sector skills plan for the health sector in south africa

SECTOR SKILLS PLAN FOR THE HEALTH SECTOR IN SOUTH AFRICA
SUBMITTED TO THE DEPARTMENT OF HIGHER EDUCATION AND TRAINING
BY THE HEALTH AND WELFARE SETA
FINAL DRAFT
FEBRUARY 2011

TABLE OF CONTENTS
EXECUTIVE SUMMARY .................................................................................................................................. x
INTRODUCTION ......................................................................................................................................... x
PROFILE OF THE HEALTH SECTOR ............................................................................................................. x
FACTORS INFLUENCING THE HEALTH SECTOR LABOUR MARKET ........................................................... xii
DEMAND FOR SKILLS ............................................................................................................................... xiv
SUPPLY OF SKILLS .................................................................................................................................... xv
SKILLS DEVELOPMENT PRIORITIES OF THE HWSETA ............................................................................. xvii
1 INTRODUCTION ..................................................................................................................................... 1
1.1 BACKGROUND ............................................................................................................................... 1
1.1 PREPARATION OF THE SSP ............................................................................................................ 1
1.2 STAKEHOLDER CONSULTATION .................................................................................................... 2
1.3 LIMITATIONS ................................................................................................................................. 3
1.4 OUTLINE OF THE SSP ..................................................................................................................... 3
2 PROFILE OF THE SECTOR ....................................................................................................................... 4
2.1 INTRODUCTION ............................................................................................................................. 4
2.2 THE SOUTH AFRICAN HEALTH SYSTEM ......................................................................................... 4
2.3 EMPLOYERS IN THE SECTOR .......................................................................................................... 6
2.4 ORGANISATIONS IN THE SECTOR .................................................................................................. 6
2.4.1 REGULATORS AND PROFESSIONAL BODIES .......................................................................... 6
2.4.2 ACADEMIC AND RESEARCH INSTITUTIONS ........................................................................... 9
2.4.3 EMPLOYER ORGANISATIONS............................................................................................... 11
2.4.4 NON-GOVERNMENTAL ORGANISATIONS ........................................................................... 11
2.4.5 PROFESSIONAL ASSOCIATIONS ........................................................................................... 12
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2.4.6 LABOUR UNIONS ................................................................................................................. 12
2.5 PROFILE OF EMPLOYEES IN THE SECTOR .................................................................................... 13
2.6 CONCLUSIONS ............................................................................................................................. 18
3 FACTORS INFLUENCING THE HEALTH SECTOR LABOUR MARKET ....................................................... 20
3.1 INTRODUCTION ........................................................................................................................... 20
3.2 HEALTH SPENDING ...................................................................................................................... 20
3.2.1 PUBLIC SECTOR SPENDING.................................................................................................. 21
3.2.2 PRIVATE SECTOR SPENDING ............................................................................................... 22
3.3 THE DEMAND FOR HEALTH SERVICES ......................................................................................... 23
3.3.1 THE PUBLIC-PRIVATE DIVIDE ............................................................................................... 23
3.3.2 THE DEMAND FOR PUBLIC HEALTH CARE ........................................................................... 24
3.3.3 THE DEMAND FOR PRIVATE HEALTHCARE SERVICES .......................................................... 26
3.4 THE MOBILITY OF LABOUR .......................................................................................................... 27
3.5 ECONOMIC DOWNTURN ............................................................................................................. 27
3.6 THE BURDEN OF DISEASE ............................................................................................................ 27
3.7 HUMAN RESOURCES CHALLENGES ............................................................................................. 29
3.8 MANAGEMENT OF THE HEALTH SYSTEM ................................................................................... 31
3.9 THE REGULATORY ENVIRONMENT ............................................................................................. 32
3.9.1 REGULATION OF QUANTITY AND DISTRIBUTION ................................................................ 32
3.9.2 REGULATION OF QUALITY ................................................................................................... 33
3.10 NATIONAL HEALTH POLICIES....................................................................................................... 33
3.10.1 PRIMARY HEALTHCARE ....................................................................................................... 34
3.10.2 COMMUNITY HEALTH WORKERS ........................................................................................ 34
3.10.3 A NATIONAL HEALTH INSURANCE SYSTEM ......................................................................... 36
3.10.4 HIV AND AIDS POLICIES ....................................................................................................... 38
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3.10.5 STRATEGY TO FIGHT TUBERCULOSIS .................................................................................. 39
3.10.6 MATERNAL AND CHILD HEALTH .......................................................................................... 39
3.11 EMPLOYMENT EQUITY AND BEE ................................................................................................. 40
3.12 VETERINARY SERVICES ................................................................................................................ 40
3.13 CONCLUSION ............................................................................................................................... 41
4 THE DEMAND FOR SKILLS.................................................................................................................... 43
4.1 INTRODUCTION ........................................................................................................................... 43
4.2 CURRENT EMPLOYMENT ............................................................................................................. 43
4.2.1 POSITIONS IN THE PUBLIC SERVICE ..................................................................................... 43
4.2.2 POSITIONS IN THE PRIVATE SECTOR ................................................................................... 44
4.3 CURRENT SHORTAGES ................................................................................................................ 45
4.3.1 VACANCY RATES .................................................................................................................. 45
4.3.2 BENCHMARKING AND COMPARISONS ............................................................................... 48
4.4 FUTURE DEMAND ....................................................................................................................... 49
4.4.1 SKILLS DEVELOPMENT TARGETS SET BY THE NATIONAL DEPARTMENT OF HEALTH.......... 49
4.5 FACTORS THAT IMPACT ON THE DEMAND FOR HEALTHCARE WORKERS .................................. 49
4.5.1 HIV AND AIDS TREATMENT POLICIES .................................................................................. 49
4.5.2 POLICIES TO CONTROL TUBERCULOSIS ............................................................................... 50
4.5.3 MATERNAL, CHILD AND WOMEN’S HEALTH PROGRAMMES ............................................. 51
4.5.4 MANAGEMENT OF HEALTH OPERATIONS AND PEOPLE ..................................................... 51
4.5.5 EXPANSION OF THE PUBLIC HEALTH INFRASTRUCTURE ..................................................... 52
4.5.6 SKILLS REQUIREMENTS FOR THE NHI .................................................................................. 52
4.6 CONCLUSIONS ............................................................................................................................. 53
5 THE SUPPLY OF SKILLS ......................................................................................................................... 55
5.1 INTRODUCTION ........................................................................................................................... 55
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5.2 THE SOUTH AFRICAN SECONDARY SCHOOL SYSTEM .................................................................. 55
5.3 INSTITUTIONAL ARRANGEMENTS AND CAPACITY FOR THE TRAINING OF HEALTH WORKERS .. 59
5.3.1 ACADEMIC COMPLEXES ...................................................................................................... 59
5.3.2 PRIVATE HIGHER EDUCATION AND TRAINING INSTITUTIONS ............................................ 59
5.3.3 PRIVATE FURTHER EDUCATION AND TRAINING INSTITUTIONS ......................................... 60
5.3.4 PRIVATE HOSPITALS ............................................................................................................ 61
5.3.5 CPD PROVISION ................................................................................................................... 62
5.3.6 NON-PROFIT ORGANISATIONS ............................................................................................ 62
5.4 PROFESSIONAL REGISTRATION ................................................................................................... 62
5.4.1 REGISTRATIONS WITH THE HEALTH PROFESSIONS COUNCIL OF SOUTH AFRICA ............... 62
5.4.2 REGISTRATIONS WITH THE SOUTH AFRICAN NURSING COUNCIL ...................................... 63
5.4.3 REGISTRATIONS WITH THE SOUTH AFRICAN PHARMACY COUNCIL ................................... 65
5.4.4 REGISTRATIONS WITH THE ALLIED HEALTH PROFESSIONS COUNCIL OF SOUTH AFRICA ... 65
5.4.5 REGISTRATIONS WITH THE SOUTH AFRICAN VETERINARY COUNCIL ................................. 66
5.5 THE SUPPLY OF NEW GRADUATES BY THE HIGHER EDUCATION SYSTEM .................................. 66
5.5.1 HIGHER EDUCATION AND TRAINING .................................................................................. 66
5.6 THE SUPPLY OF NEW ENTRANTS THROUGH NURSING COLLEGES.............................................. 68
5.7 THE ROLE OF THE HWSETA IN THE SUPPLY OF SKILLS ................................................................ 68
5.7.1 THE REGISTRATION OF QUALIFICATIONS AND LEARNERSHIPS .......................................... 68
5.7.2 LEARNERS WHO QUALIFIED ON LEARNERSHIPS ................................................................. 69
5.7.3 INTERNSHIPS ....................................................................................................................... 71
5.7.4 SKILLS PROGRAMMES ......................................................................................................... 71
5.7.5 ADULT BASIC EDUCATION AND TRAINING (ABET).............................................................. 71
5.7.6 RECOGNITION OF PRIOR LEARNING ................................................................................... 72
5.7.7 SKILLS DEVELOPMENT SUPPORT TO SMALL ENTERPRISES ................................................. 72
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5.7.8 EXPANDED PUBLIC WORKS PROGRAMME .......................................................................... 72
5.8 FACTORS INFLUENCING THE SUPPLY OF SKILLS .......................................................................... 73
5.8.1 GOVERNMENT STRATEGIES AND POLICY INTERVENTIONS ................................................ 73
5.8.2 MANAGEMENT OF THE PUBLIC SECTOR HEALTH FACILITIES .............................................. 75
5.8.3 MIGRATION OF PROFESSIONALS ........................................................................................ 76
5.8.4 THE IMPACT OF HIVAND AIDS............................................................................................. 77
5.8.5 RECRUITMENT OF FOREIGN HEALTH WORKERS ................................................................. 77
5.8.6 SOCIO-ECONOMIC REALITIES OF POTENTIAL LEARNERS .................................................... 78
5.9 CONCLUSIONS ............................................................................................................................. 78
6 SKILLS DEVELOPMENT PRIORITIES OF THE HWSETA .......................................................................... 80
6.1 INTRODUCTION ........................................................................................................................... 80
6.2 CONTRIBUTION TO GOVERNMENT’S MTSF OBJECTIVES ............................................................ 80
6.3 SECTORAL CONTRIBUTION TO STRATEGIC AREAS OF FOCUS FOR NSDS III ................................ 80
6.3.1 EQUITY IMPACT ................................................................................................................... 80
6.3.2 CODE OF DECENT CONDUCT ............................................................................................... 81
6.3.3 LEARNING PROGRAMMES FOR DECENT WORK .................................................................. 81
6.3.4 PIVOTAL OCCUPATIONAL PROGRAMMES .......................................................................... 82
6.3.5 SKILLS PROGRAMMES AND OTHER NON-ACCREDITED SHORT COURSES .......................... 82
6.3.6 PROGRAMMES THAT BUILD THE ACADEMIC PROFESSION AND ENGENDER INNOVATION
83
6.3.7 STRENGTHEN OUR OWN CAPACITY AND THAT OF OUR DELIVERY PARTNERS .................. 83
6.4 CONCLUSIONS ............................................................................................................................. 83
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LIST OF TABLES
Table 2-1 Total employment in the private sector and in the Public Service according to occupational
category ...................................................................................................................................................... 15
Table 2-2 Estimates of employment in selected occupations .................................................................... 15
Table 2-3 Total employment in private and public health according to population group ........................ 16
Table 2-4 Total employment in private and public health according to gender ........................................ 17
Table 2-5 Age profile of key professionals in the Public Service ................................................................ 18
Table 2-6 Age profile of medical practitioners (including medical specialists) in the private sector ......... 18
Table 3-1 Health expenditure in public and private sectors: 2007 -2010 .................................................. 21
Table 3-2 Use of public and private sector facilities according to medical insurance (of those who were
ill/injured or sought care): 2007 ................................................................................................................. 24
Table 3-3 Primary healthcare visits per province: 2008/09 ....................................................................... 25
Table 3-4 Primary healthcare workload per province: 2008/09 ................................................................ 25
Table 3-5 Key resources per 100 000 population in public and private sectors: 2009 ............................... 29
Table 3-6 Distribution of health professionals per 100000 population in public sector: 2008 .................. 30
Table 4-1 Total number of positions in the private health organisations .................................................. 44
Table 4-2 Total professional positions in the private health organisations ................................................ 45
Table 4-3 Vacancy rates in the National and provincial health departments in selected occupation: 31
March 2010 ................................................................................................................................................. 46
Table 4-4 Scarce skills in private and public health according to occupational category ........................... 47
Table 4-5 Public sector staff needs to meet international in-hospital benchmarks ................................... 48
Table 5-1 Grade 12 statistics – mathematics, physical sciences and life sciences: 2008 ........................... 56
Table 5-2 Grade 12 statistics – mathematics: 1999-2007 .......................................................................... 56
Table 5-3 Grade 12 statistics – physical science: 1999-2007 ...................................................................... 57
Table 5-4 Grade 12 statistics – biology: 1999-2007 .................................................................................... 58
Table 5-5 Number of professionals registered with the HPCSA as at 31 December of 2000 to 2009
(selected professions)* ............................................................................................................................... 64
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Table 5-6 Number of nurses registered with the SANC: 2000 to 2009 ...................................................... 64
Table 5-7 Number of registrations with the SAPC: 2010 ............................................................................ 65
Table 5-8 Total registrations with the AHPCSA: 2010 ................................................................................. 65
Table 5-9 Number of registrations with the SAVC: 2010 .......................................................................... 66
Table 5-10 Number of health-related qualifications awarded by the public higher education sector: 1999
to 2008 ........................................................................................................................................................ 67
Table 5-11 Number of graduates at nursing colleges: 2000 to 2009 ......................................................... 68
Table 5-12 FET level qualifications registered by HWSETA on the NQF ..................................................... 68
Table 5-13 HWSETA learnerships at FET level ............................................................................................ 69
Table 5-14 Number of learners who completed learnerships in the health sector: 2002 to 2010 ............ 70
LIST OF FIGURES
Figure 2-1 The South African health system ................................................................................................ 4
Figure 2-3 Professionals by population group in the health sector ............................................................ 17
Figure 5-1 Comparison of output in basic nursing training between public and private sectors: 2007 -
2009 ............................................................................................................................................................ 61
APPENDIX
APPENDIX A SCARCE SKILLS LIST – PRIVATE ORGANISATIONS AND PUBLIC SERVICE DEPARTMENTS ....... 93
APPENDIX B HWSETA STRATEGIC BUSINESS PLAN 2011-2016……………...……………………………………………….96
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ABBREVIATIONS AND ACRONYMS
ABET
AgriSETA
AHPCSA
AIDS
ARC
ART
ATR
CBO
CCWMPF
CHW
CPD
DBSA
DENOSA
DG
DHET
DoA
DoH
DoSD
DPSA
EMIS
FET
HASA
HCBC
HEI
HEMIS
HEQC
HET
HIV
HOSPERSA
HPCSA
HSRC
HWSETA
INSETA
ITHPCSA
LGSETA
MDG
MDR TB
MoU
MRC
MTSF
NEHAWU
NGO
NHA
Adult Basic Education and Training
Agricultural Sector Education and Training Authority
Allied Health Professions Council of South Africa
Acquired Immune Deficiency Syndrome
Agricultural Research Council
Anti-Retroviral Therapy
Annual Training Reports
Community-Based Organisation
Community Care Worker Management Policy Framework
Community Health Worker
Continuous Professional Development
Development Bank of South Africa
Democratic Nursing Organisation of South Africa
Director-General
Department of Higher Education and Training
Department of Agriculture
Department of Health
Department of Social Development
Department of Public Service and Administration
Education Management Information System
Further Education and Training
Hospital Association of South Africa
Home-Community-Based Care
Higher Education Institution
Higher Education Management Information System
Higher Education Quality Committee
Higher Education and Training
Human Immune Virus
Health and Other Service Personnel Trade Union of South Africa
Health Professions Council of South Africa
Human Sciences Research Council
Health and Welfare Sector Education and Training Authority
Sector Education and Training Authority
Interim Traditional Health Practitioners Council of South Africa
Local Government SETA
Millennium Development Goals
Multiple Drug Resistant Tuberculosis
Memorandum of Understanding
South African Medical Research Council
Medium Term Strategic Framework
National Education Health and Allied Workers Union
Non-governmental Organisation
National Health Act
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NHI
NHLS
NPO
NQF
NSF
NSDS
OFO
OVI
PHC
PSA
PSETA
QMS
RPL
SADA
SADNU
SADTC
SAMA
SANC
SANDF
SAPC
SARS
SAVC
SDA
SDL
SETA
SSP
TB
UMALUSI
W&RSETA
WHO
WSP
XDR TB
National Health Insurance
National Health Laboratory Service
Non-Profit Organisation
National Qualifications Framework
National Skills Fund
National Skills Development Strategy
Organising Framework for Occupations
Onderstepoort Veterinary Institute
Primary Healthcare
Public Servants Association
Public Service SETA
Quality Management System
Recognition of Prior Learning
South African Dental Association
South African Democratic Nurses Union
South African Dental Technicians Council
South African Medical Association
South African Nursing Council
South African National Defence Force
South African Pharmacy Council
South African Revenue Service
South African Veterinary Council
Skills Development Act
Skills Development Levy
Sector Education and Training Authority
Sector Skills Plan
Tuberculosis
Council for Quality Assurance in General and Further Education and Training
Wholesale and Retail SETA
World Health Organization
Workplace Skills Plan
Extreme Drug Resistant Tuberculosis
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EXECUTIVE SUMMARY
INTRODUCTION
The Health and Welfare Sector Education and Training Authority (HWSETA) prepared this Sector Skills
Plan (SSP) in accordance with the requirements set out by the Department of Higher Education and
Training (DHET) in the Draft National Skills Development Strategy (NSDS) III framework document. In
anticipation of the proposed restructuring of the HWSETA into two SETAs, one for health and a separate
welfare SETA, this document deals only with the health sector.
Various data sources were used to prepare the health sector analysis and to construct a profile of the
sector. Data from the workplace skills plans (WSPs) submitted by private sector employers to the
HWSETA were combined with data extracted from such plans submitted by public sector employers to
the PSETA. Information on employment by the national and provincial health departments was
obtained from the PERSAL system. Data extracted from the registers of health professionals and paraprofessionals
maintained by the statutory councils were analysed. Information from the Education
Management Information System (EMIS) and the Higher Education Management Information System
(HEMIS) kept by the Department of Basic Education and DHET respectively was also used in the
preparation of the SSP. MEDpages, a private database of health service providers in the private sector,
was combined with the other employment databases in order to obtain a comprehensive picture of
employment in the private healthcare sector. Extensive desktop research was conducted on various
aspects of the South African health sector and incorporated into the SSP. The HWSETA also invited
inputs to the SSP via an electronic survey. This feedback, together with inputs made at seven
stakeholder workshops and contributions from interviews held with five key role-players in the health
sector, was also used in the preparation of the SSP.
During the preparation of this SSP, the HWSETA encountered significant difficulties with the lack of data,
gaps in and quality of information, as well as inconsistencies in the data of the health sector’s human
resources. This hampers demand analysis, projections on future needs and planning. In the recent past,
several researchers have had similar experiences. It is vital that these information gaps be addressed
jointly by the major role-players, including the national and provincial health departments, professional
councils, higher education authorities, training institutions, the HWSETA and the private sector.
PROFILE OF THE HEALTH SECTOR
The sector served by the HWSETA forms part of the South African Health System, which spans the
economic sectors for human and animal health.
However, not all the entities in the South African Health System form part of the HWSETA sector and
there is considerable overlap with several other SETAs, the national and provincial departments of
health submit WSPs to the Public Service SETA (PSETA), for example. The economic activities that fall
within the scope of the health component of the HWSETA range from all healthcare facilities and
services, pharmaceutical services and the distribution of medicine, medical research, non-governmental
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organisations, to veterinary services. In the 2009/2010 financial year a total of 4 321 organisations paid
skills development levies to the HWSETA.
In 2010, an estimated 460 000 people are employed in the health sector, of which 179 000 (39%) are
employed in private health and 281 000 (61%) in public health departments.
A large portion of the workers in the health sector are registered with statutory professional councils
that regulate the various professions. These councils are the Health Professions Council of South Africa
(HPCSA), the South African Nursing Council (SANC), the South African Pharmacy Council (SAPC), the
Allied Health Professions Council of South Africa (AHPCSA) and the South African Dental Technicians
Council (SADTC). Members of the veterinary and para-veterinary professions are registered with the
South African Veterinary Council (SAVC) and practitioners using indigenous African healthcare
techniques and medicines will soon be required to register with the Interim Traditional Health
Practitioners Council of South Africa (ITHPCSA). In many instances these councils determine the scope
of practice for various health professions and enforce rules of ethical and professional conduct. The
professional councils are actively involved in skills development through the setting and controlling of
standards for education and training, the registration of professionals, and continuous professional
development.
In both the Public Service and in the private sector managers constitute approximately 4% of total
employment. Almost half (47%) of employees in the private sector are employed as professionals and
28% in the Public Service. Professionals include medical and dental practitioners, registered nurses,
pharmacists, and other health-related occupations such as occupational therapists and psychologists.
Community and personal service workers in the Public Service constitute 42% of total employment. This
category mainly comprises enrolled and auxiliary nurses, emergency service and ambulance workers and
food and auxiliary hospital workers and aides.
In 2010, the majority (87%) of the people working in the sector are black, while white workers constitute
only 13% of the total workforce. Most (63%) of the professionals employed in the total sector are
African, 21% are white, 9% coloured and 7% are Indian. Among community workers and personal
service workers, 80% in the private sector and 86% in the Public Service are Africans. Women constitute
75% of the health workforce and the professionals in the public sector.
The majority of medical doctors/practitioners (80%), dentists (77%) and pharmacists (74%) in public
health are younger than 45. More than 50% of professional nurses are 45 and older. Of the medical
practitioners and specialists in the private sector, 42% are younger than 45.
A number of institutions conducting research in human and animal health and the socio-economic
impact of disease play a prominent role in the health sector. In addition to their research activities, the
Medical Research Council (MRC), National Health Laboratory Service (NHLS), Human Sciences Research
Council (HSRC) and the Onderstepoort Veterinary Institute (OVI) are specifically mandated to advance
the training and development of researchers, health professionals and technicians for the health sector.
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Health professionals and practitioners are organised in numerous voluntary organisations that generally
promote the interests of specific fields of medical practice and their members, including their
educational and economic interests. The Hospital Association of South Africa (HASA) represents 90% of
the private hospital groups and is a leading employer organisation in the sector. Labour and trade
unions are well organised and mobilised within the health sector. Trade unions play a formative role in
shaping labour market policies, labour relations practices and human resources management in the
sector.
Non-governmental organisations play an essential part in the delivery of healthcare to disadvantaged
and marginalised communities, even though they fall outside the sector’s formal structures.
FACTORS INFLUENCING THE HEALTH SECTOR LABOUR MARKET
South Africans access medical care either through the public health system or through their own health
insurance arrangements with medical schemes, or incur out-of-pocket expenses. More than 41 million
people rely on the public health system and 7.9 million people are covered by medical insurance. About
28% of the uninsured population consult private practitioners, but use public hospital services. An
estimated 64% to 68% of the population is entirely dependent on public sector care.
Many inequalities are entrenched in South Africa’s public-private healthcare mix. In 2009, the per capita
expenditure on healthcare in the public sector was about R2,058, but it was six times higher in the
private sector. In 2010 total healthcare expenditure in South Africa was estimated to be above R227
billion, with more than 53% of this attributable to private sector spending. Significantly higher numbers
of health professionals serve healthcare users in the private sector than the public sector population.
For example, more than three times the number of doctors and seven times the number of medical
specialists are available to private sector users, compared to the public sector. The ratio of nurses per
private sector population is almost double that of the public sector.
From 1995 onwards the public sector moved from a hospital-based approach to a primary healthcare
(PHC) approach. This is also reflected in public sector spending, with about 41% of public health funds
allocated to district health services, which include primary healthcare clinics and community health
centres, district hospitals and AIDS interventions. In contrast, private sector spending has moved away
from PHC towards funding major medical benefits such as hospitals, specialists and chronic diseases.
Payroll expenses comprise 56% of provincial health expenditure and escalated by 19% per annum over
the four years from 2005/06 to 2008/09.
Both the public and private health sectors are experiencing increased demand for services. At the same
time South Africa is also affected by the worldwide shortages of health workers. As highly mobile health
professionals migrate to more developed economies, valuable skills are lost and local health services are
adversely impacted. Similar experiences in the veterinary profession continue to cause skills shortages
in the public sector where the vacancy rate at national, provincial and laboratory levels remains high.
The 2008 global economic crisis and economic downturn impacted the health sector on several levels.
As tax revenues decline due to economic contraction, health budgets, allocations for human resources
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and training are directly affected. Demand for public health services is likely to increase due to job
losses (and loss of employment-linked medical insurance cover). This will add further pressure on health
professionals and workers in the public sector.
South Africa is encumbered by a quadruple burden of disease attributable to diseases of poverty, the
HIV and AIDS pandemic, high incidence of communicable diseases and tuberculosis infection, as well as
high levels of chronic diseases and inter-personal violence. This disease burden is four times larger than
in developed countries and is generally double that of other developing countries. The public sector
bears the brunt of the problems.
It is widely recognised that care levels, outcomes and management of the public health system are
under strain partly because of significant staff shortages, a mal-distribution of skills between urban and
rural areas, and an inadequate skills base. Management of the health system is under strain at almost
all levels. Wide-spread inefficiencies result in services that are unresponsive to health and patient
needs, and a lack of accountability exists on a large scale.
Almost every aspect of the health system is regulated by the national Department of Health (DoH), while
the professional councils regulate the quality of the country’s health workers. Responsibility for
developing human resources in the public sector are split between the national and provincial levels.
The national DoH has to promote adherence to norms and standards for the training of human
resources, while the nine provincial departments of health are responsible to plan, manage and develop
human resources to render health services.
A key priority for the national DoH is the introduction of a national health insurance (NHI) system
offering universal coverage and free health services to all South Africans by 2014; i.e. within the
planning horizon of this SSP. Although the proposals are still under development and subject to change,
the HWSETA should take into account the implications for human resources needs and skills
requirements, especially considering the long lead-time required to train healthcare professionals.
Although the details of the scheme are not yet known, it will extend access to private care and some
analysts expect an increase in the demand for services of general medical practitioners and specialists as
patients will move away from public clinics and hospitals. In the NHI system itself, considerable
managerial, financial and information technology management skills will be required to monitor usage
and benefits offered, as well as the distribution of resources and the costs of the scheme.
Current national health policies focus on the provision of primary care and community-based health
services; expanded HIV and AIDS and TB treatment; improving the health of mothers, babies and
children; improving management and governance of the health system; and improving human resources
planning. On the animal health side, there are increasing calls to make veterinary services more
accessible to low-income communities at local government level and to introduce mid-level veterinary
workers such as primary animal healthcare workers and community animal health workers to serve
animal health needs in impoverished communities.
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Implementation of these policies drive the need for more professional and technical healthcare,
leadership and management skills, as well as skills development interventions to enhance the skills
content.
DEMAND FOR SKILLS
The health sector is a personal services industry where services are both resource- and time-intensive.
Effective delivery of health services depends upon the availability of skilled human resources with the
appropriate skills. A growing demand for healthcare and the introduction of changes in the way health
services are delivered to the public, drive the demand for skills. Such demand continues to outstrip
supply.
In 2010 there were approximately 281 000 filled positions in the Public Service Health Departments. At
the time the total number of funded vacancies was not known, and the total number of positions
available in the Public Service could not be calculated. However, the scarce skills information obtained
through the Public Service Departments’ WSPs indicate that vacancy rates are quite high and that the
Public Service total establishment is considerably larger than what is reflected in the current
employment figures. The number of current posts is only slightly higher than that of 1997/98 and has
not increased to allow for population growth or the impact of AIDS. Calculations by health economists
using the 1997/98 staffing levels as a baseline showed that the public sector required a staff
complement of 315,087 by 2008, just to keep up with population growth and the expanding disease
burden. Clearly current post levels are inadequate to meet demand for healthcare services in the public
sector.
A conservative estimate for the number of employees in the private sector is 178 921 during June 2010.
The vacancy rate in the private sector is estimated at 2.3%. By contrast, the public sector experiences a
high vacancy rate of up to 60% in certain professional categories.
One-third of the vacancies that are difficult to fill in private health organisations are for professional
positions, while 47% of the scarce skills reported in the Public Service are for professionals. Vacancies in
professional positions that both the public and private sectors find most difficult to fill exist for doctors,
medical specialists, professional nurses and pharmacists. Other scarce and critical skills needs in the
public sector are for managers in finance and information technology and in the healthcare fields of
dietetics and physiotherapy.
Employment of doctors and nurses in the public sector falls short of international benchmarks for inhospital
care and WHO minimum guidelines. According to the WHO, countries with fewer than 230
doctors, nurses and midwives per 100 000 population generally fail to achieve adequate coverage rates
of care to attain the health-related Millennium Development Goals (MDGs). Those goals relate to
reducing child mortality, improving maternal health and combating HIV and AIDS and other diseases. In
2008 the public sector had 152 doctors and professional nurses per 100 000 of the population and, if
staff nurses are also included, the ratio improves to 209.
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In public health, shortages were mostly related to growth in demand, difficulties to retain or replace
qualified staff, geographic location, new technology, and migration of employees.
Skills development targets for the health sector set by the DoH in 2006 indicate the scope of demand for
skills, but failed to acknowledge supply-side constraints to a sufficient degree. Some of these
constraints are considered in Chapter 5 of this SSP.
Programmes to accelerate HIV testing and increase the number of patients on anti-retroviral treatment
(ART) by almost three times will have a major impact on the demand for skills. More specifically, the
public sector will need additional doctors, medical specialists, nurses, administrative support staff (to
order, collect and distribute drugs) and skilled health managers to implement and oversee operations.
Demand for similar skills is triggered when key programmes to fight TB and improve the health of
mothers, children and women are rolled out. More lower-level skills and community health workers are
needed to monitor adherence to treatment regimes for AIDS and TB. Skills interventions should also
target PHC nurses involved in health monitoring programmes for children.
Specialised training on a large scale is required in TB management and infection control, and staff nurses
require targeted training in midwifery, antenatal, obstetric and post-natal care.
In the public sector, and in the district health system in particular, leadership skills and professional
management skills are required to manage complex systems and to improve operational efficiency.
Skills in the planning and implementation of programmes, as well as the monitoring and evaluation of
service and quality of care, are required. On the people side, skills are needed to manage human
resources and their performance. More particularly, managers require skills to lead and guide
subordinates, improve their productivity and instill accountability for service to patients. Other areas
for managerial development include planning and time utilisation, use of information technology, as
well as financial and capital resources management. Extensive, intensive and purposive skills
development is needed in all these areas.
Finally, the introduction of a national health insurance system will drive demand for higher levels of care
offered by doctors and medical specialists and is expected to turn utilisation of health services away
from nurse-based primary care.
SUPPLY OF SKILLS
This section describes the different elements of supply and highlights the supply-side constraints that
contribute to the current shortages. The supply of skills can be correlated directly with outputs from the
school system, graduation trends, professional registration and the role that the HWSETA plays in skills
development.
A combination of complex factors influences the supply of skills to the health sector. At the heart of the
problem is the quantity and quality of learners who complete high school. The secondary school system
is producing fewer candidates with the combination of mathematics, physical sciences and/or life
sciences required to enter tertiary level studies in the health sciences. The latest available matriculation
xv

statistics are for 2008 when the New Curriculum Statement was introduced. A total of 554 664
candidates wrote the Grade 12 examination in 2008. Of those, a total of300 008 wrote mathematics
and 89 186 (16%) achieved 40% and above in mathematics, while 61 480 candidates passed physical
sciences (or 11% of candidates who wrote Grade 12). A total of 29 8210 candidates wrote the life
sciences examination and 117 483 achieved 40% and above.
Quality standards of education in mathematics, physical sciences and life sciences are major supply-side
constraints impacting on the skills of the health sector. Sub-standard levels of literacy and numeracy
skills of school leavers and their poor level of readiness for tertiary studies further reduce the supply
pool.
Existing institutional arrangements and regulatory provisions regarding the training of health
professionals also restrict the supply of skills to the sector. Most of the health professionals who are
required to register with the HPCSA, the SANC, the SACP and the SAVC are trained by universities and
universities of technology, and undergo practical training in state-owned academic health complexes.
Production levels at these institutions are limited due to capacity and budget constraints. Regulatory
requirements prevent private sector training providers from training many categories of health
professionals.
With the exception of basic healthcare sciences, the growth in supply of new graduates from the higher
education system has been moderate, and even low over the last decade. If all the health-related fields
of study are considered, the total output from the Higher Education and Training (HET)sector grew on
average by 3.4% at National Diploma level, at 6.3% at the first three-year BDegree level and at 5.1% at
the first four-year degree level. The field with the highest growth was Basic Health Care Sciences.
Clinical Health Sciences (which more or less represents the output of entry-level medical degrees) grew
only moderately – by 3.1% per year.
This trend is carried through to the registration of health professionals with their respective professional
councils. The average annual growth rate in professional registrations across key occupational
categories has been low, and in some instances lower than the growth rates in graduates produced for
the particular professional category.
Nursing colleges play an important role in the training of nurses. Total output from nursing colleges
grew on average by 10% per year over the period 2000 to 2009. The largest growth was at the level of
pupil nurses and pupil auxiliaries.
The HWSETA also contributes to skills formation in the health sector. Since 2002 more than 25 000
learners enrolled on health-related learnerships. More than 7 000 have completed learnerships at the
time of writing this SSP, and were recorded on the HWSETA’s electronic system. Many more completed
learnership that are quality assured by professional councils and their achievements are recorded by the
councils and not by the HWSETA. The SETA also support skills development through internships and
workplace training programmes, skills programmes, ABET and small enterprise development.
xvi

The supply of skills to the health sector is not only determined by capacity at training institutions and
the scope of training activities. Health workers risk exposure to HIV and AIDS in the workplace and face
increased risks of contracting the disease compared with workers in other sectors. By 2002 the
prevalence rate of HIV and AIDS among health workers was 15.7%, much higher than the national
prevalence rate at the height of the pandemic in 2010. As a result of AIDS, skilled health workers leave
the sector prematurely, either because they fear infection, become ill themselves or need to care for
others who fall ill.
The supply-side analysis presented in Chapter 5 of this SSP shows that many of the government’s
positive strategies to improve the supply and retention of skills in the sector may be compromised by
budget constraints and various institutional problems such as weak management systems, subfunctional
working environments and poor human resources practices. The analysis also lead to the
conclusion that unless major improvements in the leadership and management of the health system at
all levels are made, migration of health professionals out of the public sector and emigration to other
countries are likely to drain the supply of skills for the considerable future.
SKILLS DEVELOPMENT PRIORITIES OF THE HWSETA
Given the nature and magnitude of the skills development challenges in the health sector, a concerted
and integrated effort is required in partnership with the national DoH, DHET, the higher education
sector, private education and training providers, public and private health facilities and the HWSETA. As
one of several institutions tasked with funding and facilitating skills development for the health sector,
the HWSETA will focus its attention in a number of priority areas in the five-year period covered by NSDS
III.
The HWSETA’s contribution to Government’s objectives will centre around close cooperation with the
DoH, support for health strategies through skills development and, within mandate and budget
parameters, enabling the supply of larger numbers of health workers equipped with the skills necessary
to improve healthcare in South Africa. It must, however, be noted that these initiatives may be
hampered by a disjuncture between the different ministries involved in the planning of health services.
Current shortages of skills in the public health sector lead to massive inequalities in terms of access to
proper healthcare and the perpetuation, and even the intensification, of inequalities in the South
African society. Therefore, the HWSETA’s activities will aim to alleviate skills shortages and develop new
skills that can serve the poorest segments of the population and under-resourced areas. Skills
development support will give preference to historically disadvantaged individuals.
The HWSETA will, in collaboration with universities and FET colleges that offer health training, support
health-specific occupational programmes to facilitate access, success and progression. It intends to
develop or fund general bridging courses and specific bridging courses in mathematics and science, and
to work on a support strategy that will be aimed at increasing the pass rate of undergraduate students.
A structured career guidance strategy will be developed to reach out to school learners and create
awareness of the occupations in the health sector at all levels.
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In collaboration with the professional bodies in the health sector, the HWSETA will continue with its
work towards the recognition of prior learning (RPL). The key focus will be on the development and
implementation of an RPL support strategy and the development of national assessment centres.
Support for vocational adult basic education (ABET) will also continue to enable people who were
previously excluded from formal education to improve their qualifications.
The HWSETA will also support pivotal occupational programmes; i.e. professional, vocational, technical
and academic learning programmes that meet the critical needs for economic growth and social
development. Research will be undertaken to identify the occupations that need to be supported
through the proposed Pivotal Grant. The HWSETA will also accredit workplaces for delivering the
workplace components of pivotal programmes and address the skills needs of staff involved in delivering
the workplace component of pivotal learning programmes. Further, the HWSETA will publicise the
scarce skills identified in this SSP and the learnerships that provide entry to these occupations. It will
also make discretionary funding available for learnership support.
The HWSETA will develop a postgraduate internship support strategy, in conjunction with employers, to
provide unemployed graduates with workplace placements and exposure.
Discretionary funding will be made available to support skills programmes and non-accredited short
courses. The HWSETA will cooperate with the professional councils to develop a CPD support strategy.
A strategy will be prepared to support the development of academic capacity and innovation via a
postgraduate bursary scheme.
The HWSETA will also support measures to strengthen its own capacity as well as that of its delivery
partners.
These skills development priorities and interventions will be implemented within the available funding
of the SETA. The success and impact of these strategies will be assessed on an ongoing basis and the
overall strategy and business plan will be revised annually.
In conclusion the HWSETA is aware of data gaps in critical areas in the sector and is undertaking further
research to ensure that these are closed in time for the second draft.
We hope that readers and fellow researchers will find the information useful in shaping their own
strategies and research work in time to come.
______________________
_______________________
Mr. P.C Smit
Ms. S. Slabbert
Chief Executive Officer: HWSETA
Chairman: HWSETA
30 September 2010 30 September 2010
xviii

1 INTRODUCTION
1.1 BACKGROUND
In terms of Section 10(1)(a) of the Skills Development Act, 97 of 1998 (SDA) every Sector Education and
Training Authority (SETA) is required to develop a Sector Skills Plan (SSP) within the framework of the
National Skills Development Strategy (NSDS).
Each SETA is obliged to submit annual strategic plans and reports on the implementation of its strategic
plans to the Director-General of the Department of Higher Education and Training (DHET). 1 SSPs are fiveyear
reports aimed at identifying skills needs (including skills shortages), as well as opportunities and
constraints in utilising and developing skills aligned with government’s skills development priorities.
On 30 April 2010 the Minister of Higher Education and Training, in consultation with the National Skills
Authority, released the first draft framework for the NSDS lll, covering the period 2011/2012 to
2015/2016. Although the framework is a draft intended for consultation with stakeholders, it called
upon SETAs to prepare SSPs for the period according to the broad guidelines set out in the framework
document. The Health and Welfare Sector Education and Training Authority (HWSETA) prepared this
SSP in accordance with these requirements.
At the time of publishing the NSDS III the DHET also published a draft proposal regarding a new SETA
landscape, which was subsequently the subject of a series of public hearings. This proposal made
provision for a split of the HWSETA into two: a health SETA and a welfare SETA. At the time of writing
this SSP there was no clarity on whether this split would indeed take place, but in anticipation of such a
restructuring, the HWSETA prepared two SSPs – one for the health sector and one for the welfare
sector. This SSP deals only with the health sector.
1.1 PREPARATION OF THE SSP
The profile of the sector presented in this SSP was constructed from various databases and information
sources. These sources are referred to below.
Workplace skills plans submitted by employers.
Private sector health service providers pay the skills development levy (SDL) and submit their workplace
skills plans (WSPs) to the HWSETA, while the national and provincial health departments submit WSPs to
the Public Service SETA (PSETA). These two SETAs have a memorandum of understanding (MoU) and cooperate
in various ways to support skills development in the health sector. The WSPs submitted to the
PSETA were made available to the HWSETA and the data was combined to form a picture of the total
health sector.
1 Previously, SETAs reported to the Department of Labour.
1

Information submitted by the departments of health/PERSAL
Information on employment in the Public Service was obtained from the PERSAL system.
Information provided by professional councils
Professionals in the sector register with various professional councils. All the councils made information
from their registers available for incorporation in this SSP.
Other databases
Information from the Education Management Information System (EMIS) held by the Department of
Basic Education, the Higher Education Management Information System (HEMIS) kept by the DHET, and
MEDpages – a private database of health service providers in the private sector – was used in the
preparation of the SSP.
Research reports
Extensive research reports on different aspects of the South African health sector have been published
in recent years. A selection of these research reports were used in the preparation of the SSP.
1.2 STAKEHOLDER CONSULTATION
In preparation for this SSP seven workshops were held and a few interviews were conducted with key
role-players in the health sector. Stakeholders were also given the opportunity to provide input to the
SSP through an electronic survey. The consultation focused on the following topics:
Strengthening of the skills and human resource base for the next five years;
The sector’s role in creating decent work and sustainable livelihoods;
Skills development for the South African youth and graduate output;
Equity impact in the health and social development sectors;
Key priorities for the next five years;
Key occupations for funding in the next five years;
Scarce and critical skills; and
Establishment of new qualifications/learning programme.
2

1.3 LIMITATIONS
Demand analysis and forecasting (which should ideally form a key component of an SSP) is sensitive to
the availability of reliable data on current employment and skills needs. During the preparation of this
SSP, the HWSETA encountered significant difficulties with the lack of data, gaps in and quality of
information, as well as inconsistencies in the data.
Difficulties were specifically encountered with the analysis of the PERSAL data on employment in the
Public Service. The PERSAL system contains several fields that describe a person’s occupation. None of
these fields are easily convertible to the Organising Framework for Occupations (OFO), the occupational
classification system that is used by the SETAs to report on employment and on scarce skills. Closer
analysis of the different fields also revealed several anomalies and inconsistencies. The OFO itself posed
further challenges: the health related occupations that currently exist on the OFO are not aligned to the
South African labour market. The occupational titles are also not aligned to the registration categories
used in South Africa.
The team who was responsible for the preparation of this SSP dealt with these challenges in the best
possible way. However, it is important that the HWSETA and other role players in the sector engage
with the OFO in order to better align it to the South African health sector. The linkage between the
PERSAL system and the OFO can only be dealt with once the OFO has been adapted. This linkage will
also be addressed by the job profiling project that the Department of Public Service and Administration
(DPSA) is currently undertaking.
1.4 OUTLINE OF THE SSP
Chapter 2 of the SSP provides a profile of the health sector in South Africa and specifically those
components of the sector served by the HWSETA. In Chapter 3 the most important factors that impact
on the sector’s labour market are discussed. Chapter 4 deals with the demand for skills in the sector
and Chapter 5 with the supply of skills. In Chapter 6 the strategic areas of focus for the HWSETA (in
relation to the health sector) are outlined.
3

2 PROFILE OF THE SECTOR
2.1 INTRODUCTION
Any sectoral skills development strategy needs to be based on a sound understanding of employment in
the sector, the environment in which services are delivered, and the changes taking place in that sector.
In this chapter of the SSP the health sector is described and discussed from various perspectives.
First, the sector served by the HWSETA forms part of the South African Health System and this chapter
starts with a short description of the national health system, a description of standard industrial
classification (SIC) codes included in the scope of the HWSETA, and the identification of points of contact
with other SETAs. This is followed by a description of the organisations that are major role players in the
sector.
The chapter then continues with a description of the employees in the sector. This section starts with
an estimate of total employment, followed by a description of employees according to occupation,
population group, gender and age.
In the conclusions to this chapter the most salient implications of the profile of the health sector for
skills development are highlighted.
2.2 THE SOUTH AFRICAN HEALTH SYSTEM
Figure 2-1 provides a graphical representation of the South African health system.
Figure 2-1 The South African health system
4

The South African health system spans the economic sectors for human and animal health. The national
Department of Health (DoH) 2 is responsible for the national human health system, which comprises both
public and private health sectors.
Key entities in the public health sector are the nine provincial departments of health, state health and
research institutions, and municipalities. Provincial health departments are responsible for public
service delivery and for planning and managing human resources for health. Academic health
complexes (where health sciences learners are trained) are financed and administered at provincial
level. Provincial hospitals operate at three tiers: tertiary, regional, and district level. The district health
system consists of 52 districts. Ambulance and other emergency services, occupational health and
primary care services are delivered at district level. Municipal health services encompass environmental
issues such as water quality, waste management, pollution control, surveillance and prevention of
communicable diseases and food control. 3 Many local authorities provide primary healthcare services
which may either be financed from municipal revenues or by provincial health authorities. 4
The private health sector is made up of private hospitals, individual health service providers, NGOs and
the medical insurance industry. 5 Extending across the human and animal health sectors are the
pharmaceutical industry, providers of health services and products, and manufacturers of surgical goods
and appliances. On the animal health side the Department of Agriculture (DoA) oversees veterinary
services, which comprise state and private veterinary services and veterinary research.
Not all the entities in the South African health system form part of the HWSETA sector and there is
considerable overlap with several other SETAs. The national and provincial departments of health
submit Workplace Skills Plans (WSPs) and Annual Training Reports (ATRs) to the Public Service Sector
SETA (PSETA), while municipalities are more closely aligned with the Local Government SETA (LGSETA).
The medical insurance industry,which comprises medical schemes and other bodies, forms part of the
Insurance Sector Education and Training Authority (INSETA). Even though pharmacists and pharmacies
are allocated to the HWSETA, many employers pay skills development levies to the Wholesale and Retail
SETA (W&RSETA). Although the HWSETA is responsible for skills development in animal health, many
veterinarians in private practice pay their SDL to the Agricultural Sector Education and Training
Authority (AgriSETA) and are more closely affiliated with this SETA.
2 Established by the National Health Act, 2003 to provide equitable healthcare services.
3 Development Bank of South Africa. 2008. A Roadmap for the Reform of the South African Health System. Report on a process
convened and facilitated by the DBSA.
4 Burger, D. 2009. South Africa Yearbook 2009/10. Government Communication and Information System. Published at
http://www.gcis.gov.za/resource_centre/sa_info/yearbook/2009-10.htm. (Accessed August 2010).
5 Coovadia, H., Jewkes, R., Barron, P. et al. 2009. “The health and health system of South Africa: historical roots of current public
health challenges”. Lancet. September 2009. Vol. 374. Published at http://thelancet.com. (Accessed August 2009); McIntyre,
D., Thiede, M., Nkosi, M. et al. 2007. SHIELD work package 1 report: A critical analysis of the current South African health
system. Health Economics Unit, University of Cape Town. Published at
http://www.web.uct.ac.za/depts/heu/SHIELD/reports/SouthAfrica1.pdf (Accessed August 2010).
5

2.3 EMPLOYERS IN THE SECTOR
The health and social development sector is a heterogeneous sector falling mainly under the Sector
Industrial Classification (SIC) category 93. Schedule 2 of Regulation No. R. 316, published on 31 March
2005 in terms of section 9(1) of the Skills Development Act, 1998 (Act No. 97 of 1998) gives the HWSETA
jurisdiction over 60 SIC codes. The employers belonging to the 60 SIC sectors are grouped into five
groups:
Community services
Complementary health services
Doctors and specialists
Hospitals and clinics
Research and development institutions.
In the 2009/2010 financial year a total of 4 321 organisations paid SDLs to the HWSETA. These are
organisations with payrolls in excess of R500 000 per year. Small practices may be excluded from this
number.
2.4 ORGANISATIONS IN THE SECTOR
2.4.1 REGULATORS AND PROFESSIONAL BODIES
A large portion of the workers in the health sector are registered with statutory councils that control
and regulate the various professions. In the health sector these councils are the Health Professions
Council of South Africa 6 (HPCSA), the South African Nursing Council 7 (SANC), the South African Pharmacy
Council 8 (SAPC), the Allied Health Professions Council of South Africa 9 (AHPCSA), and the South African
Dental Technicians Council 10 (SADTC). Members of the veterinary and para-veterinary professions are
registered with the South African Veterinary Council (SAVC) 11 and practitioners using indigenous African
healthcare techniques and medicines will soon be required to register with the Interim Traditional
Health Practitioners Council of South Africa 12 (ITHPCSA). These councils regulate the various health and
allied health professions and practices.
Statutory provisions authorise the professional councils to demarcate the scope of practice of each
category of health profession (i.e. stipulate the type of services permitted and not permitted). Among
6 Established in terms of the Health Professions Act 56 of 1974.
7 Established by the Nursing Act 33 of 2005, and previously by the Nursing Act 50 of 1978.
8 Established in terms of the Pharmacy Act 53 of 1974.
9 Established by the Allied Health Professions Act 63 of 1982.
10 Established by the Dental Technicians Act 19 of 1979.
11 Established by the Veterinary and Para-Veterinary Professions Act , 19 of 1982.
12 Established by the Traditional Health Practitioners Act 22 of 2007.
6

their statutory functions are to set and control standards for education and training, register
professionals, establish what constitutes ethical and professional conduct, and enforce compliance with
standards. The councils also set requirements for the continuous professional development (CPD) of
health professionals and technicians in order for these people to retain their registration. As such, these
councils are major role-players in the sector and contribute to skills development and ensure ongoing
professional competence. By setting and upholding the relevant standards, the councils promote and
protect the rendering of health services to the broader public and enhance the quality of these services.
All these councils are authorised to: receive, investigate and deal with complaints of unprofessional
conduct against persons registered with them; hold disciplinary enquiries; and sanction practitioners
with cautions, fines, suspension or de-registration (i.e. expulsion from the profession).
Each council exercises jurisdiction over the categories of practitioners described in its founding statutes.
The professional councils together with the Higher Education Quality Committee (HEQC) of the Council
for Higher Education and UMALUSI accredit the training institutions to offer health professional training
programmes that lead to attaining recognised qualifications. Several of the professional councils also
accredit clinical facilities where learners serve internships and undergo practical training and set the
standards for structured workplace experience and internships served by aspirant professionals.
Professional councils and voluntary associations from the health sector are also represented on the
HWSETA Board and are closely involved in the SETA’s activities and its substructures. An overview of the
councils and the professionals and practitioners falling under their jurisdiction is set out below.
a) The Health Professions Council of South Africa
The Health Professions Council of South Africa (HPCSA) is an overarching statutory body supported by 12
professional boards dealing with matters pertaining to the specific professions required to register with
the HPCSA. The twelve boards are:
Dental Therapy and Oral Hygiene
Dietetics
Emergency Care
Environmental Health
Medical and Dental and Medical Science
Medical Technology
Occupational Thearpy and Medical Orthotics/Prosthetics and Arts Therapy
Optometry and Dispensing Opticians
Physiotherapy, Podiatry and Biokinetics
Psychology
Radiography and Clinical Technology
Speech, Language and Hearing.
7

) The South African Nursing Council
The South African Nursing Council (SANC) is a statutory body established to regulate the nursing
profession. The SANC sets standards and exercises control over all matters relating to the education and
training of the nursing profession and also determines and controls the scope of practices pursued by
the five registration categories for nurses. These categories are professional nurse, midwife, staff nurse,
auxiliary nurse or auxiliary midwife. 13
c) The South African Pharmacy Council
The South African Pharmacy Council (SAPC) is a statutory body established to regulate the pharmacy
profession and practice. All persons trained as pharmacists are required to register with the SAPC
before they are permitted to practise as such. Registration categories include pharmacist, pharmacist in
community service, specialist pharmacist, pharmacist intern, student pharmacist, and pharmacist’s
assistant. Enterprises operating as pharmacies, including community, hospital, wholesale and
distribution and manufacturing pharmacies, are also required to register with the SAPC.
d) The Allied Health Professions Council of South Africa
The Allied Health Professions Council of South Africa (AHPCSA) is a statutory body charged with the
control and registration of professions contemplated in the Allied Health Professions Act 63 of 1982.
Among those professions are: ayurveda, Chinese medicine and acupuncture, chiropractic, homeopathy,
naturopathy, osteopathy, phytotherapy, therapeutic aromatherapy, therapeutic massage therapy, and
therapeutic reflexology. In the allied health professions a distinction is made between a practitioner and
a therapist. 14 Four professional boards within the AHPCSA provide that council with standards for specific
allied health professions and contribute to policy development.
e) The South African Veterinary Council
The South African Veterinary Council (SAVC) is the regulatory body for the veterinary and paraveterinary
professions and is responsible for the registration of persons practising those professions.
The SAVC keeps registers for the veterinary profession (veterinarians and veterinary specialists) and the
para-veterinary professions (animal health technicians, laboratory animal technologists, veterinary
nurse and veterinary technologists), as well as students in the respective fields. 15
f) The South African Dental Technicians Council
The South African Dental Technicians Council(SADTC) is a statutory body that regulates the profession
and acts as a public protector for persons using the services of dental technicians and technologists. The
13
Section 31 of the Nursing Act 33 of 2005. Previously the professional categories were registered nurse, midwife, enrolled
nurse and nursing auxiliary.
14 A practitioner may diagnose, and treat or prevent physical and mental disease, illness or deficiencies in humans; prescribe or
dispense medicine; or provide or prescribe treatment for such conditions. Therapists may only provide treatment for diagnosed
diseases, illnesses or deficiencies or prevent such conditions (Section 1 of the Allied Health Professions Act 63 of 1982).
15 The South African Veterinary Council. Published at
http://www.savc.co.za/index.php?option=com_content&view=article&id=277&Itemid=33. (Accessed August 2010).
8

SADTC controls all matters relating to the education and training of technicians and technologists and
their practices in the supplying, making, altering or repairing of artificial dentures or other dental
appliances or any other work pertaining to such dentures or appliances. 16
g) The Interim Traditional Health Practitioners Council of South Africa
The Interim Traditional Health Practitioners Council of South Africa (ITHPCSA) is a statutory body
established to regulate the registration, training and practices of traditional health practitioners and
students engaged in learning in that field. 17 Traditional health practice involves the performance of a
function, activity, process or service based on a traditional philosophy and uses indigenous African
techniques, principles, medication and practice. 18 Every person who renders services as a traditional
health practitioner will be required to register as such. Different categories of practitioners will register
with the Council, including herbalists (izinyanga or amaxhwele), diviners (izangoma or amagqirha),
traditional surgeons (iingcibi) and traditional birth attendants (ababelethisi or abazalisi). Spiritual or
faith healers are not included in the Traditional Health Practitioners Act. 19
Among the objects of the ITHPCSA are to promote public health awareness, ensure quality of services,
and to promote and maintain appropriate ethical and professional standards in the practice of
traditional health and medicine. The interim council is further required to promote and develop interest
in the field by encouraging research, education and training.
It is estimated that there were about 190000 traditional health practitioners in South Africa in 2007. 20
At present the traditional healers operate outside a regulated environment and they do not form part of
the formal public or private health service. However, the Traditional Healers Organisation (THO) of
South Africa, which claims membership of 29000 traditional healers, issues certificates of competence to
practitioners who have completed training and passed assessment of ethical, safe, hygienic and
competent practice. The Natural Healers Association (NHA) estimates that there are 280000 natural
healers who include professionals and practitioners with training in western medicine, traditional,
indigenous, Eastern, African and European practices, as well as spiritual healing. The National Health Act
(NHA) seeks accreditation for training in natural healing with the Services Seta. 21
2.4.2 ACADEMIC AND RESEARCH INSTITUTIONS
A number of institutions conducting research in human and animal health and the socio-economic
impact of disease play a prominent role in the health sector. In addition to their research activities,
16 Established by the Dental Technicians Act, 19 of 1979. http://www.dentasa.org.za/documents/benefits.html; http://uscdn.creamermedia.co.za/assets/articles/attachments/01519_dentaltechnamendact24.pdf.
(Accessed August 2010).
17 Although the Traditional Health Practitioners Act, 22 of 2007 was enacted in Parliament, it has not come into operation. The
date of its commencement will be published in the Government Gazette.
18 Section 1 of the Traditional Health Practitioners Act 22 of 2007.
19 Peltzer, K. 2009. “Traditional health practitioners in South Africa”. Lancet. 19 September 2009. Vol.374. Published at
http://www.thelancet.com. (Accessed August 2010).
20 Peltzer, K. 2009. “Traditional health practitioners in South Africa”. Lancet. 19 September 2009. Vol.374. Published at
http://www.thelancet.com. (Accessed August 2010).
21 Natural Healers Association. 2010. Published at http://www.naturalhealersassociation.co.za/who.htm. (Accessed August
2010)
9

several institutions are specifically mandated to advance the training and development of researchers,
health professionals and technicians for the health sector.
a) The South African Medical Research Council
The South African Medical Research Council (MRC) is a statutory body established to promote the
improvement of the nation’s health and quality of life through research, development and technology
transfer. 22 The MRC conducts research in 45 units in respect of the burden of disease in South Africa,
public health and policy matters, environmental health issues, health promotion, African traditional
medicines and aspects concerning women, maternal and child health. 23 Among the core tasks of the
MRC are to promote the training of researchers and related personnel and, for that purpose, it may
grant study bursaries and loans and pay grants for training and research in the health sciences. 24
b) The National Health Laboratory Service
The National Health Laboratory Service (NHLS) is a statutory body that provides health laboratory
services to all state clinics and hospitals and, at request, to private sector providers. 25 The NHLS
replaced the South African Institute for Medical Research, the National Institute for Virology, the
National Centre for Occupational Health, state-owned forensic chemistry laboratories, and provincial
health laboratory services. The NHLS consists of four specialised divisions, the National Institute for
Communicable Diseases, the National Institute for Occupational Health, the National Cancer Registry
and the anti-venom unit. As a network of about 265 pathology laboratories throughout South Africa,
the NHLS provides diagnostic laboratory services, research, teaching and training, and production of
serums for anti-snake venom, reagents and media. The NHLS employs approximately 6500 people and
serves approximately 80% of the population. 26
With its strong training mandate, the NHLS trains medical technologists in association with universities
of technology. It cooperates with the pathology departments of all eight faculties of health sciences 27 to
teach at undergraduate and postgraduate level in courses such as anatomical pathology, haematology,
microbiology, infectious diseases, immunology, human genetics, chemical pathology, epidemiology,
tropical diseases, molecular biology, medical entomology and human nutrition.
22 The MRC was established by the South African Medical Research Council Act, 19 of 1969 and continues to exist under the
South African Medical Research Council Act, 58 of 1991.
23 South African Medical Research Council. Undated Corporate brochure. Published at
http://www.mrc.ac.za/about/mrcbrochure.pdf. (Accessed August 2010).
24 South African Medical Research Council. 2005. Research Strategy 2005-2010. Published at
http://www.mrc.ac.za/about/MRCResearchStrategy.pdf. (Accessed August 2010).
25 Established by the National Health Laboratory Service Act 37 of 2000. Published at
http://www.nhls.ac.za/about_NHLS_ACT.pdf. (Accessed August 2010); National Treasury 2010.”Vote 15: Health”. Estimates of
National Expenditure 2010.
26 National Health Laboratory Service. Published at http://www.nhls.ac.za/about_we.html. (Accessed August 2010).
27 These are the faculties of health sciences of the universities of Cape Town, Free State, KwaZulu-Natal, Limpopo (MEDUNSA
Campus), Pretoria, Stellenbosch, Witwatersrand, Walter Sisulu University for Technology and the Science and the Oral
Pathology Department of the University of the Western Cape.
10

c) The Human Sciences Research Council
The Human Sciences Research Council (HSRC) conducts large-scale social-scientific projects for the
public sector, NGOs and international development agencies. 28 One of the HSRC’s main research units
focuses on the social aspects of HIV and AIDS and health. Research is conducted on the social
determinants of health, in particular HIV and AIDS and on public health in general. Epidemiology in
infectious disease is undertaken to understand how often and why diseases occur in the population, and
the information is used to influence the development of health policies and strategies. Specific research
is also directed at health systems, including the development and evaluation of relevant healthcare
interventions. 29
d) Onderstepoort Veterinary Institute
The Onderstepoort Veterinary Institute (OVI) has been engaged in veterinary research for more than a
century. 30 Today it is one of several research institutes of the Agricultural Research Council (ARC),
established to undertake research, development and technology transfer in the use and improvement of
agricultural resources. 31 Specific research is undertaken in viral diseases that have a major economic
impact, such as foot and mouth disease, rabies, African swine fever, blue tongue, lumpy skin disease,
African horse sickness and Rift Valley fever.
2.4.3 EMPLOYER ORGANISATIONS
The Hospital Association of South Africa (HASA) is an industry association that represents the interests
of the majority of private hospital groups and independentlyowned private hospitals in the country.
HASA is a key role-player in the health sector and represents approximately 90% of the private hospital
industry. As the official mouthpiece of the private hospital industry, it promotes entrepreneurship and
free market economic principles, engages with government on proposed legislation and policy matters,
represents the industry at commissions and institutions, and markets the industry and its services to the
public. The private hospital industry employs approximately 60 000 people. 32
2.4.4 NON-GOVERNMENTAL ORGANISATIONS
Several hundred NGOs operate within the health sector and participate in and support various health
programmes at national and provincial level. Many NGOs and non-profit organisations have entered
into partnerships with provincial health departments and district municipalities to improve the
organisation and management of health systems and monitor the delivery of health services. As such,
NGOs play crucial roles in the healthcare sector. They contribute to research, policy advocacy,
28 Established by the Human Sciences Research Act 23 of 1968. The new Human Sciences Research Council Act 17 of 2008 has
been adopted by Parliament, but was not in operation by August 2010.
29 Human Sciences Research Council. 2010. Social aspects of HIV/AIDS and Health Research Programme. Published at:
http://www.hsrc.ac.za/SAHA.phtml. (Accessed August 2010).
30 The Onderstepoort Veterinary Institute was founded in 1908 by Sir Arnold Theiler.
31 The Agricultural Research Council is established by the Agricultural Research Act 86 of 1990. Published at
http://www.arc.agric.za/home.asp?pid=1118&sec=792. (Accessed August 2010).
32 Hospital Association of South Africa. 2010. Published at http://www.hasa.co.za/about. (Accessed August 2010).
11

development and care in areas such as HIV and AIDS, tuberculosis, mental health, cancer, disability,
women’s health, family planning, orphans and vulnerable children, palliative care, and primary
healthcare. Their activities involve directly observed treatment support for tuberculosis patients, homebased
care and community care, and voluntary counselling and testing for HIV and AIDS. 33 A number of
NGOs are involved in the recruitment, training and orientation of health professionals for deployment in
the public sector. 34
2.4.5 PROFESSIONAL ASSOCIATIONS
The health sector accommodates numerous voluntary organisations and associations that generally
promote the interests of specific healthcare professions, specialised fields of professional practice and
their members. More specifically, these associations aim to protect and promote the professional,
educational and economic interests of their members and the public image of their respective
professions. Through advocacy, lobbying and negotiating the organisations seek to advance their
members’ positions and integrity as well as the standing and sustainability of their particular profession.
Typically these voluntary organisations provide information to their members on the state of the
profession and updates on regulatory changes, ethical matters, employment relations and practice
news. Several of the associations act as mouthpieces to influence health legislation and policies.
Membership of these voluntary organisations also entitles practitioners to gain access to conferences,
seminars, lectures and international associations in the same field of medical practice. A number of
associations publish clinical and scientific journals and technical newsletters to keep their members
abreast of technological advancements and the latest medical research in their field. Some also support
their members to record and meet requirements for CPD set by their respective regulatory professional
councils.
Examples of these voluntary associations are: the South African Medical Association (for medical
practitioners), the South African Veterinary Association, the South African Dental Association, the
Ophthalmological Society of South Africa, the South African Society of Physiotherapy, the
Pharmaceutical Society of South Africa, the Veterinary Nurses Association of South Africa, the
Chiropractic Association of South Africa and the Homeopathic Association of South Africa.
2.4.6 LABOUR UNIONS
Labour and trade unions are well organised and mobilised within the health sector. Trade unions play a
formative role in shaping labour market policies, labour relations practices and human resources
management in the health sector. Acting on behalf of their members, labour unions engage with
employers over better employment conditions, more beneficial contractual arrangements and safer
33 Department of Health. “Partnerships for Primary Health Care”. Published at
http://www.doh.gov.za/pdphcp/main.php?include=prog_strategies/logframe.html. (Accessed August 2010); Burger D. 2009.
South Africa Yearbook 2009/10. Published at http://www.gcis.gov.za/resource_centre/sa_info/yearbook/2009-10.htm.
(Accessed August 2010).
34 Africa Health Placements. 2010. Published at http://www.ahp.org.za. (Accessed August 2010).
12

working environments. Trade unions also collectively bargain and negotiate for better wages, monetary
allowances for health professionals, working hours and workplace benefits.
In addition, trade unions provide their members with a range of benefits such as access to medical
insurance schemes, group benefit schemes, provident funds and funeral cover. Most provide legal
advice and representation at labour disputes, grievance procedures and disciplinary hearings. 35 Among
the larger unions in the health sector are the National Education Health and Allied Workers Union
(NEHAWU), the Democratic Nursing Organisation of South Africa (DENOSA), the South African
Democratic Nurses Union (SADNU), the Health and Other Service Personnel Trade Union of South Africa
(HOSPERSA) and the Public Servants’ Association (PSA).
2.5 PROFILE OF EMPLOYEES IN THE SECTOR
In order to develop a profile of the health sector served by the HWSETA three databases were
combined. They are:
The database of Workplace Skills Plans submitted to the HWSETA in June 2010.
For the first time levy-paying organisations that applied for the mandatory grant had to submit
information on their employees at the detailed occupational level of the Organising Framework for
Occupations (OFO). This information also contains the race and gender of employees. A total of 602
organisations submitted Workplace Skills Plans. They represent 118 148 employees and 63% of the total
levies paid to the HWSETA. Close examination of this database showed that the large organisations in
the sector (for example, the large hospital groups and pharmacy groups) were well represented but that
very few of the small professional practices were included.
The MEDpages database
This database is held privately and contains biographical, practice and contact information of the
majority of approximately 60 000 private health practitioners in the country. The total number of active
records on the MEDpages database is185 962 (96 605 people and 89 357 practices and organisations). 36
Close examination of this database and a comparison with other estimates of private practitioners in
South Africa led to the conclusion that this is most comprehensive database of its kind and that it
represents the vast majority of active private health practitioners in the country.
35 National Education Health and Allied Workers Union. 2010. “About NEHAWU”. Published at
http://www.nehawu.org.za/about/index.asp. (Accessed August 2010);
Democratic Nursing Organisation of South Africa. 2010. “DENOSA About us”. Published at
http://www.denosa.org.za/DENOSA.php?id=1. (Accessed August 2010);
South African Democratic Nurses Union. 2010. “History”. Published at http://www.sadnu.org.za/history.php. (Accessed August
2010);
Health and Other Service Personnel Trade Union of South Africa. “Principles and Objectives”. Published at
http://www.hospersa.co.za/about/principles.djhtml. (Accessed August 2010);
South African Medical Association. 2010. “Member benefits”. Published at http://www.samedical.org/index.php. (Accessed
August 2010).
36 http://www.medpages.co.za/index.php?module=publicstats.
13

PERSAL database
The PERSAL system keeps individual records of all the workers in the Public Service – i.e. the workers in
the national and provincial state departments. Access to the data of the health departments was
provided by the Department of Public Service and Administration (DPSA).
For the purposes of this SSP the two private sector databases were combined in such a way that
duplication was avoided. The occupational information contained in the MEDpages database and the
PERSAL system was coded to the OFO.
a) Total employment
The three databases combined provided information on 460 000 people who are formally employed in
the health sector. Of these, 179 000 (39%) are employed in private sector organisations and levy-paying
public sector organisations (referred to later as the “private sector”), while 281 000 (61%) work in the
public health departments. Both the Public Service and the private sector figures are still underestimates
of the total number of employees in the sector. Definitely excluded from the private sector
figures are the non-professional support staff employed in the private professional practices and
employees in the non-levy paying NGOs. Excluded from the Public Service figures are the medical
personnel employed in the South African National Defence Force (SANDF). 37
b) Occupational distribution of employment
Table 2-1 shows a breakdown of total employment according to the main occupational groups of the
OFO.
In both the Public Service and in the private sector managers constitute approximately 4% of total
employment. Almost half (47%) of employees in the private sector are employed as professionals and
28% in the Public Service. Professionals include medical and dental specialists and practitioners,
registered nurses, pharmacists, and other health-related occupations such as occupational therapists
and psychologists. The category also includes professionals such as human resource professionals,
financial professionals and scientists. Estimates of employment in selected professional occupations can
be seen in Table 2-2.
Community and personal service workers in the Public Service constitute 42% of total employment and
in the private sector 22%. This category mainly comprises enrolled and auxiliary nurses, emergency
service and ambulance workers, and food and auxiliary hospital workers and aides. Sales workers
include pharmacy assistants working in retail, hospital and industrial pharmacies.
37 The SANDF has a separate payment system and its staff are not recorded on PERSAL.
14

Table 2-1 Total employment in the private sector and in the Public Service according to occupational
category
Occupational category
Private sector*
Public Service**
N % N %
Managers 6 571 4 10 960 4
Professionals 83 276 47 79 755 28
Technicians and Trades workers 7 921 4 5 725 2
Community and Personal Service workers 38 519 22 119 155 42
Clerical and Administrative workers 30 915 17 21 887 8
Sales workers 2 780 2 1 019 0
Machinery operators and Drivers 2 209 1 3 510 1
Elementary workers 6 730 4 39 299 14
Total 178 921 100 281 310 100
Sources: Calculated from *HWSETA, WSP applications, 2010 and MEDpages database, September 2010.
**PERSAL data as at 8 September, 2010 DPSA.
Table 2-2 Estimates of employment in selected occupations
OFO Description
Private
sector
Public
Service
Medical specialists 3 798 4 524 8 322
Medical practitioners (General practitioners) 11 181 11 773 22 954
Dental specialists 313 136 449
Dental practitioners 3 181 816 3 997
Registered Nurses 27 230 53 230 80 460
Pharmacists 7 719 3 113 10 832
Dieticians 1 025 767 1 792
Occupational therapists 1 870 820 2 690
Optometrists and Orthoptists 2 277 120 2 397
Physiotherapists 3 177 995 4 172
Medical Laboratory Scientists and Technologists 1 815 5 318 7 133
Radiographer 2 746 2 456 5 202
Speech Professionals and Audiologists 1 317 405 1 722
Psychologists 3 595 498 4 093
Total
Source: Combined datasets from PERSAL, HWSETA WSP submissions and MEDpages.
15

African
Coloured
Indian
White
Total
African
Coloured
Indian
White
Total
c) Population group
In 2010, the majority (87%) of the people working in the health sector are black, 38 while white workers
constitute only 13% of the total workforce. In private sector organisations, 22% of the workforce is
white and in the Public Service only 7% (Table 2-3). Fifty two per cent of professionals in the private
sector are Africans and 71% in the Public Service, while respectively 80% and 86% of community and
personal service workers in the private sector and in the Public Service are Africans.
Table 2-3 Total employment in private and public health according to population group
Private Sector*
Public Service**
Occupational
category
% %
Managers 34 8 7 51 100 66 4 10 19 100
Professionals 52 8 7 34 100 72 10 5 13 100
Technicians and Trades
workers
62 12 6 20 100 79 7 1 13 100
Community and
Personal Service
80 9 3 9 100 86 10 1 3 100
workers
Clerical and
Administrative workers
59 12 6 24 100 77 12 0 12 100
Sales workers 51 13 4 32 100 81 3 14 2 100
Machinery operators
and Drivers
75 18 2 5 100 85 9 0 6 100
Elementary workers 86 11 1 2 100 87 11 0 2 100
Total 64 10 5 22 100 81 10 3 7 100
Source: Calculated from *HWSETA, WSP applications, 2010.
**PERSAL data as at 8 September, 2010.
Most (63%) of professionals employed in the total sector are African, 21% are white, 9% coloured, and
7% Indian (Figure 2-2).
38 Blacks include Africans, coloureds and Indians.
16

Figure 2-2 Professionals by population group in the health sector
d) Gender
Seventy five per cent of the workforce in the health sector (professionals included) are women and only
25% men. In private health, 70% of professionals are women, as are 80% of professionals in the Public
Service (Table 2-9). The majority of the community and personal service workers in private and in public
health are also women.
Table 2-4 Total employment in private and public health according to gender
Occupational category
Private Sector*
Public Service**
Men Women Total Men Women Total
% %
Managers 44 56 100 33 67 100
Professionals 30 70 100 20 80 100
Technicians and Trades
workers 42 58 100 61 39 100
Community and Personal
Service workers 15 85 100 22 78 100
Clerical and
Administrative workers 27 73 100 34 66 100
Sales workers 19 81 100 51 49 100
Machinery operators and
Drivers 62 38 100 76 24 100
Elementary workers 34 66 100 31 69 100
Total 27 73 25 75 100
Source: *HWSETA, WSP applications, 2010 and MEDpages database, September 2010.
**PERSAL data as at 8 September, 2010.
17

In 2010, 460 000 people are employed in the health sector, of whom 179 000 (39%) are employed in
private health and 281 000 (61%) in public health departments. Most of the people in the sector are
black women and almost half of employees are employed as professionals – e.g. medical and dental
specialists and practitioners, registered nurses, pharmacists and other health related occupations such
as occupational therapists and psychologists. Medical practitioners and specialists in private health are
generally older than their counterparts working in public health.
Community and personal service workers such as enrolled nurses, auxiliary nurses and hospital workers,
emergency services and ambulance workers constitute a substantial proportion of employees in the
sector, especially on the public health side.
A unique feature of the health sector is that the majority of the healthcare professionals, subprofessionals
and specialised workers are regulated by a number of professional councils that play a
formative role in determining their scope of practice as well as the education and training standards
required for work as healthcare practitioners. By controlling and enforcing standards of quality, ethical
conduct and CPD, these councils promote the rendering of quality health services to the broader public.
Thus, the professional councils, together with the organised voluntary professional associations,
perform important functions in the health sector labour market and are involved in the HWSETA’s skills
development initiatives.
Increasingly, non-profit organisations and NGOs play an essential part in the delivery of healthcare to
disadvantaged and marginalised communities, even though they fall outside the sector’s formal
structures and require special attention in the SSP.
19

3 FACTORS INFLUENCING THE HEALTH SECTOR LABOUR MARKET
3.1 INTRODUCTION
Health sector analysts comment that gains made since 1994 to improve access to healthcare, rationalise
health management and attain more equitable health expenditure have been mostly eroded as a result
of the rampant AIDS crisis, disparities in spending and allocation of staff, as well as weak health systems
management. As a result, health outcomes are poor relative to total health expenditure and the health
sector workforce is substantially weaker than in the mid-1990s. 39 The impact of these challenges on
available human resources in the health sector and its skills base is considered in this chapter.
As a point of departure, the chapter examines health spending and the demand for health services in
South Africa. Global influences on the health sector’s labour resources are also considered. Thereafter
pertinent socio-economic factors affecting the delivery of health services and the health workers who
render these services are analysed. Since existing and new legislation has a bearing on human resources
and skills needs, the chapter outlines key statutory provisions influencing the health sector. Recent
developments in national policies pertaining to health services and the anticipated impact on skills
development needs are discussed as well.
3.2 HEALTH SPENDING
There is a direct relationship between health spending (both in the public and private sectors) and the
demand for health workers. In the public sector health budgets are major determinants of the number
of positions created – as well as salary levels and, consequently, the ability of institutions to attract and
retain staff. In the private sector the linkages are somewhat more complex, but equally significant.
South Africans access medical care either through the public health system or through their own health
insurance arrangements with medical schemes, or incur out-of-pocket expenses. Existing levels of
healthcare spending in the private and public sectors are shown in Table 3-1. In 2010 healthcare
expenditure was estimated to be above R227 billion, with more than 53% attributable to private sector
spending. Over the three financial years 2007 to 2009, medical scheme contributions paid on behalf of
between 14% and 16% of the population exceeded the combined health expenditure of the nine
provincial governments. In 2009 provincial health expenditure exceeded medical scheme expenditure
for the first time in a decade. 40
39 Lehmann, U. 2008. “Strengthening Human Resources for Primary Health Care” in South African Health Review 2008. Health
Systems Trust. Published at www.hst.org.za/publications/841. (Accessed August 2010); Harrison, D. 2009. An Overview of
Health and Health Care in South Africa 1994-2010: Priorities, Progress and Prospects for New Gains. Published at
www.doh.gov.za (Accessed February 2010).
40 National Treasury. 2009. “Health”. In Provincial Budgets and Expenditure Review 2005/06 – 2011/12.
20

Table 3-1 Health expenditure in public and private sectors: 2007 -2010
2006/07 2007/08 2008/09 Est 2009/10
Public sector
R Million
National Dept of Health 1 3,136 3,829 4,755 5,134
Provincial departments of health 51,938 60,645 72,444 87,596
Defence 1,602 1,743 2,024 2,265
Local government (own revenue) 1,317 1,478 1,625 1,793
Other (Correctional services, Police &
social insurance funds) 2 2,371 2,610 2,957 2,974
Total public sector health 60,364 70,305 83,805 99,762
Private sector
Medical schemes 58,349 65,468 74,089 81,128
Out-of-pocket 26,596 31,183 34,270 36,498
Medical insurance 2,056 2,179 2,452 2,660
Employer private 982 1,041 1,172 1,271
Total private sector health 87,983 99,871 111,983 121,557
Donors or NGOs 2,503 3,835 5,212 6,319
TOTAL 150,850 174,011 201,000 227,638
1. Includes selected public entities.
2. Social insurance funds are the Compensation Fund for workmen’s injuries on duty and Road Accident Fund. Costs of private
and public healthcare providers are included in the amounts paid.
Source: National Treasury. Budget Review 2010.
3.2.1 PUBLIC SECTOR SPENDING
Public spending on health declined in real terms between 1996 and 2005, and this resulted in shrinkages
of personnel and other resources. 41 However, public sector spending on health increased by 16.7%
annually between 2005/06 and 2008/09. By 2011/12 it is expected to be more than double the
spending in 2005/06. 42 Public funding of health is 3.7% of GDP and 13% of the main budget. In 2009 the
per capita expenditure was about R2,058. 43
Over the last 15 years the public sector has moved from a hospital-based approach to a primary
healthcare (PHC) approach. 44 This is also reflected in public sector spending. Government spends about
41% of public health funds on district health services which includes primary care clinics and community
health centres, district hospitals and AIDS interventions. Regional hospitals receive 18%, while central
and tertiary hospitals receive 15% of spending. 45 Hospital budgets declined by 2.3% in real terms, with
added pressure on central hospitals in Gauteng and KwaZulu-Natal and district hospitals in the Eastern
41 Harrison, D. 2009. An Overview of Health and Health care in South Africa 1994-2010: Priorities, Progress and Prospects for
New Gains. Published at www.doh.gov.za. (Accessed February 2010).
42 National Treasury. 2009. “Health”. In Provincial Budgets and Expenditure Review 2005/06 – 2011/12.
43 National Treasury. 2009. “Health”. In Provincial Budgets and Expenditure Review 2005/06 – 2011/12.
44 Coovadia, H., Jewkes, R., Barron, P. et al. 2009. “The health and health system of South Africa: historical roots of current
public health challenges”. Lancet. September 2009. Vol. 374. Published at http://thelancet.com. (Accessed August 2010).
45 HEU Information Sheet 1. 2009. “Public sector health care spending in South Africa”. Health Economics Unit, University of
Cape Town. Published at http://www.heu-uct.org.za. (Accessed August 2010).
21

Cape, Limpopo and KwaZulu-Natal. 46 Expenditure on district health programmes increased by 19.4% per
annum between 2005/06 and 2008/09. 47 Spending on the HIV and AIDS programme will reach R5.9
billion by 2011/12, up from R1.7 billion in 2005/06. 48
Payroll expenses comprise 56% of provincial health expenditure and escalated by 19% per annum over
the four years 2005/06 to 2008/09. 49 During the same period 33812 additional health workers were
appointed, with the largest staff increases in the more populous KwaZulu-Natal and Gauteng
provinces. 50
3.2.2 PRIVATE SECTOR SPENDING
In 2008/09 per capita expenditure in the private sector exceeded that of the public sector by more than
six times. 51
In 1996 per capita expenditure on medical schemes was three times higher than public spending. 52
Average annual contributions to medical schemes have risen twice as much as inflation, or from R4,500
per person in 1992 to R9,600 per person in 2008.
Private health expenditure was 55.5% of total health expenditure in 2008/09, down from 59.1% in
2005/06. 53 Hospital costs account for the largest amount of medical scheme spending (R24 billion or
37%), followed by specialists (R14 billion or 22%) and medicines (R11 billion or 17%). Spending on
hospital care has more than trebled between 1992 and 2008 if allowance is made for inflation. 54
In contrast to the public sector, private sector spending has moved away from PHC towards funding
major medical benefits such as hospitals, specialists and chronic diseases. Major medical expenditure
accounted for only 42.5% of the combined medical scheme funds in 1974, but reached 71.4% by 2005. 55
While the private sector does offer some PHC in prescribed minimum benefit packages for medical
schemes, analysts argue that it is applying ‘selective PHC’. Comparison in spending shows that the
private and public sectors are on divergent paths in their respective approaches to healthcare. 56 This
affects the nature of labour demand in the two respective sectors.
46 National Treasury. 2009. “Health”. In Provincial Budgets and Expenditure Review 2005/06 – 2011/12.
47 National Treasury. 2009. “Health”. In Provincial Budgets and Expenditure Review 2005/06 – 2011/12.
48 National Treasury. 2009. “Health”. In Provincial Budgets and Expenditure Review 2005/06 – 2011/12.
49 National Treasury. 2009. “Health”. In Provincial Budgets and Expenditure Review 2005/06 – 2011/12.
50 National Treasury. 2009. “Health”. In Provincial Budgets and Expenditure Review 2005/06 – 2011/12.
51 HEU Information Sheet 3. 2009. “The public-private health sector mix in South Africa”. Health Economics Unit, University of
Cape Town. Published at http://www.heu-uct.org.za. (Accessed August 2010).
52 Coovadia, H., Jewkes, R., Barron, P. et al. 2009. “The health and health system of South Africa: historical roots of current
public health challenges”. Lancet. September 2009. Vol. 374. Published at http://thelancet.com. (Accessed August 2010).
53 National Treasury. 2009. “Health”. In Provincial Budgets and Expenditure Review 2005/06 – 2011/12.
54 HEU Information Sheet 2. 2009. “Medical schemes’ spending in South Africa”. Health Economics Unit, University of Cape
Town. Published at http://www.heu-uct.org.za. (Accessed August 2010).
55 Day, C. and Gray, A. 2008. “Health and Related Indicators”. South African Health Review. Published at
http://www.hst.org.za/uploads/files/chap16_08.pdf. (Accessed August 2010).
56 Day, C. and Gray, A. 2008. “Health and Related Indicators”. South African Health Review. Published at
http://www.hst.org.za/uploads/files/chap16_08.pdf. (Accessed August 2010).
22

According to the Development Bank of South Africa (DBSA), South Africa’s public health expenditure is
slightly below that of comparable middle-income countries, but its per capita expenditure is above the
median level. However, when health outcomes are compared with those of peer countries, South
Africans are worse off. It could therefore be said that the health system is under-performing in relation
to its financing levels. 57 Reasons for this under-performance are, in part, related to the quality of health
care management, which in turn is related to the managerial skills available in the sector.
3.3 THE DEMAND FOR HEALTH SERVICES
3.3.1 THE PUBLIC-PRIVATE DIVIDE
More than 41 million people rely on the public health system and 7.9 million people are covered by
medical insurance. 58 Table 3-2 shows the use of public and private facilities as measured by the General
Household Survey of 2007. Of those without medical scheme coverage, an estimated 28 % use private
facilities and practitioners, but use public hospital services. 59 An estimated 64% to 68% of the
population is entirely dependent on public sector care. 60 About 6% of medical scheme beneficiaries use
public sector facilities. 61
57 Development Bank of South Africa. 2008. A Roadmap for the Reform of the South African Health System.
58 National Treasury. Budget Review 2010; Council of Medical Schemes. 2010. Comparison of data in Annual Reports. Published
at http://www.medicalschemes.com (Accessed August 2010); Statistics South Africa. 2010. Mid-year population estimates.
Published at http://www.statssa.gov.za/publications/P0302. (Accessed August 2010); Van der Berg, S., Burger, R., Theron, N. et
al. 2010. Financial Implications of a National Health Insurance Plan for South Africa.
59 Day, C. and Gray, A. 2008. “Health and Related Indicators”. South African Health Review: Published at
http://www.hst.org.za/uploads/files/chap16_08.pdf. (Accessed August 2010); Van der Berg, S., Burger, R., Theron, N. et al.
2010. Financial Implications of a National Health Insurance Plan for South Africa.
60 HEU Information Sheet 3. 2009. “The public-private health sector mix in South Africa”. Health Economics Unit, University of
Cape Town. Published at http://www.heu-uct.org.za (Accessed August 2010); Coovadia, H., Jewkes, R., Barron, P. et al. 2009.
“The health and health system of South Africa: historical roots of current public health challenges”. Lancet. September 2009.
Vol. 374. Published at http://thelancet.com. (Accessed August 2010).
61 Day, C. and Gray, A. 2008. “Health and Related Indicators”. South African Health Review: Published at
http://www.hst.org.za/uploads/files/chap16_08.pdf. (Accessed August 2010).
23

Table 3-2 Use of public and private sector facilities according to medical insurance (of those who were
ill/injured or sought care): 2007
Healthcare facility or professional
n (1000)
Percentage
Insured Uninsured Total Insured Uninsured
Public hospitals 29 777 3.2 23.9
Public clinics 26 1481 2.8 45.5
Public other 22 0 0.7
Private hospital 139 59 15.1 1.8
Private clinic 81 55 8.8 1.7
Private doctor/specialist 589 702 64.0 21.6
Traditional healer 33 0 1.0
Pharmacist/Chemist
(for 29 52 3.2 1.6
healthcare)
Employer provided healthcare 0 0
Alternative medicine 0 0
Private other 13 0 0.4
Private total 838 922 1775
Unspecified 12 54 1.3 1.7
Total 920 3257 4177 100 100
% using private sector 92.2% 28.3% 42.5%
Source: DayC. and Gray A. 2008. “Health and Related Indicators”. South African Health Review. Health Systems Trust. Published
on http://www.hst.org.za/uploads/files/chap16_08.pdf. (Accessed August 2010).
3.3.2 THE DEMAND FOR PUBLIC HEALTH CARE
Table 3-3 shows the headcount at primary healthcare facilities per province in 2008/09. It also shows
the utilisation rates by the public, expressed as the average number of visits per person per year.
Demand for primary healthcare services increased by 10.4% between 2007/08 and 2008/09, or from 106
million to 117 million visits, almost 75% up from the 67 million visits recorded in 1998/99. 62
62 Burger, D. 2009. South Africa Yearbook 2009/10. Pretoria: Government Communication and Information System. Published at
http://www.gcis.gov.za/resource_centre/sa_info/yearbook/2009-10.htm. (Accessed August 2010).
24

Table 3-3 Primary healthcare visits per province: 2008/09
PHC total
headcount
Utilisation rateannualised
Utilisation rate for
under 5 yr olds
annualised
Eastern Cape 17814953 2.6 4.3
Free State 6455360 2.2 4.0
Gauteng 19111520 1.9 3.6
KwaZulu-Natal 24495932 2.4 4.3
Limpopo 14772977 2.8 5.9
Mpumalanga 7932495 2.2 4.5
Northern Cape 3484634 3.1 4.9
North West 8329076 2.6 4.5
Western Cape 14944309 3.0 5.2
Total/Average 117341256 2.5 4.6
Source: National Treasury. 2009. “Health”. In Provincial Budgets and Expenditure Review 2005/06 – 2011/12 (from district
health information systems).
Table 3-4 compares the reported number of patients treated per day by a doctor or a nurse at primary
healthcare clinics per province in 2008/09. The clinical workload of doctors and nurses differed
between provinces. Doctors in Mpumalanga and the Free State had the highest workload. Nurses in the
Free State and Western Cape had a higher workload than their counterparts in other provinces.
Table 3-4 Primary healthcare workload per province: 2008/09
Province
Doctor clinical workload
in PHC
Nurse clinical workload
in PHC
Eastern Cape 21.5 21.7
Free State 28.6 33.9
Gauteng 24.2 28.5
KwaZulu-Natal 24.4 23.4
Limpopo 18.8 17.8
Mpumalanga 29.0 21.5
Northern Cape 17.6 25.5
North West 12.3 20.5
Western Cape 24.3 31.1
Total/Average 22.3 24.9
Source: National Treasury. 2009. “Health”. In Provincial Budgets and Expenditure Review 2005/06 – 2011/12 (from district
health information systems).
Demand for healthcare services in the public sector continues to rise and exceeds supply. Reports about
lack of medicines and equipment, as well as backlogs in payments for goods and services procured,
25

emain fairly common. 63 Not everyone requiring HIV and AIDS medication can be treated due to
resource constraints. 64 Recent research has shown that the rise in the child mortality rate in South Africa
since 1990 can be attributed to constraints in the availability of healthcare services (the coverage of
care) and the quality of care due to staff shortages. It has been shown that the available financial and
human resources are insufficient to meet the demands for care of mothers, babies and children. 65 Lowquality
care in the neo-natal stage may result in complications such as cerebral palsy and blindness
(retinopathy of prematurity) which have a long-term impact on the demand for specialist care. Demand
for healthcare among the urban poor population is also increasing due to the growing prominence of
non-communicable and chronic diseases such as diabetes, hypertension and kidney disease and certain
types of cancer. 66
A comprehensive revitalisation programme for public hospitals and public healthcare facilities is
underway. New hospitals are under construction and existing facilities are being upgraded, renovated
and repaired. 67 As the number of hospital beds is increased, so will the demand for medical
professionals and staff increase.
3.3.3 THE DEMAND FOR PRIVATE HEALTHCARE SERVICES
The private sector also experienced an increase in demand for healthcare. This is evidenced by the
increase in medical scheme membership, higher hospital occupancy rates, the growth in the percentage
of people consulting health workers, as well as considerations about the quality of healthcare.
Membership of medical schemes increased from about 6.5 million in 2000 to about 7.9 million people in
2009. The hospital occupancy rate in private hospitals also increased from 62% in 2007 to 65% in
2008. 68 A larger percentage of people with medical aid coverage (87.4%) consulted health workers in
2007 than did in 2002 (85.5%). 69
Several research studies over the last decade found that users of public health facilities remain
concerned about the quality of care due to long waiting lines, lack of equipment and medication,
disrespect for patients and rude staff. 70 Growing numbers of people from the poorest households
prefer to pay for private care, which increases the demand for private providers and GPs in particular. 71
63 National Treasury. 2009. “Health”. In Provincial Budgets and Expenditure Review 2005/06 – 2011/12.
64 Harrison, D. 2009. An Overview of Health and Health care in South Africa 1994-2010: Priorities, Progress and Prospects for
New Gains.
65 Chopra, M., Daviaud, E., Pattinson, R. et al. 2009. “Saving the lives of South Africa’s mothers, babies, and children: can the
health system deliver?” Lancet. September 2009. Vol. 374. Published at http://thelancet.com. (Accessed August 2010).
66 Chopra, M., Lawn, J.E., Sanders, D. et al. 2009. “Achieving the health Millennium Development Goals for South Africa:
challenges and priorities”. Lancet. September 2009. Vol. 374. Published at http://thelancet.com. (Accessed August 2010).
67 National Treasury. 2010. “Vote 15: Health”. Estimates of National Expenditure 2010.
68 Development Bank of South Africa. 2008. A Roadmap for the Reform of the South African Health System.
69 Van der Berg, S., Burger, R., Theron, N. et al. 2010. Financial Implications of a National Health Insurance Plan for South Africa;
Hospital Association of South Africa. 2009. Private Hospital Review:2009. Published at
http://www.hasa.co.za/media/uploads/news/.../Private_Hospital_Review_2009.pdf. (Accessed August 2010).
70 McIntyre, D., Goudge, J., Harris, B. et al. 2009. “Prerequisites for National Health Insurance in South Africa: Results of a
national household survey”. South African Medical Journal. October 2009. 99 (10). Published at
http://www.scielo.org.za/pdf/samj/V99n10. (Accessed August 2009).
71 Van der Berg, S., Burger, R., Theron, N. et al. 2010. Financial Implications of a National Health Insurance Plan for South Africa.
26

3.4 THE MOBILITY OF LABOUR
In 2006 the World Health Organization estimated the global shortages of health workers at almost 4.3
million, with the combined shortage of doctors, nurses and midwives estimated at 2.4 million. 72 The
effects of globalisation and the migration of skilled labour from emerging to developed economies
continue to affect the health sector. Job opportunities in better resourced countries that offer more
attractive working conditions, better prospects for professional advancement, and general quality of life
advantages attract trained healthcare professionals from less developed countries to work elsewhere. 73
This mobility of health professionals not only depletes the skills base in developing countries but also
adversely affects healthcare services, as well as the workloads of and working conditions for the
remaining workforce. 74
3.5 ECONOMIC DOWNTURN
The 2008 global economic crisis and the economic downturn in South Africa since 2008 impacts the
health sector on several levels. Firstly, the delivery of health services is highly dependent upon tax
revenues. During periods of economic contraction, tax revenues decline, which affects budgets,
allocation of human resources and provision for training. 75 Secondly, many non-profit organisations in
the health sector depend on international and local donor funding, and these sources of income may dip
substantially or be plugged altogether.
Thirdly, economic recessions lead to job losses, and the loss of medical insurance offered by some
employers, which situation adds to the demand for public health services. These economic factors are
likely to add further pressure on health professionals and workers in the public sector. 76
While funding resources may stagnate or weaken during periods of economic downturn, the demand for
health services will grow (especially for primary healthcare and social relief of distress).
3.6 THE BURDEN OF DISEASE
Recent research shows that South Africa has substantially larger numbers of sick people who are sicker
than those in other countries. This high burden of disease is four times larger than for developed
countries and generally double that of other developing countries. 77 This high burden is attributable to
the scale of the HIV and AIDS pandemic; the high incidence of tuberculosis (TB), malaria, inter-personal
violence and trauma; poor maternal and child health; and chronic diseases such as alcohol abuse,
72 World Health Organisation. 2006. The World Health Report 2006 - working together for health. Published at
http://www.who.int/whr/2006/06_chap1_en.pdf (Accessed August 2010); HWSETA. 2010. Sectoral Analysis for the Health
Sector.
73 Macheke, C. 2010. HWSETA Health Sector Baseline Study.
74 World Health Organisation. 2006. The World Health Report 2006 - working together for health. Published at
http://www.who.int/whr/2006/06_chap1_en.pdf (Accessed August 2010); Department of Health. 2008. Nursing Strategy for
South Africa. Published at http://www.sanc.co.za/pdf/nursing-strategy.pdf (Accessed August 2010).
75 Such concerns were raised during the baseline study of the health sector undertaken for the HWSETA.
76 National Treasury. Budget Review 2010.
77 Van der Berg, S., Burger, R., Theron, N. et al. 2010. Financial Implications of a National Health Insurance Plan for South Africa.
27

diabetes and heart disease. 7879 By 2010 the overall HIV prevalence rate was approximately 10.5%, with
5.24 million people infected, and AIDS-related deaths were estimated at 2.6 million. 80 The DBSA
estimated that by 2008 5.4 million people were infected and the prevalence rate was 11.2% 81 UNAIDS
estimates in 2007 were higher, with 5.7 million people infected according to its database. 82 South Africa
has the largest HIV and AIDS epidemic in the world and bears 17% of the world’s burden. 83 The Minister
of Health informed Parliament in March 2010 that amongst women in the age group 15 to 24 years, the
prevalence rate was nearly 22% and the mother-to-child transmission rate was 10%. 84
The country’s TB epidemic is amongst the worst and most serious in the world, with an estimated
annual incidence rate of 940 per 100000 population. 85 TB is a major cause of death and the co-infection
rate with HIV is about 70%. 86 Inappropriate and ineffective treatment of TB results in multidrugresistant
TB, which is placing a huge burden on the health system in all nine provinces. 87 Malaria is
endemic in low-lying areas of Limpopo, Mpumalanga and north-eastern KwaZulu-Natal. About 10% of
the population in South Africa lives in malaria-risk areas. 88 Child mortality remains a major and complex
public health challenge. High mortality is linked to health, social and environmental risks such as underweight
births, a poor immunisation rate; poverty and malnutrition, as well as inadequate access to clean
water and sanitation. 89
78 Van der Berg, S., Burger, R., Theron, N. et al. 2010. Financial Implications of a National Health Insurance Plan for South Africa;
Harrison, D. 2009. An Overview of Health and Health care in South Africa 1994-2010: Priorities, Progress and Prospects for New
Gains. Published at www.doh.gov.za (Accessed February 2010).; Bateman, C. 2009. “Incompetent, unaccountable managers
paralysing health care”. South African Medical Journal. October 2009. 99 (10). Published at
http://www.scielo.org.za/pdf/samj/V99n10. (Accessed August 2010).
79 It is often referred to as the ”quadruple burden of disease” which include diseases of poverty, non-communicable diseases,
HIV/AIDS and violence/personal injury. (See Coovadia, H., Jewkes, R., Barron, P. et al. 2009. “The health and health system of
South Africa: historical roots of current public health challenges”. Lancet. September 2009. Vol. 374. Published at
http://thelancet.com. (Accessed August 2010) and Van der Berg, S., Burger, R., Theron, N. et al. 2010. Financial Implications of a
National Health Insurance Plan for South Africa.
80 Statistics South Africa. 2010. Mid-year population estimates. Published at http://www.statssa.gov.za/publications/P0302
(Accessed August 2010); Harrison, D. 2009. An Overview of Health and Health care in South Africa 1994-2010: Priorities,
Progress and Prospects for New Gains. Published at www.doh.gov.za (Accessed February 2010).
81 Development Bank of South Africa. 2008. A Roadmap for the Reform of the South African Health System.
82 Day, C. and Gray, A. 2008. “Health and Related Indicators”. South African Health Review. Health Systems Trust. Published at
http://www.hst.org.za/uploads/files/chap16_08.pdf. (Accessed August 2010).
83 UNAIDS in HEU Information Sheet 1. 2009. “Public sector health care spending in South Africa”. Health Economics Unit,
University of Cape Town. Published at http://www.heu-uct.org.za (Accessed August 2010); Karim, S.S.A, Churchyard, G.J.,
Karim, Q.A. et al. 2009. “HIV infection and tuberculosis in South Africa: an urgent need to escalate the public health response”.
Lancet. September 2009. Vol. 374. Published at http://thelancet.com. (Accessed August 2010).
84 Portfolio Committee on Health. 2010. “Health plans major increase in vaccination and HIV work”. Published at
http://sabinetlaw.co.za/health/articles (Accessed August 2010).
85 Karim, S.S.A, Churchyard, G.J., Karim, Q.A. et al. 2009. “HIV infection and tuberculosis in South Africa: an urgent need to
escalate the public health response”. Lancet. September 2009. Vol. 374. Published at http://thelancet.com. (Accessed August
2010)
86 National Treasury. Budget Review 2010
87 Medical Research Council. 2006. Policy Brief, No1, January 2006. Published at
http://www.mrc.ac.za/policybriefs/managingTB.pdf. (Accessed August 2010).
88 Macheke, C. 2010. HWSETA Health Sector Baseline Study.
89 Macheke, C. 2010. HWSETA Health Sector Baseline Study.
28

Arguably, many of the driving factors in the disease burden are linked to social and economic
inequalities and are not primarily caused by poor health services. 90 The scope and complexity of these
health threats are creating increased demands on the health services and its workforce. 91 It is evident
that the sector requires well-skilled health professionals who are prepared, willing and able to tackle the
demands of treating and alleviating the burden of disease.
3.7 HUMAN RESOURCES CHALLENGES
Market forces, working conditions and career advancement opportunities are all factors that determine
where and for how long people work in a particular workplace. This is also true of the health sector
labour market. While this SSP looks at the availability of skills and the demand and supply of the skills in
more detail in the following chapters, it is useful to sketch key issues at this stage.
Decisionmakers, operational managers and analysts of the sector have expressed concerns about the
quantity and quality of healthcare professionals available in the country. It is widely recognised that
care levels, outcomes and management of the public health system are under strain, partly because of
significant staff shortages and an inadequate skills base. 92 The DBSA work groups found that South
Africa lacked an effective human resources strategy to ensure that the public sector is resourced and
that the country has an adequate supply of health professionals. 93
It is not only the numbers of health workers that is of concern, but also their distribution between the
public and private sectors. Estimates on the distribution of resources across the sectors vary, depending
on the approach adopted and the interpretation of available (and often uncertain) data. Nevertheless,
Table 3-5 compares the allocation of general medical practitioners, medical specialists and nurses per
100000 population in the public and private sectors.
Table 3-5 Key resources per 100 000 population in public and private sectors: 2009
GPs per 100 000
population
Specialists per 100 000
population
Nurses per 100 000
population
Public sector 26 9 255
Private sector 86 65 500
Total 37 19 300
Source: Econex in Van der Berg, S., Burger, R., Theron, N. et al. 2010. Financial Implications of a National Health Insurance Plan
for South Africa.
90 Harrison, D. 2009. An Overview of Health and Health care in South Africa 1994-2010: Priorities, Progress and Prospects for
New Gains. Published at www.doh.gov.za (Accessed February 2010).
91 Lehmann, U. 2008. “Strengthening Human Resources for Primary Health Care”. South African Health Review 2008. Health
Systems Trust. Published at www.hst.org.za/publications/841 (Accessed August 2010).
92 Harrison, D. 2009. An Overview of Health and Health care in South Africa 1994-2010: Priorities, Progress and Prospects for
New Gains. Published at www.doh.gov.za (Accessed February 2010); Coovadia, H., Jewkes, R., Barron, P. et al. 2009. “The health
and health system of South Africa: historical roots of current public health challenges”. Lancet. September 2009. Vol. 374.
Published at http://thelancet.com. (Accessed August 2009); Chopra, M., Daviaud, E., Pattinson, R. et al. 2009. “Saving the lives
of South Africa’s mothers, babies, and children: can the health system deliver?” Lancet. September 2009. Vol 374. Published at
http://thelancet.com. (Accessed August 2010)
93 Development Bank of South Africa. 2008. A Roadmap for the Reform of the South African Health System.
29

More than three times the number of GPs are available to private sector users as are available in the
public sector. The difference for specialists is higher, with seven times more specialists available to
private sector patients than to users of public healthcare. The ratio of nurses per private sector
population is almost double that of the public sector.
Human resources are also unevenly distributed between provinces in the public sector as staff favour
working near urban-based medical schools, and doctors prefer working in hospitals rather than in
primary healthcare facilities. 94 Table 3-6 shows the skewed distribution of different categories of health
professionals as a ratio of the population in each province.
Table 3-6 Distribution of health professionals per 100000 population in public sector: 2008
EC FS GP KZN LP MP NC NW WC SA
Professionals per 100 000 population
Dental practitioners 1.10 2.30 3.10 0.8 1.50 2.70 3.40 1.20 3.20 1.90
Enrolled nurses 31.8 16.2 52.2 110.5 53.8 38.3 27.0 21.9 54.4 55.4
Medical practitioners 17.9 23.2 32.0 34.7 17.4 18.3 35.7 14.1 37.9 26.0
Medical specialists 2.5 14.7 22.3 6.2 1.7 1.6 2.9 1.3 31.9 9.8
Occupational
therapists
1.0 3.0 2.4 1.5 2.1 2.2 2.6 1.2 2.8 1.9
Pharmacists 2.9 3.7 4.2 5.0 4.5 4.0 5.7 3.1 8.7 4.5
Physiotherapists 1.00 2.20 2.60 2.90 1.60 2.00 5.10 1.10 3.30 2.20
Professional nurses 114.2 94.5 111.7 136.3 127.5 102.9 155.0 81.1 123.4 116.6
Radiographers 4.5 6.2 7.0 5.5 2.9 2.4 5.3 1.5 10.7 5.2
Source: Day, C. and Gray, A. 2008. “Health and Related Indicators”. South African Health Review 2008.
94 Coovadia, H., Jewkes, R., Barron , P. et al. 2009. “The health and health system of South Africa: historical roots of current
public health challenges”. Lancet. September 2009. Vol. 374, Published at http://thelancet.com. (Accessed August 2010).
30

3.8 MANAGEMENT OF THE HEALTH SYSTEM
Challenges to the health system exist at managerial and governance levels, and operational levels as
well. The DBSA highlights widespread inefficiencies that result in services that are unresponsive to
health and patient needs and a lack of accountability on a large scale. 95
A decade ago the DoH’s Human Resources for Health Strategy identified skills needs in the areas of
management of health systems, organisational development, as well as education and training. Many of
these challenges persist. A health sector audit in 2009 commissioned by the Minister of Health
documented significant inefficiencies in the management of the public health system. Local managerial
capacity of and decision-making by professionals were found to be compromised by centralised
decision-making at national and provincial levels. This compromises accountability for patient care.
Valuable skills (i.e. “institutional memory”) were lost due to a combination of voluntary severance of
skills in the mid 1990s and simultaneous recruitment of inexperienced managers as replacements.
Observers are concerned that middle- and senior-level posts continue to be filled by insufficiently
qualified people who jobhop to the next opportunity without transferring skills. 96
Some of the management challenges include the lack of: efficient and effective human resources
management; training, support and supervision; and performance management. Complaints of
absenteeism, moonlighting, poor discipline and incompetence are frequent. 97
Greater accountability is needed at all levels. Managers require skills in the management of time and
resources, in planning, in performance management and financial management, in procurement of
supplies, and in leadership and innovation. 98 A particular need for planning and management skills
exists at district level in the public health sector. Research has shown that the skills of middle- and
senior management in the district health system remain weak, despite intensive training interventions.
It has been suggested that a need exists for more comprehensive and nationally standardised training
for primary healthcare and for the development of district health systems. 99
95 Development Bank of South Africa. 2008. A Roadmap for the Reform of the South African Health System.
96 Coovadia, H., Jewkes, R., Barron, P. et al. 2009. “The health and health system of South Africa: historical roots of current
public health challenges”. Lancet. September 2009. Vol. 374. Published at http://thelancet.com. (Accessed August 2010);
Development Bank of South Africa. 2008. A Roadmap for the Reform of the South African Health System.
97 Coovadia, H., Jewkes, R., Barron, P. et al. 2009. “The health and health system of South Africa: historical roots of current
public health challenges”. Lancet. September 2009. Vol. 374. Published at http://thelancet.com. (Accessed August 2010).
98 National Treasury. 2009. “Health”. In Provincial Budgets and Expenditure Review 2005/06 – 2011/12; Harrison, D. 2009. An
Overview of Health and Health care in South Africa 1994-2010: Priorities, Progress and Prospects for New Gains. Published at
www.doh.gov.za (Accessed February 2010); Coovadia, H., Jewkes, R., Barron, P. et al. 2009. “The health and health system of
South Africa: historical roots of current public health challenges”. Lancet. September 2009. Vol. 374. Published at
http://thelancet.com. (Accessed August 2010); Karim, S.S.A, Churchyard, G. J., Karim, Q. A. et al. 2009. “HIV infection and
tuberculosis in South Africa: an urgent need to escalate the public health response”. Lancet. September 2009. Vol. 374.
Published at http://thelancet.com. (Accessed August 2010).
99 Lehmann, U. 2008. “Strengthening Human Resources for Primary Health Care” South African Health Review. Health Systems
Trust. Published at www.hst.org.za/publications/841. (Accessed August 2010).
31

3.9 THE REGULATORY ENVIRONMENT
Constitutional imperatives 100 faced by the state to improve access to healthcare services and care for
vulnerable people continue to drive the regulatory environment in the sector.
The National Health Act (NHA), 61 of 2003 establishes a national health system comprising the public
and private sectors, and sets out the rights and duties of healthcare providers, health workers,
establishments and users. Responsibilities regarding the development of human resources for health
are split between national and provincial levels. The national DoH is obliged to “promote adherence to
norms and standards for the training of human resources for health”. 101 However, the critical
responsibility to “plan, manage and develop human resources for the rendering of health services” lies
with all nine provincial departments of health and it is not a national responsibility. 102 The NHA
empowers the Minister of Health to make regulations to ensure adequate resources are available to
educate and train health personnel, create new categories of health personnel, identify key skills
shortages, recruit foreign health workers, and ensure that there are adequate human resources and
planning and development structures across all levels of the national health system. 103
An extensive legislative framework is in place to regulate almost all aspects of the health sector. The
main areas of regulation relate to the quantity and distribution of resources, the quality of resources
(infrastructure and the workforce), and the price of products and services. 104 Government and the
statutory professional bodies referred to in Chapter 2 are the main regulators on matters pertaining to
the skills base of the workforce.
3.9.1 REGULATION OF QUANTITY AND DISTRIBUTION
The NHA introduces provisions aimed at regulating the numbers and distribution of public and private
facilities and providers of healthcare. Although that aspect of the NHA has not been implemented as
yet, implementation will have implications for the distribution of skills available in the sector, as well as
people trying to enter the sector. The NHA empowers the Director-General (DG) of the national DoH to
issue licences or a “certificate of need” to private hospitals and private practices of health professionals
and technologists for a prescribed period. 105 Before issuing or renewing such a certificate, the DG must
consider the need to promote an equitable distribution and rationalisation of health services and
resources, as well as other factors. The NHA empowers the Minister of Health to determine the range
of health services that may be offered at a public health establishment. 106 In this way the DoH can decide
the allocation and distribution of healthcare skills.
100 Sections 27 and 28 of the Constitution of South Africa, Act 108 of 1996.
101 Section 21(2)(c) of the National Health Act 61 of 2003.
102 Section 25(2)(i) of the National Health Act 61 of 2003.
103 Section 52 of the National Health Act 61 of 2003.
104 McIntyre, D., Thiede, M., Nkosi, M. et al. 2007. SHIELD work package 1 report: A critical analysis of the current South African
health system. Health Economics Unit, University of Cape Town. Published at
http://www.web.uct.ac.za/depts/heu/SHIELD/reports/SouthAfrica1.pdf. (Accessed August 2010).
105 Section 36 of the National Health Act 61 of 2003.
106 Section 41 of the National Health Act 61 of 2003.
32

3.9.2 REGULATION OF QUALITY
Strict regulatory controls are in place to control standards for entry into the healthcare professions.
Statutory provisions require health professionals to be registered as such in their respective fields. As
discussed in Chapter 2, the HPCSA, AHPCSA, SANC, SAPC, SADTC and SAVC control the respective
registers entrusted to them by statute. Registration as a healthcare professional or technician only
takes place once the applicant has obtained the required qualifications and has served an internship or
has completed practical training.
Several categories of healthcare professionals are required to serve one year of community service in
the public health services before they are allowed to register for independent practice. The professional
bodies also determine the scope of practice for the various categories of healthcare professionals, which
amounts to controlling the services and treatment that are permitted and those that are not. Although
the professional councils do not control or influence the supply of skills, they do control the quality of
skills available in the health sector. As such, the councils set standards for practice, education and
training and ensure that the training programmes offered meet the specifications of registered
qualifications. The councils also assess and accredit training providers entrusted with delivering
accredited programmes and perform quality assurance functions required in terms of the skills
development legislation. The councils furthermore determine the standards for the CPD that
professionals require in order to retain their registration. Generally healthcare professionals may
engage in a range of activities to update their skills, including organisational activities, self-study and
groupstudy, usage of information from latest research publications, teaching, and the acquisition of
additional qualifications. 107
The NHA establishes academic health complexes 108 where health workers are trained in primary,
secondary and tertiary healthcare facilities and are exposed to peripheral facilities serving communities.
The intention is to better prepare staff to work in a range of facilities, including primary healthcare.
3.10 NATIONAL HEALTH POLICIES
South Africa endorsed three health-related Millennium Development Goals (MDGs), which are to:
reduce child mortality; improve maternal health; and combat HIV and AIDS, malaria and other
diseases. 109 Several national health policies are focused on achieving those goals and to improve the
health profile of all South Africans. A number of the key priorities in the “Health Sector Strategic
Framework: The 10 Point Plan” 110 of the DoH have a direct bearing on the actions and skills required to
achieve national policy objectives. Among these are:
107 Macheke, C. 2010. HWSETA Health Sector Baseline Study.
108 Section 51 of the National Health Act 61 of 2003.
109 Day, C. and Gray, A. 2008. “Health and Related Indicators”. South African Health Review. Health Systems Trust. Published at
http://www.hst.org.za/uploads/files/chap16_08.pdf. (Accessed August 2010); Harrison, D. 2009. An Overview of Health and
Health care in South Africa 1994-2010: Priorities, Progress and Prospects for New Gains. Published at www.doh.gov.za
(Accessed February 2010).
110 DoH. 2010. “Health Sector Strategic Framework: The 10 Point Plan” in the Strategic Plan 2010/11-2012/13 . Published at
www.doh.gov.za (Accessed August 2010).
33

a. An overhaul of the healthcare system by re-focusing on primary healthcare and communitybased
health services;
b. Implementation of National Health Insurance (NHI);
c. Accelerated implementation of tuberculosis controls and HIV and AIDS policies (including
expanded prevention strategies and access to ART);
d. Greater focus on improving maternal, perinatal and child health;
e. Promoting the prevention of lifestyle diseases and better nutrition;
f. Strategic leadership, improved management and governance of the health system; and
g. Improvements in human resources planning and development, including the recruitment and
retention of professionals and the training of nurses, primary healthcare personnel and mid-level
health workers.
3.10.1 PRIMARY HEALTHCARE
Over the last decade the delivery mode for public health services has moved from a hospital-centred
approach to a primary healthcare (PHC)approach. Such services are rendered by nurses and community
care workers in clinics and community health centres. 111 Government plans to strengthen and develop
primary healthcare and community-based services even further. With the increasing burden of disease
the demand for primary care is increasing at a rapid rate. It is anticipated that the concomitant demand
for nurses across all categories will also increase. Through the National School Health Policy
government plans to deploy PHC nurses to schools to provide health education, impart life skills, and
screen children for diseases, disabilities, immunisation status and other healthcare needs. 112 The
development and support to nurses will be required for them to manage a large proportion of health
problems at a PHC level. The national DoH Strategic Plan for 2010/11-2012/13 also identifies the
incorporation of and utilisation of community health workers (CHWs) in the delivery of PHC services.
This implies that the development of the skills of existing CHWs will be required as well as training of
new CHWs.
3.10.2 COMMUNITY HEALTH WORKERS
Due to the rapid spread in the HIV and AIDS pandemic and TB epidemic, the health sector has
experienced a sharp growth of a range of community carers who are mostly affiliated to NGOs and
community-based organisations (CBOs). Community health workers (CHWs) or community care workers
(CCWs) are generalist health workers who provide primary care, but their mandates and conditions of
111 Lehmann, U. 2008. “Strengthening Human Resources for Primary Health Care”. South African Health Review. Health Systems
Trust. Published at www.hst.org.za/publications/841. (Accessed August 2010).
112 Burger, D. 2009. South Africa Yearbook 2009/10. Government Communication and Information System. Published at
http://www.gcis.gov.za/resource_centre/sa_info/yearbook/2009-10.htm. (Accessed August 2010).
34

service are not well defined. 113 Some are paid a stipend by provincial health departments via designated
NGOs. 114 The majority are volunteers and lay persons drawn from local communities and, without
adequate skills development, they could compromise outcomes in major healthcare programmes.
Some CHWs are trained informally, on-the-job and via short course programmes, while some may have
no training. Since the NGOs lack the capacity to become accredited training providers, the CHWs and
CCWs are not receiving accredited training. 115 There is a growing need for CHWs and CCWs with the
appropriate skills to disseminate health and social security information, facilitate access to health and
social worker care, transfer health and wellness skills to community members, and provide psycho-social
support in households. Such CHWs could be critical in monitoring adherence to the treatment of HIV
and AIDS, communicable and chronic diseases, immunization of children, providing better linkages
between the health service and community needs, community support and prevention programmes.
Significant investment in education and training, skills development and support of CHWs is necessary to
enable them to conduct competent home-based and community-based care.
In 2009 the DoH and the Department of Social Development (DoSD) jointly published a draft working
document, the “Community Care Worker Management Policy Framework” (CCWMPF) to expand access
to CHWs in home- and community-based care and improve the quality of their services. 116 This draft
policy framework aims to standardise the roles, training and supervision of CCWs. At the same time the
relationship between CCWs and non-profit organisations (NPOs) will be formalised – CCWs will become
remunerated employees subject to existing labour laws. 117 It is envisaged that provincial health
departments will incorporate home-community-based care (HCBC) into their service packages and enter
into partnerships with NPOs to deliver the required resources and care. In this way CHWs or CCWs will
become formal resources to provide basic PHC services. Specific areas of health services have been
identified for CCWs, including assistance with: post-natal care; monitoring the growth of children;
promoting immunisation; identifying mental illness and substance abuse; promoting adherence to TB
medication, ART and chronic medication; supporting family members and carers of the ill; providing a
range of information on nutrition, healthy living, and the prevention of sexually transmitted diseases
and malaria. 118
113 Harrison, D. 2009. An Overview of Health and Health care in South Africa 1994-2010: Priorities, Progress and Prospects for
New Gains. Published at www.doh.gov.za (Accessed February 2010); Lehmann, U. 2008. “Strengthening Human Resources for
Primary Health Care”. South African Health Review 2008. Health Systems Trust. Published at www.hst.org.za/publications/841
(Accessed August 2010).
114 Coovadia, H., Jewkes, R., Barron, P. et al. 2009. “The health and health system of South Africa: historical roots of current
public health challenges”. Lancet. September 2009. Vol. 374. Published at http://thelancet.com. (Accessed August 2010).
115 HWSETA. 2009. HWSETA Sector Skills Plan 2005-2010: Annual Update August 2009.
116 DoH and DoSD. 2009. Community Care Worker Management Policy Framework. Published at www.doh.gov.za (Accessed
August 2010); Lehmann, U. 2008. “Strengthening Human Resources for Primary Health Care”. South African Health Review
2008. Health Systems Trust. Published at www.hst.org.za/publications/841 (Accessed August 2010).
117 Department of Health. 2010. “Health Sector Strategic Framework: The 10 Point Plan” in the Strategic Plan 2010/11-2012/13.
Published at http://www.doh.gov.za. (Accessed August 2010); National Treasury. 2010. “Vote 15: Health”. Estimates of National
Expenditure 2010; DoH an DoSD. 2009. Community Care Worker Management Policy Framework. Published at www.doh.gov.za
(Accessed August 2010).
118 DOH and DoSD. 2009. Community Care Worker Management Policy Framework. Published at www.doh.gov.za (Accessed
August 2010).
35

A skills development framework to create a common skills base for CCWs in health and social
development services is also proposed. The CCWMPF envisages that such skills development be aligned
with SAQA-accredited learning and delivered via applied job-specific and workplace-specific skills
programmes, rather than full qualifications. 119 Those applied skills programmes will be based on the
HCBC services on offer and also incorporate adult basic education and training (ABET). According to the
CCWMPF, four applied skills programmes should be developed from a health and social development
perspective. These programmes will be for home-based care, community care, facility-based care, and
supervisors. Although these applied skills programmes will not lead to a qualification, the policy
framework suggests that a vocational qualification in health be considered. It is also envisaged that twothirds
of the training be community-based and experiential, rather than classroom work. Further
proposals include the use of accredited training providers, NPOs and qualified educators or trainers to
facilitate learning programmes. According to the DoH and DoSD, the funding for the CCW programmes
(including their remuneration, initial training, care kit, professional supervision, etc) would be drawn
from national and provincial departments, international development partners and NPOs. 120
3.10.3 A NATIONAL HEALTH INSURANCE SYSTEM
a) Proposals
Current proposals for a national health insurance (NHI) system are contained in the National Health
Insurance Policy Proposal of the African National Congress (ANC). 121 Comprehensive and universal
coverage to all citizens and legal residents of South Africa is envisaged, irrespective of contribution. 122
Services will be rendered via accredited public and private providers, mostly primary healthcare GPs,
multi-disciplinary teams and hospitals. Patients will be able to consult the practitioner of their choice as
the proposed NHI Authority hopes to contract all public and private service providers. Medical services
will be free of charge and no co-payments or out-of-pocket expenses will be required from patients.
The scheme will be financed via a dedicated payroll tax levied on formal sector employees and general
taxes paid by individuals, companies and VAT vendors. 123
119 DoH and DoSD. 2009. Community Care Worker Management Policy Framework. Published at www.doh.gov.za (Accessed
August 2010).
120 DOH and DoSD. 2009. Community Care Worker Management Policy Framework. Published at www.doh.gov.za (Accessed
August 2010).
121 ANC. 2009. National Health Insurance Policy Proposal. Published at http://www.healthe.org.za/documents/5b5e24462cdf6e214072c2e3f92ab1b9.pdf
(Accessed August 2010).
122 The current proposals available in the public domain emanate from a 2009 ANC policy document and not a draft policy
document published by the DoH for public comment.
123 Van der Berg, S., Burger, R., Theron, N. et al. 2010. Financial Implications of a National Health Insurance Plan for South
Africa; Harrison, D. 2009. An Overview of Health and Health care in South Africa 1994-2010: Priorities, Progress and Prospects
for New Gains. Published at www.doh.gov.za (Accessed February 2010).
36

) Challenges
These proposals aim to solve South Africa’s pervasive healthcare problems by introducing a financing
mechanism to enable delivery of national health priorities. 124 Over a period of almost two decades a
range of policy proposals for social or national health insurance have been put forward, but little
progress has been made. The introduction of such reforms is complex and will have to deal with the
massive disparities in the private-public sector mix referred to earlier in this chapter. 125 Observers have
commented that before any NHI system can be introduced, significant improvements will be required in
public hospital services, public perceptions of such institutions, management and governance, as well as
greater operational autonomy. 126 It will also be necessary to fill the large numbers of vacant public
sector posts and to provide additional nursing skills. 127
c) Planning
The Minister of Health has appointed an advisory committee on NHI, which is mandated to explore a
range of policy proposals. An inter-ministerial committee established by Cabinet is discussing and
reviewing the proposals and public consultations are planned for 2011. 128 Current research is focused
on identifying measures to support a feasible transition to an NHI model over a period of five years. 129
Timeframes for implementation are still uncertain, but the DoH is aiming for 2014; i.e. within the
planning horizon of this SSP.
d) Implications for human resources and skills
Although the proposals are still under development and subject to change, the HWSETA should take into
account the implications for human resources needs and skills requirements, especially considering the
long lead-time required to train healthcare professionals, specialists, clinicians and mid-level workers. 130
The draft policy recommends that a quality improvement plan covering hospitals, clinics, ambulance
services and primary healthcare facilities in both the public and private sector be implemented. It also
suggests that individual institutions prepare human resources improvement plans and that those plans
should feed into the HWSETA’s sector skills plans. 131
124 Van der Berg, S., Burger, R., Theron, N. et al. 2010. Financial Implications of a National Health Insurance Plan for South
Africa; Harrison, D. 2009. An Overview of Health and Health care in South Africa 1994-2010: Priorities, Progress and Prospects
for New Gains. Published at www.doh.gov.za (Accessed February 2010).
125 ANC. 2009. National Health Insurance Policy Proposal. Published at http://www.healthe.org.za/documents/5b5e24462cdf6e214072c2e3f92ab1b9.pdf
(Accessed August 2010).
126 McIntyre, D. and Van den Heever, A. 2007. “Social or National Health Insurance” in South African Health Review 2007. Health
Systems Trust. Published at www.hst.org.za/uploads/files/chap5_07.pdf (Accessed August 2010).
127 Van Niekerk, J. P. de V. 2010. “National Health Insurance Exposed”. South African Medical Journal. January 2010. 100 (1).
Published at http://www.scielo.org.za/pdf/samj/V100n1. (Accessed August 2010).
128 National Treasury. 2010. “Vote 15: Health”. Estimates of National Expenditure 2010.
129 National Treasury. Budget Review 2010.
130 As a minimum, it takes 14 years to train a medical specialist, 8 to 9 years to train a medical doctor, 6 years to train a dentist,
5 years to train a pharmacist, 5 years to train a professional nurse, and 5 years to train an occupational therapist, 4 years to
train a clinical (medical) assistant. The periods include one year of community service required before the practitioners acquire
full registration status at their respective professional councils.
131 ANC. 2009. National Health Insurance Policy Proposal. Published at http://www.healthe.org.za/documents/5b5e24462cdf6e214072c2e3f92ab1b9.pdf
(Accessed August 2010).
37

Recent research has projected an increase in demand for service and a concomitant increase in human
resources required to meet the demand. The scheme will extend access to private care free of charge
and will increase demand for services of GPs and specialists. 132 More patients will be attracted to
medical practitioners and hospitals in the private sector and away from public clinics and public
hospitals. 133
It has been mooted that norms and standards for care will be set to enhance quality of service and care
in the public sector. Further, packages of care containing standard lists of services to be delivered at
each level of care will be designed. Implementation of these policies may have an impact on the present
skills base, in that there may be gaps or shortages of skills to meet the standards to be introduced.
Training and skills development interventions will be required to deal with such skills gaps and
shortages.
In the NHI system itself, considerable managerial, financial and information technology management
skills will be required to monitor usage and benefits offered, the distribution of resources, and the costs
of the scheme. 134
3.10.4 HIV AND AIDS POLICIES
By 2010 the number of hospital or clinic visits associated with HIV and AIDS approached 30 million per
annum. 135 An estimated 740 000 patients were on anti-retroviral treatment (ART) by 2009.
In April 2010 government announced the accelerated implementation of HIV testing and ART
programmes to include more people on treatment. President Zuma announced that 15 million South
Africans will be HIV tested by June 2011 and be granted access to AIDS medication if they require it.
Estimates are that 2 million people may require ART within the next few years. 136 Clearly, additional
human resources will be required if the ART population is to increase almost three-fold. Health
economists predict that more than 25% of current public health resources will be required for ART over
the next 10 years, and by 2020 the resource needs will be 40% of resources currently available. 137
It is reported that the DoH plans to equip more than 4300 sites to administer the treatment (or almost
four times the number of police stations in South Africa) and to train 4800 nurses and lay counsellors to
initiate and manage the AIDS treatment. 138 The scale of the programme will require the appointment of
more administrative support staff (to order, collect and distribute drugs) and more skilled health
managers to implement and oversee operations.
132 Van der Berg, S., Burger, R., Theron, N. et al. 2010. Econex. Financial Implications of a National Health Insurance Plan for
South Africa.
133 Van der Berg, S., Burger, R., Theron, N. et al. 2010. Econex. Financial Implications of a National Health Insurance Plan for
South Africa.
134 Macheke, C. 2010. HWSETA Health Sector Baseline Study.
135 National Treasury. Budget Review 2010.
136 Steinberg, J. “The state wants our blood, to stop the three-letter plague”. Sunday Times 2 May 2010, p. 9.
137 HEU Information Sheet 1. 2009. “Public sector health care spending in South Africa”. Health Economics Unit, University of
Cape Town. Published at http://www.heu-uct.org.za (Accessed August 2010).
138 Steinberg, J. “The state wants our blood, to stop the three-letter plague”. Sunday Times 2 May 2010, p. 9.
38

3.10.5 STRATEGY TO FIGHT TUBERCULOSIS
According to the DBSA, approximately 74% of TB cases are not managed appropriately – 44% of cases
treated are not cured and 30% of cases are not reported. Poor case management in the district health
system is contributing to increases in incidence of TB and multi-drug resistant TB (MDR-TB) and
extensively drug resistant TB (XDR-TB). 139 In response, the government declared TB a national
emergency and adopted the Tuberculosis Strategic Plan for South Africa 2007-2011 to expand control
efforts, enhance access to treatment services, and improve the cure rate. The strategy requires earlier
detection, increased surveillance for MDR-TB, active case management, as well as monitoring of
treatment completion. 140 Improved infection control in hospitals and clinics will also be required to
prevent further outbreaks. 141 Clearly, skills will be required at primary and secondary level, including
doctors, nurses, pharmacists, mid-level healthcare workers, infection control officers, etc.
3.10.6 MATERNAL AND CHILD HEALTH
Mortality rates for mothers and babies have increased since the baselines for the Millennium
Development Goals (MDGs) were set. Many preventable maternal and neo-natal deaths have been
attributed to failures in the health system, such as lack of staff, inadequate skills and weak health
management systems. 142 There is a need to expand care coverage, improve obstetric and neo-natal care
and prevent mother-to-child transmission of HIV and AIDS. The DoH set a target to increase the
percentage of mothers and babies who receive post-natal care within six days of delivery from 20% in
2010 to 80% by 2013. 143 To achieve this, the quality and productivity of existing skills must be improved
and the skills base should be expanded, especially in the public sector. 144 Vaccination programmes will
also be stepped up to improve immunisation coverage and more emphasis will be placed on nutrition. 145
139 Development Bank of South Africa. 2008. A Roadmap for the Reform of the South African Health System.
140 Karim, S. S. A., Churchyard, G. J., Karim, Q. A. et al. 2009. “HIV infection and tuberculosis in South Africa: an urgent need to
escalate the public health response”. Lancet. September 2009. Vol. 374. Published at http://thelancet.com. (Accessed August
2010).
141 Harrison, D. 2009. An Overview of Health and Health care in South Africa 1994-2010: Priorities, Progress and Prospects for
New Gains. Published at www.doh.gov.za (Accessed February 2010).
142 Chopra, M., Daviaud, E., Pattinson, R. et al. 2009. “Saving the lives of South Africa’s mothers, babies, and children: can the
health system deliver?” Lancet. September 2009. Vol. 374. Published at http://thelancet.com. (Accessed August 2010);
Harrison, D. 2009. An Overview of Health and Health care in South Africa 1994-2010: Priorities, Progress and Prospects for New
Gains. Published at www.doh.gov.za (Accessed February 2010).
143 Portfolio Committee on Health. 2010. “Health plans major increase in vaccination and HIV work”. Published at
http://sabinetlaw.co.za/health/articles (Accessed August 2010)
144 Chopra, M., Daviaud, E., Pattinson, R. et al. 2009. “Saving the lives of South Africa’s mothers, babies, and children: can the
health system deliver?” Lancet. September 2009. Vol. 374. Published at http://thelancet.com. (Accessed August 2010).
145 National Treasury. 2010. “Vote 15: Health”. Estimates of National Expenditure 2010.
39

3.11 EMPLOYMENT EQUITY AND BEE
The Health Charter of 2006 was developed by the private and public health sectors to promote access,
equity and quality in health services, and to foster black economic empowerment (BEE). Among the core
strategies are to: 146
Enhance access by involving private sector professionals, especially doctors to provide primary
and clinical care in the public sector;
Create more equity by: developing a basic package of care available to all patients, irrespective of
their ability to pay; improving the profile of the health workforce to represent the population
demographic (with the aim that 60% be black and 50% be women by 2010); and adopting ethical
recruitment practices for health professionals;
Improve quality by training healthcare personnel on patients’ rights and dignity, by implementing
quality assurance programmes and learning from complaints of users of health services; and
Advance BEE through increased levels of black ownership of companies (35% by 2010 and 51% by
2014) and preferential procurement from black firms (60% by 2010 and 80% by 2014).
Observers noted that targets in the Health Charter resulted in a number of black empowerment deals
with the three major hospital groups and a number of smaller ones. While those deals met the BEE
objectives of the Health Charter, they failed to address the other objectives of access, equity and quality
in health service provision. 147
3.12 VETERINARY SERVICES 148
Veterinary professionals play a critical role in the treatment of diseases, parasites and pests in animals
that pose risks to economic growth, food security, public safety and human health. The traditional
veterinary profession has expanded to include a range of para-professionals such as animal health
technicians and veterinary nurses. The majority of the 2700 registered veterinarians work in the private
sector, with only approximately 200 employed in the public sector. 149 A particular challenge for
government is to enable emerging black and subsistence farmers to access veterinary services.
146 McIntyre, D., Thiede, M., Nkosi, M., et al. 2007. SHIELD work package 1 report: A critical analysis of the current South African
health system. Health Economics Unit, University of Cape Town. Published at
http://www.web.uct.ac.za/depts/heu/SHIELD/reports/SouthAfrica1.pdf. (Accessed August 2010); Macheke, C. 2010. HWSETA
Health Sector Baseline Study; Harrison, D. 2009. An Overview of Health and Health care in South Africa 1994-2010: Priorities,
Progress and Prospects for New Gains. Published at www.doh.gov.za (Accessed February 2010).
147 Harrison, D. 2009. An Overview of Health and Health care in South Africa 1994-2010: Priorities, Progress and Prospects for
New Gains. Published at www.doh.gov.za (Accessed February 2010).
148 At the time of writing accurate figures for veterinary practitioners were being compiled and will be included in the next
version of the documents.
149 Paterson, A. 2008. “Veterinary Skills”. In Kraak, A. and Press, K. Human Resources Development Review 2008: Education,
Employment and Skills in South Africa.
40

Veterinary skills are in demand globally and international migration is common. 150 In South Africa skills
shortages are experienced in the public sector where the vacancy rate for veterinarians at national,
provincial and laboratory level remains high. The need for veterinary services at local government level
is not known with accuracy as there is still debate about whether the responsibility for veterinary
services resides with provincial or local governments. 151 There are increasing calls to make veterinary
services more accessible to low-income communities at local government level, as they may not have
the means to afford private veterinary treatment for vaccination, sterilisation, advice and disease
control. 152
Government’s commitments to veterinary services are directed at measures to provide food safety,
public health and community animal services. Such services are often rendered by para-professionals
such as veterinary nurses and technicians rather than by veterinarians. More recently the job of primary
animal healthcare worker was introduced to support government’s veterinary service programme. 153
The Department of Agriculture (DoA) adopted the Primary Animal Health Care Policy in South Africa in
2000 to broaden access to veterinary services in rural communities in a cost-effective manner and to
improve the health status and production of animals. Implementation is proving to be challenging
because the limited veterinarian resources in government are mostly located in urban centres. The DoA
may possibly consider the introduction of community animal health workers (CAHWs) once the animal
healthcare needs of the peri-urban and rural poor communities have been assessed. 154 According to the
SAVC, there is a great need for CAHWs to increase awareness for animal rights, welfare and protection
in impoverished communities where people focus on their own basic survival needs.
A number of strategies have been mooted in order to improve access to veterinary services and alleviate
skills shortages in rural areas. Firstly, the DoA may introduce a “zoning” policy when licensing
veterinarians so that they are compelled to establish practices in under-serviced areas. Secondly,
community service for veterinarians in the state veterinary service may be introduced. Thirdly, the state
could enter into contracts with rural-based veterinarians in private practice to provide public animal
healthcare services.
3.13 CONCLUSION
Demand for healthcare services, particularly in the public sector continues to grow in the midst of a
growing burden of disease and enduring shortages of health professionals. The scope, complexity and
diversity of the disease burden presents mounting challenges for service delivery and the health
workforce. Healthcare financing in the public and private sectors remains disproportionate to the
150 Paterson, A. 2008. “Veterinary Skills”. Human Resources Development Review 2008: Education, Employment and Skills in
South Africa
151 Paterson, A. 2008. “Veterinary Skills”. In Kraak, A. and Press, K. Human Resources Development Review 2008: Education,
Employment and Skills in South Africa.
152 Paterson, A. 2008. “Veterinary Skills”. In Kraak, A. and Press, K. Human Resources Development Review 2008: Education,
Employment and Skills in South Africa.
153 Paterson, A. 2008. “Veterinary Skills”. In Kraak, A. and Press, K. Human Resources Development Review 2008: Education,
Employment and Skills in South Africa.
154 Paterson, A. 2008. “Veterinary Skills”. In Kraak, A. and Press, K. Human Resources Development Review 2008: Education,
Employment and Skills in South Africa.
41

number of users served and this affects the existing skills base. Poor health outcomes, however, can be
linked to inefficiencies in the health system, and not only to resource constraints or skills shortages.
Multiple socio-economic factors impact the availability and distribution of health workers. Attrition and
a growing population have reduced the patient/health worker ratios in the public sector. Institutional
problems and failures in management of the health system also have an impact on the availability and
effectiveness of skills. In order to maintain reasonable patient/health worker ratios and to provide
acceptable levels of service, the health sector will have to replace skills lost due to attrition. In addition,
more skilled health workers are required to meet the demands of the growing population and the
disease burden.
Several healthcare policies currently under development and in the process of implementation will
increase the demand for a wide range of skills, including those of primary healthcare and community
workers, infection control officers, clinical associates, professional nurses, staff nurses, pharmacists,
post-basic pharmacist assistants, medical practitioners and medical specialists. At the same time the
sector requires management skills at strategic and operational levels to enhance quality, performance
and accountability, as well as financial and resource management within the health system. As much as
there is a need for more professional skills, there is also a need for leadership and management skills to
improve efficiencies in the health system.
Veterinary professionals are required for animal health and public health services in the public sector.
More calls to enable affordable access to veterinary services are driving the demand for para-veterinary
and primary animal healthcare skills.
In a resource-constrained environment with enormous demands for healthcare, the country needs to
develop skills to deliver cost-effective healthcare. Government policies are changing the way healthcare
is accessed and delivered. Increasingly, government is looking at primary and community-based
healthcare to treat the ill and maintain the health of the healthy. The needs and service expectations of
the primary healthcare system are expanding rapidly and will necessitate changes to the composition
and skills base of the system’s workforce.
42

4 THE DEMAND FOR SKILLS
4.1 INTRODUCTION
The health sector is a personal services industry and such services are both resource- and timeintensive.
Effective healthcare services can only be rendered if the sector has adequately skilled human
resources with the appropriate skills content. As the demand for health services increases, so too does
the demand for human resources in the sector.
In a resource-constrained environment with enormous demands for healthcare, the country needs to
develop skills to deliver services cost-effectively. Adjustments are being made to the way health
services are delivered with the introduction of mid-level workers, mooted changes to the scope of
practice of many health professionals, and a growing focus on community-based healthcare to treat the
ill and maintain the health of the healthy. These developments will impact directly on the quantitative
demand for people in specific occupations and professions and on the skills required of them.
This chapter looks at the demand for skills in the health sector from different perspectives. It starts with
an analysis of the current positions available in the sector – those that are filled as well as vacancies. It
then looks at the skills shortages that are currently experienced in the sector. The chapter also looks at
changes in the skills required of workers in the sector and the factors that influence the demand for
skills.
4.2 CURRENT EMPLOYMENT
4.2.1 POSITIONS IN THE PUBLIC SERVICE
As indicated in Section in 2010 there were approximately 281 000 filled positions in the Public Service
Health Departments. At the time the total number of funded vacancies was not known, and the total
number of positions available in the Public Service could not be calculated. However, the scarce skills
information obtained through the Public Service Departments’ WSPs indicate that vacancy rates are
quite high and that the Public Service total establishment is considerably larger than what is reflected in
the current employment figures.
Whether the total number of positions is enough to service the growing population is a topic that has
been debated by various analysts in recent years. In 2008 the DBSA facilitated a process in which major
health sector role-players, analysts, health economists and other experts formed working groups to
assess the health system and to map out guidance for its reform. This Roadmap for the Reform of the
South African Health System also considered human resources and skills needs. 155
According to the Roadmap process, staff headcount in the public sector declined from around 251 000
to around 215 000 from 1997/98 onwards and only regained the previous level by 2007/08; i.e. 11 years
155 Development Bank of South Africa. 2008. A Roadmap for the Reform of the South African Health System.
43

later. No increases in health professionals and workers occurred, despite the growing population
requiring public health services and the increasing burden of disease mainly due to HIV and AIDS. Had
staff levels been adjusted to allow for population growth, another 64 087 posts (or a staff complement
of 315 087) were required by 2008. If further allowance were made for the disease burden, the total
public sector staff complement had to be 330 791 in 2008 just to retain the status quo of 1997/98. The
shortfall was 79 791 posts.
4.2.2 POSITIONS IN THE PRIVATE SECTOR 156
The total number of posts in the private sector was estimated by adding the vacancies reported in the
WSPs submitted to the HWSETA in June 2010 to the estimates of total employment in each occupation
(see Chapter 2).
The total number of positions in the private sector can be seen in Table 4-1. The way in which the
estimates of total employment were derived is described in Section 2.5. The total number of filled
positions is 178 921. The vacancies that were added to this are those reported by employers in their
WSP submissions of 2010. If these are added, there are at least 183 102 positions in the private sector.
Of these, 46.6% are for professionals, 22.0% for community and personal service workers and 16.9% for
clerical and administrative staff. As mentioned in Chapter 2, these are very conservative estimates of
employment and the actual number of positions available is expected to be slightly higher.
Table 4-1 Total number of positions in the private health organisations
Employed Vacancies Total positions
OFO Group
N N N %
Managers 6 571 66 6 637 3.6
Professionals 83 276 2 058 85 334 46.6
Technicians and Trades Workers 7 921 225 8 146 4.4
Community and Personal Service Workers 38 519 1 786 40 305 22.0
Clerical and Administrative Workers 30 915 15 30 930 16.9
Sales Workers 2 780 24 2 804 1.5
Machinery Operators and Drivers 2 209 6 2 215 1.2
Elementary Workers 6 730 1 6 731 3.7
Total 178 921 4 181 183 102 100.0
Source: Calculated from the HWSETA WSPs for 2010 and the MEDpages database.
Table 4-2 provides more information on the professional positions in the private sector organisations.
The largest group is nursing professionals (37.4% of all positions). This is followed by medical
practitioners (18.2%) and Health Diagnostic and Promotion Professionals (16.7%). The latter group
includes professions such as pharmacists, optometrists and dieticians.
156 Private sector includes parastatal and other public sector organisations outside the Public Service.
44

Table 4-2 Total professional positions in the private health organisations
Employment
Vacancies
Total positions
OFO Description
N N N %
Arts Professionals 14 0 14 0.0
Media Professionals 28 1 29 0.0
Accountants, Auditors and Company Secretaries 379 5 384 0.4
Financial Brokers and Dealers, and Investment Advisors 4 0 4 0.0
Human Resource and Training Professionals 1 067 14 1 081 1.3
Information and Organisation Professionals 296 4 300 0.4
Sales, Marketing and Communication Management
Professionals 1 493 16 1 509 1.8
Architects, Designers, Planners and Surveyors 16 0 16 0.0
Engineers and Engineering Technologists 502 6 508 0.6
Natural and Physical Science Professionals 2 446 82 2 528 3.0
School Teachers / Educators 88 0 88 0.1
Miscellaneous Education and Training Professionals 9 0 9 0.0
Health Diagnostic and Promotion Professionals 13 777 468 14 245 16.7
Health Therapy Professionals 11 192 8 11 200 13.1
Medical Practitioners 15 463 102 15 565 18.2
Midwifery and Nursing Professionals 30 663 1 288 31 951 37.4
Business and Systems Analysts and Programmers 161 5 166 0.2
Database and Systems Administrators, and ICT Security
Specialists 245 1 246 0.3
ICT Network and Support Professionals 171 3 174 0.2
Legal Professionals 16 0 16 0.0
Social and Welfare Professionals 5 246 55 5 301 6.2
Total 83 276 2 058 85 334 100
Source: Calculated from the HWSETA WSPs for 2010 and the MEDpages database.
At this stage there is no information available on trends in employment in the private health sector.
4.3 CURRENT SHORTAGES
4.3.1 VACANCY RATES
Shortages of staff are, in the first instance, reflected in vacancy rates. The overall vacancy rates in
certain key occupations in the National Department of Health and in the nine provincial departments
are shown in Table 4-3. The vacancy rates are, most instances, disturbing – 49% for medical
practitioners, 44% for medical specialists and 46% for professional nurses. Although some posts appear
as vacant posts on PERSAL the posts are unfunded for various reasons and the departments are not
45

actively recruiting to fill all these posts. Thus the information on vacant posts on PERSAL must be used
with caution as it does not reflect the true state of vacant posts in the public sector. .
Table 4-3 Vacancy rates in the National and provincial health departments in selected occupation: 31
March 2010
Occupation Vacant Filled Total Vacancy Rate (%)
Dental practitioners 921 770 1 691 54
Dental specialists 155 121 276 56
Medical practitioners 10 860 11 302 22 162 49
Medical specialists 3 491 4 436 7 927 44
Professional nurses 44 780 51 964 96 744 46
Staff and pupil nurses 16 202 24 315 40 517 40
Student nurses 2 458 10 906 13 364 18
Pharmacists 3 745 2 958 6 703 56
Physiotherapists 1 074 1 009 2 083 52
Occupational therapists 1 260 838 2 098 60
Radiographists 1 621 2 300 3 921 41
Psychologists 699 498 1 197 58
Source: PERSAL.
Skills shortages or scarce skills are also monitored by the SETAs in the WSPs submitted to them on an
annual basis. For the purposes of this SSP the WSPs submitted to the HWSETA and those submitted by
the health departments to the PSETA were combined to provide an overview of the shortages
experienced in the health sector. However, the two SETAs didn’t formulate their questions identically,
and, therefore, the figures are not directly comparable. Table 4-4 combines the information for the
private sector and the Public Service. In this table only occupations in which more than 75 vacancies
existed are reported. The occupations are grouped together in professional fields such as nursing and
pharmacy. A more detailed list of scarce skills according to the OFO is attached in Appendix A.
In 2010, 33% of the organisations that submitted WSPs to the HWSETA reported difficulties in filling
certain vacancies, while the national DoH as well as most of the provincial departments 157 reported skill
shortages. In the private health sector, a total of 4 184 vacancies (3% of total employment) were
difficult to fill and in the public health sector 26 441 people (13% of total employment) were required to
meet scarce skills needs. A third of the vacancies that were difficult to fill in private health organisations
were vacancies for professional positions, while 47% of the scarce skills reported in the Public Service
were for professionals such as medical specialists and practitioners, registered nurses and pharmacists
(Table 4-4). The public health sector indicated severe shortages of financial managers and managers in
information technology, while a need for more health-related professionals such as dieticians and
physiotherapists also existed.
157 Scarce skills information could not be obtained from the Mpumalanga department of health
46

Organisations are also required to explain why they found it difficult to fill the positions that they
identified as scarce skills. Organisations in private sector organisations mentioned reasons such as
general shortages of health-related professional skills e.g. registered nurses and pharmacists, a wideranging
lack of qualified and experienced black people with the requisite skills, people’s unwillingness to
work in rural areas, and the difficult working hours (nights and weekends).
In public health, shortages were mostly related to growth in demand, difficulties to retain or replace
qualified staff, geographic location, new technology (which require staff specifically trained to operate
and maintain equipment), and migration of employees.
Table 4-4 Scarce skills in private and public health according to occupational category
Field
Managers
Medicine
Dental
Nursing
Pharmacy
Other
health
related
professions
Health
support
Occupational category
Number
of
vacancies
Private sector*
% of total
employment
in category
Number
of
people
needed
Public Service**
% of total
employment
in category
Financial managers 3 1 256 >100
ICT / IT Managers 300 >100
Medical Specialists 68 12 2 795 >100
Medical Practitioners 34 8 2 444 85
Medical Science
Technician/technologists 124 2 321 >100
Dental Specialists 285 >100
Dental Practitioners 1 3 599 >100
Dental Technician 12 18
Registered Nurses 1 273 7 12 542 44
Enrolled Nurses 1 372 9 327 1
Nursing Assistants 14 0 180 2
Nursing Educators and
Researchers 8 1 86 10
Pharmacists 423 10 1 587 71
Retail Dispensary / Pharmacy
Assistants 22 1 503 >100
Pharmacist Technicians 120 12
Dieticians 687 >100
Environmental Health Officers 240 >100
Occupational Therapists 6 5 343 >100
Physiotherapists 1 1 777 >100
Radiographers 26 1 326 24
Speech / Hearing Therapists 320 >100
Psychologists 2 0 91 35
Social and Welfare Professional 53 10 157 12
Ambulance Officers and
Paramedics 75 4 767 15
47

Field
Occupational category
Number
of
vacancies
Private sector*
% of total
employment
in category
Community Development/Social
Services Support workers 284 12
Number
of
people
needed
Public Service**
% of total
employment
in category
Source: *HWSETA, WSPs, 2010. **PSETA, WSPs, 2010.
4.3.2 BENCHMARKING AND COMPARISONS
Another way of looking at skills shortages in the health sector is to compare employment figures with
international benchmarks. Health economists applied the ratios used in the DBSA Roadmap report to
calculate how many medical officers (GPs), nurses and medical specialists the public sector hospitals
would require in 2009/10 to function according to international benchmarks. The results given in Table
4-5 below show that public hospitals require an extra 5 352 GPs and 150 591 nurses in 2010. 158 These
calculations do not take into account any additional staff that would be required to implement an NHI
system.
Table 4-5 Public sector staff needs to meet international in-hospital benchmarks
Staff actual (per
Econex
calculations)
International
benchmark
(hospital)
Employed in
public hospital
Difference
Medical officer (GP) 8 027 6 075 11 427 5 352
Nurse 104 000 63 035 213 626 150 591
Medical specialist 4 026 4 202 3 846 n.a.
Source: Econex. Van der Berg, S.; Burger, R.; Theron, N. et al. 2010. Financial Implications of a National Health Insurance Plan
for South Africa.
The WHO stated that countries with fewer than 230 doctors, nurses and midwives per 100 000
population generally fail to achieve adequate coverage rates of care to attain the health-related
Millennium Development Goals (MDGs). Those goals relate to reducing child mortality, improving
maternal health and combating HIV and AIDS and other diseases. 159 If South Africa’s situation in the
Public Service is compared to this benchmark, we fall short: In 2008 we had only 209 doctors and
professional and staff nurses per 100 000 of the population who depend on public services. 160
158 Van der Berg, S., Burger, R., Theron, N. et al. 2010. Financial Implications of a National Health Insurance Plan for South
Africa.
159 World Health Organisation. 2006. The World Health Report 2006 - working together for health. Published at
http://www.who.int/whr/2006/06_chap1_en.pdf (Accessed August 2010).
160 Calculated from Day, C. and Gray, A. 2008. “Health and Related Indicators”. South African Health Review 2008. Health
Systems Trust. Published at http://www.hst.org.za/uploads/files/chap16_08.pdf. (Accessed August 2010).
48

4.4 FUTURE DEMAND
4.4.1 SKILLS DEVELOPMENT TARGETS SET BY THE NATIONAL DEPARTMENT OF HEALTH
In 2006, as part of a document entitled Human Resources for Health: A Strategic Plan, the national DoH
set targets for the production of human resources by health sciences education and training institutions
to primarily address public sector needs. At the time those targets were developed with reference to
public sector vacancies, outputs at education institutions and the potential for increased outputs,
estimated replacement needs and limited financial resources. The DoH acknowledged that the targets
should have been influenced by actual healthcare needs identified in provincial health service plans,
rather than by the affordability of services in a resource-constrained environment. 161 Further studies
were required, especially on capacity at academic institutions to meet the proposed targets. One of the
targets the DoH set was to increase the number of medical practitioners that would qualify each year
from the approximately 1 200 per year to 2 400 per year. The production of professional nurses had to
increase from 1 900 to 3 000 per year and enrolled (staff) nurses had to increase from 5 000 to 8 000 per
year.
Experts warned in 2008 that South Africa has no system in place to ensure that the production of health
professionals occurs in relation to their need and that decisions on skills development for health are
made independently of national policy. 162 Others remarked that the above targets were set, without an
implementation plan to achieve them. 163 At the time of writing this SSP, the DoH was in the process of
revisiting its Strategic Plan.
4.5 FACTORS THAT IMPACT ON THE DEMAND FOR HEALTHCARE WORKERS
In Chapter 3 several changes and challenges were discussed that will have an impact on the number of
healthcare workers needed in the country, the occupational mix needed and the actual skills required of
people within specific occupations. The most important of these are summarised below:
4.5.1 HIV AND AIDS TREATMENT POLICIES
Expanding the access to ART will impact largely at the district level. Patients will have to be introduced
to ART, advised of the risks of non-compliance with the treatment regime, followed up for risks, and
monitored for side-effects. Since there are not enough doctors to do so, the bulk of the work is
expected to shift to nurses – a professional group already in short supply and under pressure in the
161 Department of Health. 2006. “Chapter 5: Priority Areas for Implementation”. Human Resources for Health: A Strategic Plan.
Published at http://www.doh.gov.za/docs/discuss/2006/hrh_plan/. (Accessed August 2010).
162 Development Bank of South Africa. 2008. A Roadmap for the Reform of the South African Health System.
163 Wolvaardt, G., Van Niftnik, J., Beira, B. et. Al. 2008. “The Role of Private and Other Non-Governmental Organisations in
Primary Health Care”. South African Health Review 2008. Health Systems Trust. Published at www.hst.org.za/publications/841.
(Accessed August 2010).
49

public sector. 164 This may necessitate the fast-tracking of changes to the legal and regulatory
frameworks governing the nursing profession, as nurses may be required to prescribe the ART drugs.
Because the delivery of ART is regarded as a complex health intervention, nurses will require additional
training in this area. Additional higher-level skills such as those of doctors and experienced primary
health care trained nurses will also be needed to support the front-line nurses and to accept referral of
more complex cases. 165 As more medication will be dispensed to patients requiring daily life-long care,
pharmacists may be under pressure and their ranks in the public sector may require strengthening
supported by additional pharmacist assistants.
Research has shown that expansion of ART will increase the number of patients who develop
complications from ART-drug toxicity, side-effects, opportunistic infections and syndromes of the
immune system. This will potentially increase the demand for medical and specialist care at secondary
level hospitals. 166
4.5.2 POLICIES TO CONTROL TUBERCULOSIS
Preventing the development of MDR-TB and XDR-TB requires a heightened response from nursing
professionals to detect signs of these diseases and from medical practitioners to correctly diagnose
patients at an earlier stage. 167 By implication, more appropriately trained and skilled professional nurses
and doctors are required at district level to ensure that more patients are screened sooner.
Health workers experience a high TB infection rate themselves, are six times more likely to develop
drug-resistant TB, and may inadvertently be spreading the disease. 168 To combat the risk of infection
the DoH has identified the need to train 3500 health professionals per annum in TB management
control. 169
In addition, more lower-level health workers such as nursing auxiliaries and community health workers
are needed to support and monitor patient adherence to treatment regimes and to increase treatment
completion rates. The development of mid-level environmental health practitioners such as infection
control officers who are needed to prevent the risks of infectious outbreaks in hospitals and clinics is
needed.
164 Colvin, C. J., Fairall, L., Lewin, S. et al. 2010. “Expanding access to ART in South Africa: the role of nurse initiated treatment”.
South African Medical Journal. April 2010. 100 (4). Published at http://www.scielo.org.za/pdf/samj/V100n4. (Accessed August
2009).
165 Colvin, C. J., Fairall, L., Lewin, S. et al. 2010. “Expanding access to ART in South Africa: the role of nurse initiated treatment”.
South African Medical Journal. April 2010. 100 (4). Published at http://www.scielo.org.za/pdf/samj/V100n4. (Accessed August
2009).
166 Kevany, S. Meintjes, G. Rebe et al. 2009. “Clinical and financial burdens of secondary level care in a public sector
antiretroviral roll-out setting (GF Jooste Hospital). South African Medical Journal. August 2009. 99 (8). Published at
http://www.scielo.org.za/pdf/samj/V99n5 (Accessed August 2009).
167 Harrison, D. 2009. An Overview of Health and Health care in South Africa 1994-2010: Priorities, Progress and Prospects for
New Gains. Published at www.doh.gov.za (Accessed February 2010).
168 Jordan, B. 2010. “Health workers besieged with drug-resistant TB”. Sunday Times, 12 September 2010. Published at
http://www.timeslive.co.za/sundaytimes/article653446.ece/Health-workers-besieged-by-drug-resistant-TB. (Accessed
September 2010).
169 Department of Health. 2010. National Department of Health Strategic Plan 2010/11-2012/13. Published at
http://www.doh.gov.za. (Accessed August 2010).
50

4.5.3 MATERNAL, CHILD AND WOMEN’S HEALTH PROGRAMMES
The national programme to improve the health of mothers, children and women (which is linked to
South Africa’s commitment to achieve its MDGs aims to avert maternal deaths, stillbirths and improve
infant mortality rates. This programme involves improvements to the coverage and quality of care of
mothers, babies and children in the antenatal-, post-natal- and early childhood development stages.
Specialised skills are needed. It is estimated that 2445 professional nurses, 250 enrolled nurses and 134
enrolled nursing assistants with training in midwifery, antenatal-, obstetric- and post-natal care will be
needed. 170
The aim to test 100% of pregnant women for HIV at hospitals, community clinics and PHC facilities 171 will
drive the demand for nurses and community health workers with counselling skills. Efforts to prevent,
improve the diagnosis, monitoring and management of birth defects require the skills of nurses and
medical practitioners trained in human genetics care. 172
More nursing skills are required at primary care level where immunisation and vaccination coverage of
babies, infants and young children will be increased. At that level more healthcare workers also require
skills in managing childhood illnesses, and many primary-level care facilities will require healthcare
providers trained in the integrated management of childhood illnesses. 173 Expansion of school health
services requires the skills of nurses to provide health education, impart life skills, screen children for
diseases, disabilities, immunisation status and other healthcare needs.
At the tertiary level of care, the demand for nursing skills in neo-natal care and intensive care is high. A
2008 study by the Critical Care Society of South Africa found that only 3.8% of nurses had neo-natal
intensive care training. 174
4.5.4 MANAGEMENT OF HEALTH OPERATIONS AND PEOPLE
In the public sector, and in the district health system in particular, leadership skills and professional
management skills are required for managing complex systems and improving operational efficiency. 175
Skills in the planning and implementation of programmes, as well as the monitoring and evaluation of
service and quality of care, are required to strengthen management of health operations. On the
people side, skills are needed in the management of human resources and their performance. More
170 Chopra, M., Daviaud, E., Pattinson, R. et al. 2009. “Saving the lives of South Africa’s mothers, babies, and children: can the
health system deliver?” Lancet. September 2009. Vol. 374. Published at http://thelancet.com. (Accessed August 2010);
Department of Health. 2010. National Department of Health Strategic Plan 2010/11-2012/13. Published at
http://www.doh.gov.za. (Accessed August 2010).
171 Department of Health. 2010. National Department of Health Strategic Plan 2010/11-2012/13. Published at
http://www.doh.gov.za. (Accessed August 2010).
172 Department of Health. 2010. National Department of Health Strategic Plan 2010/11-2012/13. Published at
http://www.doh.gov.za. (Accessed August 2010).
173 Department of Health. 2010. National Department of Health Strategic Plan 2010/11-2012/13. Published at
http://www.doh.gov.za. (Accessed August 2010).
174 Bateman, C. 2009. “Legislating for nurse/patient ratios ‘clumsy and costly’ – experts”. South African Medical Journal. August
2009. 99 (8). Published at http://www.scielo.org.za/pdf/samj/V99n8. (Accessed August 2009).
175 Coovadia, H., Jewkes, R., Barron, P. et al. 2009. “The health and health system of South Africa: historical roots of current
public health challenges”. Lancet. September 2009. Vol. 374. Published at http://thelancet.com. (Accessed August 2010).
51

particularly, managers require skills to lead and guide subordinates, improve their productivity and instil
accountability for service to patients. Other areas for managerial development include planning and
time utilisation, financial and capital resources management. 176
4.5.5 EXPANSION OF THE PUBLIC HEALTH INFRASTRUCTURE
It is anticipated that health information systems in the public sector will be upgraded in the next five
years to support decision-making, budgeting, monitoring and evaluation of performance. 177 Major
training interventions may be required to facilitate effective application and use of such new systems, as
well as the tools to extract and analyse data. The current public hospital revitalisation programme will
increase the number of usable beds, leading to an increase in demand for health professionals such as
doctors and nurses, as well as support staff.
4.5.6 SKILLS REQUIREMENTS FOR THE NHI
The introduction of a NHI offering coverage with no co-payments to the whole population (as proposed)
will impact on the demand for healthcare services and personnel. Demand for service will be driven by
an increased rate of utilisation of healthcare (as there will be no co-payments) and greater demand for
higher levels of care. A 2010 study by Econex, shows that, based on the assumptions used in the study,
a larger proportion of the population will use higher levels of medical care offered by general
practitioners and medical specialists, away from nurse-led primary care. 178 Therefore, more general
practitioners and medical specialists will be required to meet the increased demand for service. It is
projected that South Africa will require between 5 800 to 10 000 more GPs and another 7 000 to 17 000
medical specialists to serve healthcare demand under the NHI. On the other hand, the demand for
nurses is expected to drop as the public will move away from public clinics and choose a higher level of
care. 179 The study concluded that rationing of healthcare services under the NHI would be required in
view of the scarcity of resources.
As mentioned in Section 3.10.3 there is currently no clarity of the exact structure and provisions of the
proposed NHI or the structure of the health system that will deliver the NHI. It is therefore not yet
possible to project with certainty the numbers of professionals that will be needed for the
implementation of the system. It is, however, an area that needs to be closely monitored and
incorporated in future updates of the SSP.
176 Harrison, D. 2009. An Overview of Health and Health care in South Africa 1994-2010: Priorities, Progress and Prospects for
New Gains. Published at www.doh.gov.za (Accessed February 2010); Chopra, M., Lawn, J.E., Sanders, D. et al. 2009. “Achieving
the health Millennium Development Goals for South Africa: challenges and priorities”. Lancet. September 2009. Vol. 374.
Published at http://thelancet.com. (Accessed August 2010).
177 National Treasury. 2009. “Health”. In Provincial Budgets and Expenditure Review 2005/06 – 2011/12. Pretoria: National
Treasury.
178 Van der Berg, S., Burger, R., Theron, N. et al. 2010. Financial Implications of a National Health Insurance Plan for South
Africa.
179 Van der Berg, S., Burger, R., Theron, N. et al. 2010. Financial Implications of a National Health Insurance Plan for South
Africa.
52

4.6 CONCLUSIONS
The growing demand for healthcare and the introduction of changes in the way health services are
delivered to the public, drive the demand for skills. The information reported in this chapter confirms
that the demand for skills in the health sector continues to outstrip supply.
In 2010 there were approximately 281 000 filled positions in the Public Service Health Departments. At
the time the total number of funded vacancies was not known, and the total number of positions
available in the Public Service could not be calculated. However, the scarce skills information obtained
through the Public Service Departments’ WSPs indicate that vacancy rates are quite high and that the
Public Service total establishment is considerably larger than what is reflected in the current
employment figures. The number of filled posts is only slightly higher than to those of 1997/98 and did
not increase to allow for population growth or the impact of AIDS. Calculations by health economists
using the 1997/98 staffing levels as baseline showed that the public sector required a staff complement
of 315 087 by 2008, just to keep up with population growth and the expanding disease burden. Clearly,
current post levels are inadequate to meet the demand for healthcare services.
A conservative estimate for the number of employees in the private sector was 178 921 during June
2010. The vacancy rate in the private sector is estimated at 2.3%.
By contrast, the public sector experiences high vacancy rates and although estimates from PERSAL are
not entirely accurate it does imply that there are significant staff shortages. In both the public and
private sectors vacancies in professional positions for doctors, medical specialists, professional nurses
and pharmacists are the most difficult to fill. Other scarce and critical skills needs in the public sector
are for managers in finance and information technology, and in the healthcare fields of dietetics and
physiotherapy. In public health, shortages are mostly related to growth in demand, difficulties to retain
or replace qualified staff, geographic location, new technology and migration of employees.
Skills development targets for the health sector set by the DoH in 2006 indicate the scope of demand for
skills, but fail to acknowledge supply-side constraints to a sufficient degree. Some of these constraints
are considered in the next chapter.
The rollout of key public health programmes to fight HIV and AIDS and TB and to improve the health of
mothers, children and women needs to be supported by both developing the clinical skills of existing
health workers and the employment of more doctors, medical specialists and nurses. More lower-level
workers and community health workers are needed to support and monitor adherence to treatment
regimes. Skills interventions should also target nurses involved in integrated management of childhood
illnesses and health monitoring programmes for children.
Specialised training on a large-scale is required in TB management and infection control, and staff nurses
need targeted training in midwifery and antenatal-, obstetric- and post-natal care. Extensive, intensive
and purposive skills development is required to address the considerable gaps in the management of
public health operations, its employees and technology, as well as its capital and financial resources.
53

Lastly, the introduction of an NHI system will drive demand for higher levels of care offered by doctors
and medical specialists and is expected to turn utilisation of health services away from nurse-based
primary care.
54

5 THE SUPPLY OF SKILLS
5.1 INTRODUCTION
The previous chapters clearly indicated that the health sector (and specifically the public health sector)
is in a critical state as a result of skills shortages. Clearly, the demand for skills by far exceeds the supply
of them. In this chapter the supply-side of the labour market is considered. The different elements of
supply are described, supply figures are presented (in as far as they are available), and the supply-side
constraints that contribute to the current shortages are highlighted.
The chapter starts with a discussion of the institutional arrangements and capacity for skills
development. This is followed by professional registration and graduation trends. The role that the
HWSETA plays in skills development is then discussed. The chapter concludes with a discussion of some
of the most important factors that impact on the supply of skills – both positively and negatively.
5.2 THE SOUTH AFRICAN SECONDARY SCHOOL SYSTEM
The results of the Senior Certificate examination are key factors in determining the supply of skills for
the health sector. Grade 12 mathematics is an entry requirement for most of the tertiary-level study
programmes providing access to the sector. In addition, most of the tertiary institutions require
prospective health sciences students to have studied either Grade 12 physical sciences or Grade 12 life
sciences (previously referred to as “biology”).
In 2008, a total of 554 664 learners sat the Senior Certificate examination. Of the full-time candidates
with seven 180 or more subjects, 37.8% failed. However, irrespective of subject choice, only 19.1%
(106 047) qualified for university entry. Just more than 300 000 candidates wrote Grade 12
mathematics, and only 89 186 candidates achieved 40% and above. Notably fewer candidates wrote
Grade 12 physical sciences and only 61480 achieved 40% and above in the subject. A total of 117 483
passed life sciences; i.e. 39.4% of the candidates who wrote this subject (Table 5-1).
180 The National Senior Certificate (NSC) examination of 2008 was the first that was based on the New Curriculum Statement
(NCS), which requires all learners in Grades 10 to 12 to take seven subjects. Two of these subjects must be South African
languages, one of which must be the language of teaching and learning. In addition to two languages, all learners must offer
Life Orientation and either Mathematics or Mathematical Literacy. In addition to these four compulsory subjects, learners must
choose three subjects from a list of approved subjects. http://www.education.gov.za/emis/emisweb/statistics.htm. (Accessed
August 2010).
55

Table 5-1 Grade 12 statistics – mathematics, physical sciences and life sciences: 2008
Number of matriculants who -
N
2008
% of those who
wrote
Wrote Grade 12 554 664
Wrote mathematics 300 008
Achieved 40% and above in mathematics 89186 29.7
Wrote physical sciences 217300
Achieved 40% and above in physical sciences 61480 28.3
Wrote life sciences 298210
Achieved 40% and above in life sciences 117483 39.4
Source: Department of Basic Education.
The National Senior Certificate (NSC) examination of 2008 was the first that was based on the New
Curriculum Statement (NCS), with no distinction being made between higher grade and standard grade
subjects. The NSC has been criticised for its standard of education, especially in the sphere of
mathematics, where mathematical literacy is offered as an alternative to mathematics. Learner
participation is no longer accessed at higher and standard grade, and thus the old and new curricula are
not comparable. The HWSETA baseline study found that this situation has raised concerns over the
standard of mathematics taught in schools.
Table 5-2 shows that the total number of Grade 12 candidates who passed mathematics increased from
99 366 in 1999 to 149 228 in 2007, an average annual growth rate of 5.2%.When the number of passes
in mathematics in 2008 is compared with that of previous years (Table 5-2), the number of candidates
who passed matric with mathematics decreased. In 2007, for example, a total of 149 228 candidates
passed mathematics on the higher grade and standard grade; while in 2008 only 89 186 candidates
passed Grade 12 mathematics.
Table 5-2 Grade 12 statistics – mathematics: 1999-2007
1999 2000 2001 2002 2003 2004 2005 2006 2007 AAG
Number of
matriculants who N N N N N N N N N %
Wrote matric
Not
known 489 941 449 371 443 821 440 267 467 985 508 363 528 525 564 775 2.1
Wrote
mathematics 281 304 284 017 263 945 260 989 258 323 276 094 303 152 317 642 347 570 2.7
Passed
mathematics HG 19 854 19 327 19 504 20 528 23 412 24 143 26 383 25 217 25 415 3.1
Passed
mathematics SG 79 512 85 181 78 181 101 289 104 707 109 664 112 279 110 452 123 813 5.7
Total passes 99 366 104 508 97 685 121 817 128 119 133 807 138 662 135 669 149 228 5.2
* AAG = Average Annual Growth.
Source: Department of Basic Education. Education Statistics in South Africa at a Glance in 1999, 2000, 2001, 2002, 2003, 2004,
2005, 2006 and 2007.
56

Table 5-3 shows that the total number of Grade 12 candidates who passed physical science increased
from 84543 in 1999 to 115607 in 2007, an average annual growth rate of 4%. However, it is clear that
the number of matriculants who passed physical sciences in 2008 (Table 5-1) is much lower than the
number who passed under the pre-2008 curriculum.
Table 5-3 Grade 12 statistics – physical science: 1999-2007
1999 2000 2001 2002 2003 2004 2005 2006 2007 AAG
Number of
matriculants who N N N N N N N N N %
Wrote matric
Not
known 489 941 449 371 443 821 440 267 467 985 508 363 528 525 564 775 2.1
Wrote physical
science 160,949 163 185 153 847 153 855 151 791 161 214 181 828 195 223 214 510 3.7
Passed physical
science HG 24,191 23 344 24 280 24 888 26 067 26 975 29 965 29 781 28 122 1.9
Passed physical
science SG 60,352 67 823 56 488 70 763 75 693 73 943 73 667 81 151 87 485 4.8
Total passes 84,543 91 167 80 768 95 651 101 760 100 918 103 632 110 932 115 607 4.0
* AG = Annual Growth.
Source: Department of Basic Education. Education Statistics in South Africa at a Glance in 1999, 2000, 2001, 2002, 2003, 2004,
2005, 2006 and 2007.
Biology as a subject was replaced by life sciences during the 2008 curriculum changes. Exposure to
biology or life sciences at school may stimulate learners’ interests in the health or animal health
sciences, and encourage them to pursue a career in the field. Students intending to enter tertiary-level
studies in health sciences in fields such as biomedical technology, emergency medical care, medical
clinical practice, nursing, occupational therapy, physiotherapy, optical dispensing, dental technology,
chiropractic, phytotherapy and naturopathy are required to study life sciences at secondary school
level. 181 It is concerning to note that fewer candidates are studying biology or life sciences at matric
level. In 1999, a total of 387787 candidates wrote biology and the number decreased by 0.6% per
annum until 2007. By 2008 only 298210 sat the life sciences examination and, of those, only 117483
candidates passed. Almost 33% fewer candidates passed life sciences in 2008 than those who passed
biology in 2007 (Table 5-4).
181 Various health sciences faculties: Cape Peninsula University of Technology http://www.cput.ac.za; Nelson Mandela
Metropolitan University http://www.nmmu.ac.za; University of Cape Town http://www.uct.ac.za; University of Pretoria
http://www.up.ac.za; University of Stellenbosch http://www.sun.ac.za; University of the Western Cape http://www.uwc.ac.za;
Walter Sisulu University of Technology http://www/wsu.ac.za. (Accessed August and September 2010).
57

Table 5-4 Grade 12 statistics – biology: 1999-2007
1999 2000 2001 2002 2003 2004 2005 2006 2007 AAG
Number of
matriculants who N N N N N N N N N %
Wrote matric Not known 489941 449371 443821 440267 467985 508363 528525 564775 2.1
Wrote biology 387787 356215 311026 298089 285852 300154 331457 349137 370622 -0.6
Passed biology HG 44230 40336 39853 41034 44225 42496 49419 50722 54450 2.6
Passed biology SG 119021 126363 121978 127173 124432 128441 127269 130564 141318 2.2
Total passes 163251 166699 161831 168207 168657 170937 176688 181286 195768 2.3
* AAG =Average Annual Growth.
Source: Department of Basic Education. Education Statistics in South Africa at a Glance in 1999, 2000, 2001, 2002, 2003, 2004,
2005, 2006 and 2007.
Analysis of the above statistics shows that the secondary school system is producing fewer candidates
with the combination of subjects required for entering tertiary-level studies in the health sciences.
Apart from the issue of insufficient numbers, there are serious concerns about the quality of the
matriculants. Education experts have found that the levels of literacy and numeracy skills in South Africa
are considerably lower than those of other developing and several African countries. According to the
DBSA Roadmap, in a comparison with developed countries the top 6% to 10% of South African students
were at the same level as the top 75% of students in the advanced countries. 182 These realities confirm
prevailing concerns about poor student readiness for tertiary studies. Nursing colleges report an oversupply
of under-qualified learners who do not meet the academic entrance criteria. 183 These colleges
also experience dropout rates at around 75%, which is an indication that prospective nurses are not
properly prepared for training at post-school level. 184
182 Development Bank of South Africa. 2008. Education Roadmap: Focus on the Schooling System. Published at
http://www.dbsa.org/Research/Roadmaps1/Education%20Roadmap.pdf. (Accessed August 2010).
183 Breier, M.,Wildschut, A. and Mgqolozana, T. 2009. Nursing in a New Era – The Professional Education of Nurses in South
Africa.
184 Bateman, C.2009. “Legislating for nurse/patient ratios ‘clumsy and costly’ – experts”. South African Medical Journal. August
2009. 99 (8). Published at http://www.scielo.org.za/pdf/samj/V99n8. (Accessed August 2009).
58

5.3 INSTITUTIONAL ARRANGEMENTS AND CAPACITY FOR THE TRAINING OF HEALTH
WORKERS
5.3.1 ACADEMIC COMPLEXES
Prospective health professionals are trained in academic health complexes established under the
National Health Act that aim at providing comprehensive training in primary-, district- and tertiary-level
care. Each of these academic health complexes consists of health facilities at all levels of the national
health system, including peripheral facilities and one or more educational institutions. 185 Although there
are many calls for increased output from the academic health complexes, training capacity is limited as a
result of constraints related to infrastructure, bed-count, laboratories, and other resources. Despite the
high demand for placement in healthcare educational programmes the annual intake remains restricted.
Leading health academics, in a presentation to the Parliamentary Portfolio Committee on Health,
warned that the academic health complexes are in a state of crisis due to the lack of a national
governance structure and an appropriate funding framework. According to these academics, although
provincial health departments are responsible for funding the complexes, very little money is allocated
to them. These complexes compete with other priorities in the provincial budgets, such as primary and
district health care. 186 As a result, fewer healthcare workers are produced and the quality of tertiarylevel
healthcare and training is reduced. There are fears that some academic hospitals may lose their
accreditation as teaching institutions unless funding is made available to maintain infrastructure,
provide adequate standards of service and supply medication. There is a real risk that the numbers of
undergraduate medical students may be cut and intern training posts be reduced. 187 Owing to budget
constraints the bed-count in several tertiary hospitals has dropped, and this has resulted in a diminished
capacity to train health professionals.
In addition, the HWSETA baseline study reported that the brain drain of academic and experienced
personnel leads to deficiencies within training institutions, impacting in this way on the professional
attachment and supervision of new graduates and the production of future health personnel.
5.3.2 PRIVATE HIGHER EDUCATION AND TRAINING INSTITUTIONS
Although South Africa has dynamic and well established private higher education institutions (HEIs) they
may be challenged in meeting the extensive accreditation requirements for the training of health
professionals set by the professional councils and the HEQC of the Council for Higher Education.
185 Section 51 of the National Health Act, 61 of 2003.
186 Bateman, C. 2010. “Academic health complexes bleeding in ‘no man’s land’”. South African Medical Journal. January 2010.
100 (1). Published at http://www.scielo.org.za/pdf/samj/V100n1; Development Bank of South Africa. 2008. A Roadmap for the
Reform of the South African Health System.
(Accessed August 2010).
187 Bateman, C. 2010. “Academic health complexes bleeding in ‘no man’s land’”. South African Medical Journal. January 2010.
100 (1). Published at http://www.scielo.org.za/pdf/samj/V100n1.
(Accessed August 2010).
59

Role-players in the private health sector have expressed concerns that the private higher education
sector is, to a large extent, barred from producing certain health professionals. 188 They observed that
even though the DoH acknowledged skills shortages in almost all categories of healthcare professionals,
the national Human Resources of Health Plan of 2006 neither addresses strategies to include the private
sector in training, nor does it plan for the increased intake of learners at tertiary academic
institutions. 189
Several private HEIs are accredited to train in qualifications required for registration with the AHPCSA.
In August 2010 the accredited training providers in the allied health professions of therapeutic
aromatherapy, therapeutic reflexology and therapeutic massage therapy were all private HEIs. 190 The
South African Faculty of Homeopathy offers an accredited programme that leads to the Postgraduate
Diploma in Homeopathy, which is aimed at medical practitioners already registered with the HPCSA who
wish to specialise in homeopathy. 191
The Foundation for Professional Development (FPD) is a private higher education institution (HEI)
established by the South African Medical Association (SAMA). The FPD offers a comprehensive
curriculum of training and development courses aimed at health professionals, practitioners, allied
workers, health sector managers and non-medical professionals. It offers programmes that lead to
undergraduate and postgraduate qualifications, as well as short courses. Among the key focus areas are
leadership and management in a health environment as well as clinical and multi-disciplinary courses,
some of which are designed to meet the needs of health professionals and practitioners working in rural
areas. Community engagement is sought via the development of grassroots NGOs. The FPD also
develops institutional capacity within the public sector. 192
5.3.3 PRIVATE FURTHER EDUCATION AND TRAINING INSTITUTIONS
Private FET institutions produce nursing auxiliaries (NQF Level 3) and enrolled nurses (NQF Level 4), as
well as pharmacy assistants (basic level) at NQF Level 3 and pharmacy assistants post-basic at NQF Level
4. The nursing schools of several of the large private hospital groups and independent private nursing
schools are accredited by the Department of Basic Education as FET providers.
188 Wolvaardt, G., Van Niftnik, J., Beira, B. et al. 2008. “The Role of Private and Other Non-Governmental Organisations in
Primary Health Care”. South African Health Review 2008. Health Systems Trust. Published at www.hst.org.za/publications/841.
(Accessed August 2010).
189
Wolvaardt, G., Van Niftnik, J., Beira, B. et al. 2008. “The Role of Private and Other Non-Governmental Organisations in
Primary Health Care”. South African Health Review 2008. Health Systems Trust. Published at www.hst.org.za/publications/841.
(Accessed August 2010).
190 Allied Health Professions Council of South Africa. 2010. Published at http://www.ahpcsa.co.za/rr_providers.htm. (Accessed
September 2010).
191 South African Faculty of Homeopathy. 2010. Published at http://www.homeopathysouthafrica.co.za/. (Accessed September
2010).
192 Foundation for Professional Development. 2010. Published at http://www.foundation.co.za/Course-Catalogue.html.
(Accessed September 2010).
60

5.3.4 PRIVATE HOSPITALS
Private hospitals are permitted to train nurse practitioners but constraints in meeting regulatory and
accreditation requirements limit their ability to produce certain qualifications and the required number
of nurses. Private hospitals mainly train nursing auxiliaries and enrolled nurses and offer a two-year
bridging programme towards full registration as a professional nurse for general nursing functions.
Because the private sector is limited in the clinical experience on offer to trainee nurses, it has not been
successful in attaining accreditation to offer comprehensive training for registered nurses. Even larger
private hospitals are not able to offer access to chronic psychiatric care, community-based nursing, or
midwifery, all of which are required to complete a comprehensive four-year programme. 193 The private
sector does offer specialist training in intensive care, neo-natal care and operating theatre units.
The private sector has assumed a prominent role in the production of enrolled nursing auxiliaries,
enrolled nurse and upgrading enrolled nurses to be registered as nurses. An analysis of the SANC
statistics 194 Figure 5-1 shows that the production of enrolled nursing auxiliaries in the private sector
nursing education institutions increased in 2007, 2008 and 2009 by almost 400% and for enrolled nurses
during the same period the increase was between 200% and 300%. Although the production of
registered nurses through the bridging programme remains higher in the public sector, the gap in the
production of registered nurses between the two sectors decreased from 51.5% in 2007 to 17% in 2008
and 23% in 2009.
6000
5000
4000
3000
2000
1000
2007 2008 2009
ENA No. Completed in Public Sector 1146 1061 1106
ENA Completions Private Sector 4495 4532 4673
EN No. Completed in Public sector 1339 1388 2365
EN Completions Private Sector 3419 4366 5128
Bridging No. Completions Public
Sector
0
1261 1419 1366
Bridging Completions Private Sector 832 1209 1109
Figure 5-1 Comparison of output in basic nursing training between public and private sectors: 2007 -
2009
Source: South African Nursing Council, 2010
193 Breier, M., Wildschut, A. and Mgqolozana, T. 2009. Nursing in a New Era – The Professional Education of Nurses in South
Africa.
194 ( South African Nursing Council, 2010)
61

Currently, no private hospitals are not accredited to train doctors, and, in an article the CEO of HASA,
Adv Kurt Worral-Clare expressed concerns about this situation, especially in view of capacity constraints
at academic health complexes. 195
5.3.5 CPD PROVISION
Health professionals are obliged to undergo continuous professional development (CPD) in order to
retain their registered status with their respective regulatory councils. CPD therefore plays an important
part of skills formation in the sector. Most of the professional bodies accredit providers to offer CPD
and various voluntary organisations within the organised profession facilitate access to CPD and keep
members’ records of CPD participation.
5.3.6 NON-PROFIT ORGANISATIONS
Generally, NGOs offer non-accredited training to volunteers and community health workers (CHWs) as
the organisations lack capacity to seek accreditation to offer the formal CHW qualifications registered on
the NQF. The HWSETA’s capacity to facilitate skills development for NGOs is hampered by funding
constraints because the NGOs are levy-exempt organisations. Participants in the baseline study
acknowledged the HWSETA’s role in financing skills development for NGOs and called for increased
support and capacity building in rural areas and CBOs.
5.4 PROFESSIONAL REGISTRATION
As stated in Chapter 2, health care professionals have to register with their respective professional
councils in order to have the right to practise or work in the health sector. Ideally, the professional
registers should provide a fair reflection of the stock of professional skills available in the country.
However, the registers don’t keep track of professionals’ movement out of the country and it is possible
that people who are registered no longer offer their services to the South African health sector. Some
of the registered professionals may also be employed elsewhere in the economy or may be
economically inactive. Nevertheless, the professional registers do provide an indication of the growth in
the number of health professionals available.
5.4.1 REGISTRATIONS WITH THE HEALTH PROFESSIONS COUNCIL OF SOUTH AFRICA
The HPCSA offers registration in 86 registration categories and is by far the registration body with the
largest number of categories of health professionals. At the end of December 2009 there were 142 064
people registered with the 12 registration boards of the HPCSA. This figure has almost doubled since
2000, when there were 84 682 people on the registers. This increase was, however, mainly the result of
the registration of new health workers who were not regulated in the past – for example, basic
ambulance assistants.
195 Worrall-Clare, K. 2009. “Partnering Sectors” in Private Hospital Review 2009. Published at:
http://www.hasa.co.za/media/uploads/news/.../Private_Hospital_Review_2009.pdf. (Accessed August 2010).
62

Table 5-5 shows the registration figures for a number of key professions as at 31 December of each year
between 2000 and 2009. The table also shows the average annual growth in the number of
professionals registered. The total number of registered dentists grew by 1.3% per year, medical interns
by 3.3%, and medical practitioners by 1.4%. Clearly, this slow growth is the most important reason why
the dire employment situation is not improving.
5.4.2 REGISTRATIONS WITH THE SOUTH AFRICAN NURSING COUNCIL
The number of nurses registered with the SANC over the period 2000 to 2009 can be seen in Table 5-6.
In 2009 there were 221 817 nurses registered with the Council. The number of registered nurses grew
steadily from 2003 to 2009 after it had stagnated in the period 2000 to 2002. The average annual
growth rate for all nurses was 2.9% over the period 2000 to 2009. Registration figures for pupil and
student nurses are only available from 2001 onwards. These registration categories grew from a low
base (14 460 in 2001) at an average annual rate of 9.7% between 2001 and 2009.
63

Table 5-5 Number of professionals registered with the HPCSA as at 31 December of 2000 to 2009 (selected professions)*
Profession 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 AAG
Dentist 4 481 4 503 4 560 4 500 4 644 4 761 4 836 5 047 4 890 5 015 1.3
Medical Intern 2 235 2 396 2 306 2 157 2 479 2 899 3 275 3 760 3 645 3 006 3.3
Medical Practitioner 29 788 29 927 30 271 30 578 31 330 32 443 33 507 34 449 33 534 33 800 1.4
Medical Technologist 4 784 3 929 3 942 4 713 4 869 4 877 4 954 5 048 5 151 5 311 1.2
Occupational Therapist 2 368 2 377 2 563 2 511 2 819 2 808 2 922 3 159 2 946 3 156 3.2
Optometrist 1 935 2 010 2 173 2 218 2 401 2 516 2 633 2 733 2 915 3 023 5.1
Physiotherapist 4 093 4 191 4 360 4 400 4 785 4 760 4 915 5 240 5 081 5 261 2.8
Psychologist 4 941 4 755 5 064 5 401 5 774 5 878 6 130 6 391 6 532 6 684 3.4
Radiographer 4 583 4 073 4 295 4 789 5 221 5 237 5 433 5 624 5 562 5 800 2.7
Speech Therapist And Audiologist 1 238 1 251 1 321 1 345 1 397 1 391 1 396 1 441 1 222 1 296 0.5
Source: HPCSA.
Table 5-6 Number of nurses registered with the SANC: 2000 to 2009
Registration category 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 AAG
Registered 93 303 94 552 94 948 96 715 98 490 99 534 101 295 103 792 107 978 111 299 2.0
Enrolled 32 399 32 120 32 495 33 575 35 266 37 085 39 305 40 582 43 686 48 078 4.5
Auxiliaries 45 943 45 666 45 426 47 431 50 703 54 650 56 314 59 574 61 142 62 440 3.5
Total 171 645 172 338 172 869 177 721 184 459 191 269 196 914 203 948 212 806 221 817 2.9
Student 9 527 10 338 11 478 12 280 13 096 13 272 15 258 16 457 17 167 7.6
Pupil 4 933 6 081 7 245 8 300 8 096 8 483 9 528 11 179 13 052 12.9
Total 14 460 16 419 18 723 20 580 21 192 21 755 24 786 27 636 30 219 9.7
Source: SANC.
64

5.4.3 REGISTRATIONS WITH THE SOUTH AFRICAN PHARMACY COUNCIL
By August 2010 the SAPC had registered 11 939 professionals, 3 457 post-basic pharmacist assistants
and 437 basic pharmacist assistants. At the same time there were 566 pharmacist interns and 1 507
post-basic and 3 637 basic pharmacist assistants in training. Unfortunately the Council was not able to
provide historical registration figures at the time this report was written.
Table 5-7 Number of registrations with the SAPC: 2010
Registration categories
Number of persons registered
Basic Pharmacist Assistant 437
Learner Basic Pharmacist Assistant 3 637
Post-Basic Pharmacist Assistant 3 457
Learner Post-Basic Pharmacist Assistant 1 507
Pharmacist 11 939
Pharmacist Intern 566
Source: SAPC, 2010.
5.4.4 REGISTRATIONS WITH THE ALLIED HEALTH PROFESSIONS COUNCIL OF SOUTH
AFRICA
By August 2010 3 211 people were registered with the AHPCSA (Table 5-8). Of these, 900 were
registered as reflexologists, 578 as chiropractors and 541 as homeopaths.
Table 5-8 Total registrations with the AHPCSA: 2010
Registration categories
Number of persons registered
Acupunture 130
Ayurveda doctor 14
Ayurveda primary health care advisor 34
Ayurveda yoga therapist 10
Chinese medicine 160
Chiropractic 578
Homoeopathy 541
Maharishi practitioner 3
Naturopathy 92
Osteopathy 46
Panchakarma technician 4
Phytotherapy 32
Therapeutic aromatherapy 396
Therapeutic massage therapy 194
Therapeutic reflexology 900
Unani-Tibb 77
Source: AHPCSA, August 2010.
65

5.4.5 REGISTRATIONS WITH THE SOUTH AFRICAN VETERINARY COUNCIL
The number of veterinary professionals registered with the SAVC can be seen in Table 5-9.
Table 5-9 Number of registrations with the SAVC: 2010
Registration categories Number of persons registered
Veterinary specialists 135
Veterinarians 2 769
Veterinarians in training 650
Source: SAVC, September2010.
5.5 THE SUPPLY OF NEW GRADUATES BY THE HIGHER EDUCATION SYSTEM
5.5.1 HIGHER EDUCATION AND TRAINING
As indicated above, health professionals mostly receive their academic education from the public higher
education sector. The output from the higher education institutions in health-related fields of study can
be seen in Table 5-10. If all the health-related fields of study are considered, the total output from the
HET sector grew on average by 3.4% at National Diploma level, at 6.3% at first three-year BDegree level
and at 5.1% at first four-year degree level. The field with the highest growth was Basic Health Care
Sciences. Clinical Health Sciences (which more or less represents the output of entry-level medical
degrees) grew only moderately – the number of four-year degrees increased by only 3.1% per year.
66

Table 5-10 Number of health-related qualifications awarded by the public higher education sector: 1999 to 2008
CESM Category Qualification Type 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 AAG
Basic Health
Care Sciences
Clinical Health
Sciences
Rehabilitation
and Therapy
National diploma (3 years) 250 224 234 381 439 550 428 558 392 571 9.6
First Bdegree (3 years) 102 185 199 375 348 381 516 430 407 470 18.5
First Bdegree (4 years) 259 837 625 769 788 863 1 579 1 197 1 152 679 11.3
National diploma (3 years) 311 398 387 339 306 213 171 172 163 267 -1.7
First Bdegree (3 years) 157 272 421 283 180 133 234 203 156 191 2.2
First Bdegree (4 years) 1 600 1 485 1 473 1 968 1 586 1 613 1 726 1 517 1 712 2 103 3.1
National diploma (3 years) 103 104 107 142 195 169 249 249 249 161 5.1
First Bdegree (3 years) 11 30 27 51 27 30 10 7 19 25 9.7
First Bdegree (4 years) 485 471 618 960 705 634 708 714 823 863 6.6
Pharmaceutical
Science First Bdegree (4 years) 392 393 360 521 380 491 367 308 387 392 0.0
Emergency
Service
Public Health
Veterinary
Health Sciences
General Health
Sciences
Total
Source: DHET, HEMIS.
National diploma (3 years) 27 229 131 7 24 21 42 21 49 58 8.9
First Bdegree (3 years) 0 377 293 13 194 6 9 6 3 14
First Bdegree (4 years) 10 0 1 5 5 1 9 1 15 171
National diploma (3 years) 140 127 108 212 196 126 233 212 211 176 2.6
First Bdegree (3 years) 153 2 6 53 3 62 33 32 25 24 -18.5
First Bdegree (4 years) 304 250 199 198 229 173 334 304 346 515 6.0
National diploma (3 years) 36 65 55 78 38 38 58 17 13 13 -10.7
First Bdegree (4 years) 27 98 131 147 106 110 122 96 81 100 15.6
National diploma (3 years) 53 22 27 5 0 0 0 0 0 0
First Bdegree (3 years) 7 1 1 0 0 0 0 14 29 19
National diploma (3 years) 920 1 169 1 049 1 164 1 198 1 117 1 181 1 229 1 077 1 246 3.4
First Bdegree (3 years) 430 867 947 775 752 612 802 692 639 743 6.3
First Bdegree (4 years) 3 077 3 534 3 407 4 568 3 799 3 885 4 844 4 137 4 515 4 822 5.1
67

5.6 THE SUPPLY OF NEW ENTRANTS THROUGH NURSING COLLEGES
Public and private nursing colleges play an important role in the supply of nurses to the health sector.
The number of nurses that qualified at the different levels can be seen in Table 5-11. In 2009 a total of
17 714 nurses qualified at the nursing colleges. The total output of the colleges increased on average by
10% per year over the period 2000 to 2009. The highest average growth in output was in the pupil and
pupil auxiliaries categories (16% per annum). Although there was a slight decline in the number of
nurses who qualified in the four-year programme, there was a 2.4% increase in the number who
qualified as professional nurses through the bridging programme.
Table 5-11 Number of graduates at nursing colleges: 2000 to 2009
Programme 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 AAG
Four-year Programme 2 086 1 633 1 252 1 100 1 288 1 058 1 493 1 628 1 701 1 967 -0.7
Bridging Course* 1 991 1 670 1 679 1 841 2 103 2 352 2 364 2 093 2 628 2 475 2.4
Pupil Nurses 1 919 1 932 2 771 3 158 4 273 4 565 4 816 4 758 6 154 7 493 16.3
Pupil Auxiliaries 1 509 1 914 3 078 4 390 6 698 6 754 5 422 6 136 5 593 5 779 16.1
Total 7 505 7 149 8 780 10 489 14 362 14 729 14 095 14 615 16 076 17 714 10.0
*Bridging into professional nurse category.
Source: SA NC, 2010.
5.7 THE ROLE OF THE HWSETA IN THE SUPPLY OF SKILLS
5.7.1 THE REGISTRATION OF QUALIFICATIONS AND LEARNERSHIPS
The HWSETA has registered 20 qualifications in the health and welfare sectors on the National
Qualifications Framework (NQF) and is responsible for the quality assurance of these qualifications. The
qualifications that are relevant to the health sector are listed in Table 5-12. All the qualifications are at
NQF level 4 and lower.
Table 5-12 FET level qualifications registered by HWSETA on the NQF
Qualification title
NQF level
General Education and Training Certificate Ancillary Health Care 1
National Certificate: Community Health Work 2
NC Occupational Health, Safety and Environment 2
NC Occupational Hygiene and Safety 3
NC Community Health Work 3
© 2010 S A Nursing Council
NC Primary Response in Emergencies 3
FETC Community Health Work 4
FETC Community Development – HIV and AIDS Support 4
FETC Counselling 4
FETC Occupational Hygiene and Safety 4
Source: HWSETA.
68

The HWSETA has also registered several learnerships with the Department of Labour (the registrations
are now handled by the DHET) (Table 5-13).
Table 5-13 HWSETA learnerships at FET level
Learnership title
NQF level
GETC Ancillary Health Care 1
Certificate Pharmacist Assistant (Basic) 3
Community Health Worker 3
Certificate in General Nursing (Auxiliary) 4
Certificate in General Nursing (Enrolled) 4
Certificate Pharmacist Assistant (Post Basic) 4
FETC Phlebotomy Techniques 4
Further Education and Training Certificate: Counselling 4
FETC Community Development – HIV and AIDS Support 4
Source: HWSETA.
5.7.2 LEARNERS WHO QUALIFIED ON LEARNERSHIPS
Since the inception of the HWSETA a total of 25 221 learners have entered learnerships in the sector.
According to the HWSETA’s data system, the first learners on HWSETA learnerships completed their
training in 2002. Since then a total of 6 771 learners have completed learnerships and were recorded on
the SETA’s system. Many of the others enrolled on learnerships that are quality assured by the
professional councils in the sector and their completions have not been recorded on the HWSETA’s
system.
The learnership completions that were recorded on the HWSETA system increased from 8 in 2002 to
1 414 in 2006. After that the annual figures dropped slightly (Table 5-14).
69

Table 5-14 Number of learners who completed learnerships in the health sector: 2002 to 2010
2002 2003 2004 2005 2006 2007 2008 2009 2010* Total %
Certificate in General Nursing: Auxiliary 24 146 492 483 193 136 167 1 1 642 24
Certificate in General Nursing: Enrolled 1 93 275 151 408 539 416 24 1 907 28
Certificate in Social Auxiliary Work Level 58 26 1 53 18 20 176 3
Certificate Pharmacist Assistant: Basic 8 15 37 80 112 100 77 72 24 525 8
Commercial and Financial Accountant Public
Practice 1 1 0
Diagnostic Radiography 4 3 24 11 25 20 10 97 1
Diploma in General Nursing: Bridging 18 18 52 179 157 110 190 3 727 11
Diploma in Primary Health Care: Post Basic 21 25 1 47 1
FET Certificate: Phlebotomy Techniques 7 46 39 10 102 2
First Line Manager 16 16 0
GET Certificate in Ancillary Health Care 182 50 405 259 49 56 37 1 038 15
National Certificate: Small Business Financial
Management 1 1 0
Post Basic Diploma in Medical/Surgical Nursing
(Elective: Operating Theater Nursing) 6 2 6 11 13 4 42 1
Post Basic Diploma in Medical/Surgical
Nursing: Elective (Critical Care) 1 1 35 36 33 106 2
Post Basic Pharmacist Assistant Learnership 5 28 107 28 64 64 36 12 344 5
Total 8 63 536 1 120 1 414 1 247 1 174 1 052 157 6 771 100
*Figures for this year include only learners who had qualified by August.
The figures that are reported in this table will not correspond with the total figures reported by the HWSETA, because only health-related learnerships were included.
Source: HWSETA.
70

5.7.3 INTERNSHIPS
The HWSETA has supported the implementation of internships and work experience grants since the
2006-2007 financial year. The HWSETA funded students for six to twelve months on an array of
qualifications. Some of the key occupations in which learners were supported are:
Radiographers ( radiotherapy; nuclear medicine; ultrasound)
Dental technologists
Dental assistants
Social workers
Pharmacists
Clinical engineers
Clinical technicians
Emergency medical care personnel
Paramedics
Biomedical technologists
Optometrists
Community nurses
Physiotherapists
Pathologists
5.7.4 SKILLS PROGRAMMES
The funding of skills programmes by the HWSETA is subject to the availability of accredited training
providers. The following skills programmes were implemented since 2006-2007:
Home-based Care
Basic Counseling
HIV and AIDS Awareness
The average duration of the successful skills programmes was between four to twelve weeks and they
consisted of between six and twelve unit standards. While the original intention of the skills
programmes was to address the skills needs of employees in the sector, the largest demand was from
unemployed people.
5.7.5 ADULT BASIC EDUCATION AND TRAINING (ABET)
The HWSETA supports the implementation of Adult Basic Education and Training (ABET) through
discretionary grants to enable illiterate health sector workers to learn to read and write. The reality in
the health and social development sectors is, however, that more unemployed people need access to
ABET than workers. The largest proportion of funding over the last five years was therefore used for the
benefit of unemployed persons. Workers in the health sectors who need ABET are generally employed
71

in outsourced functions such as cleaning, catering and general work, where the employers are not
registered with the HWSETA.
Participants in the HWSETA survey and baseline study in 2009 agreed that the HWSETA was providing
adequate funding for ABET and that enough ABET programmes are available. However there were some
challenges in the delivery of ABET, such as the limited availability of trainers and perceptions about too
low funding per learner and the training being imposed and not necessarily sought after.
5.7.6 RECOGNITION OF PRIOR LEARNING
In 2007 and 2008 the HWSETA facilitated RPL against 15 unit standards in the General Education and
Training Certificate Ancillary Health Care NQF 1 qualification. A total of 968 individuals in eight
provinces were declared competent against unit standards for home- and community-based-care skills.
5.7.7 SKILLS DEVELOPMENT SUPPORT TO SMALL ENTERPRISES
During the period covered by NSDS II the HWSETA provided funding to small levy-exempt BEE
enterprises for training aimed at building capacity. The training supported was based on the skills
priority needs these organisations identified in their workplace skills plans.
During the 2009 baseline study consultations, participants acknowledged that the SMMEs received
training of a high standard which would assist them with job creation. However, many did not have the
capacity to meet the HWSETA’s accreditation requirements and only a few SMMEs were accredited.
Several of the participants suggested that the HWSETA should relax its accreditation requirements and
also build capacity in the SMMEs to secure accreditation. The HWSETA provided skills to assessors and
moderators who operate as part of small enterprises.
During 2008 and 2009 the HWSETA implemented a project focused on new venture creation in
conjunction with 19 FET colleges and the Small Enterprise Development Agency (SEDA). About 450
learners were involved in a dedicated skills programme in new venture creation which covered about 70
core credits from the new venture creation level 2 learnership. Further learning support was also
provided.
5.7.8 EXPANDED PUBLIC WORKS PROGRAMME
The HWSETA participated in government’s expanded public works programme aimed at creating work
opportunities coupled with accredited training to create jobs for unemployed people. Learners were
trained on ancillary health care and home community based care at NQF levels 1 and 3 respectively.
Unemployed matriculants participated in an accredited training programme for community health
workers at NQF Level 4 over a period of 18 to 24 months.
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5.8 FACTORS INFLUENCING THE SUPPLY OF SKILLS
Apart from the institutional strengths and constraints described earlier in this chapter, a number of
other factors also impact, or are set to impact, on the supply of skills in the future. These include
government strategies and policy interventions, the management of public sector health facilities, the
migration of South African health professionals, the recruitment of foreign professionals, and the socioeconomic
realities faced by many potential professionals.
5.8.1 GOVERNMENT STRATEGIES AND POLICY INTERVENTIONS
Over the last few years government has introduced a number of strategies and plans to improve the
supply of health workers. A few of these interventions are discussed below:
a) Nursing
Healthcare provision in South Africa is affected by the global shortage of nurses. Both the public and
private sectors have suffered losses of experienced nursing professionals who are regarded as essential
components in the overall healthcare delivery system. In response to these losses the SANC and the
national DoH developed the Nursing Strategy for South Africa to “achieve and maintain an adequate
supply of nursing professionals who are appropriately educated, distributed and deployed to meet the
health needs of all South Africans”. 196 This strategy was published in 2008. Important elements of this
strategy are to provide sufficient numbers and appropriate categories of nursing skills through goodquality
education and training and to maintain high standards, professionalism and quality in nursing
practice.
In 2004 the SANC revised the scope of practice of nurses into new categories: professional nurse,
professional midwife, staff nurse, and auxiliary nurse. 197 New educational qualifications were developed
which are aligned to the revised scope of practice. The SANC planned to phase out several nursing
qualifications that had existed prior to the NQF by 30 June 2010. However, this deadline was extended
due to delays in the publication of regulations to facilitate the implementation of the new scopes of
practice for the different categories of nurses and their respective qualifications. 198 The implementation
of the revised scope of practice and the new qualifications will follow in the near future and the success
of implementation will depend in part on the availability of sufficient and suitably qualified educators
with appropriate academic and clinical skills. 199
196 DoH. 2008. Nursing Strategy for South Africa. Published at http://www.sanc.co.za/pdf/nursing-strategy.pdf. (Accessed
August 2010).
197 The previous categories were registered nurse, registered midwife, enrolled nurse and enrolled midwife.
198 South African Nursing Council. 2009. “Implementation of the new Nursing Qualifications registered on the National
Qualifications Framework (NQF)”. SANC Circular 3/2009. Published at http://www.sanc.co.za/newsc903.htm. (Accessed August
2010).
199 DoH. 2008. Nursing Strategy for South Africa. Published at http://www.sanc.co.za/pdf/nursing-strategy.pdf. (Accessed
August 2010).
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Cuts in provincial health budgets for training, the rationalisation of public nursing colleges (and the
subsequent closure and merger of many) have had an adverse effect on the supply of nurses. 200
b) Community service for health professionals
The national DoH introduced community service in the public sector for 11 health professions between
1998 and 2007. Newly qualified health professionals serve one year of community service in underresourced
areas to enhance access to healthcare and also to develop their own clinical skills
independently from the lecturers at their institutions of training. 201 Each year a number of these health
professionals are allocated to the SA Military Health Services and the Department of Correctional
Services.
The introduction of community service has alleviated shortages of health personnel in the public sector,
especially in the rural areas. 202 In 2006 and 2007 the number of GPs increased by 20% (but declined
again in 2008 when the two-year internship was introduced). The number of occupational therapists
and physiotherapists in the public sector increased by at least 33% and 40% respectively, based on
comparisons of the number of public sector posts available and the number of community service
professionals. 203 Although community service helped to alleviate skills shortages in the public sector, the
public health services still experience challenges in retaining professionals – especially in the rural areas.
c) Salary adjustments
A few years ago the DoH introduced rural and scarce skill allowances to attract and retain healthcare
professionals in areas of greatest need. 204 The introduction of the occupational-specific dispensation for
nurses in the public sector from March 2008 is also aimed at eliminating salary differentials between the
private and public sectors and retaining scarce skills. Similar arrangements to retain doctors and midlevel
category doctors in the public sector have been hampered by incapacity in provincial health
departments. 205 The national DoH also agreed to implement occupational-specific remuneration for
dentists, medical and dental specialists, pharmacist assistants, pharmacist and emergency medical
services personnel, and a proposal was made for occupational-specific remuneration for therapeutic and
related allied health professionals. 206
200 Breier, M., Wildschut, A. and Mgqolozana, T. 2009. Nursing in a New Era – The Professional Education of Nurses in South
Africa.
201 National Department of Health. 2006. “Community service to improve access to quality health care to all South Africans”.
Published at http://www.doh.gov.za (Accessed August 2010).
202 Lehmann, U. 2008. “Strengthening Human Resources for Primary Health Care” South African Health Review.
203 Harrison, D. 2009. An Overview of Health and Health care in South Africa 1994-2010: Priorities, Progress and Prospects for
New Gains. Published at www.doh.gov.za (Accessed February 2010).
204 Lehmann, U. 2008. “Strengthening Human Resources for Primary Health Care”. South African Health Review 2008. Health
Systems Trust. Published at www.hst.org.za/publications/841 (Accessed August 2010).
205 Bateman, C. 2010. “Occupation-specific dispensation – a hapless tale”. South African Medical Journal. May 2010. 100 (5).
Published at http://www.scielo.org.za/pdf/samj/V100n5. (Accessed August 2010).
206 National Treasury. 2010. “Vote 15: Health”. Estimates of National Expenditure 2010.
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d) The introduction of mid-level skills
A new category of mid-level health workers, so-called “clinical associates”, was introduced in 2004 to
improve coverage of PHC and service delivery in under-resourced areas. 207 Clinical associates are
required to work under the supervision of doctors and assist them with emergency care, procedures and
in-patient care in district hospitals. 208 They enter practice after completing a three-year Bachelor of
Medical Clinical Practice degree offered at the Walter Sisulu University, the University of Pretoria and
the University of the Witwatersrand and after serving one year of community service. Analysts have
commented that progress with the development of these mid-level skills has been slow and that the
graduation numbers are too low to offset the shortage of professionals. 209 A further constraint is that
the public sector may not have created the posts in which to accommodate these mid-level health
workers. According to certain authors there still appears to be uncertainty about their roles. 210
In order to improve access to emergency medical services, the national DoH intends to increase output
of emergency care technicians from training colleges from 127 in 2009/10 to 160 in 2012/13. 211 Health
authorities are considering the introduction of mid-level workers in the field of nutrition, but a final
decision has not been made. 212 Other training programmes aimed at developing mid-level workers may
include new pharmacist technicians, forensic officer technicians, radiation technicians and dental
assistant technicians. 213 During 2010 to 2013 specific measures will also be taken to develop and train
more emergency care technicians, nurses and health managers. 214
5.8.2 MANAGEMENT OF THE PUBLIC SECTOR HEALTH FACILITIES
The DBSA Roadmap process found that many of the human resource problems in the public sector arise
from institutional problems in the public sector itself. 215 Institutional factors such as poor planning, substandard
clinical care, poor governance, inadequate management systems, lack of effective controls, low
levels of organisational responsibility for actions and failures, and inadequate devolution of authority to
make effective operational decisions about patient care all have an impact on how effective skills are
deployed. The effectiveness of skills development and training programmes for middle and senior
207 Lehmann, U. 2008. “Strengthening Human Resources for Primary Health Care”. South African Health Review 2008. Health
Systems Trust. Published at www.hst.org.za/publications/841 (Accessed August 2010).
208 Faculty of Health Sciences. 2010. Faculty of Health Sciences Prospectus 2010. Mthatha: Walter Sisulu University. Published at
http://www.wsu.ac.za/academic/images/resources (Accessed August 2010); University of the Witwatersrand. Published at
http://web.wits.ac.za/Prospective/...../Health/UndergraduateDegreesAndDiplomas.htm. (Accessed September 2010)
209 Coovadia, H., Jewkes, R., Barron, P. et al. 2009. “The health and health system of South Africa: historical roots of current
public health challenges”. Lancet. September 2009. Vol. 374. Published at http://thelancet.com. (Accessed August 2010).
210 Hugo, J. 2005. “Midlevel health workers in South Africa – not an easy option” in Ijumba, P. and Barron, P. (eds). South African
Health Review 2005. Durban: Health Systems Trust. Published at http://www.hst.org.za/uploads/files/sahr05_chapter11.pdf
(Accessed August 2010); Lehmann, U. 2008. “Strengthening Human Resources for Primary Health Care”. South African Health
Review 2008. Health Systems Trust. Published at www.hst.org.za/publications/841 (Accessed August 2010).
211 National Treasury. 2010. “Vote 15: Health”. Estimates of National Expenditure 2010
212 Lehmann, U. 2008. “Strengthening Human Resources for Primary Health Care”. South African Health Review 2008. Health
Systems Trust. Published at www.hst.org.za/publications/841 (Accessed August 2010).
213 HWSETA. 2009. HWSETA Sector Skills Plan 2005-2010: Annual Update August 2009.
214 National Treasury. 2010. “Vote 15: Health”. Estimates of National Expenditure 2010.
215 Development Bank of South Africa. 2008. A Roadmap for the Reform of the South African Health System.
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managers is compromised as working environments are not conducive to change and innovation. 216
Other research found that poor treatment of doctors and other health professionals in the public sector
was the major reason for them leaving the public sector and the country. 217 If this situation does not
improve quite drastically, other interventions to retain staff and to increase the supply of skills may
prove to be ineffective.
5.8.3 MIGRATION OF PROFESSIONALS
Emigration of professionals and their migration from the public sector to the private sector directly
impact healthcare delivery and outcomes. Research has identified a number of factors that contribute
to increased emigration in the healthcare sector – including remuneration, working conditions, job
satisfaction, medical infrastructure, safety and risk of disease, along with more general concerns
regarding political stability, crime, and standards of service delivery. 218 South African health professionals
are a sought-after resource. 219 By 2007 more than 20 foreign commercial recruitment agencies were
working locally to recruit and place South African health professionals overseas. 220
Public sector health services in South Africa have been particularly hard hit by emigration and migration.
Migration inside South Africa takes place on two levels: from the public to the private sector and from
rural to urban public sector facilities. 221
Recent calculations estimated that up to 50% of the almost 2400 medical graduates for 2006 and 2007
would leave the country. Of the remaining 1200 approximately 75% would work in the private sector,
leaving about 230 to work in urban public facilities and perhaps 70 or 2.9% of the graduates to work in
rural public facilities. 222
Burnout due to a combination of workload, under-staffing, lack of resources, high-risk working
conditions, poor local hospital management and dysfunctional administration is another factor
contributing to public-private sector migration. 223 Doctors and nurses are often ill-prepared to work in
PHC facilities and complain of poor support while they work there. 224 In an attempt to address the
difficult working conditions, two trade unions – DENOSA and Solidarity – are calling for the introduction
216 Lehmann, U. 2008. “Strengthening Human Resources for Primary Health Care”. South African Health Review. Published at
www.hst.org.za/publications/841. (Accessed August 2010).
217 Wolvaardt, G., Van Niftnik, J., Beira, B. et al. T. 2008. “The Role of Private and Other Non-Governmental Organisations in
Primary Health Care” South African Health Review 2008. Health Systems Trust. Published at www.hst.org.za/publications/841.
(Accessed August 2010).
218 Macheke, C. 2010. HWSETA Health Sector Baseline Study.
219 Macheke, C. 2010. HWSETA Health Sector Baseline Study.
220 Bateman, C. 2007. “Slim Pickings as 2008 Health Staff Crisis Looms”. South African Medical Journal. November 2007. 97 (11).
221 Macheke, C. 2010. HWSETA Health Sector Baseline Study.
222 Bateman, C. 2007. “Slim Pickings as 2008 Health Staff Crisis Looms”. South African Medical Journal. November 2007. 97(11).
(Accessed August 2010).
223 Bateman, C. 2007. “Slim Pickings as 2008 Health Staff Crisis Looms”. South African Medical Journal. November 2007. 97(11).
(Accessed August 2010).
224 Coovadia, H., Jewkes, R., Barron, P. et al. 2009. “The health and health system of South Africa: historical roots of current
public health challenges”. Lancet. September 2009. Vol. 374. Published at http://thelancet.com. (Accessed August 2010); Day,
C. and Gray, A. 2008. “Health and Related Indicators”. South African Health Review. Health Systems Trust. Published at
http://www.hst.org.za/uploads/files/chap16_08.pdf. (Accessed August 2010).
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of legally enforceable nurse/patient ratios to bring nurses back to practise and to boost training outputs.
The implications are that if the nurse/patient ratio is reached, patients will either wait to be admitted, or
be refused treatment, or wards in under-staffed hospitals and facilities will have to close in order to
reach the prescribed nurse/patient the ratios. 225
5.8.4 THE IMPACT OF HIVAND AIDS
Workers in the health sector are required to treat, counsel and care for patients infected with HIV and
AIDS. Unlike workers in other sectors who risk HIV infection due to human and social behaviour, health
workers are exposed to additional infection risks in the workplace on a daily basis. The nature of their
work makes them more vulnerable to infection risks from HIV and tuberculosis. Surveys have found that
as many as 46% of in-hospital patients in the public sector may be HIV positive, while more than 36% of
private sector patients were infected. Exposure to these conditions increases the risks of illness and
premature death among staff and adversely affects worker morale. 226 In turn, service delivery in the
health system is affected by absenteeism, loss of skills due to preventable deaths, and the risk of neglect
as a result of increased patient load. 227
By 2002 an estimated 15.7% of health workers employed in the public and private sectors were living
with HIV and AIDS. Among younger health workers in the age group 18 to 35 years, the risk of infection
was higher and the estimated HIV prevalence was 20%. Non-professionals had a higher HIV prevalence
of 20.3% compared to professionals at 13.7%. Studies have recorded a high HIV prevalence among
nurses at 16%. Of the total number of health workers who died from 1997 to 2001, it was estimated
that 13% died from HIV and AIDS-related illnesses. 228,229
5.8.5 RECRUITMENT OF FOREIGN HEALTH WORKERS
Since 1994 the national DoH has entered into agreements with foreign governments (including Cuba,
Iran and Tunisia) to recruit and employ foreign doctors in the public health sector. The DoH also recruits
in the UK, where the number of medical graduates exceeds the number of registrar posts available. 230
An estimated 15% of the country’s public sector health posts are filled by foreign-qualified doctors, well
below the 25% norm applied in the UK and United States. Concerns were raised recently that a
225 Bateman, C.2009. “Legislating for nurse/patient ratios ‘clumsy and costly’ – experts”. South African Medical Journal. August
2009. 99 (8). Published at http://www.scielo.org.za/pdf/samj/V2009n8. (Accessed August 2009).
226 Lehmann, U. 2008. “Strengthening Human Resources for Primary Health Care”.South African Health Review. Health Systems
Trust. Published at www.hst.org.za/publications/841. (Accessed August 2010).
227 Shisana, O., Hall, E., Maluleke, J. et al. 2004. The Impact of HIV/AIDS on the Health Sector – National Survey of Health
Personnel, Ambulatory Patients and Health Facilities, 2002.
228 Shisana, O., Hall, E., Maluleke, K.R. et al. 2004. The Impact of HIV/AIDS on the Health Sector – National Survey of Health
Personnel, Ambulatory Patients and Health Facilities, 2002; Shisana, O. Hall, E., Maluleke R. et al. 2004. “HIV/AIDS prevalence
among South African health workers. South African Medical Journal October 2004. Vol. 94 (10). Published at
http://ajol.info/index.php/samj/article/view/13643. (Accessed August 2010).
229 Macheke, C. 2010. HWSETA Health Sector Baseline Study. Coovadia, H., Jewkes, R., Barron,P. et al. 2009. “The health and
health system of South Africa: historical roots of current public health challenges”. Lancet. September 2009. Vol. 374. Published
at http://thelancet.com. (Accessed August 2010).
230 Bateman, C. 2007. “Slim Pickings as 2008 Health Staff Crisis Looms”. South African Medical Journal. November 2007. 97(11),
pp 1020-1024.
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substantial number of foreign doctors (an estimated 300) are qualified, skilled and available in South
Africa to serve in the public sector, but that bureaucratic delays (specifically in the registration with the
respective professional councils) are preventing their deployment. 231
The DoH will continue to cooperate with countries that have an over-supply of healthcare professionals
and recruit foreigners to be deployed in the public sector and adopted a new policy in 2009, which is
aligned to international recruitment protocols. 232
5.8.6 SOCIO-ECONOMIC REALITIES OF POTENTIAL LEARNERS
Lastly, prevailing socio-economic realities and the lack of equal educational opportunities for different
population groups continue to impact the number of African black learners who enter the health
professions. Long training periods mean that aspiring health professionals forego earning an income for
many years and this deters people especially persons from lower socio-economic positions from
entering the professions. The relatively high costs of education in the health sciences, compared with
other tertiary programmes, may also affect the supply of skills.
5.9 CONCLUSIONS
A combination of complex factors influences the supply of skills to the health sector. At the heart of the
problem are the number and quality of learners who complete high school. The secondary school
system is producing fewer candidates with the combination of mathematics, physical sciences and/or
life sciences required to enter tertiary-level studies in the health sciences. Quality standards of
education in mathematics, physical sciences and life sciences are major supply-side constraints
impacting on the skills of the health sector. Sub-standard levels of literacy and numeracy skills of school
leavers and their poor level of readiness for tertiary studies further reduce the supply pool.
Existing institutional arrangements and regulatory provisions regarding the training of health
professionals also restrict the supply of skills to the sector. Most of the health professionals who are
required to register with the HPCSA, the SANC, the SACP and the SAVC are trained by universities and
universities of technology, and undergo practical training in state-owned academic health complexes.
Production levels at these institutions are limited because of capacity and budget constraints.
Opportunities to train healthcare professionals in the private sector are limited as private HEIs appear to
be challenged in meeting the extensive accreditation requirements for the training of health
professionals set by the professional councils and the HEQC.
With the exception of basic health care sciences, the growth in supply of new graduates from the higher
education system has been moderate, and even low over the last decade. This trend is carried through
to the registration of health professionals with their respective professional councils. The average
231 Bateman, C. 2010. “Ham-fisted policies, overworked officials put foreign doctors ‘on ice’”. South African Medical Journal.
March 2010. 100 (3). Published at http://www.scielo.org.za/pdf/samj/V100n3. (Accessed August 2010).
232 Department of Health. 2010. “Health Sector Strategic Framework: The 10 Point Plan” in the Strategic Plan 2010/11-2012/13.
Published at http://www.doh.gov.za. (Accessed August 2010); National Treasury. 2010. “Vote 15: Health”. Estimates of National
Expenditure 2010.
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annual growth rate in professional registrations across key occupational categories has also been low,
and in some instances lower than the growth rates in graduates produced for the particular professional
category.
The HWSETA also contributes to skills formation in the health sector. Since 2002 more than 25 000
learners enrolled on health-related learnerships. More than 7 000 have completed learnerships at the
time of writing this SSP, and were recorded on the HWSETA’s electronic system. Many more completed
learnership that are quality assured by professional councils and their achievements are recorded by the
councils and not by the HWSETA. The SETA also support skills development through internships and
workplace training programmes, skills programmes, ABET and small enterprise development.
The supply of skills to the health sector is not only determined by capacity at training institutions and
the scope of training activities. Health workers risk exposure to HIV and AIDS in the workplace and face
increased risks of contracting the disease compared with workers in other sectors. By 2002 the
prevalence rate of HIV and AIDS among health workers was 15.7%, much higher than the national
prevalence rate at the height of the pandemic in 2010. As a result of AIDS, skilled health workers leave
the sector prematurely – either because they fear infection, become ill themselves or need to care for
others who fall ill.
Many of the government’s positive strategies to improve the supply and retention of skills in the sector
may be compromised by budget constraints and various institutional problems such as weak
management systems, sub-functional working environments and poor human resources practices. The
information presented in this chapter shows that unless major improvements in leadership and
management of the health system at all levels are made, migration of health professionals out of the
public sector and emigration to other countries are likely to drain the supply of skills for the
considerable future.
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6 SKILLS DEVELOPMENT PRIORITIES OF THE HWSETA
6.1 INTRODUCTION
Throughout this SSP the health sector has been portrayed as a sector faced with enormous challenges,
with skills problems are at the heart of many of these challenges. The nature and magnitude of the
challenges are such that they can only be addressed through a very concerted and, as far as possible,
integrated effort of a host of role-players including the national departments of health, Higher Education
and Training, the higher education sector, private education and training providers, public and private
health facilities, and the HWSETA.
As the HWSETA is only one of a number of institutions tasked with the funding and provision of skills
development for the health sector, it is important to outline the specific role that the SETA will play in
the next five years. At the same time the SETA forms part of the institutions that have to deliver on
NSDS III. This chapter outlines the areas on which the HWSETA will focus in the five-year period covered
by NSDS III and its contribution to government’s objectives. The specific contributions that are
discussed are: the contribution to government’s Medium Term Strategic Framework (MTSF) objectives,
the contribution to the strategic areas of focus for the NSDS III and the contribution that will be made to
the President’s outcomes approach to planning government’s work.
6.2 CONTRIBUTION TO GOVERNMENT’S MTSF OBJECTIVES
Government’s MTSF have ten priorities, two of which are central to the work of HWSETA – Priority 4,
which is to strengthen the skills and human resource base, and Priority 5, which is to improve the health
profile of all South Africans.
In previous chapters of this SSP various strategies and plans of government to improve the health
system have been discussed. The HWSETA will continue to work closely with the DoH and will support
the department’s health strategies through skills development. Within its own mandate and budgetary
allocations the SETA will contribute to the supply of larger numbers of health workers equipped with the
skills necessary to improve health care in South Africa.
6.3 SECTORAL CONTRIBUTION TO STRATEGIC AREAS OF FOCUS FOR NSDS III
This section outlines the HWSETA’s contribution to the strategic areas of focus for the NSDS III period.
The section refers specifically to the HWSETA Strategic Business Plan 2011 – 2016 to which the SSP is
attached. In the discussion the specific line items in the Business Plan are referenced.
6.3.1 EQUITY IMPACT
The analysis of the health sector presented in the previous chapters clearly shows that the current
shortages of skills in the public health sector lead to massive inequalities in terms of access to proper
healthcare and the perpetuation, and even the intensification, of inequalities in South African society.
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Therefore, the HWSETA’s skills development interventions will be strongly focused on the alleviation of
skills shortages and the development of new skills that can intervene in the poorest and most under
serviced areas of the country and segments of the population.
Skills-development support and interventions will also give preference to historically disadvantaged
individuals – specifically in the professions where the racial profile is still skewed.
The SETA will also implement a special programme for people with disabilities (Strategy line 15).
6.3.2 CODE OF DECENT CONDUCT
The HWSETA intends to develop, in collaboration with its skills development delivery partners, a code of
decent conduct, to popularise this code through stakeholder capacity-building interventions and to
establish mechanisms to deal with non-compliance (Strategy line 20)
6.3.3 LEARNING PROGRAMMES FOR DECENT WORK
a) Programmes to facilitate access, success and progression
In Chapter 5 of this SSP the problems experienced at school level were highlighted. Of particular
concern is the inadequate quality of education and the fact that learners enter the health-specific
occupational programmes unprepared, which leads to high dropout and failure rates. In view of the
enormous scarcity of skills such wastage in the educational system needs to be contained. In the
planning period the HWSETA will, in collaboration with universities and FET colleges that offer healthrelated
training, develop or fund general bridging courses and specific bridging courses in mathematics
and science (Strategy lines 2 and 3).
The HWSETA will also work with universities on an undergraduate support strategy for health
professional training that will be aimed at increasing the pass rate of undergraduate students (Strategy
line 5).
b) Information and career guidance
The HWSETA will develop a structured career guidance strategy at the beginning of the period covered
by NSDS III. The aim will be to reach as many school learners (grades 7 to 12) as possible and to create
awareness of the occupations in the health sector at all levels. Special attention will be given to
occupations in which skills shortages are experienced and new mid-level occupations that are being
created to alleviate the shortages of professionals (Strategy line 1).
c) Recognition of prior learning
As explained in Chapter 5 of this SSP the HWSETA has already made progress in terms of the
development of RPL mechanisms and the implementation of RPL processes. In this planning period it
will continue with this work in collaboration with the professional bodies in the sector. The key focus
81

will be on the development and implementation of an RPL support strategy and the development of
national assessment centres for the implementation of the strategy (Strategy line 12).
d) Raising the base
The HWSETA will support vocational adult basic education in order to assist people who were previously
excluded from formal education to improve their qualifications (Strategy line 4).
6.3.4 PIVOTAL OCCUPATIONAL PROGRAMMES
Pivotal programmes are “professional, vocational, technical and academic learning” programmes that
meet the critical needs for economic growth and social development. They are also programmes that
generally combine course work at educational institutions with structured learning at work. In the
health sector most of the entry-level learning paths can be classified as pivotal programmes.
In this planning period the research unit of the HWSETA will undertake research to identify the
occupations that need to be supported through the proposed Pivotal Grant (Strategy line 6). The
HWSETA will also accredit workplaces for delivering the workplace components of pivotal programmes
and it will address the skills development needs of staff involved in the delivery of the workplace
experience part of pivotal learning programmes (Strategy line 7).
Learnerships are well established forms of pivotal learning programmes and the HWSETA will publicise
the scarce skills identified in this SSP and the learnerships that provide entry to these occupations. It
will also make discretionary funding available for learnership support (Strategy lines 8 and 13).
The HWSETA will also make bursaries available from its discretionary funding and will publicise the
availability of the bursaries linked to information on scarce skills (Strategy line 16).
Another intervention in the suite of strategies to support pivotal learning programmes is the
development of a strategy to provide unemployed graduates with workplace placements and workplace
exposure. This strategy will be implemented in cooperation with the employers in the sector (Strategy
line 17).
Lastly, the HWSETA will develop a postgraduate internship support strategy that will assist postgraduate
students to obtain placement in workplaces in the sector (Strategy line 18).
6.3.5 SKILLS PROGRAMMES AND OTHER NON-ACCREDITED SHORT COURSES
The HWSETA will publicise the list of available HWSETA skills programmes and make discretionary
funding available for skills programme support (Strategy lines 9 and 14).
The SETA furthermore intends to develop a register of short courses for the health sector, develop a
support strategy for learners on short courses and publicise the WSP-based pivotal funds available for
non-accredited short courses (Strategy line 10).
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In Chapter 5 it was mentioned that professionals in the health sector are obliged to undergo CPD in
order to retain their professional registration. The professional bodies in the sector accredit providers
of CPD. In the NSDS III period the HWSETA will develop and implement a CPD support strategy with the
assistance of and in cooperation with the professional bodies (Strategy line 11).
6.3.6 PROGRAMMES THAT BUILD THE ACADEMIC PROFESSION AND ENGENDER
INNOVATION
In Chapter 5 of this SSP the pressure under which the academic institutions in the health sector find
themselves was highlighted. In the five-year period covered by NSDS III the HWSETA will place a strong
focus on supporting the development of academic capacity and innovation. This will be done through
postgraduate bursary support, which will be formulated in a coherent strategy (Strategy line 19).
6.3.7 STRENGTHEN OUR OWN CAPACITY AND THAT OF OUR DELIVERY PARTNERS
A strong focus of the HWSETA will be on the development of the training capacity in the sector. This
development will take many forms, including the accreditation of training providers (and assistance to
those who aspire to become accredited) and the development of the “pillars” of accreditation (e.g.
assistance with the development of quality management systems and the training and registration of
assessors and moderators. These interventions will focus on both the public and private providers of
health-related education and training. The SETA will also provide similar assistance to workplaces to
become accredited learning sites (Strategy line 21).
Lastly, the HWSETA will undertake the development of qualifications and learning materials in areas of
learning that fall within its scope, with special emphasis on areas that will help with the alleviation of
skills shortages (Strategy line 22).
6.4 CONCLUSIONS
The skills development priorities and interventions set out in this chapter will be further developed and
implemented within the available funding of the SETA. The success and impact of these strategies and
interventions will be assessed on a continuous basis and the overall strategy and business plan will be
revised on an annual basis.
83

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92

APPENDIX A
SCARCE SKILLS LIST – PRIVATE ORGANISATIONS AND PUBLIC SERVICE DEPARTMENTS
The table includes only occupations in which 15 or more people are needed. (Some of the OFO codes
may seem inappropriate but were chosen by employers in the absence of appropriate codes on the
OFO)
OFO Code
OFO description
Private
health
scarce
skills
Public
health
scarce
skills
111402 General Manager Public Service 19 0 19
132201 Finance Manager 3 256 259
135101 Chief Information Officer 0 300 300
221101 Accountant (General) 1 17 18
233102 Chemical Engineering Technologist 0 15 15
234601 Medical Laboratory Scientist 78 60 138
251101 Dietician 0 718 718
251201 Medical Diagnostic Radiographer 26 345 371
251202 Medical Radiation Therapist 2 59 61
251 203 Nuclear Medicine Technologist 0 18 18
251204 Sonographer 12 8 20
251301 Environmental Health Officer 0 136 136
251401 Optometrist 0 179 179
251501 Hospital Pharmacist 122 1 411 1 533
251503 Retail Pharmacist 301 326 627
251901 Health Promotion Officer 0 18 18
251902 Orthotist or Prosthetist 233 0 38 38
252301 Dental Specialist 0 285 285
252302 Dentist 1 643 644
252401 Occupational Therapist 6 375 381
252501 Physiotherapist 1 852 853
252701 Audiologist 0 69 69
252702 Speech Pathologist 0 306 306
253101 General Medical Practitioner 34 3 471 3 505
253201 Anaesthetist 0 19 19
253301 Specialist Physician (General Medicine) 0 414 414
253315 Clinical Pharmacologist 6 15 21
253902 Emergency Medicine Specialist 0 372 372
253905 Pathologist 41 30 71
Total
233 OFO description to be verified
93

OFO Code
OFO description
Private
health
scarce
skills
Public
health
scarce
skills
253906 Radiologist 12 392 404
253910 Specialist in Rehabilitation Medicine 0 1 683 1 683
254101 Midwife 0 387 387
254201 Nurse Educator 8 86 94
254301 Nurse Manager 5 26 31
254401 Clinical Nurse Practitioner 0 5 770 5 770
254402 Registered Nurse (Aged Care) 26 0 26
254403 Registered Nurse (Child and Family Health) 59 10 69
254404 Registered Nurse (Community Health) 41 21 62
254405 Registered Nurse (Critical Care and Emergency) 259 470 729
254407 Registered Nurse (Disability and Rehabilitation) 5 25 30
254408 Registered Nurse (Medical and Surgical) 786 6 419 7 205
254409 Registered Nurse (Medical Practice) 46 2 48
254410 Registered Nurse (Mental Health) 11 30 41
254411 Registered Nurse (Preoperative) 31 0 31
254412 Registered Nurse (Surgical) 3 515 518
262102 ICT Security Specialist 0 15 15
272107 Trauma Counsellor 0 22 22
272301 Clinical Psychologist 0 51 51
272501 Social Worker 52 149 201
311203 Medical Laboratory Technician 46 9 55
311205 Pharmacy Technician 234 120 0 120
311 208 Mortuary Technician / Assistant 0 137 137
311 213 Medical Electronic Equipment Operator 0 43 43
313102 ICT Customer Support Officer 39 0 39
331 201 Carpenter and Joiner 0 18 18
331202 Carpenter 0 15 15
334101 Plumber (General) 0 141 141
341101 Electrician (General) 0 46 46
411101 Ambulance Officer 50 344 394
Intensive Care Ambulance Paramedic / Ambulance
411102 Paramedic 25 423 448
411401 Enrolled Nurse 1 372 496 1 868
411502 Ancillary Health Care Worker 20 0 20
411701 Community Worker 237 0 237
Total
234 OFO description to be verified as there are non registered in South Africa
94

OFO Code
OFO description
Private
health
scarce
skills
Public
health
scarce
skills
411705 Residential Care Officer 30 0 30
423201 Dental Assistant 0 30 30
423302 Nursing Support Worker 9 162 171
423304 Therapy Aide 0 18 18
441201 Emergency Service and Rescue Official 0 44 44
531101 General Clerk 0 87 87
621401 Pharmacy Sales Assistant 22 705 727
Total
2010 WSP data
95