The doctor surge in Ethiopia
ADDIS ABABA, Ethiopia — When Dr. Bereket Fantahun finished medical school 15 years ago in Ethiopia, she graduated with 58 classmates. Only 10 of them stayed in the country.
“Everyone wanted to go out,” the physician said. “As long as you had your license, you could go to Botswana and take the examination to practice there and then register to go to America.”
Most of them did eventually end up in the U.S., she said.
Talk to other physicians in Dr. Bereket’s generation, and they’ll share the same stories. The massive brain drain gutted Ethiopia’s health-care system because the country only had three medical schools graduating 120 doctors annually. There was only one physician for every 30,000 people in the East African nation struggling to recover from years of famine and civil war.
But in one of the world’s most dramatic medical turnarounds, Ethiopia just finished training a record 3,000 doctors this year. Because of the big boost of medical talent, the country finally has one doctor per 1,000 population — the World Health Organization’s standard.
How Ethiopia solved the problem is a fascinating case study in change leadership. The initiative began when the charismatic Dr. Tedros Adhanom — who earned a global reputation as a malaria researcher — took over as the minister of health in 2005. During his seven years in the job, he made training health professionals one of his top priorities. His strategy involved a mix of clever policy tweaks and big-thinking projects that are still unfolding.
Now, Dr. Tedros is campaigning to be the WHO’s next director-general, and he plans to make increasing access to health care worldwide one of his top priorities if he gets the job.
One of his first moves in Ethiopia caused an uproar with medical graduates, Dr. Bereket said.
“He decided not to give certificates to medical school graduates,” she said. “So you would graduate, and the ministry would write some kind of letter, and you would be assigned somewhere. You wouldn’t have any kind of document in hand, so you couldn’t go anywhere. That was the strategy.”
When the young doctors complained, the government pointed out that they got their medical education for free because the government covered their tuition costs. Now it was time to pay back the nation by doing a few years of medical service in underserved areas. The days of skipping out on the obligation were over.
But many graduates dreaded medical service because they felt they didn’t receive enough training for the hardship assignments. They also thought the duration of their service was unfair.
Dr. Tedros changed that by creating a system that allowed physicians working in remote areas to serve only two years. Those practicing in the bigger cities served for five years. Predictably, the demand for the tough-but-short assignments increased.
Dr. Mengistu Hailemariam is an obstetrician and gynecologist who did his service in a rural area in the north near the Eritrean border, where he was the first Ethiopian OB/GYN to serve the community.
Before the doctors left for their assignments, he said they would attend an orientation program that Dr. Tedros initiated that lasted two to three weeks. At the end, they had a banquet during which Dr. Tedros would give an inspiring speech. The last thing he would do is give everyone his mobile number.
“He would say, ‘If you face any problem, please call me anytime.’ He may be in a meeting, but Dr. Tedros is known for his text messaging, so you could send a text,” Dr. Mengistu said.
The idea was to support the young physicians and also collect valuable feedback about problems in the health system so that they could be fixed.
“Someone might call him and say, ‘I have this woman bleeding, and we don’t have this drug,’ and he would say, ‘OK, wait for me and someone will call you,’” Dr. Mengistu said.
“Then he would tell his staff that a physician working in a rural area is really in need, so please drop everything and help him. Here’s a number, call him and ask him what he needs.’”
Dr. Mengistu added, “This is how he won the hearts of many doctors in this country.”
Despite the improvements, many doctors would still leave the country. So a key part of the strategy was to ramp up the training of doctors and flood the system with physicians. Although some would emigrate, plenty more would stay.
A building boom ensued and since 2006, the number of medical schools rocketed from three to 33. Many of the new institutions grew out of existing universities, leveraging their infrastructure.
Maintaining the quality of education amid such explosive growth is a huge challenge. The Ministry of Health has distributed about 20,000 tablet computers to students nationwide, providing them with better access to online textbooks and other materials.
Bethlehem Admasu is one of Dr. Bereket’s students at St. Paul’s Hospital Millennium Medical College, one of the nation’s leading public institutions. The growing pains that she and her classmates are coping with amid the seam-bursting medical expansion were on display as Dr. Bereket led the students on morning teaching rounds.
Dressed in crisp white coats over skinny jeans, Admasu and her 12 classmates stood shoulder to shoulder, squeezing into the corner of the crowded pediatrics ward. Scribbling notes, they huddled around the bed of a baby who has been vomiting and suffering with diarrhea for two weeks.
After the class, some students grumbled that there are too many students and too few instructors. But Admasu shrugged off the complaints and said the school was doing its best. Her medical studies were inspired by patriotism, and she has never considered leaving Ethiopia.
“When I applied to medical school, I did it because the country didn’t have enough doctors,” said the 20-year-old student who wants to be a pathologist. “If I train here and leave, there’s no point.”
Admasu also doubted that many of her classmates would emigrate.
“The reason many of our doctors left the country before was because there was no residency training,” she said. “But at St. Paul’s and other hospitals, there is residency training now, so they have no reason to leave the country.”
St. Paul’s is a collection of low-rise stucco, tile and concrete buildings in the northern part of the capital, Addis Ababa. The institution is as much a construction site as it is a medical facility. The whirl and whine of steel-cutting saws can be heard from the new 400-bed maternal and children’s hospital that’s going up in the middle of the complex.
Across the street, the mechanical arm of an excavator rips into the ground of a muddy empty lot and scoops up piles of rocky soil. Dump trucks hauling mounds of dirt rumble away from the site, narrowly dodging Toyota Land Cruiser ambulances delivering patients to the hospital.
A huge billboard at the site describes the US$45 million project: a new National Center of Excellence for Oncology and Cardiology. The sign shows two sleek glass-and-concrete buildings that will house a 350-bed cancer center, 205-bed cardiology center, two cath labs, cardiac surgery theater and bone marrow transplant center, among other facilities.
Much more is in the works. A transplant center with 100 to 150 beds is on the drawing board, along with a new 400-bed burn, trauma and emergency hospital.
The man running St. Paul’s is the energetic Dr. Zerihun Abebe. He said that to an outsider, the frenzy of construction might look like an irrational building boom. But it’s not when you consider that Ethiopia is starting from a low base, responding to an explosion in demand that has long been ignored.
“In five years, we’ll be a hospital with 2,300 beds,” nearly three times the current capacity, Dr. Zerihun said. “For a country nearly twice the size of France, we need all this. Right now, if you build anything, it will be filled in two weeks.”
The expansion projects add to the urgency of producing more doctors, Zerihun said. He will soon send 67 doctors and nurses to India for training in cardiology and oncology.
Fortunately, more physicians are staying in Ethiopia, he said. One factor is that there are fewer placements in the U.S. for foreign medical graduates than there were 10 years ago, he said.
A more significant factor is that there are more challenges for young doctors now, he added. Many doctors won’t be lured overseas with more money if they can stay in Ethiopia and pursue interesting opportunities.
“In the U.S., everything in your mind has been done by somebody else. You have to be super to do something new,” Dr. Zerihun said. “Here, you go anywhere and you start digging in the ground to build something, and it will be the first in the country. It’s going to be neurosurgery or cancer care. An increasing number of young people are realizing there is a great deal of opportunity here.”
