Striking a rock

November 4, 2005 -- Today South Africa's Business Report ran a generally good opinion piece by Terry Bell about nurses' displeasure in the wake of the national assembly's recent passage of the Nursing Bill. The piece, "MPs leave nurses feeling angry and undervalued again," does a good job of setting nurses' objections to the Bill in the larger context of the nursing crisis that has crippled South African health systems. Relying heavily on a nursing union leader, the piece stresses that persuading the nurses who have gone overseas to return home will require that the nation address both nurses' low pay and poor working conditions, especially the "severe" understaffing that afflicts the public hospitals.

The piece makes the link between the Nursing Bill and the deeper issues right up front, leading with the idea that nurses who "consider themselves undervalued" are even angrier now because of what they see as another sign that they are "taken for granted." Not only did the crucial, "long-awaited and controversial" bill fail even to draw a quorum of MPs when it first came before the assembly--an obvious sign that nursing is considered inconsequential--but the bill retained two key features to which nurses had strongly objected. The piece explains that the Democratic Nursing Association of South Africa (Denosa), a national union, had argued against provisions placing the profession's regulatory body, the Nursing Council, under ministerial control, and others imposing an "ill-defined" requirement for community service that the nurses found "illogical and impractical."

The piece might have explained what the Bill's supporters thought they were achieving with these provisions, and also the specific problems the nurses had with them. In particular, placing a professional regulatory body under the direct control of the government would seem to be inconsistent with the needs of an autonomous profession, a profession that, as the piece does note, the World Bank has called "the most cost-effective resource for delivering high quality health care." Some have questioned whether the resulting Council will have a sufficient number of nurses on it; of course, one might think that such a group should be composed solely of nurses. Nurses have also suggested that the community service requirement, as drafted, could actually provide an incentive for more nurses to leave. The piece might also have explained in basic terms what else the new law does.

The piece does include quotes from Denosa general secretary Thembeka Gwagwa expressing disappointment that the nurses' concerns were evidently ignored. It notes that the nursing unions had hoped that the Nursing Act would "signal the start of a more efficient and effective approach" to nursing, and it moves on to address the general state of the profession. Although there are "officially" 180,000 registered nurses in South Africa, those figures reflect the number who maintain their registration, and no one knows how many are really available. According to Gwagwa, recent survey data from one regional Denosa affiliate found barely more than half of the official number actually working as nurses. And the nursing vacancy rate in another region is reportedly 46%.

Where are the nurses going? The piece notes that an "increasing number" are working abroad, joining the estimated 14-19% of South African physicians doing the same. As one example of this nursing "brain drain," Gwagwa says she has heard of an ICU at a top Saudi Arabian hospital that is staffed entirely by South African nurses. Union officials discount the "confident comments" of the nation's health minister that such nurses are "heeding appeals to return."

The piece suggests that the unions' contacts with overseas colleagues indicate that the nurses would return on two basic conditions. Not surprisingly, the nurses would like better pay. The piece notes that starting salaries for staff nurses "after four years of training" have actually fallen by more than 4.4% in real terms over the past four years, and that such declines in pay have occurred at all levels of nursing. But the unions stress that pay alone will not bring the nurses back. At the top of the expatriate nurses' list are "major improvements in working conditions in often severely understaffed public hospitals." Gwagwa says calling these hospitals understaffed is "a gross understatement," and the vacancy figure cited above would clearly support that view.

The piece notes that nurses cannot strike in South Africa because they are an "essential service," and so "there seems little the nurses can do to force the issue." However, it does quote Gwagwa as saying that the nurses' situation is "a gender issue too": "Nursing is still largely a profession of women and so it is undervalued in our society." This is a good point. But the piece closes with another quote from Gwagwa: "I think those in authority should remember an old slogan: 'Wathint'abafazi, wathint'imbokodo' - When you strike the women, you strike a rock."

See the November 4, 2005 article by Terry Bell "MPs leave nurses feeling angry and undervalued again" in the South African Business Report.