Date: Wed, 11 Feb 2015 21:58:06 +0100
Africa's doctors, feeling extremely unloved, are leaving in droves. It could get worse
In Ebola-ravaged Liberia, in 1973 there were 7.76 doctors per 100,000 people, in 2008 this had dropped to 1.37 doctors. The pain is growing.
TWO unrelated events in East Africa are serving to cast a light on a trend that has in recent years had a major impact on the continent’s wellbeing, and consequently threatens its productivity and subsequent the sustainability of the ‘Africa Rising’ meme.
In Kenya, in the week that the country’s executive launched a $420 million medical equipment project for local hospitals, news filtered through that five doctors in Lamu, one of the country’s 47 counties, had tendered their resignation, leaving just one doctor tending 100,000 citizens.
The doctors cited among other grievances low pay, poor working conditions and hostility from the employing county—a common grouse by the estimated 800 doctors who have quit public service for either private care providers or to look for opportunities abroad in just one year since since the national government devolved the health function to local governments, citing the country’s new constitution.
In neighbouring Uganda, a closely-watched court case looks to further recast the debate about African health workers, who are increasingly confronted with the dilemma of seeking better work conditions or being patriotic and soldiering on.
An advertisement last year placed by the East African country’s foreign ministry sought applications from Ugandan medics willing to work in Trinidad and Tobago, with the rich Caribbean state saying the workers would “strengthen its health service sector”.
At least 261 health workers were shortlisted after nearly 500 put in their papers, triggering the court case brought by a local think-tank seeking to bar what it said is a plan by the Ugandan government to “export” much-needed health workers.
In its petition, the Institute of Public Policy and Research (IPPR) wants the recruitment of public health workers for another government declared as violating the constitutional rights of Ugandans to access basic medical services, news wire AFP reported.
The country’s ministry of health said it had not been involved in the recruitment, suggesting a lack of internal coordination, but Uganda’s attorney general is arguing that it is the constitutional right of all professionals to seek gainful employment elsewhere, a position that has been backed by other government officials and diplomats.
One of those interviewed by the news agency, 47-year-old nurse Santina Obina, said she earned a net salary of $245, which she said was too little and often delayed, in a country where parliamentarians earn over $6,000 a month—a similar basic salary to that of MPs in Kenya, where a doctor takes home under $500 monthly.
Does not add up
Obina also cited overwork, with Uganda having less than 5,000 doctors and 30,000 nurses for a population topping 35 million people, according to World Health Organisation data. She would have liked to stay, but the math simply did not add up, she said.
The US has about 775,000 doctors and 3 million nurses and midwives for a population only eight times that of Uganda.
It is not clear what Trinidad and Tobago, which is ranked in the top 70 countries for the quality of its healthcare will pay the Ugandans, but it is expected to be several times better, further complicating the IPPR’s case.
The cadres sought include nurses, midwives, anaesthetists, surgeons and paediatricians, in addition to one of Uganda’s three neurosurgeons.
The IPPR says its case, which it terms the first ever public interest litigation cases on medical “brain drain”, is a particularly important one for Africa, with other countries such as South Africa, Ghana, Malawi, Zimbabwe and Zambia also “badly affected”.
Research would appear to support the claim. One of the most authoritative studies yet on the subject found that sub-Saharan African countries, including Uganda, had conservatively lost $2.17 billion they invested in training doctors who then left to find work in more developed countries.
This amount could easily run into the tens of billions of dollars as the 2011 study by Canadian scientists focused on only nine countries that have a heavy HIV/Aids burden, and only on doctors.
Additionally, there are those who had left but were not practising meaning they are not captured in official data— cryptically referred to as “brain waste”—while the study was further conservative as it did not factor in the cost of post-graduate education.
It gets grimmer: if this figure is compounded over the entire length of an average doctor’s career, and using a conservative deposit rate for each country to factor in the hit to potential investment, the nine countries would have lost $13.53 billion.
The scientists narrowed their study to Ethiopia, Kenya, Malawi, Nigeria, South Africa, Tanzania, Uganda, Zambia and Zimbabwe. Doctors from these countries have tended to emigrate to Australia, the UK, US and Canada, but newer destinations like Saudi Arabia and the Middle East are also emerging.
This means the destination countries are saving themselves billions of dollars in training costs by recruiting doctors trained abroad—at least $4.55 billion according to the study—with the UK, which has the biggest number of African doctors, accounting for nearly half of these savings.
The scientists, led by Edward Mills, who is chair of global health at the University of Ottawa, found that South Africa and Zimbabwe had the biggest economic loss on investment in training doctors.
Uganda subsidised an estimated $21,000 of a doctor’s education, South Africa $58,700, Nigeria ($36,400), Kenya ($36,450) and Zimbabwe $38,600.
“In the setting of HIV epidemics and related health problems, the loss of these vital members of society undermines both health and social stability in African communities,” they said.
“Quantifying economic losses may help motivate and encourage policy makers to improve working conditions and incentive programmes to retain doctors in the countries where they are trained, and to support improvements in the infrastructure of medical training in sub-Saharan Africa.”
These exits bring the pull and push factors for health workers sharply into view. Sub-Saharan Africa’s low physician to population ratio in part doubles back to the low numbers of medical schools. The last comprehensive study found less than 200 schools in sub-Saharan Africa, many with a shortage of, or unmotivated, faculty.
This is responsible for many graduates declining to work in rural areas due to a lack of clinical support, as mirrored by the Kenya dispute.
Add to this the ever-present poor pay and working conditions and shortages of supplies and equipment and the situation becomes desperate. Strikes in sub-Saharan countries have become common-place, with wide-reaching consequences: picketing by Nigerian health workers in the week Ebola reached the West African shores could have had major ramifications had infections taken off. (Ironically, the strike meant Nigeria’s patient zero went to a private facility first, reducing the risk of spread).
The African Union is currently deploying health workers to Ebola-hit areas, but there has been little mention of accreditation requirements, many of which vary widely across sub-Saharan Africa. (Such new threats also take their toll on Africa: of 822 medics infected with Ebola by February 1, 2015, some 488 have so far died.)
Further, curricula across the region are struggling to keep up with emerging international trends, as research opportunities remain few and far between, many bankrolled by donors.
African governments have also underspent in meeting basic infrastructure such as electricity, water and roads, while internal official coordination is often weak, leading to health worker grievances going regularly unaddressed.
Many healthcare workers thus seek to train abroad with better facilities, but a significant majority, ensnared by better opportunities and career considerations, do not return, either immediately or at all. The migration culture them becomes self-fulfilling; the more medics migrate, the more others want to migrate.
These factors have conflated with historical grievances. A newer study found that neatly half of the sub-Sahara Africa-trained physicians who are in the US emigrated during the 1984-1999 implementation years of the structural adjustment programmes.
In some countries the move to the US was dramatic: over the last ten years physician migration from Nigeria and Ghana increased 50%, Ethiopia by 100% and 200% in Sudan. In Ebola-ravaged Liberia, in 1973 there were 7.76 doctors per 100,000 people, in 2008 this had dropped to 1.37 doctors.
There may be some respite in terms of remittances—professionals in sub-Saharan Africa are this year projected to send back $38 billion; a 9.1% growth rate over last year, according to the World Bank’s Migration and Development Brief. The region also remains one of the few in the world where official development assistance is large than remittances.
However, the overall cost to the African healthcare system far outweighs this, not to mention the bulk of the money sent back goes to families and not into improving health facilities.
The overall effect is that the continent cannot dent its sizeable disease burden—nearly one-fourths of the global total—when it has only 2% of its doctors. The region has only nine nurses and midwives for every 10,000 citizens; Europe has 65, according to the World Health Organisation, and 15 times as many doctors.
This puts into doubt its meeting of poverty targets such as the Millennium Development Goals, and their post-2015 successor, as current GDP spending on health hovers around 6.5%. In the Americas, where Trinidad and Tobago is to be found, health spending is nearly 15% of GDP.
There have been calls for a balance. In 2010 the World Health Assembly overwhelmingly adopted the first code of practice on the international recruitment of health personnel—and only the second by WHO after one regulating breast-milk substitutes marketing in 1981.
Among the recommendations, which are voluntary, are a call to mitigate the negative effects of health worker migration, given the right for people to attain the highest possible standard of healthcare, and for any individual to legally migrate.
It also calls for wealthy countries to provide cash to source countries and address underlying causes of migration, but also discourages the active recruitment of health personnel from countries facing critical shortages.
The US is a significant player in Uganda’s healthcare system, and as expected expressed its concern over the pending “exports”. But in taking in African doctors, it is effectively pocketing back part of its billion-dollar health aid to the region. By neglecting to love its doctors, African governments are just as complicit.