Dr. E. Tsiri Abenyega, Dean of the KNUST Medical School was featured in an article in the New England Journal of Medicine; he contributed to a discussion
on health sector crisis in the country. Herewith the article.
The New England Journal of Medicine
Volume 356:440-443 February 1, 2007 Number 5
Doctors and Soccer Players — African Professionals on the Move
Fitzhugh Mullan, M.D.
On June 22, 2006, the nation of Ghana erupted. SUVs flew through the streets of Accra with flag-waving celebrants jammed through sunroofs. Crowds led by shirtless drummers banging garbage-can tops snaked down major roads, picking up revelers as they went. Hundreds of thousands of people took to the streets, shouting jubilantly. Ghana, playing in its first World Cup, had beaten the United States and earned a berth in the final stage of the global soccer pageant. It was a paroxysm of national pride that Ghana had rarely experienced.
"It's the same for football players as it is for doctors," I was told by Tsiri Agbenyega, dean of the medical school in Kumasi, Ghana. "We have to train a lot more than will end up in Ghana, because they all leave. The football players go to Europe, and the doctors to America and the U.K." Agbenyega spoke with a mixture of frustration, pride, and resignation. He was pleased that Ghanaian athletes and physicians were competitive internationally, but their success meant a loss to the country — a loss more problematic in medicine than in football.
The World Bank considers Ghana a low-income country, but its 20 million people enjoy natural resources (gold, timber, and cocoa) and a relatively stable recent political history. Ghana has a strong tradition of education, a public health system that has resulted in greater longevity and lower infant mortality than in much of West Africa, and a prevalence of HIV infection among adults of 2.3% — lower than the sub-Saharan African average of 6.1% and far lower than southern African levels exceeding 20%.1 So the country would seem to be in a good position to build and sustain a health care workforce that could rapidly reduce loss of life among infants and parturient women in Ghana (both mortality rates are more than 10 times those in high-income countries2) and initiate widespread antiretroviral treatment to stem its AIDS epidemic. If Ghana could show the way, one might think, other African countries might be able to follow.
But not so. For much of the past decade, health improvement in Ghana has been at a standstill, and health statistics in many sub-Saharan African countries are sliding backward.3,4 AIDS is a culprit, but so is the exodus of doctors and nurses who are lured by U.S. training and employment opportunities. According to the Ministry of Health, Ghana has about 13 physicians per 100,000 population (as compared with 256 in the United States) and about 92 nurses per 100,000 (as compared with 937 in the United States). Today, there are 532 Ghanaian doctors practicing in the United States. Although they represent a tiny fraction of the 800,000 U.S. physicians, their number is equivalent to 20% of Ghana's medical capacity, for there are only 2600 physicians in Ghana. An additional 259 Ghanaian physicians are in practice in the United Kingdom and Canada — and this group includes only those who have successfully been licensed after leaving Ghana. In other countries, the situation is even worse: 60% of Liberia's physicians are in practice in the United States or Britain.5
"Our only recourse is to try to train more in the hopes we will keep more," explained Yaw Boasiako of Ghana's Ministry of Health, who outlined an ambitious plan for doubling the number of physicians and nurses educated in the next few years. Ghana, like many English-speaking developing countries, is caught in an educational conundrum: the better the quality of their universities and the more health professionals they train, the more they lose to the United States and the United Kingdom. They have a leaky bucket now. In desperation, they're building a bigger leaky bucket.
But that's not all they're doing. As in most developing countries, the private medical sector is small, and most physicians work for the government health service, which staffs the public hospitals and clinics where most people receive care. Although the salaries of Ghanaian doctors are better than those in many African countries, doctors are quick to point out that their pay is still modest. "A trained physician can make more in London in two months than we can make in a year in Ghana," I was told frequently. Struggling with a limited budget and against the lure of Western incomes, the government has embarked on some creative strategies to retain physicians. These include pay increases, cheap car loans for doctors in "hardship posts," and a plan to subsidize staff housing in rural areas. To address the desire of medical graduates to obtain specialty training, the government has launched an expanded program of in-country medical residencies.
To augment physicians' services, the ministries of health and education are expanding training opportunities for community health nurses, technical officers, and "medical assistants" — midlevel practitioners who substitute for doctors in shortage areas. For many years, the Rural Health Training School in Kintampo has provided experienced nurses with a year of advanced training and 6 months of internship to enable them to function independently as medical assistants. The school is doubling its class size to 200 but is changing to a non-nurse model, since the loss of nurses to emigration has depleted the ranks of program candidates. In the future, medical assistants will be secondary-school graduates who will receive 3 years of didactic training followed by a year of internship. Although all health care workers are subject to the pull of emigration, the global market for midlevel practitioners is not standardized, and the government hopes that most medical assistants will remain in Ghana.
There are some physician reinforcements available, particularly from Cuba — currently, 200 Cuban doctors make up 7% of Ghana's physician workforce. But when I asked a class of Ghanaian medical students how many of them would like to go abroad for further study after graduation, virtually every hand went up. When I asked, "How many of you think you would come home again?" about half the hands went down. Many of them see their futures in New York or London, where they believe professional and income opportunities will outweigh any hardships associated with leaving their country. Given the massive economic imbalance between the West and Africa, even the most creative domestic employment strategies may not do much to curtail this ambition.
Nonetheless, much can be done in the developed world to help build the health workforces of developing countries, including continued investments in training and retention programs and an increased commitment by U.S. health care professionals to work in developing countries. However, the single most important contribution that the United States could make would be to train more doctors at home. About 25% of the physicians practicing in the United States went to medical school abroad — as did roughly the same proportions in the United Kingdom, Canada, and Australia.5 For years, we have been educating about three quarters of the doctors we need and relying on the rest of the world to supply the balance. For 25 years, the number of students admitted to U.S. allopathic medical schools has remained constant, while the number of physicians we import has climbed steadily. Without ever enunciating a strategy of dependence on the world, we have created a huge U.S. market for physicians educated elsewhere, inadvertently destabilizing the medical systems of countries that are battling poverty and epidemic disease.
A commitment in the United States to ramp up medical school opportunities to a level closer to national needs would do much to slow medical migration and bring stability to medical programs in poorer countries. Perhaps soccer players will always migrate to the elite leagues of the world, but if doctors and nurses stayed closer to home, lives would be saved.
Source Information:
Dr. Mullan is a professor of pediatrics and health policy at George Washington University, Washington, DC.
