The end of the short course route to become a SA paramedic

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.

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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)

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15 thoughts on “The end of the short course route to become a SA paramedic

  1. sad days indeed … the end of an era … in my opinion the entire process by the Board is seriously flawed. They never have, never wanted to properly integrate the short course with the formal university qualifications. The work was done in 2006 by the SGB’s to align the courses with SAQA and the NQF and then it was shelved – I know, I served on the SGB and we did all the work writing curriculum’s as Unit Standards, so persons could overtime align and upgrade!

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  2. Well written and so spot on.
    If they really wanted to advance the profession, the theory could’ve been conpleted via UNISA with core instructors evaluating final outcomes and practical work in selected hospitals. Only those born into privilege will be able to become paramedics now….where as with the short courses everyone stood a chance. Those in our poorest communities could uplift themselves and their medical knowledge helped their communities. I’m shocked the minister would stop a course system that helped previously disadvantaged and favor a system mainly of ‘white privilege’. Those most in need have now lost the ability to enhance and uplift themselves and the communities most in need have now been hurt the most.

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  3. Well the question arrises if you have 2 degree qualified medics on board who will be doing the grunt work? Everyone has his or her place on the ambo and some guys, sorry if this offends anyone, just does not have the abilities to move on up. It is to be noted that a hierarchy is omni present and having 2 similarly qualified professionals may inadvertently lead to clashes. Considering the interpersonal dynamics and personality traits of medics in general this could be a problematic situation in my opinion. So it is my opinion that this regulation will kill off EMS as we know it and due to this the South African community as a whole will be poorer because of this action. It is to be noted that this action was done without the consultation of any intersted parties and as such does not benefit anyone in South Africa. So in conclusion it was a sad day when this legislation was brought into power. Not only for the guys and ladies out there that would have no way of getting to move up and would be stuck in the level of qualifications that they are at because they dont have the needed university release to enable them to go and study to further their abilities to support their communities and also their families. This is not even taking into account the financial needs for an individual to go and do this. So where do we go from here? Well this is a good question? And something I think needs to be addressed by our esteemed Minister of Health. He would need to give guidance in this regard as he needs to show the strategic plan on how personnel will be trained and how they expect to retain EMS Personnel in South Africa to support the South African communities. I just think it would have been more important to protect the resources that we have got in ensuring that they are protected on our roads from situations where they are robbed or attacked or worse. Also looking at how to retain these skills to serve our communities. And this in conjunction with the lack of consultation with interested parties makes me feel that there may be some form of ulterior motives for making these changes. Is this worth fighting for? I think it would be a waste of time effort and money as numerous individuals have tried and are still trying and it is falling on deaf ears. So a sad day indeed as there is not much that can be done.

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  4. Hi, thank you so much for the comments, I received a lot of negative comments on Facebook and private mail about the blog being biased and not factual, so I am copy and pasting the reply that I posted on Facebook. I should’ve included proper references however due to space I did not. IN retrospect that was a mistake as this is such an emotive issue for all of us. Here is the comment:
    ‘Hi, Thank you for comments on my blog. It is not an article, it is a blog, thus it is an opinion piece, which is therefor biased. With regards to broad statements, yes I should’ve included the evidence, my apologies. However, it would have taken more space than the blog itself. Also note that I did not use experience as the measurement or based my entire blog on experience. I first referred to the nursing situation – you can check the statistics on SANC.org.za furthermore you can also search for articles and statements from DOH, Solidarity for the stats used. Risen has published extensively on the role of moonlighting on nursing. I then referred to the budget and cost, yet again, you check the stats on the DOH website 2015/2016 annual report for actual budget, overtime costs, training costs and vacancy rate. Finally regarding the statement broad statements – I will stick to mentioning a few articles – unfortunately it is not open access so I can shared the articles: Macfarlane and Benn (South Africans) Evaluation of EMS: a classification to assist in determination of indicators. Liberman et al. Advanced or basic life support for trauma: a meta- analysis and critical review of the literature. Eissen, JS, Dubinsky ALS vs BLS support field care: an outcome study. Cayten CG BLS vs ALS for injured patients with a severity score of 10 or more. Eckstein et al the effect of prehospital ALS on outcomes of major trauma patients. Demetriades D et al: paramedic versus private transportation of trauma patients the effect on outcome. Murray et al. Prehospital intubation in patients with sever head injury. Shuster M, Keller J. The effects of prehospital care on outcome in patients with cardiac illness. Due to space I’m referencing it properly, but it should provide the idea of what I based my broad statements on.’

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  5. Hi Charmaine, why can’t the short course program be included into the UT course as correspondent courses, so when they have done their hour’s they can apply to write the certificate, diploma then degree, so all paramedics get the chance to write, it’s standardised and fair, so you will eventually get across the board paramedics based on hard work and knowledge.

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  6. Think this whole proposal is ridicoulous. Look at what happened in the teaching proffession when they scrapped the teacher training colleges. The degreed teacher now has to handle classes of up to 50 pupils because the school cannot afford to employ more teachers within their budget. Also how many that have the real passion to become a teacher cannot do so because their parents do not have the money to send them to university

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  7. While I acknowledge that every country is different, you will find that in the long-run the workforce and the community will be better off with degree-qualified paramedics. First responders should still be able to do short courses and provide their important services to the community.
    Please don’t have knee-jerk reactions about degree qualified paramedics. In Australia, we find that the students and graduates are not that much different in their motivations and attitudes to vocationally trained people from my generation. I trained more than 40 years ago. They do, thankfully, have more knowledge and skills than we ever had. Give the system and the graduates time to succeed. Also remember who will be teaching them – you, the experienced paramedics, many of whom will eventually make the transition to a profession alongside the new graduates.
    I do hope that there will be pathways for the vocationally trained paramedics provided such as bridging courses that recognise prior learning. This is how we started and now the same thing is now happening in Canada on Prince Edward Island.
    Your concern might be more about the processes used rather than the ultimate objective. Come and visit us and see first hand how things are panning out in the long term with entry-level degrees the norm and postgraduate programs for advanced practice. Even doctorates for paramedics; and its not just the young graduates getting these qualifications.

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    • Hi Peter, thank you for your comments. I’ve heard a lot of good things about the Australian system. I think more than process, a lot of my concerns are based on the business side of things. My M is business administration and my dissertation topic was regarding the sustainability of volunteer ambulances services. So I’m used that as basis for the argument.
      For instance the Western Cape Health budget, which is known as the best EMS system in South Africa – was 7 million rand over budget for patient transportation in 2015/16; in 2012/13 they exhausted the overtime budget in the first quarter of the year. This is paying non-degree paramedics. A degree paramedic will have a higher salary expectation – and there is nothing wrong with that. But how are we going to afford it? Looking at the nursing example, it means cutting quantity….in a country where we not quite getting timeous access to healthcare right, thus the patient suffers. If the salaries are not aligned to meet a market related income for a person with a 4 year degree, what will happen is that (a) less people will study paramedicine, (b) those that study it will leave the country to go to Aus, UK, etc. where they earn well.
      I’m not against the degree course and it’s needed to advance the field. However scrapping the short courses might not be in the best interest of the country, even if it is in the best interest of the professional paramedic. And that gap needs to be addressed by the policy makers prior to scrapping the short course route.

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      • Charmaine,
        The maintenance of volunteer systems is a largely separate issue to university education in Australia where about a third of our providers are volunteers (mostly unpaid, but not free). These volunteers and retained staff (paid for call outs and some training) do a range of vocational education programs depending on whether they are first responders or actually staffing ambulances in more remote areas. In my experience as an ambulance service manager in rural areas and now as a researcher, the two systems seem to coexist fairly well most of the time.

        More and more we are seeing the appointment of professionally educated and trained staff to leadership positions to support volunteers. A form of community paramedic. Some volunteers in Auatralia are given the opportunity and sometimes scholarships to undertake degrees, but it is not expected. I agree with you that scrapping the vocational programs that volunteers need is unlikely to be in the best interests of the community. Improving them and making the credits transferable to degrees is another issue. The reality is that paramedics need to live with first responders and volunteers, while developing and sustaining their own profession through improved education and scholarship. This is not something many other health professionals face, meaning there is no template.

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  8. Thanks for taking the time to put your view out there Charmaine. I didn’t read the replies on FB. Sorry if you are having nasty messages – that is unacceptable and no way to engage on a very important topic. I almost never post, but feel this is too important to leave alone.

    Unfortunately, poorly structure, one-sided articles like this really do not help either the morale of those working hard to provide clinical services, or those who are teetering on the edge of a decision whether to leave overseas.

    Your piece is superficially attractive, but unfortunately – as we have seen increasingly since early 2016 (think US election, or Brexit) – omits many important facts. It is therefore littered with common cognitive biases (including Occam’s Razor, System justification, Pessimism bias, In-group bias, Group attribution error, Confirmation bias, to name but a few) which are just reaffirming your existing beliefs.

    In addition, you make the same errors about the opposite view that so many people make if they don’t take the time to carefully present – or at least consider – both sides: that the person holding that view must be ignorant (not in possession of the facts), an idiot (they have the facts but can’t see the truth), or evil (they have the facts and see the truth, but have some other agenda to push).

    The reality is that this is a very complex issue and, as happens so often on social media, you have lost much of the nuance. There are 2 sides, and a lot of very smart people have spent a very long time considering both sides, and – on balance, considering all of the variable facts – decided that the course of action signed by the MoH this week is the one which is most likely to produce the best impact on patient care and development of the profession.

    It is very easy to provide counter arguments to each of your points. I do this below not to argue with you, but to try and provide a balance to your one-sided view. Everyone of course is entitled to their opinions and must be free to express them openly, but if they are emotive rather than fact-based they do little to help the industry to move forward to provide the much needed improvements in patent care that we seek in the country.

    1. University qualified paramedics = higher salary expectations = higher budgetary demand
    The flip side of this argument is of course that higher salaries may well help to drive recruitment and retention. Yes it will cost more, but does anyone out there disagree that EMS staff deserve higher pay?

    2) Related to the above. The cost to train a degree paramedic
    Yes it costs more to train on a degree. But only 5010% of the future workforce will have the 4 year degree – most will have 1 or 2 years, or some form of bridging. Even if it does cost, isn’t this an important investment in better patient care? Or should we take this position, and argue that EMS doesn’t need more resources?

    3) Brain drain
    We will never ever stop this, unless we have unqualified staff on the road. We already lose CCAs to some countries and some are looking at taking ILS staff. It isn’t as if EMS is the only profession losing staff overseas, or SA the only country. But even ignoring every else surely professional development and higher salaries will help offset this? And despite losing a lot of staff, isn’t it better for our patients that the staff that remain are better qualified?

    4) Loss of tacit knowledge and experienced practitioners
    They are still in service, and in fact have opportunities for increased skills and knowledge, especially in clinical service provision. That isn’t a bad thing! You just argued that we are losing qualified staff overseas, but now in this point you want them to stay and become managers instead: taking them away from patient care.

    5) Increased barriers to access emergency care
    Increasing the appeal of EMS as a profession, and increasing investment in staff, is a barrier to access?

    6) Impact on fire services
    We have a duty to provide quality care to our patients. We are about to being in licencing legislation – like the W Cape has had for a few years – to regulate and help improve quality. Training is part of that. Why should Fire Services be exempt? So the argument then is that EMS must provide quality care, but if they are not first on scene qualified Fire can do as they wish? No: patients who need to be attended to by EMS staff should receive quality care – public or private, EMS or Fire.

    7) Paramedicine = exclusivity
    We are aiming at 5-10% of national EMS staff at ALS level. Having >90% of staff at ECA or ECT level isn’t exclusivity.
    Also, whether staff feel “exclusive” is not about your qualifications but rather the culture in both the training institution and the service they work in

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    • Hi Lee, thank you for taking the time to comment, I really value your input. I agree that this is a complex issue and my blog does not address (or attempt) to address all the angles.
      What is important to state though is that this is a blog, a personal ‘log of thoughts’, it’s very nature is biased and based on the perceptions/experience etc. of the blogger. It does not meet the criteria of an article.
      I’ve been privy to the ‘on-the-ground’ speculations for about 13 years. The concerns are real to the many of us and it needs to be voiced, so that there can be discourse and feedback that address specific concerns.
      The information that you provided as ‘counter argument’ are the most comprehensive information that I’ve seen on this topic. We need more information and reassurance right now and I daresay that it is needed from the paramedic leadership of South Africa.
      My blog is definitely not helping with any reassurances. What it has done is to stimulate worthwhile conversations on various platforms, along with negative references to some female anatomical parts. That certainly shows the negative power of social media, yet it also demonstrates the level of emotive intensity regarding this topic. I’ve certainly evoked a lot of emotions and I knew prior to posting it that I need to prepare myself for a backlash so that’s ok. From that perspective an objective article published in a peer reviewed journal would’ve been the safer option 🙂

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