The Evolution of Church/Mission Hospitals in Africa
by Philip B. Wood
An informal survey of church/mission hospitals in sub-Saharan Africa discerns trends in medical missions.
Twice before I have reported on trends within church/mission hospitals in Africa (Wood 1991, 2001). I now share an informal survey1 of church/mission hospitals in sub-Saharan Africa in order to discern trends that may help in future planning.
This third survey was undertaken at the biannual Christian Medical and Dental Society in Limuru, Kenya, in February 2010. Some 192 doctors from 37 different countries (meeting with 80 faculty, mostly from the USA) provided a wonderful resource for this study. Twenty-two hospitals were surveyed. (See chart below.)
|Overview of the past three surveys conducted|
|Number of hospitals surveyed||42||37||22|
|African countries in this number||15||21||18|
|Number of expatriate doctors in these hospitals||172||76||43|
|Number of national doctors in these hospitals||58||89||107|
|Radio of expatriate to national doctors||1:0.3||1:1.2||1:2.5|
Below we will highlight six major findings from the survey.
Increase in local doctors. The increase in local doctors is encouraging, since the particular trend that preoccupied missionary doctors in 1990 was the indigenization of medical care in Africa. We are now seeing a steady increase of new national doctors. In Democratic Republic of Congo, for example, local health care workers in Kinshasa are training prodigious quantities of doctors and have several thousand first-year medical students. In contrast, there are only between ten and twenty-five doctors trained in Malawi each year. Whether training many or few, however, all those surveyed welcomed outside missionaries with medical qualifications.
Change in ownership. In 2000, there was considerable discussion on the ownership of mission hospitals, since they were by and large handed over from mission agencies to the churches these same organizations had founded. Recently, some hospitals have also been registered (with the national government by a local lawyer) as private charitable foundations. There was much discussion concerning the increase in various government legislation regarding medical services.
The majority of the twenty-two hospitals surveyed are private institutions, owned by a church or mission agency, and integrated into the various national institutions. The degree of integration varies from country to country. In Congo, a number of private church hospitals are given considerable authority to organize and supervise all the medical work in a “health zone,” be it state, church, or private facilities. One hospital in Nigeria has been taken back by the local community after a major decrease in services offered. (However, this takeover seems to have been based on local land rights and not government intervention.)
Increase/change in finances. In 1990, we reported a drop in government subsidy to church/mission hospitals. In 2010, we can report an increase in state funding. This is particularly noticeable in the hospitals surveyed in Kenya and Rwanda, countries that now have national health plans. In Rwanda, every citizen is expected to pay about $2/year. If this happens, then eighty-five percent of outpatient care and ninety-five percent of inpatient care is funded by the government in an approved hospital. In Kenya, people pay a little under $2/month and their hospital care is paid at $30/day.
Zambia pays the salaries of staff in mission/church hospitals in rural areas, but these hospitals are then not allowed to charge for services. With or without insurance, the vast majority of the twenty-two hospitals surveyed fund at least ninety percent of their operating costs from patient receipts. There are just three hospitals that raise fifty percent of their salaries and medicine costs from the missions that own or have given birth to these institutions.
Increase in training. All of the hospitals surveyed suggested that training programs were either important or extremely important. Most run informal, one-on-one training programs for doctors, but only eight run official state-recognized colleges—and these are either for diploma or graduate nurses. There are a number of inter-hospital cooperative programs like the Pan African Academy of Christian Surgeons and a similar cooperation that is being set up to train doctors in internal medicine.
Supplies from non-Majority World nations. Every church/mission hospital surveyed benefits from gifts of instruments and supplies, mostly discarded equipment from medical services in the West. Samaritans Purse, International Aid, and in the past ECHO in the U.K. have been the principal suppliers, although local churches and individuals have also helped. A number of Christian hospitals have developed organizations in the West that encourage gifts and supplies.
Importance of chaplaincy. Sixteen of the twenty-two hospitals have at least one chaplain. Kijabe Hospital in Kenya employs eight chaplains, although not all are full time. There were no reports of restrictions on the activities of chaplains in Christian hospitals.
Where Do We Go from Here?
Below are nine areas Christian healthcare workers and mission agencies need to consider concerning changes taking place throughout sub-Saharan Africa.
The nationalization of mission hospitals. It would seem that nationalization is no threat to hospitals and that governments in Africa wish to retain the historical link and benefit of church/mission relationships. Mission agencies, therefore, will likely not lose control over their investment in church hospitals. At the same time, governments do wish to integrate private institutions into the national health program in order to avoid a duplication of services and ensure acceptable standards with some uniformity of care for common diseases.
Private charitable foundations. This relatively new initiative has the advantage that decisions concerning healthcare can be made locally, without reference to the dictates of outside bodies (although they still must take note of donor stipulations). One wonders if the loss of the vetting of expatriates by mission agencies or the possible loss of prayer support might be a significant price to pay for local autonomy.
Moral duty to the national Church. Many mission agencies are seeing a drop in recruitment for Africa. This is because attention is being drawn to unchurched areas. It is easy to say that the Church in sub-Saharan Africa is now large and growing and needs less help. However, mission agencies have left behind many medical institutions for which they have a moral responsibility. Christian hospitals in Africa continue to experience open doors for the evangelization of individuals who would never enter a church.
Mission hospitals leading the way. One reason for continuing the support of mission/church hospitals is that they are providing excellent care compared to the alternatives. This is evidenced by patients who vote with their feet, in their attendance at clinics and hospitals. Tenwick Hospital in Kenya, for example, has been pioneering heart surgery in Kenya.
Young, national doctors who need training. There would seem to be two opposing trends: (1) less mission doctors offering services due to the high level of debt which doctors accrue at graduation and (2) a significant increase in the number of national doctors being trained. These trends intersect at the point where there are fewer specialists available for the ongoing mentoring of young nationals. Several schemes, such as the Pan African Academy of Christian Surgeons, are being developed to address this need. Email mentoring, where an African doctor discusses case presentations with a foreign specialist, has been suggested through CMF in the U.K. and CMDS in Canada. These relationships can lead to important published articles and the planning of research projects. Short-term visits are a proven option.
Short-term demonstrations and seminars. Specialists visiting Africa enjoy the relaxed atmosphere of a mission hospital and the interesting spectrum of cases they encounter. It is extraordinary what can be taught in practical demonstration, even with communication barriers. Seminars and workshops are appreciated by local staff, and visitors are treated with utmost respect.
The place of long-term mission doctors. On the other hand, the traditional, long-term mission doctor is likely to be less warmly received since he or she may represent a threat to the private practice of a local doctor. All the expatriates we interviewed spoke of being well received, but this is by the local population. Unfortunately, within the medical profession jealousy and pride has strained relationships. There has not always been a happy relationship between missions and government doctors. Each has kept their distance from the other. Expatriates need to show considerable flexibility if they wish to influence rather than dictate.
The future. Undoubtedly, there will be increasing governmental involvement in Christian hospitals in Africa. Is this to be feared or welcomed? Will governments influence medical workers toward a purely secular outlook, or will the large Christian presence in African governments and the enormous goodwill that has been built up over the years mean that mission hospitals will influence governments?
Where will mission hospitals be in fifty years? The answer depends upon the commitment mission agencies are prepared to make in the next few years. Will the result be institutions that are Christian in name only, or will there be a more overt presence? With God’s help, there will be a strong Christian witness that reflects the numerically strong Church of Africa.
The challenge for mission agencies is to decide whether they want to accept or reject the invitation to be involved in this evolving situation. Will they concentrate exclusively on church planting in restrictive access nations? Will they strengthen their historical links with the institutions they have founded? Will they get involved in the training programs that Africans so desperately crave? Will they, or how will they, influence the next generation of Christian doctors?
This is not a financial challenge. Vast sums of money are being given for medical work in Africa, much of which is benefiting mission hospitals. Individuals and churches have been extremely generous in their support of medical projects.
Christian hospitals continue to provide a significant proportion of healthcare south of the Sahara. The number of expatriate doctors is decreasing and the number of nationals increasing. The hospitals are benefiting from increased national government funding in some places, and the increasing level of government legislation is on the whole seen as helpful. There is a general recognition that training is a priority, as well as planning new initiatives for existing programs. No restrictions are placed on Christian witness in Christian hospitals.
We must encourage overseas missions to maintain and increase their involvement in Christian hospitals, with training being given the priority. Imaginative solutions, mainly modular and short term, are to be strongly encouraged. Missions have done amazing things for healthcare in Africa. Their contribution can and should be ongoing.
1. This survey must not be considered unbiased since the Limuru conference attracts missionary doctors who are looking for continuing medical education. This is then a survey of institutions that have (or have had) a strong missionary presence. Nevertheless, it appears that the number of overall expatriate doctors is decreasing, while the number of national doctors is increasing.
Wood, Philip B. 1991. “Mission Hospitals in Africa: What’s Their Future?” Evangelical Missions Quarterly 27(2):168-171.
________. 2001. “Church/Mission Hospitals in Africa.” Evangelical Missions Quarterly 37(2):174-177.
Philip B. Wood is a surgeon who has served twenty-seven years in Africa. For ten years, he was the Canadian director of WEC International.
EMQ, Vol. 47, No. 3, pp. 336-340. Copyright © 2011 Evangelism and Missions Information Service (EMIS). All rights reserved. Not to be reproduced or copied in any form without written permission from EMIS.