In some rural areas of South Africa, there are only three doctors for every 100,000 people. How can we tell the UK not to recruit our doctors if we do the same. Thami Mseleku

With more South African doctors now working abroad than in the country's ailing public health sector, the government needs to start aggressively recruiting health workers from other countries, according to a non-profit recruitment organisation.

Dr Clarence Mini, of Africa Health Placements, which specialises in placing public-health professionals, told a national tuberculosis conference in the port city of Durban earlier this month that more than 4,000 doctor's posts were currently unfilled in South Africa's state hospitals, while 3,000 South African-qualified doctors are working in the United Kingdom and 2,000 in the United States.

Health workers have become a highly mobile resource that countries have to compete for, Mini told delegates. First-world countries that offered better salaries and working conditions have managed to attract the lion's share of those resources: the United States now has about 550 doctors per 100,000 citizens, compared to South Africa's 65.

To make matters worse, 75 percent of South Africa's doctors work in the private sector, and most of those remaining in the public sector work in urban areas, while in rural areas the doctor-to-patient ratio can be as low as three doctors to 100,000 people. In the context of South Africa's HIV/AIDS burden, this amounts to a crisis.

One of the quickest and cheapest solutions to the problem, argued Mini, was to recruit foreign doctors and nurses: it cost about R2 million (US$263,000) to train a doctor, compared to about R100,000 (US$13,000) to recruit one from overseas.

The South African government has taken the stance that recruiting health workers from other African countries with similarly or even more poorly staffed pubic health sectors is not the answer.

Responding to Mini's presentation, health department director-general Thami Mseleku said that health ministers from Zambia and the Democratic Republic of Congo had pleaded with him not to employ their doctors. "How can we tell the UK not to recruit our doctors if we do the same?" he asked.

South Africa's human-resource plan has set a target of employing just five percent of doctors from other countries. Currently, about 15 percent of doctors are foreign, compared to an average of about 25 percent in the developed world.

According to Prof Helen Schneider of the University of Witwatersrand's Centre for Health Policy, in Johannesburg, the government has tried to recruit only from countries such as Cuba and the Philippines, which have surplus doctors.

"My understanding of the department of health's official position has been that if one is going to recruit foreign health workers, you need to do it in an ethical way," she told IRIN/PlusNews.

Mini urged the government to start by, at least, recognising the qualifications of African doctors already in the country as refugees and asylum seekers. "Instead of making them car attendants, let's get them into hospitals to help our patients," he said.

He also asked why the bureaucratic requirements could not be cut down for doctors from developed countries who wanted the experience of working in a rural South African health facility.

South Africa also needs to increase the number of medical school graduates to keep up with demand, said Mini. Over the last decade, intake at the country's eight medical schools had remained the same, while the number who actually graduated had decreased.

Keeping those graduates in the country and in the public health sector should be the next priority. "If all of South Africa's graduates had remained in the country, we wouldn't have this crisis," said Mini.

The Centre for Health Policy recently reviewed a number of studies carried out in low- and middle-income countries to examine the effect of interventions to retain health workers.

The authors found that while money was important, salary increases were not usually enough to prevent health workers from migrating; feeling valued and recognised, and having opportunities for career development, were also of crucial importance.