Too many African doctors lost to local NGOs – we need to fix the ‘internal’ brain drain.

A recent article in the British Medical Journal brought to the world’s attention the significant financial cost of the external brain drain. It studied 9 African countries that typically export doctors, and 3 western countries that tend to import doctors and assessed the cost. The final tally – African countries lost $2.6billion dollars training doctors who are now living in western countries. According to this article 25-50% of African-born doctors are now living and working abroad. These numbers are impressive and concerning. If we are to address the severe shortage of physicians in Africa we certainly need to plug this leak and encourage western countries to find ways to become self-sufficient in producing enough doctors.

There’s another brain drain that doesn’t seem to get as much attention – the internal brain drain. Of those medical graduates who chose to stay in-country after training, many don’t go on to clinical practice – they get lured into non-clinical jobs by governments or local NGO’s. Foreign NGO’s pay better and offer better benefits. I remember when I was in a hospital in Tanzania a few years ago talking to the one internist working there – he complained that so many of the residents he trained would go off to do a Masters in Public Health because then they could get a job with the Clinton Foundation – have a good salary and still feel like they were improving the health of their country.

The Sub-Saharan African Medical School Study examined the plight of faculty in medical schools. These faculty often see patients in public hospitals along side their teaching responsibilities. This study found that in a 5-year span, 25% of faculty were lost to internal brain drain (either working for the government or NGOs).

Ironically, when I’ve talked to physicians in Africa who have moved from clinical to policy or public health work, they miss their patients. In fact, in a recent trip to Ethiopia some of these docs say they would be happy to see patients on a part-time basis or in the University clinic with residents but their jobs would not allow them that option.

There are two questions that need to be addressed:

- What are the real numbers of this internal brain-drain? A brief look at physician tracking systems in Africa reveals that these numbers are likely not being captured. We need tracking systems that gather this data and we need more research done to understand the breadth and scope of this problem.

- What can NGOs do to address this issue? Can they allow or even require their physician on staff to do some amount of clinical work? Can they partner with governments or Universities to allow their employees to work in public clinics or medical schools? If NGO’s made this a policy, it could apply to all doctors working in the country – not just the African-trained doctors. Imagine if all doctors who come to Kenya for research or policy work were required to spend even one day a month in a clinic – access to specialists would certainly improve! 

Both quantifying the internal brain drain and finding innovative ways to address it must be on the table if we are to scale up the physician workforce in Africa.

How many doctors does Africa need?

According to the 2006 WHO World Health Report, there were 54million health care workers – which includes service providers and administrative/support staff. Still there was a deficit of 4.3million. Of the 57 countries with critical shortages, 36 are in Africa – leaving the continent with the biggest crisis of healthcare workers. In 2008 the WHO published a document called ‘Scaling up, Saving Lives’ which advocates for scaling up low and middle level providers to improve access. This scale up has already started with 15,000 health extension workers trained in Ethiopia alone. With improved access, comes more demand for higher-level care and an increased need for supervision of these low- and middle level workers. Hence the need for more doctors in Africa. The WHO has estimated that African needs 167,000 more doctors to meet the basic health needs of the continent. With less than 170 medical schools in the country, and an annual throughput estimated at around 11,000, where will all these doctors come from? Looking at the pipeline for physician training in Africa, we need to plug the leaks. The in-country brain-drain to NGOs and ministerial jobs is a challenge. Another leak in the pipeline is the out-of-country brain drain that ranges from 25-50% depending on the country. 

As we invest in health system strengthening in Africa, we must invest in strengthening the physician pipeline, putting more students through the pipeline and fixing the brain drain both within and outside the country.

Successful examples of mHealth applications in Africa…from the mHealth Summit

As promised, here are a few examples of innovative mhealth applications in Africa from the mHealth Summit last week in DC:

• In Tanzania, D-Tree with Harvard faculty tested eIMCI with significant impact on the sickest kids because full guidelines were followed. Interestingly, patients felt they were getting better care (with use of PDA vs. paper) because clinical officers were referring to a phone/guidlines.
• MoTeCH in Ghana provides pregnancy information for women and their families using $40 phones, and using an open source software Open MRS for their platform. Interestingly, most families preferred getting their information using voicemail rather than text messages (due to literacy rates)
• Operation Asha in India uses fingerprints/biometrics to track TB treatment, sending an SMS if missed doses. Good results and the cost is $3/patient.
• Wired Mothers Project in Zanzibar  reported a 4 fold increase in skilled birth attendants present at birth when mobile phones connect midwives.
• In India, lactation consultants providing cell-phone consultations resulted in increased rates of exclusively breast fed infants

With African having 60% penetration of mobile phones (and growing…) and South Africa with 20% penetration of smart phones (compared to 50% in the US) there is certainly a lot of potential for real impact using mhealth.

5 Highlights from the mHealth Summit in DC

I thoroughly enjoyed the mHealth summit. The crowd was a mix of people from different sectors, all energized about the potential of mhealth and clearly everyone felt we are on the verge of a major transformation in medicine. A few messages came through:

1. There are many, many pilots in mhealth – globally. What’s needed now is a focus on interoperability, scalability and sustainability.

2. Financing is a challenge – there was little talk about how physicians will get reimbursed for services related to mhealth. Incentivizing physicians is going to be a challenge.

3. Multiple stakeholders – clearly there is a need for inter-sectorial collaboration to make mhealth scalable, and successful. The government needs to provide oversight and the private sector needs to drive the innovation. There were many examples of successful private-public initiatives from around the world. The Switchboard partnership with Vodafone in Ghana is my favorite.

4. Data, data, data – with home monitoring and 24-7 data being created, there is going to be a need to analyze this data, and present it both to the patient and the physician in a meaningful way that drives appropriate treatment.

5. Training – there was really not much talk about this, but I think it’s critical that we start thinking about training physicians in technology and change management. This next decade will see radical transformations in medicine by technology, yet medical school curricula and their developers are not even thinking about providing in ehealth. While it may be difficult to train on specific technologies because the winners are not yet clear, we should certainly be thinking about training doctors in change management. Our next generation of doctors should be able to adapt to a rapidly evolving environment when they graduate.

I’m very energized by the conference and definitely hope to return next year. I will be writing about specific highlights in the days to come.

An Innovative and Profitable Venture that Keeps Track of Doctors in Ghana

Given the increasing brain drain of doctors leaving Africa, the issue of retention is a top priority for Ministries of Health (MOH) and medical schools in Africa. The MOHs want to incentivize physicians to both stay in country and go to the rural parts of the country. The medical schools are trying to entice students to practice in rural settings by increasing the quality and quantity of training in the community. The challenge is the measure of their success cannot be determined without a physician tracking system. There are few countries in the world with a physician tracking system.

That said, I heard at the mHealth Summit in Washington DC this week an innovative public-private initiative that has created a tracking system in Ghana, as an indirect benefit of a business venture. Vodafone (who only has 18%) of the market share in Ghana, teamed up with the Switchboard (a US company) and the Ghana medical association. They gave each of the 2200 doctors in the country (public and private) a sim card with which all the doctors could talk freely to each other. They were already spending minutes and money consulting each other – now these minutes were free. All the rest of their calls to non-physicians are charged. Vodafone got 100% of the physician market, making 1.3M in the process and the doctors got free calling to one another. When they distributed the SIM card, they collected names, specialty and place of practice – so now the MOH even has a tracking system to know where all their doctors are. They are now expanding to Tanzania.

That is mHealth at it’s best – innovative, scalable and sustainable. I like it.

A great resource for teaching doctors in Africa how to find, organize and use information….

I came across an interesting group African Medical Librarians and Deans - who have put together a number of online courses and presentations addressing internet literacy among medical students. This is an example of how the approach to ehealth in Africa will most certainly be different in Africa compared the America. Most people in the US are computer and/or web-literate. Certainly medical students have the skills to use both. But in Africa where students come from different backgrounds, including rural areas, computer literacy is variable. Starting from the basics is essential not only for students but for faculty alike. This particular website has seven modules addressing finding, organizing and using health information. Interestingly, there’s a module here called Scholarly communication in which the latter part discusses how to write a journal article. Ironically, this type of information/training would even be helpful for American medical students!

mHealth in Africa – examples of success.

Just read a great article on mobile phone use in Africa. It’s a topic that’s become quite popular but reading about specific examples of success and one that even reports the number of hours and money saved. This article gives the following examples of mobile phone use

• Pill bottles that tell doctors when a patient has taken meds
• An application that allows patients to send a text to their doctor even when they have no money left on their card to say “call me”.
• Tracking disease information
• Reminders on the phone for patients to take their medications
• Phones for doctors serving in remote areas with clinical decision support tools.

I think the use of mobile phones is going to change the playing field in healthcare in Africa. The last example in the article talks about Medic Mobile and how a pilot project in Malawi saved 1200 provider hours and $3000 in transportation costs. This is great data.  The more data like this we gather, the more likely mhealth will be funded and embraced in large-scale.

When I was in Uganda last month and one interesting thing I noticed was the use of mobile phone GSM technology providing wireless internet in the rural areas. We went to Kayunga Hospital which was about a 2 hour drive outside of Kampala and the clinic computer room there was using this technology (along with solar panels for electricity). Many people told us of this technology being used for wireless internet (it’s a bit slow, can be inconsistent but it works)

I’m hoping to attend the NIH mHealth Summit in December to learn and hear more about this exciting field.

How the mobile phone will soon help Kenyans find a Doctor

This is very cool – set to launch on October 1 this could really change the playing field of mhealth – next on deck is using mobile phones to enable training in the rural sites.

“medAfrica from Kenyan startup Shimba is a phone-based medical reference and real-time public health tool meant to dramatically increase the well being of Kenyans, and eventually people throughout the developing world. Similar in many ways to Indian company mDhil, the smart phone version of the app allows a sick individual to check his or her symptoms against an encyclopedia of ailments, such as fever, swelling or other maladies, and the tool will allow them to call a relevant medical professional with a single click.

There are 40 million people in Kenya, and only 7,000 doctors nationwide. There’s too much knowledge locked up in too few heads, as co-founder Mbugua Njihia quipped from the stage during his presentation. Their app helps to narrow this knowledge gap in many important ways. And while smart phone penetration is steadily rising throughout Kenya and Africa as a whole, the real power comes from medAfrica’s ability to deliver health information to remote areas through the use of SMS.

What works in Africa can work anywhere, in terms of scale and internationalization, and the team believes that if they can reach 200 million downloads, at $10 of revenue per customer per year, they will be a billion-dollar company within five years.”

How do you incentivize resource-strapped medical schools to embrace open access?

It sounds obvious that medical schools in developing countries should share curricula. That open access is the way to go to address the severe shortage of doctors, and especially of faculty to train doctors. In fact I think there’s a real opportunity out there for someone to create a destination site that would have  comprehensive collection of lectures, articles, curricula for a complete medical education.  I’ve seen a number of potential sites recently – Science Supercourse and even OER has a few courses posted under ‘medicine’, but there doesn’t seem to be a definitive leader in this space.

And as I understand it, to create open access material you need to have your material licensed so that it can be shared, reused etc…I haven’t done it myself but expect that it does take some time to deliberately prepare your material to share. Enough time and effort that this is one of the primary services offered by OER.

So the challenge, in my opinion, is how do you incentivize resource-strapped medical schools in Africa to go through this process and make their material open access? I don’t doubt their intentions,  but why should they spend the time it takes to obtain the licenses and make their material ready for open access when they have more pressing challenges on their minds? There may be exceptions such as Stellenbosch University, who already have elearning material ready to share and do so, but most schools are still trying to develop content for their elearning programs.

This might be an opportunity for a grant, a competition or for partner schools in developed countries to take on as their social mission. Given the shortage of doctors, the shortage of faculty and the fast pace of new medical schools in Africa, increasing open access material and establishing a definitive destination could make a huge contribution to the field.

The question is – how do you get this done?

 

Medical education programs in Africa should follow the trend and start doing homework in the classroom.

The Khan Academy is changing the way the world approaches education. Sal Khan (an MIT grad) provides 10-minute online tutorials on thousands of topics. He makes complicated topics easy to understand. He’s a gifted teacher, he doesn’t charge tuition and you can listen to him at your own pace. You can stop, rewind, fast-forward or replay.  This is revolutionary. While the traditional model is you go to school to hear the lecture and then go home to apply the knowledge, Bill Gates and Sal Khan, through the Khan Academy are suggesting that we should switch those activities around.  We should get the best teachers in the world to provide lectures online, then students can listen at their own pace. Students come to the classroom to do problems, apply their knowledge and get tutored/mentored by the teacher when they get stuck.  It’s already being tested in schools across America.

Now think about this in the context of medical education in Africa. Throughout Africa the biggest challenge is the lack of faculty…not enough teachers. In Ethiopia the government plans to train 20 thousand doctors by 2020 so medical schools are challenged by trying to teach upwards of 300 students in a class. In Zambia though the classes are not so big, there just aren’t enough basic science faculty to teach in the pre-clinical years.  So what if we apply this model. Take the best teachers in the school, city or region and tape the lectures. Give students access to these lectures by video, CD, intranet or internet. If the resources are really limited, you can just give them the reading material but expect them to come to class prepared.

Then when students gather in the class, they spend their time doing what used to be their homework, i.e. solving problems. Working through a case. Teaching each other and trouble-shooting together. The strong students will help the weak students. Together they will make their knowledge come alive. They don’t need experts in the room to teach, they just need facilitators to answer questions – these could be post-graduate students, senior students, junior faculty etc.

This model is already being used in some schools referred to as Team-Based Learning (TBL). At my institution, George Washington University, we use TBL in Anatomy. There are already schools in Africa such as the Kilimanjaro Christian Medical School using it in medical education.

As countries throughout Africa try to train more doctors with few faculty, they need to consider new models of delivery. It’s learner-centered, team-based and efficient on faculty time and expertise.  The Khan Academy is really on to something….