Governments - beware! / by Alastair Anderson

Governments-beware ! by Alastair Anderson 11he scene was a familiar one. Several hundred people poured through the streets chanting slogans and calling for jus- tice. The police stood by watching and, when things looked to be get- ting out of hand, they charged. Batons dispersed the demonstrators and the demonstration broke up in diasarray . However , the authorities had received the message , and pre- sently some concessions were an- nounced that went halfway towards meeting the protesters' claims. What was different about this demonstration was that it did not concern students or trade union members of political activists. The protesters were junior doctors , fresh out of medical school, but with no jobs to go to; their " demo " was a demand for the government to find them employment consis- tent with their long professional training. This particular incident happened last August in Dhaka, the capital of Bangladesh , but it could have taken place in any number of capital cities. Almost certainly , such inci- dents will become commonplace over the next few years. Why? Because the output of the world's medical schools is far outstripping the capacity of health services to provide the new physicians with employment. Other articles in this issue of World Health will report figures in support of this alarming statement. One striking example will suffice here : in 1982, Latin America and the Caribbean had 295,000 physi- cians, but at the same time no fewer than 300,000 medical students were going through the schools. This means that the medical workforce will double within the next few years while the employment capaci- ty of the health sector in this region will remain stagnant. What chances will most of these new-fledged doc- tors have of ever finding work com- mensurate with their skills? Not only doctors are affected by this superfluity. Dentists and nurses too , in some countries , are being produced in greater numbers than can be absorbed by public health services or the private sector. How has this situation come about? First of all, there has been little or no coordination over years and de- cades between ministries of health , which are directly concerned with deploying skilled health workers , and ministries of education , which are usually responsible for adminis- tering the medical schools. Health personnel may pay dearly in the future for this lack of" intersectoral cooperation." But governments cannot be blamed for the continuing world economic crisis which has forced cutbacks to be made in all sectors, but particularly in spending on health services. What had been re- garded as a steadily expanding sec- tor has itself become stagnant or even retrograde. No longer can young doctors take it for granted that a hospital post or a medical practice will be readily available for them in a locality of their choice. The phenomenon of qualified phy- sicians driving buses or acting as tourist guides instead of following their chosen calling has become more and more common. If " blame " must be apportioned, some of it must also fall on indi- viduals who struggle to enter medi- cal schools . Most of them , let us A Togolese nurse checks her syringe. Photo L. Sirman © W oRLD HEALTH , April 1987 Confrontation: French students took to the streets last December to demand, among other things, unlimited access to university courses. Photo Keystone © hope, are genuinely impelled by a desire to help the suffering and heal the sick. But the financial rewards too are alluring enough to attract youngsters to study medicine de- spite the hard work , anti-social working ho,urs and additional years of study needed to qualify. Special- ists in particular can expect very high rewards. The prestige factor is very high, and personal ambitions are often boosted ~ by parental pressure when mothers and fathers· yearn to be able to claim : "My son, the doctor. . . . " All the more frustrating will it be, therefore, for the hundreds of thousands of highly qualified young men and women who will presently emerge from the medical schools only to find themselves among the ranks of the unemployed . There is another side to this coin. While many countries - almost cer- tainly over half of WHO's 166 Mem- bers States - already recognise that they have a surplus of doctors, many others (or even in some cases the same countries) accept that they have too few doctors serving the communities of the remote country- side. The same prestige that im- W oRLD HEALTH, April 1987 bues medical students with such high expectations of their profes- sional life inclines them to stay amid the bright lights of the cities and to shun the less rewarding practice of "the country doctor". Again, this is true of dentists , nurses and other health professionals. Solutions So what can be done to redress this gross imbalance - firstly, of too many highly-skilled professionals emerging on a depleted market- place and , secondly, of too few health workers being able and will- ing to serve in the rural areas where the needs are desperate? Last year's Acapulco conference on "Health manpower out of bal- ance" recommended urgent re- search into this fast-growing prob- lem and regular exchanges of infor- mation between countries. Dele- gates recognised that uncontrolled growth of both state-run and pri- vate medical schools had helped to bring about the imbalance, and they foresaw that six to ten years might be needed to reduce the output of medical graduates. But the delegates also discussed much more drastic solutions that might be forced very soon upon governments. Ideally, one might say that governments should spend more on health; with a bigger budget , more jobs can then be found to absorb the unemployed doctors. Equally, a larger share of the national budget should make it possible to create physicians' posts in the countryside or so to reward country doctors that they will actu- ally prefer working in rural areas to working in the cities. In the present economic climate, the chances of such changes are slim. An obvious remedy is to choke off admission to the medical schools , perhaps building in a very strict quota for each year's intake of students. If this is not done, the spectre arises of having to close down some medical schools in their entirety. There may have to be a greater sharing of medical practices by three or four doctors where one doctor has hitherto managed to cope. A compulsory retiring age for doctors would help to create jobs in hospitals, health services and pri- vate practice. And there is the question of salaries. At Acapulco, Professor B . Abel-Smith adduced the following figures: in any given country a rural medical aide (primary level educa- tion and six months' training) will be paid two currency units, a nurse, medical assistant or sanitarian (completed secondary education and three years' training) will be paid six currency units, and a doctor or dentist (five to eight years' train- ing) will be paid 20 currency units. 9 10 Governments-beware I The medical fraternity will not like me saying so and will retort that journalists are overpaid!) but in my personal view that last ratio is too high. Yet to reduce physicians' earnings to a more reasonable level vis-a-vis nurses and rural health workers might tax all the cour- age and political will of any government . Even more fundamental is the need to bring about balanced num- bers of health workers at all levels. It has been estimated that at least 80 per cent of the interventions carried out by a general practitioner can be done by health workers at a lower professional level. Com- munity health workers with a few months or even weeks of training have proved their worth in such skills as vaccinating, implanting intra-uterine devices, testing eye- sight and treating minor ailments or mJunes. It follows that the world's medi- cal schools might be better employ- ed turning out many more nurses than doctors, and many more com- munity health workers than either doctors or nurses. Such a re-balanc- ing of health manpower would go a long way towards ensuring health services for the millions of under- served people who live in remote villages or in the slums of our great cities. Above all, there is a pressing need for coordinated planning of health manpower by all sectors of government, in order to curb the massive oversupply of physicians and to correct the imbalances with- in countries. Governments should be warned: already associations of unemployed physicians have been founded in both developed and developing countries. In recent months, France witnessed the leverage of student- power as thousands of youngsters demonstrated in the streets de- manding, inter alia, unrestricted ac- cess to university places. Protest marches by hordes of unemployed people are regular events in many capitals. But the potential spectacle of highly vocal health professionals -the backbone of the "middle classes" -demonstrating by the thousands in city streets and de- manding political and economic sol- utions to their unemployment prob- lem should give all politicians food for thought. • W oRLD HEALTH, April 1987