Physician workforce situation and health system’s response in Ethiopia: a mixed-methods study
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Date
2017-12
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Addis Ababa Universty
Abstract
Background: Shortages and imbalances in physician workforce distribution between urban and
rural and among the different regions in Ethiopia are enormous. However, with the recent rapid
expansion in medical education training, by adopting the so called “flooding strategy”, it is
expected that the country can make progress in physician workforce supply. Nevertheless, the
effectiveness of the intended strategy also relies on a lot of interrelated factors. Factors such as
accessibility, composition and turnover of the medical education workforce; the role of medical
instruction in influencing the medical students’ attitudes and career choices; and also the level of
preparation and cooperation made in the system when such strategy is implemented.
Objective: This research aimed to investigate physician workforce (distribution, attrition and
associated factors), medical students’ career choice and intention (to work in rural/remote locations
and to leave abroad), and to discover the health system response and its consequences which have
been made to overcome the physician workforce shortages in Ethiopia.
Methods: The study employed a mixed-methods study design (organizational survey, medical
students’ survey, and qualitative study design by adopting a grounded theory approach). A
longitudinal medical education and physician workforce data sets of about six years (between
September 2009 and June 2015) were retrospectively collected from seven government owned
medical schools, and five regional and two city administration health bureaus to examine the
physician workforce distribution in and turnover from the public health sector and the medical
schools. In measuring the medical education workforce turnover, the study employed the concepts
of survival analysis with a Cox Proportional Hazards Model. However, the study opted to use
Poisson Regression Model hence the data collected from regional health bureau and city
administrations failed to satisfy the Cox’s Proportional Hazards Model assumptions. For medical
student survey, 959 medical students who pursue their medical education in six government owned
higher learning institutions of Ethiopia were involved through self-administered questionnaire to
examine the medical students’ career choice and intention to work in rural and remote locations,
and also regarding moving abroad.
The qualitative study was employed to discover perspectives and viewpoints on the health system
response and its consequences by involving 43 purposefully selected respondents from
government, academics, and private settings. Each interview was transcribed verbatim, coded and
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analyzed using the grounded theory research approach and presented in a narrative form. Finally,
the relationships between the main categories were illustrated using figures.
Results: In the public health care settings, the majority of the medical doctors were males (80.5%),
young (born after the year 1985 (50.9%), work experience of less than three years (57%), and were
general practitioners (84.2%). A decreased incidence of turnover was observed among physicians
born between 1975 and 1985 compared to those born after 1985. However, increased rate of
turnover was found among females, physicians working in district and general hospitals, and in
Amhara Region.
Similarly, in the academic health care settings, a total of 6,670.5 physician-years observation was
analyzed. About 15.7% of the observations were completed and the remaining 84.3% were
censored. In this setting, lower risk of turnover was observed among those who were born before
1975 and with those high academic rank (associate professors and above). The risk of turnover
was also lower among those working in Mekelle and Gondar universities but the reverse was
observed among those working in Jimma University.
Regarding medical students’ career choices, (70.1%) of the medical students wanted to practice in
clinical care settings. However, only a small proportion of them showed interest to work in rural
and remote areas (21% in zonal and 8.7% in district/small towns). On the contrary, most of them
had the intention to leave abroad for both economic and non-economic reasons. For the majority
of them internal medicine was the first specialty of choice followed by surgery. However, students
showed little interest in obstetrics and gynecology, as well as in pediatrics and child health as their
first specialty of choices. In addition, medical students’ attitudes towards their institution in
preparing them to work in rural and remote areas, to pursue their career within the country and to
specialize in medical disciplines in which there are shortages in the country were very low.
In the qualitative study, almost all participants agreed that physician migration (emigration and
out-migration) has contributed to skilled human resource shortage in the country. The most
frequently cited reasons were both financial and non-financial. The latter one includes lack of
recognition, not valuing expertise, and incompetent leadership and management as well as external
factors which include opportunities and value shift.
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In relation to massive admission and production, two distinct types of preparation were identified;
preparation that needs to be made in the medical schools and in the system, though at the time of
the study, both were not sufficiently addressed. As a result, there were potential consequences at
the present. These were related to clinical service delivery, patient right and privacy, medical
education workforce, and quality of medical education. In the future, it was anticipated to affect
the graduates, the system, as well as the community in the short and long term consequences of
physician workforce flooding. Besides, in relation to HRH preparation and utilization, lack of
cooperation, strategic planning and capacity, and system continuity were also identified as
underlying and basic problems of the system, respectively.
Conclusion: Overall, young and less experienced physicians make up significant proportions of
the public and academic physician workforce of the country, which is a signal for the presence of
substantial improvement in supply. However, without retention efforts, skilled turnover will result
in a “system of ever-green hands (Ac16)”; a system staffed with junior physician workforce. In
addition, shortage, lack of composition and diversity, and low satisfaction of the medical education
workforce can hinder the quality of medical education, which failed to influence the medical
students’ attitudes to prefer to work in rural and remote locations including their career choices.
Moreover, across the settings, economic and non-economic reasons were the main reasons of
turnover as well as the reasons behind the medical students’ intention to move.
Furthermore, massive admission has negative impact on the quality of medical education, patient
care and satisfaction, and also on the medical workforce at the present with its additional
consequences on the medical graduates, system and the community at large in the long run. Hence,
the flooding is not only limited to issues to do with what currently has been observed but also
rooted in the underlying (strategy, planning, and capacity) and basic (functional continuity of the
system) problems of the health system.
Recommendations: Therefore, there is a need to revisit the flooding strategy in such a way as to
minimize the consequences of massive medical students’ admission and physician workforce
production along with working on the other dimensions of the problem.
Description
Keywords
flooding, grounded theory, medical education/students, medical/health workforce, mixed methods, system response, survival analysis, physician workforce turnover/attrition.