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Daily Maverick
22-05-2025
- Health
- Daily Maverick
Nursing in South Africa: A passionate calling under siege by budget cuts and safety risks
Groote Schuur Hospital's first male nursing manager, Aghmat Mohamed, reflects on the pressures of nursing in South Africa. Before International Nurses Day and the release of a major global report on the state of nursing, Spotlight chatted to him about his decades on the front lines of healthcare. Nurses cradle new life with tender hands and soothe those at the end of it. Yet despite their tireless grace, they're underpaid and risk getting stabbed and robbed on their way to work, says Aghmat Mohamed. After three decades in nursing, including nine years supervising 1,600 nurses as Director of Nursing Services at Groote Schuur Hospital, he considers himself an ambassador for the profession. While expressing deep passion for his work, Mohamed does not mince his words when outlining challenges in the field. This includes a 26,000 nursing shortfall across South Africa's public and private sectors, an ageing work force, training system bottlenecks, uneven distribution of nurses — particularly in rural areas — and simply not enough investment from the government. He said that while nursing shortages in South Africa were nothing new, this pressure was exacerbated by annual budget cuts at public hospitals. 'Currently, we are 26,000 nurses short in the country,' he told Spotlight. 'That's a lot of nurses. And yet, it is expected that the show must go on. Posts are being cut, the money's getting less, and there is this full-on expectation of nurses to continue delivering quality care.' Groote Schuur, Cape Town's tertiary public hospital giant with just under 1,000 beds, lost 70 professional nurse posts due to budget cuts just last year, said Mohamed. 'Money is the problem,' he said. 'Most of any organisation's budget is staffing, between 60 and 70%. So the easiest way to decrease costs is by cutting staff. We've had budget cuts every single year. I mean, last year I lost 70 posts — professional nurses, just like that. So how do you continue to deliver quality patient care?' Plugging holes Mohamed noted that at Groote Schuur they were 532 nurses short across units that provided a 24/7 nursing service. 'And it's the kind of battles that leadership like myself face every single day, trying to plug the holes. Every day we need to compensate for those missing 532 nurses, for example, by using agency nurses, and overtime for our already exhausted and burnt-out nurses.' He explains how nursing agencies work: 'Out of that 532, for argument's sake let's say 15 of them are Intensive Care Unit (ICU) specialist nurses, so every day we must get 15 nurses for ICU from agencies.… It's different nurses from different agencies each day and it's not ideal because you don't know who you are getting, you don't know how experienced they are. So these are additional stresses that managers in the hospital deal with.' The concept of 'patient acuity' is used to allocate nursing resources, he says. This refers to the severity of a patient's condition determining their priority and level of care. A calling but also a profession Commenting on the professionalisation of nursing, Mohamed notes how the scope of nursing as a profession is ever-expanding, without adjusted remuneration. He points out how in a primary healthcare system, nurses are responsible for more patient care than ever. 'Clinics are run by nurses,' he says. 'We bring children into the world, we hold the hands of dying people. When there isn't a doctor, the next best thing is to give the task to a nurse. And that's fine, because we love what we do. And we try to make sure that we're upskilled to be able to do these tasks. But the thing is, for decades, we've allowed this to happen: the scope of nursing is expanding and expanding, but the money's not getting more. So you have more responsibility, are more accountable, but nobody's talking more money.' Mohamed added that nursing was a profession governed by a nursing council and tertiary qualifications, and ought to be respected and paid accordingly. 'You would be surprised how many nurses with PhDs are at the bedside, because they want to be. They just love being with patients. So nursing is a calling, certainly, but it can't be mahala (without payment). We need to be properly remunerated.' State of the world's nursing On Monday, 12 May 2025 — International Nurses Day — the World Health Organization (WHO) and the International Council of Nurses (ICN) released the State of the World's Nursing 2025 report. Much in the report echoes Mohamed's arguments, placing South Africa's nursing challenges in a global context. The report notes: 'While professionalisation can improve care quality, it should be accompanied by differentiated roles, scopes of practice, and corresponding compensation in work settings, to not fuel nurse migration to countries that offer better professional opportunities.' Greener pastures Figures quoted in the report suggest that one in seven nurses worldwide — and 23% in high-income countries — are foreign-born, highlighting the migration of nurses to wealthier countries. South Africa is considered an upper-middle-income country, with an estimated 8% of nurses being foreign-born. Mohamed can attest. After working as a nurse at the Red Cross War Memorial Children's Hospital and some community health centres in Cape Town, in 2004 he accepted a job at St James's Hospital in Dublin, Ireland. To his surprise, the hospital paid for his studies at the Royal College of Surgeons in Ireland, where he obtained a Bachelor of Science degree in nursing and a Master of Science degree in leadership. 'I always knew I wanted to work abroad,' he says. 'When I left, it was supposed to be for two years, but that became 10… Literally, doors just opened up for me, like, wow! I was so fortunate, I didn't spend a cent on these two degrees. So this is how first world countries retain staff; opportunities lead to job satisfaction.' Mohamed said healthcare employers in wealthy countries snapped up South African nursing graduates. Graduates who specialised in ICU, the operating theatre, trauma and emergency, psychiatry and oncology, were in high demand worldwide. He argued the only remedy to retain graduates was South Africa's government creating better working conditions for nurses and job incentives. 'So the government must look at ways of investing in nursing. We need a national strategy. Why is this not prioritised? I want to see more strategies from the government — national government, not just provincial government.' The WHO report attests similarly around domestic investment. 'Low- and middle-income countries are facing challenges in graduating, employing, and retaining nurses in the health system and will need to raise domestic investments to create and sustain jobs,' it reads. Dwindling workforce To start with, South Africa's nursing graduation rate is low. The report notes that 70 552 students enrolled in nursing education in South Africa, with only 3,154 graduating annually. This very low number might, among others, be attributed to recent regulatory and accreditation bottlenecks in the tertiary system, as previously reported by Spotlight. (According to our back-of-the-envelope calculation, there should be about 17,5000 graduations per year given that training typically lasts four years. This calculation excludes people who drop out of training.) The report also notes South Africa's ageing workforce, with only 4% of nursing staff aged under 35, and 33% aged over 55. This raises critical red flags for future staffing. Safety concerns Furthermore, the report states that of the global nursing workforce, 85% are female. In South Africa, this is slightly higher at 90%. Speaking to Spotlight in the lounge of his home in upper Woodstock in Cape Town, a few blocks away from Groote Schuur, Mohamed outlines urgent safety concerns for his staff, whose shifts are from 7am to 7pm, and 7pm to 7am. 'It is expensive to live here (near the hospital) and I can't expect a staff nurse or an assistant nurse to be able to afford even a room around here. So these women travel far to get to work, getting into a taxi at 4am, or walking to get a bus with two or three changes. They get robbed, they get stabbed, they get assaulted. So safety is another big issue. I mean, nursing is a calling and that's fine, but in a country like ours, your safety should come first.' Reflecting on being Groote Schuur's first male nursing manager, Mohamed shrugs, exuding pride and confidence in his position. He intends to celebrate International Nurses Day with a formal event and gift boxes for his staff. 'We take any opportunity to boost morale, you can see the effect in people's facial expressions,' he said. Manenberg inspiration As a child growing up in Manenberg, Mohamed said that in the mornings he would stand on a kist (chest) at their front window watching the neighbours — two nurses in crisp uniforms — leave for work. 'They were two sisters,' he recalled. 'I used to be very curious about them; the way they dressed, the way the community admired them. I was fascinated. I used to stand up on the kist watching them walk up the road to catch the bus.' Back then, it was safe for them to walk in the dark, he said. In a poetic twist of fate, one of the neighbours who inspired Mohamed as a child, Sister Shahieda Kader, was now among his staff at Groote Schuur. Additional inspiration in his formative years was a district nurse who cared for his grandmother, who had a foot wound due to diabetes. 'The district nurse would interact with my grandmother and bring a smile to her face. The wound wouldn't heal, but when the nurse came to our house, we saw how she made that wound better! And eventually my gran was able to walk again. This woman, she brought hope into our family,' he recalled. Mohamed started his diploma in general nursing at the former Nico Malan Nursing College in 1995, followed by more qualifications. Today, with five bars on his nursing epaulettes, he remains involved in Manenberg. Along with friends, he organises a year-end party for up to 350 elderly people each year. 'It's because of these older people that we are who we are today,' he says. 'You know, they were our role models, so I always feel like I owe them something.' DM
Mail & Guardian
10-05-2025
- Health
- Mail & Guardian
Newborns still dying needlessly in South Africa
Challenges: Women have trouble accessing care for their newborns as well as facing problems such as poverty, food insecurity and a lack of transport. Photo: File Pregnant women in South Africa face significant barriers to getting care for themselves and their newborns, prompting renewed calls for grassroots interventions to reduce neonatal and perinatal deaths. 'The persistently high burden of neonatal and perinatal mortality in South Africa reflects deeper systematic challenges,' said Shakti Pillay, a neonatologist at Groote Schuur Hospital in Cape Town. Those difficulties include inequitable access to quality maternal and newborn baby care; staff shortages; resource constraints and the broader social determinants of health, such as poverty, food insecurity and a lack of transport. Although the number of live births increased annually in 88% of districts from 2019 to 2020, the longer-term trend shows a national decline in live birth rates. 'There has been a trend of declining live birth rates year on year across most districts with only one district reporting an increased number of live births in 2023-24 compared to 2022-23,' according to the 2023–24 District Health Barometer Report. 'The overall downward trend in birth rates is confirmed by decreasing home affairs [department] birth registration rates.' The report also found that the projected census estimate of the number of children under the age of one, as used in the District Health Information System, 'is in line with this trend' — showing a decline from 1 139 380 in 2021-22 to 1 135 771 in 2022-23 and to 1 132 896 in 2023-24. Despite declining birth rates, neonatal mortality has remained constant over the past decade. Though it is still within the UN's sustainable development goals of 12 deaths per 1 000 live births, the goal is to reduce this to below 12 by 2030. South Africa is likely to achieve this goal in the next five years, but access to well-resourced healthcare facilities needs to be prioritised, and intervention at community level would also reduce the number of newborn deaths, said Sthe Velaphi, a neonatologist and head of paediatrics and child health at Johannesburg's Chris Hani Baragwanath Academic Hospital. 'Attendance at an antenatal clinic is important. When attending an antenatal clinic, pregnant women get checked for infections like syphilis, HIV and other health issues. 'If you pick them up in time, and we start the motherhood treatment, you might reduce them getting to pre-term labour and also having their babies die from other conditions. 'So, that is the point that they come to the clinic, get managed, get seen, history is taken, pick up those at risk, get managed, and follow them up very closely. That is another level of preventing this. 'Once they are in labour, we need to make sure that they have easy access to the healthcare facilities, so things like ambulances, emergency medical services must be available at all levels, both from the community to the hospital or between the hospitals that you might want to refer a patient to a specialised facility. 'That's another area where prevention can take place.' (Graphic: John McCann/M&G) At national level, the antenatal first-visit coverage was 69.4% in 2023-24, down 7% from the previous year's coverage of 76.4%, and continues a downward trend in antenatal attendance since 2020-21. This was also the lowest documented coverage in the past five years, according to the 2023-24 Antenatal first-visit coverage refers to the proportion of patients going for at least one (booked) antenatal visit. The report attributed this decline to budget constraints in more recent years that might have negatively affected the accessibility of services. It showed that the number of women who booked for antenatal care in 2023-24 declined to 906 788 from 998 043 in the previous year. Coverage was lowest in KwaZulu-Natal (64.7%) and highest in the Northern Cape (86.1%). Five provinces achieved a coverage level greater than the national average of 69.4%, while the Free State, Eastern Cape, North West and KwaZulu-Natal were Over the past two years, 40 districts showed consecutive declines in antenatal first-visit coverage and only Namakwa, Northern Cape, reported a consecutive increase in coverage. Pillay said neonatal mortalities — deaths during the first month of a baby's life — were often not a result of inadequate knowledge or technology but 'inconsistent implementation of simple, evidence-based interventions, such as antenatal corticosteroids, thermal protection, infection prevention and timely, effective neonatal resuscitation'. 'Ensuring that these essential interventions are delivered consistently and equitably across all levels of care remains one of our greatest challenges — and one of our greatest opportunities to prevent avoidable deaths.' Last month, Health Minister He also said the National Health Council had decided to purchase 25 000 beds, 80 000 mattresses, 7 655 bassinets for new babies and as well as linen, including sheets and pillows, at a total cost of R1.346 billion. 'It is for that reason that we wish to announce that we have checked province by province what that need [is] in the form of hospital beds and bassinets for newborn babies. 'We remember with a sense of shame how babies were put in While the announcement to increase resources in healthcare facilities is encouraging, healthcare practitioners said more efforts were needed to ensure that they were properly implemented and could improve health outcomes for newborn babies. 'Increasing posts or procuring equipment, in isolation, will not translate into improved outcomes unless these efforts are embedded within a broader framework of health-system strengthening,' Pillay said. This included equitable recruitment and deployment; structured onboarding; ongoing clinical training; mentorship; reliable supply chains and strong facility-level leadership, she said.
