Effie Schultz

 Human Resources for Health
Human Resources for Health

In the course of an audit of the chronic non-communicable disease care services at Alexandra Health Centre and University Clinic in Johannesburg, I met dedicated but untrained lay health workers who were frustrated by their lack of appropriate knowledge, clinicians who had no confidence in their ability to manage chronic diseases, and patients eager to learn how to care for themselves. In other words I identified a lack of appropriately trained personnel. In the previous two decades I had formulated at several clinics, which I had established in both urban and rural settings, a staff training programme and service methodology that could be successfully deployed even in poorly resourced areas without doctors. I now wanted to set up a cadre of medical service providers based on my deliberately monitored and evaluated experience that could help meet the challenges of the emerging chronic communicable and non-communicable disease pandemics.

In November 1996 I sent proposals for the training, registration and deployment in South Africa of two new categories of medical service providers (primary care clinicians and health educators) and one medical sub-specialty (chronic disease care specialists) to academic, professional and government institutions for their consideration and supportive action. The proposals were situated within a new service paradigm more appropriate to local needs and resources than the current one which was foisted onto colonial and working class people by a dominant bourgeoisie with its hierarchies and individualist values where health is regarded as a marketable commodity. The proposals made provision for horizontal and upward mobility in qualifications and practice, and in the case of chronic disease care specialists for specialisation appropriate to different levels of care. They addressed the different grades and levels of care as well as the possible extended roles of the new categories and offered a partial solution for poor staff retention in underserved areas and for poaching by industrialised countries of staff trained elsewhere.

Discussions in the Department of National Health and with Prof William Pick and other important role-payers as well as presentations at academic seminars and professional conferences prompted revisions and reformulations.

There was no uptake. Perhaps the matter will be revisited as the need for a new service paradigm and new categories of medical service providers still exists and the related problems of staff retention in rural and remote areas and the poaching of trained staff are no nearer to resolution.

  1. New Categories of Medical Service Providers. 1996 — 2001
    Proposals for the training, registration and employment of primary care clinicians, health educators and chronic disease care specialists, and comments on discussions with senior government role-payers.

    View PDF file 162KB


  2. Primary Care Clinicians. September 2000
    Primary Care Clinicians - a medical manpower option. Presentation made to the Department of Community Health at the University of the Witwatersrand. NBD Magobe, E Schultz and M Sefoka.

    View Slide Presentation 122KB


  3. Medical Care Providers. August 2006
    Medical Care Providers. Shuffling and Stumbling or Forging Forwards. Presentation at the 10th Annual Conference of Rudasa (Rural Doctors Association of Southern Africa). There is widespread concern about the shortage of trained, competent and caring personnel to promote health and prevent and manage disease.

    There is a serious nursing crisis due to under-staffing, difficult working conditions and discordance between training and responsibilities. There is a shortage of medical manpower with nurses deployed as proxy doctors. Rural areas and poverty-mired, high density urban and peri-urban areas and informal settlements are dangerously under-served. Primary care clinicians and nurses are not being replaced by new recruits and the attrition rate of existing staff is high. People trained in poor countries are being poached by rich countries. The same applies to members of allied professions. The training and deployment of assistants - soon apparently also medical assistants - will not solve the problem and may create others.

    Medical care is increasingly unaffordable even in affluent countries due often to ineffective or delayed primary care with consequent increased disease severity. There is little professional guidance on healthy living, but a lot of possibly deliberate mis-information fuelling epidemics of non-communicable diseases. These will exacerbate human resource insufficiencies and health system difficulties.

    This presentation offers a solution! It is predicated on a paradigm shift in health promotion and disease management systems in both ambulatory and in-patient care. Service will be provided by doctor-led teams which must include health educators. Nurses will have supporting roles only. A chronic disease care model, based on continuity of care, a mutually respectful and empathetic patient-carer relationship, good communication and informed, empowered patient participation, will be followed.

    Human resource categories are re-defined and rationalised. A new arrangement for outcomes-based, tiered training of clinicians is outlined. Criteria for admission, curriculum, duration of training, internship and registration are outlined.

    View Slide Presentation 128KB


  4. Health Educators. August 2006
    Health Educators. Proposals for their expanded role, training, registration, and deployment. Poster presentation at the 10th Annual Conference of Rudasa (Rural Doctors Association of Southern Africa).

    The need for education and advice on health and disease is currently met in South Africa on an ad hoc basis by over-worked, un-skilled doctors and nurses and a host of assorted, often unpaid, un-registered care-givers, counsellors, lay health workers, community health workers and others, variously trained and deployed by miscellaneous non-state organisations.

    Health Education can be defined as a scientific discipline encompassing the theory and practice of educating and informing people about health and disease, and a Health Educator can be defined as somebody formally trained in Health Education and working within a regulated and accountable framework. Health Education is not synonymous with community health work. It is a discipline in its own right. It may have been discredited in South Africa in the past because of its top-down political subtext and its non-participatory, didactic approach but it should be re-claimed and embraced in a transformed format in the new South Africa.

    The Department of Health in its publication, National Human Resources Plan for Health, dated April 2006 refers to pressure to create new categories of health professionals - mostly mid-level assistants. It does not mention Health Educators.

    The need for Health Educators, their role in medical facilities, in patients' homes, in community structures and at places of work, and their relationship with other health workers is outlined. Criteria for admission to training, scope of practice, required competencies, syllabus, internship, qualifications, certification, registration with a controlling body, deployment, career path and up-grading are presented. The option of transferring to health education from related disciplines and of incorporating the burgeoning list of assistants and the new category of community health worker into the rubric of health education is noted.

    View Slide Presentation 89KB


  5. Community Health Workers. November 2005
    Community Health Workers. Correspondence with Dr Irwin Friedman from The SEED Trust, Botha's Hill in KwaZulu Natal.

    View PDF file 80KB


  6. Community-Based Health Workers. November 2005
    Comments on an article on the utilisation and effectiveness of community-based health workers in Africa which was co-authored by Dr Irwin Friedman.

    View PDF file 61KB


  7. The Future Role and Training of Doctors. October 2001
    Comments on a presentation in March 2001 to a South African Medical Association Conference on the Future of Medicine by Prof Max Price, Dean of the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg. entitled "What is the Future Role of Doctors and How Should We Train Them".

    View PDF file 81KB


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