The inequitable distribution of health workers between public and private, rural and urban, primary and tertiary, and poor and rich settings is an important determinant of countries’ inabilities to meet the Millennium Development Goals, and to reap the rewards from scaled-up investments in essential health services such as HIV care and maternal services
[1–3]. In Africa, the situation of inequitable distribution of health workers has been termed ‘critical’. The continent houses 24% of the global disease burden, including 68% of all people living with HIV
; yet has only 3% of the world’s health workers to tackle these problems
South Africa has a relatively plentiful supply of health workers, with over four doctors, nurses, and midwives per 1,000 people, according to the World Health Organization’s (WHO) Global Atlas. This falls above the ‘critical’ benchmark of 2.5 health workers per 1,000 people, as defined by the Joint Learning Initiative in 2004
, and above most other African nations. This reflects South Africa’s status as a middle-income country with a relatively advanced medical infrastructure
However, South Africa’s internal or within-country distribution of health workers is highly inequitable. The Western Cape, a rich, urbanized province in the country, has over triple the number of doctors per capita than four of the most rural provinces. Limpopo Province has only one doctor per 5,000 people, according to the Health Professions Council of South Africa in 2010.
The private sector, meanwhile, employs around 28% of all nurses, 46% of GPs, and 56% of medical specialists
. This is to serve the wealthiest 15% of the population with private health insurance
. Since all South African doctors train in the public sector, and many start their careers in rural internships, this implies health workers are migrating away from areas of highest healthcare need
The situation significantly undermines South Africa’s ability to effectively tackle its public health crises, including its HIV and TB epidemics. According to the Actuarial Society of South Africa’s 2008 demographic model, almost 11% of all South Africans are HIV positive. Most recently, WHO estimated 795 TB cases per 100,000.
Retaining health workers where they are needed within South Africa is thus an important policy imperative
. This may be true now more than ever, given the government’s renewed commitment to provide HIV treatment after a period of institutionalized HIV ‘denialism’
. There are also ongoing plans to ramp up public health services in general, in preparation for a National Health Insurance (NHI), that is, a system of universal health coverage
[12, 13]. Success of these ventures depends on greater health worker availability for under-served populations
This article focuses on how to better retain medical specialists in the public sector of South Africa. Specialists, also known as consultants, are critical for the provision of tertiary-level services, and in training and supervising the next generation of doctors. They are also one of the most inequitably distributed of all health worker cadres between public and private sectors (see above). In order to assess how to better retain public specialists, the article explores the ways the public, relative to private, sector provides ‘job satisfaction’ to South African specialists.
The concept of job satisfaction is focused upon here since it is an important conceptual
[15, 16] and empirical
[17–19] determinant of retention, along with other determinants including organizational loyalty
[20, 21]. Job satisfaction originates in the organizational psychology literature, but has been adopted by some researchers in the field of human resources for health
[17, 22, 23]. The concept is defined by Locke as ‘a pleasurable or positive emotional state resulting from the appraisal of one’s job or job experiences’
. Essentially, job satisfaction is critical to retention since if an individual is satisfied in their job, they are more likely to stay in it, that is, be retained. Conversely, if an alternative job provides higher satisfaction, an individual is more likely to leave
[21, 24]. This conceptualization of job satisfaction is much like that of ‘utility’, which economists similarly use to understand retention/migration behavior.
As noted by Spector
, job satisfaction is commonly understood as determined by wages
, by the ‘work context’, including working conditions; by the social work environment; and by enjoyment of the work itself. Job satisfaction implies workers can be considered what Ben-nur & Putterman
 call ‘other-regarding’ and ‘process-regarding’, implying they are motivated partly by concern for others, and ethical concerns, as well as individualism. This is important since altruism and ethics explicitly form part of health workers’ professional values
[27, 28]. The concept of job satisfaction thus seems a well-developed and realistic way to understand retention behavior, though other studies may also use the concept of utility in a similar way.
Job satisfaction can be conceptualized in a number of different ways
, but in this article, as in a number of strands in the literature
[16, 24, 30], it is assumed to result from the fulfillment of individuals’ needs, as well as their values and expectations. Note that needs may be universal, as with physiological survival needs
, whereas values and expectations are at least partly determined by organizational culture, and personal history and individual preferences
. In all cases, the fulfillment of needs, values, and expectations is assumed intrinsically satisfying.
Needs, values, and expectations are hierarchical, with some taking precedence over others
[16, 31]. For instance, basic survival needs are likely to be most important for individuals to fulfill, generally through income, as stressed by Maslow in his 1954 theory of a hierarchy of needs
. Once such needs are fulfilled, however, other concerns come to the fore, such as the need for recognition and praise (a social environment factor), or the value placed on mentally stimulating work (a ‘work itself’ factor). This implies, somewhat counter-intuitively, that the more individuals earn, the less prominent income becomes in decisions to stay in particular jobs
[33, 34]. As such, specialists, who earn well compared with other health workers, may be expected to be at least partly, if not primarily, satisfied by non-financial factors. Economists term this as a result of decreasing marginal returns to income.
Previous empirical studies have found that although doctors may have relatively few unfulfilled financial needs, their expectations of income can be high
[35, 36]. Thus income may be important to specialist’s career decisions in spite of earning relatively high wages to begin with. Doctors have also been found (dis)satisfied empirically, to a significant degree, by non-financial factors. These factors include physical working conditions such as the state of hospitals
, how demanding patients are
, degree of working autonomy
[23, 36], and over-working or ‘burnout’
. It thus seems reasonable to expect a variety of financial and non-financial factors affecting doctors’ job satisfaction.
In South Africa, public doctors have been found dissatisfied by pay, as well as non-financial factors including: ‘lack of equipment, drugs… unsupportive management systems… [and] lack of a career structure’, especially in rural areas
[39–41]. Much has been made in the media, in addition, of poor public working conditions such as dirty hospitals, lack of beds, and regular power cuts
[42, 43]. However, no detailed case studies have been undertaken to date of South African specialists’ job satisfaction, despite high rates of attrition. This article aims to address this gap, highlighting both reasons for specialists staying in the public sector, and reasons for migrating to the private sector.