DISCUSSION
5.5 Main reason for seeking work abroad
5.5.2 Working environment
government financial efforts may also be a reflection of the weakness of financial incentives as retention factors in that the increased income is quickly incorporated into expenditure and the employee starts looking for a higher salary. This is also in agreement with most authors' observations that whereas money does matter in retention it alone is not enough to sustain long lasting retention (Delany & Turvey 2004:30 Kaye & Jordan- Evans, 2000:29; Mengel, 2001:32; Naidoo, 2004:37).
The findings differ significantly from previous studies that found crime was the most frequently cited reason for seeking work abroad (Jones 1999:19; Van der Vyer & De Villiers, 2000:18) and other earlier studies that highlighted dissatisfaction with the political dispensation of the time (Bourne, 1983:447; Wynchank & Granier, 1991:532).
The findings of the current study are likely to be a true reflection of the current situation as to why the doctors are seeking jobs abroad. Crime of all categories has also declined as shown by the statistics of the South African Police (SAPS, 2004), which may further support the leading role of financial issues. In support of this, financial issues are also ranked first in the ratings section and are the most frequently cited factors that employers and government must improve to keep doctors in South Africa. Crime according to Padarath et al. (2003:10) is an exogenous 'push' factor in the health workers decision to seek a job abroad, the reduction in this 'push' factor should ideally be followed by a decline in loss of human capital. Unfortunately this does not appear to be so, as crime seems to be replaced by other endogenous 'push' factors, namely financial and working environment.
This is also reflected in the weighted average ratings were they were rated second only to financial issues. The unfavourable working conditions make the practise of medicine much more difficult for the doctors and may result in poor job satisfaction and an increased tendency to look for alternatives. Some of the problems of the working environment e.g. equipment shortage may be due to limited budgets or due to poor management. Limited budgets in the public sector may be a result of the differences between the private and public sector state funding as already discussed. The private sector cited factors similar to the 'public sector and other' respondents.
The factors related to working environment are very complex and can interplay in multiple ways resulting in positive or negative outcomes. For example the lack of appropriate equipment can make a doctor feel that he/she is offering a substandard level of care to patients. This, in turn, leads to lack of job satisfaction which may result in seeking alternatives were he/she will be able to practise what he/she considers appropriate level of medicine. Factors relating to working environment were cited as major issues by both the private sector and the 'public sector and other' respondents. It is not clear why the private sector respondents cited these issues as they are self employed.
The study by Van der Vyer and De Villiers (2000:18) also found lack of job satisfaction to be a factor as to why doctors left the country. Most of the issues associated with working environment like: lack of job satisfaction, poor support, lack of job security and overworked would be considered endogenous to the healthcare work (Padarath et al.
2003:10) or intrinsic (Birt and Winternitz, 2004:27) 'push' factors to the job. As noted by Stewart (1997:67) the doctors, like all knowledge workers, have loyalty to their work and not the employer, so if they feel that their needs are not well served they will avail their services to the best employer that meets their needs regardless of location. Thulare's (2003:20) observation that knowledge workers crave for professional satisfaction is reflected in this context whereby a lack of professional satisfaction almost inevitably leads to departure of knowledge workers. The doctor is a free agent with boundaryless career, as such organisations need to be seen as, according to Cappelli (2000:11), employers of choice in order to attract and retain doctor's talent.
Problems of workload on doctors may be partly due to shortage of staff due to the 'medical brain drain', this increased workload on those left tends to 'push' them into considering leaving because the work becomes unbearable. As the provincial budgets struggle to limit expenditure to within the allocated budgets there is freezing of posts, which means once a doctor has left that post can not be filled, this further aggravates the staff shortage. 'Overworked' may also be a reflection of the perceived imbalance between the remuneration and the job done by the doctors. These issues were highlighted by Padarath et al. (2003:24) as the knock-on costs of the 'medical brain drain', which are usually not counted as costs.
In the ratings section factors related to working environment were ranked number 2, 3 and 7: poor management of health services, lack of resources and overworked, respectively. Poor state of health services includes state of hospitals, equipment and availability of services per se e.g. inadequate theatre time. While inadequate funding may be responsible for part of the poor services; a low morale among employees may account for poor job performance. It is difficult to distinguish where management starts and ends since every person is in principle a manager in their own work area and task performance.
The role of management, government and doctors themselves in creating an enabling working environment is therefore intertwined. Insufficient chance for promotion was ranked 11 and cited by a significant number of respondents in the unstructured questions.
Some respondents blamed affirmative action for what they termed unequal opportunity for promotion. This may lead to some doctors seeking a job somewhere were they will get the appropriate post, this is in keeping with the 'protean career' model as described by many authors (Feller, 1995: Flood, 2002; Schreider & Theron, 2001) where instead of a predictable linear rise up an organisation's hierarchy, careers are now characterised by movement between many organisations during the course of individuals' working life.
A comparison of the private sector to the 'public sector and other' respondents shows that for the private sector working environment was rated lower than certificate of need which was ranked number 2. This could be directly related to the fact that the private sector doctors manage their own work environment to a larger extent than the public sector
doctors. The certificate of need is however a very important aspect to the doctors in private practise because it will limit the freedom of practise to those that the government designate as need areas which may be not be suitable to the doctors. Although the certificate of need is legislated in the act, it has not yet been implemented by the Department of Health.
It is clear from the rankings that the working environment is the second most significant factor in decision making to seek work abroad. Work load, which may be in amount of work or number of unpaid hours worked by doctors were cited as very significant. The condition of hospitals and available services were identified by respondents as possible factors in the working environment. In this author's view it was strange that respondents cite condition of facilities and services as the second most frequent issue because relative to other areas of the country Western Cape is one of the better resourced provinces in South Africa (Padarath et al. 2004:304). This finding could be an indication of what other doctors experience in the rest of South Africa.