For years there have been rumors about the end of short course training for paramedics in South Africa. It became real on 27 January 2017 when the Department of Health published a regulation pertaining to the qualifications for registration of the short courses.
A brief background to those unfamiliar with the system: Until now there has been a dual system to become a paramedic. Taking the short course route meant completing a 4-6 week course in order to qualify as a Basic Ambulance Assistant (BAA). The BAA can do the basics including (but not limited to) the administration of oxygen and splinting of fractures. For a long time (possibly still?) BAA’s was the backbone of the Emergency Medical Services (EMS). Especially in the urban areas where there is a high density of hospitals, the BAA is valuable because they can perform basic care, load the patient and rapidly proceed to the closest facility. This implies fast access to definitive care. Career-wise to advance the BAA had to complete working full-time for 6 months or 1000 hours as prerequisite to apply for the next course. If successful, the BAA could then do the Ambulance Emergency Assistant (AEA) course. The AEA can perform skills including nebulization and commencing IV therapy. Again after 1000 hours or 6 months of full-time working, they can apply to do the 9 month advanced life support paramedic course. This course has limited space and the entry exams are tough; thus AEA’s often have to work for a number of years and gain experience prior to doing the course. This pathway to become an Advanced Life Support Paramedic is now being scrapped in favor of a 4 year degree program at selected UT’s.
In many ways this agenda has been driven by a desire to professionalize and create the capacity for research within the field. Still there is an eerie sense of dèjá vu; the impact on training is similar to what happened to nursing not so long ago. During the late 90’s in an attempt to restructure nursing, various colleges were shut down, shorter nursing courses were suspended, the university curriculums were adapted and the intake of nursing students at these institutions reduced. Shortly thereafter community service for new nursing graduates became compulsory and to become a nurse meant 5 years of studying. Fast forward about 20 years, and South Africa has an estimated shortage of 45 000 nurses, with only 3 500 new nurses are trained per year. According to Nursing Council statistics 48% of Professional Nurses are above the age of 50 with 25% of nurses under the age of 40; of these only 5% are under the age of 30. The shortage of nurses is dire and will continue for the foreseeable future, especially when the 48% above 50 start retiring in the next decade.
The shortage gave rise to contract nursing, also known as ‘moonlighting’ where nurses work overtime shifts or only work as agency nurses. Moonlighting caused (well-described) drastic consequences on the quality of nursing care in South Africa. Furthermore it attributes nurse burnout. Sadly it also costs the hospitals more money to buy-in agency staff, it increases the load on the nurse managers to process hours, plan staffing, negotiate and book agency staff.
There are a few lessons to learn from the above. Sadly though, paramedicine seems to be on the same trajectory. Other concerns include
1) University qualified paramedics = higher salary expectations = higher budgetary demand
Remunerating a workforce that consists of degree paramedics will be at a far higher cost than paying different levels of short-course practitioners. In a country where the health system is struggling with budgetary constraints exists I’m not sure whether the provincial health services would be able to accommodate increased salary budget demands without compensating other vital aspects such as vehicle maintenance, equipment or stocks.
2) Related to the above. The cost to train a degree paramedic
The cost per student is higher at a university than with in-service training. The duration of the courses are longer, meaning that any investment will only yield results in 4-5 years. How can this be seen as cost-effective in a country with budgetary constraints, a growing burden of disease and ever-increasing demand?
3) Brain drain
It is not a new problem that newly qualified paramedic graduate leave the country in hordes. They earn better salaries in Qatar, the UK and as contractors for the oil and gas industry. Thus the back bone of the provincial services has remained short course paramedics. In the Western Cape the vacancy rate for paramedics in the public sector is 7.5% (2015/16 DOH report). This is the highest across all healthcare professionals in the public sector; it is even higher than the nursing vacancy. Taking away the short courses, spending all the money to train graduates and then have them leave the country doesn’t seem to solve the pressing issue of high vacancy rates. The vacancy rate might already imply a paramedic shortage.
4) Loss of tacit knowledge and experienced practitioners
Over the past decade the career progression for paramedics that came through the ranks by doing the short-courses has become more and more limited. Often despite their years of experience, they cannot apply for management positions; they earn less that their newly qualified inexperienced colleagues. Because they know the system they often end up carrying newer qualified degree paramedics. Over the years with the constant threat of the end of short-course training, and the rise of more and more degree paramedics, these practitioners have become disgruntled and unhappy. Now that their qualification is officially extinct, why should they stick around in the industry? And can South Africa really afford to lose their knowledge and experience?
5) Increased barriers to access emergency care
I’ve been part of the Hout Bay Volunteer Ambulance Service (HBVEMS) since 2004, a community-driven ambulance service that predominantly functions with short course practitioners. With no more short courses, the growth and sustainability of services such as HBVEMS are stunted. The volunteer pool will shrink until there is no service left. This is true for volunteer services across the country and it creates a gap in service delivery and access to essential emergency care.
6) Impact on fire services
In Hout Bay and other areas, the fire services fill an important gap as first responders. Often patients are taken to fire stations where care is rendered whilst waiting for an ambulance. This is done by fire fighters that have completed the short courses. As rendering emergency care is not their primary duty is seems nonsensical for them to do a 4 year degree. Again the impact of fire fighters no longer being qualified to render basic care will be felt by the community.
7) Paramedicine = exclusivity
A degree program has higher entry requirements than skills based programs, helping the professionalization of the field. I fail to see how the professionalization and more elite paramedical qualification contributes to better serving the need of our country’s growing population. Would the same money to train degree paramedics, not be more useful if used to purchase more ambulances? Is scrapping short-courses really in-line with the needs of the population of South Africa? Not to mention that there’s been studies questioning whether having higher qualified paramedics on scene actually equals better care, as they are more likely to spend longer time on scene performing advanced interventions that is not always required. In the end one of a paramedic’s core functions is to stabilize and transport to definitive care.
The key arguments for discontinuing short courses are that short courses do not comply with the National Qualification Framework Act. And in order to professionalize paramedicine a degree program is required. It has also been stated that the Health Professionals Council of South Africa has to protect the public by ensuring the registration of appropriately qualified emergency care providers who has the skills to practice their profession safely.
“We learn to do something by doing it. There is no other way.” – John Holt
I completely agree that there should be a degree program that helps advance the field, promote research and education. However in the end, a good paramedic is someone that can apply their skills. Paramedicine is a skills-based function and whether having a degree equals being more skilled to perform practical interventions are questionable. I disagree that the ‘professionalization’ of paramedicine at the expense of short-course programs is the best way forward. Especially in a country that has a growing population, quadruple burden of disease and inequality in accessing care. In fact to solve some of the problems that we face in emergency care, maybe we should rather follow one of the ideals of the Gates foundation: “The ideal is creating a skills-based credential that is well trusted and well understood enough that employers view it as a true alternative to a degree” (Bill Gates 2013)