Where are the doctors?

An efficient health system is of paramount importance to every country in the world. It has therefore be adequately trained and really available human resources for health (HRH).

A well functioning health information system, efficient service delivery, adequate medicines and medical supplies, appropriate vaccines and technologies. Also proper health financing and committed leadership is needed for the system to be realized.

The health services are primarily intent to enhance health and protection of the surrounding community.

Despite its importance in the community, its performance is inversely proportion to the population growth which stands at over 45million people in Tanzania.

However the health sector is overwhelmed by shortage of skilled staff, as it is estimated to be in the least of 57 countries facing the shortage.

According to a research conducted by Sikika in 2013 titled “where are the doctors?”, one of the main cause are uneven man power distribution between urban and rural areas, poor retention schemes, and low production of health workers, lack of career development programmes and lack of motivation.

The report reveals that, due to above reason health care industry in the country is now and again hit by human capital flight, talented creative and highly trained employees tend to migrate either internally or externally, within and outside the medical profession in search of greener pastures.

Consequently, the fewer workers left behind in the heath care system, after the said human capital flight, are left with a heavy burden of taking care of many more patients than they can handle, and this definitely leads to low productivity. Although this situation is common in all health worker cadres it is more serious among medical doctors.

The survey revelled that 39.6 percent of the tracked medical graduate were not practicing clinical medicine. The remaining 60.4 percent medical graduates, who were practicing clinical medicine, were working in hospitals, NGOs, health training institutes, or were pursuing further studies.

According to the research, with regard to their occupation 42.9 percent of graduate doctors were working full time in hospitals, 15.6 percent were pursuing further studies, 13.8 percent were working in NGOs, 11.9 percent were working in health training or research institutions, while other 15.8 percent were either working in non-health businesses.

Most medical doctors who reported to this survey were based in major cities and towns including Mwanza, Dar es Salaam, Mbeya and Moshi Municipality which accounted for 41.7 percent of the tracked graduate doctors.

In such areas, as it would be expected, there are major health facilities, referral hospitals, or medical training and research institutions. Dar es Salaam alone accounted for 32.3 percent while the remaining regions shared 11.3 percent of the tracked medical graduates.

Moreover, research reports show that nearly all countries, rich and poor face a critical shortage of competent health workers particularly in rural areas, where the need for basic care is usually enormous.

The Human Resources for Health (HRH) crisis are characterized by severe shortage of health professionals. The shortage has seriously eroded the capacity of local health system to function effectively, efficiently and equitably in the delivery of service to the poorest members of the community.

The research shows that, the migration of health professionals (from Sub-Saharan African to another regions and continents, from one Africa country to another, from rural to urban health facilities, and from public to private health systems in the same country) and the chronic under-investment in public sector healthcare system are major contributing factors to the health crisis.

Like in other developing countries, Tanzania health sector is understaffed and characterized by uneven distribution of health workers, with rural and remote places being the most disadvantaged.

According to World Health Organization (WHO) 2006 report, Tanzania has the lowest per capital of highly trained health workers (physicians) in the world. It has been documented that 57 African countries including Tanzania have a shortage of 2.4 mil doctors and nurses.

Additionally to WHO 2006 report, while Africa has 25 percent of the global disease burden, it has only 1.3 percent of the world’s experienced health care workers. Tanzania doctor’s population ratio improved from 0.2 physicians per 10,000 people in 2011.

The shortage is further compounded by low productivity, ineffective financial and non-financial incentives, poor working environment, and lack of supportive supervision, poor career schemes, and migration to other attractive healthcare labour markets in and outside Africa.

On the other hand, health Sector Performance Profile Report 2011 shows that, there were 52,637 workers in the entire health sector, for the reporting year.
The report also indicates that the trends of healthcare workers prior to 2011 were 33,715 in 2005/2006, while 38,527 in 2006/2007, 47,537 in 2007/2008, 44,547 in 2008/2009 and 48,637 in 2009/2010 this is according to MoHSW report of 2012.
The Human Resource for Health- Public Expenditure Review Survey report (HRH PER of 2011) shows that the 11 local government authorities that were surveyed had an average of 60 percent of the required medical doctors.

In 2009, Sikika carried out a survey in 103 district of Tanzania to track deployment of various cadres of the heath workforce. The HRH tracking study revealed an overall HRH gap of 54 percentages and a follow up study in 2012 revealed an overall HRH gap of 49.1 percent.

In addition, it was also discovered that some cadres include doctors, medical technicians, pharmacist and physiotherapists were unavailable in some districts. The study further established that 30 out of 103 districts surveyed had no graduate medical doctors.

During the 2012, doctors’ strike in Tanzania, none among the Ministry of Health and Social Welfare (MoHSW), Medical Association of Tanzania (MAT), researchers or activities was able to present a correct figure of graduate medical doctor available in the country.

Moreover Sikika report shows that, the extent of internal migration, as well as migration of this scarce cadre, is not well documented. One of the complaints by the striking doctors was excessive workload and poor working conditions characterized by lack of working facilities.

The study carried out by Sikika indicated that, from 2,246 medical doctors involved in the study the ratio of one doctor to population appear to be 0.5 doctors per 10,000 people which basing on the country’s total population of 44,928,923 obtained from 2012 NBS statistics gave an estimated number of 2,250 medical doctors.

A large proportion of the tracked doctors were male accounting for 69.5 percent and nearly quarters 72.1 percent were MUHAS graduate, followed by KCMC graduates 18.4 percent. IMTU and HKMU had the least number of tracked medical doctors.

According to the study, almost all 95 percent of the 2012 graduates were practicing medicine internship at the time of the study. Nearly a half of 45.2 percent of the 2003 graduates were not practicing clinical medicine, while two thirds (66.4 percent) of the 2004 graduates and more than three quarters (78.4 percent) of the 2008 graduates were practicing clinical medicine. Most of the 85 percent of the tracked medical doctors who had earned their degrees in 2011 were not practicing clinical medicine at the time of study.

The report adds that, less than a half 42.9 percent of the tracked medical doctors were working full time in hospitals. About 15 percent of the doctors were pursuing further studies and 13.8 percent were working in NGOs.

While almost three quarters 74.9 percent of doctors tracked in regions other than Dar es Salaam, Mbeya, Kilimanjaro and Mwanza were practicing clinical medicine, only two-thirds 66.7 percent of those living in Dar es Salaam were practicing clinical medicine.

Dar es Salaam alone account for 32.3 percent of the tracked medical doctors compared to other regions that accounted for 11.3 percent. More than one third 38.8 percent of the tracked doctors did not have a workstation at the time of the study.

According to Tanzania Human Rights Report 2013 released in April this year, Tanzania is one of the countries with the lowest doctors-to-patient ratio in the world. It is estimated that the doctors-to-patient ratio to 1 doctor per 30,000 patient.

In developing countries the ratio of doctors to patients is 1 doctor per 300 patients per annum. The deficit also extends to other health workers. There is weakness in production, recruitment and retention.

In terms of production, the country has few universities that are offering medicinal degree programmes compared to social sciences.
There are only six universities that are offering medicine degree programmes whereas there are more than 30 universities offering social science programmes.

The Human Right report shows that, in terms of recruitment, the government through the Ministry of health and Social Welfare has now increased issuance of recruitment permits in regional hospitals. In the year 2012/13 reached 8602 health workers.

It elaborates that, the country aims at increasing workforce in health sector as preparation for the Human Resource Strategy, 2014-2019, is underway. This will reduce the current shortage of workforce in health sectors as to date the shortage is 58 percent, whereas in 2006 the shortage was 70 percent.

The shortage of health workers also varies greatly from one region to another, whereby in Tanga the deficit of health workers is 45.3 percent, in Lindi account up to 60.1 percent. Comparatively, majority of the workforce prefer to work in big cities and not in councils and municipals. For instance, in Tanga if one requires a dental service from the government hospital in Lushoto, Kilindi, Korogwe and Mkinga districts, he/she has to travel to Tanga town.

Sikika and MAT also wanted to establish the proportion of those who had left clinical practice for other activities. The information gathered is to be used by Sikika and stakeholders to advocates for improved retention of graduate medical doctors and other healthcare workers, thereby enabling more people to access services offered by qualified health providers. 

Reprint from THE GUARDIAN