School is becoming too expensive for doctors

It has been a stormy week in the medical fraternity. Many young doctors felt their dreams of progressing in their profession being doused.

University of Nairobi (UoN), School of Medicine, the founding medical school in Kenya, announced a 300 per cent increment in the tuition fees for doctors interested in pursuing a Master’s of Medicine in the various specialty courses.

Considering the school absorbs approximately 70 per cent of all locally specialising doctors, this decision has had a ripple effect across the country.

The specialisation training of doctors and other healthcare workers is nothing like a regular master’s programme. One cannot do this part-time, neither can it be done remotely/online. Worldwide, taking up a master’s programme is a full-time venture.

No university can undertake the training without either owning a hospital or partnering with one. The hospital must generally be a high volume institution to qualify for training.

So what does a typical training entail? The trainee is a qualified and licensed doctor attached at the training hospital, working in resident/registrar/senior house officer capacity. She will work full time at the hospital, taking care of the patients within the area of specialisation, as part of the department team. She is the backbone of the hospital workforce.

In any training hospital, the residents have a call rota that covers their department on a 24-hour basis.

Lower number of specialists

For this reason, the training hospitals have done away with cadre of general practitioners at the department level, releasing them to cover the accident and emergency departments. On the other hand, the hospital specialists have a much lighter burden as most of their emergency work is done by residents. This cuts down on the number of specialists the hospital requires to employ.

The training programme involves continued patient care throughout the course duration, interspersed with formal lectures, skills demonstration, research and mentorship. The course requires that 70 per cent of the time is spent in the wards, clinics, operating theatres and the emergency department. One cannot purport to train without providing service to patients.

Across the world, specialty training is recognised as an integral part of strengthening the health systems. Therefore, it follows that governments intentionally make a concerted effort to invest in the training. Despite this heavy investment, the demand for specialists across the world remains unmet, with the brunt of shortage being borne by developing countries.

The recognition that the doctor in training is providing services that the patients have to pay for sets the rationale for compensation of these residents while in training. In developed countries, this training is hospital-run and domiciled in approved training hospitals. The hospitals are then supported by government to ensure sustainability.

In Kenya, the training of specialists largely remains domiciled in universities. The doctors were largely employed as general practitioners across the country and would be released from their work stations to relocate to Kenyatta National Hospital under the auspices of UoN for training.

The government retained them on the payroll as civil servants and paid their school fees in full. Once they graduated, they were posted where the government had the need for their newly acquired skills.

Along the way, the landscape has drastically changed and this university system is beginning to come apart at the seams. For four decades, the University of Nairobi has carried on with minimal innovation in how to make the programme sustainable.

The responsibility of training has been straddled between two ministries - Education and Health - neither being adequately funded, or motivated to ensure the programme stays afloat.

The assumption that all doctors will be working in the civil service at the time they will be going back for postgraduate studies has not stood the test of time.

In the past two decades, the university has taken in trainees who have to foot their own tuition fees, but there is no entity that has bothered to compensate the work they put in at the hospital while in training. And this is the beginning of the coming down of the house of cards.

What ails the system? In any decent society, no one should have to work without compensation; it goes against the labour laws and amounts to slavery. How do we correct this? Local standards have already been set on how we can do things differently.

Subject to slavery

The Aga Khan University Hospital has demonstrated that the resident doctor can actually be paid in part and the rest of value for his work goes to contributing to his tuition.

This is a perfect model of a university-owned hospital. The university is both trainer and employer and for this reason, it is able to work within its capacity to sustain a functional residency.

The second kid on the block is the newly developing collegiate training system. This is an adaptation of the UK training programme.

In this system, the trainer basically goes to the doctors rather than the doctors leaving their work stations to go to the university. Hospitals across the country are evaluated for their suitability to train and the college moves in to co-opt trainers and provide other training support both locally and remotely.

The collegiate training may have had a lot of challenges but it is gradually settling in and has graduated us a good number of surgeons.

The idea of not uprooting the doctor from their point of service means they continue to contribute meaningfully to the hospital and remain on the payroll. However, the collegiate training has to put in place sound financial policies for the sustenance of the programme in the event the current donor support runs dry.

It is alarming to see other public universities spreading their wings towards postgraduate training and falling into the same trap as the University of Nairobi. The universities must be able to afford the cost of training. However, they cannot continue to subject their trainees to slavery while demanding hefty fees. An earning resident can afford to pay fees.

Just like quality healthcare is becoming the preserve of the rich, specialty training is about to be for the wealthy.