How African doctors make ends meet: an exploration.

This paper is an attempt to identify individual coping strategies of doctors in sub-Saharan Africa. It also provides some indication of the 'effectiveness' of these strategies in terms of income generation, and analyses their potential impact on the functioning of the health care system. It is based on semi-structured interviews of 21 doctors working in the public health sector in sub-Saharan Africa and attending in 1995 an international Master's course in Public Health in Belgium or in Portugal. This small sample of physicians yielded reports about 28 different types of individual strategies. Most of these potentially affect health service delivery more through reduced availability of staff than through the more blatant misappropriations. Activities related to the health field are mentioned most often. Allowances and per diems seem to be top regarding frequency and effectiveness, followed by secondary jobs, private practice or gifts from patients. None of the interviewees, however, admits using public resources for private purposes. Side activities may bring in very considerable amounts of income, out of proportion to the official salary, and can also be very time consuming. Nevertheless, all interviewees identify themselves in the first place as civil servants. Individual coping strategies may lead to undesirable side-effects for health care delivery, through a net transfer of resources (qualified personnel-time and material resources) from the public to the private-for-profit sector. There may also be positive effects though, be it in terms of mobilization of additional resources, of stabilization of qualified personnel or of realization of professional goals. However, these emerging strategies call for innovative mechanisms, likely to shape coping strategies in such a way that they remain compatible with equity and quality of care to the population.