Scaling up the Health Workforce
4.4 Applicability and feasibility of various international scaling up approaches in South Africa
4.4.2 Building institutional capacity
All recent HRH policies have articulated the need for South Africa to urgently increase the production of most categories of HCPs. This would, however, only be feasible if there is an adequate supply of school-leavers interested in and able to pursue studies in the health sciences (Crisp, 2008). The South African Committee of Health Sciences Deans report to the Health Sciences review Committee of the Department of Higher Education (Berman, 2001) indicated that applicants who meet the minimum admissions criteria exceed available slots two to ten-fold.
This excess demand holds true for most HCPs, excluding nursing where interest is declining (DoH, 2013).
4.4.2.1 Scaling up public-sector production capacity
The intention of the state to increase the number of public-sector academic health institutions is on record and is slowly being realised. Two new medical schools are being established and some nursing colleges have been reopened; universities would require appropriate and adequate resource allocation to meet the new legislative requirements for rN production beyond 2019. The most substantive barrier to realising government’s intention is financial (See Chapter 10). The current DoH HRH strategy assumed an economic growth rate of 3.5% which is unlikely in the medium term (kumo et al., 2015). Additionally, the highly publicised #Fees- must-fall campaign (Baloyi and Isaacs, 2015) and subsequent commitments made by government to freeze university fee increases will place further pressure on the fiscus, potentially hampering this option.
It is not so much the lack of qualified applicants but rather inadequate human, operational and infrastructural resources, including an expanded clinical training platform, that prevent universities from producing sufficient numbers of HCPs. There have been concerted efforts by government to increase funding to public-sector academic institutions (See Chapter 10) to address existing restrictions hampering scale up (Essack, 2010):
a Inadequate infrastructure for teaching and learning spaces, skills laboratories and residences, is being addressed through the infrastructure and efficiency (I&E) grant which needs to be continued and expanded.
b Inadequate clinical teaching and training platform, with respect to both student-placement sites, as well as the facilities at these sites for non-clinical teaching and learning. given the large number of healthcare facilities in South Africa, both public and private, expanding the clinical training platform is theoretically feasible, but this will require ensuring that all facilities meet the standards set by the relevant statutory bodies. The DoH has initiated a number of projects to improve the quality of public sector facilities such as the Ideal Clinic Project (Steinhobel et al., 2015), implementing quality standards through the Office for Standards Compliance (Jolson, 2011) that should increase the likelihood of facilities meeting the accreditation standards.
c Shortage of clinical supervisors on the clinical teaching and training platform due to high vacancy rates and high workloads within public-sector student- placement sites. This means that staff to student ratios, mandated by the professional councils, are increasingly difficult to maintain. The staffing component of the clinical training grant (CTg) should be continued in perpetuity to address the number of staff required to undertake clinical supervision in fulfilment of the experiential training component requirements mandated by the professional councils while potential partnership with the private sector can also help address this problem.
d Limited and dwindling pool of credentialed HCPs pursuing careers in the academic health sciences. Purely improving salary packages will not solve the problem and improving technology, resources and conditions of service would need to be addressed while supplementation from abroad should receive serious consideration.
e Increased operational costs, particularly transport costs linked to an expand- ed clinical teaching and training platform can be addressed through the op- erational component of the CTg that should become a permanent funding source to sustain these activities.
4.4.2.2 Building institutional capacity through the private sector
given the oversubscription for intake slots for the majority of public-sector health sciences faculties and budget constraints linked to low economic growth, increasing the role of the private sector should be considered. The majority of middle-income countries and all of the BrICS (Brazil, russia, India, China and South Africa) countries have embraced this option.
The statutory environment created through the Higher Education Act that estab- lished a single accreditation and quality assurance mechanism for both public and private higher education institutions (PHEIs) accords with international best prac- tice (rSA, 1997). This should allay fears about the risk of discrepancies in the quality of private and public higher education. The Register of Private Higher Education In- stitutions (DHET, 2014) in 2014 indicated that there are 90 fully registered institutions and 26 provisionally registered institutions, enrolling around 94 000 students (DHET,
2014) annually. The level of qualifications offered has been steadily increasing up to Masters and PhD level. Regulatory oversight is deemed effective, with the DHET reporting more than 80 institutions that have either been discontinued or voluntarily deregistered. At present there are relatively few private higher education institu- tions involved in the training of HCPs.
A number of legitimate concerns exist, which unless addressed strategically, will not only create barriers to increased private sector participation but could also undermine other efforts to increase production. These are:
a That private HPE would be prohibitively expensive excluding poor students and hampering efforts to achieve demographic transformation. Concerns around the cost of private education are however not supported by comparing current tuition fees between private and public institutions of higher education although it should be noted that the limited role currently allowed for the private sector in health professions education limits such comparisons. A comparison in November 2015 of tuition fees charged for the training of pharmacy assistants showed a difference of less than 10% in tuition fees across four providers, with both the highest and lowest fees charged by private providers. To increase accessibility for poor students, the state could provide bursary assistance to deserving students who study in the private sector as in a model used in Brazil (Redden, 2015), and restrict the private educational provider from charging additional co-payments.
b That private academic institutions would siphon students away from public facilities. given the demand versus supply mismatch, this is unlikely. Additionally, in Brazil where private sector expansion has been encouraged for two decades, two-thirds of students are still enrolled at public facilities which are still perceived as more prestigious.
c Fears around poaching academics from the public sector or reducing the ability of the public sector to fill vacancies could be mitigated by using a public-sector teaching platform, as this would reduce the need for the private provider to employ large numbers of academic specialists. Private educational providers are also much more likely to contract part time rather than full-time faculty and recruit academic staff from abroad or from retired academics.
4.4.2.3 Undergraduate production
A potential barrier to undergraduate production in the private sector is the suitability of the private practice clinical environment as a teaching platform. The willingness of private patients to be exposed to undergraduate students is untested, although anecdotal evidence from models where public-sector students do electives in the private sector and from private nursing schools seems to indicate that this will not be a major barrier. Teaching in a private hospital setting may also inadvertently increase costs due to longer hospital stays linked to academic ward rounds or examinations that medical insurers would be unwilling to cover, while the issue of potential medical litigation risks is unexplored. A potential win-win solution would entail PHEIs using a public-sector clinical training platform thereby creating an incentive for PHEIs to strengthen public sector facilities. This model would also address concerns about private HCPs not being prepared for practice in the public
sector and meeting internship and community service requirements. Should the proposed NHI reforms be fully implemented, the distinction between public and private sector facilities will blur, potentially negating these concerns.
4.4.2.4 Postgraduate production
Limited production of nursing specialists already takes place through PHEIs but considerable potential exists to rapidly increase the production of medical specialists using the private healthcare sector as a clinical training platform given that preparation for speciality and sub-speciality qualification is predominantly based on practical clinical experience which can be monitored through portfolios of evidence developed under the tutelage of qualified specialists. At present the majority of specialists practise in a private-sector environment and with minimal aligning of incentives the private sector could provide a clinical training platform at no cost to the state. Private practices with high patient volumes could fund registrar positions, removing the onus on the state to fund additional registrar posts. This model exists in Switzerland, where academic specialists run large private practices in academic hospitals and directly employ registrars against their practice income (Bauer, 2013). The existence of an independent examining body in the Colleges of Medicine further supports the feasibility of this. A current constraint is that the HPCSA does not approve of specialists employing generalists, however, exceptions have been made in the past for private specialists who have large clinical trial practices.
At some medical schools, public sector employed registrars already do rotations at private practices to facilitate training in the use of techniques or equipment not available in the public sector.