Estimating the emergency care workforce in South Africa

Background Emergency care is viewed as a fundamental human right in South Africa’s constitution. In the public sector, all emergency medical services (EMS) come under the Directorate: Emergency Medical Services and Disaster Medicine at the National Department of Health (NDoH), which provides regulation, policy and oversight guidance to provincial structures. Aim The aim of the study is to understand the supply and status of human resources for EMS in South Africa. Setting This research was undertaken for South Africa using the Health Professions Council of South Africa (HPCSA) database from 2002 to 2019. Methods A retrospective record-based review of the HPCSA database was undertaken to estimate the current registered and future need for emergency care personnel forecasted up to 2030. Results There are 76% Basic Ambulance Assistants registered with HPCSA. An additional 96 000 personnel will be required in 2030 to maintain the current ratio of 95.9 registered emergency care personnel per 100 000 population. The profile of an emergency care personnel employed in South Africa is likely to be a black male in the age group of 30–39-years, residing in one of the economically better-resourced provinces. Conclusion It is time that the current educational framework is revised. Policy interventions must be undertaken to avoid future shortages of the trained emergency care personnel within South Africa.


Introduction
Across the world, emergency conditions constitute a large part of the global burden of disease. 1,2,3 As the world population grows in numbers and age, there is an complementary increase in the demand for acute curative services response to life-threatening emergencies, acute exacerbation of chronic illnesses and several routine health problems that still require prompt action. 4 High-quality emergency care is seen as a potential tool to address and prevent a substantial portion of death and disability worldwide. 4,5,6 Thus, emergency care interventions and services must be integrated with primary care and public health measures to ensure comprehensive strengthening of health systems. 4 Pre-hospital emergency care broadly has three components: Care in the community, care during transportation, which is related to access and care on arrival at the receiving health facility. 7 Emergency care is designed to overcome the factors most commonly implicated with preventable mortality, such as postponements in seeking care, access to a health facility and the provision of adequate care at the facility. 7 For lower-middle-income countries (LMICs), it has been suggested that priority be placed on developing minimum guidelines for emergency care that may save lives (and at what cost?) 3 Within South Africa, emergency care is viewed as a fundamental human right. 8 There is no clarity about the exact meaning of emergency care being a human right. There is no explanation http://www.phcfm.org Open Access about whether all persons only have the right to basic emergency care or only definitive and intensive care treatment. 9 All emergency medical services (EMS) in public and private sector are under the purview of Directorate: EMS and Disaster Medicine at the National Department of Health (NDoH) in Pretoria, with regulation, policy and oversight guidance provided to provincial structures. 9 Emergency care services are delivered in South Africa at two levels of care pre-hospital sector that has public and private arenas, with nationally based private services and provincial public services 9 and hospital-based care that has been traditionally staffed and managed for basic, intermediate and advanced life support and emergency care. 10 Emergency care delivery is an essential part of health systems.
To deal with the increasing burden of diseases, a robust health system is needed as it can help translate healthcare services into improved health outcomes. Health systems across the globe are dependent on the health workforce in improving health outcomes. Within Africa, there are limited healthcare resources and critical shortages of trained healthcare personnel in all cadres. 11 South Africa has a quadruple burden of disease because of communicable diseases such as human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) and tuberculosis (TB), maternal and child mortality, noncommunicable diseases such as hypertension and cardiovascular diseases, diabetes, cancer, mental illnesses and chronic lung diseases such as asthma and injury and trauma, 12 and continues to struggle with control of these long-standing national health concerns. As per the cause of death profile for South Africa for the period 1997-2012; HIV/AIDS and TB constituted 33.6% of total deaths followed by cardiovascular diseases 18.5%, injuries 9.6% and cancers 8.7%. 13 Complications arising from these diseases contribute to the need for appropriate emergency and critical care services.
However, the burden of these diseases and the subsequent need for emergency and critical care services is excessive; the available infrastructure, associated human resources, diagnostic and treatment capabilities, and financial resources devoted to the provision of emergency and critical cares services are not optimum. Despite these challenges, patients with illnesses and injuries are provided emergency and critical care services at the district and regional hospital levels 14 and in remote rural areas. 14,15 However, rural district hospitals lack trauma surgical services and other medical specialities, consistent with district hospitals in different countries across sub-Saharan Africa. 16,17,18 Over the past decade, there have been some changes in emergency care education in South Africa.

Methods
Profiling the demographic characteristics of the Emergency Care Professionals.

Study design
This was a retrospective record-based review of the HPCSA database from 2002 until 2019.

Setting, study population and sampling strategy
The database was procured by the Department of Global Health, Stellenbosch University, through a special written request made to the HPCSA. The complete database (census) was considered for the analysis that included data on all emergency care personnel under the following categories: AEA, BAA, Emergency Care Practitioner (ECP), ECT and ANT including age, sex, population group and location. In this article, we have used the term population group in line with the definitions in the Population Registration Act (Act No. 30 of 1950), 22 , which previously classified South African citizens into four major population categories: White people, 'coloured' people (mixed ancestry) 'Indian people' and 'Black people'. 22 Although the legislation was repealed in 1991, the population categories are still used in reporting in sectors such as the Department of Higher Education. Racial data remain essential in monitoring the redress in the education and training of emergency care personnel who were previously denied access to such training in terms of legislation.
The emergency care personnel categories, along with their educational courses (aligned with NQF levels) and the date of registrations closed for new registrations have been provided in Table 1.

Data collection and data analysis
The relevant de-identified data were collected for the mentioned categories listed on the database using a standardised data collection sheet. This included numbers registered each year, numbers and distribution by healthcare sector (including public/private) and province, qualifications and experience and the demographic profile by sex, population group and age. A similar approach was adopted in previous studies 25,26 in which relevant data was collected using a data collection sheet that included the following variables: (1) category of health personnel (emergency care personnel), (2) geographical location, (3) age groups, (4) population group and (5) sex. Data were entered into a Microsoft Excel spreadsheet and analysed using the Statistical Package for the Social Sciences (SPSS version 22.0). Frequency distributions, cross-tabulations and graphical representations were used as descriptive statistical methods. Anonymity and confidentiality of all personnel were ensured as the data accessed from the HPCSA and presented in this article is de-identified. In addition, the personnel and salaries management system (PERSAL) data for 2019 27 was also compared with HPCSA registration data for estimating the privatisation of emergency care professionals.

Estimating and forecasting the need for emergency care professionals Study design
The forecasting estimates for the need for emergency care professionals were undertaken from 2020 to 2030.
Setting, study population and sampling strategy: A forecasting exercise was undertaken for all five emergency care professionals' categories using the HPCSA database for the entire workforce (census).
Data collection and data analysis: South Africa's population projections from 2020 up to 2030 were estimated from the population estimates and projections as per the World Bank. 28 The annual supply of emergency care personnel was estimated from the HPCSA database. The unique registrations carried out during the year 2019 under the registry names 'Ambulance Emergency Assistant', 'Basic Ambulance Assistant', 'Emergency Care Practitioner', 'Emergency Care Technician' and 'Paramedic' were considered as the number of trained personnel available for the South African health system in May 2019.
The attrition from the workforce pool was calculated from the year 2020 to 2030 occurring in the form of retirement (at the age of 65 years) using the HPCSA registration database. The supply was calculated on the basis of unique registrations carried out in all five categories from 2014 to 2019. The future supply was forecasted from 2020 to 2030 using the exponential smoothing technique.
Net emergency care workforce for 2020 was calculated using the following formula: For subsequent years, a net workforce of previous year (n) was assumed to be equivalent to number of personnel for the next year (n+1). Whereas forecasted supply and exits through retirements were different for each year.
The current number of emergency care personnel per 100 000 population was calculated for the year 2020 and the same was used as the target ratio up to 2030. Thus, the requirement for number of emergency care professionals to maintain current (2020) status quo up to 2030 was forecasted.

Results
The demographic profile of emergency care personnel

Age distribution
The mean age of registered emergency care personnel (at the time of registration) was 36 years (±8.8). As displayed in Table 3, almost half (42%) of the workforce was between 30 and 39 years old. The unknown categories of age were not included in this analysis.

Population group
More than two-thirds (79.8%) of all personnel classified themselves as black people; 10.2% classified as white people and 5.6% as mixed race (Table 4).

Sex
Majority (55.0%) of the emergency care professionals were male. Similarly, in all five categories, male professionals were in the majority: 68.9% in AEA, 51.1% in BAA, 67.6% in ECP, 68.7% in ECT and 78.6% in ANT (see Table 5).

Forecasting the need for emergency care personnel
For 2020, it was calculated that there were 95.9 emergency care personnel per 100 000 population in South Africa. 29,30 Thus, to keep the forecast more realistic, we forecasted the supply using the past registrations for the previous five years (2014,2015,2016,2017,2018). A negative trend in the growth was observed for registrations of four out of five categories, as registrations for the following four categories have been closed: BAA, AEA, ECT and ANT.
It was observed that if the current trend continues and the registrations remain closed as on date, then in the year 2024, the net registered workforce will be less than the workforce needed to maintain the status quo of 95.9 emergency care personnel per 100 000 population ( Figure 2). Thus, if this trend continues till 2030, an additional 96 000 personnel will be required to bring the emergency care registered workforce back to the current 95.9 emergency care personnel per 100 000 population ratio. However, it must be observed that the current number of actually employed EMS personnel is less than 50% of the emergency care personnel registered with HPCSA.

Discussion
Emergency medical conditions generally occur through a sudden injury to the body or mind, often through injury, infection, obstetric complications or some chemical imbalance.   They may also arise as a result of persistent neglect of chronic diseases. Emergency medical services treating these conditions constitutes rapid assessment, timely provision of right interventions and prompt transportation to the nearest health facility suitable for the patient by best possible means to increase chances of survival, control morbidity and prevent disability. 6 This study sets out to describe the status of human resources for emergency care personnel in South Africa. The profile of an emergency care personnel employed in South Africa is likely to be black male and in the age group of 30-39 years, working in one of the economically better-resourced provinces. The distribution trends across three provinces (Gauteng, WC and KZN) over the last 15-year period show that they have always enjoyed more resources, and little has changed despite calls for a more equitable distribution of human resources. For instance, in 2019, Gauteng had 30.2% of emergency care personnel, KZN had 13.2%, Limpopo had 11.7% and WC had a 9.5% distribution of emergency care personnel.
Apart from registrations, it is also essential to see the provincial health expenditure by programme per province within South Africa. If we observe the health expenditure per province for 2019-2020, then Free State does maximum expenditure of 7.2% (of all provinces) on emergency health services, which is followed by Northern Cape (6.5%) and Eastern Cape (4.9%) ( Table 6) 30 . Whereas national expenditure remains at 3.9% of the total health expenditure. 31 In financial year 2020, emergency medicine was the fifth in terms of funding for national health expenditure, that is after District Health Services, Central Hospital Services, Provincial Hospital Services and Health Facilities Management. 31 The current ratio of emergency care professionals for South Africa is 95.9 per 100 000 population. However, as per an analysis undertaken for 50 most populous metropolitan areas in the United States, the top five areas had availability of Emergency Medical Technician (EMTs) and ANTs within the range of 102.7 to 121.3 per 100 000 population. 32 It was observed that if the current trend continues and the registrations remain closed as on date, there will be a shortage of around 96 000 emergency care personnel by 2030. The net registered personnel will be short of 33 000 personnel and to maintain the current ratio of 95.9 emergency care personnel per 100 000 population, an additional 96 000 emergency care personnel will be needed. It is imperative that the current educational framework is revised and policy interventions are undertaken to avoid future shortages of trained emergency care personnel within South Africa. Also, it is unclear how many of these registered personnel (as per the HPCSA register) are active and contributing to the South African health sector. In a recent study, healthcare workers from South Africa responded having negative perceptions of the public health system because of high patient loads, long working hours, inadequate resources and occupational hazards, which in turn lead to either leaving or avoiding employment in the health sector. 33 In addition, it has been   For South Africa, the current skills mix ( Figure 3) represents a majority of BAA (76%), followed by AEA (18%), ANT (3%), ECT (2%) and ECP (1% This study is timely and relevant as it provides a comprehensive and detailed summary of the current emergency care service delivery in terms of HRH within South Africa. Our findings highlight the prioritisation of resource utilisation in a resource deficit environment. This study can be used as a framework for other African countries and lower and middle-income countries to analyse current availability and estimation of optimum HRH levels of access to care for emergency care services.
The limitations of this study include that the accuracy of HPCSA figures cannot be fully guaranteed. The existing data only described the current situation. Most notably, this research only considers the number of personnel registered with HPCSA and not the number employed within EMS in South Africa. Some of the other key HRH aspects of the emergency care workforce are also unreported such as possible changes in the burden of disease, service delivery models, facility planning, facility workloads, skills mix, remuneration systems and health worker productivity, all of which are important in projecting future HRH needs and costs. The findings raise some concerning questions about the profession and specific implications for access to emergency care services. It should also be noticed that one of the author is involved with the revision of current educational framework thus there may exist a research bias in interpreting the policy data. Furthermore,, this study did not set out to assess if the syllabus or contents of any of the courses of Emergency Care Professionals was appropriate.
South Africa is working towards a National Health Insurance (NHI) system, thus for ensuring that the NHI has a significant transformative impact on the health sector related to emergency care services as well, we propose a two-pronged strategy to meet the inadequacy of emergency care professionals and to optimise their skills mix. Firstly, a stepby-step approach should be set up based on public sector colleges and higher education institutions and their training capacity. As a first step, public sector colleges should become HEIs for emergency care courses as provided by the Minister of Higher Education and Training (Notice 1040 of 2012; Government Gazette No. 36003 of 14 December 2012). 20 The educational courses re-aligned as per suggested NQF levels should have ample seats to accommodate students with a target of meeting future workforce shortages. As a second step, the number of staff and infrastructural resources in public sector colleges should be scaled up. As a third step to not reduce the number of operational EMS personnel, service providers need to create or increase supernumerary positions (on a rotational basis).

Conclusion
Under-resourcing and disparities in the profile and distribution of emergency care professionals remain an abiding concern that negatively impacts the provision of emergency care services and equitable health outcomes.
de-identified and analysed the data. R.N. checked the analysis. R.T. and R.N. wrote the first draft of the manuscript. R.E. and U.C. commented on and contributed to the first draft. All authors assisted in interpreting the data. All authors contributed equally to the conceptualisation and revisions of the manuscript and approved the final version of the manuscript.