New report highlights hardships of doctors in some developing countries

Public health doctors in some developing countries, who earn only one fifth of what their counterparts in private practice do, sometimes engage in “predatory” practices in order to increase their incomes, according to a study published today in the journal of the United Nations World Health Organization (WHO).

“Staff struggling to make ends meet is a major difficulty faced by more than half the national health systems of the world,” says Orvill Adams, WHO’s Director of the Health Service Provision department. “Yet until recently it has been treated mainly as a problem of corruption rather than the systemic challenge that it is for health services.”

According to the study conducted by Wim Van Lerberghe and colleagues in the WHO Bulletin, doctors in rural areas suffer additional disadvantages, and most health staff naturally do all they can to avoid these hardships.

“The brain drain is not merely a matter of Congolese doctors moving to South Africa or Philippine nurses to the United States; it also means migration from public to private practice and from rural to urban areas,” the authors says.

Those who choose to stay in their practices compensate with “predatory” coping strategies, such as demanding under-the-counter fees, pressuring patients to attend private consultations, and selling drugs that are supposed to be free. More acceptable ones may simply involve staff switching between public and private practice to top up their incomes.

Administrators may have fewer opportunities than clinicians, but they can also be better placed to misappropriate funds, the report says. They can also pursue legitimate alternatives such as teaching, taking other work outside office hours, or doing short-term contracts for development agencies.

While “topping-up” helps to retain valuable expertise in public service, it also raises financial barriers to access to health care, makes staff less available, and jeopardizes users’ trust, the report says. In the long run, many of the best clinicians end up in private practice and many of the best managers in development agencies.

The authors say that closing the gap between private and public sector salaries is not affordable for civil services as a whole, and politically difficult to do for only selected parts of them. The first step is to bring the problem out into the open and recognize its complexity.