Following 2 years of protracted lobbying and negotiation by the Rural Doctors' Association of Southern Africa (RuDASA), and other groups, in 2003 the registering authority, the Medical and Dental Professional Board of the Health Professions Council of South Africa (HPCSA), the registering authority, has again made it possible for foreign qualified doctors to obtain registration without necessarily sitting an examination. This enables eligible doctors to work more easily in South Africa in order to assist with the current crisis in rural hospitals
The process of registration remains as per current regulations, which have not been amended, in that any non-South African qualified doctor must be assessed by the HPCSA. The new system mandates the Examinations Committee of the HPCSA to do that assessment on the basis of qualifications, experience and, if necessary, interview. On the basis of that assessment, the Committee decides if a candidate needs to write an examination in order for their competence to be confirmed, or whether there is enough evidence for them to be registered immediately. Those who will be registered immediately are likely to be doctors from developed countries with recognised medical education and appropriate post-internship experience. Doctors who are thus registered will be able to enter public service only (ie to practice in the government sector), and will be registered for 3 years only, although this is potentially renewable.
RuDASA has welcomed this move as a major development which has great potential to improve the staffing situation in rural hospitals. It is expected that hospitals and provincial departments of health will use this opportunity to recruit appropriate doctors to areas of great need. This new approach has been endorsed by the National Department of Health which will give assistance with the recruiting process, in line with a new approach to immigration adopted by the Department of Home Affairs, which makes it easier for skilled migrants to enter the country.
This decision has, however, raised many issues that cannot be ignored, as difficult as they may be. This article seeks to explore some of these, rather than to look at the issue of the ethics of international recruitment (subject of a recent editorial1 and also the major focus of the Melbourne Manifesto, adopted at the 5th World Rural Health Conference in Melbourne, Australia, in May 2002)2.
I have deliberately focussed on the foreign doctor in South Africa. Much of the discussion, however, would equally apply to other health-care professionals, and the debate has relevance for other countries in a similar position.
Difficulties associated with foreign-qualified doctors
Short-term tenure vs long-term commitment
The first issue raised by the decision to allow foreign-qualified doctors to obtain South African registration is the place of foreign-qualified doctors in the South African health-care system. One of the concerns that RuDASA had in terms of advocating this change and in supporting the need to recruit foreign doctors to assist rural hospitals was the assumption, unfortunately made by a number of people including prominent politicians, that the organisation supports foreign doctors over local doctors. It needs to be clearly recognised that foreign doctors, in whatever form and in any country, should always and only be a short-term solution. Foreign doctors are used all over the world to address critical shortages of doctors, especially but not exclusively in rural areas. Some countries seem comfortable using foreign doctors to make up their shortfall in training on an ongoing basis; the Melbourne Manifesto2 seeks to address this. However, in most cases, foreign doctors are seen as an interim solution and are used for the short-term filling of gaps. Unfortunately, the controls do not usually exist for this contribution to remain short term and many of these doctors turn their initial contract into a long-term commitment.
Strategies to prepare South African doctors
In South Africa, too, the use of foreign doctors should be seen only as a short-term measure. It may be that this short-term measure will be in place for a long time, but it needs to be constantly reviewed. The long-term process of training more appropriate for rural-hospital doctors in South Africa is something that must be advocated strongly and supported in every way possible. This process requires changes in the way students are selected for medical schools, changes in their undergraduate curricula, different approaches to postgraduate training and the development of incentives for rural hospital work. There needs to be planning and implementation of a clear strategy for the future in order to address the needs of rural hospitals. I would be very happy if South Africa could reach the situation where we do not need foreign doctors in order to staff rural hospitals. Unfortunately that day is a long way off.
The origin of foreign-recruited doctors
Another area of difficulty is where such foreign doctors should be recruited from. Two factors are in play here. First, 1990s there was a flood of doctors (and other professionals) who came into the country from the rest of Africa as the political situation in South Africa changed3. These doctors have provided a very useful and important service to the country and many rural hospitals are still staffed almost entirely by such doctors, together with the community-service doctors who have been sent out to these hospitals in more recent years. However, these doctors have often been made to feel unwelcome, in common with their non-medical counterparts4, which has been very distressing. As a result, we have lost many very able African doctors to countries such as Australia and Canada. This is especially true for doctors who have obtained additional training and qualifications in family medicine, which has made them more useful to South Africa but at the same time more eligible for registration in other countries. They have usually cited the constant difficulties they faced from the Department of Home Affairs and the lack of support from other officials as key factors pushing them to make the decision to move on.
At the same time it must be recognised that South Africa caused serious problems for countries to its north by letting their doctors come into this country. Many of these countries started facing serious shortages of doctors as a result of the southward migration of so many. Whether this should be a concern or not is a matter of great debate. Some people would argue that it is the responsibility of those countries to ensure that their doctors are well looked after, paid and catered for. If doctors want to leave, the argument goes, it is not the concern of the country that recruits them but rather of the country that is not supporting them to stay. The problem with this argument is that, internationally, it becomes a cycle of the richer countries always getting the best because poorer countries cannot offer the same. On the African continent, South Africa is the rich neighbour and as such will always be able to offer more than countries to the north. In the same way as South Africa is unhappy with her doctors being recruited to countries such as Australia, Canada and the United Kingdom by attractive packages, so it needs to be recognised how the same can apply in Africa.
The difficulty comes where there are places suffering major conflict such as civil war. An example of this has been the Democratic Republic of Congo (DRC). Some doctors have been desperate to leave the conflict situation where they have valiantly continued to work over many years. If they cannot get into South Africa, they go to any developed country that will accommodate them, and are lost to Africa altogether. It does seem inhumane not to allow them this opportunity to remain on the continent, but where does one draw the line and how does one decide which countries are in such situations of conflict and which are not. And what happens after the time of conflict has ended, such as is now approaching in the DRC? These are questions for which I do not have easy answers.
The second issue regarding recruitment of doctors is the fact that it is more expensive for a country to train a doctor than to recruit a doctor. It would thus seem only fair that countries with sufficient resources to train more doctors should be targeted for recruitment, which of course would mean mainly the developed countries. The fact that these countries often report that they have their own shortages of doctors relates both to increasing demands from patients and to increasing specialisation on the one hand and to failure to use their resources fully due to an expedient reliance on overseas trained doctors on the other. The principle of distributive justice would seem to me to allow for recruitment in those countries. It would also redress the balance where these countries have been and are actively recruiting in South Africa.
An additional aspect in terms of recruiting from these countries is that there are many doctors there who would like to render overseas service in a developing country for a couple of years before returning to continue working in their home country. Unlike many of their counterparts in developing countries, they have no desire to leave their country of origin but simply want to gain a different experience. Thus, providing short-term opportunities of up to 3 years for such doctors allows them to achieve their goals as well as helping South Africa to staff its rural hospitals. This is surely a win-win situation. In counter argument, however, doctors from Africa argue that this is discriminatory and unfair to them, individually.
Acceptable standards of training
The next area of difficulty is how to decide what constitutes acceptable training and appropriate qualifications. The HPCSA has evaluated and assessed various countries' medical education systems and has identified a number that are comparable with the medical training and education system in South Africa. This would seem a fair process. However, due to historical factors, the charge of eurocentrism and bias towards certain countries because of a shared colonial history could be made. The system does allow for medical schools or graduates from any medical school to submit their curricula for assessment by the HPCSA so that the countries identified to have appropriate training can be adjusted in the future. It seems at least equivalent training to the South African system should be a minimum requirement. It is recognised that many countries' medical graduates lack the practical experience that South Africans get, hence the need for additional post-internship experience as part of the assessment process seems to be logical and rational. The focus on hands-on practical experience (especially in the domain of maternal and child health), as well as generalist practice with procedural skills are key aspects of health care in South Africa. The argument is made that doctors from developing countries, whatever their educational background, often have more appropriate skills and experience, enabling them to provide better service. Taken together with the lack of practical experience of many students in European medical schools, the difficulty is not easily resolved.
The dilemma in all this is who should dictate the process. In other words, is it the responsibility of the HPCSA or the Department of Health to decide who should be eligible for registration and who should not? In this regard one can question the decision of the HPCSA to favour doctors from developed countries. On the one hand the HPCSA needs to maintain its independence and its role as a statutory body. On the other hand it has to work within the context of South Africa, its political system and its political history. One cannot ignore current realities. The Department of Health has taken a clear decision that it will not offer work to doctors from developing countries, and specifically as part of the African Renaissance agreements5, will not employ doctors from other African countries. Therefore, for the HPCSA to offer registration to such doctors knowing they would not be able to obtain employment in South Africa would seem an unwise thing to do and would open the HPCSA to litigation. However in the current system the HPCSA will not refuse to register such doctors if they pass the registration examination and obtain a work offer from the Department of Health.
The way ahead
Given all this, what is the way forward? I believe that rural hospitals in South Africa should grab with both hands the opportunity to recruit doctors from developed countries which is now provided for them. Doctors from such countries should make use of the challenging opportunities that will now arise. At the same time I believe that every effort should be made to make foreign doctors currently working in the country, especially those from developing countries who have been providing a service for some time, feel welcome in this country. They should be given the necessary permanent residence and even citizenship opportunities so that they are not recruited to work in other countries. In terms of doctors from developing countries, I believe recruitment should be on the basis of government-to-government agreements between South Africa and those countries which may have an excess of doctors they are then able to offer for 'export'. Furthermore, other candidates should be reviewed on an individual basis in terms of their situations of origin, especially in terms of conflict situations. At all times the importance of a well trained and experienced doctor who is able to function in a rural hospital in South Africa must be borne in mind.
Finally, as stated before, there needs to be continuing development of a strategic plan to ensure that South African doctors are in sufficient supply to staff rural hospitals adequately in the not too distant future.
1. Couper ID, Worley PS. The Ethics of International recruitment. Rural and Remote Health 2 (online), 2002. Available from: http://rrh.org.au
2. WONCA Working Party on Rural Practice. The Melbourne Manifesto: A Code of Practice for the International Recruitment of Health Care Professionals (online, September 2003). 5th Wonca World Rural Health Conference, 3 May 2002, Melbourne, Australia. Available from: http://www.globalfamilydoctor.com/aboutWonca/working_groups/rural_training/melbourne_manifesto.htm (Accessed 5 June 2003).
3. Southern African Migration Project. Thinking About the Brain Drain in Southern Africa (Migration Policy Brief No. 8; online, 2002). J Crush and V Williams (Eds). Available from: http://www.queensu.ca/samp (Accessed 5 June 2003).
4. Southern African Migration Project. Transnationalism and African Immigration to South Africa (Migration Policy Brief No. 9; online, 2002). J Crush and V Williams (Eds). Available from: http://www.queensu.ca/samp (Accessed 5 June 2003).
5. New Partnership for Africa's Development. A Summary of NEPAD Action Plans. Available at: http://www.avmedia.at/cgi-script/csNews/news_upload/NEPAD_2dCORE_2dDOCUMENTS_2edb.ASummaryofNEPADActionPlans.pdf (Accessed on 5 June 2003).