by Philip B. Wood
Today’s tough decisions concern structure more than finance.
Over the last 10 years there have been considerable changes in central Africa. On the political front the first post-colonial leaders have been replaced with a less powerful group, whose hold on government sometimes appears tenuous. Several countries in central Africa are at war and there are few signs that there will be any speedy resolution to many of these conflicts. To the outsider, the continent appears to be in complete disarray, with some governments barely functioning, including their health departments.
Not that there aren’t signs of progress. One hospital in war-torn Congo boasts two satellite phones. The head nurse in the operating room of this institution also has a TV dish on the roof of his house and regularly watches CNN. Cell-phones are everywhere in Abidjan, Accra, or Kinshasa and massive advertising billboards are proliferating in many of these capital cities.
In the midst of this constantly changing political and social climate, church/mission hospitals strive to deliver quality care with very limited financial resources. Their clientele are very needy populations amongst whom the expectation of life is declining.1 Medical institutions are being forced to change as they adapt to the current situation. Two general trends involve: (1) national doctors who are assuming leadership roles and; (2) issues involving the ultimate control of hospitals as they continue their movement from the domain of foreign mission to that of the local church.
Hence I choose to refer to Christian medical work as being church/ mission-since sometimes it is the church in ultimate control, sometimes the mission.
Ownership is still a surprisingly touchy issue for medical workers in Africa. Where the church has been intimately involved in the management of an institution for decades, there is little problem. The leaders of these facilities have generally concluded that there is a need for ongoing expatriate help and are happy to continue to receive it. In a few situations, a hand-over to the church is still being planned. This sometimes involves training programs that envision expatriates moving out ‘en bloc’ when the hand-over occurs.
The numbers of expatriate workers in many hospitals has declined rapidly in the last 10 years. ELWA hospital in Liberia had five expatriates in 1990. Now there is only one. Nyankunde in Congo had seven expatriate doctors in 1990, but now none remain. In both cases, government instability has led the missionaries to leave.
It is still very difficult to estimate the proportion of medical care provided by church/mission hospitals as measured against government services. It is, however, probably fair to make two general observations:
1. Much more care is given in rural areas by church hospitals than government services.
2. Most church/mission hospitals see the need to be more connected with government institutions.
Suffice it to say that church/mission hospitals still provide an extremely important service in Africa today.
In 1990 I surveyed 42 mission hospitals during a refresher course for Christian doctors in Kenya.2 I repeated that survey in 2000 at the same refresher course. Some of the differences that I found can be seen in Table 1. As I took my survey I was surprised by a number of common elements. Despite the difficulties, many hospitals are expanding their community health programs. In the past, considerable sums of money have been made available for such programs, particularly through USAID to such countries as Congo and Liberia. In many cases these funds are no longer available. Nevertheless, departments struggle on and try to expand their activities. The ethos of "appropriate care in Africa," first enunciated by King and colleagues in Kampala,3 would seem to be well accepted and now firmly entrenched.
Table 1: Survey of Church/mission hospitals in Africa
No. of Hospitals Surveyed: 42
In this No. of countries of Africa: 15
No. of expatriate doctors: 172
No. of national doctors: 58
Ratio of expat to national doctors: 1:0.3
Hospitals surveyed: 37
No. of countries in Africa: 21
No. of expatriate doctors: 76
No. of national doctors: 89
Ratio of expat to national doctors: 1:1.2
With rampant inflation, the loss of some funding, and a deterioration in the infrastructure of a number of countries, it is no wonder that many hospitals find it increasingly difficult to get supplies. Twinning between hospitals (one in the West with one in Africa) has allowed the transfer of some technology and supplies, as well as an exchange of personnel. Such exchanges can go a long way toward meeting the unending need to improve the training of medical personnel on the continent. Without such help administrators can be tempted to believe that improved medical care can come simply by asking for more money. As an alternative to a purely economic approach, one can point to vast improvements where individuals’ horizons have been broadened through experience in another institution. Much more could be done in this vein.
Administrators are constantly being asked for a "quick fix" of difficult situations. It is possible to attempt to fix all the minor problems without regard for the bigger picture. What impact is the institution having on the local community or on the Kingdom of God? What is the vision (or mission) of the hospital?
In talking to African doctors at this year’s Kenya conference it was sad to hear their impression that few missionaries work well with the church. It may be that paternalistic attitudes are still prevalent and reflect a sense of cultural superiority that missionaries themselves may not be aware of.
This refresher course has become increasingly better known since it started in 1980, and I would not take the increase in numbers attending to indicate a significant change in the number of Christian doctors in Africa. On the other hand their ethnic origins may be a reliable indicator of the mix of Christian doctors working on the continent. By using stereotypes that may not be accurate, one could argue that there seems to be fewer bold innovative Americans starting projects in Africa today and more European doctors who seem to work more easily under national leadership.
National doctors pay a price in working in the largely rural church hospitals when salaries in the cities are higher and schools for their children are of a higher standard. However they often gain better facilities for work and a healthier Christian community for living.
HIV infection is a gigantic challenge in Africa today with from six to 30 percent of the population between the ages of 15 and 49 infected.4 Half the patients in some church/mission hospitals are HIV positive. The church has a major role to play in the prevention of AIDS, offering a change in life style and morality rather than the scare tactics that are most often used to influence people’s way of life.
Africa is poor. In Congo the vast majority of patients find it difficult to pay even the modest fees that church hospitals charge in order to pay their staff and purchase pharmaceutical products. Not that there is not economic advance as witnessed by the Mercedes cars outside Ferekesedougu Hospital, or the cell phones, rental cars, and billboards of the large cities. But these are for the elite few.
Church/mission hospitals in Africa are changing due to the multitude of circumstances they face. Still, they continue to provide a significant proportion of the medical services offered the population south of the Sahara. AIDS and war are major difficulties faced by these institutions, but the church is in a unique position to play a significant part in the amelioration or resolution of these problems.
1. Projected changes in life expectancy. UNAIDS Joint Conf. of African Ministers. Addis Ababa, May, 1999.
2. "Mission Hospitals in Africa: What’s Their Future?" in EMQ, 1991, 27, No. 2: 168-171.
3. King et. al. Medical Care in Developing Countries, OUP, 1966.
4. Spread of HIV in sub-Saharan Africa. UNAIDS Joint. Conf. of African Ministers. Addis Ababa, May, 1999.
Philip Wood is a surgeon who served 17 years in Africa. For the last 10 years, he has been Canadian director of WEC International and is preparing to return to Congo.
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