Specialist training of health workers is urgent
According to Dr James Avoka Asamani, a health economist, and his associates at the World Health Organization’s regional office in Africa, as well as Dr Christmal Dela Christmals, a senior lecturer at the Centre for Health Professions Education at North-West University, and Dr Champion Nyoni, a senior researcher at the University of the Free State, both South African institutions, the lack of clarity in terms of titles and their not being recognised by professional associations could impact on the career progress of health specialists.
“A striking example is within the pharmacy profession, where some established universities have several advanced-level pharmacy programmes that are not recognised as specialist programmes by respective pharmacy councils, thereby denying the graduates the necessary recognition and remuneration,” stated the researchers in a study, ‘Exploring the availability of specialist health workforce education in East and Southern Africa: A document analysis’, that was published in BMJ Global Health, a peer-reviewed journal.
The researchers also found that most countries in the two regions they studied focused their training on generalists – health workers such as doctors and nurses – to provide essential primary healthcare.
This focus came at the expense of specialist healthcare training or postgraduate training that would allow professionals to specialise – for instance, to practise as cancer specialists, neurosurgeons and cardiologists.
Specialist healthcare training
Across the professions, there are 288 specialist programmes in 10 categories – medicine, nursing, public health, dentistry, biomedical sciences, nutrition, clinical psychology, pharmacy, physiotherapy and occupational therapy – spread across 157 universities and colleges in 20 countries.
Medical specialist programmes are the most prominent as there are 193 programmes in 36 universities, constituting 67% of all the health specialist programmes in the two regions.
Specialist nursing programmes are a distant second, as researchers located 37 programmes in 46 universities across 15 countries and representing 12% of all the healthcare specialist training programmes available within the countries in the two regions.
Public health, dentistry and medical laboratory sciences recorded 17, 15 and 13 specialist programmes, respectively, and constituted 15.6%, while occupational therapy and physiotherapy were the least available specialist programmes and were only available in Kenya, South Africa and Zambia.
Although there are two postgraduate specialisation pathways in medicine, the medical fellowship programmes and the Master of Medicine, or MMed, each of which takes a minimum of three years and a maximum of seven years, the MMed is the most popular route in the two regions.
Even then, the distribution of MMed programmes varied widely across the two regions, whereby MMed in general surgery was the most common programme as it is available in 11 countries, while MMed programmes in anaesthesia, internal medicine, paediatrics, ophthalmology and obstetrics and gynaecology are available in nine countries, and pathology in eight.
Researchers located 28 dental specialist programmes, of which 50% were in South Africa while the rest were shared between Tanzania (five), Ethiopia (four) Kenya (four) and Uganda (one). Pharmacy programmes were found in only seven countries: South Africa, Ethiopia, Tanzania, Kenya, Rwanda, Zambia and Zimbabwe.
Although there are indicators that public healthcare programmes leading to the awarding of Master of Public Health, or MPH, and PhD (Public Health) are widely available in the region, researchers noted that the public health specialisation category for non-physicians is available only in universities in Ethiopia, Kenya, Namibia, Uganda, Zambia and Zimbabwe.
Based on available data, whereas the specialist healthcare workers with postgraduate training are inequitably distributed within the 20 countries, what is in acute shortage are sub-specialist level experts (postgraduate training that would allow professionals to specialise).
Highlighting the problem, the World Health Organization, in a report, The State of the Health Workers in the WHO African Region, noted that, in 2018, in the region there were about 0.33 medical doctors – both generalists and specialists combined – for a population of 1,000 people which, in real terms, meant that there were only 33 doctors for every 100,000 persons in most countries in Sub-Saharan Africa.
Taking into account that it takes much longer to train medical sub-specialists, it means the density of healthcare workers, such as cardiologists, neurosurgeons, plastic surgeons, chest specialists, cancer specialists and other sub-specialist level experts, is inadequate in most countries.
Cost of specialisation
According to Professor Hazel Miseda Mumbo, the vice-chancellor at Kenya’s Great Lakes University and a health economist, Kenya has a huge gap in health specialists that include cardiologists, neurosurgeons, oncologists, nephrologists, lung and skin specialists and cardiology and oncology nurse specialists. Explaining the magnitude of the gap, Miseda said many of Kenya’s 47 counties do not have a single specialist in some of those fields.
According to Asamani and his associates, in addition to limited opportunities in sub-specialist level training, there are large cost variations of MMed and other healthcare postgraduate programmes from one country to the next, and also among local and international students.
In South Africa, it costs a medical doctor between US$9,300 and US$12,700 per annum in specialist programmes in tuition fees with the upper limit set for international students while, in Uganda, a local student pays US$1,300 and an international student US$5,100 at Makerere University.
At the University of Botswana, medical specialist training to local students costs US$1,200 in tuition fees compared with US$6,100 in Rwanda while, in Malawi, the cost of the Master of Nursing programme is US$2,000 for locals and US$8,000 for international students.
Amid efforts to strengthen the training of healthcare specialist personnel across Sub-Saharan Africa, as well as to improve career progression of such specialists, the WHO says there is a need for governments to establish accreditation mechanisms for health training institutions by 2030.
National accreditation regulatory bodies, according to the WHO, are expected to establish professional standards, quality of training, and evaluation processes of healthcare workers.
But, as universities in Eastern and Southern Africa struggle to increase the number of specialist healthcare workers, as well as to improve their training, there is a need to rethink how to retain them as many had been leaving their countries after professional certification.