By Dibussi Tande
Surgery at the Fraternity Medical Center, Buea
The news from the Ministry of health was quite gloomy. In a special report that appeared in the Cameroon Tribune last week, it was announced that Cameroon’s medical system was in crisis due to a severe shortage of medical doctors resulting from the massive exodus of Cameroonian MDs to countries in the developed world.
Click here for a downloadable/printable version of the article in PDF format
According to the report, about 5000 Cameroonian medical doctors are currently plying their trade abroad (with about 500-600 in the US alone, according to the Minister of Health). In an interview with Cameroon Tribune, Pr. Tetanye Ekoe, the Vice President of the National Order of Medical Doctors in Cameroon, reveals that some 4200 MDs reside in Cameroon. However, this is only half of the story; of the 4200 listed on the rolls of the Order, only about half are actually practicing MDs. About 1000 are on secondment to the Ministry of Health where perform a variety of tasks, including purely administrative ones. The rest are either with the Faculty of Medicine and Biomedical Sciences, of University of Yaoundé I, with NGOs, or with the private sector. The nearly 1500 MDs in the private sector handle less that 10-15% of patients.
Pr. Ekoe points out that the limited number of practicing MDs in the country makes the official national doctor-patient ratio of 1 doctor per 10.000 inhabitants largely meaningless. He reveals that the real ratio is closer to 1 doctor per 40,000 inhabitants, and that in remote areas such as the Far North and Eastern Provinces, the ratio closer to 1 doctor per 50,000 inhabitants.
Unfortunately, the country’s lone faculty of medicine is unable to meet internal demand because it produces only about 100 MDs annually. To make the already bleak situation worse, the IMF and World Bank have imposed hiring quotas (which do not take retirements and death into account) that limit the number of MDs who can be integrated into the public service each year. The result is that some foreign-trained MDs actually return home to find out to their horror that they cannot be employed…
So the internal pool of MDs continues to shrink as more Cameroon-trained MDs move on to greener pastures in the West, while Western-trained MDs don’t return home.
The Brain Drain at a Glance
In its 2006 World Health Report, the World Health Organization (WHO) uses data from the 30-member Organisation for Economic Co-operation and Development (OECD) to shed light on the medical brain drain phenomenon in sub-Saharan Africa:
It appears that doctors trained in sub-Saharan Africa and working in OECD countries represent close to one quarter (23%) of the current doctor workforce in those source countries, ranging from as low as 3% in Cameroon to as high as 37% in South Africa. Nurses and midwives trained in sub-Saharan Africa and working in OECD countries represent one twentieth (5%) of the current workforce but with an extremely wide range from as low as 0.1% in Uganda to as high as 34% in Zimbabwe (p. 99)
According to the report, 109 doctors trained in Cameroon are currently working in OECD countries (p. 100)
The effects of this migration are disastrous, according to the WHO report:
“… when large numbers of doctors and nurses leave, the countries that financed their education lose a return on their investment and end up unwillingly providing the wealthy countries to which their health personnel have migrated with a kind of “perverse subsidy” (23). Financial loss is not the most damaging outcome, however. When a country has a fragile health system, the loss of its workforce can bring the whole system close to collapse and the consequences can be measured in lives lost. In these circumstances, the calculus of international migration shifts from brain drain or gain to “fatal flows”. (p. 101).
If the statistics above are to be trusted (and there is no reason not to trust them), then the situation in Cameroon and most of sub-Saharan Africa, has shifted from simple brain drain to that of “fatal flows” with a wide scale system collapse a potential reality.
To begin to adequately address the problem, we must start by clearly understanding the reasons that push MDs to leave and why others are not returning home after their training in foreign countries.
Why they are leaving
Although the Cameroon Tribune special report touches on some of the factors that contribute to the prevailing situation, it tries too hard to sell the patriotism angle, i.e., in spite of the hardship, Cameroonian MDs should be more patriotic and be willing make sacrifices for their country. This, in my opinion, is a rather simplistic analysis of the problem, which can only lead to equally simplistic solutions that will resolve nothing.
In its analysis of the reasons that cause the brain drain, The WHO report states that:
Classically this is provoked by a (growing) discontent or dissatisfaction with existing working/living conditions – so-called push factors, as well as by awareness of the existence of (and desire to find) better jobs elsewhere – so-called pull factors. A recent study from sub-Saharan Africa points to both push and pull factors being significant. Workers’ concerns about lack of promotion prospects, poor management, heavy workload, lack of facilities, a declining health service, inadequate living conditions and high levels of violence and crime are among the push factors for migration. Prospects for better remuneration, upgrading qualifications, gaining experience, a safer environment and family-related matters are among the pull factors
In Zimbabwe, for example, a startling 77% of final university students were being encouraged to migrate by their families (13). Beyond the individual and the family, accelerated globalization of the service sector in the last two decades has helped drive migration in the health field (14–18). In addition, there is a growing unmet demand for health workers in high income countries due in part to rapidly ageing populations. Two important responses in the global market are occurring. First, a growing number of middle income countries are training health workers for international export and second, professional agencies are more actively sourcing workers internationally, raising questions about the ethics of recruitment. (p. 99).
The first step
Understanding and accepting these reasons – which have little or nothing to do with patriotism or a lack thereof -- gives Cameroonian policy makers a better chance of tackling the brain drain issue head-on.
In a paper presented at the international seminar on International Dialogue on Migration, Jorge de Regil & Mel Lambert have a word of advice for countries such as Cameroon which are suffering from the migration of indispensable health resources:
"Governments have to be more open and honest about the reality of migration of human resources for health in the country…Given the choice most people would prefer, all things being equal, to remain in their home country. Consequently, in devising policy solutions to migration, making a country a good place to work and to live in must be the starting point: developing a culture where advancement (in education or professional life) depends on quality, not on political affiliation, race, religion, national origin, etc."
Cameroon must therefore go beyond the blame game and look at effective and viable internal solutions to the problem. For example, the Government can seek a moratorium on current Bretton Woods hiring quotas for medical doctors on national security grounds. Or simply go against IMF and World Bank recommendations. There is a precedent here. In 1991, for example, the Government created five new universities in the country, against the specific wishes of the Bretton Woods institutions which argued that the country could ill afford such an expensive venture. 15 years later, there is hardly anyone in Washington who still believes that the creation of these universities was a bad idea.
Without doubt, the medical profession in Cameroon has lost its erstwhile glory and part of the effort to stem the tide of migration must include making it attractive once more in terms of salary, career growth, and social mobility. As long as the situation where a Policeman with a high school diploma earns as much, if not more than an MD persists, the brain drain will continue.
There are a plethora of possible solutions to these problems.
According to the e-Africa online journal (Sept. 2003), the government of South Africa, for example, set aside R500 million in 2003 and R750 million in 2004 “to adjust the salaries of public-sector doctors and expand the number of rural medical jobs”.
Regil and Lambert propose a solution along the same lines:
"Developing countries need to try harder to entice their high skilled healthcare professionals back. This could be done, for instance, through schemes where top public officials in countries have their public sector pay ‘topped up’ through aid assistance schemes so as to encourage them to stay. Schemes could be developed were medical expatriates are brought back for a period of time to impart skills on the home population. However, any such schemes need to be sustainable in their own right and not create artificial situations that could dry up as soon as any funding ends."
In search of global solutions
Beyond what could be termed the “classical solutions” to the brain drain, African governments must craft global, bold, innovate and effective policies that go beyond the case of MDs. Even though theirs is the most visible case, the situation is equally critical across the board. In Cameroon, for example, about 25%-30% of professionals trained in the country are working abroad while 70-80% of Cameroonians trained abroad do not return home after their education.
Creativity is in order. Hence, asking the Diaspora community to visit Cameroonian embassies abroad or the website of the Prime Ministry for possible job opportunities in the country, as Prime Minister Inoni did during his July 2005 visit to the United States, shows a lack of vision and innovation.
In the long run, Cameroon may probably have to turn for inspiration to countries such as Nigeria, Ghana, South Africa and the Philippines which are tackling the brain drain crisis in the most innovative manner possible.
“Nigeria has a special assistant to the president for the diaspora. Senegal created a ministry of foreign and diaspora affairs. Ghana changed its laws to allow dual citizenship to make it easier for the diaspora to return… One lesson from Ghana’s effort is that if Africa wants émigrés to return, the process must be easier. In particular, spouses and children born abroad should have the opportunity to claim citizenship easily and be allowed to maintain dual citizenship to make it easier for émigrés to continue to conduct business. The Ghanaian embassy in Washington maintains a computer skills bank on its nationals working in the US.” (e-Africa, September 2003).
In 1995, the Filipino government established the Philippine Overseas Employment Administration charged with promoting the return and facilitating the reintegration of migrants. The Employment Administration offers privileges to returning Filipinos such as loans for business capital at preferential rates and eligibility for subsidized scholarships.
There a dozens, if not hundreds of solutions that have been tested around the world. If Cameroon is serious about the brain drain issue, it knows where to start rather than trying to reinvent the wheel…
Picture courtesy of Direct Relief International
Tags: brain drain Public Health migration medical doctors Africa Cameroon
2135 Doctors who become nurses
Drop this one in the "unintended consequences" category. Immigration to the United States for nurses is much simpler than it is for physicians. Consequently, since 2000, more than 3500 Filipino physicians have taken accelerated nursing courses and have left for nursing jobs abroad. More than 4000 physicians are now in nursing school, not just new physicians, but internists, surgeons, anesthesiologists, family practitioners, and subspecialists. Now, the U.S. recruits nurses from abroad, creating crises in those countries, and depresses wages here at home. Sometimes it seems the more laws you make to protect one labor group, the worse you make it for someone else. (Story from New England Journal of Medicine, v. 354:5;529.)
http://collectingmythoughts.blogspot.com/2006/02/2135-doctors-who-become-nurses-drop.html
Posted by: Ady | April 16, 2006 at 08:32 PM
Very interesting piece with very revealing statistics. It would be great to read from MDs who have left the country in recent years. Does this article, particularly the WHO report adequately capture the reasons for their departure?
Posted by: Abangma Peter | April 16, 2006 at 10:06 PM
Perosnally I think the article says it all. It gives the possible solutions and if the Minister of Health and the Cameroon government pretends over it, then is a sorrowful situation for Cameroon.
I will give you a scenario of myself which is not different I guess from many of my colleagues.
I am a Nigerian trained doctor, after my graduation and intenship and some working expereicne in Nigeria, I decided to venture back home(Cameroon). While in cameroon, I could ONLY(TAKE NOTE) work in the private sector, as I couldn't get into government services since not a graduate from CUSS. So therefore, got the peanuts paid in private medical practice in Cameroon.
Now as a young doctor, I needed more experience and more education by means of specialization. Again, the lone University teaching Hospital,CUSS in Yaounde, getting into it, is as difficult as you can imagine,the bribery and the "God father" stuff(refuse this if you care) is what some of us can't stand it.
I had no option than to move out of the country, where presently my skills are recognized and I am presently pursuing a specilization programme, something that would be difficult if not impossible if I were still in Cameroon. Here I am able to earn a "decent" living standards with my take home allowance, call it what ever you like, more than 6 times what I got while at home.Nothing much if you take into account the cost of living this way(living Standard)
Now, I will like to come home, UNLESS the situation changes. I therefore have this to add as a pull factor that prevents many Cameroonian doctors from Going back home even after finishing.
This is a Job that needs alot of sacrifices, committement and dedication. In as much as you MUST give Your ALL, You MUST, I MEAN MUST stay alive. What do I mean by this! A doctor is also a human being, who has a family of his own, his relatives and dependents. He must cloth himself and those who depend on him. If you can't MEET this simple duties in life after a minimuim of 6years just for a basic Medical degree + X-years of specializations, then talking about PATROTISM to me, is useless.
We should ask, what is it that attracts Cameroonian doctors to the West. Simple!
1)Better working conditions
2)Better salaries and benefits
Nobody is asking and I have talked to colleagues, nobody is saying we need exact working conditions as in Europe and America or we need Salaries to the amount payable, level wise as in the USA, but what I am saying is, MY TAKE HOME PAY MUST BE ABLE TO TAKE ME HOME, anything short of that, then forget it.
You are working in a hospital, basic utilities are absent, basic instruments are lacking. Patients die in numbers infront of your very eyes, lives you could safe with basic things, how disheartening it could be.I will say in my own experience that, 3 out of every 5 deaths in any Cameroonain hospitals could be prevented by this basic utilities and instruments. Yet a Delegate of health comes to that same Health centre with an entourage all in jeeps and prados,for inspection, yet basic things are lacking in the hospital.
The truth is this, Even the President of Cameroon, Paul Biya, knows exactly what to do to bring us back home, they are just pretending talking about patrotism.As usual the Cameroonian way.
Ask our President, Ministers, Governors, the wealthy ones, when they are sick, they are flown to Europe/America. I tell you the truth, nothing too extra ordinary is done to them that is not possible and feasible in Cameroon.Some of the best brains this way are Africans and amongst then numerous Cameroonians who attend to this same people when they arrive here. why then can this people not be encouraged to come back home, so that the millions of frs CFA remains with us? My country People, this is the real fact.Nothing short of that.
Make just the above two options workable, you need not ask Doctors to come back home, you will see them trooping in in their numbers. After all is not easy out here in the white man's land, Who says HOME IS NOT HOME? But if home should be HOSTILE, I will have no option than to seek refuge even in a ZOO.
As you make your bed so shall you lie on it. The government needs to know just how well to make the bed, they have the means, that Country of Cameroon has what it takes but just the WILL is LACKING.
God save Cameroonians
Posted by: Dr E.A .S | April 17, 2006 at 05:32 PM
Ouch! Reality hurts! I weep for my country Camroon - the solutions to most of our problems are so obvious and well within reach but we prefer to bury our head in the sand!
Posted by: Bouba | April 17, 2006 at 06:44 PM
This is an excellent article, which the government must take a careful look at. It should formulate its policies by integrating the tested approaches described in the article.
However, the focus should be not only on the medical profession. There are many Cameroonian professionals working abroad against their wishes, simply because the working conditions at home do not encourage them to return.
I would like the government to make a serious attempt to reach out to these professionals so that they are encouraged to return and contribute to the development of the country.
These professionals must be made to feel wanted or valued; and adopting policies that facilitate their return would certainly go a long way towards encouraging them.
Posted by: Dr. A. A. Agbormbai | April 21, 2006 at 10:29 AM
Those abroad will NOT return home. The only hope is to make sure those at home stay home. Improve their work conditions and ofcourse give them a real salary! All this talk about patriotism is nonsense. I don't know if it makes any sense at all in the Cameroon context! Who in that Country can raise his hand to say "I am Patriotic You are Not" There are two categories of cameroonians in Cameroon:
Those who can't go abroad
Those who don't want to go abroad
Those who can't, just can't, simple.
Those who won't are fine at home, simple.
Now ebable those who can't go abroad and they will go abroad.
Disable those who are fine and they will go abroad as well.
These people are not patriotic, they are conditional opportunists!
The best thing to do is completely overhaul the Country.
Round up all those in charge and let them answer for their roles in running the Country.
How do we do these? I have no idea
Posted by: fmg | April 21, 2006 at 11:53 AM