Medical Doctors profile in Ethiopia: Production, Attrition & Retention In Memory of 100 years of Ethiopian Modern Medicine & the New Ethiopian Millennium

Yifru Berhan M.D Dean, 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: 1st hospital was constructed in 1896. ‡ Ethiopian Medical Association (EMA) was established in 1947. ‡ Ministry of Health (MOH) structured in 1948 ‡ Ethiopia become member country of WHO in 1954. ‡ Original articles published in Ethiopian Medical Journal (EMJ) since 1961. ‡ The 1st medical school opened in 1964. ‡ The

Hospitals construction trend in Ethiopia in the last 100-years 160 139

140

Number of hospitals

120 110 100 86

80 62 60

63

67

70

70 74

51 46

40

20 1

1

4

11

0 1896 1906 1930 1935 1948 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 Year (G.C)

New hospital constructed by MOH and other sectors in the last 11 years (1995 – 2005) 100 90 80

Number of hospitals

80 70

82

83

83

85

87

76 70 65

71

65

60 52 50 40 30 20

21

21

23

25

1996

1997

1998

30

30

1999

2000

33

36

2001

2002

44

46

2003

2004

10 0 1995

MOH

O th e rs

2005

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 1800

1596

1600

1447 Number of medical doctors (all type)

1400

1366

1200 1112 1000 829

800

638

600

400 256 260 200

0

110 3

1

163

315

402

174

47

1896 1906 1937 1948 1958 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2006 Year (G.C)

Doctors graduated from Ethiopian & abroad medical schools School Addis Gondar Jimma Abroad

Year 1968 – 2006 1983 – 2006 1990 – 2006 Total 1987 – 2006 Grand total

Graduated = = = = = =

1890 1014 824 3728 756 4484

Total number of doctors in the public sector in Ethiopia in 1985 -2006 1800 1658 1596

1600

1447

Total medical doctors (MOH) number

1467 1363

1416

1400

1483 1415

1366

1407 1327

1200

1283

1163

1000

1332

1301

1263

1185 1112 1077

987

800

745 638

600 489

400 200 0 1984

1986

1988

1990

1992

1994 Year (G.C) 1996

1998

2000

2002

2004

2006

Number of doctors /100,000 population in the public sector in the last 23 yrs(`84-`06) 4 3.6 3.4

3.5

3.1

Physician/100,000 population

3.2 3

2.7

2.7 2.5

2.7 2.7 2.7 2.6 2.4

2.4

2.2

2.2

2

2.1

2.1 1.9 1.7

1.8 1.5

1.5

1.5

1.2 1 0.9 0.5 0 1984

1986

1988

1990

1992

1994

1996

Year (G.C)

1998

2000

2002

2004

2006

Doctor to population ratio WHO minimum recommendation for developing countries

1:10,000 WHO 2003 report: Cuba Belarus Russian federation Lithuania U.S.A UK Sudan

1:167 1:217 1:233 1:250 1:355 1: 500 1:2,000 (2004)

Total Doctors : Population ratio in Ethiopia reported by MOH (1998 – 2005) 0.4

1:26,000 1:27,000

0.35

1:28,000 1:36,000

0.3

1/Antilog

0.25

1:42,000 1:38,000 1:48,000

0.2

1:49,000 0.15

0.1

0.05

0 1998

1999

2001

2002

2003

2004

2005

Doctor to population ratio since 1984 (public sector) Year 1984

Ratio 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 100 90 80

Physician in percent

70 60 50 40 30 20 10 0 1984

1986

1988

1990

1992

1994

Physician available

1996

1998

2000

Physician deficit

2002

2004

2006

Doctors-to-hospital ratio in the last 12-years in public sector out side A/A (1995 – 2006) 40 Tigray Amhara

35

Oromia

Physician-to-hospital ratio

SNNP

30

Other regions

25 20 15 10 5 0 1995

1996

1997

1998

1999

2000

2001

Year (G.C)

2002

2003

2004

2005

2006

Total doctors working in MOH 2004 - 2006 496

500 450

414

Number of medical doctors

400 350 300 248 250 186

200

163 131

150 100 50

182

133

77

121

106 110

68 39

152 94

64

43

0 Tigray

Amhara

Oromia 2004

2005

SNNP 2006

Others

A/A +Central

Number of doctors in 76 MOH hospitals outside Addis- December 2006 40 36 Total doctors Specialist

35

Number of hospitals

30 25 20 16

15

15 11

10

9

10 5

12 8

7

7

6

6 4

3

2 0

0

0

0 0

1

2 3 4 5 6 Number of doctors per hospital (last value >=8)

7

8

Specialists: Population ratio in the regional states outside A/A, December 2006 Number

Specialist-topopulation ratio

Specialist-tohospital 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

Qualification

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

Specialist

929

224

1153

General

2944

532

3476

538

2938

Total

3873

756

4629

932

3704

Available

394

Loss

759

Medical doctors annual gain vs annual loss in the public sector, 1987-2006 800

700

Annual gain Annual loss

600

Number

500

400

300

200

100

0

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

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

Academic staff in five medical schools involved in training medical students, Dec 2006 200 181 180

Total 2nd degree & above 1st degree

176

Academic staff number

160 140 118 120 100 76 80

71 64

63 52

60

44

42

35 28

40 20

7

5

8

0 AAU

Gondar

Jimma

Hawassa

Mekele

Distribution of selected specialists in 4 medical schools, December 2006 25

23 A/A Gondar Jimma Hawassa

20 17

20

15 Number

12

10 7

7

4 5 2

3

4 3

6 4 3

1 0 Surgeon

Gynecologist

Internist

Pediatrician

3

Why this much medical doctors crisis happened in Ethiopia? „ „

Production rate was so low Retention ‡ High migration to greener pastures - internal and international ‡ Unattractive career options ‡ Rapid

expansion as well as extremely high

remuneration in private and NGOs

Shortage of experienced teachers/ trainers in postgraduate school „ number and quality ‡ Fast population growth ‡

Total remuneration in Birr in 2006 MOE

MOH

SP(FT)

3325

SP (CT)

10,900

10,000

GP(FT)

2480

2945

Private

NGOs

5145-9,000 15,000 20,000

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 up For Ethiopia: ‡

Production is more cost effective than employing expatriate.

‡

Training cost: = 250,000-300,000 Birr/6yrs/student

‡

Expatriate salary = 1 million Birr/6yrs/person 10 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 Doctors

2015 6,000

2020 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) 14 11.9 12 9.9

11

Physician/100,000 popn

10 7.8 8

8.9

6.2 6.7

6 4 4

3.6

4.5

3 2.7

2

2

1.9

3.1

3.5 2.5

2.2 1.5

1.5 0.9

0 1989 1991 1995 2000 2002 2004 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Big questions ‡ How

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) 80 75 71 73

70

67 69 63 59

60

58

53 Total population in millions

61

56 50

48

50

46 43 41 42

40

30

28

47

65

54 51

49

44

32

22 24 20

10

0 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)

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 forward ‡ The 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 standardization ‡ 5 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 implementation ‡ MSc in emergency surgery (Obstetrics, Gynaecology, general surgery) curriculum accredited by MOH and planned to start in 4 medical schools using 20 teaching hospitals ‡ Objective: 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 drain „ Help 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/ specialists „ Help 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 funding „ Support 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 paper Ethiopian 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