Monday, 20 May 2013

Hope at last for foreign nurse recruitment?

An infuriating logjam in the enlistment of vitally needed foreign qualified nurses for South Africa stands to be broken with the hiring of the dynamic rural health-worker recruitment NGO, Africa Health Placements (AHP) – but bureaucrats will need to add their own muscle to clear two vital obstructions.

The famously slow-moving SA Nursing Council (SANC) must streamline and simplify its cumbersome and outdated examination requirements (at least to bring them in line with those for foreign qualified doctors), and the government must urgently increase nursing accommodation in rural areas. With just these two key ‘logs’ moved, the hundreds of foreign qualified nurses who meet minimum local standards and annually knock on official and NGO doors, could begin pouring in to help in the important revitalisation of primary health care and delivery of the all-embracing nurse-dependent National Health Insurance (NHI). This is according to the CEO of AHP, Dr Paul Kornik, whose seven-year-old organisation has outstripped all government agencies and universities in identifying and placing healthcare workers in rural public sector posts. He doesn’t expect it to be smooth sailing given the endorsement needed from the various health departments, SANC requirements, finding the appropriate rural vacancy and securing a provincial job offer. However, AHP staffers are veterans at negotiating most of this territory on behalf of applicants.
Create a ‘non-exam track’ of properly qualified candidates

Kornik says if the SANC just emulates the Health Professions Council (HPCSA) in identifying countries whose medical qualifications match local requirements to create a ‘non-exam track’ category of applicants, the waiting times would immediately drop by six months and his strike rate would soar. ‘At present all foreign nurses fly here to write the exam and apply, fly back, wait … it’s time consuming and expensive, with no guaranteed outcome. Then there’s all the back and forth of documents for verification, especially when one vital piece of information is missing. If the nursing council just automated their application into a computerised form that doesn’t allow you to continue until all requirements are in, that would also speed up things dramatically.’ These bureaucratic and unnecessary ‘hoops’ were hugely off-putting for foreign qualified nurses, of whom there were many more than government departments and the nursing council seemed to realise. ‘Thousands of nurses have approached us to work here over the years, but most just lose interest when they see all the hassle. So far our focus been mainly on placing doctors in rural public sector facilities,’ he said. With a non-exam category of applicants, nurses from countries like the United States, Western Europe, Canada, Australia and New Zealand would immediately be available while those from countries where qualifications were not always up to local standards would appropriately be required to write the local exam. The AHP, in spite of its historical focus, has recruited 60 foreign qualified nurses, but it’s in the other healthcare fields that it has really shone. It has placed 2 600 healthcare workers in the public sector since 2005, 1 500 of them foreign qualified doctors. For doctors, this is more than the country’s combined annual university medical school output (a miniscule percentage of whom choose to ‘go rural’ after serving their internship and discharging their community service obligations).

The desperate need is best illustrated by the following facts. Nearly half of South Africa’s population lives in rural areas, where just 19% of the nation’s nurses work. According to the government’s White Paper on Human Resources for Health, nursing numbers dropped by 10 000 between 1996 and 2008 (nursing colleges closed in 2007, after which specialist nurse numbers plummeted even faster, especially in intensive care, advanced midwifery and psychiatry). The white paper reveals the current nursing workforce to be ageing, with 46% of nurses over 50 years old and 16% already at retirement age (60). Most worryingly, it says that just to sustain the current ratio of nurses-to-population, 51 200 nurses must qualify over the next decade, clearly an impossible task.
Health minister eager to support acceleration

Kornik said nurse accommodation was very thin on the rural ground while nurse salaries were much less competitive than those of doctors, two factors which if even partially addressed would make a rural nursing stint of one to three years for a foreigner far more attractive. He is optimistic that national health minister, Dr Aaron Motsoaledi, will move mountains to solve these two problems, given that doing so is vital to achieving his overall NHI goals. (The NHI plan requires 260 locally-hard-to-come-by specialist nurses to carry out three vital primary healthcare delivery objectives. These include, for each of the 52 health districts, the following: an advanced midwife, advanced paediatric nurse and an advanced primary health care nurse for the District Specialist Support Team, a professional nurse for the School Health Programme and a specialist primary health nurse for the municipal-ward-based Primary Health Care agency.)

The AHP collaboration with the Nursing Council comes in the form of a memorandum of understanding, signed in May this year. It will see a full-time AHP administrator seconded to the SANC’S foreign qualified nurse registration department. This person, with AHP staff backing, will screen applicants to ensure that only complete documentation is submitted to the SANC. Active recruitment starts within six months. Kornik is eagerly awaiting the new USAID/PEPFAR funding cycle which begins on 1 October to see how his expanded funding application (to include foreign nurse recruitment) pans out. In the meantime he’s slotting the nurse recruitment initiative into his overseas marketing and identifying the nursing needs of the worst-off rural hospitals so he can earmark and forewarn provinces willing and able to shell out the necessary salaries (not always a given). ‘We’ll be driven by the needs of the provincial departments of health and we’ll certainly concentrate on getting more senior and more specialised nurses to help out with on-site training. We’re most certainly not after economic migrants though we may help out some of the African nurses already here to secure permanent positions. We’re after people willing to contribute to the developing world for one to three years,’ Kornik said.

SA Nursing Council Registrar, Mr Tendani Mabuda, told journalists initially that the SANC and the AHP would form a management task team with two representatives from each party to ‘co-manage’ the implementation of the agreement. In spite of numerous attempts by Izindaba to contact Mabuda, he did not respond to the vexing question of streamlining foreign recruitment. The SANC’s media relations department said such complex matters were best dealt with by Mabuda.

Chris Bateman

Figures from: Human Resources for Health for South Africa 2030. Draft HR Strategy for the Health Sector: 2012/13 – 2016/17. Consultation Document. August 2011.

S Afr Med J 2012;102(9):723-724 .

Thursday, 18 April 2013

Cape Town & Obstetrics

So..... we have arrived in beautiful South Africa and received into the waiting arms of our loving family. There is nothing quite as special as returning home!

What I have learnt so far from maternity statistics in South Africa has made me incredibly sad when I am not just hopping angry. 

There is a 90% cesarean section rate in Cape Town within the private sector (can anyone say obstetric malpractice). I refuse to belive that all these women choose major adbominal surgery and accept all asociated risks with complete and ethical informed choice.

Within the public sector there is a 20% cesarean section rate wich is concidered normal in Europe, although the maternal and infant mortality rate is sky high. 

In Africa: 
280 000 women die annually during birth! 
10 million die due to pregnancy, or due to post partum complications. 
3 million newborns die annually, many from infections.
2.6 million stillborns annually. 

So these issues flag up two huge healthcare needs in South Africa both envolving EDUCATION, EDUCATION, EDUCATION and RE-EDUCATION. Being just one intrepid midwife in a land as vast and diverse as you can imagine, I feel this not a burden but an opportunity to engineer change, to be part of progress and a future with better maternal and neonatal outcomes. 

No-one disputes a woman's right to choose how to deliver her baby. However, making an informed choice regarding an elective cesarean section means taking an objective look at the risks. According to a study led by Alan T.N. Tita, assistant professor in the UAB Department of Obstetrics and Gynecology, "Women who choose to have their babies delivered via repeat cesarean at 37 or 38 weeks without a medical or obstetric indication, risk serious complications for their child." 

 Cesarean Section Neonatal Complications &  Risks include: 
 Premature birth when the delivery date is not accurately calculated. 
 According to a recent study, cesarean section neonates may not have the same beneficial gut bacteria at birth as babies delivered naturally. This may cause immune related troubles to develop later in life. 
 Babies born by cesarean section are more likely to develop breathing problems like asthma and allergies later in life. 
Cesarean section is known to raise a child's risk of diabetes by 20 percent. 
Lower Apgar scores at birth. 

Cesarean Section Maternal Complications &  Risks include: 
Major abdominal surgery. 
Surgical wound complications such as adhesions that can cause bowel obstruction and chronic pain. 
Resultant placenta accreta or percreta in subsequent pregnancies. This can result in complete hysterectomy to treat major haemorrhage after delivery of the placenta.
High risk of DVT - anti-thromboric medication should be prescribed, this is in the form of subcutaneous injections which sting and depending on risk may be required everyday for up to six weeks.
Loss of sensation at incision site.
Six weeks of no driving or lifting any weight heavier than the baby. In South Africa where nothing is accessible without a car this may lead to isolation and/or dpression. 
May affect breastfeeding success. 
May contribute to postnatal depression
May affect maternal-neonate bonding
Dramatically reduced incidence of skin to skin resulting in system and hormonal consequences both for the mother and neonate.

Monday, 8 April 2013


Postnatal home visits
To end this blog is too sad, it brings a tear to my eyes and a lump to my throat and therefore I am not going to end it. This intrepid adventurer is headed to beautiful South Africa in an attempt to carry on humanitarian work in the land of her birth, so stay tuned for further developments.

This journey has taught me to be still, to be grateful and to accept the tides that is our life paths. I have learnt about myself that perhaps I am not the spoilt princess I had thought and that I can be happy sleeping on the floor and that running water and electricity are not necessarily the trappings of a life fulfilled.

I have shared knowledge with the local midwives of Cambodia and in doing, have found a connectedness and camaraderie in woman-ship that has lit a fire in my heart. South Pacific Asia and the amazing,  resilient women of Cambodia will always hold a very special place in my heart and I will carry with me, this experience, their beautiful smiles and wisdom until the end of my days.

It has been hard, it has been raw and at times I wasn't sure if I had what it took to make a difference, yet through this, through the struggle I found myself again. My strength, my gift, my faith...........

I bring merely kindness!

To leave behind fear, and have the courage to walk the road of ones hearts desire is no small task. The prayer I whisper to the wind, is that I may have the courage of my convictions to journey to a place were there is peace in my heart, love at my side, kindness on my lips and caring in my hands.

Beautiful midwives

To all my wonderful family, friends and husband: Your love, support and donations have brought education, medical supplies, sanitation and safe medical practice to some very remote rural areas of Cambodia. You should all feel very chuffed with yourselves for choosing this worthy cause and I want to again reassure you that 100% of your donations has gone directly to the cause.

Weighing the baby

Birthday en-route

Up eeeeaaaarly to catch our flight from Phnom Penh to Singapore, wouldn't be so bad except we were all sleeping so badly with poor Emma suffering the worst. 5 hours a night was considered good and of course our last night in Phnom Penh was no exception.

The girls got me a beautiful hand made silver box from duty free for my birthday which was very sweet and unexpected. I love you guys, THANK YOU:-)

Arrived in Singapore too early to check into our hostel to we dumped out bags and went shopping which was fun. Singapore Slings at Raffles long bar, dinner at our street restaurant and dreams of an early night, but of such luck. Group of very noisy boys kept us awake and then eeeeeeaaarly wake up to catch flight from Singapore to Heathrow were I finally made it into the waiting arms of my gorgeous, amazing husband and promptly burst into tears of exhaustion, happiness and relief. I had not fully realised how much I missed him........He is my centre, my love, my life, my guiding star without whom, non of this would have been possible, without whom, I could not be everything I can be and without whom, life would have no meaning of purpose. Thank you my love!

Duped again

So....getting back to Phnom Penh

This time we though we would be very clever and procure our clever little selves a "barung bus" (bus for soft Westerners with mod cons like air con and a toilet. During our conversation with the travel agent, we learnt there are 3 choices:

1. A local bus (like we got before) noooooo thank you.
2. A VIP bus (air con, toilet, refreshments cart and non-stop)
3. A luxury bus (Wi Fi, air con, toilet, refreshments cart and non-stop)

Being very clever, and dead set against repeating our previous experience we decided to go for the VIP bus as Wi Fi is doge at the best of times and therefore deduced that paying and extra $7 would not be worth it.

Picked up from the hotel by mini bus and started thinking....."now this is more like it" until of course the minibus started picking up locals who got on the mini bus with their lunch. This consisted of a live chicken tide up with strips of plastic bags with chop sticks stuck on its back (well how do you suppose lunch would stay fresh in the stinking heat)?

Any-hoo, the bus did turn out to be air conditioned, however it it also made unscheduled stops to drop of and pick up passengers on the way which would not have been so bad if there was in fact a toilet and a refreshment cart. Refreshments turned out to be 500ml of water thrown at us on departure and that was all she wrote. Journey took 7.5 hours and wasn't so bad as we weren't melting. Sat next to a stinking German man who kept falling asleep all over me and his hair tickled my nose. So I was very mean and would sit forward quickly which would cause him to fall into my seat and wake him up for 10 mins at which time he would relocate himself into his designated space until our little game started all over again, and again, and again:-) quite entertaining and funny.

Arrived in Phnom Penh in a torrential down pore, left the girls huddling under a shop awning and made my way to the guest house solo as was popping for the loo. Got lost and tormented by naked teenagers dancing in the rain in the street  Had to seek refuge in a shop as they got quite bold circling me and touching me despite my angry "no's".

Found the girls and the guest house in the end, watched the prostitutes from the balcony on the 3rd floor. I think the building across the street was a brothel. Must have been a slow night as we didn't see much of interest.

Travelling by Tuk Tuk to rural villages for postnatal home visits

Back when Tuk Tuks were still a novelty:-)

Tuesday, 2 April 2013

Temples of Siem Reap

Siem Reap is beautiful,  I'm so sad we do not have more time here.

Early morning excursion to the gorgeous temples.

Angkor Wat
We decided to see Bayon by elephant - amazing, incredible,  awesome
I am so grateful, it felt like a spiritual experience
Trees at Ta Promh
Ta Promh - nature reclaiming the stones
Ta Promh my very favourite temple
Temple sculptures at Ta Promh
Incidentally, this is were Tomb Raider was filmed.
More pictures to come...


Whole day travelling from Takeo to Siem Reap.

Taxi at 05.30: Takeo - Phnom Penh (2hrs)
Local bus 12.30: Phnom Penh - Siem Reap (7.5hrs of stinking hot, destroying travelling)

Bus dropped us off in the pitch dark, out of town, hounded by tuk, tuk drivers.

Ravenous, dehydrated.....beautiful hotel, with a pool:-)