According to a factsheet produced by the World Health Organization (WHO) [1
], by 2006 there were 59.8 million health workers globally involved in the provision of health services or the management and support thereof. These individuals are commonly referred to as human resources for health (HRH); the individuals whose job it is to protect and improve the health of their communities. Fifty-seven countries worldwide have been identified as having a critical shortage of HRH, the majority located in Africa and Asia. This global shortage collectively amounts to 4.2 million HRH, with medical officers, nurses, and midwives accounting for approximately 2.4 million of this number [1
]. Reasons for this shortage vary between regions, with common factors being retirement, migration, death, low production rates, and poor working conditions [1
South Africa’s medical officer and nurse density ratios are favourable compared to other southern African countries. Based on its density of medical practitioners to population ratio, South Africa is ranked slightly higher than low income countries which have a ratio of 50:100 000, but is hugely under-resourced in comparison to other middle and high income countries that have ratios of 180:100 000 and 280:100 000 respectively [2
]. Estimates for 2010 have put the number of nurses and doctors (medical officer and specialists) working in South Africa at 221 817 (2009 data), 17 801 and 9 630 respectively, which implies a nurse and doctor to patient ratio of 410 and 55 per 100 000 population [3
]. South Africa’s medical officer to population ratio falls way below countries with a similar level of economic development such as Mexico (198 per 100 000) and Brazil (185 per 100 000) [3
]. Conversely, the nursing population ratio is more favorable than Mexico (400 per 100 000) and Brazil (290 per 100 000) [4
]. These data indicate that South Africa’s combined medical practitioner and nurse density ratios are above the minimum level of 230:100 000 recommended by the WHO [5
]. However, these favorable density ratios hide internal disparities particularly between provinces and between the public and private health sector, as well as urban and rural areas.
The migration of skilled public sector employees led to the development and implementation of the Occupation Specific Dispensation (OSD) in 2007 by the South African government. The OSD aimed at improving the conditions of service and remuneration for public service workers, including public sector health professionals. The objectives of the OSD were to improve the public services’ ability to attract and retain employees, to provide differentiated remuneration dispensations for the vast number of occupations in the public service, to cater for the unique needs of the different occupations, to provide a unique salary structure per occupation, to prescribe grading structures and job profiles to eliminate inter-provincial variations and to provide adequate and clear salary progression and career path opportunities based on competencies, experience, and performance [6
Whilst there are a number of reasons for the attrition of HRH, this article will focus on the overseas migration of HRH influenced by salaries and benefits as a pull factor.
HRH migration in South Africa
In 2008, there were roughly 250 000 HRH employed in South Africa’s health system, similar to the number in 1997/98. After taking into account population growth and the burden of disease, the Development Bank of South Africa calculated a staff shortage of 79 791 HRH in 2007/08 [8
]. This critical shortage of HRH is being experienced at a time when the population and the burden of ill-health, primarily due to HIV, AIDS and TB, are increasing among the population [9
]. Africa Health Placements, an NGO that recruits doctors to work in under-serviced rural areas in South Africa, estimated that half of the 2 400 South African medical graduates in 2006 and 2007 would leave the country; of the remaining 1 200 medical officers, 75% would work in the private sector, leaving 300 to work in the public sector; of those 300, possibly 70 would work in the public health services in a rural facility [10
Whilst there is no agency that collects standardised data on international migration flows disaggregated by occupation, research estimated the amount of African-born doctors working abroad using census data [11
]. This data suggests that in 2001 about 25% of all South African-born doctors were working in seven other countries. For that same year they also estimated that roughly 5% of South African professional nurses worked abroad, which is equivalent to approximately 4844 in 2001. This study reaffirms an earlier study which reports that since 1975, 45% of University of Witwatersrand medical school graduates were located abroad, mostly in North America, the United Kingdom, Canada, Australia and New Zealand [2
]. In the mid-2000s, there were reportedly more than 20 overseas commercial recruitment agencies working locally to recruit South African qualified doctors, with 10% of Canada’s hospital-based physicians having graduated from South African medical schools, and 6% of the United Kingdom’s total health workforce, including professionals (nurses and doctors), trained in South Africa [10
The Southern African Migration Project (SAMP) reported in 2008 that half of South Africa's health professionals planned to emigrate within the following five years [12
Reasons for the attrition of HRH in South Africa
This attrition of HRH is attributed to push and pull factors depending on whether the factor is located in the source or destination country. Prominent push factors for HRH in sub-Saharan Africa include resource limited health care systems, deteriorating work environments, human resource shortages, low salaries, political tensions, gender discrimination, lack of personal security, HIV/AIDS, and deteriorating quality of life and social systems such as education and welfare [11
]. Salient pull factors include the availability of jobs in the destination country, more manageable workloads, high remuneration, better working conditions, safer living environments, better quality of life and a more economically and politically stable country [11
]. A South African study identified financial factors, better job opportunities, schooling opportunities for children abroad and the high crime rate in South Africa, as significant factors encouraging emigration [17
Table illustrates salary differentials across selected HRH categories in selected destination countries. The South African data displays pre- and post-OSD salaries for each HRH category. As we can see, the new OSD salary structure has raised South African salaries by over half in some cases.
Selected gross HRH salaries in national currency units and US dollars
Despite the introduction of the OSD, all selected foreign countries offer salaries that are considerably higher than their South African counterparts. This paper sets out to use these data as a baseline from which to make a truer comparison, namely using PPP ratios.
The Occupation Specific Dispensation (OSD) for health professionals
The development and implementation of the OSD arose from the recognition that improvement in the conditions of service and remuneration for health professionals constituted an urgent priority. Announced in 2007, the OSD resulted in all HRH in the public service being re-graded according to their qualifications and years of experience with their remuneration increasing [33
]. It was agreed that nursing would be the first profession to benefit from the OSD.
With regard to nurses, it was agreed that there would be two phases to the salary adjustment, followed by a minimum adjustment to nurse salaries in line with the OSD and, secondly, there would be a recalculation and progression based on recognition of relevant experience. As part of phase 1, entry level salaries for professional nurses and nursing assistants were increased by 24%, while entry level salaries for enrolled nurses were increased by 20% [34
The entry level OSD salary in July 2007 for nurses prior to phase 2 of the OSD, when relevant years of experience were taken into account, was R106 086 ($12525) for professional nurses, R70 140 ($8281) for enrolled nurses, and R53757 ($6347) for nursing assistants. The salary notches of nurses were further increased in July 2008 and again in July 2009. These appear in Table . The entry level salary notches of professional nurses employed in general nursing positions increased by 10.5% for each grade from 2007 to 2008, followed by an increase of between 10.5% and 11% in 2009. In comparison to the entry level salary of professional nurses of R85 362 ($10078) prior to the OSD, presented in Table , the entry level salary notch for professional nurses (Grade 1) in July 2009 reflects a 52.4% increase.
Remuneration for professional nurses, pre- and post changes to the OSD, 2007-2009
Medical, dental, specialists, pharmacists, and emergency medical services (EMS) were identified for implementation in 2008. However, due to inadequate funding, salary adjustments could only be implemented in 2008/2009 [6
]. Medical interns experienced a substantial increase of between 31% and 53% in their salary package. Categories of medical professionals, such as community service medical officers, medical officers in Grade 1, 2, and 3 saw significant salary adjustments of up to 68% with medical specialists in Grade 1, 2, and 3 posting increases of between 2 and 50% in Year 1 of implementation. This was followed by further significant increases across medical categories in Year 2, as illustrated in Table [6
Remuneration for medical officers and specialists with percentage increases at Year 1 and Year 2
Given the new South African OSD dispensation described above, this paper examines how that new salary structure compares to selected foreign countries in comparable HRH categories using PPP adjustments. Country choice was based on historical migration patterns where South African HRH migrants tend to target countries such as the United Kingdom, Australia, Canada and the United States [2
]. Saudi Arabia is included as a representative Gulf state due to the increasing flow of HRH to the Gulf region. It is estimated that 80
% of HRH, in the Gulf, are foreign trained [35
]. Whilst Saudi Arabia is well known for its tax-free status, it also provides additional benefits such as free (furnished) accommodation, medical care (especially for those working in a hospital), emergency dentistry support and extensive leave are common place [31
]. The earnings available in Saudi Arabia make these additional benefits trivial in terms of understanding HRH migration patterns.