Medical Recruits: the Temptation of South African Health Care Professionals

Christian Rogerson

Series Editor: Jonathan Crush
Southern African Migration Project
Migration Policy Series No. 45

PLEASE NOTE: Readers are welcome to reproduce and reference this article as long as appropriate acknowledgments are given.

EXECUTIVE SUMMARY

Health workers are one of the categories of skilled professionals most affected by globalization. Over the past decade, there has emerged a substantial body of research that tracks patterns of international migration of health personnel, assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is attracting growing interest. For almost 15 years South Africa has been
the target of a ‘global raiding’ of skilled professionals by several developed countries. How to deal with the consequences of the resultant outflow of health professionals is a core policy issue for the national government.

This paper aims to to examine policy debates and issues concerning the migration of skilled health professionals from the country and to furnish new insights on the recruitment patterns of skilled health personnel.
The objectives of the paper are twofold:
• To provide an audit of the organization and patterns of recruitment of skilled professionals from South Africa in the health sector. The paper draws upon a detailed analysis of recruitment advertising appearing in the South African Medical Journal for the period 2000-2004 and of a series of interviews conducted with private recruiting enterprises.
• Based upon the above analysis and additional interviews with key stakeholders in the South African health sector, the paper offers a series of recommendations for addressing the problem of skilled health migration. These recommendations are grounded in both South African experience and an interrogation of international
debates and ‘good policy’ practice for regulating recruitment.

The paper is organized into five sections. Section Two positions debates about the migration of skilled health professionals within a wider literature that discusses the international mobility of talent. Section Three reviews research on the global circulation of health professionals, focusing in particular upon debates relating to the experience of countries in the developing world. Section Four moves the focus from international to South African issues and provides new empirical material drawn from the survey of recruitment patterns and key interviews undertaken with health sector recruiters operating in South Africa. Section Five addresses the questions of changing policy interventions in South Africa towards the outflow of skilled health professionals and the recruitment of foreign health professionals to work in South Africa. The final section provides a short conclusion and specific recommendations related to the recruitment industry.

The main policy issues at national and international levels in relation to the migration of skilled health professionals concern the monitoring, management, or regulation of such flows. Although several strategies have been put forward for national strategies and international co-operative measures to address the issue of skilled health migration, the realistic options available for most poor countries are limited. It has been argued, for example, that in order to manage migration effectively, it is necessary for governments and other agencies to develop a more strategic approach towards regulating the flow of health workers between countries. The international record shows that there are no ‘off the shelf solutions’ or universal panaceas and that each country has to develop its own strategy for dealing with the issue of migration in its own context. Nevertheless, the international policy consensus appears to be moving in the direction of national and global cooperation for the
‘managed migration’ of health professionals using bilateral agreements or international codes for recruitment.

The empirical research on recruitment points to the urgent need for such policy interventions in South Africa. Over the five-year period 2000-2004 a scan of recruitment advertisements appearing in the South African Medical Journal (SAMJ) records a total of 2522 recruitment initiatives for South African medical personnel. The numbers of advertisements appearing each year fluctuated from a low of 458 in 2004 to a peak of 646 in 2002; overall, the average number of advertisements was 504 per annum across the five-year study period. The advertisements varied from seeking applicants for specific positions available in particular countries to more general recruitment of personnel by international agencies for placement in either designated countries or for opportunities and placements across a range of international destinations.

Moreover, the type of recruitment spanned the entire spectrum of medical personnel from general doctor to specialist. The most critical set of findings relates to the international origins of the recruitment initiatives of South African medical personnel. In terms of individual countries, the analysis discloses that the greatest volume
of recruiting across the study period was for appointments in the United Kingdom. Overall, a total of 35.5 percent of all advertising was for positions in the UK. The second and third most important recruiting countries were New Zealand and Australia, which represent 21.8 percent and 16.2 percent respectively of all recruitment. Canada occupies fourth position with a 12.4 percent share of all recruitment advertisement.

As a whole, therefore, these four countries – the United Kingdom, New Zealand, Australia and Canada – account for 85.9 percent of all recruitment advertising for South African medical personnel in the period 2000-2004.
Of significance is the changing ranking and share of countries in the total volume of recruitment advertising. In 2000, New Zealand was the leading source of recruitment advertising for South African medical personnel
with 26 per cent of the total. By 2001, the United Kingdom had emerged as the most important destination for recruitment, a position it retained for the rest of the study period. In 2000 the United Kingdom was responsible for a 22.6 percent share of advertisements and by 2004 this had risen to 42.1 percent. By 2004 the numbers of recruitment advertisements for South African medical personnel to work in the United Kingdom matched the combined recruitment advertising from Australia, Canada and New Zealand.

The business of recruitment is dominated by UK-based enterprises such as Global Medics, Medacs Healthcare Services, Corinth Health Care or NES Healthcare UK. Significant players recruiting in South Africa outside the UK include Auckland Medical Bureau for New Zealand, AMAQ Services for Australia, and Northern Medical Services in Canada. Many of the large UK recruitment agencies are long-established and have been in operation for 25 years or more. Most offer placements in both the private sector and the National Health Service of the United Kingdom. From the analysis of the contact details provided on recruitment adver tisements, it is evident that the largest share of advertising in the SAMJ is placed by overseas recruiters. In year 2004, for example, only 15 percent of recruitment advertisements for South African medical personnel included any local contact details. For 85 percent of recruitment the channel of communication was through email or web contacts outside South Africa and overseas telephone/fax communication. This finding is of considerable policy relevance for it points to the weak position and limited room for manoeuvre of the South African gover nment in dealing with the activities of the international recruitment industry. Indeed, looked at from an international industry perspective, the operations of the cluster of recruitment agencies in South Africa are minor players. Enterprises are small in size, often branch operations of UK-based operations, or represent independent niche operators.

From inter views with recruiters, several key policy points emerged.

• South Africa lacks adequate knowledge and data on the numbers of medical personnel leaving the country.
• The core of the recruitment industry is based outside South Africa and local enterprises emerge as only minor players in the global context.
• Recruiters are responding to a demand fuelled by shortcomings in the existing wage and working conditions in the South African health care system.
• At least two different recruitment channels may be differentiated. The largest channel is that of young South African medical graduates seeking short-term appointments as locums or RMOs in the UK health system. The majority of such recruits probably return to South Africa after the close of their temporary contract appointments. A subsidiary channel is that of a permanent movement of more experienced medical personnel to appointments in New Zealand, Canada or Australia.
• In recent years there is evidence that the trend towards the recruitment of South African medical personnel for permanent appointments abroad has slowed and been replaced by temporary appointments.
• The major catalyst for temporary recruitment is that of the ‘wage gradient’, which is attracting medical personnel to the UK, the Middle East and other destinations (including recently for Iraq and Iran). For permanent migrants issues of long-term working prospects and family considerations are of importance.
• South African recruiters have identified potential sources of medical skills in several Asian countries, but have not been permitted to tap these pools of medical talent.

Overall, the study argues that ‘competing for talent’ is now recognized as an essential element of international competitiveness in the current world economy. In this r egard a central role is played by private and public sector recruitment agencies in shaping the international mobility of talented or skilled individuals. South Africa’s re-integration into the global economy in 1994 exposed the new democracy to the full forces of this new international competition for talent. The initial ad hoc policy responses were weak and failed entirely to comprehend the organizational dynamics and structures that shape the new global movements of professionals. In terms of the health sector, the country hemorrhaged an important segment of its most experienced medical personnel.

Moreover, without the enactment of countervailing replacement strategies and of a national strategy for managing the country’s human health resources, South Africa was vulnerable to the activities of ‘global
raiders’. There has recently been an important and welcome policy shift away from the early reactive ad hoc policy responses to the development by 2006 of a more comprehensive strategic response that seeks to manage the mobility of health professionals.

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