18 April 2017

Tanzania: Doctors' Crisis - Unlocking the Paradox of Plenty

Photo: The Citizen
Doctors during operation (file photo).
analysis

Until about two weeks ago, Dr Reuben* was waiting to be shortlisted for a job to go to work in Kenya after the Tanzanian government promised to send 500 doctors to the neighbouring country--but last week, the young medic made up his mind. He says he has lost hope.

As he recounts his tribulations of hustling for a job, he doesn't want to reveal his name in a newspaper--at least for now. Why? He says, "Things are not yet straightforward [that he is not free enough to speak because his chances for a job are not yet guaranteed elsewhere]."

The young medic has been jobless for about two years since he completed his registration and licensing as a medical doctor at the Medical Council of Tanganyika (MCT).

The existing irony

Dr Reuben is one among the over 2,000 doctors who, apparently, has not been recruited in any state-run health facilities in the country for the past two years, data provided by the country's Health Minister, Ummy Mwalimu show.

It's here that one health economist in Dar es Salaam, Dr Samwel Ogillo says, "Tanzania is now starving in the middle of plenty... [Because it has more doctors than it can employ, yet most health facilities are still understaffed.]

"It's now time for the government to come up with innovative solutions or models on how to deal with the ever growing doctors' crisis," suggests, Dr Ogillo who is also the Chief Executive Officer of the Association of Private Health Facilities of Tanzania (APHFTA).

In a passionate appeal to the government on the doctors' crisis, another stakeholder, Executive Director of Sikika, a health advocacy NGO, Irenei Kiria, believes that Tanzania should now officially look to the private health sector for the employment of doctors.

And, he adds, "The government should now draft the universal health coverage bill, a health insurance plan that will allow common people to meet the treatment costs when seeking health services at private health facilities."

This, he says, can create more opportunities for private doctors who will now provide more pre-paid services to patients.

With more clients in the private health facilities, it means that more doctors will now be recruited outside the government system.

Health Minister Ummy Mwalimu has publicly admitted that the government cannot put all the newly licensed doctors on pay roll. "The Wage Bill is the determining factor, and we have reached a point where we can't accommodate all the doctors," she said.

The fate of the doctors

So, what are the doctors currently doing?

"Some doctors have managed to get jobs in private health facilities, others are now working with NGOs and some are out there doing something else--not practicing medicine--and others are simply jobless," says Dr Obadia Nyongole, Chairman of the Medical Association of Tanzania (MAT),

About four years ago, 39 per cent of the Tanzanian doctors who were tracked down, were not practicing medicine, says a report titled "Where are the Doctors? - Tracking Study of Medical Doctors," released in 2013 by health advocacy NGO, Sikika and MAT.

By looking at their job descriptions, it was found out that 42.8 per cent of graduate doctors were working full time in hospitals, 15.5 per cent pursuing further studies, 13.7 per cent worked in NGOs, 11.9 per cent are worked in health training or research institutions and 16.1 per cent others were engaging in non-health businesses.

A new study published in Global Health Action predicted last month that more than 50 per cent of all medical students enrolled in Tanzania between 2011 and 2020 will not be practicing medicine by the year 2025 and won't be captured anywhere as medical doctors in the public medical institutions.

Yet, it remains costly to train the medics. It costs USD27,500 [equivalent to Sh60.5million] to train one doctor in Tanzania. This means that for every 100 unemployed doctors, a minimum of USD2.75 million is lost. This is equivalent to about Sh5.8 billion [equivalent to Sh6billion according to the current exchange rate]lost, says another study published early this April in the Human Resources for Health Journal.

The country continues to produce about 1000 new medical graduates each year--all from more than eight medical schools in Tanzania, says the study, titled: "Training and deployment of medical doctors in Tanzania post-1990s health sector reforms: assessing the achievements."

"Regardless of the observed increase in the number of medical doctors from training institutions, the shortage of doctors in the country is still high, says Dr Nathanael Sirili, the lead author of the study.

And, there is an outcry for doctors across country's health facilities. A Task Sharing Policy Guideline for Health Sector Service of 2014 which will end in 2019 shows the government needs at least 3,510 doctors to be distributed in various referrals hospital at the regional and district level.

As for Dr Reuben, a graduate of Muhimbili university of Health and Allied Sciences (Muhas), teaming up with over 400 newly licensed medics to apply for a recently publicised opportunity to work in Kenya was the only option available.

However, the government's plan to take the doctors to Kenya is now mired in controversy following an ongoing legal dispute at the Labour Relations Court in Nairobi; which bars the country from recruiting foreign doctors--including the 500 from Tanzania.

And, the Tanzanian government is expected to be able to employ only about 500 doctors in the 2017/18 financial year, according to Health Minister, Ummy Mwalimu.

That means that if only the 500 doctors went to Kenya, plus the other 500 medics that the government says it would recruit, at least half of the doctors who are "jobless" would have been put on payroll--but all this is still a plan.

Doctors beyond borders

Dr Reuben has now lost hope. He tells Your Health that the hopes of him going to Kenya have faded. He adds, "I have realised that banking all my hopes in the government for a job will always leave me disappointed."

"It has reached a point where I think my medical degree is useless. Working as a doctor in Tanzania is now proving difficult. I am now thinking of seeking for an opportunity in Rwanda or elsewhere," he says, believing that there are greener pastures on the other side, beyond border.

There are cases of doctors from Tanzania like him; and elsewhere in Sub-Saharan Africa who for various reasons, migrated to Australia, Canada, the United Kingdom, and the United States.

This has prompted researchers to suggest that these countries where doctors go to, should consider paying back--investing in training for in countries where the doctors come from and strengthening the health systems.

This is because, the financial cost of doctors emigrating to those countries in huge.

The benefit to destination countries of recruiting trained doctors was largest for the United Kingdom (USD2.7bn) and United States (USD846m).

That was according to a study in British Medical Journal (BMJ) in 2011, titled: "The financial cost of doctors emigrating from sub-Saharan Africa: human capital analysis," which looked at Tanzania, Ethiopia, Kenya, Malawi, Nigeria, South Africa, Uganda, Zambia, and Zimbabwe.

The story of Dr Reuben who now thinks of going abroad and other medics like him who continue to hustle for jobs in Tanzania is partly on the mind of researchers who have captured the situation in the study published in the Human Resources for Health Journal, aforementioned above.

The role of private health facilities

The study, funded by the Swedish International Development Cooperation Agency (Sida), suggests that the Tanzanian government should now revisit how it plans and distributes health workers but more importantly, it must audit its human resource database.

"... planning should consider the demand and supply model," recommends the study and further suggests, "Auditing and improvement of the human resource for health database is highly recommended in dealing with Tanzania's medical doctors' crisis."

The unemployed youth, Dr Reuben, says he's now eyeing chances in private hospitals but he is cautious about his decision. "Working in the private health sector--especially in hospitals which are not owned by NGOs is very challenging. The sector is unstable, 'he says.

Dr Sirili, the lead author in the Sida-funded study says the private health sector can be expanded to become an alternative for doctors who have failed to find jobs in government-run hospitals.

"But that has to come with a lot of initiatives from the doctors themselves and the government on the other side," says the researcher.

One of the ways, Dr Sirili suggests, is that the young medics should be sensitized to form associations through which they can be assisted.

"Then, the National Health Insurance Fund (NHIF) can offer soft loans to the doctors to build private health facilities. Later the medics can pay back to the NHIF. In this way, the doctors will have got jobs."

He says the private health facilities should also be well coordinated in the way they recruit doctors. "... each facility, organisation or institution now has its own deployment system," says the Sida-funded study, authored by Dr Sirili.

The government should also work on reducing the "barriers" that make it difficult for doctors to start-up private health facilities, says Dr Sirili.

On the barriers, for instance, Your Health has learnt that NHIF does not register new private health facilities until after three years of operation. This situation has been highly criticised by Dr Samwel Ogillo, CEO of APHFTA, who called on the government to start engaging the private sector on how to deal with the crisis. "... and by removing oppressive regulations that hinder private health sectors growth," notes Dr Ogillo.

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