The surgical workforce shortage and successes in retaining surgical trainees in Ethiopia: a professional survey

The WHO Global Code of Practice on the International Recruitment of Health Personnel states that, “Member States should strive, to the extent possible, to create a sustainable health workforce and work towards establishing effective health workforce planning, education and training, and retention strategies that will reduce their need to recruit migrant health personnel” [13]. This is the first study of its kind to address these issues among surgeons in Ethiopia by striving to describe the current place of residence, practice and setting of Ethiopian graduates of surgical residencies.

The present study demonstrates that the majority of Ethiopian surgical trainees continue to live in Ethiopia and practice in the public sector. Furthermore, the proportional retention of surgeons in Ethiopia and of those serving in public sector hospitals has steadily increased since the inception of formal general surgery training programs in Ethiopia. The findings herein indicate that 75.8 % of Ethiopian general surgery trainees continue to practice in Ethiopia and that 80.9 % of these do so in the public sector. These figures are markedly higher than those indicated by Berhan, who found that from 1987 to 2006 only 27 % of Ethiopian physicians continued to practice in the public sector [16].

Several factors likely contribute to the low surgeon attrition rate in Ethiopia. One possible explanation is the impact exerted by the Ethiopian surgical faculty, who continue to work in the public sector themselves, thus serving as role models for trainees. Another possible explanation is the evolution of the private sector, which allows an increasing number of surgeons to engage in dual practice, maintaining their principal affiliation at a public hospital while augmenting their salary with a supplementary private practice. While dual practice reduces the time spent by surgeons in public hospitals, where they may have the greatest impact on the country’s burden of surgical disease, it combats emigration and makes practicing in Ethiopia financially sustainable.

In addition, over the past 10 years, new programs for subspecialty training, including paediatric surgery, cardiothoracic surgery, urology, neurosurgery, and orthopaedic surgery, have been developed, thus allowing more trainees to establish a unique niche and contributing to greater job satisfaction among surgeons. Finally, residency training in Ethiopia is partially funded through public sponsorship; therefore, many of the trainees who graduated within the past 10 years are obliged to remain in Ethiopia and practice in the public sector.

Ethiopia continues to have a marked shortage of general surgeons, with only 248 general surgeons, compared to the predicted need for 820. Further, this shortage is most pronounced in rural regions, which have an average of only one surgeon per million inhabitants or less (Table 3) [15]. The data presented in Table 3 demonstrate the tremendous disparity in distribution of surgeons throughout Ethiopia. Two rural regions (Benishangul-Gumuz and Gambella), which have a joint population of approximately 1.4 million people, have no residency-trained Ethiopian surgeons practicing there. While the number of surgeons is projected to increase dramatically with the continued expansion of newly established residency programs, there is ongoing uncertainty about the best way to meet Ethiopia’s surgical workforce demands. One such option, which has been successful in other contexts, is the establishment of rural practice pipelines, which recruit and support medical students interested in practicing in underserved regions [20, 21]. However, the lack of equipment and infrastructure necessary for surgical practice remains a major challenge at many hospitals around the country [17].

SNNPR The Southern Nations, Nationalities and People’s Region

Although emigration and attrition among Ethiopian surgeons occurs less frequently than would be expected, this study shows that these phenomena remain real challenges in addressing Ethiopia’s surgical workforce shortages. Strategies have been described to encourage African doctors to remain in the settings where their services are most needed [22, 23]. In addition, some African countries have focused attention on training non-surgeons to perform basic, life-saving operations [24]. This approach has been successful in rural Ethiopia, although more complex operations continue to demand the expertise of fully trained surgeons and subspecialists [25].

Another approach to the surgical workforce shortage is a shift from urban, university-based training to rural, hospital-based training as suggested in Article 5.5 of the WHO Global Code of Practice, which calls on Member States to “consider strengthening educational institutions to scale up the training of health personnel and developing innovative curricula to address current health needs” [13]. This approach has been undertaken in Ethiopia by the Pan-African Academy of Christian Surgeons at Soddo Christian Hospital in southern Ethiopia, with great success in retaining graduates in rural and underserved areas [26]. There are many benefits to a hospital-based surgical residency. Foremost, trainees remain in their home communities, encouraging them to stay in rural areas following their training. These programs may also be easier and less expensive to scale up than university-based programs. Hosting a residency program requires training hospitals to be accredited through a process that ensures adequate infrastructure and human resources, thus encouraging rural hospitals to improve their capacity. However, the Pan-African Academy of Christian Surgeons’ model, which relies on significant financial and workforce support from foreign donors and volunteers, may not be scalable and therefore more government support for rural surgical training is urgently required.

University-based training programs remain an important component of surgical education in Ethiopia, training academic surgeons and subspecialists who will eventually lead surgical education, research and innovation. However, university-based training programs often require residents to migrate long distances from their homes to train in urban centres, and graduates are often reluctant to return to rural settings following completion of their training. Further, as training programs expand, trainees may not receive adequate hands-on experience or supervision during their residencies. As the volume of surgical training in Ethiopia continues to increase, it is crucial to ensure the continued quality of training through standardized curricula and board examinations, and to guarantee that Ethiopian surgeons have access to the physical and financial resources and infrastructure required to effectively care for their patients.

Although the development of the private medical sector in Ethiopia likely helps to combat surgeon emigration and attrition, it is unclear how much private sector surgery addresses the true burden of diseases requiring surgical care in LMICs. Important topics for further research include a comparative quality assessment of different resident training models, a more detailed characterization of the professional activities of surgeons practicing in Ethiopia, an investigation into the factors that influence the career decisions of Ethiopian surgeons, and an analysis of the clinical skills of surgeons trained in Ethiopia. In addition, article 5.7 of the WHO Global Code of Practice states that, “Member States should consider adopting measures to address the geographical maldistribution of health workers and to support their retention in underserved areas” [13]. Effective means of incentivizing, recruiting and retaining rural surgeons deserves further attention. These findings will help ensure that surgical training in Ethiopia truly addresses the country’s burden of disease.

There were several significant limitations to this study. Firstly, it relied on second-hand reporting of graduates’ current location and practice when these could not be successfully contacted directly. The weak medical infrastructure and lack of a robust alumni network for surgical trainees in Ethiopia made a more traditional data collection strategy unfeasible. Nevertheless, we were able to confirm our findings for many surgeons living in Ethiopia. On the other hand, the lack of reliable contact information limited our ability to learn about the current practice models of Ethiopian surgeons practicing abroad. In addition, data were not collected on Ethiopian citizens who trained in surgery in countries other than Ethiopia or Cuba or non-Ethiopian surgeons practicing in Ethiopia. However, we believe that the latter constitute a very small portion of the surgical workforce in Ethiopia. Finally, many public sector surgeons in Ethiopia are believed to have dual practice in the private sector to augment their income, yet we were unable to quantify the scope of this phenomenon herein.