The healthcare system in Ethiopia faces numerous challenges, including a shortage of medical professionals and inadequate resources. Despite these obstacles, the country has made significant strides in improving the health of its population over the past few decades. This article explores the current state of medical doctors in Ethiopia, the factors influencing their migration, and the ongoing efforts to strengthen the healthcare system.
Map of Ethiopia showing its regions
The Health Workforce in Ethiopia
The greatest health workforce shortage is in sub-Saharan African (SSA) countries which bear a quarter of the world’s disease burden but have only 3% of health workers and less than 1% of the global financial resources to address the burden. Ethiopia primarily losses its physicians to migration ranking as one of the leading countries in Africa in aggregate loss following Egypt, Nigeria, South Africa and Ghana. Ethiopia implements compulsory service programmes as a way to deploy and retain physicians as a compensation for the state funded medical education for all students except those who graduate from private medical schools. Despite this, the level of physician emigration in Ethiopia is alarming because the country has not been able to train sufficient number of physicians to provide adequate medical services for its ever-growing population.
In 2016, the physician-to-patient ratio in Ethiopia was 1:20,000, which is below the WHO recommended minimum density of 2.3 doctors per 1000 population needed to achieve the minimum levels of key health interventions. Comparatively, as of 2018, there was a total of 8395 physicians in Ethiopia, 168 in Liberia, 165 in Sierra Leone, 6400 in Angola, 5832 in Democratic Republic Congo and 3026 in Zimbabwe. Put in perspective, this indicates that the aggregate stock of physicians in these six SSA countries is less than half of the doctors in the Netherlands. It should be noted that the combined population of these six countries (N=252 million) is nearly 15 folds larger than the Netherlands.
The Ethiopian Federal Ministry of Health has drafted a Human resources for Health (HRH) strategic plan to address the recruitment, training, deployment and management of HRH. However, given the high emigration of physicians, it touches the issue very lightly and reviews the push factors inadequately.
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Physician Migration: Push and Pull Factors
Migration of physicians is one of the most pressing global health problems of our time with the greatest implications in sub-Saharan African countries. Physician migration from low-income countries (LICs) to high-income countries (HICs) has been a pressing global issue in recent decades. One SSA country particularly affected by this health problem is Ethiopia.
The emigration of Ethiopian physicians is made after weighing the push and pull factors. Push factors are more crucial than pull factors, and financial reasons play the leading role. Junior physician unemployment, politicisation of hospital administration, and poor medical migration governance are growing problems. Junior physician unemployment is a recent phenomenon in Ethiopia and with a potential to be a leading push factor if appropriate intervention is not taken. Although studies have explored and produced important quantitative data about the impact of medical migration in the health sector of Ethiopia, the motive behind Ethiopian physician migration have been explored less thoroughly.
Several theories have evolved about international migration in general. The push-pull theory which was initially introduced by Ravenstein in 1889 and expanded on by Lee in 1966 is the most frequently cited explanation for migration. Lee conceptualised the factors related with the decision to migrate and the migration process into four categories: (1) Factors related with the place of origin; (2) Factors related with the place of destination; (3) Intervening obstacles and (4) Individual factors. In each area, there are different factors that either drive people away (push factors) or attract and hold people to it (pull factors). This ‘push/pull’ dichotomy is a frequently employed research model to evaluate causes of health professionals’ emigration. These are factors that ‘push’ health professionals to leave, and ‘pull’ factors that make emigration a worthy and workable option. Current global social and economic forces compel movement of health professionals from LICs to HICs. The push-pull framework has been utilised to analyse and identify such forces in SSA countries.
Economic Factors
This theme examines the economic factors driving the international emigration of Ethiopian physicians. Financial reason was perceived as the main determinant influencing the decision for migration. Most respondents acknowledged that their wage was very low for the services they provide. Respondents were frustrated about unmet basic needs and difficulties to support their families. It was felt that the salary is unacceptably low even to the standards of other LICs.
It is worth mentioning that access to a house and a car was more important than salary for all participants. Respondents believed that these non-salary instruments were probably the most important factors that would have convinced physicians against emigration. The economic situation gets better after postgraduate training depending on the type of specialty, employer, and region.
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Professional Factors
This theme explores the professional factors that drive the international migration of Ethiopian physicians. Data analysis revealed that it was perceived to be one of the central reasons that influences the decision to migrate. Respondents expressed a major concern regarding recent job insecurity for young medical graduates. Participants indicated that the already deteriorating quality of education was made worse consequent to the same ‘flood and retain’ policy. Moreover, a medical graduate may not get a region of his/her choice in the national residency matching process: a centrally managed postgraduate study placement system.
Another major reason that caused dissatisfaction among these young physicians is the poor quality of healthcare, commonly mentioned as working conditions. This included the healthcare facilities/resources and their administration. Lack of essential infrastructure, medical supplies and equipment was perceived to be a major contributor to most deaths in public settings. In cases of hospital administration, respondents unanimously disapproved the political motives in the hierarchical structure.
Political and Sociological Factors
This theme examines the political and sociological elements that determine physician migration from Ethiopia. The current ethnic rivalry and political instability in Ethiopia is perceived to contribute to internal and external physician migration. Personal recognition or appreciation from the government, community, and hospital administration was an important issue for the respondents. Most respondents felt that the sacrifices the profession requires is undervalued. Other sociological reasons that cause emigration include family reunification and better prospect for children.
The political instability, ethnic political dynamics and inadequate recognition are worthy to mention in their repelling powers, while political freedom, stability and better life standards for family are the pull factors affecting the migration decision of physicians.
Efforts to Improve Healthcare in Ethiopia
As literacy and socioeconomic status improves in Ethiopia, the demand for quality service is also increasing. The government of Ethiopia is working towards building a universal health care system through a community-based health insurance model, where households can pay into the official health insurance fund of their woreda, or district, and draw upon it when in need of medical care.
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The current health care financing strategy of Ethiopia focuses on financing of primary health care services in a sustainable manner. It envisions reaching universal health coverage by 2035. The prioritized initiatives are mobilizing adequate resources mainly from domestic sources, reducing out-of-pocket spending at the point of service use, enhancing efficiency and effectiveness, strengthening public private partnership and capacity development for improved health care financing.
The Health Extension Program (HEP) was introduced in 2002/03 with a fundamental philosophy that if the right health knowledge and skill is transferred, households can take responsibility for producing and maintaining their own health. It was planned to cover all rural kebeles with the aim of achieving universal primary health care coverage by 2008. Services are organized along geographic lines with construction of a comprehensive network of primary health care units throughout the country with one health post in every rural kebele of 5000 people linked to a referral health center.
Health Extension Program
Health Extension Workers in Ethiopia
Addressing equity and quality of health services are the main focuses of the new Ethiopian Health Sector Transformation Plan. Improving the competence of health extension workers and the Women's Development Army is crucial. In cities and urban areas, the Family Health Team approach will be introduced. The team will be composed of clinicians, public health professionals, environmental technicians, other health professional, social workers and health extension professionals to provide services for urban dwellers.
Historical Context
In Ethiopia, the quest for modern medicine beyond traditional practice started during Emperor Lebna Dengel’s reign in the 15th century, when the emperor appealed to the Portuguese king for physicians and surgeons to cure illnesses. Later in 1866, western medicine was introduced by Swedish missionary doctors and nurses. The first Ethiopian hospital was established in 1897, the Ministry of Health in 1948 and the first medical school in the country opened in 1964.
Recent Developments
In 2019, a movement called Ethiopia Health Professionals Movement, (EHPM), a collective of doctors formed in 2019. They issued a 12 point list of demands to the government, asking for an increase in salaries, health insurance, transport support, and improved workplace conditions. After this request was ignored by the government, they began to go on strike. As of the 2020s, Ethiopia's healthcare workers are paid the lowest in East Africa, according to the World Bank. The Ethiopian government has declared the strikes illegal and cracked down, arresting many healthcare workers.
Junior Doctors' Performance and Competencies
A cross-sectional study was conducted in February 2015 to assess the practice of junior doctors working at public hospitals. The study aimed to identify gaps in medical education and practice and to determine the composition of subjects in the licensing examination for medical undergraduates.
A total of 191 junior doctors participated in the study. The response rate was 96.5%. Most respondents were males (74.6%), were 25-29 years of age (92.6%), and had less than 2 years of work experience (69.8%). Junior doctors frequently performed tasks of internal medicine and pediatrics. Their participation in obstetrics and gynecology, ophthalmology, psychiatry and dentistry services was infrequent. Junior doctors had competency gaps to conduct clinical procedures, research and health programming tasks.
The top five routine tasks done by more than 151 (80%) doctors were diagnosing and managing urinary tract infection, diagnosing and managing hypertension, managing pneumonia in children, managing diarrhea and vomiting in children, and managing childhood fever. More than 151 (80%) doctors were engaged in the following domains: internal medicine, public health, emergency medicine, surgery and pediatrics. In contrast, less than 113 (60%) doctors were engaged in dentistry, ophthalmology and psychiatry.
| Source | Description |
|---|---|
| Federal and Regional Governments | Government funding for health services |
| Grants and Loans | Funding from bilateral and multilateral donors |
| Non-Governmental Organizations | Contributions from NGOs |
| Private Contributions | Household spending and user fees |
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