“The need is so great"

How does brain drain affect your country’s health care system?
This is really a critical issue. People tend to believe that things are better for health care workers abroad. Many professionals leave the country. But our longstanding problem with shortages of nurses and doctors has several other reasons:

• Cameroon does not train enough nurses to meet demand.
• Matters were made worse by structural adjustment programmes, which were designed by the World Bank and International Monetary Fund, and imposed hiring quotas in the public service. The health sector was not exempted, and staff retirements or deaths were not taken into account, though a sizeable number of health care professionals retire every year, and some die from various diseases. It is deeply frustrating that, even though our health sector needs more personnel, there are unemployed nurses in the country who cannot find employment.
• Our country’s disease burden is above average. Cameroon is located in sub-Saharan Africa, which carries about one third of the world’s disease burden, especially HIV/AIDS.

The situation has become so bad that we cannot adequately treat our own citizens.
 
What does that mean in tangible terms?
Well, let’s consider maternal mortality. In the 1980s, the maternal mortality rate stood at about 500 deaths per 100,000 mothers, but it has since risen to 900 per 100,000. According to the WHO’ World Health Statistics of 2011, Cameroon has 16 nurses and midwives per 10,000 inhabitants. The comparative figure for Germany and France is 110. Cameroon has two doctors per 10,000 people; the rich nations that are members of the Ogranisation for Economic Cooperation and Development have 20 to 40 doctors for the same number. And don’t forget that the situation is worse in our rural areas. In some parts of northern Cameroon the ratio is probably one doctor
to 30,000 inhabitants or so.  
 
So the workload is huge?
Yes, it is, and it keeps growing, which affects the motivation of the health personnel still in place. Indeed, this trend itself is an incentive to leave. All summed up, our health services are deteriorating, which hurts our development prospects. A healthy population is obviously more productive and vice versa, so poorer health services result in a poorer country. Moreover, it is frustrating that, when a large number of nurses and doctors emigrate from our country, we lose the return on the investment that was made to train and educate them and end up providing professionals to wealthy nations. This is a kind of perverse subsidy we cannot really afford. But financial loss is not the greatest problem, the sorry state of our health care system is the greatest problem.
 
How are doctors and nurses trained in
Cameroon?
The training of doctors is carried out in university settings, after an advanced-level certificate in
sciences, with priority given to chemistry and
biology. It takes future doctors six to seven years to earn their first degree, and then there are specialist courses that take another two to four years. Nurses are trained at professional schools and universities, most of which are state owned. They need four years of professional training. There are specialist courses for nurses too, including options to move on to masters and PhD programmes. Finally, we have assistant nurses. They require one year of training at a professional school, and their qualifications correlate to those of licensed practical nurses in the USA. The sad truth, however, is that many assistant nurses are doing nurses’ work in Cameroon because the need is so great.
 
Couldn’t Cameroon train more doctors and nurses?
Yes, and training capacities have indeed been scaled up. Initially, only one state-run university offered medicine degrees, now at least five univer­sities do. The professional schools’ intakes have been scaled up too. This year, more than six private schools were approved to train nurses. But the problem is that there are too few employment opportunities. The health care system cannot improve until it gets more funding.
 
Where do health professionals migrate to?
In my eyes, brain drain started as an issue of colo­nialism. Today, Cameroonians will first consider France and United Kingdom, but some people move to the USA, Canada, Germany and other OECD countries. South Africa and, more recently, Asian destinations like Hong Kong or Dubai are relevant too.
 
What should be done to motivate doctors and nurses to stay in Cameroon?
Well, we need to consider all pull and push factors. Although some reasons may not be perfectly understood, the following aspects certainly matter:

•  low salaries,
•  poor working conditions, including poor facilities and equipment,
•  incompetent management,
•  political instability,
•  lack of career and even employment opportunities,
•  excessive workloads,
•  lack of patriotic spirit and
•  increasing globalisation

All of these issues must be tackled to redress the situation.
 
How do hospitals cope with the lack of qualified staff?
Various measures have been tentatively taken. The most common include:

•  task shifting, the systematic delegation of tasks to less specialised and qualified staff,
•  higher workloads and longer working hours,
•  policy guidelines to boost motivation and
•  retention of willing staff beyond retirement age.

What can be done to boost motivation, if higher pay is not an option, though it would obviously be quite effective?
Yes I think a higher salary may be the solution. I remember in the early 1990s when there was a big salary slash of about half what each civil servant was earning, most nurses and doctors were looking for ways to leave. However, some management perspectives think that salary is a worker’s right and should not be considered an incentive. There are a lot of arguments for and against that. I think the greatest motivation especially for young nurses just from school is the assurance of job. For those already working, better working conditions, workloads commensurate to pay, better management and opportunities to advance will really boost motivation.  
 
To what extent must you rely on paramedics and informal trainings?
Well, as I just said, task shifting is highly practiced. Moreover, some voluntary nurses have been accepted into clinical practice. These are young unemployed nurses who willingly come to “help” unpaid so as not to lose their skills after graduation. Non-professionals, however, are not trained to perform clinical tasks, so we don’t compromise quality.
 
How does your hospital prepare staff for task shifting?
We do on-the-job training. For instance, nurses who have undergone general nursing training are taught to carry out specialised tasks like midwifery, anaesthesia and minor surgery. Doctors, moreover, are trained to perform specialised tasks such as surgery, obstetrics and gynaecology. Such on-the-job training is the basis for task shifting, and it is supported by various continuous education programmes run by the state and funding bodies.