|ORIGINAL RESEARCH PAPER
|Year : 2011 | Volume
| Issue : 3 | Page : 614
Career intentions of medical students trained in six sub-Saharan African countries
VC Burch1, D McKinley2, J van Wyk3, S Kiguli-Walube4, D Cameron5, FJ Cilliers6, AO Longombe7, C Mkony8, C Okoromah9, B Otieno-Nyunya10, PS Morahan2
1 University of Cape Town, Faculty of Health Sciences, Department of Medicine, Anzio Road, Observatory, Cape Town, South Africa
2 Foundation for Advancement of International Medical Education and Research, Philadelphia, PA, USA
3 University of KwaZulu-Natal, Nelson R Mandela School of Medicine, Durban, South Africa
4 Makerere University, College of Health Sciences, K'la, Kampala, Uganda
5 University of Pretoria, Pretoria, South Africa
6 Stellenbosch University, Centre for Teaching and Learning, Manewales, Stellenbosch, South Africa
7 University de Kisangani, Kisangani City, Democratic Republic of Congo
8 Muhimbili University of Health and Allied Sciences, dar es Salaam, Tanzania
9 University of Lagos, College of Medicine, Akoka Yaba, Lagos, Nigeria
10 Moi University, School of Medicine, Eldoret, Kenya
|Date of Submission||17-Jan-2011|
|Date of Acceptance||02-Aug-2011|
|Date of Web Publication||16-Dec-2011|
V C Burch
University of Cape Town, Faculty of Health Sciences, Department of Medicine, Anzio Road, Observatory, Cape Town
Source of Support: None, Conflict of Interest: None
Introduction: Sub-Saharan Africa (SSA) is the world region worst affected by physician migration. Identifying reasons why medical students wish to stay or leave Africa could assist in developing strategies which favour retention of these graduates. This study investigated the career intentions of graduating students attending medical schools in SSA to identify interventions which may improve retention of African physicians in their country of training or origin.
Methods: Final year medical students attending nine medical schools in SSA were surveyed - students from four schools in South Africa and one school each in the Democratic Republic of Congo, Kenya, Nigeria, Tanzania and Uganda. The response rate was 78.5% (990 of 1260 students); data from the 984 students who indicated they were remaining in medicine were entered into a database, and descriptive statistics were obtained.
Results: Most (97.4%) of the 984 responding students were African by birth. The majority (91.2%) intended to undertake postgraduate training; the top three specialty choices were surgery (20%), internal medicine (16.7%), and paediatrics (9%). Few were interested in family medicine (4.5%) or public health (2.6%) or intended to practice in rural areas (4.8%). Many students (40%) planned to train abroad. About one fifth (21%) intended to relocate outside sub-Saharan Africa. These were about equally divided between South Africans (48%) and those from the other five countries (52%). The top perceived career-related factors favouring retention in Africa were career options and quality and availability of training opportunities. Several factors were reported significantly more by South African than the other students. The top personal factors for staying in Africa were a desire to improve medicine in Africa, personal safety, social conditions and family issues. The top careerrelated factors favouring relocation outside Africa were remuneration, access to equipment and advanced technology, career and training opportunities, regulated work environment and politics of health care in Africa. Several of these were reported significantly more by students from the other countries as compared with South Africans. The top personal factors favouring relocation outside Africa were personal safety, opportunity for experience in a different environment, social conditions and greater personal freedom.
Discussion: The career intentions of African medical students are not aligned with the continent's health workforce needs. A number of interventions that warrant further attention were identified in this study.
Keywords: Career choice, clinical practice location, medical migration, medical students, medical workforce, retention, rural practice, sub-Saharan Africa, undergraduate medical training
|How to cite this article:|
Burch V C, McKinley D, van Wyk J, Kiguli-Walube S, Cameron D, Cilliers F J, Longombe A O, Mkony C, Okoromah C, Otieno-Nyunya B, Morahan P S. Career intentions of medical students trained in six sub-Saharan African countries. Educ Health 2011;24:614
|How to cite this URL:|
Burch V C, McKinley D, van Wyk J, Kiguli-Walube S, Cameron D, Cilliers F J, Longombe A O, Mkony C, Okoromah C, Otieno-Nyunya B, Morahan P S. Career intentions of medical students trained in six sub-Saharan African countries. Educ Health [serial online] 2011 [cited 2021 Mar 5];24:614. Available from: https://www.educationforhealth.net/text.asp?2011/24/3/614/101416
Africa has a critical shortage of health care workforce. The continent carries 24% of the burden of disease globally and has only 2% of the global health workforce1. A recent study predicted that Africa needs at least 167,000 additional physicians by 20152 to 'reach two of the World Health Report 2006 goals; 80% measles immunisation coverage and 80% of live births attended by a skilled health worker'1. While the need to train more physicians is clear, the continent is served by only 168 medical schools3; there is approximately one medical school for each 6.9 million people as compared to Europe with one medical school for each 1.9 million people4.
The situation is further aggravated by ongoing physician migration from Africa, particularly sub-Saharan Africa, which is the world region worst affected5. Approximately 28% of all sub-Saharan African-born physicians lived outside the continent in 20006. In some countries such as Mozambique, Angola, Tanzania, Zambia, Ghana and Kenya, more than 50% of physicians born there are now working outside Africa6. Given the projected increase in global workforce demands, particularly in affluent countries with aging populations and increasing burden of chronic disease, such as the USA7-9, Africa will continue to supplement the health workforce needs of these countries at enormous cost to the continent.
Strategies to increase the physician workforce in Africa have been implemented over the past two decades. At least 58 new medical schools have been built, but these have not yet had a major impact on the growing shortage of physicians3. Available data suggest that the current annual throughput of SSA medical schools is only in the order of 10,000 to 11,000 graduates3. Indeed, political and economic instability in some countries, such as Nigeria and the Democratic Republic of the Congo, continue to limit the throughput of African medical schools10.
Almost all studies of physician migration from Africa provide data gathered by recipient countries5,11,12. Investigating the problem from an African perspective has been severely hampered by the lack of databases tracking the migration of health professionals13 and limited records, which are not easily and readily available10. Table 1 provides an overview of English language reports about the career intentions of students and graduates of African medical schools over the past 20 years. Most of the studies focused on one university or one country. The largest single country study, which included 876 South African medical students14, and the largest multi-country study, which included 336 doctors from six countries13, both highlight the challenges facing researchers in Africa – it is difficult to obtain accurate data and it is costly to conduct this type of research.
If more data could be obtained about the career intentions of African medical students, it may be possible to develop strategies which specifically target students prior to graduation and in their early careers post graduation. This window of opportunity, when it may be possible to influence longer term career choices, has not been extensively explored15. The aim of this study was to explore the career intentions of final year students attending medical schools in six sub-Saharan African countries so as to identify interventions that may improve the retention of African physicians.
Table 1. Studies examining migration intentions of students and graduates from African medical schools.
This study was designed and conducted by participants in an international faculty development programme sponsored by the Foundation for Advancement of International Medical Education and Research (FAIMER)27,28 . In 2006 there were 12 sub-Saharan African medical schools where FAIMER fellows served as faculty, and nine of the 12 schools agreed to participate in the study. Ethics Committee approval was obtained from each school.
Four schools from South Africa and one each from the Democratic Republic of Congo, Kenya, Nigeria, Tanzania and Uganda participated. This provided a convenience sample of final year medical students from nine schools in six sub-Saharan African countries; this cohort represents about 10% of an estimated annual output of 10,000-11,000 graduates from all medical schools in sub-Saharan Africa3.
Using a paper questionnaire, available in English and French, a cross sectional survey was conducted of all final year students at each institution. The co-authors or a designated staff member met with class representatives to explain the survey, and emphasised the anonymity of the data and that individuals’ responses would not be seen by school faculty. The survey was distributed to students at times appropriate in their schedule. In some cases, surveys were distributed to the entire class at one time; in others, the survey was distributed to groups of the class when they were on campus.
The information gathered included biographical data, such as country of birth and geographic location of secondary school attended. Students were asked about their intention to undertake postgraduate training, the geographic location of intended training, and clinical practice intentions. In Africa, doctors trained in family or community medicine, primary health care and/or rural practice typically work in community settings, including district hospitals and primary care clinics. In Africa, these are recognised as primary care specialties; all other specialties are mostly practiced in urban settings. For those students who indicated an intention to work outside Africa, questions regarding their longer term intention to return home or to practice abroad were included. Respondents also used a four-point Likert scale (1=very important; 4=not important) to indicate the extent to which they perceived a variety of factors would impact upon their intention to work within or outside of Africa.
International definitions of 'rural' and 'urban' do not exist. We formulated definitions using data from South Africa (StatsSA) and elsewhere29. In South Africa there are six metropolitan centres each with a population of more than one million residents, 46 district municipalities each having a population of about 300,000 people, and 231 small local municipalities. Based on these data, we defined 'urban' as a centre with a population of more than 250,000 people. 'Rural' areas have previously been defined by the distance travelled by road from main centres (80-400 kilometres) or the time taken to do so (1-4 hours)29 . Distances beyond 200 kilometres or more than two hours travel by road tend to be called 'rural remote' and so we defined 'rural' as an area more than two hours’ travel by road from the nearest urban centre. Many urban centres in Africa have a high-density sprawling peripheral 'informal' component which we referred to as 'near urban,' i.e. within two hours’ drive from the main urban centre. These areas are typically very poorly resourced, and most people living in these areas derive their income from and /or go to school in the nearby urban centre. In this study we used the location of secondary school attended as an indicator of rural or urban origin, as indicated by recent studies29,30.
We entered all data into a database and analysed descriptively for the total student sample, and we calculated the proportion of students who rated each factor ‘very important’ or ‘somewhat important’. To identify differences between students who attended South African medical schools and those who attended schools in other countries, z-scores comparing importance ratings were calculated for each factor as well. Statistical analysis was performed using SPSS v. 15®, and significance was established as p=0.01 or less.
Questionnaires were completed by 990 (78.5%) of 1260 students surveyed. Six students did not wish to pursue a career in medicine and were excluded from the study. Data from the remaining 984 students were analysed. Table 2 provides a list of the participating countries and the number of students from each participating school. Since South African students comprised more than half (57%) of all students surveyed, for some analyses the responses of the South Africans were compared to those from the other five countries.
Table 2. Response rate by medical schools (n=984)
Most of the 984 students (92.9%) included in the study were 30 years or younger, and just over half, 50.8%, were women. A total of 93.1% had attended secondary school in an urban (70.9%) or near-urban area (22.2%); only 6.3% had attended secondary school in a rural area.
Almost all of the respondents (97.0%) were born in Africa, and 83.7% were citizens of an African country. Most (92.9%) were from the six countries surveyed: South Africa (50.4%), Nigeria (15.7%),Tanzania (10.6%), Uganda (7.4%), Democratic Republic of the Congo (6.8%) and Kenya (2.3%). The rest were citizens of Botswana, Cameroon, Ghana, Lesotho, Mauritius, Namibia, Sierra Leone, Sudan, Swaziland, Zambia, and Zimbabwe. Only 7.1% of the students had dual citizenship; of these, the great majority (84.2%) were citizens of two African countries, while the remaining 11 were citizens of a country outside Africa. Most of the students surveyed attended medical school in their country of birth, but 3.2% may have left their birth country because of limited local training facilities.
Obligatory Clinical Service
About half (49.3%) of 964 respondents were required to complete a period of obligatory service after graduation (20 respondents did not answer this question). These students were predominantly from South Africa (64.4%). Only 28.7% of respondents reported a service obligation, usually related to repaying financial aid. The vast majority of these students (84.4%) intended to fulfil their service obligations. Most (79.4%) were required to work in a government health care facility and the remainder were to work in private, non-government or other organisations. Of the 475 students reporting obligatory service requirements, 391 provided information on the period of obligatory service. Service periods ranged from less than a year (1.8%), to 1-3 years (69.8%), to four or more years (28.4%).
Postgraduate Training Intentions and Preferred Location
Of the 984 student respondents, 91.2% wished to undertake postgraduate training (Figure 1). The most popular disciplines were the traditional disciplines of surgery and internal medicine (including subspecialties), followed by paediatrics, obstetrics and gynaecology and psychiatry, which together accounted for 58.2% of the reported choices. Family or community medicine and public health were much less popular career options (8.0%). The remaining students considered careers in disciplines such as pathology, anaesthetics, diagnostic imaging, forensic medicine, emergency medicine, health management, sports medicine, occupational medicine, and alternative medicine. Of note, 21.6% had not yet decided on their specialty of choice at the time of the survey during their last year at medical school.
Figure 1. Top ten specialties chosen for intended postgraduate training
When asked about their one preferred location (country) for postgraduate training, 60.0% of the 866 respondents preferred to train in their country of undergraduate study or another African country. South Africans were significantly (p<0.01) less likely to want to leave Africa (86.4% intended to stay) than students from the other five countries (29.6%). Of the 40% who wished to train outside Africa, most indicated as their training destination the USA (n=129), the UK (n=92), Europe (n=47), Canada (n=39) or Australia (n=23).
Clinical Practice Intentions and Preferred Location, after Postgraduate Training or Completion of Obligatory Clinical Service
Of 921 respondents who specified a preferred practice type, 30.1% intended to work in private practice. The South Africans (35.2%) were significantly more likely (p <0.01) than students from the other countries (22.8%) to indicate a preference for private practice. A similar total proportion (29.1%) intended to pursue government medical practice (28.0% South Africans; 30.7% other countries (p=0.27). Only 11.5% overall intended to pursue a clinical academic career, and 5.3% preferred to seek employment with a non-government organisation. As with specialty intention, almost one quarter of graduating respondents (24%) were still undecided about the nature of their intended clinical practice.
Students were also asked about the location of their intended clinical practice. Of the 984 student responses to this question, most (79.0%) reported an intention to practice in Africa (82.4% South Africans; 74.5% other countries; significance of difference: p < 0.01). Only 4.8% of students expressed an interest in rural practice beyond the completion of any obligatory training and service commitments.
Students Wishing to Stay Outside Africa
Twenty one percent of the 984 student respondents indicated that they had already decided to live and practice, not just train, outside Africa. Given the choice of one or more destinations, the 207 students intending to migrate most commonly indicated preferences for the UK (74.8%), USA (73.4%), Canada (59.4%), Australia (38.2%), other European countries (28.5%) and New Zealand (19.3%). When asked to indicate all of the important factors in determining their intended length of stay abroad, the most common responses were visa regulations (78.9%), quality of life in home country (63.0%) and family obligations at home (32.4%).
When questioned about living and practicing outside Africa and their intended length of stay in a country outside Africa, 13.3% of all 984 students surveyed indicated that they would consider returning home, while 7.7% did not plan to return. Of those 131 who indicated they wished to return, 28.1% intended to stay overseas for a period of between one and five years, 22.6% for six to ten years, and almost half (49.3%) intended to stay for a period of more than ten years. Thus, of all 984 students surveyed, 14.2% (n=140, including the 64 students who intended to stay for more than 10 years and the 76 students who indicated they would not return to Africa) planned to leave Africa and stay abroad for more than 10 years. Of the 207 students who intended to work abroad, 28.5% had already made arrangements to study or work outside Africa, and 15.9% had already attempted to gain foreign registration. These data indicate that a substantial proportion of students in their final year of medical school in Africa, at least the 14.2% noted above and perhaps as much as 21.0% (n=207 who had already decided to live and work outside Africa), would be lost to clinical practice in Africa.
Reasons to Stay in Africa
Numerous factors were rated by over 80% of respondents as ‘very important’ or ‘somewhat important’ in their intention to live and work in Africa, and many of these factors were career-related: good career options (92%), opportunity for further education (88%), quality (88%) and availability (87%) of specialist training, and connections to desired employment (87%). An almost equal number were personal: a desire to improve medicine in Africa (86%), personal safety (85%), social conditions (84%) and attachment to spouse or partner (82%). Data on all factors included in the questionnaire are provided in Table 3.
Table 3. Reasons for staying in africa for medical practice
There were statistically significant differences between students from South Africa and the other five countries for nine of the factors (Table 3). A significantly larger proportion of South African students rated seven factors as important for their reasons to stay in Africa. Only two were related to career options: availability of specialty training (91% of students at South African schools vs. 83% of students attending schools in the other five countries; p< 0.01) and quality of specialty training (91% of South Africans; 83% of other respondents; p <0.01) in their field of interest. The other five were personal factors: family attachment to spouses/partners (88% vs. 73%; p <0.01), children (80% vs. 70%; p=0.01), and parents (84% vs. 64%; p<0.01), language differences (69% vs. 51%; p <0.01), and the opportunity to repay student loans (62% vs. 34%; p<0.01). Only two factors were rated important for staying in Africa by a significantly smaller proportion of South Africans than other respondents: desire to improve medicine in Africa (93% of students attending schools in countries other than South Africa vs. 81% of South African students; p<0.01) and opportunity for research (85% vs. 54%; p<0.01).
Reasons to Leave Africa
Thirteen factors were rated by over 80% of respondents as ‘very important’ or ‘somewhat important’ in their intention to leave Africa for medical practice. Most were career-related: salary (96%), access to medical equipment and technology (95%), regulation of the work environment (90%), career options (90%), positive feedback from others who have practised abroad (86%), politics of health care in home country (85%), quality (84%) and availability (81%) of specialty training and opportunity for further education (84%). Top personal considerations included personal safety (86%), opportunity for experience in a different environment (85%), social conditions (82%) and greater personal freedom (80%). Data for all factors surveyed are provided in Table 4.
Table 4. Reasons for leaving Africa for medical practice
A significantly smaller proportion of South Africans rated seven career-related factors as important reasons for leaving Africa (p<0.01). As shown in Table 4, all of the students from the other five countries rated access to medical equipment/technology as important compared to 91% of South African students. Similarly, students from the five other countries rated opportunity for research as important (87% vs. 42% of South African students); quality (100% vs. 68%) and availability (95% vs. 66%) of specialty training; opportunity for further education (95% vs. 72%); career options (98% vs. 82%); and other professional reasons (83% vs. 26%).
In contrast, a larger proportion of the South Africans as compared with the other medical students rated two personal factors as important reasons for leaving Africa: personal safety and greater personal freedom.
This multi-country study of African medical students provides information about the demographic profile and career intentions of the pipeline of doctors being educated in Africa.
This study points to several possibilities for addressing the need for more primary care physicians and physicians serving rural patients. At least 48% of the respondents, mostly from South Africa, were required to complete a period of obligatory service upon graduation. This strategy is not widely used in Africa (countries that require service include South Africa, Mozambique, Ethiopia and Nigeria)3 , but it could be implemented in other countries as a way of expanding public health services. The study data also indicate that there may be an additional 'window of opportunity' to attract graduates to the public health care service as up to 24% of final year students who had not yet decided on a specialty or type of clinical practice. If public service working conditions are made more attractive, it may be possible to increase physicians in the public sector. While students of rural origin may be more likely to be attracted through such strategies, Stagg et al. suggest that some urban origin students also may be 'convertibles'15.
This study confirms that the pattern of recruitment of students from urban areas to medical schools is ongoing despite a growing body of evidence supporting the hypothesis that students of rural origin are more likely to return to rural practice29-34. This is of great concern in Africa where the average physician to population ratio is 0.22 per 1000 and may be as low as or even lower than 0.03 per 1000 population in rural areas35-37. Increasing the number of rural physicians is a matter of top priority if Africa’s medical schools are ever to come close to meeting the health care needs of the continent.
One of the most important aspirations of the students surveyed was the intention to pursue postgraduate studies; more than 90% of students indicated an interest in further training. Importantly, about 88% (especially students from South Africa) indicated that the availability and quality of postgraduate training in their home country were reasons for staying, while a similar proportion (especially from the five other countries) indicated these same issues were reasons for leaving Africa. Our data suggest that there are actual or perceived differences in availability and quality of postgraduate training capacity across the continent that could be addressed. To increase awareness of locally available training opportunities, an easily accessible, up to date, electronic database of all African specialist training programmes could inform interested graduates about programmes available in their own or neighbouring countries.
In addition to increasing awareness of existing training opportunities, some international organisations have sought to create new opportunities within Africa. Focusing on availability and quality, a programme providing on-site specialist training by faculty from a USA university has been successfully implemented in Ghana38. This model considerably reduces the cost of training and obviates the need for African graduates to leave their home country. This is a critical factor, because longitudinal tracking has shown that international medical graduates entering the USA for postgraduate training frequently obtain visa waivers to stay after completing their training39. Recent data from the programme in Ghana indicate that this strategy does improve retention of postgraduate trainees in Africa40.
In the current study less than 10% of students were interested in the primary care specialties of family medicine, community medicine and public health. This finding from students in 2006, which has been observed in much of Africa (Table 1), is disturbing. It may reflect that recent initiatives, such as Primafamed-network (www.primafamed.ugent.be), to promote family medicine had not yet come to fruition. This minimal interest in primary care may be a result of actual or perceived lack of availability or quality of local postgraduate training opportunities. It may also be due to limited exposure at the undergraduate level to community-based clinical practice in either a rural or urban setting. Such exposure has been shown to be one effective strategy for improving interest in rural primary care services29,32-34,41. It is, therefore, essential that medical schools provide adequate undergraduate engagement in community-based health care. There are a few rural medical schools in Africa that provide examples with data showing improved retention of graduates in rural practice42-44. Since almost a quarter of students surveyed had not yet chosen a speciality to pursue, it may be possible to persuade students to consider a career in the primary care specialities through well-structured community-based clinical clerkships29. This strategy, combined with more attractive public health care service opportunities, could make African postgraduate opportunities in primary care more appealing to medical graduates. There is a clear need to develop such programmes and it should be made a priority.
It is estimated that Africa will require 167,000 additional physicians by 20152. According to a recent study, Sub-Saharan Africa is estimated to produce about 10,000 medical graduates per year3; or about 40,000 new graduates by 2015. Obviously the current total possible thoughput is not sufficient to bridge the need gap. If 20% of new graduates emigrate in the next five years, as predicted by our study and others6, the gain will be reduced to about 32,000 physicians, leading to the need for a five-fold increase in throughput of medical schools to fulfil the most basic workforce needs by 2015.
While more medical schools and additional infrastructure are clearly needed, the lack of adequate human resources to teach students is of equal concern. A recent study of 105 medical schools in SSA showed that 51 of 98 responding schools had less than 100 teaching staff (salaried full-time or part-time and volunteer) and that half of the surveyed schools lost between 6% and 18% of their teaching staff in five years3. In this study only 11.5% of students intended to pursue an academic career. Already insufficient to meet current needs1,45, it is definitely insufficient to meet the predicted health workforce training needs in the next five years. Strategies to make an academic career more attractive to medical students have not been explored; this may be another avenue where recipient country funding could be used to build capacity in Africa so that it is better equipped to address its own needs46,47.
Although this survey was the result of an extensive collaboration amongst a network of scholars, it was not without limitations. This convenience sample consisted of students from only six sub-Saharan African countries, with about half from South Africa. However, this cohort represents about 10% of all students graduating from sub-Saharan African medical schools each year3; moreover, second only to Nigeria, South Africa produces more graduates per annum than any other country in sub-Saharan Africa.
To address the disproportionately greater number of students from South Africa in the sample, we analysed factors viewed as important for staying or leaving Africa to South Africans as compared with the other five countries. South Africans were more likely to report career factors as important reasons for staying in Africa, likely reflecting a better developed health professions education and delivery system. Consistent with this, students from the other five countries were more likely to report career factors as important reasons for leaving Africa. Of concern were the findings that a greater proportion of South Africans reported personal safety and greater personal freedom as reasons to leave Africa. Future research is needed to investigate whether this relates to students’ perceptions of the climate in South Africa as compared with the rest of Africa, greater expectations for personal safety and freedom as countries become more developed, or other complex factors.
Although responses were anonymous in this survey, the students may have provided answers that would be considered socially desirable. However, the the fact that 44.4% of students intending to work abroad indicated that they had already registered or were planning registration abroad suggests considerable willingness to disclose future plans. Finally, changes in migration regulations during and since the study was conducted may affect interpretation of the results48-50.
This study provides a snapshot of the career intentions of a cohort of sub-Saharan African medical students. Work is currently underway to determine differences in practice and migration intentions based on gender and secondary school attended as well as whether specialty choices are similar for those intending to stay as compared to those intending to migrate. Qualitative study will also explore the deep personal and career reasons behind the factors viewed as important reasons for staying or leaving Africa.
The authors acknowledge the support of the Foundation for Advancement of International Medical Education and Research.
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