The health sector has been especially hard hit by the brain drain from South Africa. Unless the push factors are successfully addressed, intense interest in emigration will continue to translate into departure for as long as demand exists abroad (and there is little sign of this letting up.) Health professional decision-making about leaving, staying or returning is poorly-understood and primarily anecdotal. To understand how push and pull factors interact in decision- making (and the mediating role of variables such as profession, race, class, age, gender income and experience), the opinions of health professionals themselves need to be sought.
This paper reports the results of a survey of health professionals in South Africa conducted in 2005-6 by SAMP. Since there is no single reliable database for all practicing health professionals, SAMP used the 29,000 strong database of MEDpages. All those on the list were invited by email to complete an online survey. About 5% of the professionals went to the website and completed the questionnaire; some requested hard copies or electronic copies of the questionnaire which they completed and returned. Although the sample is biased towards professionals who have internet access and those who were willing to complete an online questionnaire, the sample represents a good cross-section (though not necessarily statistically representative sample) of South African health professionals and offers insights into their attitudes and opinions about emigration and other topics. In partnership with the Democratic Nursing Organisation of South Africa (DENOSA), SAMP also distributed the survey manually to a sample of nurses and received an additional 178 responses.
Data on 1,702 health professionals was collected. The largest category of respondents was doctors (44%), followed by nurses (15%), dieticians/therapists (12%), psychologists (10%), pharmacists (7%) and dentists (5%). The sample was almost evenly split between males and females. About 70% of the respondents were white, followed by blacks (10%), Indians (6%) and Coloureds (3%). The pre-dominance of whites is primarily a historical legacy of the apartheid system which was racially biased in its selection of health trainees. About 57% of the sample came from the private sector, 23% from the public sector and 17% had employment in both sectors. Half the respondents were under 42 years of age. Just over 20% were in their first five years of service while 26% had twenty or more years of service. There was more variation within professions but, in general, the sample provided an extremely good mix of professionals at different stages of their career. The survey asked questions relating to (a) living in South Africa, (b) employment conditions and (c) attitudes about moving to another country. Each answer was evaluated against the set of basic demographic characteristics to see if there were important differences in response e.g. did health sector make a difference or did gender make a difference? The seven demographic characteristics analyzed were: sex, race, health sector, health profession, domicile, household income and years of service.
The survey revealed the extreme dissatisfaction of many South African health professionals, a sentiment that cut across profession, race and gender. The profession is characterized not by a groundswell of discontent but a tidal wave of unhappiness and dissatisfaction with both economic and social conditions in the country. For example: With regard to general conditions in the country, there were very high levels of dissatisfaction with the HIV/AIDS situation (84% dissatisfied), the upkeep of public amenities (83%), family security (78%), personal safety (74%), prospects for their children’s future (73%) and the cost of living (45%). In only three categories were there fewer dissatisfied than satisfied professionals: availability of schooling (29% dissatisfied versus 46% satisfied), housing (30% versus 45%) and (perhaps unsurprisingly) medical facilities (19% versus 57%). In terms of working conditions, the most important source of dissatisfaction was taxation levels (58% dissatisfied, 14% satisfied) followed by fringe benefits (56% and 17%), then remuneration (53% and 22%), the availability of medical supplies (50% and 28%), workplace infrastructure (50% and 31%). prospects for professional advancement (41% and 30%) and work load (44% and 31%). Consistent with widespread concerns about safety, as many as a third were dissatisfied with the level of personal security in the workplace. Around a third of the respondents were dissatisfied with the level of risk of contracting a life-threatening disease in their work (35% versus 28% for HIV/AIDS; 32% versus 30% for TB and 37% versus 26% for Hepatitis B), an extraordinarily high percentage which is indicative of the conditions under which many work. On only two measures was there general satisfaction among the health professionals: collegial relations (76% satisfied, 5% dissatisfied) and the appropriateness of their training for the job (71% versus 14%). Variables with the greatest impact on satisfaction levels included profession and sector (public or private). Other variables (e.g. age, gender, race and years of experience) were not significant. The highest dissatisfaction levels expressed were as follows: for Workload: public sector employees, nurses and pharmacists; for Workplace Security: public sector, nurses, dentists and pharmacists; for Relationship with Management: public sector and nurses; for Infrastructure: public sector, nurses and black professionals; for Medical Supplies: public sector and public/private employees; for Morale in the Workplace: public and public/private sectors and nurses; for Risk of contracting TB: public sector; for Risk of contracting HIV/AIDS: nurses, doctors and dentists; for Risk of contracting HEP B: nurses and dentists; for Personal Safety: black professionals. Overall, public sector employees and nurses tend to have the highest levels of dissatisfaction. Income levels do significantly influence satisfaction levels on some broad issues including schooling for children, finding a house, cost of living and availability of products. In general, the higher the income the greater the percentage that are satisfied. Black professionals are more dissatisfied than others regarding finding a house (61%), schooling for children (52%) and accessing medical services for family/children (39%). Younger professionals are the most dissatisfied when it comes to finding a house (51%) and nurses have the highest percentage dissatisfied with the cost of living (62%). Comparing life in South Africa today with the situation before 1994, respondents were divided almost equally with 35% feeling it had improved, 31% that it was the same and 35% that it had deteriorated. Not surprisingly, race had a significant impact with over 50% of black, Coloured and Indian respondents feeling that life was better now than before.
In sum, it is alarming that South Africa’s health professionals find satisfaction in little except their interaction with colleagues. While their views of living and working in South Africa are very negative, they hold very positive opinions about other places: When asked whether life would be better in a number of potential destination countries overseas, responses were overwhelmingly positive. Topping the list of where life would be better were Australia and New Zealand (77% better, 6% worse), followed by North America (77% better, 7% worse) and Europe (72% better, 10% worse). The Middle East was also rated highly, particularly by dentists and nurses. As many as a half the sample felt that their lives would be better there. There was little evident enthusiasm for the Southern African region with 69% of respondents thinking it would be worse to live there, and only 9% thinking it would be better. However, as many as 30% of black respondents said they would do better in other Southern African countries than in South Africa. Asia was viewed in a more positive light than the rest of Southern Africa. When asked where they would likely go if they left South Africa (their personal MLD or Most Likely Destination), most selected developed countries or regions. The most popular choices were Australia/New Zealand (33%), the United Kingdom (25%), Europe (10%), the United States (10%) and Canada (9%). The results were generally consistent across the demographic variables although the UK is a more likely destination for dentists (38%) and Europe a more likely destination for psychologists (17%). Only black health professionals rated a move to a SADC country (14%) about as likely as a move to a developed country such as Canada (12%) or the United States (21%). Respondents were asked to compare employment conditions in South Africa with those in their MLD. Five features were identified by over 60% of respondents as better in the MLD: workplace security (69%), remuneration (65%), fringe benefits (63%), infrastructure (63%) and medical supplies (61%). Other issues rated by about half as better in the MLD included workload and career and professional advancement. Only training preparation was rated as better in South Africa. Hence, there is a very general perception that most aspects of the work environment are better in the MLD than in South Africa. Many also listed existing push factors that would prompt them to seek employment overseas. Some 72% cited inadequate remuneration as a reason to emigrate. Next came workplace infrastructure (cited by 27%), educational opportunity (25%), professional advancement (23%), job security (22%) and workload (19%).
How serious are South African health professionals about actually leaving the country? Almost half of the respondents have given it a great deal of consideration and only 14% have given it no consideration at all. Male health professionals have given emigration more serious consideration than females (53% v 41%); white professionals have given it marginally more serious consideration than black (45% v 41%), while both groups have given it less consideration than Indians and Coloured professionals. Professionals in the private sector have actually given it more consideration than those in the public sector (48% v 44%). And professionals under 30 have given it more consideration than their older counterparts (indeed, this measure of emigration potential declines with age). Type of profession is a clear differentiating variable: pharmacists (at 68%) have given emigration a great deal of consideration, followed by dentists (58%), physicians (48%) and nurses (46%). Place of residence and level of income make little difference. Indeed it would appear that rampant dissatisfaction is translating directly into a serious consideration of leaving for a large percentage of health professionals. Around half of the respondents (52%) said there was a high likelihood they would leave South Africa within the next five years. This includes 25% likely to move within two years and 8% within six months. About 14% of the respondents had already applied for work permits in other countries. Six percent had applied for permanent residence, 5% for citizenship and as many as 30% for professional registration overseas.
Recruiters are often identified as the guilty party in the “poaching” of health professionals from developing countries and are clearly very active in South Africa. The survey showed that health professionals get most of their information about foreign job opportunities from recruiter advertisements in professional journals and newsletters. Health professional publications such as the South African Medical Journal and Nursing Update carry copious job advertisements, primarily from the UK, Australia and Canada. Many of these advertisements are placed by both local and international health recruitment agencies. Agencies also make direct contact with health professionals about employment opportunities in other countries. Nearly two in five (38%) had been personally approached, with greater than half of all doctors (53%) having been contacted. However, survey respondents minimized the role of recruitment agencies, saying their influence was marginal. Less than a quarter of respondents had actually attended recruitment meetings. Despite this, the role of such agencies should not be discounted as having an impact on emigration.
The survey also provided insights into the phenomenon of return migration. A third of the sample had already worked in a foreign country and returned to South Africa. Are South African health professionals who have international experience more or less satisfied with their life and job than those who have no overseas experience? This is an important issue given the growing attention being paid internationally to encouraging “return migration.” Those who have lived and worked in foreign countries might have found that conditions are not as attractive as once imagined. Certainly, there is anecdotal evidence that some émigrés return to South Africa because their expectations are not met. On the other hand, returnees may be influenced to return by nostalgic images of South Africa that fail to reflect current realities. In such a case, those who return to the country may be even more dissatisfied with conditions and choose to emigrate once again.
The main conclusions are as follows: The vast majority of return migrants were doctors (63% of the total and 50% of doctors in the sample). Very few nurses had worked outside the country (only 5% of the total and 11% of nurse respondents). While living and working conditions are a major driving force in emigration; they do not attract people back. People return for a variety of less tangible reasons including family, a desire to return “home”, missing the South African lifestyle, patriotism, wanting to make a difference, and the fact that the ‘grass is not as green’ as anticipated on the other side. Returnees are generally more satisfied with living and working conditions than those who have never worked in a foreign country. With regard to employment and working conditions, return migrants are less dissatisfied on virtually every measure. The difference is particularly marked with regard to prospects for professional advancement (35% of return migrants dissatisfied versus 58% of non-migrants), income levels (34% versus 59%) and taxation (32% versus 60%). When it comes to living conditions in South Africa, return migrants are more positive about some issues, especially the cost of living, finding suitable accommodation and schools, and medical services. But they are equally as negative about certain others, especially the HIV/AIDS situation in the country, personal and family safety, public amenities and their children’s future prospects. In other words, while experience overseas has softened some attitudes about many determinants of emigration, it has done little to affect opinions related to safety or perceived health risks, especially as it relates to HIV/AIDS. Return migrants are primed for re-emigration. Those who have returned to South Africa are just as likely to leave again as those who have never left. For example, 1 2% of return migrants said they would probably leave within 6 months (compared to 6% of non-migrants). About a quarter of each (27% and 25%) said they would probably leave within two years. And around half (53% and 51%) said they would probably leave within five years.
Finally, the survey provided insights into the attitudes of health professionals towards government policy. The South African government has moved recently towards more proactive retention policies for the health sector. Despite this, there is considerable scepticism among health professionals that conditions will improve. The overwhelming majority (94%) disapproved of the way the government has performed its job in the health sector over the last year. The survey results reported in this paper demonstrate the intense dissatisfaction of health professionals with working and living conditions in the sector and the country. Emigration is set to continue and even accelerate. The possibility that the health professional shortfall will be met by health professionals currently being trained in South Africa is disproved by a recent SAMP survey which showed that the emigration potential of health sector students is greater than students in the non-health sector; 65% indicated they would emigrate within five years.
The level of dissatisfaction in the sector is such that it may seem difficult for government to know where to begin. Certainly it could begin with itself. There can be few professions where practitioners are as unhappy with their government department. The reasons for this need to be addressed and confidence built or restored. The health department, in concert with its provincial counterparts, also needs to address workplace conditions identified by respondents as needing change. When it comes to other factors, family and personal safety and security are rated as reasons to leave. Unless and until the level of personal security improves, health professionals will continue to be attracted by countries that are perceived to be safer.
The other policy option facing South Africa would be for the country to become a recruiter and net importer of health professionals itself. Here there is a very real dilemma. To date, the Department of Health has adopted a policy of not recruiting health professionals from developing, particularly other African, countries. The problem, as some critics have pointed out, is that if South Africa does not recruit them, someone else will. At least this way, it is argued, health professionals are not lost to the region or continent. The only way this would benefit other countries is if they had greater access to South African health care facilities in return.
There are compelling reasons for South Africa to adopt a more open immigration policy towards the immigration of health professionals from parts of the world that are being actively recruited by developed countries. In May 2007, under its new quota system for immigrants, the government announced the availability of 34,825 work permits in 53 occupations experiencing labour shortages. Significantly, not a single health professional category is on the designated list. This is clearly not in the country’s best interests. There is a decided and growing shortage of health professionals. Morality may suggest that a no-immigration policy is the best one to pursue but no country uses morality as a basis for making immigration decisions and South Africa certainly is not applying such criteria to other sectors. A twin-pronged strategy is urgently needed: address the conditions at home that are prompting people to leave and adopt a more open immigration policy to those who would like to come
