV in the world and has the highest number of people living with HIV - 5.6 million are HIV-positive. Estimated that about 600 people die of HIV-related illnesses each day. Average of 15,7% of nurses were HIV positive. Shisana et al 2003

13. Impact of migration on health services in SSA Rural areas- often only one nurse/clinic. Doctor only once week / month. When sick /leave –no services. SA - recent report of disciplinary hearing - found that cleaner were giving injections at clinic to immunimize children. Kenya & many other countries – up to 90 patients in 30 bed wards. Patient ratios in general wards in three hospitals in Malawi were reported to be one nurse to 120 patients Aitken and Kemp 2003:12 Patients wait for days to see health workers -even die while waiting to see health professional.

14. SA Private Hospital Survey Survey on impact of the global nursing shortage on quality patient care and nurses quality of worklife among Registered Nurses in the Private Hospital Sector (Zondagh, 2004) found the following: 16 % of the respondents indicated that they plan to work overseas within the next two years and another 25% indicated that there is a possibility that they might plan to work overseas within the next two years.

15. SA Private Hospital Survey 84 % of the respondents have indicated that they have experienced an increase in their workload. 70% of the respondents indicated that they would not recommend the nursing profession to their children or someone else

16. UK The UK is an important receiving country from a Southern African perspective. 2003 -UK health permits were approved for 5880 nurses and doctors from South Africa, 2825 from Zimbabwe, 1510 from Nigeria and 850 from Ghana. 8 999 SA born Health Professionals reported to work in UK OECD 2003

17. Migration to UK SA entered into bilateral agreement with Britain on the recruitment of health professionals. The arrangement is to allow health professionals from South Africa and Britain to work in these 2 countries for a specified period and then return.

18. SA- Strategies to Retain Since 2001, SA made commitment not to recruit from SADC unless under terms of specific agreement with country of origin. Policy not to recruit professionals from fellow developing Africa countries assisted in stemming internal African brain drain to SA SA National Dept Health April 2006

19. SA -Retention allowances Community service of one year – most of health professionals. Nurses will ?start in 2007. Rural Allowance (8 -22%)paid to health professionals working in rural area. Scarce Skills allowance - 10% - 15%

20. South Africa Min Health launched Human Resources for health plan on 7 th April 2006. Plan will assist Dept Health to ensure the right human resource mix in health to fulfill health care delivery objectives. Set of targets for production of health professionals which should be trained

21. South Africa HRH Plan RNs: 3000 p.a by 2011 –current national production is 1896 p.a Staff Nurses : 8000 p.a by 2008 –current 5000 p.a ENA: 10 000 p.a by 2008 – current 6 600 p.a. Change Scope of Practice of nurses

22. Other strategies Malawi, for example, has begun to implement a six-year emergency human resource program. Zambia and other countries are implementing successful measures to improve rural deployment. Kenyas project to develop a computerized nurse workforce database recognized as a good practice. Ghana and other countries are beginning to benefit from increasing health workers salaries and allowances.

23. What should be done…. All countries around the world should increase training of nurses. Developed countries should train own nurses and should not be so dependant on migrant workers from developing countries. All countries should comply with ethical recruitment practices.

24. Need to improve conditions As long as work conditions do not improve - industry will fail to retain qualified health professionals. Producing more graduates will do little good - if these health professionals become disillusioned and drop out after a few years of facing the reality of working in the healthcare environment. Need to improve the Image of Nursing Profession

25. Conclusion Each person has the fundamental right to migrate and seek work and opportunity elsewhere if they so desire. Whatever strategies are developed to address the worsening situation in the health sector as a result of health personnel migration, this must be taken into account.

26. Thank you