The “push” factors and “pull” factors that drive health care worker migration patterns have been well documented (see below, WHO, 2006). Botswana is unique among African nations to be a net recruiter of foreign medical doctors. In the case of many doctors I met, the main attraction of working in Botswana was better remuneration. But in exchange for good wages and housing, they lived complicated and unpredictable lives. As Ministry of Health employees, they could be moved hundreds of kilometers away with as little as two weeks notice. Their jobs were often difficult – working in rural hospitals and clinics as general practitioners, they often faced medication stock-outs and supply shortages. A night on call in the hospital would regularly include several complex adult patients (mostly suffering from complications of HIV and TB), pediatric admissions, minor trauma surgeries, and delivering babies (sometimes by Caesarian section). How could Botswana, trained in resource-rich settings with little to no medical experience in Africa, be expected to return to practice in such an environment?
As my work continued in the country, I began to work more with the new University of Botswana School of Medicine and teach in its first internal medicine M.Med (residency) program. In the first class of four, all were nationals who had been employed as medical officers (general practitioners) within the Ministry of Health. Their education was supported in part by a Medical Education Partnership Initiative (MEPI) grant, funded jointly by Fogarty International Center/NIH and the US Health Resources and Services Organization.
In 2011 I began to take residents with me on outreach visits to rural district hospitals. We made ward rounds and worked in the outpatient clinics together. It was incredible to watch the nature of the doctor-patient interaction change. I saw a level of familiarity that had never been there when I, a foreigner, rounded with expatriate medical staff (despite my meager attempts to communicate in Setswana). Their cultural savoir-faire put patients at ease and garnered immediate trust. Even though they were normally under the care of highly competent non-national clinicians, the first question out most patients’ mouths was, “when are you coming back to take care of us?” I was immediately jealous, but also satisfied – this was the future of medical care in Botswana – Batswana doctors caring for their countrymen and women.
Unfortunately, statistics are not on their side. According to the American College of Physicians, only about 20 to 25% of internal medicine residency graduates enter a career in general medicine – the rest subspecialize (ACP, 2012). The statistics from Africa are harder to find, but a 2005 study from South Africa demonstrated about a 40% rate of specialization among medical school graduates (6% to internal medicine) – the rate of subspecialization was not studied and is not available on the College of Physicians of South Africa website (SAMJ, 2005). Unless incentives for primary care are offered, it is reasonable to assume that the trend toward subspecialization would continue, even in the African context. Retaining them in the public sector is another challenge entirely.
The establishment of a residency program is only the first step towards creating a cadre of well-trained national physicians. Retention will still be an important challenge – will they be mandated to work in Botswana before considering work outside the country, or will they, like their colleagues training in the U.K. and Ireland, be allowed to migrate without restriction? What assurances are being made that they will work in the public sector, or in primary care for that matter? Certainly the country needs subspecialists, but primary health needs are mounting along with the demand for local, skilled specialists.
I am confident that programs like the MEPI, targeted at building educational capacity in Africa, are a step in the right direction to solving the human resources for health crisis in low- and middle-income countries. However, the road to success in these programs is a long one and requires new data about health worker retention and barriers to careers in primary care. Only when local doctors can articulate and manage health problems in their own words will the need for foreign health workers begin to abate. And I know that the Batswana waiting in the clinic queue will also look forward to the day that they see one of their own sitting in the exam room waiting to care for them.
Kerry VB, Ndung’u T, Walensky RP et al, Managing the Demand for Global Health Education, PLoS Medicine 2011, 8(11): e1001118.
World Health Organization, “Working Together for Health – the 2006 World Health Report,” WHO 2006.
Joint Learning Initiative, “Human Resources for Health: Overcoming the Crisis,” JLI 2004.
Botswana Central Statistics Office, “Botswana AIDS Impact Survey III,” CSO 2008.
American College of Physicians, “Residency Match Results Not Encouraging for Adults Needing Primary Care,” ACP Newsroom, , accessed 4/27/12.
Price M, Weiner R, Where have all the doctors gone? Career choices of Wits medical graduates, S Afr Med J 2005, 95: 414-419.
Matthew Dacso, MD, MSc is a general internist from Houston, Texas. He studied music at McGill University, international development at the University of London School of Oriental and African Studies, and medicine at the University of Texas Medical Branch in Galveston before completing residency at Brown University in Providence, Rhode Island. He has worked in health care in Argentina, Peru, the Dominican Republic, Mexico, and Botswana. His current research focuses on non-communicable diseases in HIV, traditional medicine, and global health medical education. He continues his work in community health and development as an HIV outreach specialist for the Botswana-UPenn Partnership and is an active faculty member of the Department of Internal Medicine at the University of Botswana, both based in Gaborone, Botswana. In 2010, he co-edited the Tarascon Global Health Pocketbook.