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Ppt for ph d defense hrh
1. Physician Workforce Situation and
Health System’s Response in Ethiopia:
A Mixed-methods Study
Tsion Assefa (MPH)
Dec. 6, 2017
Supervisors:
Prof. Damen H/Mariam (MD, MPH, PhD)
Dr. Wubegzier Mekonnen (BSc, MSc, PhD)
Prof. Miliard Deribew (MD, FRCS, FCS (ECSA)
5/6/2019
2. Outline of the Presentation
•List of articles and manuscripts
•Background
•Conceptual framework
•Objectives
•Methods
•Results and discussion
•Strengths and limitations
•Conclusions
•Recommendations
•Acknowledgments
5/6/2019
3. List of Articles & Manuscripts
I. Assefa T, Haile Mariam D, Mekonnen W, Derbew M, Enbiale W. Physician
Distribution and Attrition in the Public Health Sector of Ethiopia. Risk
Management and Health Care Policy. 2016; 9: 285–295.
II. Assefa T, Haile Mariam D, Mekonnen W, Derbew M. Survival Analysis to
Measure Turnover of the Medical Education Workforce in Ethiopia. BMC
Human Resources for Health 2017;15 (23).
III. Assefa T, Haile Mariam D, Mekonnen W, Derbew M. Medical Students’ Career
Choices, Preference for Placement, and Attitude Towards the Role of Medical
Instruction in Ethiopian (BMC Medical Education 2017; 17: (96). DOI:
10.1186/s12909-017-0934-z
IV. Assefa T, Haile Mariam D, Mekonnen W, Derbew M. Health System Response
for Physician Workforce Shortages and the Upcoming Crisis in Ethiopia: A
Grounded Theory Research BMC Hum Resour Health. 2017; 15: 86. Assefa T,
Haile Mariam D, Mekonnen W, Derbew M. Physician Migration and Potential Solutions in
Ethiopia: A Qualitative Study (manuscript)
V. Assefa T, Haile Mariam D, Mekonnen W, Derbew M. Accelerated Medical Doctors
Training in Ethiopia: Health Policy Brief
5/6/2019
3
4. Background
•Human resources for health (HRH) is a global
agenda over the last several years:
•Demand: predicting HRH needs
•Economic actors: efficiency and productivity
•Necessary resources to address health policies
•Many countries face critical shortages of HRH
• Greatest in SSA countries including Ethiopia.
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5. Background…
•In Ethiopia health worker to population ratio is low.
• The least MD density to population ratio.
•Contributing factors
•low production,
•medical demand,
•migration (brain-drain), and
•problems related to policy, strategy and planning
(Awases M, et al, 2004; WHO 2010, 2011; Bezuidenhout MM, et al 3009)
5/6/2019 5
6. Background…
The situation drives to different initiatives:
I. Task shifting to low and mid-level health
workers (WHO 2010).
• Ethiopia trained (31,831 HEWs and >8000 Hos)
•However, there are problems related to these
accelerated programs (FMOH, 2014, 2015)
II. Retention strategies
•Obligatory services, salary increment, training
5/6/2019 6
7. Background…
III. Rapid expansion in medical education
• # medical schools grew from 3 to > 33
• # of graduates expected to reach 3000 each year
• Commonly called “flooding strategy” (WHO 2010)
5/6/2019 7
8. Background…
The flooding strategy contradicts:
• HRH planning process: often incremental, detail
situational analysis (Nyoni J, et al 2006)
• Unidimensional solution for multidimensional
problem (WHO 2010)
•The requirements for medical education (Rizk D, 2007;
Chen C, et al, 2012)
5/6/2019 8
9. Rationale of the Study
The effectiveness of the strategy may depend:
• Clear HRH strategy and planning;
• Training resources;
• System’s capacity to absorb and utilize; (Bossert T, et al,
2007)
• The level of preparation and cooperation made
among the stakeholders; and (WFME,1988)
• Lesson learnt from accelerated programs?
5/6/2019
9
10. Rationale of the Study …
• However, in spite of the rapid transition to
overcome the shortage no comprehensive
study has been carried out to assess the situation.
• Therefore, the purpose of this research is to fill
the gap in information and generate evidence
around this issues.
•Which is timely and essential to all stakeholders.
5/6/2019 10
12. Objectives
1. To examine the distribution and attrition of physician workforce
in public sector (Paper I);
2. To identify the distribution of medical education workforce
and factors associated with their turnover (Paper II);
3. To assess medical students’ career choices and intentions
where to work and role of medical instruction (Paper III);
4. To explore reasons for physician workforce migration from
the public health sector (Paper V); and
5. To discover how the health system response using the so
called ‘flooding strategy’ is viewed by different stakeholders
(Paper IV)
5/6/2019 12
13. Methods
Study Settings:
•RHBs and city administrations:
• Six RHBs (Amhara, Oromia, SNNPR, Tigray…), and two
(AA and Dire Dawa)
Medical schools:
• For medical education workforce: (AAU, BUD, JU,
HaU, HU, MU and UOG,)
• For Medical students survey:
• For qualitative study: non-specific
Study Period: between February and July 2015
5/6/2019 13
14. Specific
methods
Study
objectives
Specific
designs
Mixed
methods
designs
Study
design
Mixed
methods
Quantitative
Organizational
surveys
Physicians
workforce
Medical
education
workforce
Retrospective
longitudinal data
(1258)
Medical
students’
Survey
Medical
students’ career
choice Questionnaires
(959)
Qualitative
Reasons for
physicians
migration
Interview
Perspectives on
health system
response
Qualitative Grounded
theory research
Qualitative Grounded
theory research
Reasons for
physicians
migration Interview
(43)
Perspectives on
health system
response
Qualitative Grounded
theory
Organizational
surveys
Physicians
workforce
Medical
education
workforce
Medical
students’
Survey
Retrospective
longitudinal data
(1258)
Quantitative
Organizational
surveys
Organizational
surveys
Questionnaires
(959)
Retrospective
longitudinal data
(1258)
Interview
(43)
Questionnaires
(959)
Retrospective
longitudinal data
(1258)
Reasons for
physicians
migration
Perspectives on
health system
response
Interview
(43)
Questionnaires
(959)
Retrospective
(N=2300)
Retrospective
longitudinal data
(1258)
Medical
students’ career
choice
Reasons for
physicians
migration
Perspectives on
health system
response
Interview
(43)
Questionnaires
(959)
Retrospective
(N=1258)
Grounded
theory
Physician
workforce
Medical
education
Medical
students’
Survey
Organizational
survey
Medical
students’
career choice
Reasons for
migration
Health
system’s
response
Interview
(N=43)
Questionnaires
(N=959)
Study Design
5/6/2019 14
15. Overview of Data analysis
Objectives Statistical models and procedures
Objective #1
(Paper I)
Poisson Regression
Incidence rate ratio (IRR)
Goodness of fitness: Deviance test is (P=0.818)
Objective #2
(Paper II)
Survival Analysis
• The Kaplan-Meier survival curve
• Cox PH model: Hazard ration (AHR)
• PH Assumption: Posttest of PH P=0.466
Educational level, and service year excluded b/c collinear
Objective #3
(Paper III)
Binary logistic regression
• Model fitness: Hosmer and Lemeshow test (P=0.404;
P=0.583)
Objective #4 &5
(Paper IV &V)
GT research approach (Strauss. A, Cobin. J: 1990)
Constant comparative analysis (Open, axial coding …)
Narration and graphic illustration5/6/2019 15
17. Physician distribution and attrition
(Paper I)
5/6/2019 17
• In 5 RHBs and 2 city administrations; 2009 to 2015
•2,300 medical doctors were available.
• Of these, 76% were actively working and 24% were
attritions
• 131(24.4%) had more than one appointments
• the attrition rate among specialists ranges from
21% in Dire Dawa to 43% in Amhara
18. Characteristics of actively working physicians
Variables %
Male 80.5
Born after 1985 50.9
<= 3 years experience 57
GPs 84.2
Residents/fellows 19.6
General hospital 56.4
• In medical schools (61.7% GPs/lecturers, Prof. <5%) Paper II
Implications
• Might be a reflection of increased in supply (FMOH 2015)
• Skill and gender imbalances (Zurn P, et al. 2004)
5/6/2019 18
19. Turnover types for physicians (2009 to 2015)
5/6/2019 19
41.2
25.1
16.6
10.3
1
2.4 2
0.18
46.2
3
41.7
3.5 3 2.1
0.5 0
Percent
Regional health
bureaus
Medical schools
Might be a signal for the
dissatisfaction with the economic
and non economic factors and the
use of the existing opportunities
(QUAL findings)
20. Factors associated with turnover
(Poisson regression model)
5/6/2019 20
• > 44% of the medical students wanted to
practice in referral hospitals (Paper III)
21. Medical Education Workforce Distribution and
Attrition (Paper II)
•1,258 faculty physicians in 7 medical schools
•A total of 6,670.5 physician-years.
•198 (15.7%) observations were completed, and
1,060 (84.3%) were censored.
•Turnover rate is 29.7 per 1,000 physicians.
•Out flows rate 47 to 55 per 1000 physicians (Kinfu Y. et
al, 2009)
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23. Distribution by Specialty…
•Shortage/ lack of diversity in the medical
education workforce is critical:
• Pediatrics & OBS/GYN: to address the MCH needs
•Influence on medical students’ career (Paper III)
• The system aims to provide quality, compassionate,
respectful care? HSPT 2015 (FMOH, 2015)
Implication:
•to balance the enrollment limit with the workforce
5/6/2019 23
24. Cox’s PH model
(risk factors for faculty physician turnover)
Variables Category AHR SE P-
value
95% CI
LL UL
Born after
1985
(Ref.)
1975-1985 0.91 0.23 0.73 0.56 1.49
Prior 1975 0.37 0.11 0.002* 0.20 0.69
Lecturers
(Ref.)
Asst. Prof. 1.03 0.24 0.89 0.66 1.61
Assot. & + 0.25 0.11 0.002* 0.11 0.60
AAU (Ref.) UOG 0.46 0.14 0.01* 0.25 0.84
JU 1.66 0.36 0.02* 1.08 2.55
MU 0.16 0.07 0.00** 0.06 0.41
5/6/2019 24
25. Medical Students’ Career Choices,
Preference and Attitudes (Paper III)
• 70.1% wanted to practice in clinical areas:
• Only 10.8% in zonal and 5.5% in district hospitals
• 73% had the intention to move abroad
• (35.6%) sometimes, often (16%), always(12.8%)
•Opinion towards medical schools
• highest proportion (34.1%) had neutral stand
towards the role of their medical schools in preparing
them to work in rural places
5/6/2019 25
26. Top Specialty Choices by Medical Students
Internal
medicine
Surgery Pediatrics OBS/GYN
Radiolog
y
Ophtha Dermato
Psychiatr
y
3rd choice 1.77 0.94 19.08 7.61 3.44 6.47 4.59 5.53
2nd choice 1.67 27.95 12.30 12.83 6.47 2.29 1.77 1.15
1st choice 45.99 30.03 6.78 5.53 2.92 1.25 0.94 0.73
0.00
10.00
20.00
30.00
40.00
50.00
60.00
Percent
5/6/2019 26
Reasons for specialty choice
Personal interest (88%)
Income potential (42%)
Professional prestige (30%)
Influence from others (16%)
(Manwai C. Ku,et al; 2008).
27. Top Three Specialty Choices …
•This might be dependent on medical education
workforce composition (Paper II).
• Future skill mix within the physician workforce?
Implication:
• The attentions need to be given for composition,
faculty value (Bland CJ, Meurer LN, Maldonado G. 1995).
• The need for proper career guidance to medical
students (Ossai EN et al. 2016).
5/6/2019 27
28. Factors Associated with Students’ Intention to
Work in Rural Areas
Variables Intended Place AOR (95% CI)
Rural Urban
Gender Females 89 129 1
Males 308 258 1.55(1.05, 2.28)*
Place of birth Urban 215 262 1
Rural 162 106 1.52(1.03, 2.25)*
Medical school Others 243 283 1
AAU 152 100 2.34(1.64, 3.34)**
Desire to
serve within
the country
No 161 198 1
Yes 221 172 1.62(1.18, 2.25)*
5/6/2019 28
Despite supply imbalanced distributions might remain
29. Characteristics of the respondents, 2015
Characteristics NO Characteristics NO
Gender Educational level
Male 40 BSc 3
Female 3 GPs 5
Date of Birth MD+SP/SS* 25
After 1980 12 MPH 4
1981-1970 16 PhD 1
1969-1950 8 MD+MPH 5
before 1950 7 Service years
Affiliation <=10 17
Academics (full Prof.) 21(4) 11 to 20 10
Public health (senior) 16 (5) >20 16
Private (researchers) 6 (2)
5/6/2019 29
Qualitative Findings
Note: Ac=Academics; Gov=Government ; Pr =Private
30. Core and Main Categories
Massive
physician
production
1.
Physician
migration
3. Role of
the system
2. Massive
production
5/6/2019 30
extent of migration
reasons for migration, and
physician retention
potential solutions
reasons for expansion
preparation
the consequences, and
flooding as a strategy
cooperation
strategy & planning
system’s capacity and
institutional continuity
external influence
31. Physician Migration and Potential
Solutions (Paper V)
I. Extent of migration
Most participants agreed on the extent of migration and its
contribution for skilled HR shortages in the country.
•Potential destinations for emigration:
• US
• Europe, and
• Other African countries
•For out migrants:
• Working with NGOs, and
• The private sector
5/6/2019 31
32. II. Reasons for Migration
5/6/2019
32
Reasons for
migration
Economic
Amount of pay
Lack of uniformity
Satisfaction
Relativity
In-kind incentives
Non-economic
Lack of recognition
Not valuing expertise
Work environment
External Value shift
Opportunities
33. II. Reasons for migration …
•Economic and non-economic factors determining the
level, distribution, and performance and job
satisfaction (BossertT, et al. 2007).
•Economic and non-economic reasons are the Push
factors
•Opportunities (internal and international) are Pull
factors (Bossert T,et al 2007)
5/6/2019 33
34. Reasons for migration …
•Recognition:
“It is not a matter of money, never, not money. First,
there should be recognition that means ‘making
the physicians part of a problem and a
solution of their own country’ ”. (Ac2)
Consistent with the principles of participation and
ownership (Bracht N, Tsouros A. 1990).
• Lack of recognition might be due to lack of leadership
capacity, lack of attention and cooperation.
• Reported as a challenge by the ministry (FMOH 2014; 2015).
5/6/2019 34
35. •Low retention efforts
• Production without retention efforts “system of ever-
green hands” phenomenon. A system staffed with
junior physician workforce (Ac17).
• Because when the new graduates coming to the
system the experienced/competent will leave from.
• Comparable with a "revolving door" phenomenon
indicates high movement with less retention efforts (Pong
RW,2008).
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III. Physician Retention
36. III. Physician Retention…
• Factors contributing to retention
• Personal interest
• Forming family
• Economic and social stability
• Obligatory services schemes and
• Senses of belongingness
• Potential solutions
Improving incentives/recognition
Creating conducive work environment
Increase in supply with retention
Building culture of communication
Making the sector competent and self-
sufficient
5/6/2019 36
38. Health system’s response to physician
workforce shortage (Paper IV)
Massive
physician
production
• reasons for expansion
• Preparation
• the consequences, and
• flooding as a strategy
Role of the system
on HRH
development
• cooperation
• strategy & planning
• system’s capacity and
• institutional continuity
• external influence
5/6/2019 38
Main categories
39. I. Massive Production
1. Reasons for massive production
None of the study participants denied about the
demand but on the way how it has been taken; “the
flooding strategy”.
Reasons:
•high physician workforce demand
•political advantage/ pressure
“… ‘Speed, Volume and Quality’ should not go
together at once“ (Pr5)
5/6/2019 39
40. I. Massive production …
2. Preparation for massive enrollment
1. the capacity of the medical schools, and
2. demand to absorb the medical graduates
Problems:
1. Mismatch between enrollment limit and resources
2. Inadequate teaching workforce with multiple
roles
3. Lack of cooperation between actors
• Important component to succeed (WHO, 2010; WFME , 1988).
4. In the system premature signals of saturations for
GPs. E.g Addis Ababa and Dire Dawa
5/6/2019 40
41. 3. Consequences of massive enrollment
At the present
• quality of patient care
• teaching learning process
• workload and dissatisfaction
Intermediate
• medical graduates: low
quality, competency
• Poor patient outcomes
Long- term
• surplus, unemployment
• low performance and
productivity
5/6/2019
41
I. Massive production…
42. 4. Flooding as HRH strategy
• Viewed as ‘forced’, ‘disastrous’ and ‘wrong’
“…the government forces public universities to take a
huge # of students at once without equipping … That is
a disaster. (Ac10)
“It may compromise quality, yes, it may. But …it is the
right strategy” (Gov4)
“…what if the number is not working?” (Ac17)
• Competence is widely accepted standard (WFME ,
1988’; FMOH AND FMOE , 2011).
5/6/2019 42
I. Massive production…
43. II. System's Role on HRH development
System’s role HRH
development:
cooperation
HRH strategy &
planning
system’s
capacity
institutional
functionality
5/6/2019 43
External
influence
Challenges (FMOH
2015).
“but still now we do not
have strategy …” (Pr1)
“…things are short lived
and there is no
institutional memory…
…It is simply said, oh
this is changed, that is
changed ”. (Pr3)
45. Implications of system’s response
• The system has been moving from shortage in
quantity to scarcity in skills:
• Too many MDs with inadequate training decrease
productivity.
• Too many specialists may drive the health system
towards hospital-based care (inequality with rural
primary care?)
• The consequences are often slow to appear
• training takes longer period of time and no HRIS
5/6/2019 45
46. Strengths of the study
•Use of mixed methods study is a rigorous
procedure (Creswell JW. 2007)
• In data collection and analysis
•Grounded theory: allowed to study complex
phenomena
• Helped to discover the underlying and the basic
problems
• To verify, clarify and justify the quantitative findings
•Medical students’ survey: developing new survey
items
5/6/2019
46
47. Limitations of the study
• The available HR data lack uniformity and
limited scope
• to control the effect of confounding
• The qualitative study did not capture the
perspectives of patients/ clients and under medical
students
5/6/2019 47
48. Conclusions
• Although there are substantial improvements in physician
workforce supply;
• There are shortages and lack of diversity among faculties
• Physician migration is related to economic, non-
economic, and external factors;
• A rapid transition, from low to massive production has
various negative consequences; and
• Problems related to HRH development are deep-rooted in
to the underlying (strategy, capacity …) and basic
(system continuity ) problems of the system.
5/6/2019 48
49. Recommendations
FMOH, FMOE, RHBs and Medical schools
• Need to work closely to minimize the consequences
• Revisit the current flooding strategy
• Improving the financial and non-financial matters
• Work on the underlying and basic problems of the system
Medical Schools
• Need to improve their workforce composition
• Design a strategy to influence their students’ intention
and career plans
5/6/2019 49
50. Recommendations…
Practicing/faculty physicians
• Need to maintain their professional integrity
• Exercise free dialogue and tolerance with leadership and
management.
Longitudinal study is recommended:
• Examine the effect of massive production at
various stages of the workforce life
• Evaluate the extent in which intentions of students
will be converted into practice
5/6/2019 50
51. Acknowledgments
My supervisors: Prof. Damen Hail Mariam, Dr.
Wubezgier Mekonnen, and Prof. Milliard Deribew
My family: Ms. Tadelch Hailu (the care taker of my
little baby) and my husband-Dereje, my mom, sisters
and brothers
PhD committee;
Prof. Abrham H/Amlak and Dr. Zewdie Birhanu, of JU
Instructors of SPH, AAU and staffs
RHBs and the medical schools, data collectors,
supervisors, respondents
PhD students and my colleagues
MEPI for financial support and the project staff
Prof. Mekonnen Assefa, former professor at JU5/6/2019 51
