Quality, not quantity of doctors, must be Uganda’s priority

Whereas full employment and continued education of all recent medical graduates in Uganda is of utmost urgency, it should be accompanied by concurrent, independent external reviews of the fourteen medical schools in the country. Thirteen of these medical schools have been started in the last 35 years, with more than half of them opening their doors in the last 12 years.

According to the Uganda National Council for Higher Education, the fourteen medical schools are at Makerere University, Kampala International University, Uganda Christian University, Uganda Martyrs University, King Ceasor University, Equator University of Science and Technology in Masaka, Mbarara University of Science and Technology, Kabale University, Fins Medical University in Kabarole, Busitema University, Islamic University in Uganda, Soroti University, Lira University, and Gulu University. Seven (Makerere, Mbarara, Kabale, Lira, Gulu, Soroti, and Mbale) are faculties of public universities. The other seven are part of private universities, three of which are not-for profit religious based institutions.

This proliferation of medical schools in Sub-tropical Africa is not unique to Uganda. For example, Kenya has 12 approved medical schools, Tanzania has 9 (including a branch of the Kampala International University), Zambia has 9 (six of them in Lusaka alone), Congo Free State has 15, Ethiopia has 18, Nigeria has 45, and Somalia is said to have 18.

Interestingly a few countries have avoided this rapid planting of medical schools. Wealthy South Africa, with a population of 60 million, has only 10 medical schools, six of which were started between 1912 and 1955. Likewise, wealthy Botswana and Namibia, with populations of 2.7 million and 3 million, respectively, have only one medical school each. Rwanda and Burundi, each with a population of 14 million, have three medical schools each.

It is difficult to ascertain an accurate number of Ugandan medical graduates every year. Newspaper reports have suggested less than 1000 a year. There were at least 1,383 medical doctors that were eligible for employment as interns in 2024. Hundreds of them are currently unemployed, suggesting that there is no integrated planning between the universities, the ministries of education, health, and finance, the National Planning Authority, and the district administrations, to ensure balanced supply and demand.

With a current population of 46 million, and a high birthrate that will make Uganda home to 85 million people by 2050, our country needs a larger number of doctors than it has now. The current doctor: patient ratio of about 1:25,000 is well below the WHO recommended ratio of 1:1,000. So, the theoretical ideal would be to accelerate the production of doctors to meet requirements.

However, producing large numbers of doctors that become unemployable is most unwise. The only thing worse than that is to produce doctors whose knowledge and skills fall below international standards. Very high-quality doctors should always be a non-negotiable expectation by the citizens and the government of Uganda. The quality, not the quantity, of doctors must be the priority. It is better to have very few but thoroughly educated and competent doctors than large numbers of half-baked degree-holders that are a danger to the patients, the community, and to themselves.

There is an old Latin adage, primum non nocere, meaning “first, do no harm.” This has been held as the gold standard for medical practice in most of the world. Coined by the seventeenth century English physician Thomas Sydenham, and not Hippocrates as is often erroneously stated, this is a principle that demands that whatever doctors do, it must not be to the detriment of their patients’ wellbeing.

However, many of us believe that this adage falls short of accurately describing what we desire for our patients. First, it is impossible to be a good doctor and do no harm. Every medical or surgical intervention, including drawing blood for laboratory examination, carries the risks of inflicting harm through temporary pain or side effects. Second, a doctor who is sub-optimally educated and possessed of limited experience, can avoid doing harm to a desperately ill patient by doing literally nothing except to send them to someone else. The harmless doctor in Mityana, who sends a bleeding pregnant woman to a specialist in Kampala without initiating a venous infusion of fluids, even blood, does harm by doing no harm.

What we need is a very well-educated doctor that will act immediately, methodically, and efficiently, with an excellence consistent with the expected standards of care. This will involve some invasive life-saving procedures, performed with confidence and competence born of excellent education and supervised practical learning. In the process, the good doctor will do no harm by doing harm to the patient.

This is expressed with the phrase primum, noce apte (first, do harm appropriately), which Dr. Joseph Bernstein, an orthopedic surgeon at the University of Pennsylvania, USA, has proposed to replace primum, non nocere. I like it very much.

For example, a doctor who recognises obstructed labour and does the good harm of cutting the mother’s abdomen to save her and her baby, does no harm to her. Knowing when to do this demands excellent, current knowledge and competent experience learnt from the very best teachers before independent practice.

Uganda, with a population of 46 million in 2024, is theoretically attempting to narrow its doctor-to-population ratio, which remains way below the WHO recommendation of a ratio of 1 doctor to 1,000 people. Whereas it is very difficult to determine the actual number of doctors in active medical practice in Uganda, the current doctor-to-population ratio appears to be somewhere around 1:25,000.

However, the priority must be the quality of medical graduate that is allowed to engage in independent practice. The medical schools, the internship training centres, and programs for mandatory continuing medical education for maintenance of competence for all doctors, must be of uncompromisingly high standards.

That is why I personally favour fewer but well-staffed and well-equipped medical schools and teaching hospitals, with very high entry requirements, that produce doctors that stand shoulder-to-shoulder with graduates from any first-class medical school in the world. Serious consideration should be given to mergers of some of the publicly funded medical schools, to take advantage of economies of scale, and maximise the limited human and financial resources in the land.

Furthermore, drastic reduction of the numbers that both public and private medical schools admit should be implemented. The medical school class sizes can then be gradually increased again as resources permit, without compromising standards of excellence.

These and other remedial and long-term measures would probably be best handled by a Uganda Medical Education Council, created as an independent organ, and charged with setting standards, ensuring their maintenance in all medical schools, preparing, administering, and marking standardized nationwide examinations for final year medical students, validation of physicians’ credentials, and maintenance of doctors’ competence through lifelong medical education.

Doctors need fair pay and respect, not lectures about patriotism

Medical interns need support from their elders in their struggle for recognition as doctors