Producing doctors – what Africa can learn from Asia
By World Healthcare Journal-
In Asia there has been an exponential expansion in private medical schools over the last decade, says Dr Ken Grant, Technical Director International Health Mott MacDonald.
Africa is short of doctors. Not just short - very short. At the start of the Ebola crisis in Sierra Leone in 2014, there were only 136 doctors for 6m people. The 2017 Global Health Workforce update makes depressing reading, with most sub-Saharan African countries having fewer than five doctors per 10,000 population. Many have less than one per 10,000(e.g. Zimbabwe 0.7, Burundi 0.4, DRC 0.9. , and Ethiopia 1.0). Most OECD countries have between 25-30 per 10,000 population.
While doctors are not the only health worker they are probably the most important, both for their leadership qualities and for their overall understanding of disease causation, prevention and treatment. They also possess the clinical and public health skills needed for successful interventions at both the individual and population level.
Migration will always be an issue. It will always be cheaper and easier for OECD countries to rely on attracting trained doctors to augment their own inadequate production programmes. Doctors from Africa and Asia will always be able - with some exceptions - to earn much more in OECD countries. We have to accept this. The answer, surely, has to be to keep producing more doctors.
Better human resource planning does not seem to be the answer. The WHO, through its Global Health Workforce Alliance, has tried recommending better political engagement, 10-year workforce plans and other initiatives. None of these have worked sufficiently. Perhaps it is time to let the market try and deliver what public planning has failed to do.
We see this is happening in Asia where there has been an exponential expansion in private medical schools over the last decade. Nepal, with a population of 30m has 20 medical schools, 12 of which are private. India (population 1.3bn) has 183 government medical colleges and 215 private colleges, while Bangladesh (population 165mn) has 36 public medical schools and 54 private.
There is a big demand to enter medical school and the private sector has responded to meet the demand.There is the obvious question around quality, but all private medical schools are regulated by the countries respective medical councils, and for those wishing to emigrate they must take the respective entry qualifications of the counties they wish to practice in. If there are concerns around quality, the answer is to work to improve it through better regulation and quality assurance rather than restricting the market.
To contrast, in Africa (population 1.2bn) private medical schools have been slow to develop. The most authoritative study on African Medical schools is a 2012 study by Chen et al. This study points out that sub-Saharan Africa suffers a disproportionate share of the world's burden of disease, while also struggling under some of the greatest health care workforce shortages. Twelve per cent of the world’s population lives in sub-Saharan Africa, yet the region suffers 27% of the world's total burden of disease, has only 3.5% of the world's health care workforce and 1.7% of the world's physicians. They identified 146 medical schools of which 22 were private, but only 7 of these were for profit.
The Cuban solution
Cuba has 25 medical schools from which 11,000 doctors graduate annually. South Africa decided to take advantage of these schools and from 1996 it sent up to 100 students each year. It was expanded in 2012 when 1‚000 students were sent to study in Cuba. At that stage‚ South Africa’s eight medical schools are graduating about 1‚200 doctors a year. The plan then was to continue to send a further 1000 students a year.
However, there were issues in absorbing the returning students into the South Africa system. The Cuban students had a focus in their training and on primary care and prevention and needed further training on return in curative medicine. There Was difficulty in absorbing them both in further undergraduate training in finding early training posts for them. The jury is still out as to whether this was cost effective and whether it would have been better to train more doctors within South Africa itself.
There are obviously constraints to the expansion of medical schools – physical facilities, access to clinical environments and above all good quality teaching staff. All were identified in Chen et al’s study. However, perhaps it is time to see if the market can respond better in addressing these issues than the public sector has done. If Asia can do it, Africa can do it.
Dr Ken Grant, Technical Director of International Health at Mott MacDonald
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