In 2014, Benedictine, a 403-bed district hospital, was plagued by severe staff shortages with only six South African doctors serving a catchment population of 270 000. Without the doctors it required, the facility was battling to deliver quality healthcare services to all its patients.
Zululand is a deeply rural district in the north-eastern part of KwaZulu-Natal. It is one of the poorest districts in South Africa with a high number of HIV and TB patients increasing the burden on understaffed public health facilities in the area. The district has a TB incidence rate of 930.6 per 100 000 people ─ the sixth highest rate nationally. The 2012 Antenatal Sero-prevalence Survey showed a decrease in the antenatal HIV prevalence from 39.8% in 2010 to 35% in 2012. However, this is still higher than the national average of 29.5%.
The hospital is located in Nongoma, approximately 300km from Durban. The name of the town is derived from the Zulu word, “ngome” ─ the mother of songs.
The scenery surrounding the hospital is far removed from the province’s popular beaches, beautiful coastline and sub-tropical forests. The tourism attractions and natural beauty of KwaZulu-Natal are usually major selling points to draw doctors. However, Benedictine’s location made it more challenging to promote the hospital using the attractions traditionally associated with KwaZulu-Natal.
How did AHP attract doctors to such a remote facility?
We used our extensive experience to source and match the right candidates to respond to Benedictine’s desperate call for more doctors.
Firstly, we connected with the needs on the ground by visiting the hospital regularly to build relationships with hospital management. When it comes to recruitment, we partner with public sector stakeholders through all levels within the health system: From the minister’s office through to provincial health departments, district offices, and healthcare facilities. The resolution of staffing shortages is critically dependent on such successful partnerships. Our efforts at Benedictine were characterised by strong partnerships between AHP and the passionate managers at the hospital who were committed to filling the vacancies in order to improve patient care.
Secondly, we know that doctors require credible and accurate information about a healthcare facility to make an informed decision about where they want to work. Our Recruitment Officer was proactive in sharing information about Benedictine with candidates. She created a profile of the hospital, including services offered and tourism-related information, to attract doctors to the area. From our extensive experience in recruitment and insights from market research we have learnt that doctors are attracted by the lifestyle opportunities South Africa offers, the clinical experience they can gain, and the chance to make a difference to communities that need assistance. These three selling points were emphasised in the profile.
Thirdly, we do not follow a ‘one size fits all’ recruitment approach. We know that doctors have rational and emotional reasons for undertaking the journey to South Africa and we ensure we meet each doctor’s unique needs during our sourcing process. Our Recruitment Officer connected with doctors who expressed an interest in working at Benedictine and provided relevant information which enabled them to feel secure in their decision to join the hospital. Each doctor was selected for the contribution they could make to specific departments, including obstetrics and gynaecology, HIV, general medicine and paediatrics. Our Recruitment Officer emphasised the difference these doctors could make in such an incredibly underserved area and highlighted the opportunity to gain specific clinical experience in their area of interest and to initiate research projects.
Our assistance to these doctors did not end with making them aware about the benefits of working in South Africa’s rural areas, but also included supporting them with the registration process to work in the country. AHP works with the Health Professions Council of South Africa (HPCSA) and the National Department of Health’s Foreign Workforce Management Programme (FWMP) to support the registration process.
The result: A melting pot of skills
Our recruitment approach yielded impressive results. Between August 2014 and January 2015, we recruited nine doctors to join the six local doctors at the hospital: A volunteer from the United States of America (US) who volunteered for three months, four doctors from the UK, and two doctors each from Zimbabwe and Holland respectively.
The core team of our internationally-qualified doctors alleviated the pressures of the staffing crisis and helped the facility to attract more local skills. At the beginning of 2015 the provincial Department of Health allocated two community service officers to the facility. These junior doctors were attracted to the hospital after they became aware through the word-of-mouth network that exists among health workers that Benedictine had received more doctors. The increased capacity meant they would be part of a supportive team and be mentored by more senior doctors. Having more doctors at the facility made an enormous impact on the quality of care patients receive. Queues were much shorter and the morale of staff visibly improved.
Dr Siphesihle Mkhize, who completed his community service year at Benedictine in 2010, says human resources are key to improving services: “We pulled through, but now that we have more passionate people we can provide better service to our patients. When patients are happy, doctors are happy. We are able to strengthen primary healthcare and do outreach in the community. We just needed more people and now that the people are here we can focus on delivering a more efficient service”.
Asked why he stayed on at such a remote facility after his community service year, Mkhize echoes what so many other doctors working in rural health say: “I felt I could make a difference”.
What motivated the foreign-qualified doctors to choose Benedictine?
British doctor Dr Michael Ball says he picked the facility because he was eager to work in a different medical environment. “I wanted to work somewhere where I could have a positive impact. We heard the hospital was underserved and that’s why we came.”
Dr Anthony McKie, also from the UK, was motivated by a sense of adventure and the opportunity to make a difference. “It’s easy to be disillusioned by paperwork. I was motivated by the challenge of doing something different. If you work in an urban area, it would be quite similar to back home. Rural is completely different and you learn resilience.”
Working in rural South Africa also offers foreign-qualified doctors the opportunity to gain unparalleled clinical experience. The generalist nature of the medical services required in rural hospitals provides doctors with excellent exposure to the full range of primary medical disciplines, including obstetrics and gynaecology, anaesthetics, surgery, and internal medicine. This allows them to develop proficiency in a wide range of medical fields. In addition, they gain invaluable experience in the treatment of patients in advanced stages of diseases such as HIV/AIDS, as well as exposure to emergency situations, including violent trauma and birth complications, which are not prevalent in their home countries. Dr Trevlen Moodley, Benedictine’s Medical Manager says: “The number of C-sections that the doctors were exposed to in one month during their induction equals the number of procedures they would see in two to three years in the Netherlands. In South Africa you learn to make decisions and work independently”.
Dr Akkelien de Vries from Holland says she has acquired valuable new skills since joining Benedictine in October 2014. “I was trained in obstetrics and gynaecology and had to work in the outpatient department. I learnt a lot. Each patient was a steep learning curve.”
Orientation key to ensuring successful transition to rural South Africa
Our support to the facility did not end with sourcing and placing these doctors. An important component of our Recruitment Programme is the implementation of a structured Orientation Programme to prepare internationally-qualified doctors for life in a rural environment and ensure that the transition from their home country to rural South Africa is as stress-free as possible.
Our Orientation Programme aims to orientate and effectively integrate these doctors into their team and community during their stay in South Africa and focuses on clinical, cultural and logistical orientation. Effectively orientating international health workers can contribute to retaining more health workers in rural areas.
As part of the Orientation Programme, we host regular contact orientation sessions for foreign-qualified doctors. As part of these orientation sessions, doctors attend a three-day workshop on the integrated management of TB, HIV and sexually transmitted infections to prepare them for South Africa’s disease burden. Local experts give clinical talks to alleviate any anxiety these doctors might experience about working in a rural area and doctors participate in cultural activities to introduce them to the cultural and historical landscape that informs South African life. They also receive an orientation satchel comprising medical books and other resources. Seven of the doctors placed at Benedictine attended an AHP contact orientation session.
To assist the doctors to acclimatise to a new country and medical system, we also arranged that the newly placed foreign-qualified candidates spent their first week at Benedictine to understand their environment and then the subsequent four weeks at the surrounding referral hospitals (Ngwelezane Hospital and Lower Umfolozi Memorial Hospital). This gave the doctors time to adapt to the realities of the South African public healthcare sector before they formally started their roles at the more rural Benedictine. Doctors also got to know the consultants at these facilities which they now call for advice on complicated cases. The AHP-doctors say this induction helped them tremendously to adapt to working in a rural hospital.
Our partnership with the South African Department of Health has brought together a melting pot of doctors from four different countries that are working together as an effective team to improve patient care in rural Zululand. Dr Moodley sums up the benefits of having such a unique team: “Everyone has something to contribute. We mix and match our skills”.
 All these doctors, excluding the volunteer, still worked at the facility in June 2015 when this case study was conducted.
Nongoma map credit: Weather Forecast
Photo credit: Road into Nongoma by kind permission of Hugh Bland.