Medical doctors profile in Ethiopia: production, attrition and retention. In memory of 100-years Ethiopian modern medicine & the new Ethiopian millennium.Ethiop Med J 2008; 46 Suppl 1:1-77EM
Although the practice of western medicine in Ethiopia dates back to the time of King Libne Dengel (1520-1535), organized and sustainable modern medical practice started after the battle of Adwa (1896).
To review hospitals construction, medical doctors production and attrition, and to suggest alternative medical doctors retention mechanisms in the public sector and production scale up options.
METHODS AND MATERIALS
In this article, 100 years Ethiopian modern medical history is revised from old and recent medical chronicles. Until December 2006 primary data was collected from 87 public hospitals. Much emphasis is given to medical doctors profile (1906-2006), hospitals profile (1906-2005), medical doctors to population and hospitals ratio (1965-2006), Ethiopian public medical schools 42 years attainment (1964-2006), annual attrition rate (1984-2006), organizational structure of medical faculties & university hospitals, medical doctors remuneration by the Ministry of Health (MOH), Ministry of Education (MOE), NGOs and private health institutions. This article also addresses the way forward from physician training and retention perspectives, multiple alternate mechanisms to increase physicians' motivation to work in government institutions and reveres the loss. Medical doctors production scale up option is also given much emphasis. Most data are presented using line and bar graphs.
Literature review showed that the first three hospitals were constructed in 1896 (Russian hospital), 1903 (Harar Ras Mekonnen hospital) and 1906 (Menelik II hospital). In 2005, 139 hospitals (87 public and 52 others) were reported. Remarkable hospital construction was done between 1935 and 1948, and recently between 1995 and 2005; however, in the latter case, private hospitals construction took the lions share. By the time MOH was established (1948), 110 Ethiopian and expatriate medical doctors were working, mainly in the capital, and 46 hospitals constructed. Physician number increment was very slow till 1980 at which time it started to get doubled every five years and reached peak (1658 medical doctors of all type) in 1989 in the public sector. As there was sharp increment in physician number, on the contrary, there was sharp decline in the last 15 years (1990-2006) to nadir 638 doctors in 2006 in the public sector. The last 25 years of Ethiopian modern medical history, in reference to physician number, forms a triangle with the lower and upper base 1980 and 2006, respectively. Since MOH of Ethiopia started registering health professionals with qualifications in 1987, 5743 (76.5% Ethiopian and 23.5% expatriate) medical doctors were registered for the first time. Out of these, 3717 were general practitioners. The three prestigious medical schools (Addis Ababa, Gondar, Jimma) were established in 1964, 1978 and 1984, respectively. Since establishment till 2006, about 3728 medical doctors were graduated with MD degree from the three medical schools. Addis Ababa university medical faculty alone graduated 1890 general practitioners (1964-2006) and 862 clinical specialists (1979-2006). In the 23 years period (1984-2006), the highest and lowest physician to population ratios in the public sector were found to be in 1989 (1:28,000) and 2006 (1:118,000), respectively. In 2006, the physician to population ratio in Amhara, Oromia and SNNPR regional states was computed to be 1:280,000, 1:220,000, and 1:230,000, respectively. The physician deficit analysis in the last 23 years in relation to the WHO standard for developing countries (1:10,000) revealed the lowest record at the national and regional states in the last 12-years. Average physician to hospital ratio in five regional states in December 2006 was 3.6 (Tigray), 4.3 (Amhara), 6.1 (Oromia) and 5.3 (SNNPR). As the December 2006 direct interview with 76 public hospitals outside Addis Ababa showed, there was no specialist in 36 hospitals and no doctor at all in 3 hospitals. Seven public hospitals located in big regional states' town took the lions share of medical doctors. In short, in December 2006, 80.3% of regional hospitals were equipped with 0-2 specialists of one kind, and in 48.7% there were 0-3 General practitioners. Highest medical doctors annual attrition rates (20%-54.3%) were found in 1991-1992, 1998, 2002-2006. In general, in 20 years period (1987-2006), 73.2% of Ethiopian medical doctors left the public sector mainly due to attractive remuneration in overseas countries and local NGOs/private sectors. The number of postgraduate programme in Addis Ababa, Jimma and Gondar medical schools in December 2006 was 22, 12 and 3, respectively. The total number of fully employed academic staff of the medical schools in declining order was Addis Ababa 181, Gondar 118, Jimma 71, Hawassa 63 and Mekele 52: those with second degree and above being 97.2%, 35.6%, 90.1%, 55.6% and 15.4%, respectively. Currently (2006), there are about 416 clinical residents in 3 medical schools.
High annual attrition rate, fast population growth, governmental and nongovernmental health institution expansion, low production and increased postgraduate enrollment in the last 3-4 years contributed for extremely low physician-to-population ratio in Ethiopia. Although the Ethiopian government and private sector worked and achieved much on health infrastructure construction and midlevel health professionals training, it does not appear that medical doctors retention mechanisms are sorted out so far. As a result, even despite salary equivalent top up payments in some regions, more than 80% of public hospitals outside Addis Ababa were found ill-equipped with the most important human element--physicians. This implies that the push factors may not invariably correlate with remuneration.
It is high time that the government discusses the possible solutions among health professional associations/societies and other health stakeholders, and apply concrete medical doctors retention mechanisms before the public medical schools and hospitals dry off doctors. Among actions to be undertaken from the current Ethiopian perspective: providing land plot for physicians for residential house construction, giving priority to physicians in providing low cost houses, low interest or interest free loan for residential house construction and automobile procurement, allowing duty free automobile procurement, improving the fully employed academic staff taxation system, approving the different remuneration options proposed, adopting the other countries experience of dual employment to academic staff working in teaching hospitals, modifying the academic rank promotion based on year of training, for university hospitals either establishing hospital organizational structure in the Ministry of Education or letting them be under MOH, establishing joint appointment (mutual beneficiary) agreement between medical schools and local hospitals, directing donors and stakeholders to work on the line of reducing internal and external medical doctors brain drain, making independent MOH and higher institutions from Civil Service Agency are proposed as short term solutions. Retention as a strategy & production as a programme, medical doctors production scale up options are proposed as a long term solution to achieve physician to population ratio of 1:15,000. and 1:8,000 by the year 2015 and 2020, respectively.