When there is no village doctor

An international financial recession threatens to worsen the “severe medical workforce crisis” faced by almost 60 African and Asian countries, according to the UN World Health Organization (WHO). The fewer health workers there are, the less chance a woman has to survive childbirth and a child his or her infancy, according to WHO.

In the last such statistics recorded by WHO, the agency in 2006 estimated a shortage of more than four million health workers in Africa and Asia.

The WHO Global Health Workforce Alliance estimates that on average one in four doctors and one in 20 nurses trained in Africa leave the continent to work in wealthier countries for the experience, more pay and better living conditions.

But Mubashar Sheikh, executive director of the workforce alliance, told IRIN prohibiting health worker migration is not a solution. “The movement of health workers can have both positive and negative consequences. [Because] while remittances sent back home contribute to the economic development of the country, health systems in such countries might be weakened by health worker out-migration.”

Rather, Sheikh said the answer lies in training and retaining more health workers in areas that face severe shortages, such as West Africa.

No matter how developed a country’s economy is, doctor shortage is a shared burden across West Africa. Even though Cape Verdeans earned 10 times more on average than Sierra Leoneans in 2007, according to the World Bank, both countries struggled to treat the sick.

Sierra Leone

In Sierra Leone, for a population of more than five million there are 75 state medical doctors as of February 2009, according to the Ministry of Health. In addition, there are 25 medical specialists and 23 public health workers.

The country’s only ear, nose and throat specialist Arthur Wright told IRIN he trained in Europe before returning home to work in 1967. “Many of the colleagues who trained with me left during our country’s civil crisis,” said Wright.

During Sierra Leone’s war from 1991 until 2002, human rights observers reported tens of thousands of civilians falling victim to killings and mutilations, and approximately one-third of the population fled.

Wright said medical training in Sierra Leone still has a long way to go to patch the health worker gap. “Brain drain is still a tremendous problem. We lose a lot of doctors to the United States, Saudi Arabia and England every year.

"Even with about 1,000 enrollees at the [local] College of Medicine and Allied Health Sciences and 15 to 20 physician graduates every year, 75 percent of them will leave the country. They cannot make a living off of [the government salary] $100 per month,” said Wright.

As a doctor and former professor at the medical school, Wright's pension after 30 years of government service is $140 per month, he told IRIN. “Without my private practice, I could not afford to remain in my country.”

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The Sierra Leone government has requested 110 doctors from Nigeria, Sudan and Cuba, according to the Ministry of Health.  Egypt’s government has pledged to send six specialists.

But Wright told IRIN such recruitment can bring only short-term relief. “We need to address the middle- and long-term needs to improve health services and training. These doctors will leave. And then?”

When asked why he had not left Sierra Leone to pursue more lucrative medical jobs, Wright said: “This is my country. I have to give service to my people.”

Cape Verde

With a population of less than half a million, according to the most recent government census, Cape Verde has no medical school. WHO reported 231 doctors in the archipelago as of 2006, all trained overseas.

To cover the gap, the government pays 50 doctors, mostly Cuban, to work on up to three-year contracts.

More than half of Cuba’s 79,000 doctors work on temporary contracts in more than 70 countries, according to the Cuban government. Host governments pay the doctors’ salaries and benefits.

Visiting doctor Cristina Cedeño told IRIN that rural residents dispersed throughout Cape Verde’s nine inhabited islands have a hard time accessing care. She added that anything beyond basic medical care is still scarce in Cape Verde. “Up until seven days ago, there was only one oncologist. Before that people with money went to Portugal or stayed here for general care.”

Cape Verde's Health Ministry director Jaqueline Pereira told IRIN doctor shortages are a problem. She said discussions to create the country’s first medical school are scheduled to begin this year.


But for David Werner who wrote the widely-translated 1970s village health care manual, “Where There is No Doctor,” medical specialisation is not necessarily the answer. “Experts come in and think they have all the answers, and end up drowning out solutions villagers could devise themselves.”

Werner said more doctors do not guarantee improved community health. “Doctors are specialists in the narrow area of health care called medicine. More trained community health workers and a fundamental change of the underlying social determinants of health are needed.”

The biologist, author and health educator told IRIN poverty is more powerful than knowledge. “No matter how many experts tell a mother to feed her child, without the means, she cannot follow their advice.”