Researchers warn of South Africa's critical care specialist shortage

SOUTH Africa had just 82 critical care subspecialists in 2023, according to a new study by UCT and University College London Hospitals researchers. 

The study published in the South African Medical Journal also shows that the specialist density per 100 000 people increased by just 28% despite population growth. 

The study aimed to highlight stark gaps in specialist availability both nationally and between urban centres and rural areas through data collected from the Health Professions Council of South Africa (HPCSA) covering 2010 to 2023. 

By comparison, the US had about 20 000 full-time intensivists in 2015, the UK had fewer than 1 150 in 2022, and Australia recorded 756 fully qualified intensivists in 2016.

The researchers set out to assess the number of critical care subspecialists across provinces and examine the workforce’s ethnic and gender composition. 

This was the first study to quantify the country’s critical care subspecialists, detailing their provincial distribution, their split between the public and private sectors, and the demographics of the workforce.

"Despite transformation in the field, white males continue to dominate the workforce. Similarly, anaesthetists continue to be the main contributors to the field of critical care medicine. The workforce density was greatest in the Western Cape and Gauteng, both highly urbanised provinces, and the more rural provinces such as North West and Limpopo had no specialists at all, indicating high levels of inequality between the provinces. 

“Additionally, 29% of the workforce is situated in the private sector, which exacerbates the disparity between the apparent and actual availability of subspecialists.

"To compare South Africa with similar upper-middle-income countries, Brazil estimated 6  500 intensivists in 2022, Mexico had 1  139 critical care specialists in 2021 and as of 2019, China had 20 985 certified critical care consultants. The data initially suggest that the number of critical care consultants per 100  000 adult population in South Africa  is far below the numbers in comparable upper-middle-income countries."

However, the study noted that it may be undercounting the number of critical care subspecialists in the country, because there are subspecialists who are certified in critical care but choose not to register as critical care subspecialists with the HPCSA. This decision is influenced by billing protocol within the private sector, said researchers. 

"The evidence provided emphasises that the subspecialty of critical care is not prioritised sufficiently in South Africa. Additionally, the country appears not to be training enough critical care subspecialists to meet its needs. There are very few funded fellowship posts in critical care, but the exact number is beyond the scope of this article, as the number of posts is not publicly available.

“A similar problem is being faced by the UK, which is combatting the problem by allowing doctors to train in intensive care medicine as a 7-year standalone specialty, meaning that they do not need a base specialty."

The distribution of ICU beds in South Africa also mirrored the inequality in the distribution of critical care subspecialists. 

Only 25% of ICU/high care beds are in the public sector, which caters for around 71.5% of the total population.

"The Western Cape Province has a public sector ICU bed: population ratio of 1:20  000 and Gauteng a ratio of 1:25 000, while Limpopo’s ratio is 1:150 000 and North West 1:110 000."

The study recommended that a multifaceted approach  be adopted to effectively address the maldistribution of critical care subspecialists across the provinces.

"Rural pay and increased benefits for doctors may attract and retain doctors in those areas. Increasing critical care fellowship posts in North West and Limpopo will attract more young doctors to those areas.

"Although a significant proportion of ICU beds are in the private sector, the survey revealed that most certified critical care subspecialists are employed within the public sector. The rollout of the National Health Insurance (NHI) aims to promote a fair distribution of resources throughout the country."

Cape Times