As South Africa rolls out its national treatment programme, the country continues to lose skilled healthcare professionals to wealthier nations abroad, leaving severe shortages in an already over-stretched public health system.
On a Tuesday morning earlier this month at Johannesburg General Hospital's medical wards, an exhausted-looking Dr Candace Latilla was about to go off duty. But, as the only doctor on call that night, she would be back in a couple of hours.
Latilla has been working at the hospital as an intern doctor for the past nine months. With a staff component of 470 doctors and 1,300 nurses, Johannesburg General handles more than 1.5 million patient visits a year.
As the medical ward slowly came to life, Latilla took refuge from the slow trickle of cleaners, nursing staff and patients, to get through some paper work in the small doctors' room.
"Sitting and talking [like this] is a real treat. We see so many patients on Tuesdays that you can go for the whole day without eating or resting," she said.
In a health system struggling to retain its skilled staff, junior doctors are viewed as cheap labour, often spending their internship without adequate supervision.
But 28-year-old Latilla's brief respite in the spartan doctors' room was interrupted by the registrar's request to help him perform a bone marrow test. Her replacement, Dr Willie Odendaal - another intern doctor - rushed in halfway through the procedure and took over, finally giving Latilla a chance to escape.
"These poor interns end up doing all the work because there are just not enough people here," the registrar, who asked not to be named, told IRIN.
Tuesdays are set aside specifically for admissions. After being assessed at the main entrance, patients are sent to different units, including Area 264, the medical admissions ward where Dr Odendaal works under the supervision of Dr Pretissha Harrichund, a registrar specialising in internal medicine.
Six patients were already lying in the beds, waiting to be seen by the doctors. "This is just the tip of the iceberg," Odendaal said as he drew the curtains to examine his first patient.
Harrichund and he spent the whole day seeing patients, joined by another intern doctor later in the afternoon. "I'm supposed to knock off at seven tonight, but it will probably be 10 o' clock by the looks of things," said Odendaal. "Sometimes I wish I could tear myself into four people to get more done."
After doing a year's community service in a smaller hospital on the outskirts of Johannesburg, working in the 'Joburg Gen', one of the city's largest hospitals, was "a bit overwhelming", Harrichund told IRIN.
Three years down the road, she had learned to accept that "there are not enough people and not enough resources in a hospital this big", but she could "not imagine" leaving the country for a more lucrative job overseas, despite all her frustrations with the public health system.
Odendaal, on the other hand, was non-committal: "I don't even know where I'll be doing my community service ... right now, I'm saddled with too much work and red tape to think about that."
The exodus of skilled healthcare workers has been significant. The country's 2003 Health Review estimated that 600 South African doctors are registered to practice in New Zealand; 10 percent of Canada's hospital-based physicians are South African, as are 6 percent of hospital-based doctors in the United Kingdom.
But the greatest shortages are in the nursing sector. According to the South African Nursing Council (SANC), 172,338 nurses were registered with the council in 2001. SANC estimates there are 2,300 nurses working overseas, and the council receives about 200 new applications per month for overseas registration, which allows nurses to work in foreign countries.
THE IMPACT OF AIDS
In the face of the HIV/AIDS epidemic, the human resources factor is even more critical. Civil society groups have warned that the government programme to provide free antiretrovirals (ARVs) could fall apart unless more professionals are attracted into the health system.
According to government's 2003 HIV/AIDS prevalence report, about 27.9 percent of pregnant women attending public clinics are infected with HIV. The total number of South Africans living with the virus is now 5.6 million.
Coping with the disease is a challenge for recently qualified doctors in public health facilities. Although Latilla and Odendaal admitted to receiving "some AIDS training" in medical school, the reality of treating HIV-positive patients was different.
"When you're treating people, you don't look at the AIDS thing - you treat their immediate problem. With so many patients, we don't have time to spend with them. You do what you have to do and get on with it," Latilla said.
Although the hospital now provides free ARVs at its AIDS unit, "every other patient we see is positive and they can't all get the drugs. Sometimes you feel like you're not really doing anything," she added.
The impact of the disease on health professionals is not lost on Odendaal and Latilla, as they are confronted daily by a loss of co-workers due to illness, absenteeism, low staff morale and the increased burden of the patient load.
Government has taken several measures to try and cope with the crisis in the health personnel sector. A recently introduced rural and scarce skills allowance is designed to attract and retain health professionals in the public health sector.
The health department has also implemented community service in the hope of attracting staff to under-resourced areas and a compulsory year of community work has been an inevitable part of most doctors' careers in this country since it began in 1998.
In 2003, physiotherapists, occupational and speech therapists, clinical psychologists and dieticians were among the professional groups added to the list. In 2005, nurses will also be required to serve their communities.
But health experts are sceptical about whether community service will be an effective retention strategy. According to the Health Review, one study found that between 20 and 45 percent of all community service practitioners were planning to work overseas after completing their year.