The Provision of Medical Services in Africa
By R.E. Tunbridge
[Published in Leeds African Studies Bulletin 3 (October 1965), pp. 16-18]
(Notes of a talk given to members of the African Studies Group by Professor R.E. Tunbridge, on 29th April, 1965)
Africa, medically, is where we were in 1800, but its sights are on the year 2000, The problems arise from poverty and malnutrition, and from infectious diseases which are widespread, including some of the more common ones which have been controlled elsewhere. However there are also the parasitic ones e.g. malaria, and others. In Africa, 40% of the population is under the age of 15, and the medical problem is that of a young population exposed to all these diseases.
On behalf of the World Health Organisation, I visited Tunisia twice, Cameroon once and the Commonwealth East African countries once. I am glad to say that our recommendations with regard to Tunisia were accepted, and a medical school is being established in Tunisia. There is at present only one medical school for all of East Africa.
In Tunisia the finance available and the medical services available, are very unevenly distributed. One-third of the country is rich grain country, the old granary of the Roman Empire, and largely French-speaking. One-third is largely Arab, partly urbanised. One-third is nomadic, and surprisingly pro-British, because we buy the pampas grass, and we taught them to plant trees in order to gain water supplies. Tunisia has a population totalling 4 million, and is essentially an agricultural country, with almost no minerals, but with a little oil and natural gas. The country is very Franco-phile, and there is very little Arab influence. There are 2000 students a year of University standard, and until recently all of them received their university education in France. There are fewer than 500 doctors for a population of 4 million, 500 of these were educated in Prance, others come from all over Europe, including Yugoslavia and Bulgaria, and from Israel. There are 150 doctors in government, service, of whom about 30 are Tunisian. Tunis itself has a population of 300,000 and greater Tunis about three-quarters of a million. .. The doctor ratio in Tunis itself is comparable to that of the United Kingdom; thus it is evident that in the country it is very much less.
In Cameroon the population numbers about 4 million also, and there are 96 qualified doctors, of whom 20 are Cameroon in origin and 76 are French military personnel. The medical services are appalling which is serious from the international point of view, if we recall the experience of Congo where malaria, smallpox and typhus were rife after independence. The position is appalling in the French equatorial ex-colonies, but preventive work needs money which is not forthcoming.
In the East African territories, the British established at least the facade of a British system of government. These territories lack trained personnel but the system does work, even if creakily, and this has helped to maintain standards and services. The three territories realise that they have something in common, and they have still the Common Services Administration. The populations are increasing rapidly and are estimated at 8 million in Uganda, over 9 million in Kenya and 12.5 million in Tanganyika, which is greater than the demographers’ figures had indicated. For tho 8 million in Uganda there are 429 doctors, including 150 in government service; Uganda is a special case, made so by the highly developed Baganda tribe. There is also a strong mission influence in the country. Kenya was held back by Mau Mau, but has approximately 700 doctors, including 175 – who are rapidly disappearing – in government service. In Tanganyika, where German influence is still strong, there are 550 doctors, including 90 in government service, but very few are Tanzanian. The overall position is thus very series, because these numbers of medical personnel also have to provide administrators, area officers etc. Most of the African doctors are quite young, and were educated abroad. Many were trained in India, and the Indians are a minority not readily accepted.
In this situation, what is to be done? These African countries need fully qualified doctors, in the Western sense, but this requires a minimum of seven years’ training after an advanced school education. Should the doctors be trained in their own country or abroad? To choose the latter is a serious fault. To send a student in his formative years for- seven or nine years to an alien culture and then return him whence he came is culturally very serious. Medically too, the emphasis is wrong. Western medical education is oriented towards disease in the second half of life. Field work in Africa, for a doctor with Western cultural experience, often married into the alien culture, is hard and lonely. Therefore African doctors should be trained in their own country, trained in its problems and able to be with their own people. This problem must be faced. A further aspect of the problem is that if the best is regarded as what comes from France or England, African education is looked on as second best.
We must also be realistic financially. Take East Africa. The Medical School of the University of East Africa is, by agreement, at Makerere, and Makerere is a dream university, better than anything in Britain. Provision of facilities of this standard has been criticised, but I would defend it, because, bearing in mind the home circumstances of the students, and the distances they have to travel, good facilities are necessary if they are going to do their work. Medically, however, it is too precious. They have until recently been training 20 students a year – now it is 60 – from all three East African territories. Until this year the curriculum too was more British than the British. Only now are they going out among ordinary people. They should have adapted the curriculum to meet African needs.
In Tanzania there are only 200 students a year with 2 Advanced level passes. Thus the total qualified for University entry is 200. Of these 80% or 90% would prefer to do medicine, but even so many of them would become politicians by the age of 45. The Governments have to limit the numbers who will take medicine. The comparable figures for students with two “A” levels in the other territories are 400 in Kenya (which has the aim of increasing this to 4000) and rather more in Uganda (with the aim of increasing it to 3500).
There is a lack of manpower for all educational work. Furthermore, because they have not had the educational opportunities, Africans tend to be older in school – for instance Indians take “0” Level at 15 and a half but Africans at 17 or 17 and a half so that an African doctor, after taking “A” level and his medical course, will be in his late twenties.
The most important need is a preventive medical service – although of course the social needs are great for the removal of poverty and for better nutrition. But it is important to control the water supply and improve personal hygiene. In East Africa nearly all townships are western made. Village life is not a very strong feature of the territories and therefore it is not easy to get across the idea of community responsibility. We need to introduce health personnel having minor nursing skill but considerable skill in teaching hygiene to mothers etc. – a cross between a Health Visitor, a Sanitary Inspector and a Nurse. This service should be staffed by both men and women, perhaps after a three-year course. A multiplicity of health personnel is quite lost in these countries. Hospitals are few, but clinics are needed even more, and the hospital staff should be got to go on district. At Dar es Salaam there is a training course lasting four years for medical auxiliaries, which is quite adequate for a Diploma, and many of the students could pass Conjoint, but these students are alienated from the University, and they lack a career structure, which is essential, and which is not provided for in the Titmuss scheme. Yet these will never do the job adequately in time. So we must produce a cadre of personnel with limited competence, and from the best of them choose some to train along with the doctors.
In these African countries I have mentioned, there is no state health service. Hospitals are state-run, and there are free services for some people in dire necessity. There is a skeletal service in East Africa. The establishment of a state health service is partly a question of cost. Health services take 10% of the budget (and education takes 25%) but these percentages represent only a small amount of money – in Tunisia it represents £3 million or £4 million a year. Compare this with the cost (£20 million?) of establishing a teaching hospital and medical school in the United Kingdom. So if one advises the establishment of a medical school one is asked, how is it to be financed? All this involves a new concept of what a doctor is, and what he is being trained for.