Reflecting on the current scenario and forecasting the future demand for medical doctors in South Africa up to 2030: towards equal representation of women

The history of medicine in South Africa is one of stark and intractable inequality. This is highlighted in the disparities with regards to the provision of health-care services for its citizens, the wide-ranging discrepancies in resource allocation between public/private and urban/rural sectors, as well as the skewed gender and racialized representation of healthcare providers. The profession is shaped distinctively by the segregationist policies of the apartheid system in South Africa, as well as by the overwhelming “patriarchal structures of a largely colonial society” [1]. Recent research points to systemic gender discrimination and inequalities in pre-service and in-service health education and employment [4‐6]. Gender discrimination and inequality in the health workforce have received scant attention by HRH leaders and researchers which impacts on the delivery of optimal and equitable healthcare [7]. South Africa ranks as one of the most unequal countries in the world [8, 9]. This labour market inequality is mirrored in the statistics for post-school education and training participation and attainment of educational qualifications. Income inequality in South Africa is pervasive, intractable and affecting every area of life, with those classified as Black trapped in the lower ends of the inequality scale.

Since 1994, attempts at health reforms have focused on the creation of a more equitable and less fragmented health system with a simpler, more efficient regulatory framework. One of the first major policy imperatives for change was contained in the 1994 National Health Plan [2], which was considerably developed in the White Paper for the Transformation of the Health System in South Africa [3]. This document is the driving force for rectifying the racialized, gender and regional disparities in the South African health system.

The most important interventions the Department of Health instituted related to the:

The systems of medical professionalization, colonialism, patriarchy, and politics are deeply intertwined. While considerable improvements have been realized since 1994, assessment of inequalities in the system is essential as the salience of the effect of these policies still defines representation in medicine as well as the distribution and dispensation of health care.¹ The first person of African descent joined the South African health workforce only in 1883 [5]. After more than half a century, the first female doctor of African descent registered in the South African workforce [6].

This study focusses on fair representation of women in medicine, as a first step towards understanding the various forms of inequality in the profession. The increasing feminization of medical profession is well acknowledged across countries. However, in South Africa, little is known about the extent of disparity in female representation in medicine across regions, sectors, population groups, areas of specialization and leadership positions—to inform health workforce planning and policy towards a more gender equitable² workforce. By forecasting the need for medical practitioners and considering equally the need for fair representation of women in the medical workforce, this study provides a view of gaps towards reaching gender equity targets, to inform policy-makers towards addressing the inequalities in future human resources for health (HRH) in South Africa. Workforce planning can be a powerful tool to achieve equitable levels and mixes of HRH availability, to deliver required services to a target population [7].

We forecasted the requirement for medical doctors within South Africa up to 2030 using a manpower-to-population ratio method with a gender equity lens. While estimations of the gap between the supply and demand of selected healthcare professions have been conducted in the country, to our knowledge, this HRH planning and forecasting approach is the first-of-its-kind in that it has been conceptualized with gender equity as a focus. We hope this kind of gender equity-focused HRH planning approach will encourage government, funding agencies and foundations from similar middle-income countries to conduct research programmes examining the integration of forecasting models towards gender equity in workforce planning.

The World Health Organization (WHO) classifies health workers into five groups: health professionals, health associate professionals, personal care workers in health services, health management and support personnel, and ‘other’ health service providers not classified elsewhere (which includes medical students, hospital volunteers and members of the armed services). The health professionals further include several categories such as generalist medical practitioners and specialist medical practitioners [10]. Medical doctors (specialists and generalist medical practitioners) serve a key role in health-care provision in health systems [8]. In this study we focus on medical doctors (Appendix).

Improving the equality in representation of women, and particularly women of colour, in education, training and employment, remains a compelling goal. Despite continued policy commitment, there is a persistent under-representation and inequity in treatment and salaries of women, more so with women of colour in different locations and fields of specialization. Within the South African context, the intersectional nature of inequality⁵ thus cannot be ignored.

In the United States of America (USA) in 2015, more than one third (34%) of the active doctor workforce was female [21] and an estimated 46% of all doctors-in-training and more than half of all medical students were women. However in the United Kingdom a pronounced gender gap among specialist doctors was observed with 1:0.5 qualified male vs female specialists on the register [21]. Although on the general practitioner (GP) register, women outnumbered men with 1:1.2 ratio for male vs female GPs on the same register [22]. In India, more than 58% health workers are male, and around 25.7% women do not work in the workforce despite possessing a medical graduate degree. All this despite several government initiatives in recent years, including enhanced retirement age and suitable working conditions for female workers, to mainstream such technically qualified persons [23]. As compared to these countries, South Africa in terms of its male:female doctor ratio fares relatively well, however there is a continued need to understand HRH equity with a gender and racialized lens.

Gender equality in HRH has been recognized as a catalyst for all the Sustainable Development Goals (SDGs), alongside assertions of the invaluable role women can play as health-care providers [24]. However, it has been recognized that there exists a considerable gender disparity within the profession [25], as well as within global health leadership [26] that globally contributes to negatively affecting the health outcomes for women and children [27].

In this study, when forecasting for male doctors the workforce needed has been estimated at status quo, i.e. 4.69 per 10,000 population for male doctors and 3.21 for female doctors—which is subsequently scaled up to 4.69 for female doctors as well to strike the equity target. We did not use any other benchmarks here as we undertook a gender equity-based HRH forecasting exercise.

The WHO has identified a threshold on the need for health workers in the context of the Millennium Development Goals; and estimated that 2.28 skilled health professionals (midwives, nurses, and physicians) per thousand population were generally necessary to achieve 80% coverage of skilled birth attendance [28, 29]. This narrowly defined threshold became widely used to assess the adequacy of the supply of health workers around the globe. Also, WHO's "Health workforce requirements for universal health coverage and the Sustainable Development Goals" quantify through an innovative empirical approach, the health workforce requirements for the attainment of SDG 3. It suggests a new benchmark of 4.45 physicians, nurses, and midwives per thousand population [29]. Finally, the workforce SDG 3c talks about 40% of Member States not achieving a minimum of 1 medical doctor per 1000 [30]. So contextually, the norm of 1 medical doctor per 1000 population can be said to availability of a minimum and not a recommendation. However, in this HRH forecasting exercise we are not aiming for the 1 medical doctor per 1000 norm but consider the required supply to reach gender equity through workforce forecasting—targeting equal representation of women and men in the medical doctor workforce. In the current scenario if both genders are combined then doctor per 1000 population density will be 0.79 per 1000 (i.e. 0.47 male + 0.32 female). If we try to reach the 1:1 equity ratio for both genders then the final doctor:1000 population density will be 0.94 per 1000 population (0.47 male + 0.47 female), which indirectly would lead us to the overall course correction of HRH density (gold standard of 1:1000) while keeping in view the issue of gender inequity.

It seems governmental efforts to encourage women of colour to come forward and enter into the medical profession is bearing fruit, though such efforts need to be accelerated and sustained in future as well. With higher growth in the production of female doctors suggests that over time, it is possible to reach equitable representation in the medical workforce. Clear projections and estimations of the supply-side planning that is required to reach these targets within a timeframe have been absent from policy discussion for some time.

The increasing feminization of the medical profession is a well acknowledged trend globally. However, as has been shown, this does not always lead to equitable representation of women within medicine, in terms of socio-demographic indicators (for example, population group and class), and/or across different specialties, leadership positions within the profession, regions and sectors of practice. An important pre-requisite for effective policy intervention (whether demand- or supply-side) is a baseline of understanding on the extent of disparity in female representation in medicine. This study provides a framework particularly for other African countries as well as lower and middle-income countries for the analysis of current availability and estimation of optimum HRH levels towards alternatively reaching gender equity targets.