Feature Analysis: A National Paradox: Ethiopia Struggles with Shortage of Physicians while Physicians Struggle to find Employment

Hawasa University Medical School Graduates (Picture: Hawassa University)

By Siyanne Mekonnen @Siyaanne

Addis Abeba, October 19/2020 – In Ethiopia, the situation of unemployed physicians has become a major topic of public conversation lately. Physicians have been expressing their frustration and the hardship they are experiencing trying to find a job. The unemployment of freshly graduated physicians was unheard of in Ethiopia.

Ethiopia has one of the most acute  shortage of physicians in Sub-Saharan Africa. Recent studies show that Ethiopia stands at 2.5 physicians per 100,000 people below the recommended number by the World Health Organization (WHO) which is a minimum of 10 physicians per 100,000 in low-income countries. Ethiopia is also battling a global pandemic just like every other country in the world.

In an attempt to address the shortage of physicians, the Ethiopian Federal Ministry of Health (FMoH) and Federal Ministry of Education (FMoE) initiated what is called a “flooding” policy or “rapid scale-up”. This policy was designed to combine speed, volume, and quality of human resource development. It required existing public medical schools in Ethiopia to expand their enrollment three to four fold. Studies found that medical schools have increased enrollment mandated by this policy. A study published in 2015 shows that 11,291 medicine students are in training.

The FMoH was in charge of deploying graduates across the country after the training was complete. This practice was halted after physicians went on a strike demanding some changes. Dr. Brook Genene who is a graduate of Tikur Anbessa Hospital Medical College told Addis Standard that “some demands of the strike related to improvement of working hours and payment were answered.” Adding, “Apart from that nothing has changed,” he explained. “Many of the pressing problems like health insurance for healthcare professionals, better working conditions, risk payments and most importantly unemployment are issues that are yet to be answered.”

Dr. Firew Asrat, General Practitioner (GP) graduated from Hawassa University in the year 2020, stated that one of the demands of the strike was to lift off the half a million (500,000) ETB requirement to be granted a license to practice medicine. The requirement had no legal background according to Dr. Firew and is not a part of the higher education cost sharing agreement signed between medicine students and the Ministry of Science and Higher Education (MoSHE).

Cost Sharing Agreement

In an effort to expand health coverage, especially in rural areas where physician shortages are most severe, after completing medical school,  all graduates of public medical schools  are required to serve in Ethiopia as a general practitioner for two to four years. This is without acquiring a license and an original copy of their medical degree, Doctor Firew explained, adding that they are able to acquire it after completing the service years. Addis Standard‘s attempts to speak with the Human Resources department in the MoH was unsuccessful.

Answering the demands of the protest was coupled with a stumbling rock that left fresh graduated physicians in a limbo. Following the strike, all graduates in the medical field, have been asked to seek employment by themselves.  As of May, 2019, MoH lifted its central top to bottom responsibility to assign physicians at random and without specific requirements such as language.

Regional and city administration health bureaus have now taken the mandate to hire physicians. “This has opened doors for corruption and nepotism in the recruitment process.” said Dr. Brook. His opinions are shared by Dr. Firew who recalled his experience of the job hunt. “I traveled all corners of Ethiopia searching for a job. First I applied to a hospital in my hometown but the job was given to those who could speak the local language even though we graduated from the same university.”

Dr. Firew spoke of the psychological distress he faced as a result of unemployment.  He recounted the hardships he faced due to the massive disarray and inconsistency of the practice in regional and zonal health bureaus, lack of cooperativeness of the health bureau officials, having to travel amidst the coronavirus pandemic and the traveling costs. He noticed how some hospitals hire more general practitioners than their permitted quota.

Dr. Brook said the assurance of employment was one of the things that made medical school worthwhile. But with the new practice, regional and zonal health bureaus complain of lacking budget to afford hiring fresh graduate physicians. Some are working in temporary vacancies of Covid-19 treatment stations. A doctor who graduated from Arba Minch University told Addis Standard that regional health bureaus complain of a lack of budget allocation to pay for extra hours and other benefit payments to those who are serving at Covid-19 stations. She expressed uncertainty and fear of going unemployed after the contract ends.

Contrary to MoH’s announcement of a renewed commitment to Universal health coverage, in December 2018, the health sector ranked the 8th largest funded sector  with 12.8 billion birr coming in second to last before Security and justice related allocations in the annual budget allocation for Ethiopia’s 2019-2020 fiscal year. The health sector’s abandonment by policy makers is also noticed in the fact that it is not on the list of   “key development sectors”  in the 10 year development plan.

Another consequence that followed the strike is that MoH  began the practice of conducting Certificate of Competency (CoC) exams for doctors to acquire their licenses. The new practice is intended to “improve the quality of healthcare provision and education”, according to the director of Health Professional’s Competency Assessment and Licensure Directorate at MoH, Tewodros Abebaw. Dr. Brook asks, “what does the internship qualification stand for? Why are we required to take the exam after practicing medicine for a year as an intern?” Upon successful completion of qualifying examinations, students are required to complete an internship year and are referred to as “interns” (Year 6).

Tewodros Abebaw, Health Professional’s Competency Assessment and Licensure Directorate Director at MoH  (Picture: Addis Standard)

Tewodros on his part said that the rationale behind Certificate of Competency (CoC) exams for doctors is to ensure an internationally accepted standard quality health care. He explained that “the practice is adopted from the experience of developed countries. The exam will focus on real life scenarios unlike the pre-internship qualification exams so that it prepares doctors for practice”. He added that it will include a practical exam in the coming few years. Whether or not the license is permissible in foreign countries depends on their policies but the ministry believes that it is internationally accepted.

The exam is also expected to correct irregularity of performance and create uniformity of curriculum among health universities across the country. The decision to conduct Certificate of Competency (CoC) exams for doctors was made years ago according to Tewodros, but it hasn’t been practiced until now.  He admitted that there weren’t direct studies done to support the decision but the need arises after what the ministry was able to pick up on from studies done on patient satisfaction. Lastly, Tewodros explained that stakeholders such as MoSHE, policy makers and members of the Ethiopian Medical Students Association (EMSA) were involved in the decision. Addis Standardtried to contact the EMSA but was not successful.

After the coronavirus outbreak, the MoH has not been able to conduct Certificate of Competency (CoC) exam for Doctors. Due to this, fresh graduate doctors who have graduated but have not taken the exam yet were unable to apply a job. To solve this issue, the minister of the MoH, Dr. Lia Taddese wrote a letter that asks employers to recruit fresh graduate doctors until they are able to get a license through Certificate of Competency (CoC) exam after November, 2020. Dr. Brook shared his experience of hospitals refusing to hire based on that letter and that hospitals have now made practicing licenses a major requirement to hire.  Subsequently many are forced to sit idle for months without being able to apply for a job.

A letter from MoH asking employers to recruit fresh graduate doctors with their COC

Dr. Firew said that they feel let down by both the EMSA who were supposed to look out for fellow physicians speaking up on their behalf. He recalled a job creation scheme that was proposed by the MoH back in January, “I feel lucky to have found a job after all the hardship but there are many who are still waiting for jobs” he said.

In an interview  with Addis Zemen newspaper, the president of EPA, Dr. Tegbar Gizaw said that the association is doing what it can to put a pressure on the government to emphasize the role of the private sector in the health market. He spoke about the need to consider sending deploying doctors to foreign countries as a last resort. This will not only create more jobs but also help ease the pressure of the declining hiring capacity of the government. Dr. Tegbar emphasized that the more practical solution in a country with a low number of professionals, is to raise the domestic budget, creating jobs and improving the private health sector.

Notice of the next COC exam

More medical students are expected to graduate in the coming months and having to wait for the Certificate of Competency (CoC) exam with a 3 months interval is going to create a larger number of jobless doctors. The next round of CoC exam will be conducted on October 21, 2020. AS

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