Where Are the Doctors?
"Can you take me back to the U.S. with you?"
My friend Dr. Dan Rudasingwa is a general practitioner (GP) at King Faisal Hospital in Kigali, Rwanda. His family returned to Rwanda after 30 years of exile in Uganda to help rebuild the country. Now he wants to leave Rwanda.
Dr. Rudasingwa loves his country. He also cares about his own future. He wants to pursue specialty training in neurosurgery, which is not available in Rwanda. Everyday, he sees patients who need brain surgery, heart surgery, chemotherapy, or other specialized treatments to survive. There is no doctor who can provide these treatments. The best he can do is to watch the patients die. The only person he was able to "save" recently was a high-level official who was airlifted to South Africa after a head injury.
The problems with health care access in Africa are often attributed to lack of resources, but a more insidious and perhaps more difficult problem is the dearth of doctors.
Africa is facing a severe crisis of doctor shortage, on a scale almost unimaginable in the U.S. and Western Europe. Rwanda, a country with 10 million people, has about 500 doctors — a ratio of one doctor per 20,000 people. This is less than 10 percent of the World Health Organization recommendation. The vast majority of the country will not see a physician in their lifetimes. The Congo and Burundi have similarly poor ratios. Suburban U.S. hospitals could have more than 200 doctors on staff, while in Burundi, 165 doctors serve 8 million people.
The shortage of specialists is particularly acute. The only cardiologist in Rwanda is a Kenyan with a two-year contract in Rwanda. There are just 10 specialists for the 5 million people in the North Kivu province of the Congo. Even at the HEAL Africa hospital in Goma, which always has at least five visiting specialists, waits for gynecological and orthopedic surgeries be 60 days.
Where are the doctors? Blame is often — and rightly — attributed to the global brain drain. One-third of practicing doctors in the US trained in non-U.S. medical schools. Lower-income countries supply between 40 to 75 percent of these foreign-trained doctors. While one can hardly fault an individual like Dr. Rudasingwa for wanting to seek new opportunities, the developed world has an obligation to ensure that we are not poaching doctors from areas where they are most desperately needed. To meet American workforce needs, we should be opening more medical schools instead of taking individuals that other governments trained and need.
In Central Africa, the pipeline for doctors hits a kink even before the brain drain occurs. Countries are not producing nearly enough doctors. Rwanda only has one medical school. All graduates become general practitioners, but few have the option of going through specialty training. The few lucky graduates are able to obtain training in just four specialties in Rwanda — to study other fields like neurosurgery or cardiology, they have to vie for fellowship spots in Kenya or South Africa.
What can we do to help resolve the crisis of doctor shortage? I believe the solution lies in both ensuring adequate pipeline from the front end and preventing the brain drain from the bottom end.
To increase production of doctors, we should assist developing countries with building capacity for training both generalists and specialists. GPs are easier to train, and one way to help is to assist medical schools with their curriculum. I was astounded that no textbooks are used in the medical schools of the three countries we visited. Following a standardized curriculum could make medical education easier to expand to more students.
We can increase specialty training by developing short modular training courses. There are many Western doctors who go abroad for health care work. While the medical care delivered by visiting doctors will assist patients, what will help patients more is training local doctors. An intensive 3-month training session might not be enough to teach complex brain surgery, but would be enough for a doctor to be comfortable performing c-sections or managing diabetes. Capacity building for health care has much longer-lasting and wider-ranging effects than delivering direct care.
To prevent brain drain to developed countries, we should strive to retain qualified and trained doctors to serve their own country. As an immigrant, I certainly understand the desire to pursue a better future, especially if one's own country is mired in poverty and conflict and offers little prospect for advancement. Restricting immigration is not the best policy. Rather, incentives should be created to retain doctors, such as better pay, more autonomy, and more resources to better assist patients.
There is also a recent trend of an internal brain drain from the public sector to private NGOs. In Rwanda, well over half of the national health spending is from international NGOs, many of which have recruited physicians away from working in public hospitals by offering higher salaries and better benefits. A more responsible policy for NGOs is to tie their work to existing public infrastructure. Dr. Paul Farmer's clinic in Rwinkwavu, Rwanda, is a good example of private funding to assist a public hospital. All of the doctors in the Partners in Health hospital work for the public sector, yet also receive competitive benefits.
Finally, not everyone needs to see a doctor. We can work to train ancillary staff and community health workers. Just because their abilities are limited doesn't meant that we should not provide formal training and fair pay, and hold them accountable for their responsibilities.
I believe that most physicians enter medicine for the right reasons, and have a strong sense of social responsibility to provide for their country. Dr. Rudasingwa said that there is no question he would stay in Rwanda if he can get trained as a neurosurgeon and has the equipment to help his patients. We should do what we can to help him stay in his country, and do our best to alleviate the overall doctor shortage crisis in the developing world.
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