Newsletter, May 2010

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SAMSS Newsletter, May 24, 2010


Dear Colleague,

The Sub-Saharan African Medical Schools Study (SAMSS) tracks innovations in medical education in Sub-Saharan Africa.  This Newsletter and the website are designed to raise awareness about issues related to medical education in Sub-Saharan Africa.  Using this information, policymakers, donors and medical educators can make informed decisions that will strengthen their health systems. 

In this issue the SAMSS newsletter will focus on the retention of physicians in underserved areas within Sub-Saharan Africa.

In “Wrong schools or wrong students? The potential role of medical education in regional imbalances of the health workforce in the United Republic of Tanzania”, Beatus Leon of the Centre for Educational Development in Health in Arusha, Tanzania, and Julie Riise Kolstad of the University of Bergen, Norway asked fifth-year medical students whether they were willing to accept a position in rural practice. They found that students with parents from rural areas were the most likely to be willing to work in rural areas.  Surprisingly, students who participated in a community health rotation during medical school were far less likely to opt for rural postings than those who did not. The authors believe this may be due to students finding poor conditions during their rural rotations and/or to poor organization of the rotation by their medical school. Leon and Kolstad conclude that selecting the correct students (ones who have family in rural areas, for instance) and exposing them to positive experiences in rural settings during training will positively impact physician distribution in Tanzania.

The May 2010 issue of the Bulletin of the World Health Organization focuses on retention of medical school graduates in rural and underserved areas. Many articles within the issue shed light on this important topic from various perspectives.  A study in Ghana looked at medical students’ reactions to different incentives packages to see which could be used to encourage them to take rural postings. In this study, every fourth-year medical student in Ghana was asked to choose between theoretical rural postings (no choice was in an urban area), each with a different package of financial and non-financial remuneration. Improved infrastructure, supportive management and increased pay had the largest effects upon students’ choice of posting.  Students’ choices also showed that they were willing to earn less pay if sufficient improvements were made in rural clinics and housing. A study of compulsory service programs worldwide asks if they might contribute to better distribution of medical school graduates within countries. These programs include the commonly used system of contracting medical students to work in underserved areas in exchange for scholarships or post graduate education. The researchers found that such programs, if they are carefully constructed, can increase graduates’ likelihood of working in rural areas, as well as rural residents’ access to trained doctors. A study in Ethiopia and Rwanda explored the roles of intrinsic motivation (the stated desire to ‘help the poor’) and personal background on medical students’ attitudes toward rural posting. This study showed that only 7% of Rwandan medical students are willing to work in a rural area if they are paid the current expected wage. However if salaries were to be raised, students who rank “helping the poor” as an important part of being a doctor, or who are from rural areas or less wealthy families would be convinced to take rural postings given smaller wage increases than those from wealthy or urban families.  Other articles in the same issue look at the topic of retention of doctors in underserved areas from different perspectives. 

Finally, last month saw the publication of “Career plans of final-year medical students in South Africa” by Elma de Vries of the Collaboration for Health Equity through Education and Research in the South African Medical Journal.  The study showed that students from rural areas or small towns were less likely than students from cities to want to leave the country, more likely to intend to work in the public sector, and more likely to be willing to work in rural areas.  Nearly all students planned to specialize, but about half intended to work in rural areas for some time after specializing.  The authors noted that the proportion of graduating medical students considering leaving the country permanently (about 1 in 15) was much smaller than the proportion considering emigrating 19 years ago (about 1 in 2). 

The growing body of evidence regarding strategies for the retention of physicians is encouraging in that it allows national and educational leaders to make evidence-based decisions.  It is clear that the reasoning behind a doctor’s choice of location and specialty is a topic of interest throughout Africa and beyond.  We commend the efforts of the academics doing research in this area, the policymakers working to achieve a distribution of doctors that improves national health status, and the medical schools that are training the next generation of doctors equipped to heal where healing is most needed. 





Francis Omaswa, MBCHB, MMed, FRCS, FCS

Executive Director, African Centre for Global Health and Social Transformation

Co-Chair, SAMSS Advisory Committee



Fitzhugh Mullan, MD

The George Washington University

Principal Investigator, SAMSS


Seble Frehywot, MD, MHSA

The George Washington University

Co-Principal Investigator, SAMSS


On behalf of the SAMSS Advisory Committee



A recent graduate from the Catholic University of Mozambique (second from right) teaches three current medical students in the pediatric ward of a public hospital as part of her nationally required community service.


SAMSS Advisory Committee

Magdalena Awases PhD, MA, HMPP, RN

Charles Boelen MD, MPH, MSc

Mohenou Isidore Jean-Marie Diomande MD

Dela Dovlo MB Ch.B, MPH, MWACP

Diaa Eldin Elgaili Abubakr MD
Josefo João Ferro MD

Abraham Halieamlak MD

Jehu Iputo MBChB, PhD

Marian Jacobs MBChB

Abdel Karim Koumaré MD, MPH

Mwapatsa Mipando MSc, PhD

Gottlieb Monekosso MD, DSc, FRCP, FWACP, DTMEH

Emiola Oluwabunmi Olapade-Olaopa MD,. FRCS, FWACS

Francis Omaswa MBCHB, MMed, FRCS, FCS

Paschalis Rugarabamu DDS, MDent

Nelson K. Sewankambo MBChB, M.Sc, M.Med, FRCP




During medical school, students at the University of Malawi stay in house like this one during their exposure to rural areas.



The Sub-Saharan African Medical Schools Study
The SAMSS secretariat is located at The George Washington University Department of Health Policy.
SAMSS is supported by the Bill & Melinda Gates Foundation.

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