Shortage of health care professionals in South Africa’s public sector :an exploratory study of the clinical associate programme regarding the encouragement of internal labour migration to rural health care facilities

Loeffler, Thorsten
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Inequality in the healthcare system is a reality in South Africa. On the one hand, there is the private sector with excellent service who can only afford by the wealthier part of the population. On the other hand, there is the public sector which struggles to provide the basic healthcare needs, suffers from equipment and medical staff. In fact, more than 80% of the population in South Africa have to rely on the public sector. Additionally, there is a severe shortage of Health Care Professionals in the country. Such shortages are not only a South African phenomenon but a global one. In South Africa the public sector and rural areas are most affected. Initiatives and programmes, as well as bilateral agreements on a local and global level seek to encourage Health Care Professionals to work in rural areas by offering them different incentives. These initiatives address doctors and nurses who already finished their studies. In contrast to that, there has been a 3-year university programme (Clinical Associate Programme) implemented in 2008 with the aim that graduates work in the public sector and in underserved areas. A Clinical Associate is a mid-level healthcare provider between a nurse and a doctor. There are only some studies available regarding Clinical Associates. Most of the studies focus on the effectiveness of the Clinical Associate Programme, i.e. on economical factors. The aim of this research project is to put emphasis on the mobility of Clinical Associates instead. The social phenomenon of mobility and migration can be described by the pull and push theory, by the agency and structure dualism and by parts of the “Sustainable Livelihood Framework”. The study focusses on students and graduates of the University of the Witwatersrand, Johannesburg - one of the leading universities regarding research and education. There is one overall research question which should be answered through this study, namely: What are the main reasons for participants (students and graduates from the University of the Witwatersrand, Johannesburg) of the Clinical Associate Programme to move to a rural area of South Africa in order to work in a public health care facility? 2 objectives derive from the research question:  To explore incentives for Clinical Associates to change their opinion if they do not want work in a rural area  To explore the experiences of the programme for both current students graduates after 10 years of implementation The study uses a qualitative research design with a semi-structured interview guide. Data collection methods are individual interviews as well as online surveys with open questions. Participants of the study are students, graduates and staff members of the University of the Witwatersrand, Johannesburg. In total, 48 participated in the research project (46 students/graduates and 2 staff members). The findings of the study show that Clinical Associate are more likely to move to a rural area for work when they are originally coming from those areas. Reasons to move to a rural area are intrinsic factors, like the passion about medicine and to help people and the community. But there are also external factors like unavailable jobs in urban areas. Participants mention financial compensations as major incentive for Clinical Associates to convince someone to move to a rural area. Other factors are not directly incentives but more improvements of circumstances like better working / living conditions or better recognition of Clinical Associates. According to the staff members one of the main current challenges of the programme is the decreasing number or unavailability of scholarships and jobs in rural areas, problems to find a job as a Clinical Associate and knowledge gaps to work in rural areas. The conclusion of the study is that participants of the Clinical Associate Programme have a high level of agency and are more willing to work in rural areas in comparison to other groups of Health Care Professionals (e.g. doctors). The number could even be higher if the overall conditions and the recognition of Clinical Associates by the government and the National Health Department would be improved.
A research report submitted to the Faculty of Humanities University of the Witwatersrand, Johannesburg, in partial fulfilment of the requirements for the degree of Master of Arts in (Migration and Displacement), May 2019
Loeffler, Thorsten. (2019). Shortage of health care professionals in South Africa's public sector :an exploratory study of the clinical associate programme regarding the encouragement of internal labour migration to rural health care facilities. University of the Witwatersrand,