This is the second essay on government policy in Ethiopia directed at developing and retaining talent. Last week's post addressed the challenge of improving research productivity.
On May 3rd 2019, the Prime Minister (PM) of Ethiopia held a meeting with 3 thousand health professionals from all over the country to discuss the state of health services and the challenges health workers are facing. Although the Prime Minister declared that the meeting was “key for policymaking” the health professionals appeared to be unsatisfied with the way he addressed their predicament. In spite of the concessions and the many promises made, a wave of strikes continued across the whole country.
While the solution to this particular turmoil might be the immediate concern of the government, there is general recognition that the sector’s challenges extend far beyond the current standoff and need structural and systemic changes. The government vows to make additional efforts and changes with the involvement of relevant stakeholders at national and regional levels. One challenge that needs to be addressed is the migration of health professionals, especially physicians, a tendency that has seen little change over the years.
Healthcare and medical education in Ethiopia
At a global level Sub-Saharan Africa is known for the lowest density of healthcare workers. According to the World Health Organization, Ethiopia has a health workforce ratio of 0.7 against the recommended ratio of 2.3 per 1000 population that is considered to be imperative for health coverage and making meaningful health interventions. Ethiopia’s physician-to-population ratio of 1: 21,000 is also regarded as one of the lowest in Sub-Saharan Africa.
Since 1994 the government’s health development programs have had important impact on the sector’s growth. According to the Ministry of Health (2016) there has been a significant increase in health posts, health centers, hospitals and personnel including officers, nurses, midwives and health extension workers. The number of schools and colleges providing health education training has increased; the graduation output of public and private schools including higher education institutions has also grown more than 16-fold since 1999/2000. According to the Ministry of Education (2018) there are currently more than 80,000 undergraduate students who pursue studies in medicine and health sciences both in public and private higher education institutions.
Despite the efforts towards improving the healthcare system that have produced quantitative gains, many challenges remain. The system is still deficient in infrastructure and resources, quality of education, internal quality assurance systems, performance assessment and retention, skill distribution, regional disparities that result in poor motivation to work in rural areas, little inclination to specialize in disciplines where there are skill shortages and more.
In order to respond to these multi-faceted challenges, the Ministry of Health has devised several strategies including its popular “flood and retain initiative” designed to bring meaningful change to the number of available health workers at all levels. While some improvements have resulted through such interventions, it has not been possible to solve the various challenges of the sector in a fundamental way, including the migration of physicians who continue to leave the public sector and Ethiopia for greener pastures inside the country and elsewhere.
Immigration plans and patterns
Sub-Saharan Africa has the highest levels of health worker migration in the world. Ethiopia remains one of the countries with the highest emigration of physicians in Sub-Saharan Africa. According to Berhan (2008), Ethiopia trained 4629 physicians (including 1153 specialists) between 1987 and 2006 but the public sector managed to retain only 20 percent, or 932 professionals in the same period. Though limited, other studies made of the brain drain and emigration aspirations of medical students continue to reflect a situation in Ethiopia that is quite alarming.
Deressa and Azazh’s study (2012) in Addis Ababa University showed that around 53% of medical students hoped to emigrate upon graduating, particularly to the United States and Europe. The desire to migrate was higher among fourth year and internship students than those in the first and second year, stronger with male students than female students, and particularly strong among those with clinical experience as compared to those in the pre- clinical stage.
Johansson’s 2014 study in Jimma University and St. Paul’s Millennium Medical College in Addis Ababa revealed that 59.4 % of medical students plan to work abroad in 5 years and as many as 73.4 % indicated their intention to go abroad in 10 years. The only exceptions were female candidates and trainees who had altruistic motives for serving the community and showed less inclination to leave their country immediately after graduation. It should be noted that mobility is also a common phenomenon among a significant number of health professionals who would like to move from rural to urban areas and from the public to better-paying jobs in the private sector. Compared to other professional areas, the medical career appears to be the most susceptible to the temptation to emigrate owing to the increasing demand for health professionals in the developed world that offer better pay, better living conditions and a better working environment.
Addressing the challenges
Educating medical doctors is an expensive enterprise for any developing country. According to one conservative estimate nearly 30,000 USD is lost for every medical school graduate who emigrates.
The decision or intention to emigrate is a complex issue that can be influenced by a plethora of factors. The health professionals meeting with the PM expressed their concerns about not only improving financial rewards to health professionals, but also improving the quality of education, career satisfaction, retention incentives, career advancement opportunities, health facilities and addressing administrative inefficiencies and corrupt practices in the system.
While the importance of overhauling the system and addressing various challenges of the sector is a matter of urgency it would not be an easy task in a country where there are a multitude of other societal challenges and serious resource limitations. In terms of priorities, however, the country cannot afford to continue to educate, and then lose its medical professionals in whom significant investment of public funds has been made and whose contributions are critical to the improvement of the health system. Hence, one major component of addressing the multi-faceted challenges of the health sector should hinge on devising efficient mechanisms for preventing the emigration of health professionals and tapping the expertise of those who have already left.
Wondwosen Tamrat is an associate professor and founding president of St. Mary's University, Addis Ababa, Ethiopia.