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THE STATE OF GLOBAL HEALTH

One nation’s response to nurse migration: The view from South Africa

by Bhungani ka Mzolo

South Africa has nine provinces: Gauteng, KwaZulu Natal, Eastern Cape, Western Cape, Limpopo, Mpumalanga, Northern Cape, Free State and North West. With the possible exception of Gauteng, where Johannesburg is situated, and Western Cape, the seat of parliament of the Republic of South Africa, the other provinces are poor. This is especially so with Eastern Cape, Limpopo, most parts of KwaZulu Natal and North West.

Bhungani ka Mzolo

If a province is relatively well off economically, private health facilities are available. For that reason, many private hospitals and clinics are concentrated in Gauteng and Western Cape. Because there is only one private hospital in Limpopo, people in that province go to Gauteng or Western Cape to get what they consider top medical care.

As for public health facilities, there are government hospitals and clinics that try to offer the best possible care. This has been especially true since 1990, when Nelson Mandela was released from prison. South Africa became a democratic country four years later. Since then, the goal has been to ensure that all South Africans have access to quality health care. Nevertheless, vast numbers of people cannot afford such care, as it is quite expensive.

In South Africa, just under 30 percent of the population of 45 million can afford private health care. For most, this requires membership in a medical aid scheme, or what is often referred to in other countries as group health insurance. Private health care doesn’t always provide optimum care, but it is true that private hospitals and clinics are well equipped. The rest of the population has to make do with public health care which, in most cases, is under-resourced and understaffed.

Pre-1994
Before 1994, South Africa practiced apartheid. In other words, the country was ruled by a small group of white people who had a policy of discrimination, oppression and exploitation of black people, who constituted the majority of its citizens.

As an apartheid state, South Africa made sure that whites had the best trained doctors, nurses and other health professionals. So excellent was the medical care offered by the state hospitals and clinics during that period that there actually was no need for private health care, although it was available.

South Africa had, and probably still has, more medical schools than all other African countries combined. In fact, many of the other countries sent their students to South Africa to be trained in medicine and nursing. Presidents and prime ministers from these countries often go to South Africa for medical treatment. The point is, white South Africa provided medical care and treatment comparable to the richest countries of the world, countries such as Germany, Canada, the United States and Britain.

In contrast, black South Africans, considered second-class citizens, received inferior health care. Health professionals responsible for treating them—physicians, nurses, physiotherapists, occupational therapists and others—received inferior education at inferior institutions.

The result was, because of their inferior social, political and economic status, black people suffered and died from preventable diseases such as malnutrition, pellagra, scurvy and kwashiorkor or those associated with living in squalor, such as pulmonary tuberculosis. Whites, on the other hand, suffered from diseases similar to the ones experienced by people in rich European countries.

I’m reciting this painful history for two reasons. First, many commentators remarked that South Africa was a microcosm of the entire world. By looking at South Africa, one could see what was happening elsewhere.

What we were seeing was, quite frankly, not good. Was it really true that quality health care was available only to those privileged few? Was it true that poor people received poor medical and health care the world over? Were black people in the diaspora receiving inferior health care because of the color of their skin? Many questions begged answers.

The second reason I’ve recited this history is to point out that denial of access to proper health care for black South Africans did not happen in the 14th or 15th century, but in the present.

South Africa and the world
The international community welcomed South Africa after it became a democracy in 1994, with Nelson Mandela as president. In the past 12 years, we’ve been interacting with all the peoples of the world.

Now, South Africa is a developing country, alongside other African and Latin American countries. What seems common in the Third World is that, because these countries are generally poor, they can’t afford to put the resources they would like into education, health, housing, roads and other such essentials. Other demands, such as ending ever-present wars, providing food and coping with the HIV/AIDS pandemic, place heavy strains on their limited budgets.

The irony is, while affluent First-World countries can afford to build universities and train health workers, they use their highly valued currencies to buy these skills from poor countries such as South Africa. Large numbers of Third-World nurses, physicians and people in other health care specialties now practice their professions in Australia, Canada, the United States and the United Kingdom. These professionals, trained at great cost to their respective countries, now abandon their people for lucrative job offers overseas. When their governments question their patriotism, they argue that it is their right to sell their expertise to the highest bidder.

What’s to be done?
The obvious solution would be for developed countries to stop poaching professionals from other countries and train their own, but I doubt very much whether that would go down well. Some countries, such as the United Kingdom, argue that their population is aging, and they do not have the time to train young people. They need nurses and doctors right now. Yet there are many English nurses working in Saudi Arabia and other countries in the Middle East.

What are we to do? Obviously, one cannot run a proper health system without properly qualified health professionals. To deal with migration of health professionals, South Africa has come up with some innovative measures. There are talks of introducing what is called a mid-level worker to help fill the gaps left by doctors. Training for these workers would take four years.

For nurses, the government is working with nonprofit health care organizations to identify people to be trained as community health workers (CHW). The Department of Health gives them basic training in just under three months, to make sure they understand their roles. The CHW are not employed by the department, but they receive a stipend to help them with transportation and food. Here are some of the ways that the CHW help the government in providing health care:

Care for sick people in their homes.
Support DOTS (Directly Observed Treatment Strategy), a South African program that provides information to tuberculosis patients and encourages them to take their medication.
Privately counsel people about voluntarily taking HIV tests.
Educate pregnant women about preventive measures to reduce chances of passing HIV to their babies.
Help people follow antiretroviral (ARV) treatment.
Assist pregnant women during pregnancy, the first part of labor and after the baby is born.
Help families who have a child with a physical or mental disability.
Help poor people who are struggling with stress or mental illness.
Teach people what to do when there is an outbreak of disease.

In general, the CHW look for health problems and needs in the community and refer people to appropriate health care professionals. The government sees this initiative as a way to help alleviate poverty. Like most developing countries, South Africa is facing unemployment, especially among young people.

It would seem that all of us—government, communities and nongovernmental organizations—are going to have to do what we can to ensure that people live healthy lives. Clearly, poor people cannot rely on health professionals who put profit before the health of the communities they serve. RNL

Bhungani ka Mzolo, a nurse and member of the Africa Honor Society, serves as a spokesperson for the Gauteng [Province] Health Department, headquartered in Johannesburg, South Africa. Prior to that assignment, he served as editor of Nursing Update, a four-color magazine published for nurses, and Curationis, a peer-reviewed journal for nurses and allied professions, both of which are published by the Democratic Nursing Organization of South Africa (DENOSA).