The anatomy of a white elephant
Elephants of the natural variety are normally grey. These natural pachyderms can be dangerous as they will trample fields and people but they are not half as dangerous as man-made white elephants. The formula for creating these deadly beast is, in all places, the same. Just add three parts hubris, two part ignorance of the facts (or in some cases just greed will do) and one part cowardice and sure enough, there you have a perfect man-made white elephant. If a country makes enough of these it will financially self-destruct. I have seen many and the one recently built at UNAM, the Medical Faculty fits the formula perfectly.
In the past you could be assured that if you sent your child to study medicine or nursing they would, unlike so many other graduates, end up with a good well paid job. Based on that assumption large numbers of Namibians sent their children abroad to countries like South Africa, Russia, China, Ukraine and Cuba for medical studies. Many have started to return and they have begun to compete with the increasing number of home-grown UNAM doctors seeking internships that are the next stage of completing their studies and apprenticeship. As of 2017 government was training more than 180 medical interns under a two-year programme at three of its biggest hospitals, the Katutura Intermediate Hospital, the Windhoek Central Hospital and the Oshakati State Hospital. The estimates are that there are some 200 doctors returning from overseas this year.
The first 35 UNAM medical graduates entered the market in 2015 and since then the Medical faculty has expanded and the number of graduates in was 80 but based on agreements with health and education is expected to have an intake of 60 in 2018 , with drop outs this will mean about 40 will graduate in six years. But staff in 2016 there were 130 staff on the recently renamed and recession proofed, Hage Geingob Campus. It is staff-student ratio that teachers in other faculties of UNAM only dream of but it is precisely that which makes the UNAM Medical faculty a white elephant. Recent reviews of the School of Medicine have indicated that UNAM has the lowest staff student ratios of any medical school in sun-Saharan Africa.
In 2016 UNAM spent some N$240,000 (US$18,000) per medical student per year. In other words for a six year medical degree the cost of the education is, give or take, $N1.5 million. This does not include the cost of the two year internship nor does it include the grants given by government to support medical students or the cost of university and residence fees. By contrast the University of Pretoria costs some ZAR 390,000 for a six year medical degree. So why is Namibia so expensive? The reason that the cost is so high is common to virtually everything the country produces – economies of scale. We are simply too small to be low cost. The University of Botswana which created a very similar and expensive white elephant in its own medical faculty estimated that in order to enroll 100 students it would need approximately 125 staff. In Namibia the Medical faculty employs good highly specialized professionals and most of the people who teach doctors are foreign specialists who require internationally competitive salaries to be attracted to come and work in remote places like Botswana and Namibia.
The most recent problem is that the number of internships is insufficient for the number of graduates coming from UNAM as well as the Namibians returning from studies overseas. The problem is that there is a desire and a real need to expand the number doctors and if you look at the data Namibia has approximately half the number of doctors per head of population compared to neighboring South Africa. Clearly, Namibia needs more doctors but increasingly government simply does not have the revenues to be able to hire the number of doctors required or to produce enough to make the medical faculty viable.
In the 2017 state of the nation address the President, Mr Hage Geigngob said that ‘in the public health sector, our per capita ratio is one doctor to every 5,092 people and one registered nurse to 914 people. In contrast, the World Health Organisation’s benchmark is one doctor or one nurse per 435 people, respectively’ So how much would this cost? It would mean that we have to increase the number of doctors from around 450 in the public service to around 5,000 doctors for the public service to achieve this WHO target. That would cost the government N$7.6 billion just to train that many doctors and then a further $2.5 billion in extra salaries every year. Clearly, having the right number of doctors is an important objective but one that will have to wait until the country has a real economic recovery. So we have a medical faculty that produces expensive doctors and a government that does not have the money to keep hiring them. That is the definition of a white elephant but surely one that any reasonably trained official could have readily foreseen.
So if it costs that much to train a doctor in Namibia then perhaps the least cost option is to close the faculty and send the students abroad as was case before Namibia built its very expensive white elephant. This might make accounting or economic sense but it would be difficult to find a politician or health/ education policy maker that would countenance such an option even if setting up such a high cost institution as the medical faculty for 2.3 million people was utter economic foolishness in the first place. Politicians don’t readily admit such colossal blunders and so we will continue to drain the nation’s resources and will soon produce unemployed doctors because the government does not have the money to hire them.
What then are the options if closing the faculty is politically unpalatable? There are several options and they relate simply to becoming bigger. UNAM could co-operate with UB on training because the two countries are simply too small to support such expensive white elephants on a national scale in both countries. But the very purpose of the medical faculty is based on developing national capacity rather than relying on external sources. The unwillingness of small African countries to co-operate is pure political hubris- arrogant pride rather than being based on something that makes any economic sense in terms of development of the country.
The broader question that arises is how do countries like Namibia and Botswana make such colossal financial mistakes and how can they be stopped? It is not because there are no competent people in both the ministries of health and education who could not warn their superiors that with such a small country could not possibly undertake such a venture in a cost effective way. So why was such foolishness not stopped by a bureaucracy that should know better? Some ministers want pyramids built in their name so that they are remembered. And those that care nothing for pyramids at least want the 10% kick-back on the construction project. Those who know the facts are, for good professional reasons, unwilling to tell political or bureaucratic masters that such infrastructure proposals are an economic nonsense. Only those who agree with their political and bureaucratic masters get promoted, troublemakers or those who ask difficult questions are on a fast track to nowhere. The only way to protect the people from such folly is to submit all these massive proposed infrastructure projects to a thorough and independent cost-benefit analysis which could be undertaken by the ministry of planning or, better still, by an independent parliamentary agency that would rank them and tell the people the facts. Otherwise we shall continue to propose and build white elephants that only harm the long term development of the country.
These are the views of Professor Roman Grynberg and almost certainly not those of UNAM where he is employed.