Why Africa is losing its doctors

By Stéphanie Wenger
Posted on Thursday, 27 January 2022 07:15

First-year medical students at La Rabta Hospital, near Tunis. © Andrew Testa/Panos-Rea

Young African doctors often go abroad to complete their studies and then stay there. This has resulted in a massive brain drain during this time of Covid-19. Morocco, Tunisia, Rwanda and Senegal have put countermeasures in place.

Since its creation in 2015, the University of Global Health Equity (UGHE) – a gleaming campus located in a district of Kigali, close to large hotels, convention centres and shopping malls – has welcomed students from all over the sub-region. 70% of them are girls, thanks to a gender-sensitive recruitment policy.

The university, which is financed in particular by the Bill & Melinda Gates Foundation, has a master’s program in public health (for which recruitment was at the baccalaureate level) and provides bachelor’s degrees (post-baccalaureate) to enable young people to begin their medical studies at the establishment and then become, five to 10 years later, either general practitioners or surgeons.

Students who sit their exams in December – either in Uganda, Tanzania, Burundi or the DRC – can join the institution in their first year of higher education. The UGHE’s aim is to train health professionals on the continent from start to finish. The tendency right now is for medical students to complete their training in Europe and North America. However, the problem is that they often never come back, thus leaving their country of origin understaffed.

According to WHO, there were on average only 4.5 doctors per 10,000 inhabitants in Africa during 2012-2016. At the same time, the Mo Ibrahim Foundation says the proportion of doctors trained in Africa has increased in Western hospitals. In the US, the number grew by 27% between 2008 and 2018, which is equivalent to hiring one doctor per day – who will most likely have been trained in Egypt, Ghana, Nigeria or South Africa.

French-speaking African practitioners often choose France, where they pursue hospital specialisation courses at the end of their medical studies, before finally settling in the European country.

Loss of healthcare workers

Some sub-Saharan African countries are particularly affected by this loss of healthcare workers. In 2019, Senegal had 0.88 doctors per 10,000 inhabitants, while Burkina Faso had 0.94 and Rwanda 1.19.

The UGHE in Kigali hopes to reverse this trend. “Medical education has a high cost, which the majority of our students cannot afford. That’s why we provide free tuition and accommodation. What matters to us is these young people’s ability to be good practitioners. This is the criterion on which they are selected,” says Ethiopian surgeon Abebe Bekele, dean of the medical faculty at the UGHE.

Under the Umusanzu (‘contribution’ in Kinyarwanda) programme, young people who start their studies at the UGHE in 2022 will sign an agreement with their respective ministries of health: they commit to working for six to nine years in their home countries once they graduate. In return, their ministry is expected to hire them.

For master’s students, partnerships already exist between the UGHE and Rwandan hospitals, notably in Kigali and the Butaro district, near the Ugandan border.

Professor Bekele was not a teacher when he became dean of the Addis Ababa Medical School in 2012. “I was not prepared to run a school. I learned on the job. We lack professionals who are ready to take on their role in structuring our health systems. In ministries as well as in universities, there is a need for doctors! Some HUG graduates will be able to lead public policies, and effectively,” he says.

Towards new health policies

Sociologist Christelle Fifaten Hounsou, a specialist in migration and the medical professions (at the University of Paris-VII and the Convergences Migrations Institute), is cautious in her analysis of the phenomenon known as the ‘flight of the white coats’. “Doctors have always moved to train,” she says.

For local training courses to be able to keep doctors on the continent, African states must be prepared to invest in their health systems, both public and private.

According to her, this African emigration is most often encouraged by the health policies of Western countries. “Above all, the reason many African doctors have stayed in France is because they are needed there: the French hospital system is understaffed and there are real medical deserts in rural areas,” she says.

“For local training courses to be able to keep doctors on the continent,” says the specialist, “African states must be prepared to invest in their health systems, both public and private.” The latter can, with financial support, take on a growing number of patients, including those with modest incomes.

In the field of medical training, the researcher notes that the trend is to strengthen private provision. This is the case in Morocco, Tunisia, Senegal and Burkina Faso. In these countries, good quality public university courses also exist, which attract students from beyond their borders. For example, in recent years, Morocco and Tunisia have opened their doors to other African students and the fees for international students is low.

Promoting mutual recognition of diplomas

Policies of understanding and harmonisation must also be developed at a regional, or even pan-African or international level. The aim is to encourage positions to be opened to doctors from other countries on the continent and promote mutual recognition of diplomas. This is the mission of the Conférence Internationale des Doyens et des Facultés de Médecine d’Expression Française (Cidmef). It brings together representatives from 150 French-speaking universities and medical training institutions on all continents, and issues accreditations that are recognised worldwide.

When the quality of […] training in their country of origin is recognised, African doctors are less tempted to go and train in more developed countries and then establish their careers there.

“The faculties of medicine in Marrakech and Tunis have obtained Cidmef accreditation. This will soon be the case for those in Sousse and Yaoundé,” says Tunisian paediatrician Ahmed Maherzi, Cidmef’s vice-president.

“When the quality of […] training in their country of origin is recognised, African doctors are less tempted to go and train in more developed countries and then establish their careers there,” says this former dean of Tunis’ Faculty of Medicine (2011-2017), who is now a visiting professor in Montreal. “It is up to each country to conduct an appropriate policy to retain its doctors. This means improving the quality of training, ensuring adequate salaries for health workers and, above all, enabling them to work in optimal conditions,” he says.

The training establishments must also begin to change. “Medical faculties have mainly favoured training in university hospitals, thus promoting specialties at the expense of general medicine,” says Maherzi, who believes that this strategy should be reviewed.

“Organising a health system by territory, around a medical campus and a regional hospital centre located in a medium-sized town, would make it possible to train practitioners whose skills are in line with the needs of the population. This is much more effective than forcing young urban doctors to practice for a few years in medical deserts, even in their own country,” says Maherzi.

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