Medical Doctors Profile in Ethiopia: Production, Attrition ... Berhan.pdf · Medical Doctors...
Transcript of Medical Doctors Profile in Ethiopia: Production, Attrition ... Berhan.pdf · Medical Doctors...
Medical Doctors profile in Ethiopia:
Production, Attrition & Retention
In Memory of 100 years of Ethiopian Modern Medicine
& the New Ethiopian Millennium
Yifru Berhan M.DDean, Hwassa University Medical Faculty
Outline
• Medical doctors profile
• Health manpower production & crisis: Reasons & the way forward
• Government & medical schools response
• Challenges • Expected from Wales & other International
partners
Ethiopian modern medical history.
Indicators, not late in starting:The 1st hospital was constructed in 1896.Ethiopian Medical Association (EMA) was established in 1947.Ministry of Health (MOH) structured in 1948Ethiopia become member country of WHO in 1954.Original articles published in Ethiopian Medical Journal (EMJ) since 1961.The 1st medical school opened in 1964.
Hospitals construction trend in Ethiopia in the last 100-years
11
86
110
139
74707067
6362
5146
411
0
20
40
60
80
100
120
140
160
1896 1906 1930 1935 1948 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005
Year (G.C)
Num
ber
of hosp
itals
New hospital constructed by MOH and other sectors in the last 11 years (1995 – 2005)
87858383828076
71706565
21 21 23 2530 30
33 36
44 4652
0
10
20
30
40
50
60
70
80
90
100
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Num
ber o
f hos
pita
ls
M OH Others
Ethiopian Doctors Profile
15th century: Portuguese "barber-surgeon" (Joao Bermudes)
16th century: German missionary (Peter Heiling 1632-1667)
1896: Three Russian Physicians
1898: Dr. Workineh Martin (1st Ethiopian doctor)
1920s: Dr. Melaku Beyan (the 2nd Ethiopian doctor)
Total doctors in Ethiopia since 1896 in public health institutions
402
829
1596
1366
1112
1447
315260256
174163110
4713
638
0
200
400
600
800
1000
1200
1400
1600
1800
1896 1906 1937 1948 1958 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2006
Year (G.C)
Num
ber o
f med
ical
doc
tors
(all
type
)
Doctors graduated from Ethiopian & abroad medical schools
School Year Graduated
Addis 1968 – 2006 = 1890 Gondar 1983 – 2006 = 1014 Jimma 1990 – 2006 = 824
Total = 3728Abroad 1987 – 2006 = 756
Grand total = 4484
489
745
987
1163
1416
11851112
638
1077
130113321366
12631283
141514831447
14071363
1327
1467
15961658
0
200
400
600
800
1000
1200
1400
1600
1800
1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006Year (G.C)
Tota
l med
ical
doc
tors
(MO
H) n
umbe
rTotal number of doctors in the public sector in Ethiopia in 1985 -2006
Number of doctors /100,000 population in the public sector in the last 23 yrs(`84-`06)
1.2
1.8
2.4
2.7
3.2
1.5
0.9
1.5
1.71.9
2.12.2
2.1
2.22.4
2.62.72.72.72.7
3.1
3.43.6
0
0.5
1
1.5
2
2.5
3
3.5
4
1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006Year (G.C)
Phys
icia
n/10
0,00
0 po
pula
tion
Doctor to population ratio
WHO minimum recommendation for developing countries1:10,000
WHO 2003 report:Cuba 1:167Belarus 1:217Russian federation 1:233Lithuania 1:250U.S.A 1:355UK 1: 500Sudan 1:2,000 (2004)
Total Doctors : Population ratio in Ethiopia reported by MOH (1998 – 2005)
1:36,000
1:38,000
1:27,000
1:26,000
1:28,000
1:48,0001:49,000
1:42,000
0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
0.4
1998 1999 2001 2002 2003 2004 2005
1/A
ntilo
g
Doctor to population ratio since 1984 (public sector)
Year Ratio1984 1:84,000
1989 1:28,000
2006 1:118,000
Regional states doctor to population ratio since 1984 (public sector)Year Tigray Amhara Oromia SNNP _
1994 1:40,000 1:57,000 1:56,000 1:42,000
2000 1:53,000 1:76,000 1:86,000 1:77,000
2006 1:100,000 1:280,000 1:220,000 1:230,000
Doctors deficit in % in the public sector (MOH): 1984 - 2006 by WHO standard
0
10
20
30
40
50
60
70
80
90
100
1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006
Phys
icia
n in
per
cent
Physician available Physician deficit
Doctors-to-hospital ratio in the last 12-years in public sector out side A/A (1995 – 2006)
0
5
10
15
20
25
30
35
40
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006Year (G.C)
Phys
icia
n-to
-hos
pita
l rat
io
TigrayAmharaOromiaSNNPOther regions
Total doctors working in MOH 2004 - 2006
77
39 43
131 133
68
186 182
121106 110
64
163 152
94
414
496
248
0
50
100
150
200
250
300
350
400
450
500
Num
ber o
f med
ical
doc
tors
Tigray Amhara Oromia SNNP Others A/A +Central
2004 2005 2006
Number of doctors in 76 MOH hospitals outside Addis- December 2006
3
36
9
1615
11 10
2
7
46
0
8
0
6
0
12
7
0
5
10
15
20
25
30
35
40
Num
ber o
f hos
pita
ls
0 1 2 3 4 5 6 7 8Number of doctors per hospital (last value >=8)
Total doctorsSpecialist
Specialists: Population ratio in the regional states outside A/A, December 2006Qualification Number
Specialist-to- population ratio
Specialist-to- hospital ratio
Surgeon 44 1:1.6 million 1:1.7
Obstetrician & Gynecologist 39 1:1.8 million 1:1.9
Pediatrician 16 1:4.5 million 1:4.8
Internist (Physician) 15 1:4.8 million 1:5.1
Ophthalmologist 7 1:10.3 million 1:10.9
Total (Addis Ababa) 88 1:34,000 11:1
National (MOH) 219 1:342,000 2.6 :1
Total Ethiopian specialists graduated in the country or abroad since 1987 and available in ALL public sector, Dec 2006.
Aggregate loss of Ethiopian doctors from public sector between 1987 and 2006
Total Number of Doctors graduated Status as of 2006
Ethiopia Abroad Total Available Loss
Specialist 929 224 1153394
759
General 2944 532 3476 538 2938
Total 3873 756 4629 932 3704
Medical doctors annual gain vs annual loss in the public sector, 1987-2006
0
100
200
300
400
500
600
700
800
Num
ber
Annual gainAnnual loss
Annual gain 246 304 284 315 322 319 265 287 246 226 271 220 261 218 225 306 342 418 384 284
Annual loss 70 51 42 377 451 459 229 243 206 190 339 352 281 115 259 337 458 526 349 758
1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Academic staff in five medical schools involved in training medical students, Dec 2006
181176
5
118
42
7671
64
7
63
3528
52
8
44
0
20
40
60
80
100
120
140
160
180
200
Aca
dem
ic s
taff
num
ber
AAU Gondar Jimma Hawassa Mekele
Total2nd degree & above1st degree
Distribution of selected specialists in 4 medical schools, December 2006
23
7
23
17
1
43
12
4
7
3
20
6
43
0
5
10
15
20
25
Num
ber
Surgeon Gynecologist Internist Pediatrician
A/AGondarJimmaHawassa
Why this much medical doctors crisis happened in Ethiopia?
Production rate was so lowRetention
High migration to greener pastures - internal and internationalUnattractive career optionsRapid expansion as well as extremely high remuneration in private and NGOs
Shortage of experienced teachers/ trainers in postgraduate school
number and qualityFast population growth
Total remuneration in Birr in 2006
MOE MOH Private NGOs
SP(FT) 3325 5145-9,000 15,000 20,000
SP (CT) 10,900 10,000
GP(FT) 2480 2945
Initially recommended on this paper. As the Way Forward to reverse the loss
1. Undergoing specific measures to scale up production of medical doctors and other frontline health professionals.
2. Improve motivation to work in the government institutions.
3. Maintain quality of training by increasing production of specialists/ trainers.
From Ethiopian perspective To maximize physician retention
Give priority to physicians in providing land plot for residential house construction Provide loan, allow duty free automobile procurement
Adopt other countries’ experience of dual employment to academic staff working in teaching hospitals.
Establish mutual beneficiary agreement b/n medical schools and local hospitals.
Direct donors and stakeholders to work on the line of reducing internal and international brain drain of medical doctors.
Medical doctors production scale upFor Ethiopia:
Production is more cost effective than employing expatriate.
Training cost:= 250,000-300,000 Birr/6yrs/student
Expatriate salary = 1 million Birr/6yrs/person10 expatriates or 40 medical students?
Number of doctors expected to graduate from the 5 medical schools over 9 years (2007 – 2015) - without production scale up
Year Cumulative total 10% attrition Population
2015 5808 5227 94 million
Number of physicians/100,000 population hypothesized without production scale up
(2006-2015)
Specific measures to scale up of production of doctors
Increase medical students intake of medical schools from Sept. 2008
A/A = 500/yr, Other 4 medical schools each = 200/yr Annual intake = 1300
Establishing Joint appointment with local hospitals
Expected outcome WITH PRODUCTION SCALE UP
2015 2020Doctors 6,000 13,000
Doctor / population 1:15,000 1:8,000 Ratio (With 10% attrition rate)
Ethiopia Population 94 million 106 million
Number of physicians/100,000 population hypothesized with production & retention scale up
(2006-2020)
3.6
3.1
2.7
2.2
1.9
1.50.9
1.5
2
2.5
3
3.5
4
4.5
6.26.7
7.88.9
9.9
11.9
11
0
2
4
6
8
10
12
14
1989 1991 1995 2000 2002 2004 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Phys
icia
n/10
0,00
0 po
pn
Big questionsHow production scale up programme is realized?
How do we reach Millennium Development Goals (MDG) by 2015?
How can we go with fast growing Ethiopian population?
Ethiopian population (1965 – 2006)
2224
28 32
4142
43
44
4647
48
49
50
51
5354
5658
5961
6365
6769
7173
75
0
10
20
30
40
50
60
70
80
1965 1970 1975 1980 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Year (G.C)
Tota
l pop
ulat
ion
in m
illio
ns
Government & medical schools response to recommendations
This paper was presented:- In Ethiopian Medical Association Annual
Conference at ECA hall- During MOH higher officials meeting (Minister,
state ministers, BPR team) MOH minister undergone series of discussions with other higher officials and myself on the way forwardThe issue of medical doctors crisis has become hot discussion in every health related issues.The Minister for MOH publicly announced the scale up programme (enrolling >1000 students/yr).
Response cont…
Medical doctors salary increased up to 92%. Other professionals 28% (average) The prime minister publicly promised to give land & loan for physicians & university academic staff.Paradigm shift: production scale up should
include medical doctors.MOH & MOE take medical doctors production
as 2008 major agenda
Response cont…Medical Schools Deans Council established- jointly lead by state ministers for health and education.Purpose – Production scale up implementation
- Medical curriculum standardization5 medical schools agreed to increase annual enrolment by 3-4 fold. (A/A, Jima & Gondar = each 400/yr; Hawassa & mekele = each 300/yr). Potential university affiliated teaching hospitals identified All medical schools are now preparing their requirement for the scale up.
Response cont…“Research as incentive for rural doctors”document prepared, approved by MOH and submitted to EMA for implementationMSc in emergency surgery (Obstetrics, Gynaecology, general surgery) curriculum accredited by MOH and planned to start in 4 medical schools using 20 teaching hospitalsObjective: producing 1000 masters in 10 years period for 600 Type A health centres
Challenge !!
Who is going to train?- Medical students - MSc students- Health officers
What Wales and other International partners can do to help?
Immediate and Short term:Help to stop international and internal brain drainHelp with teaching and training at all levels –come even for short time visits, on sabbaticals or on early retirement as teachers in Regional hospitals and colleges Help with Training of the trainers/ specialistsHelp with capacity building in essential resources
What Wales and other International partners can do to help?Medium and long term
Collaborate in research in prevalent diseases Support in the form of research fundingSupport building capacity in production of medical doctors and Masters in emergency surgery Work together to develop health strategies to help us take our health care setup to reach MDG and beyond.
So far success stories of this paperEthiopian Medical Association: - The best Scientific paper of the year 2007- Gold medallist
Ethiopian Medical Journal published it as:Special issue; Millennium Supplement
Ethiopian Government (MOH & MOE):- 2008 special health agenda
Medical schools:- On preparation to increase medical students
enrolment and to start MSc training
Big success by 2020 Provided that the government commitment
and partners support continued, I am optimistic that the 2020 target of achieving the WHO physician - to - population ratio is indeed achievable.
1: 8,000
Thank you