Retaining and securing medical specialists for Africa is a necessity, not a luxury, for quality integrated public healthcare, say experts, who warn that the coming shortage will put the continent’s healthcare progress further on the back foot.
It will also deepen global inequities and ultimately throttle the training pipeline of professionals, believes Eric Buch, chief executive of the Colleges of Medicine of South Africa (CMSA) and a professor in health policy and management at the University of Pretoria.
These challenges are tipping points for worst-case scenarios for public healthcare, and will have an impact on the success of meeting the aspirations of universal health coverage, including in South Africa through the National Health Insurance, he adds.
Daily Maverick reports that the topic was the focus of last week’s two-day International Medical Education Leaders Forum – Africa conference at the university about pushing for greater investment in and promotion of specialised medicine as “not a healthcare luxury” but a vital part of building integrated public healthcare systems across Africa.
There was also a clear warning from speakers that Africa must raise a stronger unified voice, otherwise specialist expertise will continue to be exported to richer countries or be reserved for the elites.
Another call was to simultaneously work on staff retention strategies, including tackling underlying conditions causing job dissatisfaction, while pushing back harder on things like the World Health Organisation’s (WHO) code of conduct on international recruitment. The code is meant to prevent “brain drains” but has become too easily circumvented and doesn’t carry adequate consequences for non-adherence.
For decades the continent has borne the brunt of the loss of medical expertise and weakening training support and infrastructure. A WHO survey released in June 2022 and published in the British Medical Journal Global Health found that even at a primary healthcare level the continent falls short of the WHO’s threshold density of 4.45 health workers (physicians, nurses and midwives) per 1 000 people.
Across 47 countries the average was just 1.55 health workers per 1 000 people. Only Mauritius, Namibia, Seychelles and South Africa scored above the threshold ratio.
Specialists must act urgently, added Buch. “The agenda of this gathering representing nine Colleges of Medicine in South Africa (CMSA), West Africa and East Africa, is a first of its kind … because as specialists we have the responsibility to drive an agenda about the unique and essential contribution of specialists to healthcare and the threats to those systems if we don’t make our voices heard.”
The conference drew representatives from an 11 000-member community.
The aim now, Buch said, was for a detailed report to be compiled with clear recommendations and actionable steps, to be presented to the WHO, the African Union and the global community of medical education fraternities and colleges.
Conference representatives also focused on the wellness, support and leadership development of doctors.
It’s an overlooked area, said Professor Suvira Ramlall, CMSA president at the College of Psychiatrists, and “there is terrible irony that doctors are often the worst patients, neglecting their own mental health needs”.
Other speakers raised concerns about stigma and fear of seeking help because of the risk of losing licenses to practice or suffering reputational damage.
Speakers said that many doctors, as a result, start their journey to specialisation with unseen or hidden burdens of mental health issues.
Pressures to succeed in advancing their careers are coupled with often working for low pay, in appalling conditions. Being unable to help their patients in the way they are trained to do also amounted to moral injury, burnout and ultimately, leading to them exiting the public healthcare system.
Data presented also showed a growing reality that many doctors and health workers depend on alcohol and drugs to cope.
The third key conference theme focused on improving and consolidating examination and assessment standards for specialists. It’s become crucial to improve public trust of specialists trained on the continent.
“We have been working towards workplace-based assessment and a programme of entrustable professional activities that every specialist knows their discipline, not that they’ve just filled a logbook,” said Buch of efforts in South Africa.
Even though the CMSA had more than 5 000 candidates going through the same final exit exams annually, the output of specialists still faced severe bottlenecks. “There just aren’t enough specialist training posts at academic hospitals. So, the pipeline is too small to produce the number of specialists required to meet national needs.”
It’s a deepening crisis for South Africa, and already a disaster in many countries in the rest of Africa. For Dr Jane Obudu Fualal of Uganda, president of the College of Surgeons of East, Central and Southern Africa, that means patients from countries like hers must travel to South Africa or overseas for specialist treatment. Many who can’t afford it simply die.
Those who spend on treatment outside their borders add to the economic bleed for their countries.
Fualal said it should be a trend that can be reversed with better strategising and investment and called for more locally appropriate solutions and innovation. “We must make governments understand we don’t have to lose billions and can instead make Africa a destination for specialist medical tourism.”
Lives above profit
Professor James Jawi, Kenyan executive director of the African Centre for Global Health, said the conference’s message needs to reach politicians and policymakers.
“For too long we have been led by economic thinking stating that the key thing is to control inflation so that the economy can grow, and only then will you have enough money to provide healthcare. Economists and politicians need to start thinking about values differently, other than GDP and profit, and that what matters are the lives of people.”
Jawi said the coming healthcare threats will look like a repeat of the Covid devastation of 2020.
“The few people we train as specialists at home we lose to other countries because we don’t give them sufficient incentives to stay. Governments must understand that specialist medicine is not ‘too expensive’ and healthcare is not a consumptive sector – it is a productive sector.”
GLobal Health
See more from MedicalBrief archives:
Africa Check puts together the numbers on doctor-patient ratios
Medical interns from African countries struggle after removal from SA critical skills list
Exodus of doctors, nurses pushes up healthcare costs, says expert
Zimbabwe wants compensation for brain drain of nurses and doctors
Health tourism by Africa's leaders costs their countries dearly
SA’s doctor shortage has worsened substantially in past 3 years