From Backlog to Brain Drain: The Key Issues Behind East Africa’s Medical Intern Absorption Problem

In March 2024, hopeful medical interns in Kenya took to the streets in a 56-day-long strike. The issues under contention? A directive from the Salaries and Remuneration Commission had proposed to reduce intern stipends from Ksh 206,000 to between Ksh 47,000 and Ksh 70,000 – a reduction of nearly 80%.  Moreover, 1,200 newly graduated doctors were awaiting assignment to a medical internship, a mandatory step on the way to medical licensing. The Kenyan government seemingly had no solution – and no urgency. 

The Root of the Issue 

Unfortunately, the problem is not uniquely Kenyan. For two years, Ugandan medical interns have protested the delays in their deployment. Last year, the Ministry of Health announced that it had set aside UGX 35 billion – less than half of the amount it had promised in the previous year – to deploy 2,000 medical interns. All of this, while the doctor-patient ratio in the nation is approximately 1:25,000 – much, much lower than the WHO-recommended 1:1,000. 

Medical interns have been called the backbone of the medical industry; they provide invaluable services to the healthcare system. Yet they are unemployed, unpaid, and unhappy. Indeed, in Kenya and Uganda, the absorption of post-internship doctors into the healthcare system is as low as 45.8% and 48.2% respectively. 

This underutilisation not only hampers individual career progression but also contributes to a form of internal ‘brain drain’. According to the International Journal of Health Planning and Management, trained professionals are unable to secure ‘decent, regular and regulated work and become “surplus” to the absorption capacity of the health system,’ essentially remaining idle in countries with already pressing healthcare needs.  These workers are, then, more likely to seek employment abroad, effectively compounding the scarcity issue.  

This situation demands strategic policy reforms and investments in the healthcare sector. Effectively integrating these professionals into the national health workforce would mitigate the factors driving internal and external medical brain drain, enhancing healthcare delivery in the process. 

Mismatched Growth Between Slots and Graduates 

There is a demand and supply element to the issue. Governments may be inadequately providing professional and employment opportunities, as evidenced in the recent frustrations.  

In Kenya, for example, it has been found that medical schools are training students at a pace which the public-sector demand has been unable to fiscally match, with some public schools doubling, and even tripling, their yearly intakes. The same is true in Uganda, where the number of aspiring medical interns grew from 965 to 1,901 between 2016 and 2023.   

This disparity between the supply and demand for medical officers (MOs), coupled with ineffective recruitment processes, results in a significant number of MOs remaining unabsorbed by the public sector, leading to issues of unemployment and underemployment.  

Data-Driven Solutions for Healthcare Management in Ethiopia 

Ethiopia has emerged a pioneer in health management innovations in East Africa. A study on data-driven decision-making for district health management in Ethiopia analysed the efficacy of the nation’s Data-Informed Platform for Health (DIPH) utilisation program.  District health teams used this platform in 24 Ethiopian districts to make data-driven decisions by defining problems, reviewing data, considering solutions, prioritising the most feasible ones, and developing action plans. Ultimately, they uncovered general enhancements in decision-making practices through better data utilisation and systematic problem analysis. 

Ethiopia's success in implementing data-driven decision-making processes at the district level demonstrates that other countries can enhance health management practices and optimise resource allocation through prioritising data-informed strategies. In Kenya and Uganda, a systematic collection and analysis of medical school admission rates and student progress could be used to forecast annual internship needs. Governments would be able to proactively handle the resource allocation owed to these students and reduce backlogs over time.  

Ambitiously also, these governments could borrow from tech innovations in other countries. Researchers at Universitas Pendidikan Ganesha in Indonesia developed an artificially intelligent system which recommends internship placements to students according to their demonstrated skills and aspirations. Governments could, similarly, implement an AI-based algorithm which factors in both the students’ preferences and hospital capacities to pair medical students with available internship positions. Effective in equitably managing placements, a system like this would greatly reduce the administrative burden on institutions while simultaneously increasing satisfaction rates in students and hospitals alike. Of course, this solution is progressive and may be a while on the uptake. 

Funding Gap Stalling Medical Internships 

Governments often underfund healthcare sectors, leading to delays in paying for intern stipends, supervision, and hospital infrastructure. For example, following the Abuja Declaration by African states in 2001 to allocate 15% of their national budget to the health sector - not a single East African nation met this benchmark in the previous decade. And, while this target is more a guide than a rule, this chronic shortfall is emblematic of systemic underfunding of the region’s health systems.   

Before 2023, medical interns in Uganda were paid a monthly UGX 2.5 million, until the government reduced this to UGX 1 million due to budgetary constraints, payments of which were often delayed.  Similarly, many Kenyan counties simply cannot afford the stipends for the medical interns. A county cannot absorb medical officers who it cannot pay. Therefore, county governments recruit other medical cadres such as nurses or health workers, which furthers the absorption issue. Low pay or no pay, as we have seen, continues to agitate these young professionals, and the working conditions are not much better. Medical interns in Uganda, for example, often work over 12 hours a day for seven days a week. This was true even during the recent Ebola and COVID-19 outbreaks, where healthcare professionals sometimes went without protective gear. 

The solution is simple: governments must prioritise healthcare in their national budgets to ensure that they can efficiently fund medical absorption. However, where this may not be possible, they can alternatively stimulate private-public collaboration through corporate social responsibility initiatives. Private healthcare providers and pharmaceutical companies can, in this way, be incentivised to relieve some of the burden caused by this issue.  

For example, the African Health Markets for Equity (privately funded) demonstrated that engaging with the private sector has the capacity to bolster private healthcare access and quality for low-income clients. In the same way, through fostering partnerships with private health stakeholders, governments can leverage additional resources and expertise to ensure that their medical graduates have access to quality training. 

Rural Flight and Absent Incentive 

If the urban situation is bad, the rural one is dire. The phenomenon of ‘rural flight’ among medical professionals in East Africa poses significant challenges to healthcare delivery in often underserved rural regions. Many medical graduates prefer urban postings due to better infrastructure, professional growth opportunities, and living conditions, leading to a shortage of healthcare workers in rural areas. A study on final-year medical students in Kenya found that 52% of physicians work in urban areas, 42% in peri-urban, and only 6% in rural areas. This urban preference exacerbates health disparities and leaves rural populations with limited access to quality healthcare services. 

Addressing this issue could alleviate the demand strain in urban areas and increase the supply of healthcare professionals in rural ones, creating new opportunities for medical interns in the process. This can be done by addressing the current absent incentive. Offering medical interns salary enhancements, professional development pathways, or loan forgiveness can make these positions more attractive. In fact, a study done on Kenyan community health workers (CWHs) found that monetary incentives were the most effective motivator for keeping them active, with 92.8% of CHWs citing salaries, allowances, or stipends as their primary source of motivation.  

By improving rural healthcare infrastructure, offering competitive incentives, and providing well-tailored professional development opportunities, East African countries can work towards a more equitable distribution of medical professionals and enhance healthcare access. 

Conclusion 

The ‘brain drain’ phenomenon goes beyond the emigration of medical professionals from East Africa. The underutilisation of trained healthcare workers leads to an ironic problem: too many under and unemployed medical professionals in a region which desperately needs them. This disconnect only worsens existing health disparities, as underserved communities remain in need despite the availability of capable professionals. Meanwhile, the lack of opportunities for trained professionals to practice leads to financial instability, skill deterioration, and frustration. 

Consequently, healthcare systems cannot capitalise on their potential to build capacity, improve existing services, or alleviate the burden of overworked staff. This vicious cycle perpetuates poor health outcomes despite an otherwise capable workforce. 

To break this, Kenya and Uganda must prioritise policy reform, adequate funding, and creating effective deployment mechanisms to ensure that medical professionals can meaningfully contribute to their healthcare systems. From leveraging the diagnostic power of artificial intelligence to introducing simple monetary incentives, the proposed solutions tackle the underutilisation of medical professionals head-on. These measures would not only reduce the overwhelming backlog in healthcare systems but also transform the sector into a hub of expertise and innovation – a true shift from backlog to brain gain.