Experiences of public health - push and pull factors


AHP conducted interviews with four local and foreign-qualified doctors to determine what factors attracted them to South Africa and what factors could potentially push them away from working in the public sector. 

Some of the main issues raised:

  • Pull factors

The relaxed lifestyle in rural areas, South Africa’s natural beauty, and gaining medical experience in a different healthcare setting were the main reasons foreign-qualified doctors came to South Africa. Doctors from African countries came here more out of necessity – political and economic reasons play a bigger role in their decision to work in South Africa. A local doctor that made the move to the public sector after working in the private sector for years mentioned the desire to make a difference and treat patients that really needed medical care. He also mentioned the work satisfaction and the relaxed lifestyle as major attractions. Although language barriers and staff shortages were mentioned as barriers, foreign-qualified doctors also said that these challenges attracted them to South Africa.

  • Push factors

Money was not mentioned as a major factor. Two doctors mentioned struggling with different drug names as an initial challenge. A Nigerian doctor said that management, especially in deep rural areas, don’t always recognize the important contribution made by foreign-qualified doctors in improving healthcare. Another Nigerian doctor complained about the lengthy exam process and the lack of guidance on the actual exam.  


UK doctor working in KwaZulu-Natal for less than six months

AHP: Why did you come to South Africa?

Doctor: “I wanted to work in a different healthcare setting and have more responsibility than at home. I thought it would be interesting to work with a different patient group. I wanted to come to a country that had good facilities. We also heard from friends of friends about South Africa. It sounded scary and interesting. On a personal level, we wanted adventure and to explore a new country. We also wanted to go to the beach and meet new people.”

AHP: What has the working conditions been like?

Doctor: “We went through a period of adjustment. The biggest adjustment was to get used to working in a different setting. Drugs in South Africa, for example, are not called their generic name, but by the name they are marketed under. We are not taught that in the UK. It took a while to get used to that. You also have to work more independently and be more self-reliant.”

AHP: Has the clinical work been very different from what you would do in the UK?

Doctor: “There’s a lot more obstetrics. It’s good for bread and butter, but nothing very complex. You see a lot more extreme pathologies.”

AHP: Is the hospital a welcoming environment?

Doctor: “We’ve been welcomed. Because of staff shortages, they have been glad to get doctors from abroad. It’s been nice. The nurses have also been very welcoming.”

AHP: Has coping with staff shortages been challenging?

Doctor: “We are a little protected in the theatre. You can only see one patient at a time. There are also similarities with the UK. There are still hospital politics and not enough beds. It’s a bit more extreme. The waiting time is longer. A big difference is the language barrier. Most patients speak Zulu and you have to get an interpreter. It makes it interesting. That’s why we didn’t go to Australia. It would be too similar to the UK.”

AHP: Has it been difficult to cope with the lack of resources?

Doctor: “You have to be more inventive and find ways around a problem. The good news is we just got an ultra sound machine. Anaesthetics is less chaotic than casualty.”

AHP: When would you say is a good time to come to South Africa?

Doctor: “It depends on your life. We had a specialist skill and didn’t feel that we would put our patients at risk or that we would be set loose. We had good training, but not much responsibility. We have more responsibility now and we have to get used to that. We can also teach and give back. When you are a junior doctor your life is less complicated. There are no kids or mortgage. You need more supervision, but people learn quickly over here.”

Nigerian doctor working in KwaZulu-Natal for more than five years

AHP: Why did you come to South Africa?

Doctor: “I worked in another African country for about three years and wanted to explore. In the public sector the patients are so diverse. You get to meet different patients. It’s the best place to learn.”

AHP: Was it difficult to adapt?

Doctor: “In the other country I initially had difficulties in being accepted by the nursing staff. I didn’t have a problem with the doctors. Once I was there for seven or eight months I settled down and I was accepted.  I had no issues and they were sad to see my leave. I came to South Africa and I was well-accepted.”

AHP: Have you experienced any form of xenophobia in South Africa?

Doctor: “During the first six or seven months I felt I was not always understood. I did have a supportive medical superintendent though. I was well-received. Apart from the first months, I haven’t experienced xenophobia.”

AHP: What about outside the hospital? Do people accept foreigners?

Doctor: “They will know I’m a foreigner because I don’t speak conversational Zulu. I don’t see it as an issue. People are quite tolerant. At both hospitals I’ve worked at I’ve been well-received. I haven’t seen anything.”

AHP: Are deep rural hospitals perhaps less accepting of foreign-qualified doctors?

Doctor: “I have heard of foreign-qualified doctors complaining in rural areas. Management has not been so receptive. Even CEO’s complain about the competencies of foreign-qualified doctors. I won’t say there’s 100% acceptance. South African doctors are reluctant to work in rural areas and management accepts this reality. For the most part foreign-qualified doctors are accepted. Not speaking the local language can make it more difficult.

“Individual managers can also make a difference. I attended a conference where a hospital CEO had a negative perception about foreign-qualified doctors and the CEO probably had some justification for this perception. I, however, said to delegates that that is a generalisation. In rural hospitals even the medical managers are often foreigners. Mostly they are well-respected and people are tolerant. South Africa needs foreign-qualified doctors, but foreign-qualified doctors don’t always feel welcomed. I must say, generally in the last five years I haven’t had any issues, but I’m only one person.”

Nigerian doctor working in KwaZulu-Natal for less than six months

AHP: Why did you come to South Africa?

Doctor: “When you are in Africa, people are generally curious about South Africa. The history kept it in your awareness. There was that kind of attraction.”

AHP: Why did you want to leave Nigeria?

Doctor: “For me there were compelling reasons. I was involved politically. Things moved on. If for instance your enemy gets into power, you are compelled [to leave]. In Africa a lot of things can go wrong. I was basically looking for a place to go into exile.”

AHP: What is the management like?

Doctor: “The guys are overworked and they are trying to cope. When they recruit people it’s only for replacements. It’s not reducing the workload. The hospital is always understaffed and it affects everything. It’s not their fault. Management is trying, but they are struggling in the face of an overwhelming workload.”

AHP: What is the pay like?

Doctor: “It was not about the salary for me. I was just looking for a nice quiet place where I could work and stay under the radar.”

AHP: What is the relationship like between local and foreign-qualified doctors?

Doctor: “It’s different case by case. If you are a foreign-qualified doctor you go through an initial period of struggle. You struggle with patients, you struggle with understanding the language. If you are a local homeboy you can take more chances. Foreign-qualified doctors are often more mature. A lot of things could have happened to them before they came to South Africa. Obviously I don’t feel happy that there are positions I can’t go into. I guess that’s the way things are everywhere. There’s nothing you can do.”

AHP: Is there tension between locals and foreign-qualified doctors?

Doctor: “Working relationships are an individual thing. You get nice doctors and some people are not nice. It varies. Things are called different names. Drugs are not called by their real names, but by South African names. There’s a need for orientation. If you go to the US and they ask you if you want Kellogg’s and you say you want Corn Flakes, they’re going to ask you why you don’t know Kellogg’s. The names are challenging.”

AHP: What has been the most challenging?

Doctor: “In the hospital where I work I have to do the work of a medical officer and an intern. I have to go look for things and get results. You have to do the more junior work as well. It’s the nature of the hospital, it’s not specific to me.”

AHP: Are there any other challenges you’ve faced in South Africa?

Doctor: “In terms of the exams: I know there is a push to reduce the red tape. It’s challenging for doctors. You have to wait to write the exams and you can’t do anything. Medicine is practical work. If you are out for two or three years, you need to catch up. If the red tape is reduced that will really make it easier. A refresher programme would be great. If you do the Australian Board Exam you go for training and do mock clinical work to prepare you for the exams. You don’t have that here.”

South African doctor working in Mpumalanga for more than a year

AHP: How long have you been in the public sector?

Doctor: “I did my community service in KwaZulu-Natal and then spent seven years in private practice in the Western Cape. In 2011 I moved to the public sector.”

AHP: Why did you make the move?

Doctor: “I love working here. There is more to life than the business side. When you treat patients here, you focus on healthcare and not on a financial transaction.”

AHP: What are the benefits of working in the public sector?

Doctor: “You are working for the benefit of the patient. They have never heard of anything else than pulling out teeth, but you can do a root canal and crowns for them. They didn’t even know it existed. It’s fantastic for the patient. There’s not the stress of dealing with administrative issues like accounts. I don’t wake up stressed about work.

“At the end of the day, I’m a happy person. You’re not stuck in an office all day. The work is less clinically precise, but it is also more diverse. You deal with rural diseases, car accidents and fractured jaws. You don’t see that in private practice. Public health gives you the freedom to build up departments, so you are able to practise all treatment modalities (within reason) provided you show efficiency, motivation, and most of all improved statistics.”

AHP: What would you say to other healthcare professionals in the private sector that are perhaps frustrated?

Doctor: “If you are not enjoying your job anymore, don’t do it for the rest of your life. Make the change so that you can be happy at the end of each day. I’m sure there are lots of people in the same boat. There is a little voice telling you to open another practice, but do what you want to do.”

AHP: What about the money? Are you paid enough?

Doctor: “Money in government hospitals is not so bad. You can lead a decent life.”

AHP: What other advantages are there to working in a rural environment?

Doctor: “The town where I am working is such a beautiful town. The air is clean. You can do fishing, birdwatching or visit game reserves. It’s a smaller town. People are friendly and a lot more welcoming. I’m a happier person than before I started here.”