Training doctors in Africa: A recipe for better medical care?
By Fiorenzo Conte
Last week Healthy Lives, via the Washington Post, reported the engagement taken up by the US government to train 140,000 African health workers. More specifically, $130 million from PEPFAR will be made available as grants to medical schools in Africa to work with partners in the United States. The goal of the intervention is to tackle the chronic shortage of health workers in Sub-Saharan Africa. This is good news because until recently a ceiling of $1 million per country was imposed by the US Congress on the training of health-care workers. The rationale behind this new measure is the following: more trained health care workers leads to a lower patient/doctor ratio and therefore to better medical care. Does it make sense? Yes, but:
- The training by itself is not sufficient to improve the level of health care. As Garrett points out
“Where aids and drug-resistant TB now burn through populations like forest fires, health-care workers say that the absence of medicines and other supplies leaves them feeling more like hospice and mortuary workers than healers.”
The discouragement caused by a lack of medicine and poor equipment in the hospitals is compounded by poor salaries. Therefore having more trained physicians and nurses won’t automatically translate into more effective health care. Other obstacles remain in the way.
2. This intervention seeks to create a stock of health workers, which is believed to have been depleted by international migration. More particularly, it aims to
“stem, and even reverse, the brain drain of doctors and nurses who receive expensive, subsidized training in Africa, only to be recruited to work overseas amid a worldwide shortage of health professionals…”
The first underlying assumption is that brain drain causes public losses in countries of origin in the amount of their training costs. This idea is misleading for a number of reasons, as shown by an article in Foreign Policy. First, surveys show that African physicians spend on average 5 years serving in their countries. Secondly, skilled migrants send money back in form of remittances. These two trends can by themselves account for the recovery of the training costs. The second assumption is that the emigration of doctors kills people in Africa. The idea is that the emigration of doctors is depleting a finite stock of doctors in developing countries. As the stock shrinks there will be more patients per doctor and therefore the quality of the services will deteriorate. However, as discussed in point 1, the level of medical care provided in a country is only marginally influenced by the international migration. More important factors include poor salaries, poor equipment, weak transportation infrastructure and weak rural services incentives. So for example, in rural areas there is a high patient/doctor ratio not because there are not doctors in the country but because they have no incentive to work in rural areas: they prefer to work in urban areas, where normally there is an oversupply. This is reinforced by the fact that there does not exist a negative relationship between the departure of health workers and health indicators of the country.
To sum up: the promise of $130 million to train health workers is a good news in itself. More trained health workers are indeed needed on the continent. However, other obstacles remain in the way of improved medical care and international migration is only a marginal one. If one wants to lower the patient/doctor ratio and address the shortage of health workers one should be more concerned about topping up salaries for physicians to work in rural areas or make sure that hospitals are provided with a stock of medicine rather than trying to stem the migration of physicians and nurses. If one tackle the formers physicians and nurses will have incentives to stay.