TCS Daily

What Ails the Doctors?

By Richard Tren - June 3, 2004 12:00 AM

On a recent flight from Johannesburg to London, I sat next to a South African nurse named Queeneth who was returning from a short holiday to her job in Wales. She decided to swap working at Chris Hani Baragwanath Hospital in Soweto, the largest hospital in the world, for a quiet, well paid job in a nursing home in the north of Wales. Although she admitted that she missed South Africa terribly, she isn't planning to return for at least 10 years. "The money is far too good and I get treated well" she admitted to me. But if South Africa's Minister of Health gets her way, the overseas opportunities for nurses such as Queeneth may dry up.

Manto Tshabalala Msimang, South Africa's controversial Health Minister, has just been elected as one of five vice presidents of the World Health Assembly (WHA). Her election could be both good and bad news for millions of people around the world. The Minister's position on malaria control has been excellent and the policies that she promotes to control the disease have saved thousands of lives. The news will be good if her new position gives her the power to extend South Africa's polices elsewhere. The news will be very bad however if her other ideas on healthcare -- which punish the private sector, drug companies, doctors and other health professionals are -- allowed to take root at the Assembly.

South Africa has a long and proud history of malaria control. It recently controlled one of the worst epidemics in the country's history by reintroducing indoor spraying of the insecticide DDT along with the new, highly effective artemesinin combination therapy drugs (see the study I co-authored with Roger Bate for the Cato Institute). South Africa's Minister of Health has been outspoken on the topic of DDT spraying and, based on the successes in South Africa, has encouraged other African countries to follow suit. Her leadership has allowed both Zambia and Zimbabwe to reintroduce DDT and Uganda will also begin spraying soon. The Minister's DDT advocacy is highly commendable as it will reduce disease, save lives and promote development.

Unfortunately the good news ends there. Minister Tshabalala Msimang has proposed a resolution that she hopes will stem the flow of qualified health personnel from developing countries to wealthy western countries. The loss of medical personnel is a serious concern, especially as countries like South Africa attempt to roll out complicated long term health programmes such as HIV/AIDS treatment. Yet WHA resolutions and government interventions are not the way to go; in fact, they will probably make matters worse. Indeed so far, the South African government's health sector reforms have done more to chase doctors and nurse out of the country than anything else.

In recent years, the South African government has brought in a number of far reaching health sector reforms. Among them, newly qualified doctors are required to complete 2 years of community service before they can begin practicing medicine in the private sector. While the compulsory service may provide them with some good experience, the mere fact that doctors are treated as cattle of the state doesn't do much to encourage them to remain in the country.

Most state doctors and nurses are poorly paid and work under very trying conditions. A qualified and experienced nurse can expect to earn no more than $700 per month, for which she is expected to work at least 60 hours a week. Apart from the poor pay and long hours, working conditions are often unsafe. "Sometimes we feel threatened, especially if we have to drive to clinics in dangerous areas," says Dr. Ralf Brummerhoff, psychiatric registrar at the University of Witwaterand. His concerns are real; last week a colleague of his was shot and her car stolen as she entered Chris Hani Baragwanath Hospital.

Yet instead of trying to offer better pay and conditions, the government appears to be turning on doctors themselves. The new Health Act which was passed last year requires doctors to obtain a certificate of need before they can practice in a particular area. In an effort to ensure a greater spread of health professionals around the country, the government looks set to deny doctors the right to practise in some urban areas and may force them to set up practices where the Minister deems appropriate.

In many poor and rural areas where there are no pharmacies, patients usually get their medicines from doctors. Yet the Minister of Health has outlawed the right of doctors to dispense medicines and now requires doctors to get a licence to dispense. Doctors are required to go through an expensive and time consuming procedure to apply for the licence, which may or may not be granted by the Department of Health. Doctors are understandably outraged, not only with the interference in their businesses, but with the effect that this will have on their patients, particularly poor and vulnerable patients.

The government's aggressive position towards research based drug manufacturers is very well documented. The new drug pricing regulations will ensure that South Africa is far less profitable than before and therefore less worthy of investment. Much of the continuing professional development was paid for by these companies in the past and so without their continued investment and commitment to the country, medical personnel may well fall behind their peers in other countries.

Earlier this year, South Africa's doctors, led by Dr. Kgosi Letlape of the South African Medical Association marched on parliament to demonstrate against government policies. We have reached a low point when educated professionals are treated so badly that they have to resort to street demonstrations. If South Africa wants to keep its medical personnel it should start treating healthcare as more of a business and encourage the private sector, which can pay its staff more and treats them better, to invest. Yet unfortunately the government has done quite the opposite; hence the exodus of Queeneth and her colleagues.

If the Minister's WHA resolution is anything like her health policy prescriptions we should get ready for more demonstrating doctors and unfortunately more healthcare problems in poor countries.

Tren is a regular contributor to TechCentralStation and a director of the South Africa based health advocacy group Africa Fighting Malaria.


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