Mission Hospitals in Africa: What’s Their Future?

by Philip B. Wood

They are still essential, but changing circumstances require some tough decisions.

Medical care is getting more expensive and many mission agencies are cutting back their medical ministries. But such decisions should be based on an analysis of the contribution that medical missions are making.

Unfortunately, hard data are very difficult to obtain, especially in Africa, where the administrative infrastructure does not exist to provide accurate statistics. However, it is possible to discern some trends.

CHANGING PATTERNS IN MEDICAL MISSIONS
Back in 1968, according to one study 30 percent of total medical services in Sub-Saharan Africa were provided by mission hospitals. It is difficult to calculate a similar figure today, but probably mission hospitals are carrying a larger share of national medical programs. Large government hospitals have not done well over the intervening years. For example, in 1972 Mama Yemo Hospital, in Kinshasa, gave a very high standard of service, but consumed 40 percent of Zaire’s health budget. It no longer provides sophisticated care, and consumes far less funds. The John F. Kennedy Memorial Hospital was donated to the Liberian people in 1975 and had to be closed in 1984. It once had a bed occupancy of only 40 percent. Mulago Hospital in Uganda was a thriving institution when Idi Amin took power in 1969, but it has rapidly deteriorated. As a result of "serious, insurmountable problems" at Mulago, one expatriate doctor spent two days a week in a mission hospital where he found "dedication, optimism, and hope where all around were economic and political turmoil and insecurity."

The failures of government hospitals have been linked to inadequate salaries. The professor of surgery at the Medical College in Freetown, Sierra Leone, receives the equivalent of $2O a month. However, the federal minister of health in Nigeria has suggested that the major problem of African teaching hospitals was "leakages." He was referring to the continuing high rate of theft, looting, and corruption.

More exact statistics are available in Kenya, and it has been estimated that half the hospital beds in the country are provided by missions. Beds in mission hospitals may be used more efficiently than at government hospitals. The average length of stay at ELWA Hospital, Liberia used to be three days, while down the road at a large government hospital it was 21 days.

RECOGNIZING THE CONTRIBUTION OF MISSION HOSPITALS
Tacit recognition that mission hospitals are using money more efficiently than other institutions has been given by the United States government, which has invested money in ecumenical church organizations, such as the Eglise du Christ au Zaire and the Christian Hospital Association of Liberia. Governments could have expected this money to be given to their health ministries.

While outside agencies have been increasing their funding of mission hospitals, African governments are reducing it. The Zaire government gave generous subsidies until about 1978, and initially all drugs were free through the DCMP (Depot Central des Medicaments Pharmaceutiques). Since 1980 the DCMP warehouse in Kinshasa has been as good as empty, despite some attempts to get it restarted. Also, African governments are happy to privatize government hospitals and services. Today it is possible to buy a government hospital in Zaire for $1 for a two-year period. The hospital will be just a shell, but the government is happy for missions to refurbish their hospitals. About 10 years ago, the Nigerian government took over mission hospitals, but is now asking the missions to take them back again, indicating they recognize the contribution of mission hospitals.

MISSION HOSPITALS, A SURVEY
To gather some up-to-date information, I surveyed 42 mission hospitals in 15 Sub-Saharan countries during a conference of mission doctors in Kenya in February, 1990. Only three governments (Zambia, Zimbabwe, and Swaziland) provided substantial help to mission hospitals. The vast majority of hospitals fund their operating costs from patient receipts. Usually that is easier to do in the relatively richer countries where patients have more money.

One item of relatively uniform costs, regardless of the receipts of the hospital, is drags. Most countries do not have locally available medicines and most hospitals buy, in American dollars, from the International Pharmacy Association in Holland (IPA). Since salaries and medicines account for the bulk of operating expenses, hospitals in poor countries tend to speed all their resources on essential drugs. They have little money available for salaries.

Doctors’ salaries, in most hospitals, are much higher than nurses’ salaries; hospitals with many national doctors have huge salary bills. Salary bills can, therefore, be most easily reduced by employing fewer national doctors.

One aim of most mission hospitals is to indigenize the work as soon as possible, but we have made little progress over the years. In 1963 the Directory of Protestant Church-Related Hospitals listed 1,231 mission hospitals staffed by 828 missionary doctors and 1,317 national doctors-a ratio of missionary to national of about 1:2. Today, in this survey of 42 hospitals, 172 missionary doctors and dentists are working with 58 national doctors, a ratio of 1:1/3. Without a doubt, some missionary doctors are not being replaced by nationals, because it costs too much to hire a national doctor. Also, if a national removes a missionary he replaces a potential source of hard currency.

Most hospitals want to build on the confidence the local people have in their medical services, in order to branch out into community-based, preventative health care. Unfortunately, people fail to see the imperative of prevention, and although they will pay large sums for care when they are sick, it is extremely difficult to raise funds for preventative programs. Because such programs drain finances, they tend to receive a low priority regardless of their potential value.

SURVEY CONCLUSIONS
1. Many patients still come to Christ in mission hospitals. More people pass through a Christian hospital than any other Christian institution.

2. Christian hospitals are providing examples of discipline and good administration that can be followed.

3. Undeniably, mission hospitals are having considerable difficulty making ends meet; this is reflected by the low number of national doctors employed in these institutions.

4. If there is value in our hospital work, we need to raise more prayer support and increase our staffs, even if in some cases financial support must be reduced.

5. We must disseminate the accumulated experience of mission hospitals by their closer integration into government services, but without losing the particular Christian ethic of hospitals. This could have a great impact on the next generation of African doctors.

SUMMARY
Mission hospitals are undoubtedly contributing greatly to medical care in Africa. Whereas government hospitals are plagued with "leakages" of various sorts, mission hospitals have had the discipline to stanch some of the leaks. Mission hospitals are further along the road to financial self-sufficiency than many government institutions. In this regard, interdenominational missions are showing the way, since they have never had the financial backing of a large denomination.

Further prospects look grim, since medical students see poor examples to follow in government institutions. Therefore, well-run mission hospitals should train doctors, and offer medical students and administrators attainable standards. Our future planning should be based on more than the availability of dollars and cents.

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