Discovered on a Sunday morning talk show

Q&A with Ethiopia’s minister of health

ADDIS ABABA, Ethiopia — Dr. Kesetebirhan Admasu was a young physician just beginning his career in Ethiopia’s Ministry of Health when he was invited to be a guest on a Sunday morning TV talk show called “Coffee and Tea.”

He was supposed to discuss the country’s brain drain problem, and he shared his opinions about why many of his classmates and colleagues were now working abroad. Much of his criticism targeted the ministry, and after the show he was worried that perhaps he was a bit too blunt.

A few days later, he got a call from the minister of health at the time, Dr. Tedros Adhanom. The minister explained that he rarely watched “Coffee and Tea,” but by coincidence he caught the program when Dr. Kesetebirhan was on it.

“We talked and he really appreciated my candor, and he really wanted me to play an important role in terms of working with him in the Ministry of Health in retaining health workers and designing a number of strategies that would improve the working environment,” Dr. Kesetebirhan said.

When Dr. Tedros became the foreign minister in 2012, Dr. Kesetebirhan succeeded him at the Ministry of Health.

Recently, Dr. Tedros announced his candidacy to become the next director-general of the World Health Organization. Dr. Kesetebirhan discussed his mentor’s legacy and how the ministry continues to build on his success:

What did you learn from your experience on the “Coffee and Tea” talk show and Dr. Tedros’ response to your criticism of the ministry?

I think that experience basically explains what Dr. Tedros is about. He appreciates candor. That’s what he always says, and he wants to work with people, whether you agree with him or not. He’s always open to listen to other perspectives. After that interaction I was given a number of assignments. Over time, the relationship grew, and I ended up succeeding him.

Medical students on morning teaching rounds in Addis Ababa.

Can you recall the specific criticisms you discussed on the TV show?

What I was saying was that when doctors graduate from school, they come to the Ministry of Health. They have to do mandatory service because we receive our medical education for free. Ethiopia is a vastly diverse country with different settings. But you would serve the same number of years if you were assigned to the capital or went to remote areas where there is no electricity and the living conditions are difficult. That was not fair on the part of the physicians, but at the same time it was also difficult for the communities because many doctors weren’t going. They were just leaving the country.

How well did the ministry prepare the young doctors for medical service?

When you went to the ministry to be deployed, the environment was not receptive. There was no interaction, guidance or description of what you might face. So as a young physician getting out of school, ready to work in whatever settings you were assigned to work, the preparation from the Ministry of Health was not there. It was not a friendly environment at the time.

Were the physicians properly compensated?

The allowances they were getting were not fair because it was small amount of money for working long hours, often into the night and during holidays. I also said the pay structure was not acceptable. These issues, he really understood them and designed what has now become a tradition. Before health workers are deployed to rural areas, they get a two-week retreat where they receive an orientation about national policies and strategies. They also have an honest conversation about what’s expected from the physicians and what they should expect from the ministry. They also discuss the type of challenges they might face in rural areas and how they should come up with interventions. Dr. Tedros also worked with the Ministry of Finance and Ministry of Civil Service to revise the allowances.

Waiting for the doctor in Addis Ababa.

Was anything done about the length of the assignments?

The number of years people were expected to serve in the different settings of Ethiopia were revised. So the country was divided into three categories. If you go to the most difficult places, you are expected to serve only two years. In places like the capital and some of the big cities, you would serve five years. And some places in between would be three years. These are the kinds of changes that followed after the discussion.

How else did Dr. Tedros address the brain drain problem and the severe shortage of health professionals?

Dr. Tedros has always said that the shortage of human resources for health is the result of mainly a lack of supply. The number of people involved in health and science education programs has been very small over the years. The brain drain was also playing a role, but it was secondary. The main driver of the problem was the lack of supply.

What was done to increase the supply?

Since he became the minister, we have had a long-term human resources strategy that was implemented in phases. The first phase was to build a strong primary-care system with community and health extension workers, nurses, midwives and health officers and other professionals who worked at the primary-care level. So a massive expansion of these primary-care staff training programs has been undertaken. For example, nationally we have one nurse for 2,500 people. That is above the minimum standard the WHO has set for developing countries, which is one nurse per 5,000. So when he became minister, we had one nurse for 15,000 or 16,000 people. So that shows you how much the expansion of nurse-training programs has succeeded. The same is true for midwives and other professionals at the primary-care level.

The shortage of physicians was also severe. How was this problem addressed?

Once we fulfilled the priority of building the human capital for primary care, it was a logical step to build the human capital for secondary care, which obviously required physicians. So we have expanded medical schools to 28. In 2011–12, 13 new medical schools, using a new innovative medical education program, were launched and that has increased enrollment from what used to be only 300 to now 3,000. For the first time in our history, we will have 3,000 doctors graduate this year. This will basically change the landscape of medical practice in this country. So far, we have about 8,000 doctors working in public facilities throughout the country, so the arrival of these 3,000 doctors into the system will mean we will have one doctor for less than 1,000 population. This means we have met the WHO minimum standard for health workers to population in all categories.

20,000 tablet computers have been distributed to medical students nationwide.

When you drastically increase the number of new doctors, how do you maintain quality?

That’s a big challenge, of course. When you expand the medical schools within a short period of time, the lack of faculty and labs has been a challenge. Having adequate textbooks has been a challenge. But we have tried to consider other options to improve the training. The first option was to link some of the older schools with the new ones so that they exchange faculty and support each other. The students also rotate. That kind of mentorship support with the older medical schools has been critical to making some of the newer schools to be better.

The second approach has been to create a cluster for medical schools, particularly for the new medical education programs. They have been meeting on a regular basis, reviewing how they are doing and getting the support they need. Since they follow a new curriculum, we have been doing a lot of training for the junior faculty.

The third is to look for international training opportunities. Some of the schools have really benefited from those kinds of training programs. A case in point is St. Paul’s Hospital Millennium Medical College and a partnership it has with the University of Michigan. The training program at St. Paul’s has expanded. In addition to the undergraduate medical program, they have also started graduate training programs, and they have introduced new services, such as a kidney transplant program in collaboration with the University of Michigan. Other such programs are happening at other schools.

How about the textbook issue? I’ve heard stories from older doctors who said they had to share one textbook with several other students.

We have been providing tablets to medical students to address the problem of access to textbooks so that they have access to an online library through the Ministry of Education and partner institutions. So we are making sure the medical students have these opportunities. In fact, we have distributed 20,000 tablets to medical students throughout the country. This big drive is to make sure we have everyone covered, not only in the newer schools but in the older ones as well. In addition to the training program with local and international institutions, we are involved with the private sector. Physicians working in the private sector have served as faculty in the newer schools.

Do you foresee a time when you might scale back this aggressive program to flood the system with doctors?

Of course, we will look at the demand and the need for increasing production. Based on our plan, it will remain constant as it is now or probably be decreased by a small margin over the next few years. At this point in time, some of the newer schools will have fewer medical students compared to the older schools, which have a higher number of staff. So that kind of adjustment will be made. But more or less, we will remain constant as we invest in the faculty.

Dr. Tedros launched the Health Extension Program, which trained tens of thousands of workers who helped promote basic health practices in communities nationwide. How is the program doing?

The philosophy of the Health Extension Program was to transfer responsibility to families and individuals for them to produce their own health. The program helps each individual to take responsibility for modifying their lifestyle and taking up preventative measures and critical health services that improve the lives of people within their family.

A Health Extension Program worker checks that a child has been vaccinated.

How is this program evolving?

The service package will change over time based on the complexity of the problems we have and the epidemiological transition we have and the needs of the community as well. Because of the investment of our HEP workers have done over the last 10 to 12 years, the incidence of communicable disease has been down, maternal and child health outcomes have improved, hygiene and sanitation outcomes have improved tremendously. The next challenge we face is making sure that there is no complacency in addressing these communicable diseases. Although we have controlled malaria today, it can always come back — sometimes with a vengeance. The same is true with HIV and TB. Unless you eliminate the diseases, the risk of them coming back in a big way is always there. So the mission of the HEP will be to continue and consolidate the gains and take it to the next level, which is making these diseases not a major public health problem in the country.

What might be the focus of the program in, say, 10 to 15 years?

Noncommunicable diseases and injuries are on the rise. Diabetes, hypertension, some cardiovascular problems, cancer and asthma have been a problem. We have included these in the second generation of the HEP, and we are upgrading the HEP workers to be able to deliver the package for the second generation of the HEP. The vision we have is in probably 10 to 15 years from now, some of the HEP workers will be family physicians.

(Photography by Xaume Olleros.)

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