No Problem Exists in a Vacuum
A colleague made a fascinating comment during a meeting the other day. Deep in my post-Taco Thursday food coma, I did not process his words until long after.
“Under staffing is protective in one sense: [they] do not have the resources to pay everyone if the facility was fully staffed.”
This blew me away (once I woke up enough to consider it). Almost any description of the health burden in sub-Saharan Africa trots out the lack of trained medical personnel as one of the top issues. The US has approximately 390 patients per doctor; Rwanda has 20,000 (check out this map with numbers based on the 2006 World Health Report). Nurses staff most health centers and doctors typically appear only at the district hospital level. The international community spends millions of dollars on capacity improvement and medical education every year in order to decrease that ratio ever so slightly. Admittedly, Rwanda is much better off than many other places; but could it really be that increasing the number of trained medical personnel would only cause other problems?
Before we answer, let us consider some context! One of the many factors that drew me to Rwanda was this article by the New York Times last year describing the innovative Mutuelle insurance program. In short, Mutuelle aims to provide universal coverage to all Rwandans for a sliding-scale premium which pays into a community-risk pool. The poorest of the poor pay nothing while wealthier individuals pay up to 5000 RWF per year—about $8. According to the New York Times, the program currently covers about 85-90% of Rwandans and allows most people to access medical services for a minimal user fee (based on my experience here so far, I think the actual coverage is much lower).
Of additional interest to me and this post, however, is the impact of the Mutuelle program on hospital staffing. Because doctors now get paid the same regardless of which hospital they work in, the pressure to abandon rural postings for more lucrative urban ones is much reduced. Even far-flung rural district hospitals have several physicians, a stark contrast to rural hospitals I visited in other countries that were lucky to have one.
Clearly the need for more trained medical personnel exists, but we must exercise caution when considering a single story. No problem exists in a vacuum and to act otherwise is to ignore the complex intersection of health, economy, and education. Simply training more doctors will not resolve the health problems Rwanda faces for the exact reason my colleague described. You can train all the doctors you would like, but if you cannot pay them or provide opportunities for professional growth there is little incentive for them to stick around.
So the answer to the question above is “yes,” if we stay myopically focused on fixing one problem to the exclusion of others. I feel the same could be said of many other issues. My colleague’s comment highlighted for me the importance of considering the broader picture. To address global health issues, we cannot focus on one small piece at a time without consideration of the context. The health issues that GHC and our partner organizations combat each year do not exist as standalone problems, hence why our activities cover such a broad range—from medical training to M&E to health infrastructure improvement. The scale of it feels daunting at times, but such range is necessary to really make an impact. Big issues require bigger thinking.