Abstract
Few medical schools and sustained emigration have led to low numbers of doctors in many sub-Saharan African countries. The opportunity to undertake specialty training has been shown to be particularly important in retaining doctors. Yet limited training capacity means that doctors are often sent to other countries to specialise, increasing the risk that they may not return. Expanding domestic training, however, may be constrained by the reluctance of doctors to accept training in their home country. We modelled different policy options in an example country, Malawi, to examine the cost-effectiveness of expanding specialty training to retain doctors in sub-Saharan Africa. We designed a Markov model of the physician labour market in Malawi, incorporating data from graduate tracing studies in 2006 and 2012, a 2013 discrete choice experiment on 148 Malawian doctors and 2015 cost data. A government perspective was taken with a time horizon of 40 years. Expanded specialty training in Malawi or South Africa with increasing mandatory service before training was compared against baseline conditions. The outcome measures were cost per doctor-year and cost per specialist-year spent working in the Malawian public sector. Expanding specialty training in Malawi is more cost-effective than training outside Malawi. At least two years of mandatory service would be more cost-effective, with five years adding the most value in terms of doctor-years. After 40 years of expanded specialty training in Malawi, the medical workforce would be over fifty percent larger with over six times the number of specialists compared to current trends. However, the government would need to be willing to pay at least 3.5 times more per doctor-year for a 5% increase and a third more per specialist-year for a four-fold increase. Greater returns are possible from doctors with more flexible training preferences. Sustained funding of specialty training may improve retention in sub-Saharan Africa.
Highlights
Low production and high emigration have led to few doctors in many sub-Saharan African countries, impeding the delivery of essential health services and response to new health threats (Sidibé and Campbell, 2015; World Health Organization, 2006, 2015)
At the end of year 6, specialists start to complete their training leading to a rise in their number in the public sector
At least two years of mandatory service in the public sector before training in Malawi would be more cost-effective, with five years adding the most value in terms of doctor-years
Summary
Low production and high emigration have led to few doctors in many sub-Saharan African countries, impeding the delivery of essential health services and response to new health threats (Sidibé and Campbell, 2015; World Health Organization, 2006, 2015). Retaining doctors in their country of training, has been the focus of recent policy efforts. The opportunity to train in more advanced health systems is often popular with doctors, but augments the risk of emigration This presents a dilemma for policymakers: sending doctors to train in other countries is likely to increase retention of doctors in the short-term, but may produce specialists more likely to emigrate in the long-term. Many countries will be unable to reduce their dependence on foreign-trained specialists without expansion of specialty training, yet specialists are costlier to produce and employ than generalist doctors
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