Poor countries can keep doctors local
Countries are using innovative schemes to train and retain health professionals — but they need support, says WHO expert Manuel M. Dayrit.
When you picture the doctor of the 21st century, what do you see — a specialised professional working with lasers and robots in a high-tech hospital?
There will no doubt be such doctors — in the countries that can afford them. But many countries will be too poor for technologically advanced hospitals, or to sustain an educational system whose medical graduates aspire towards such specialisation while basic health needs remain unmet.
What a poor country needs is doctors it can rely on to serve where they are most needed — to ensure that mothers deliver their babies safely, for example, or that HIV infection does not spread unchecked.
The reasoning may seem straightforward but the reality is not. Medical schools in poor countries continue to produce doctors that they will eventually lose to more lucrative careers in cities or other countries.
Can these countries do something about this? Yes they can — and they are already showing bold efforts to meet the challenge.
Prioritising the community
Ethiopia has only three doctors for every 100,000 people — below the average for Sub-Saharan Africa — according to the Sub-Saharan African Medical School Study (SAMSS).  The government, determined to address the shortage, required all medical schools to expand their class sizes in 2009.
Jimma University, one of 11 medical schools in the country, aimed to increase student enrolment from 200 to 350 starting with 2009–2010. The university faces huge challenges, among them the lack of faculty and facilities. And once the students graduate, Ethiopia faces the challenge of providing jobs.
Most students interviewed by SAMSS in 2009 were looking to migrate abroad for better salaries and career opportunities. Policies on compulsory service put in place recently have been adhered to by 99 per cent of graduates, according to the health ministry, but the long-term effects on retention in rural areas remains to be seen.
More importantly, the university's strategy was to provide community-based education to equip students to serve in rural areas. The curriculum requires students to work in communities 30–40 kilometres from the university, where they learn skills including data collection and diagnosing community needs.
To support these activities, efforts to strengthen research capacity among students and faculty began in 2006 with the establishment of the Health Service Research Institute, which helped coordinate research efforts and disseminate research findings. 
Success in Sudan
In Sudan, the University of Gezira Faculty of Medicine is already reaping rewards from a community-based curriculum established in 1978.  The school capitalises on a close working relationship with the Federal and State Ministries of Health to integrate its teaching programmes with the health service delivery activities of government agencies.
When SAMSS interviewed Gezira students in early 2010, it found "prevention is better than cure" ingrained in the students' thought processes. The school aims to train 1,000 family physicians in the coming years to increase the capacity to deliver care in rural areas, particularly in Gezira State. 
In 2005 the school also began to train village midwives in emergency obstetric and neonatal care, successfully integrating them into the government-funded health system.
According to Professor Elhassan Elhassan, who heads the initiative, the programme exceeded its target of reducing maternal and prenatal mortality by 50 per cent in five years. Field research has also shown a reduction in 2010. The results have encouraged Gezira University to promote the approach in other states in Sudan.
Innovative course design
Programmes implemented in the Philippines are also showing signs of success. In 1976 the University of the Philippines College of Medicine created a different type of medical school in Leyte province, one of the country's poorest.
The school recruited students from poor communities in dire need of health workers, and the student entered into a social contract with the community by pledging to return to service after completing training.
Even more innovative was the design of the course, known as the step-ladder curriculum. This allows students to enter or exit their training at any level along a ladder which starts with barangay (village) health workers and ends with physicians. 
Of close to 3,000 students that have graduated since the programme started, 70 per cent served as midwives, 25 per cent went on to practise as nurses, and five per cent became physicians. Two more provinces, Quezon Province and South Cotabato, have since adopted the approach.
The school has lost just ten per cent of its graduates to emigration — by contrast the University of the Philippines College of Medicine in Manila lost 50–100 per cent of its graduates.
These innovative programmes are clear examples of how countries are fighting against strong market forces to ensure enough adequately trained doctors for their populations.
What has made them succeed against the odds? Their innovative design, coupled with the vision and commitment of teachers and students — when matched by support from government, communities and organisations.
Over time a critical mass of like-minded people moves the mission forward. But more needs to be done. Supportive policies must be put in place to ensure that students graduate to stimulating jobs over the long-term, and receive adequate payment to keep both body and idealism alive.
Manuel M. Dayrit MD, MSc is director of the WHO Department of Human Resources for Health in Geneva, Switzerland. He has served as secretary of health of the Philippines.
 SAMSS site visit report [895kB] — Faculty of Health Sciences, Jimma University, Ethiopia (SAMSS, 2009)
 SAMSS site visit report — Faculty of Medicine, University of Gezira, Wad Madani, Sudan [1.29MB] (SAMSS, 2010)
 Bringing health to rural communities: Innovations of the U.P. Manila School of Health Sciences (University of the Philippines, 2011)