International University of Africa

Faculty of Medicine and Health Sciences

African Medical Students Association

Health Problems in Africa: Is there any hope left?
10 11 January 2013 AD / 28 29 Safar 1434 AH

Khartoum - Sudan

Challenges faced by Doctors and Health Workers in East Africa

Prepared by:

Dr. Yusuf Adam Khalil, Registrar (Obs/Gyne) at Univ. of Cape Town, S/Africa, Head of Firstligh Healthcare Clinic, Narok - Kenya
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Introduction
Over the past few decades East Africa as a region has witnessed gigantic growth in its population, increased dependency on foreign loans and grants. Economic growth however is not at par with the population growth. Development has been slowed down by unconstructive politics, corruption and occasional civil unrest. Famine, drought and poor sanitation remain a major challenge in several areas of the region. Health sector though relatively better than preindependence and peri-independence period, is still ages behind the ideal target and the standards of the developed world. The big three infectious diseases namely malaria, HIV/AIDS and tuberculosis are still at large. Millennium Development Goals on health are yet to be achieved. Doctors and other Health workers have little to smile about as evidenced by health staff strikes and demonstrations in the recent past. Based on my personal experience as a doctor and through interactions with other health staff I know that long irregulars working hours, demotivating remuneration and poor working conditions are just some of the challenges the health professionals face. Many of these challenges are caused by failure of implementation of the masterpiece policies that were adapted from the developed and customized to our scenarios but are gathering dust in our ministries of health. However, a few of these challenges are caused by the health workers themselves. This paper aims to highlight most of these challenges if not all and give recommendations thereof with the hope that stake holders in the health sector will deliberate on the issues with the aim of salvaging the situation.

1. Long irregular working hours

This is one of the most common type of challenges faced by doctors and Health workers around the world. The reason being the profession requires health workers to be ready to attend the patient whenever patient is in need of health services. In other words, the challenges faced by general doctors are such that most of the times they are on call that means they have to go to their place of employment or where the patient is whenever they are informed that their services are required. It can sometimes result in varying levels of exhaustion and sleep deprivation.

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This challenge could be attributed to multiple factors. First and foremost the numbers of all cadres in the health profession is very decimal compared to the general population they are required to serve. For instance, the doctor patient ratio in east Africa in generalis about 1:30000. this ratio compared to the one in Europe 1:1000 simply means a doctor in east Africa has to work 30 times more than a doctor in Europe! The annual numbers of medical graduates is still very little and even less for medical post graduates. Compounding this issue especially in the public health facilities is the fact that some of the government doctors would rather spend most of their time doing part time jobs in private facilities to supplement their poor salary packages. Secondly, due hostile working environments and a general perception that there are greener pastures elsewhere, East Africa is losing a lot of its health professionals to the developed world. Thirdly, despite of attempts to sensitize the public on proper family planning methods very few people actually implement these methods hence the number of unplanned and unwanted pregnancies is still persistent. The population is steadily on the rise. To face these challenges in profession, it is prudent for the governments and other stake holders to invest more in learning institutions that produce doctors and other health professions so as to increase the graduating numbers and to improve the working conditions of the health workers to prevent brain drain. Strict working hours policy should be implemented such that not health worker should be overworked. A suggestion would be to have a 40 hour per week arrangement, any extra hour should be well compensated. Also measure should be increased to cut down the steady rise in population such as doubling efforts to educate people on family planning.

2. Low remuneration
East Africa as whole faces this challenge and not only in the health sector alone but also in other sectors. Despite the rising cost of living , the salary scales still remain stagnant. Money has lost its value, you need so much to do so little. In Kenya for instance the average monthly salary of a general practitioner is about USD 1000 and it is even lower in the other east African countries. Allowances that are awarded to health workers are unrealistic and negligible, for example people who work in hardship area

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are given hardship allowance that cannot even cater for their fares from the hardship areas! There is no overtime given to health workers despite the fact that they are expected to serve the patient whenever their services are required. Low remuneration has resulted in a number of negative effects affecting both the doctors and the health workers personal and professional lives and subsequently the standard of care for our patients cannot be optimal. At a personal level the health workers have to struggle to make ends meet for themselves and their dependants. Professionally they find it difficult to further their education because of lack of funds. Most of the public health workers would rather technically appear in public facilities for a short while then run off to private facilities where they supplement their salaries. Others decide to remain at their station of work but indulge in corrupt and unprofessional ways like extorting money from patient to move a name up in a theatre list, to open a patient file, to book an appointment for a procedure etc. others even indulge in illegal activities like criminal abortions for a fee or even stealing the hospital supplies and selling them to private health facilities. This happens to be the main reason for the brain drain that our countries are now experiencing, the common saying among health workers is that they better go abroad where they will work like donkeys and in some cases be discriminated but at the end of the day they get paid well rather than being at home where people respect you and think you are well off but in real sense you are slaving and getting nothing! The strikes and demonstrations by health workers in the recent past in Kenya and elsewhere clearly displays the enormous dissatisfaction amongst health workers. Evidently, low remuneration has a lot of negative ramification and clearly the respective governments should revise the health workers salary packages and improve the basic pay, allowances and pay overtime where required. Risk allowance should also be included in the health workers package for their jobs expose them to many health risks.

3. Difficulty in furthering education

It is the dream of every health professional to reach the educational pinnacle of his career. The major challenge is that this noble endeavor is not easy mainly because of financial constraints and the limited number of

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government scholarship offered. On top of that most employers, the government included are hesitant to give study leaves and where given they are mostly unpaid leaves. This further makes the situation even more difficult. The situation for those who are already in the programs of their choice is not a bed of roses either, for instance the registrar doctors are simply medical laborers who work more than they actually study besides that some of the consultants are very difficult and condescending, they offer minimal supervision especially in thesis. Sadly the registrar is at their mercies and they decide at their own discretion whether to pass or to fail any candidate. Some of the privately sponsored registrars who are not being paid by the government spend most of their time locoing hence they dont get time to read and subsequently graduate as half backed consultants! Adding to this problem is that the fact that our institutions of higher learning can only accommodate a little number of trainees for meaningful learning to take place, some of areas like laparoscopy, ICU nursing and various subspecialty courses are still not offered in our region. Interested candidate have to seek this specialized training abroad. This is not possible for many individuals who might have an interest, firstly because of financial burden involved and secondly because of the rigorous application process that is involved in applying to learning institutions abroad. On job trainings to refresh the knowledge previously learnt and to inform of new updates in the various medical practices are also very important but rarely organized at the various health institutions. These leads to health workers to lag behind in term of medical education. For the quality of care to improve education is key, measures should be taken to encourage learning for all the health professionals by increasing government sponsorships, employers to give paid study leaves, making on job training a routine and having resource centers in all the health facilities. Postgraduate lecturers and supervisors should make the learning environment conducing by acting professionally. Strategic planning should be done to ensure that in the near future our region offers all specialty and subspecialty training.

4. Poor working environment

The number of health facilities is on the increase though not in keeping with the population rise. Its almost normal for al large area to be served by very few facilities. This lead to over crowding in facilities and

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overwhelming of the already few resources available. This highly compromises the quality of care, increases time spent by patients in the hospitals, theatre lists and other booking appointments are very long. Equipments like ECG, CTG, patient monitors, pulse oximeters lack in many facilities making emergency care futile. Doctors in internship centers do not get maximum supervision and end up gambling with patients management as a result patients lives are lost and this is very demoralizing hence most of the doctors decide to go for administrative posts rather than clinical posts. There are very few specialist centres e.g. for cardiac, kidney , critical care etc patients presenting in need of these services usually die in the hand of doctors and health workers who care for them as a care giver you are forced to see a patient dying of a known illness helplessly knowing to well that it can be treated but the remedy is not available! Such situation cause a lot of psychological stress to the care givers. Another challenge at work related to the female staff who have to nurse their young one. Our facilities are not friendly to lactating staff member. Hence their productivity during this period drops as they have to abscond duties to breastfeed. Stake holders in health should increase the number of facilities and equip them appropriately. Proper referral system should be put in place to avoid congestion in a few facilities. Facilities should be connected in such a way that patients data is easy to access and senior reviews make easy eg having the PACS and DICOM for diagnostic imaging where a few centrally located radiologists could report imaging sent to them from various peripheral health facilities. Special facilities should be provide to ensure that lactating mother can attend to their young ones as and when needed.

5. Challenge in patient care

There are many challenges related to patient care. This mainly affect the doctors and health workers working in the so called urban areas and are treating the affluent and educated class of the society who are exposed to technological advances like the internet or some have even resided in the developed world for some time. Firstly, the challenge of selfdiagnosis and treatment by patients. With the advent of the Internet, many patients are seeking diagnosis information online. While websites such as

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Wikipedia and WebMD are valuable, they can be a crutch in communicating health information to patients. Some patients will selfdiagnose online, and begin treatment without the oversight of a doctor. While health information available online is usually accurate, selfdiagnosis involves an unprofessional and potentially dangerous interpretation of disease symptoms. Many patients may not diagnose symptoms of an illness correctly, which can lead to a false diagnosis. This can result in a severe illness being misdiagnosed as a benign disease, and vice versa. Further complicating the situation, some treatment options may be inappropriate for some patients, and can endanger their health. Secondly, conflicting treatment plans with self-educated patients. Doctor-patient communication becomes impaired when patients self diagnose. Some patients trust information found online more than that provided by a primary care physician. Some patients will verify and fact checks all treatment options or diagnoses stated by a healthcare provider, without understanding the full process behind the diagnosis. This can lead to lapses in treatment, belligerence in communication with healthcare providers, and failure to schedule follow-up visit. Thirdly, bias in treatment options. Provided many doctors and healthcare professionals are inundated with a barrage of pharmaceutical representatives and medical equipment sales people. Providing objective health-care is becoming more challenging for doctors in all areas of medicine. Private interests can unconsciously influence treatment options that doctors decide to pursue ans especially so in the private sectors. A patient will be subjected to an array of investigations and even procedure so as to maximize on the income of that particular facility. Another challenge related to this is cultural beliefs that hinder health seeking by the affected individuals. Doctors must pay attention to how technology has evolved and changed over the past few decades. For many professionals, continuing education can ensure that doctors and healthcare providers can provide timely and beneficial service to all patients into the future. As far as cultural beliefs that antagonize health seeking behavior is concerned health education should be done intensively and in a manner that is acceptable to people.

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6. Inefficiency at the ministries of health

Some challenges that doctors and health worker face are caused by the governments themselves. Postings have always been an issue and is still is, it takes ages for new employees to be posted plus the employees do not have a say in their areas of posting. For instance one is posted in a hardship area most of the times away from the family. This really causes social stress to the doctors and health workers as well as financial stress because of the transportation. Attempts to transfer to a persons region of choice is also very bureaucratic. There are lots of papers to be filled, lots of signatures and there is no guarantee of transfer. Delayed promotions, it takes very long for someone to be promoted from one job group to another when promotions are due. This is very demoralizing to the doctors and health workers in general. The relevant ministries should ensure speedy posting of staff and give people a choice on where to be posted and where one does not get the region of choice or where transfer is not possible proper incentives should be given. Promotions should be expedited as well.

CONCLUSION
Most doctors and health workers at the end of their practice lifetime, would vouch for the fact that the fulfillment of a medical career outweigh these challenges by far. A career in medicine offers an individual the prospect of an enormously satisfying career and a fulfilling life! That said the challenges aforementioned impinge heavily on the quality of care of patients as well as the doctors and health workers quality of life hence it is prudent to alleviate them. All stake holders in the health sector ranging from the doctors and health workers, health institutions managements, respective ministries of health, non governmental organizations and relevant international bodies should deliberate on these challenges and come up with solutions thereof. These should include all sectors in the health indusrry and all other related sectors. These measures should cut across all dimensions of doctors and health workers career spreading from the training to working environment. This should be done knowing that the bulk of the African population in general and the East Africa specifically heavily rely on the health services provided locally because they cannot seek it elsewhere. If serious steps are

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taken then the dying under five year old children, the suffering pregnant ladies of Africa and the continent as whole would have a reason to smile. It is through such efforts that Africa will rise be the cradle of mankind, safe to leave in and free of diseases where all staff involved in healthcare will be happy and proud to serve patients relentlessly. Its a known fact that Africa is very rich in a variety of mineral and natural resources all that is left is to get the right leadership, one that is based on policies. With the right leadership then we will rise above all challenges and to heights that no continent has seen before. We are so rich to be poor and so strong to be weak. Though the developed world is helping us presently, the greatest and the most sustainable assistance would be the one that is home grown, when we deliberate on our challenges and raise solutions thereof. We already have the intellectuals who can set the ball rolling.

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