‘They used to wear these white dresses…’: Nurse midwives’ experiences with change in South Africa’s health workforce

Sarah C. Wilhelm MCH Research Festival June 7, 2006

Introduction

 Grounded theory study exploring social & political changes in South Africa from the perspective of experienced Black African nurse midwives    Struggle against & end of apartheid system of racial segregation HIV/AIDS epidemic - prevalence now >20% nationally, almost 30% in study community “Brain drain” of health workers from the public sector - 27% of all health posts vacant in 2005

Study Aim

 Thesis examines themes that emerged from open-ended, semi-structured interviews related to:  Participants’ experiences with change in the public and private health sectors  Factors contributing to health workers leaving the public sector

Timeline of key contextual events

Social and Political Context

Apartheid Regime comes to power Aparthei d and Resistance ŅBantu Education Ó introduced Soweto Uprisings Multiracial Democracy

- Political transition/violence - Free elections Rise of HIV/AIDS epidemic

Court rules SA government must provide nevirapine 1948

Implications for Nursing/Midwifery

1961 1976 Rapid gro wth in numbe r of Black African nurses 1980s 1992-1996 1998 Nurse unionization and strikes Free primary health care introduced 2002 2005 Interviews conducted

Methods

    In-depth, open-ended interviews   14 Black African nurse midwives Working in NGO-run PMTCT clinics in an urban township Transcribed and cleaned Coded using atlas.ti qualitative analysis software Grounded theory approach to analysis - allowed themes to emerge from the data

Results

 Participants  Age 45 to 71, average age 61    All had some work experience in the public sector Over half had more than 25 years’ experience working in the public sector All except two were Coordinators of NGO’s PMTCT clinics, operating within 13 government-run community health clinics

Changing Status of Nurses

Nurses of today, they are not like us, with patience for their people. They just… I don’t know whether it’s the generation or what. We used to like to take care of a client… like if you are passing and you see the baby is sick, “Ma, you must go to the doctor.” I don’t think it happens with the nurses of today. They are too sophisticated. So, it’s the modern times…I’m sure they don’t take nursing as a career, they chase money. They go for money, ‘I’m working… So what? It’s fine.’ We were working because we wanted to help our community. We wouldn’t just pass a person seeing as this person is very sick, because this is inside you.

Deteriorating health services post-apartheid

We are not getting things that we used to get in the old government. Unfortunately. Because I as a person believed where we now had a black government, we were going to get more things than what we got. But really I must say we are not getting as much as we used to get. Everything was smooth. We had everything. We were working comfortably… …there was never a shortage of medicines during apartheid. They were getting treatment. Really and truly speaking. I don’t support it [apartheid]. I’m not supporting it. I’m just facing facts.

Public/private sector tensions and HIV/AIDS related care

Right now, we have sisters working in the maternity. But they are not all PMTCT trained. You know? It was even called the “NGO thing”. And it is still like that now, even if it is integrated into the program, it is a program now, by the department of health. But they still wouldn’t want to do it, as long as we [the NGO] are still doing it, it’s still hard for them. To, you know, come in and ask and, they still, it’s still our [the NGO] patients, you know? Yeah, it’s still like that.

Well, as I say, [the NGO] started the project and the Government was quite happy because, much that they wanted to do… they wanted extended hands I think. To say, ‘Okay, they’ve started. Then we join them.’ Now, I learn that they even joined in formula subsidies, and so on.

That they are doing it, they’ve come in. But what is still being done is still [the NGO] is still taking charge, in the clinics of doing this project. I suppose they are grateful that there is staff which may not be theirs but is helping. Because with their problem of staff shortage…

Health Workforce Shortage

In 2002, we actually lost a mother here who was diagnosed positive. She came to the My problem now is that mainly… with all trends of this clinic. She came and then she spoke with Sister… the Sister said to wait there I’m my main cry is still staff shortage. With all that is coming. During that time she just faint and died. You won’t believe me. Maybe if the Doctor was here, Doctor could have been being done to try and improve services, shortage of staff is still the crux of the matter.

about that. I’m saying, you know, if a clinic can only be run by nurses?

Discussion

 Staff shortages in the public sector critical issues in S. Africa today  Experiences of these nurse midwives provide insights into motivations of nurses leaving the public sector  Suggests complexity of the issue in post-apartheid, HIV/AIDS era South Africa

Implications for Future Research

 Why have the ideals of post-apartheid South Africa not been achieved in the health sector?

 What can be done to keep experienced leaders in the health workforce, like participants in this study, in the public sector, which serves 85% of the population?

 What is the domestic impact of nurse migration from Africa to the U.S.?

Acknowledgments

   Thesis Committee    Michelle Bell, Chair James Pfeiffer Lois Price Spratlen At the UW    Shira Rutman, MPH(!) Amy Hagopian Andrew Levack In South Africa    Zandile Myeni Avy Violari G. Carter   Funding      Puget Sound Partners for Global Health US Department of Health and Human Services, Health Resources and Services Administration’s Maternal and Child Health Bureau (Title V, Social Security Act), grant # T76MC00011-21-00 My family Martha & David Wilhelm, Christine Kolstad Fatsilah & Oopah Jesse Hagopian The nurse midwives whose lives and stories made this study possible and whose inspiration keeps me going!

Questions? Comments?