Manpower crisis in health care in Ethiopia In Memory of 100 years of Ethiopian Modern Medicine & the New Ethiopian Millennium Yifru Berhan M.D Dean, Hwassa University Medical Faculty Coordinator Southern Ethiopia Gwent Health Link

The pioneering hospitals Name of hospital Year Remark Russian 1896 Closed 1906 Harer Ras Mekonnen 1903 Menelik II hospital 1906 Diredawa Railway 1911 Gulele hospital 1922 Bete Saida 1923 Zenebework 1930 Ras Desta Damtew 1932 Zewuditu hospital 1933

Ethiopian Doctors Profile 15 th century: Portuguese "barber-surgeon" (Joao Bermudes) 16 th century: German missionary (Peter Heiling ) 1896: Three Russian Physicians 1898: Dr.Workineh Martin (1 st Ethiopian doctor) 1920s:Dr.Melaku Beyan (the 2 nd Ethiopian doctor)

Total doctors in Ethiopia since 1896 in public health institutions

Doctors graduated from Ethiopian medical schools SchoolYearGraduated Addis1968 – Gondar1983 – Jimma1990 – Total3728

Total number of doctors in the public sector in Ethiopia in

Number of doctors /100,000 population in the public sector in the last 23 yrs(`84-`06)

Doctor to population ratio WHO minimum recommendation for developing countries 1:10,000 WHO 2003 report: Cuba 1:167 Belarus 1:217 Russian federation 1:233 Lithuania1:250 U.S.A1:355 UK1: 500 Sudan1:7,000 (2004)

Total Doctors : Population ratio in Ethiopia reported by MOH (1998 – 2005)

Doctor to population ratio since 1984 (public sector) YearRatio 19841:84, :28, :118,000

Regional states doctor to population ratio since 1984 (public sector) Year Tigray AmharaOromiaSNNP _ :40,000 1:57,000 1:56,0001:42, :53,000 1:76,000 1:86,0001:77, :100,000 1:280,000 1:220,000 1:230,000

Doctor deficit in % in the public sector (MOH) by WHO standard

Doctors-to-hospital ratio in the last 12-years in public sector out side A/A (1995 – 2006)

Total doctors working in MOH

Number of doctors in 76 MOH hospitals outside Addis- December 2006

Specialists: Population ratio in the regional states outside Addis Ababa, December 2006 Qualification Number Specialist-to- population ratio Specialist-to- hospital ratio Surgeon 441:1.6 million1:1.7 Obstetrician & Gynecologist 391:1.8 million1:1.9 Pediatrician 161:4.5 million1:4.8 Internist (Physician) 151:4.8 million1:5.1 Ophthalmologist 71:10.3 million1:10.9 Total (Addis Ababa) 881:34,00011:1 National (MOH) 2191:342, :1

Total Ethiopian specialists graduated in the country or abroad since 1987 and available in ALL public sector, Dec 2006.

Aggregate loss of Ethiopian doctors from public sector between 1987 and 2006 Total Number of Doctors graduated Status as of 2006 EthiopiaAbroadTotalAvailableLoss Specialist General Total

Medical doctors annual gain vs annual loss in the public sector,

Academic staff in five medical schools involved in training medical students, Dec 2006

Distribution of selected specialists in 4 medical schools, December 2006

Discussion Manpower Crisis in Ethiopian Health Care  Shortage of medical doctors as well as other non-doctor frontline health workers Production rate Retention  High migration - internal and international  Unattractive career options  Rapid expansion as well as extremely high remuneration in private and NGOs  Shortage of experienced teachers/ trainers number and quality  Fast population growth

Total remuneration in Birr MOEMOHPrivateNGOs SP(FT) ,00015,00020,000 SP (CT)10,90010,000 GP(FT)

The Way Forward: Manpower Crisis in Ethiopian Health Care 1. Specific measures to scale up production of doctors and other frontline qualified health workers 2. Improve motivation to work in the government institutions 3. Maintain quality of training by increasing production of specialists/ trainers, and ‘Training the trainers’ and CME programmes

From Ethiopian perspective To maximize physician retention  Give priority to physicians in providing low cost or condominium houses  Provide improved schooling facilities for their children in regional towns  Adopt other countries’ experience of dual employment to academic staff working in teaching hospitals.  Establish mutual beneficiary agreement b/n medical schools and local hospitals  Direct donors and stakeholders to work on the line of reducing internal and international brain drain of medical doctors and other essential frontline health workers

Medical doctors production scale up For our country:  Production is more advantageous than expatriate employment  Training cost/student = 250, ,000 Birr/6yrs  Expatriate salary = 1 million Birr/6yrs For UK/U.S.A The minimum cost to produce a medical doctor is over £250,000, which is more than 3 million Birr

Number of doctors expected to graduate from the 5 medical schools over the next 9 years (2007 – 2015) - WITHOUT PRODUCTION SCALE UP YearCumulative total 10% attrition Population million

Number of physicians/100,000 population hypothesized without production scale up ( )

Specific measures to scale up of production of doctors  Increase medical students intake of medical schools from Sept A/A = 500/yr, Other 4 medical schools each = 200/yr  Establishing Joint appointment with local hospitals  Increase postgraduate trainee intake

Expected outcome WITH PRODUCTION SCALE UP Doctors 6,00013,000 Doctor / population 1:15,0001:8,000 Ratio (With 10% attrition rate) Ethiopia Population 94 million 106 million

Number of physicians/100,000 population hypothesized with production & retention scale up ( )

 What happens now and until 2020?  How do we reach Millennium Development Goals by 2015?  How production scale up programme is realized?

Hospital to population ratio In Ethiopia  85% population lives rurally  139 hospitals for 77 million people ( 1 per 550,000); 36 hospitals are in the capital  Many hospitals are over 150 km from the rural population

Hospitals construction trend in Ethiopia in the last 100-years

New hospital constructed by MOH and other sectors in the last 11 years (1995 – 2005)

Health centre expansion programme  Majority of the population currently depend on 650 health centres (1 per 138,000) and 700 Health officers (3 years clinical and public health training)  Plans to build 3000 health centres and train 5000 health officers by 2012 to try reach Millennium Development Goals

Who is going to train?  Doctors  Non-doctor frontline health workers eg Health officers, Midwives, nurses

What Wales and other International partners can do to help?  Immediate and Short term Help to stop international and internal brain drain Help with teaching and training at all levels – come even for short time visits, on sabbaticals or on early retirement as teachers in Regional hospitals and colleges Help with Training of the trainers/ specialists Help with CME programmes Help with capacity building in essential resources

What Wales and other International partners can do to help?  Medium and long term Support teaching and training at all levels Collaborate in research in prevalent diseases Support building capacity for expansion in production of health workers as well as of health care institutions Work together to develop health strategies to help us take our health care setup to reach MDG and beyond

Thank you