Nurse shortages and the training of nurses in South Africa were in the spotlight at a two-day conference on the future of nursing hosted by the South African Nursing Council (SANC) in Johannesburg last month. Since then, what some call a "nursing crisis" in South Africa has made the headlines in several leading publications.
The "nursing crisis" in South Africa is not new.
In October 2021, for example, Spotlight reported that close to half of the country's nurses were set to retire within 15 years. At the time, the national spokesperson for the Democratic Nursing Organisation of South Africa (DENOSA), Sibongiseni Delihlazo, referred to the situation as a "ticking time bomb".
South Africa's 2030 Human Resources for Health Strategy (HRH strategy), first made public in 2020, also raised the alarm about healthcare worker shortages in South Africa and made a compelling case for dramatically increased investment in human resources in the health sector. However, as of mid-2023, the sustained increase in investment called for in the HRH strategy hasn't materialised - although there was some additional investment to help cope with the COVID-19 pandemic.
Finding the money, both for the training and for the employment of nurses, is one aspect of South Africa's "nursing crisis". Another has to do with the highly contested terrain of how nurses are trained in South Africa and who is accredited to train how many and what role the private sector plays in all this. We'll take these issues one by one to try and keep things as clear as possible.
Not employing all the nurses we do train
In an interview with Spotlight, Dr Matlou Molepo, chairperson of the SANC, admitted to the nurse shortages and training challenges, but said that ultimately, not all the nurses they train are absorbed in the public health system - mainly due to funding constraints.
"We are training them but provincial departments cannot absorb them," said Molepo. "To train nurses [costs] a lot of money and they go through a lot of departments, and they utilise a lot of health equipment during their training. [This] costs money. So we can't be training nurses, but then they are not absorbed because the provincial departments or the private hospitals don't have money to absorb them. Therefore, it means we're training more than we can absorb and yet we have a shortage of nurses."
That the absorption of nurses is a real and urgent problem is confirmed by the Department of Health. According to Dr Anban Pillay, deputy director general for Health Regulation and Compliance in the department, the department has made an investment case to the National Treasury for the funding of more healthcare workers. Pillay was addressing the nursing conference.
We are training them but provincial departments cannot absorb them. - Dr Matlou Molepo, SANC chair
"So we have made a case and actually the budget that we've been given is reduced from what we had before in nominal terms, which effectively means that it's not just a case of making a case for more, we are going to battle to keep the people we have. That's how bad the case is," he said.
We followed up after the conference with Foster Mohale, spokesperson for the National Department of Health, to get a further sense of how seriously the department considers the situation. "The point he [Pillay] is making is that our budget has been cut," said Mohale. "Then National Treasury says we must absorb the 7.5% wage increase from the allocated budget. This decline in budget means we now have less than in the previous year. Then if you consider inflation, the situation is even more serious."
According to Dr Kobie Marais, Director for Nursing Education and Training in the national health department, their human resource department is working on a costing for the HRH strategy that will cover all public sector healthcare workers. It's quite a big process since we are thousands and thousands of health workers," Marais said. She could not say when this costing would be complete.
Recently, however, Health Minister Dr Joe Phaahla was quoted by ENCA as saying, "Just in terms of the immediate basic needs, we did indicate that across the board, we need an amount of just under a billion rand - about R950 million, which is required just to be able to make sure that we can meet the basic needs."
Too few specialist nurses
Nursing has several sub-specialities and in several of these, the shortages are particularly acute. Spotlight has, for example, reported on the urgent need for more theatre nurses.
Molepo said that the council is aware of the shortage of nurses within certain specialities and as a regulator, they are working towards a solution with relevant stakeholders - among them the Council on Higher Education, which is responsible for quality assurance in higher education.
"We have also realised that we have run into a shortage of specialist nurses. And because of developments in health, we now have a lot of specialities. And with every speciality in health, we need nurse specialists within that particular category," she said, adding that the retirement of specialist nurses poses a particular challenge.
Understanding the exact extent of the problem is not straightforward. As pointed out by Professor Ntombifikile Mtshali, CEO of the SANC, the number of retired nurses with additional qualifications is not known since even after retirement, some nurses prefer to maintain their license to practice.
That said, the SANC does provide a relatively extensive set of statistics on its website (see several reports for 2022 here). Some specific big-picture figures for the period from 2013 to 2022, paint a worrying picture. Over the ten years, the number of nurses on the register has grown by 4%, from 260 698 to 271 047. The SANC quotes StatsSA figures indicating that over the same period, the population of South Africa has grown by around 14%. Taken together, this means that in 2022, we had fewer nurses per person than we had in 2013. The SANC figures also show a worrying dip in the number of student nurses in the various categories in 2021 and 2022.
The number of nurses the country can produce has been affected by changes in nurse training. - Dr Matlou Molepo, SANC
Knowing how many nurses we have in different categories is of course only a starting point. For future planning, we also need to know how many we need in the various specialisations. Mtshali was not able to put numbers to how many nurses we need in the various categories. She said provincial health departments are best placed to answer this question.
The HRH strategy provides some estimates of the numbers needed - which makes the National Department of Health's costing of the strategy an important next step toward South Africa budgeting for and employing more healthcare workers. It is critical for public engagement that the costing should be made public once completed.
A disruptive transition
According to Molepo, the number of nurses the country can produce has been affected by changes in nurse training. As Spotlight previously reported in some detail, nurse training has, and is, going through a major transition in South Africa. In short, the qualifications nurses train for have changed and training institutions now have to be accredited by both the SANC and the Council for Higher Education. The changes, intended to speed up the professionalisation of nurse training, have in some instances contributed to major disruption of training institutions in, for example, the Eastern Cape.
We definitely do have a shortage in some categories of nurses and that's why we do training plans according to the needs for health services. - Dr Kobie Marais, NDoH
Molepo said that with the transition, there has been "a gap created in the middle" so the production of nurses' specialisation programmes could not continue and also considering that older nurses who were specialists were already retiring. "We are producing more nurses, but because we changed from the post-basic nursing programmes to the post-graduate diploma programmes, that change in between also affected us - thus the shortage," she said.
Molepo said, "The figures have been affected by different nursing institutions and the ending of the legacy qualifications. Basically, the public nursing colleges are producing 80% of the nurses that we have and the specific figures will then depend on which province and which public nursing institution ended their legacy qualification and started on new programmes."
Asked if the transition [to the new training curriculum] is now complete, Molepo said the transition could not be completed because more nursing training colleges might be opened or private hospitals might want to open nursing training institutions. This will then make the accreditation process continue so the transition will be ongoing. The SANC provides a list of currently accredited institutions on their website.
Also weighing in on the shortages, especially of specialist nurses, Marais said, "We definitely do have a shortage in some categories of nurses and that's why we do training plans according to the needs for health services. So we're going to train specifically for specialist nurses because there is a bigger shortage, though there was overproduction of some of the lower categories previously."
What role for the private sector?
One of the most contentious issues in recent weeks has been the role of the private sector.
According to Marais, there are some nurse training colleges in the private sector. "Some of them are affiliated to the big hospital groups, like Netcare, Life, and Medi-Clinic and then there are also independent private nursing colleges." She said that HASA-affiliated Nursing Colleges (Netcare, Life, and Mediclinic) have been conditionally accredited by the SANC to train nurses in nursing specialties - Critical Care, Emergency Nursing, Peri-operative Nursing, and Health Service Management over and above training nurses for basic programmes such as Nursing Auxiliary and General Nursing Programmes. "This means that if the Council on Higher Education also accredits them, they can offer these programmes," she said.
But Life Healthcare Group Chief Executive Peter Wharton-Hood has said that while Life Healthcare has the capacity to train up to 3 000 nurses per annum, they are currently only accredited to train 800. The Netcare group has raised similar concerns. In a statement, Life Healthcare reaffirmed its commitment to investing in the training and development of nurses and ensuring a sustainable pipeline of nursing professionals for the future. However, they wrote, the organisation cannot achieve this without the support of regulators.
"There is a scarcity of specialised skills for several reasons," said Merle Victor, Chief Nurse Officer at Life Healthcare in the statement. "One of them is that not enough training opportunities have been made available. That is a serious problem for our country, considering our burden of disease. Additionally, to ensure our patients get adequate care, we need specialist nurses with the appropriate knowledge, skills, and competence."
When asked about the concerns raised by Life Healthcare, Mohale (of the health department) said the SANC would be the appropriate body to comment on the issue.
It all comes down to the question of whether or not the SANC is over-managing nurse training in South Africa.
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The SANC responded in a statement that "the [Life Healthcare] statement that depicts SANC as the stumbling block for nurse training is unfounded". "The SANC is mandated to protect the public on matters relating to health and in particular nursing. Therefore, it is duty bound to ensure that quality Nursing Education and Training is provided and cannot compromise this obligation for any other interest outside production of safe and competent practitioners for patient safety," it said.
The SANC stressed that a variety of factors are considered when deciding whether or not to grant accreditation. Among others, these include a letter of support from the provincial department of health, classroom capacity, available clinical facilities, and the facilitator/student ratio. They said that they cannot act irresponsibly by allowing a patient-student ratio in clinical facilities that may compromise the quality of clinical learning and the safety of patients. Though the SANC does not state this outright, the implication is that more private training is not being accredited because it does not meet all the requirements.
It all comes down to the question of whether or not the SANC is over-managing nurse training in South Africa. From the outside, it is hard to tell whether or not they are, although the general view from outside of the SANC seems to be that they are.
Dr Sue Armstrong, a lecturer at the Department of Nursing Education at the University of the Witwatersrand and Chairperson of the Nursing Education Association, previously told Spotlight that what needs to happen is that the Nursing Council must become more "facilitative". She said the council is being "very authoritarian" and seems to believe they have a right to control the numbers that are trained. "In some ways, the SANC is there to protect the public and yes, we would not want anyone to train thousands of nurses if they weren't being trained properly but those nursing education institutions with capacity should be allowed to train the maximum number," she said.
Such views would have been bolstered by a judgement of the Supreme Court of Appeal last week (see a media summary of the case here). In essence, the court rejected the SANC's decision that Khanyisa Nursing School may only start offering specific courses at the start of 2023, rather than in mid-2022. The SANC's argument was that starting in the middle of the year would fall outside the definition in the relevant regulations of an academic year. In this specific case at least, the court left little doubt that it did not agree with the SANC's inflexible approach. In part, the judgment reads, "There is no reason to think that, in a modern era of vocational training, there is any convention that requires an academic year to run from January to December. On the contrary, there are very good reasons to suppose, as the founding affidavit reminds us, that the shortage of qualified nurses requires flexibility as to the period within which an academic year can run."
