The Storm After the Calm: South Africa Moves to a Primary Healthcare Model

Valerie A. Douglas-Sweet, BSN, RN


Topics in Advanced Practice Nursing eJournal 

In This Article

The Nurse as Primary Healthcare Provider

Like much of the world, South Africa is trying to cope with a dire shortage of nurses, physicians, and other healthcare workers. The active recruitment, or as some say "poaching," of South African nurses to better paying jobs in other countries leaves South Africa bereft of nurses to care for its poor. South African nurses are desirable because they are well-trained and highly experienced. A shortage of physicians plagues South Africa as well. The physician to patient ratio is 1:549 (Paine A. Personal communication. 2007). In the United States, the physician to patient ratio is 1:69. Even with its narrower ratio, the United States struggles to meet the demands of a population increasing in number and morbidity.

The lack of human resources has led the South African government to levy political pressure to expand the nurse's scope of practice and increase retention of recent graduates. The Nursing Act No. 33 of 2005, signed into action in May 2006, creates the legislative framework to ensure that the expanded scope of practice for different categories of nurses is in accord with the needs of the healthcare system. Nursing curriculum at the undergraduate level reflects the academic and clinical preparation necessary to ensure that nurses are qualified and competent to practice in these advanced roles.[6]

As the main point of access for the community, the nurse must be educator, facilitator, and manager of care. Community-based outpatient clinics (CBOCs) are structured with the nurse as the primary provider of care. Nurse-run clinics are common, and physicians are present in most clinics only 1 day per week.

In the townships, we visit community health clinics where the atmosphere is tense. Some healthcare workers are on strike, awaiting the government's acknowledgement and response to their list of demands. Workers believe that a strike is the only way to improve working conditions and wages. The debate is heated. Is it ethical for healthcare workers to strike and leave the country without care? Some workers feel that the strike is unethical and even illegal. The day we arrive at the clinic, our bus leaves us at the front gate. The gate is quickly opened and we file in. Three sisters run this women's and children's clinic where women in the township receive STD screenings as part of their initial acceptance into the clinic. Women can then receive birth control, gynecologic services, well-woman check-ups, and HIV medications if necessary.

As we are ushered into a tiny meeting room, our eyes are drawn to the walls. Posters are written in Xhosa and Zulu, but the messages are clear: store food properly to preserve it, use condoms to protect against STDs, and do not mix baby formula with contaminated water (Figure 7). The sister nods to a fellow worker who brings in a tray with tea and butter biscuits. We listen attentively as she describes nursing -- its responsibilities and its rewards -- in her township.

Figure 7.

Poster in clinic.

We ask the sister why she is here when the others have gone on strike. She smiles. She and other nurses are wearing street clothes instead of uniforms as a symbol of support for their striking colleagues. "I thought about striking," she said, "but who will take care of the babies and the people who need their medicines?"

No trace of an ethical dilemma clouds her mind. She would like to be paid more. She wishes that more nurses would stay in South Africa and serve their own communities instead of gravitating to higher-paying nursing positions. She said she once considered it, but she is needed here in the community. This is her home and these are her people. I ask one last question about avoiding burnout. She can barely hide her amusement at the naivete of my question.

"In this clinic, we see the same patients all the time. I give prenatal care to women who know they are HIV positive but who are afraid to tell their partners, so they get pregnant and risk transmission to their partners and their babies. I have seen many men who know they have been exposed to the virus but refuse to be tested or use protection. I have babies here whose mothers must be taught about immunizations. I don't have time to think about being burned out." Her eyes twinkle. She is not angered by the inquiry. It simply demonstrates our ignorance about the depth of her commitment. I am embarrassed by my question.

Across town, my colleagues are on buses attempting to tour private and public hospitals. Machine guns and tanks announce the presence of the National Guard (Figure 8). Monitoring picket lines, guardsmen have been deployed to keep the peace. Anger and hostility permeate the air. A lack of workers necessitates shutting down entire wings of hospitals. The visits are short.

Figure 8.

National Guardsman outside Helen Joseph Hospital in Johannesburg, South Africa.

During our debriefing, we discuss our visits. The stories of the nurses and nursing students who visited the birthing centers are the most shocking. Midwives deliver the townswomen's babies. These midwives handle the uncomplicated deliveries, perform episiotomies, and even perform vacuum extractions. Three hours later, the new mothers and their babies are discharged. In the United States, nurse practitioners and midwives are advanced practice nurses. In South Africa, a BSN graduate has been educated and prepared to assume this role. These graduates are basically functioning as advanced practice nurses with none of the academic or economic recognition.


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