HOW AFRICAN DOCTORS MAKE ENDS MEET - AN EXPLORATION

This paper is an attempt to identify individual coping strategies of d octors in sub-Saharan Africa. It also provides some indication of the 'effectiveness' of these strategies in terms of income generation, and analyses their potential impact on the functioning of the health care system. It is based on semi-structured interviews of 21 doctors worki ng in the public health sector in sub-Saharan Africa and attending in 1995 an international Master's course in Public Health in Belgium or i n Portugal. This small sample of physicians yielded reports about 28 d ifferent types of individual strategies. Most of these potentially aff ect hearth service delivery more through reduced availability of staff than through the more blatant misappropriations. Activities related t o the health field are mentioned most often. Allowances and per diems seem to be top regarding frequency and effectiveness, followed by seco ndary jobs, private practice or gifts from patients. None of the inter viewees, however, admits using public resources for private purposes. Side activities may bring in very considerable amounts of income, out of proportion to the official salary, and can also be very time consum ing. Nevertheless, all interviewees identify themselves in the first p lace as civil servants. Individual coping strategies may lead to undes irable side-effects for health care delivery, through a net transfer o f resources (qualified personnel-time and material resources) from the public to the private-for-profit sector. There may also be positive e ffects though, be it in terms of mobilization of additional resources, of stabilization of qualified personnel or of realization of professi onal goals. However, these emerging strategies call for innovative mec hanisms, likely to shape coping strategies in such a way that they rem ain compatible with equity and quality of care to the population.