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