MiWORC-PolicyBrief-3-Foreign-health-professionals-in-SA

MiWORC Policy Brief 3 - [1]
A disposable workforce:
Foreign health professionals in the
South African public service
Aurelia Segatti, Research Associate,
African Centre for Migration & Society (ACMS),
University of the Witwatersrand
Introduction
The South African public health sector is characterised by chronic shortages
of health care workers in urban and especially rural areas.
The effects of this shortage are only made worse by:
 the quadruple burden of disease1
in the country,
 a limited output of medical graduates by tertiary institutions,
 attrition of staff into the private sector, and
 emigration of health professionals.
Despite this context, there are stark contradictions between the need for
more workers in public health care and inhibitive South African policy
frameworks.
While South Africa will not by itself meet its health staff shortages with its
current policy instruments, little has been done to facilitate the smooth
recruitment and immigration of foreign health workers, especially with
regard to those from SADC and other developing countries.
Over the past two decades, on the basis of a restrictive reading of World
Health Organisation recommendations, the National Department of Health
(DoH) and the Health Professions Council of South Africa (HPCSA) have
adopted a principled position against the recruitment of staff from
developing countries and increasingly enforced restrictive measures
regarding this.
1 HIV and TB; child and maternal mortality; non communicable diseases; injury and violence
MiWORC Policy Brief 3
A summary for policy makers,
NGOs and media practitioners
Based on MiWORC Report N°7:
Segatti, A. (2014) MiWORC Report
N°7. A disposable workforce: Foreign
health professions in the South
African public service.
Johannesburg: African Centre for
Migration & Society, University of the
Witwatersrand.
The report can be accessed online:
http://www.miworc.org.za/docs/Mi
WORC-Report-7.pdf
Report No
7 is part of the
Migrating for Work Research
Consortium (MiWORC) Work
Package 3 which explores the
impact of low and high skilled
migration in key sectors of the
economy: construction and
mining, commercial agriculture,
hospitality, domestic work, and
public health.

A disposable workforce: Foreign health professionals in the South African public service
Aurelia Segatti
Meanwhile, many voices in the sector, particularly in rural health care, have
called for increases in foreign staff, better coordination of their recruitment,
targeted training programmes, and incentives for their retention in the
public sector.
The recently articulated DoH strategy on human resources (HR) recognises
the current challenges and the need for further recruitment without
recommending any concessions regarding the ban on recruiting from
developing countries. Nonetheless, in practice, the vast majority of foreign
doctors employed in South Africa are from the Southern African
Development Community (SADC) region.
Key Findings about Foreign Health Professionals and their
Workplace Experiences
Profile of foreign health professionals
Using statistics drawn from the government’s human resources database,
the Personnel Salary System (PERSAL), in February 2013, foreign health
professionals in the public service comprise about 1,5% or 2 640 out of
173 080 qualified staff. Foreigners represent 13,1% of the workforce among
medical practitioners, 7,5% among specialists, 3,8% among dentists, 3,4%
among pharmacists and less than 0,3% among nurses.
In terms of the origin of foreign personnel in the most qualified health
professions, SADC countries are the origin of 38% of foreign medical
practitioners, specialists, dentists or pharmacists, while 26% are from the
rest of Africa, and 36% from the rest of the world.
The methodology of the study
The findings in MiWORC Report N°7
are based on two years of
qualitative and quantitative
research spanning 2013 and 2014,
over 70 in-depth interviews with key
informants and randomly selected
professionals, as well as statistical
analysis of public sector human
resources data.

Aurelia Segatti
Work experiences of foreign health professionals
Foreign interviewees reported positively on their work experience and this
included skills acquisition, experience and good practice. However, several
challenges continued to render their experience in public service particularly
difficult as a direct result of their nationality. These included a growing
division of labour between locals and foreigners, contract precarity due to
their immigration status, discrimination, xenophobic attitudes, exploitation
in the workplace, and employment in illegal conditions (as locums) or in
occupations well below their level of qualifications.
Remigration and retention
There were issues of retention of foreign health professionals because South
Africa was initially a second choice for a majority of the foreign interviewees,
who came here because it was the only international option available to
them or through their own networks. Interviewees would have preferred to
go to Europe (Belgium, France, and the UK), North America (Canada, the
USA) or Australia. In some instances, health professionals were already
planning to relocate, mostly to Western Europe and North America.
Key Findings about the Recruitment Process
Extremely bureaucratic recruitment process
Recruitment processes put in place for foreign nationals were in many
instances cumbersome and dysfunctional with unreasonable numbers of
verification stages and poor interdepartmental coordination, particularly
between the national and provincial Departments of Health, and between

Aurelia Segatti
the DoH and the Department of Home Affairs (DHA). This resulted in
turnaround times in the processing of applications which were
unacceptably long, and which work towards discouraging foreign
professionals from applying.
In order to efficiently place and retain health professionals in rural areas, the
DoH has had to rely on the assistance of non-governmental organisations
such as Africa Health Placements (see sidebar on page 6). This reliance points
to the strategic and structural weaknesses of the Department of Health in
regard to recruitment of foreign health professionals.
The Current Policy Environment
The employment of foreign health staff in the public sector has become
more stringent over the past two decades. This is particularly a result of
concurrent policy dynamics:
 The DHA has imposed more and more restrictive legislation regarding
the employment of foreign nationals.
 The DOH and the HPCSA have felt the need to ensure compliance with
the new immigration framework (instituted in 2002) but also to retain
their independence from the DHA in the assessment of skills and
issuance of authorisations to practise.

Aurelia Segatti
 South Africa has also had to align itself with WHO recommendations on
the “international recruitment of health personnel”; the DoH’s 2010
policy on the Employment of Foreign Health Professionals selectively
aligns itself with the WHO 2010 Code of Practice by focusing on the
most restrictive aspects related to anti-‘brain drain’ positions while
leaving aside the more collaborative dimensions in the Code about the
building of regional partnerships.
 The DoH’s policy has chosen to prohibit immigration from developing
countries, including from its own region and sub-region (SADC). This
has been done in spite of the fact that large numbers of foreign African
professionals, mostly from SADC, are already employed in and keep
arriving in South Africa.
Policy Contradictions
Policies are not addressing the chronic shortages of public health workers
These policies do not address a staffing situation which faces an
overstretched public health system dealing with a quadruple burden of
disease, a limited output of medical graduates by tertiary institutions,
attrition from the public service of staff into the private sector, and
emigration of South African health professionals. Overall, all these factors
have led to chronic shortages of public health workers in urban and
especially rural areas.
In practice loopholes are used
Realising this, the government has found itself caught in its own policy
contradictions and resorted to loopholes in its immigration system to
incorporate foreign African professionals. The asylum system provided for
in the Refugees Act has been found to be one of the loopholes which have
been used both by the South African government and applicants to
circumvent the anti-‘brain drain’ principled position on importing skills from
developing countries, placing a substantive number of applicants in very
uncertain conditions and creating unnecessary vulnerabilities and risks in
terms of the sustainability of their recruitment.
De facto reliance in some areas on foreign African professionals
While this research study has shown that foreign-born professionals
comprise a small part of the total workforce, it is also clear that in certain
facilities, specialities, and rural areas, foreign African professionals have
become a vital component of extremely fragile and vulnerable systems,
despite official policy against the recruitment of professionals from
developing countries

Aurelia Segatti
Temporary and precarious employment of African professionals
Many professionals from other African countries have been accepted or
recruited by South Africa temporarily, which deliberately keeps them in
precarious conditions of employment eventually leading to the perpetuation
of embedded prejudices against African professionals. Resultantly, the
vulnerability and exploitation of these highly-skilled professionals continues
as they are policed rather than supported in their attempts to integrate into
the system.
This leaves a lot to be desired at a policy level as these unresolved policy
dilemmas seem less and less sustainable in the global context of
competition for skills.
Areas in need of urgent attention
Turnaround times in the processing of applications by the DoH and
provincial administrations
Urgent improvements are needed in terms of turnaround times and the
elimination of unnecessary steps.
Interdependence between the verification of qualifications, consideration
of applications by the Foreign Workforce Management Taskteam in the
Department of Health, and migration permitting by the Department of
Home Affairs
This situation seems to delay processes considerably and it is unclear what
independence was gained by the DoH vis-à-vis the DHA since so many steps
in the process remain dependent on assessment by the DHA, regardless of
applicants' levels of qualification.
Outsourcing of credentials verification to a company in the USA
Not only is this particularly time-consuming and costly for applicants, but it
also means that related expertise is not being built within the DoH including
for applicants from SADC.
The use of the asylum system as a loophole
The use of asylum as a backdoor to recruitment for developing country
nationals emerged as a particularly contentious and complex issue. From a
state perspective, the fact that some sections of public administration
directly or tacitly encourage their public to exploit loopholes in public
legislation seems short-sighted and irresponsible, particularly with such
consequences as increased corruption and long-term precarisation of part of
the workforce. It also points to a lack of political courage to undertake the
necessary reforms to facilitate the intake, stabilise and retain such a
workforce.
An alternative recruitment
processing model?
African Health Placements (AHP) is
an NGO with its roots in an initiative
in 2005 by the Rural Doctors’
Association of South Africa to
facilitate the recruitment of health
professionals for rural facilities.
Working closely with the South
African DoH and HPCSA as well as
with the Lesotho and Swaziland
governments, AHP performs a
number of critical recruitment and
assessment tasks. AHP staff assist
applicants throughout the
application process by streamlining
all steps and ensuring the full
compliance of applicants prior to
submission of applications, thereby
speeding up the overall processes.
They also work in the following
areas: workplace planning
assessments and human resource
recommendations for selected
facilities; retention programmes in
rural areas; and placement of local
and foreign staff.
www.ahp.org.za

Aurelia Segatti
The ambivalent position adopted by the professional boards and the DoH
on the longer-term role of the foreign workforce in its policy design
A complete rethink of this dimension, focusing on the need to shift policy
efforts towards regional development rather than regional antagonisms and
isolation seems urgent more than 20 years after the end of apartheid.
Such policy consideration should explore bilateral cooperation agreements
within the region including on circular migration schemes, twinning of
academic facilities, and twinning of internship and specialisation
programmes; as well as a shift to a system of recruitment quotas managed
on the basis of known regional outputs and surpluses.
The need for overall policy coherence and harmonisation
Policy development work needs to be organised in order to shift towards
maintaining a stabilised workforce, including staff from developing countries.
Recommendations regarding the administrative system
 Professionalise administrative processing of applications, drawing on the
experience of Africa Health Placements (AHP) and similar projects
globally.
 Explore the possibility of an integrated ‘one-stop shop’ between the
DoH, professional boards and the DHA.
 Set up proactive recruitment programmes in developed and surplus
countries wherever possible with set targets and regular monitoring.
 Build on transnational networks of professionals residing in South Africa
to advertise South Africa’s competitiveness in the health sector.
 Work on the SADC Regional Qualifications Framework (RQF) in order to
define common standards of qualifications for SADC medical and nursing
staff rather than resort to an overseas private qualifications verification
organisation.

Aurelia Segatti
Research Reports
Christopher Changwe Nshimbi & Lorenzo Fioramonti – Report #1 –
July 2013
A region without borders? Policy frameworks for regional labour
migration towards South Africa
Deborah Budlender – Report #2 – July 2013
Improving the quality of available statistics on foreign labour in
South Africa: Existing data sets
South Africa: Strategic recommendations
South Africa: Suggestions for a Quarterly Labour Force Survey
migration module and municipal level surveys
Deborah Budlender – Report #5 – June 2014
Migration and employment in South Africa: Statistical analysis of
the migration module in the Quarterly Labour Force Survey, third
quarter 2012
Christine Fauvelle-Aymar – Report #6 – August 2014
Migration and employment in South Africa: An econometric
analysis of domestic and international migrants (QLFS (Q3) 2014)
Aurelia Segatti – Report #7 – November 2014
A disposable workforce: Foreign health professionals in the South
African public service
Bob Deacon, Marius Olivier & Reason Beremauro – Report #8 –
June 2015
Social security and social protection of migrants in South Africa
and SADC
Janet Munakamwe & Zaheera Jinnah – Report #9 – November 2015
A bitter harvest: Migrant workers in the commercial agricultural
sector in South Africa
Monica Kiwanuka, Zaheera Jinnah & Becca Hartman-Pickerill –
Report #10 – November 2015
Getting the house in order: Precarity, migration and domestic
work in South Africa
Zaheera Jinnah & Rafael Cazarin – Report #11 – December 2015
Making guests feel comfortable: Migrancy and labour in the
hospitality sector in South Africa
Fact Sheets, Policy Briefs & Policy Updates
Fact Sheet #1
Labour migration by numbers: South Africa's foreign and
domestic migration data
Policy Brief #1
A region without borders? Policy frameworks for regional labour
migration towards South Africa
Policy Brief #2
Migration and employment in South Africa. Statistical and
econometric analyses of internal and international migrants in
Statistics South Africa's labour market data
Policy Brief #3
A disposable workforce: Foreign health professionals in the South
African public service
Policy Brief #4
Getting the house in order: Precarity, migration and domestic
work in South Africa
Policy Brief #5
A bitter harvest: Migrant workers in the commercial agricultural
sector in South Africa
Policy Brief #6
Making guests feel comfortable: Migrancy and labour in the
hospitality sector in South Africa
Policy Update #1
Adoption of the SADC Labour Migration Policy Framework
Working Papers
Veronique Gindrey – Working Paper #1 – October 2015
The position of foreign health professionals in the South African
public health service: A statistical analysis of PERSAL data -
Supplementary paper to MiWORC Report #7
Christine Fauvelle-Aymar – Working Paper #2 – November 2015
Immigration and the South African labour market
African Centre for Migration & Society,
Wits University
Private Bag X3, Wits 2050, South Africa
T: +27 11 717 4674
miworc@migration.org.za
Writers:
Wendy Landau & Kuda Vanyoro
Coordination of production:
Thea de Gruchy
Printing & dissemination:
Wendy Landau & Thea de Gruchy
The Migrating for Work Research Consortium
www.miworc.org.za
The research consortium was a partnership from 2012 to 2015 led by the African Centre
for Migration & Society (ACMS) at Wits University between a range of academic and
international partners.
MiWORC was based on a matching fund principle. The European Union, in the
framework of the EU-South Africa Dialogue Facility, funded 50 per cent of the
consortium. Beyond an ambitious scholarly agenda, one of MiWORC’s objectives was to
avail empirically-based evidence to the EU-SA Dialogue Facility, as well as to a range of
key stakeholders in government, organised labour, business, and the NGO sector.

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