Brain Drain: Why are Cameroonian Medical Doctors Leaving?

By Dibussi Tande (Originally posted on Scribbles from the Den)


Surgery at the Fraternity Medical Center, Buea

The news from the Ministry of health was quite gloomy. In a special report that appeared in the Cameroon Tribune last week, it was announced that Cameroon’s medical system was in crisis due to a severe shortage of medical doctors resulting from the massive exodus of Cameroonian MDs to countries in the developed world.

According to the report, about 5000 Cameroonian medical doctors are currently plying their trade abroad (with about 500-600 in the US alone, according to the Minister of Health). In an interview with Cameroon Tribune, Pr. Tetanye Ekoe, the Vice President of the National Order of Medical Doctors in Cameroon, reveals that some 4200 MDs reside in Cameroon. However, this is only half of the story; of the 4200 listed on the rolls of the Order, only about half are actually practicing MDs. About 1000 are on secondment to the Ministry of Health where perform a variety of tasks, including purely administrative ones. The rest are either with the Faculty of Medicine and Biomedical Sciences, of University of Yaoundé I, with NGOs, or with the private sector. The nearly 1500 MDs in the private sector handle less that 10-15% of patients.

Pr. Ekoe points out that the limited number of practicing MDs in the country makes the official national doctor-patient ratio of 1 doctor per 10.000 inhabitants largely meaningless. He reveals that the real ratio is closer to 1 doctor per 40,000 inhabitants, and that in remote areas such as the Far North and Eastern Provinces, the ratio closer to 1 doctor per 50,000 inhabitants.

Unfortunately, the country’s lone faculty of medicine is unable to meet internal demand because it produces only about 100 MDs annually. To make the already bleak situation worse, the IMF and World Bank have imposed hiring quotas (which do not take retirements and death into account) that limit the number of MDs who can be integrated into the public service each year. The result is that some foreign-trained MDs actually return home to find out to their horror that they cannot be employed…

So the internal pool of MDs continues to shrink as more Cameroon-trained MDs move on to greener pastures in the West, while Western-trained MDs don’t return home.

The Brain Drain at a Glance
In its 2006 World Health Report, the World Health Organization (WHO) uses data from the 30-member Organisation for Economic Co-operation and Development (OECD) to shed light on the medical brain drain phenomenon in sub-Saharan Africa:

It appears that doctors trained in sub-Saharan Africa and working in OECD countries represent close to one quarter (23%) of the current doctor workforce in those source countries, ranging from as low as 3% in Cameroon to as high as 37% in South Africa. Nurses and midwives trained in sub-Saharan Africa and working in OECD countries represent one twentieth (5%) of the current workforce but with an extremely wide range from as low as 0.1% in Uganda to as high as 34% in Zimbabwe (p. 99)

According to the report, 109 doctors trained in Cameroon are currently working in OECD countries (p. 100)

The effects of this migration are disastrous, according to the WHO report:

“…  when large numbers of doctors and nurses leave, the countries that financed their education lose a return on their investment and end up unwillingly providing the wealthy countries to which their health personnel have migrated with a kind of “perverse subsidy” (23). Financial loss is not the most damaging outcome, however. When a country has a fragile health system, the loss of its workforce can bring the whole system close to collapse and the consequences can be measured in lives lost. In these circumstances, the calculus of international migration shifts from brain drain or gain to “fatal flows”. (p. 101).

If the statistics above are to be trusted (and there is no reason not to trust them), then the situation in Cameroon and most of sub-Saharan Africa, has shifted from simple brain drain to that of “fatal flows” with a wide scale system collapse a potential reality.

To begin to adequately address the problem, we must start by clearly understanding the reasons that push MDs to leave and why others are not returning home after their training in foreign countries.

Why they are leaving
Although the Cameroon Tribune special report touches on some of the factors that contribute to the prevailing situation, it tries too hard to sell the patriotism angle, i.e., in spite of the hardship,  Cameroonian MDs should be more patriotic and be willing make sacrifices for their country. This, in my opinion, is a rather simplistic analysis of the problem, which can only lead to equally simplistic solutions that will resolve nothing.

In its analysis of the reasons that cause the brain drain, The WHO report states that:

Classically this is provoked by a (growing) discontent or dissatisfaction with existing working/living conditions – so-called push factors, as well as by awareness of the existence of (and desire to find) better jobs elsewhere – so-called pull factors. A recent study from sub-Saharan Africa points to both push and pull factors being significant. Workers’ concerns about lack of promotion prospects, poor management, heavy workload, lack of facilities, a declining health service, inadequate living conditions and high levels of violence and crime are among the push factors for migration. Prospects for better remuneration, upgrading qualifications, gaining experience, a safer environment and family-related matters are among the pull factors

In Zimbabwe, for example, a startling 77% of final university students were being encouraged to migrate by their families (13). Beyond the individual and the family, accelerated globalization of the service sector in the last two decades has helped drive migration in the health field (14–18). In addition, there is a growing unmet demand for health workers in high income countries due in part to rapidly ageing populations. Two important responses in the global market are occurring. First, a growing number of middle income countries are training health workers for international export and second, professional agencies are more actively sourcing workers internationally, raising questions about the ethics of recruitment. (p. 99).

The first step
Understanding and accepting these reasons – which have little or nothing to do with patriotism or a lack thereof -- gives Cameroonian policy makers a better chance of tackling the brain drain issue head-on.

In a paper presented at the international seminar on International Dialogue on Migration, Jorge de Regil & Mel Lambert have a word of advice for countries such as Cameroon which are suffering from the migration of indispensable health resources: 

"Governments have to be more open and honest about the reality of migration of human resources for health in the country…Given the choice most people would prefer, all things being equal, to remain in their home country. Consequently, in devising policy solutions to migration, making a country a good place to work and to live in must be the starting point: developing a culture where advancement (in education or professional life) depends on quality, not on political affiliation, race, religion, national origin, etc."

Cameroon must therefore go beyond the blame game and look at effective and viable internal solutions to the problem. For example, the Government can seek a moratorium on current Bretton Woods hiring quotas for medical doctors on national security grounds. Or simply go against IMF and World Bank recommendations. There is a precedent here. In 1991, for example, the Government created five new universities in the country, against the specific wishes of the Bretton Woods institutions which argued that the country could ill afford such an expensive venture. 15 years later, there is hardly anyone in Washington who still believes that the creation of these universities was a bad idea.

Without doubt, the medical profession in Cameroon has lost its erstwhile glory and part of the effort to stem the tide of migration must include making it attractive once more in terms of salary, career growth, and social mobility. As long as the situation where a Policeman with a high school diploma earns as much, if not more than an MD persists, the brain drain will continue. 

There are a plethora of possible solutions to these problems.

According to the e-Africa online journal (Sept. 2003), the government of South Africa, for example, set aside R500 million in 2003 and R750 million in 2004 “to adjust the salaries of public-sector doctors and expand the number of rural medical jobs”.

Regil and Lambert propose a solution along the same lines:

"Developing countries need to try harder to entice their high skilled healthcare professionals back. This could be done, for instance, through schemes where top public officials in countries have their public sector pay ‘topped up’ through aid assistance schemes so as to encourage them to stay. Schemes could be developed were medical expatriates are brought back for a period of time to impart skills on the home population. However, any such schemes need to be sustainable in their own right and not create artificial situations that could dry up as soon as any funding ends."

In search of global solutions
Beyond what could be termed the “classical solutions” to the brain drain, African governments must craft global, bold, innovate and effective policies that go beyond the case of MDs.  Even though theirs is the most visible case, the situation is equally critical across the board. In Cameroon, for example, about 25%-30% of professionals trained in the country are working abroad while 70-80% of Cameroonians trained abroad do not return home after their education.

Creativity is in order. Hence, asking the Diaspora community to visit Cameroonian embassies abroad or the website of the Prime Ministry for possible job opportunities in the country, as Prime Minister Inoni did during his July 2005 visit to the United States, shows a lack of vision and innovation.

In the long run, Cameroon may probably have to turn for inspiration to countries such as Nigeria, Ghana, South Africa and the Philippines which are tackling the brain drain crisis in the most innovative manner possible.

“Nigeria has a special assistant to the president for the diaspora. Senegal created a ministry of foreign and diaspora affairs. Ghana changed its laws to allow dual citizenship to make it easier for the diaspora to return… One lesson from Ghana’s effort is that if Africa wants émigrés to return, the process must be easier. In particular, spouses and children born abroad should have the opportunity to claim citizenship easily and be allowed to maintain dual citizenship to make it easier for émigrés to continue to conduct business. The Ghanaian embassy in Washington maintains a computer skills bank on its nationals working in the US.” (e-Africa, September 2003).

In 1995, the Filipino government established the Philippine Overseas Employment Administration charged with promoting the return and facilitating the reintegration of migrants. The Employment Administration offers privileges to returning Filipinos such as loans for business capital at preferential rates and eligibility for subsidized scholarships.

There a dozens, if not hundreds of solutions that have been tested around the world. If Cameroon is serious about the brain drain issue, it knows where to start rather than trying to reinvent the wheel…

Picture courtesy of Direct Relief International

Comments

[Agendia Aloysius]

I don't comprehend why the Cameroon government keeps ranting that there is an acute shortage of medical doctors and other para medical personnel yet, the same government appoints surgoens and other medics to go and manage money in offices like the case of the Government Delegate to the Douala City council among others,whereas their places should be in the theatres and hospitals. Dirty politics and visionless politics

I dont understand why the government allows the several medics trained in CUSS with tax payers money to evade the country for so called greener pastures.
Inasmuch i advocate decent pay for public service medics, the government should compell all CUSS graduates wishing to leave the country to refund money enough to train at least, two medical doctors before they leave.
AGENDIA

[oleme]

I definitely agree with you Mr Agendia. A lot of tax payers money is incured in training these guys. Tell me which medical school in the world will train you for free. I mean, train you and just let you disappear into thin air. Law makers in Cameroon are a bunch of heavy sleepers. Can't they figure out a way to minimize this abuse?

What about all those trained teachers that are abroad yet still earn salaries at home? With all these corrupt practices from left and right, top and bottom, what will be left in Cameroon. That nation has been raped and abused. Who is to be blamed? Sad but true.

[facter]

A country in which doctors effectively make less than street cops is in serious trouble.

[UnitedstatesofAfrica]

This is a dumb question with a simple answer.

BECAUSE THEY ARE UNDERPAID AND OVERWORKED. Duh! It doesn't take a rocket scientist to see that.

[Ras Tuge]

Is this not the same country where doctors treacherously claim to go for further studies, and still expect the chickenfeed salaries paid eventhough they never want to return?! The Bumboklaats say they're getting plenty money in Babylon, but i wonder why they won't let some diligent person back home to get that little bread. Why blame the country when all some of us do is cheat her? What a disgrace!

[Facter]

What is the solution? I know many doctors from the 70s and 80s who came originally with the intent to return and they got caught up in their lives here. Since the 90s the doctors who come have left with no intention to return. One of the solutions is to make it easy for doctors to form private partnerships and corporations and to open private practices freely that compete in price and quality of care. Right now the regulations make it very hard to do this. It is a socialist model, when Cam government is not committed to it. Socialist models work, as long as the government is committed. West Cameroon government had a socialist model, and it provided better quality service than we see even today, because the hospitals were clean and had supplies at least. Most health care systems in Europe are socialist and are quite good. Cameroon government likes to imitate everything from France, so on surface it looks like a socialist model, but it cannot sustain it.

My solution is to Take the restrictions off the private sector. Government and medical societies should concern itself with exercising standards. Foreign medical doctors meeting those standards should be allowed to emigrate from such places as Nigeria, Ghana, India and Cuba. The problem will be solved very quickly, but such a free market solution should be accompanied by other measures to liberalize the economy

[the son]

2004 statastics indicated that only about 1000 out of he 4000 doctors were employed by the government sector leaving 3000 unemployed and this should be a typical reason for the massive brain drain.

[Bwemakai]

I live in Brescia, Italy and just in this small town close to Milan there are 7 Cameroonian practising doctors ranging from Orthopaedics, Surgeons to Anesthetists and others,about 4 more will graduate within the coming year and none is intending to go back home. I wander what the situation is like in other towns,cities and countries in the diaspora. If all these sons and daughters of Cameroon decide not to go back and serve their country then the government should find out why and redress the situation because you can't tell me that all these folks just want to stay here and practise here where they are given the jobs and paid well but still looked upon as immigrants and outsiders. So let the government look into this matter seriously and address the concerns of not only doctors but other health professionals if she really wants to address the inbalance in the physician/population ratio.

[Ras Tuge]

Son, not anywhere in a million countries would you have the government employing everybody. That is just an unrealistic expectation man. Doesn't it suffice for the 4000 doctors according to your statistics, to be fortunate enough to get free education? Do you know the price some of us had to pay to be trained in Babylon, and yet many people still have the will to assist in building a new Cameroon?

Like i've said before, the average Cameroonian is neither ambitious nor enterprising. Must the government give you a beautiful girl and a golden bed to jam her? Gosh, the manner in which some of you guys reason really baffles me. It's about time Cameroonians assist in creating alternative avenues for employment back home, and then the government shall be compelled to listen. Hopefully a new regime shall soon come that will understand these things.

[Tori Massa]

Those in power wants people to leave the country so that they become Lords and keep away competition.

[Doctor Ben]

Ras Tuge, doctors are not free to open private practices. The processes are opaque and byzantine and take unduly long. In most countries, it is well regulated, but the process is quite straight forward. I have practiced medicine in 5 different countries, and in no country could I practice without a license, but then the conditions for getting a license were direct. You produced your credentials, payed a fee to a professional authority that looked over them and generally within a month, you get a license. In Cameroon, I applied but did not see the license over a year later. I was already practicing "illegally" by then, with a lot of discomfort, because in most jurisdictions, it is an offense that could land you in prison. A private practice permit is an even bigger problem. In most places, all that is required is a business license and inspection of the premises by health and safety officials to make sure you are up to specs. The backwardness in Cameroon is to a large extent the product of policy. It is easier to emigrate than to fight the power or to do things that are illegal or unregulated.

[Patsy]

As long as the conditions of service remain poor, doctors will continue to leave. Also if the gov't says school fees for all tertiary institutios is fifty (50,000) francs including faculty of medicine, it is crap to read that doctors are trained free. The problem is not the cost of training doctors, because Cameroonians go to Niger, Chad, Mali, Togo in hundreds to attend medical schools and the pay at least 500.000 frs for fees, but will still move to seek greener pastures.Change things and keep your docs home.Period

[njimaforboy]

Your blame the victim argument makes no sense. Go easy on the smoke man.

[GLE]

Well said Paty. Pure CRAP that doctors are trained on tax payers money in CUSS for free. Apart from the fees they have to pay, you have to see the conditions under which those students study: under equipped hospitals, labs with 19th century microspcopes, with as many as 15 students crowded over 1 of those old microspcopes. The truth is, the tax payers money is eaten by the corrupt officials of the governement and they dont giv a shit to the hospital conditions under which these doctors are trained. If they were concerned, they would use the tax payers money to build infrastructure and equip those teaching hospitals for those MD students. But what do they do: the president goes on a holiday spree where he spends 2million CFA in a single day. So stop talking shit about CUSS MDs bieng trained for free. Doctor Ben and others who are more intelligent have responded well. The environment is hostile to their growth and survival. Furthermore the government wants to remain in the middle ages, doesnt want to relax its terrible grip to ease creation of private practice and the setting up of private businesses, talk less of facilitating the return of those who are trained abroad. And about compelling CUSS graduates to stay home, thats the dumbest thing I have heard for a while, for it simply wont work. The solution, which has already been clearly aoutlined above, is simple and as someone has said it, it doesnt take a rocket scientist to figure it out.

[Judwin]

Its easy to talk but when you`re in the situation, you really get to feel the ipact. How easy is it to work under very unfavourable working conditions? Like seeing a patient die and you cant do a thing? Because you dont have the appropriate diagnostic facilities and may instead worsen a situation? Its easy to say, but te reality is that its very frustrating working here. No incentives, the wrong guys get promotions just because they have the connexions, etc. Am a 6th year Cameroonian medical student, in the University of Buea. I really want to work in Cameroon, but as i see things more clearly, i wonder if one can cope with this disgusting system! Its not all about the money as people think

[Dr Ben]

I feel your pain, my child. Why do I say my child? Most of you medical students were not yet born by the time I got out of medical school. Cameroon is trapped in the hands of unpatriotic thieves. Most doctors do not want to practice politics. They just want to take care of people while not living in abject poverty. Most countries do something to make sure that something of the sort happens. People of the profession leave Cameroon because they begin to die inside. Can Philemon Yang change things?

[Dr Fongue]

i trained in nigeria,during my internship (housemanship)i received abt 600,000frs cfa monthly,.what am i coming to do again in cameroon?Cameroon government should stop insult civil servants,especially doctors.And i am on my way to america i just urge my colleagues to once in a while come home and give a helping hand.

[limbekid]

I am still sceptical about the idea of increased wages as a solution to brain drain. Given our level of technological development, any increases in wages without corresponding increase in value, would only lead to inflationary spiral. I think some form of subsidised living (well equiped estates for highly-skilled essential professionals) is a better option.

I am also wary of selective indignation: by personal estimation, at least 90% of Cameroonians trained abroad through the public purse, never return. They completely ignore that they are also the products of collective effort. Also, very few (if any) Cameroonians raised eye brows when consecutive governments waisted billions paying "stipends" to university students, instead of improving infrastructure.

If you benefit from a bad system, you are an accomplice.

Happy New Year to all regular contributors of Upstation Mountain Club

[drug rehab new york]

There should be incentives for the profession. This is to control the large migration of doctors.

[John Dinga]

To understand the problem of medical practice in Cameroon one needs to recognize how politics has crept amoeba-like into all possible domains and crippled everything. Doctors in the public service are hardly happy because of the usual man-know-man practice that is so pervasive and tends to place neophytes over their professional seniors,oblivious of the consequences for morale.

Logically, the answer would have been to move on to private practice. But here again, it is a very distressing scenario. Quite apart from official red tape, the individual practitioners too have fallen victim to the Cameroonian curse of "trust-nobody-but-thyself". What do I mean by this? Just take a look at the once thriving private practices in towns like Bamenda, Kumba or Victoria. Dr.Kwankam died and his clinic in Kumba went with him. The same can be said of Dr.S. M. Abba and his Moselo Clinic, also of Kumba, and Dr. Effiom. In Bamenda, Dr Mundi's clinic is only in the archives. Dr. Nana, Dr. Adeso. In Victoria, Dr Tchwenko's clinic got burnt to ashes, Dr. Abunaw's went thirty-nine steps down to no-return, Dr. Mokonya Njie's and so on and so on. I am sure many others can be documented, with the same sad endings. What is true of clincs is equally true of Pharmacies. If these were products of teamwork, I am certain the institutions would survive their founders.

Take a look at the relevant presidential decrees that provide for the opening and operation of these human service institutions. Most of them are inoperable, requiring a real Darwinian battle of survival of the fittest or those who can speak the language very well. Na lie?