The Sudanese Medical Exodus

Someone in Khartoum said to me that Sudan has no middle class. Was he right? Is Sudan a socialist idyll, where contentment, fraternity and rational distribution flourish under a red-hot sun?

Well no, Sudan is in fact real country, not some rosy proletarian fantasy. My friend went on to declare that Sudanese society consists of just two classes; there are the elites, sitting up high on top of their mountain, and then ‘everyone else’ living down beneath their feet. Now I don’t think that either of us believed literally in this two-class hypothesis. But whether there are really two or twenty-two social strata in Sudan is not so important for the purposes of this post. Rather it is the feeling which prompted my friend, a doctor, to make his comment. It is this same feeling, of disaffection and disempowerment, which drives one of Sudan’s continuing tragedies, the exodus of health-workers. This blog explores this topic firstly through some facts and figures, to get an idea of the scale of things, and then secondly through considering what social status means across different societies and what some of the ‘push and pull’ factors there are for doctors in Sudan.

1 – In Facts and Figures: Education & Emigration

It wouldn’t be an exaggeration to say that almost every medical student or doctor to whom I spoke on my elective expressed a wish to leave Sudan and to work or study abroad. Most people knew someone who had already left and gone to the UK, US, Europe or to one of the states on the Arabian Peninsula such as Kuwait, UAE or Saudi Arabia. Indeed the issue is so widely acknowledged that one of the Sudanese newspapers even carried an editorial on the topic whilst I was there (Sudan Vision 26th September 2012).

So what is the real scale of this? (Here follows five short paragraphs involving one or two statistics which aim to clarify the scale of the ‘exodus’.)

In a study published in 2005, Mullan lists an ‘emigration factor’ for Sudan of 11.1, i.e. 11.1% of doctors who qualified at home now work abroad in either the UK, US, Canada or Australia (Mullan, NEJM 2005). This proportion is likely to be much higher in reality. Mullan does not consider migration eastwards across the Red Sea, or indeed to Ireland where there are reportedly 600 Sudanese doctors registered with the Irish Medical Council (Ali et al 2012). However, using this estimate of 11.1% yields a minimum figure of 1250 practicing doctors who have left Sudan (anyone who wants to see my working is welcome!). Add to this figure those doctors working on the Arabian Peninsula, in Ireland and those within Sudan who have left the profession before retirement-age for whatever reason and you’re looking at a high number of doctors lost to the Sudanese medical system.

Statistics from 2008 show that Sudan had a total workforce of 10,000 doctors serving a population of 35 million people, which yields a workforce density of 0.28 physicians per 1000 population (which is fairly low) (WHO Global Atlas of Health Workforce). For comparison, the UK has a total of around 160,000 doctors serving a population of 62 million, yielding a workforce density of 2.6 physicians per 1000 population (OECD 2011; Global Atlas of Health Workforce2010).

To increase Sudan’s ‘physician density’ (taking into account an annual population growth rate of 2%), Sudan would need to have a net increase of at least 200 doctors per year (i.e. a positive balance between the number of newly-graduated doctors entering the system and those emigrating or retiring out of it) (UN Data).

This might sound fairly easy and indeed there are grounds for optimism from a statistical point of view. There are reportedly 2-3000 medical graduates each year from around 30 Sudanese medical schools, following two decades of rapid growth in the medical education sector (Fadlalla et al 2012; Ali 2009).

However, there are no available data on the rate of medical migration i.e. how many doctors leave each year, so it is impossible to predict the speed with which physician density in Sudan may increase.

Furthermore an increased number of medical graduates doesn’t automatically equate to more doctors. The percentage of government resources spent on health has decreased between 1995-2010, whilst total government resources are diminished following the separation of South Sudan (WHO Global Health Expenditure Atlas). Indeed I met graduates who had waited for up to a year for a House Officer position. So whilst more graduates might help to fill Sudan’s hospitals, they can also lead to a greater pool of young professionals looking for work, and considering emigration.

2 – The Faces and Feelings: Status and entitlements

Photo of London by Jason Hawkes

So much for the facts and figures, what about people and their motivations? One of the doctors I worked with was a fairly typical example, bright, competent and independent – a pretty good doctor to have in your health system. And she wanted to leave. Her brothers worked in the UK, cousins in the US, an uncle in Kuwait and several friends were now in Saudi Arabia. We discussed her own options outside Sudan; the US medical licensing exams (STEP 1, 2 & 3) are hard and require an extended period of intense studying (on top of making a living). The visa requirements for entry to the UK have tightened over the last few years, and include rigorous English language-, and a different set of medical-, exams. It’s easier to get a visa and a license to practice in another Arabic country, but career progression is slower, as employment contracts for junior doctors often include a commitment to an extended period of work at a junior level.  So wherever a prospective émigré chooses, they must jump, spin and study their way through a whole series of hoops, hurdles and exams without a guarantee of success (e.g. gaining a visa or a job) at the end. So why go through it?

This is where we come back to my friend’s feelings about social relations. On the one hand, students and doctors wanted me to share in their strong affection for their people, country and it’s potential. On the other, they felt strongly that staying in Sudan themselves meant accepting for some years a life of limited opportunity and social stasis.

Without getting too theoretical, there are many ways to analyse a person’s societal status. In simple terms, you might consider the size of their bank balance, house or car. At the more sophisticated end is Amartya Sen’s Entitlement theory which was developed in the context of famine. Here, an individual’s status is effectively defined by their ‘entitlements’ which include all the means they can access, whether legal, financial, moral or whatever-else, to use in getting what they want (Sen 1981). Simplifying and applying this beyond a famine setting to society in general, a person’s status might be defined by all the means and opportunities they have to improve their professional or domestic situation – their chances of gaining a better quality of life.

Graduating from medical school in Sudan does not mean the same things as it does in the UK. In Britain, I don’t think it would be too controversial to say that medical qualification signifies an individual’s accession to a comfortable middle-class status. UK medicine (whatever doctors might grumble), is a well-rewarded profession. It carries a decent salary, robust degrees of domestic comfort and job security, and opportunities for career advancement. It also generally means admission to one of the medical unions, such as the British Medical Association (BMA) or the Medical Defence Union (MDU) which act to protect doctors’ interests. So for UK doctors, entitlements (as defined above) come in all shapes and sizes; financial resources, career mobility (i.e. you can progress up the career ladder) and legal support.

And isn’t this the way it should be? On the one hand, quite apart from the fact that doctors are all delightful people, they actually provide a very valuable service to their community. Shouldn’t they be afforded the advantages proportionate to this social worth? On the other hand, aren’t doctors merely performing their job like another other honest citizen and so should be paid on the same scale? Does a doctor working nine-to-five in an air-conditioned clinic have a harder job than the man who works day and night washing cars? It would be an abuse of doctors’ position to demand more money, no? In fact this second stance is perhaps not too far away from where things are in Sudan.

A hard-working car-washer can reportedly earn more in a month than a junior doctor (around US$500 or ~SDG£95/day). After their first year as a House Officer, Sudanese doctors must then take a pay cut and work without a contract as a ‘General Practitioner’. Career progression to the post of registrar depends on studying hard, saving-up the entrance fee for a further set of exams (e.g. the UK MRCP or MRCS exams) and doing enough shifts to stay afloat. Whilst Sudan does have its own “Medical Specialisation Board”, openings for postgraduate training are acknowledged to be limited and poorly funded. So it’s quite possible to get stuck at this level for several years (although once at the Consultant level remuneration can increase exponentially as opportunities for private sector work arise).

Since they may be unable to get a foot on the property ladder at this stage, doctors often live in hospital accommodation – which may be subsidised or even free – unless they can live with family. Whilst this might be a cheap, convenient and communal option, it is not (to put it one way) exorbitantly luxurious. Neither are the parking nightmares lived by UK healthcare staff a feature in Sudan, since relatively few doctors have cars.

As for legal rights, medical organisations do not function as trade unions and so do not engage in any political action. In 2010-11 doctors’ strikes were organised independently over unpaid salaries, working conditions and accommodation. These were met bluntly with threats, arrests and imprisonment, with no subsequent action taken by the government to address doctors’ grievances (McDoom 2010; Sudan Radio Service 17 March 2010; Sudan Tribune, 18th March 2010, 3rd June 2010, 17th May 2011). The government response to this was perhaps tempered by remembrance of the 1985 revolution overthrowing Sudanese President Jafaar Al-Nimieri, which involved professional unions of doctors, lawyers, bankers and academics.

So overall, many of the entitlements that define UK doctors’ status are rather different in Sudan – whether this is in terms of a salary, a house, a car, job security, professional training and promotional opportunities or legal protection. So are doctors so different from car-washers in Sudan?

Perhaps the defining status symbol is a travel visa. Ultimately, medical knowledge and skills provide greater weight to a visa application than a bucket and sponge. Whilst migration may be difficult for Sudanese doctors, it remains possible. And the significance of a visa application is that it is the first step in reaching out towards the opportunities that exist in other countries.

Solutions (?) & Conclusions

The Sudanese Minister for Health, Dr Bahar Idris Abu Garda, is understandably keen to retain doctors within the health system. International solutions have been proposed including tightening immigration restrictions in countries such as the UK, ethical recruitment policies (i.e. not advertising NHS or BUPA vacancies in Africa) and paying compensation for training costs and labour value to the government of an immigrant. Such ‘solutions’ are likely to be little more than fripperous baubles, glittering briefly for those who glance at this issue, but lacking any impact on the root problems.

Surely the only real solution (and the hardest to achieve), is to begin lowering the mountain, to create opportunity, increase social and professional mobility and to close the gap between the elites and ‘everyone-else’. In other words, it would be better to try and make people want to stay, rather than just preventing them from leaving.

Maybe this starts with greater and more structured investment in the health system. There have been significant achievements already; undergraduate medical education has grown rapidly over two decades. Now postgraduate training and employment capacity need the same level of attention.

Quite how this is to be achieved is difficult to conceive, given Sudan’s reduced national income (since the secession of South Sudan), its high defence spending and the burden of international debt. But the green shoots of regeneration are present in the new cohorts of medical graduates and doctors coming through, with their desire to improve their country. The best response is not to decrease opportunities to leave, but rather to increase opportunities for those who stay.



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Ali, Z. (2009) The third international conference on medical education in Sudan: lessons about undergraduate medical education. Sudanese Journal of Public Health. 4 (4) 411-413

Ali, Z., El-Higaya, E., Ibrahim, N., Elmusharaf, K., Shadad, A., Elshafei, M. Ahmed, M. (2012) Migration of Sudanese Doctors: Dynamics and Opportunities – Conference Report. Sudanese Medical Association UK and Ireland. 9th June 2012.

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Storm clouds and CT scans (and some food puns to chew over)

My Friday evening this week was spent in a seminar room in a Khartoum hospital, sheltering from the thunder and lightening outside, and listening to a presentation on radiology and orthopaedics.

These first few roasting weeks have sometimes left me looking like a tender young lobster who has fallen into some strawberry ice cream (so yes indeed, exotic AND delicious). Even though I’ve now become a little more used to the heat and the glare, such a dramatic change in the weather was quite fun. Huge storm clouds blocked out the sun, lightening stretched from horizon to horizon, rumbling thunder drowned out the traffic. On the road towards the university, wind whipped up dust to fill the air (plus eyes, ears, nose and mouth), and just a few rain drops fell.

So instead of spending the evening being fried and battered (by lightening, wind and sand), we (the three other international elective students and me) sped off to a hospital to learn about bones on a radiological plate. The lecture was delivered (in English) by a Sudanese radiologist recently returned from working in Britain. It explored ways in which radiology can aid orthopaedic surgery, focusing on knee and back problems. I’m including the event in this blog just because it was interesting just how little seems to change between medical contexts. Indeed, in many ways the session was identical to every clinical meeting I have attended in the UK (although there were a few differences).   

The audience was arranged around a conference table, with the presentation projected onto the wall at the far end of the room, just as it might be in the UK. The senior professors and consultants, dressed in white jellabiyah (ankle length gown) and imma (turban) were sat around the table, with the juniors spread out behind on both sides.   The presentation itself (on powerpoint of course) was about an hour long, during which the row of turbans in front of me bobbed and shook at significant points (just as the front-row of heads do in the UK).

Afterwards came the questions. It seems that senior clinicians throughout the world develop their own tried and trusted habits, techniques and theories – their own ‘flavours’. ‘Question-time’ is a chance to share these favourite flavours, to give everyone a good long taste. And, just as in the UK, there is always some culinary disagreement, leading to more bobbing or shaking and a second round of tasting. The dessert, after all that, was two presentations from the pharmaceutical companies sponsoring the event.

There were also some interesting observations about the way in which the Sudanese health system is fragmented. There are a large number of different hospitals in Khartoum alone, some public (state-subsidised), some private, some general and others specialising. This has many effects; it results for example in a large number of referrals between hospitals, with little continuity of care and no central patient data system. It also means that for disciplines such as radiology, where large and expensive equipment is involved, very few centres are large enough to afford such equipment, or will use it often enough to make it cost-effective.

I believe that health financing in Sudan is largely private, with patients at both private and public hospitals bearing most of the costs of their care. Health insurance companies and state health insurance also play a growing role. International organisations and mechanisms also support specific vertical programmes or local health facilities, such as the detection and treatment of tuberculosis or leishmaniasis. The balance between patients and profits is often a controversial one in health systems, and I suspect that a study of health financing in Sudan would make for some interesting reading (if anyone knows of any then please get in touch!).

So altogether, a stormy appetiser, some tasty morsels and plenty of food for thought!