PHYSIOTHERAPY GRADUATES CONTRIBUTION TO SOUTH AFRICA'S HEALTH NEEDS A TEN YEAR SURVEY OF THE UNIVERSITY OF THE WITWATERSRAND

Graduates of the University of the Witwatersrand Physiotherapy department were surveyed by means of a questionnaire over a ten-year period, 1980-1990. It was found that almost thirty percent of the graduates were not in any way contributing to the health needs of the country. Twenty percent have left the country and a further nine percent are not practising physiotherapists. Of the remainder, only twenty-six percent are working in the public health sector which serves eighty percent of the population. Their work profiles and job satisfaction are also discussed.


INTRODUCTION
South African medical schools have provided over the years excellent gradu ates skilled in first world medicine with little or no understanding of preventative and community-based health care. Skilled practitioners have developed the private sector in the major South African cities, while many have left the country in con siderable numbers. Now, in a changing political climate, medical educators are beginning to ask themselves whether they are preparing graduates to provide an appropriate health service to meet the country's chang ing health needs1.
The Physiotherapy Department of the University of the Witwatersrand started a programme of curriculum review in 1991. This initiative came about due to the real isation that in order to be relevant in the changing South A frica, professionals needed to be trained, who understood the health needs of all our communities and who would have the skills to provide an appropriate physiotherapy service. As part of this review the Physiotherapy De partment decided to survey its graduates over the past ten years to establish their contribution to health provision in South Africa.

M ATERIALS AND M ETHODS
In the period between and including 1980 and 1990,340 physiotherapy students graduated from the University of the Wit watersrand.
In order to survey these graduates by means of a questionnaire, current ad dresses of the registered graduates were obtained from the South African Medical and Dental Council (SAMDC), and com pared with the graduation lists obtained from the University Records Department.
Physiotherapists living overseas were not included in the study, as they are not contributing to health needs in this coun try. For the same reasons, graduates not registered with the SAMDC were not in cluded, as registration with this organisa tion is a prerequisite for practice in South Africa.
Confidential questionnaires were then sent to the 277 registered graduates with stamped envelopes for their return. All the graduates to whom the questionnaires were sent were followed up telephonically in order to improve the percentage return of the questionnaires. Of the 277 question naires that were sent out, 133 (forty eight percent) were returned.
The questionnaire covered the follow ing three main areas; • Demographic profiles of the respon dents. • Work profiles of the respondents. • The respondent's perception of job sat isfaction.
The results of the questionnaire were tabulated, analysed as percentages and graphically represented. RESULTS AND DISCUSSION Demographic profiles of the respon dents Both the n i1 mber of gradua tes and those registered with the SAMDC had increased from 1980-1990 (Fig 1). This increase is due to the increase in the intake of the number of students into the course. An average of 80% of the total graduates over the ten year period, 1980-1990 were registered with the SAMDC in 1991. This compares favour ably with a similar study conducted in Queensland Australia in 19872 in which 80% of their graduates were also registered and practising in the country. Year of graduation _ _ _ _ _ _ _ Fig 1: Registered physiotherapists_ _ _ _ _ _ _ Nine percent of the respondents are not practising at present, and when added to those who are not registered, it is seen that almost 30% of our graduates have left the profession. It is doubtful whether the country can afford to provide the expen-ABSTRACT Graduates of the University of the Witwatersrand Physiotherapy De partment were surveyed by means of a questionnaire over a ten year period, 1980-1990. It was found that almost thirty percent of the gradu ates were not in any way contribut ing to the health needs of the coun try. Twenty percent have left the country and a further nine percent are not practising physiotherapists. Of the remainder only twenty-six per cent are working in the public health sector wnich serves eighty percent of the population. Their work profiles and job satisfaction are also dis-Vcussed______________________ŝ ive education of the nature found in medi cal schools, and justify a 30% drop-out rate. A possible reason for this drop-out rate may be due to the fact that family commitments are greatest during the first ten years after graduation.
There has been however, an increase in the number of male graduates over this period. While there were no male gradu ates in 1980, four graduated in 1981 and the trend continued to 1990 where there were * nine male graduates.
Very few students from racial groups other than white have graduated during this same period. Their poor preparation for university because of the existing edu cational system, as well as an apparent lack of awareness of the profession may be con tributing factors to this picture. This imbal ance needs to be rapidly redressed, if the profession wishes to survive in the immi nent new political system.
Three percent of our respondent sample are presently working in the rural areas in which 50% of the African population re sides3, 14% in towns and an overwhelming 83% in the cities (Fig 2). This figure reflects the severe maldistribution of health pro fessionals, including physiotherapists, in Our status as independent relocation consultants, together with our wide range of contacts and experience throughout America, will ensure that you benefit from Excellent opportunities -only the best available positions in the USA and Canada Top rates of pay -guaranteed to be on a par with your American colleagues & Personal service -we're always on hand to help with the many aspects of your move. Let Action Medical link you to a New World of opportunity. Call Julia Swain now on 021 794 7736 or send your CV to us today. We will send you a full information pack by return of post. The rest is^lain sailing! South Africa, with people in cities being well cared for and those in rural areas having little or no access to comprehensive health care4. There were once again vast differences in the total time spent working in public hospitals between the cities, towns and the rural areas. Seventy one percent of the time was spent in city hospitals, 20% in town and 9% in rural hospitals. A reason for this may be that professional people usually prefer to be in the more sophisticated en vironment of cities which offer better edu catio n al and cu ltu ral o p p o rtu n ities. Greater incentives need to be offered to encourage professionals to spend time in rural areas.

W ork profiles of the respondents
Twenty-six percent of the sample are presently working in state and provincial ie public hospitals, where according to Slabber5, approximately 80% of the popu lation, who do not have access to medical aid benefits, obtain health care. Seventyfour percent of the respondents work in private practice which serves approxi mately 20% of the South African popula tion who are also covered by medical aid schemes. In contrast, 38% of physiothera pists in Queensland2 worked in private practice while 62% worked in hospitals (Fig 3). The percentage of graduates working in public hospitals increased during the pe riod 1980-1990 (Fig 4). This is probably because recent graduates are working off bursary commitments or are wanting to gain generalised experience before em barking on a career in private practice where the financial rewards are better. The lack of experienced physiotherapists in public hospital practice makes the provi sion of physiotherapy services to special ised units and the clinical supervision of undergraduates difficult. It also reiterates the maldistribution of physiotherapists for the general population.

PRIVATE PRACTICE vs HOSPITAL
Time spent in specific areas of physio therapy practice was established from each respondent, averaged and expressed in years (Fig 5). Six areas of practice were found to be relatively under serviced, namely geriatrics, spinal cord injuries, cerebral palsy schools, schools for the physically disabled, special schools and administration. Areas found to be rela tively over serviced were spinal mobilisa tions, soft tissue and sports injuries, ortho paedics (trauma and cold) and chest physiotherapy (medicine, surgery and in tensive care). These are all areas that are more than likely to be covered by medical aid schemes, which may be one reason for this over servicing.
The above distribution of time reflects the poor contribution of the profession to the rehabilitation of spinal cord injuries, cerebral palsy and neurological conditions which are notoriously poorly covered by medical aid schemes. This also reflects the profession's lack of involvement with the population who cannot afford private health care.
Thirty four percent of the graduates are presently involved in or have completed post graduate studies. While it is pleasing to know that some of our graduates are involved in ongoing self education it is of some concern that 66% of the physiothera pists surveyed appear not to be involved in on-going education.

The respondent's perception of job satisfaction
When comparing the perceived job sat isfaction of respondents in public hospitals . to those in private practice (Fig 6) it can be seen that the graduates in hospitals are more satisfied with their profession.
The majority of graduates working in private practice are only slightly satisfied with their profession. Salary levels in pri vate practices are higher than in public hospitals and for many it becomes a choice between earning well versus job satisfac tion. The reason for the higher level of Fig 6: Job satisfaction of respondents in hospitals _ _ _ _ _ _ _ _ _ _ _ _ and private practice_ _ _ _ _ _ _ _ _ _ _ _ perceived job satisfaction in hospitals may be due to a more varied selection of work, contact with other health professionals, continued learning with and from others and possibly better housing, medical and pension benefits.

CONCLUSION
It appears that approximately 70% of our graduates are contributing to the 'health needs of South Africa, 30% having left the profession. This contribution is skewed to the private sector in cities, with over servicing in certain areas of therapy, namely spinal mobilisations, soft tissue in juries, orthopaedics and respiratory condi tions relative to the major rehabilitation areas of neurology, spinal cord lesions, cerebral palsy and other long term disabili ties.
If we wish to address the>broad health needs of the South African population, both our training institution and the pro fession need to change their orientation.
Steps have been taken at the University of the Witwatersrand to introduce a commu nity based approach to physiotherapy em phasising the health needs of all South African communities.