Healthcare workers and the brain drain

Article Outline

• Abstract
• 1. Introduction
• 2. Health workforce brain drain: Reproductive and sexual health
• 3. Brain drain and the Millennium Development Goals
• 4. Causes and determinates of migration
• 5. The changing face of the brain drain
• 6. Economic and social implications of the brain drain
• 7. Health implications of the brain drain
• 8. Current health workforce disparity and needs
• 9. Measures to combat migration of the health workforce
  • 9.1. Improving the health workforce database
  • 9.2. Improving wages, health resources, and working conditions
  • 9.3. Payback from recipient countries and migrant health professionals
  • 9.4. Task shifting
  • 9.5. Securing additional investment in the health workforce
  • 9.6. Locally relevant medical training and research
• 10. International initiatives to manage the pressures of the international health workforce market
• 11. Conclusion
• References
• Copyright

Abstract 

The brain drain of health workers occurs mostly from low- and low/middle-income countries to resource-rich countries and from rural to urban areas. Shortage and uneven distribution of healthcare workers aggravated by the brain drain from Africa, Asia, and Pacific countries has contributed to impaired reproductive and sexual health services and the high rate of maternal and newborn mortality and morbidity in these counties. Brain drain impedes maternal, neonatal, and child health and the fight against HIV/AIDS, and translates into loss of potential employers, teachers, and role models. Source countries spend US$ 500 million each year to educate health workers who leave their home countries for North America, Western Europe, and South Asia. A code of practice on international recruitment of health personnel is needed. Improving the health workforce database, wages, health resources and working conditions, task shifting, pay-back from recipient countries and migrant health professionals, securing additional investment in the health workforce, and the development of locally relevant medical training and research are useful measures to combat this problem.

Keywords: Brain drain, Health workforce, Millennium Development Goals, Reproductive and sexual health

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1. Introduction 

The international migration of skilled workers, the “brain drain,” is not a new phenomenon or limited to the health sector. One of the first documented brain drains occurred during the Dark Ages, when emigrants from the Byzantine Empire played an important role in the transmission of classical knowledge to the Islamic world and Renaissance Italy. In the 19th and 20th centuries there were notable emigrations to North America from Europe. In modern times, brain drain occurs mostly from low-resource to high-resource nations and from rural to urban areas.

The brain drain of the health workforce is a global problem. Doctors from Sub-Saharan Africa, Asia, and Pacific countries migrate to resource-rich countries [1], and it is estimated that more than 20% of physicians working in Australia, Canada, and USA come from other countries [2].

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2. Health workforce brain drain: Reproductive and sexual health 

Brain drain of health workers has a negative effect on the reproductive and sexual health of the people in the source country, especially those who rely on public medical services in rural areas. Shortage and uneven distribution of healthcare workers, aggravated by the brain drain, has contributed to the high rate of maternal and newborn mortality and morbidity in the source countries compared with the recipient countries, causing the largest disparity of all public health measures.

Annually, 210 million pregnancies occur and 42% suffer complications, 15% of which are life threatening. More than 99% of all maternal deaths occur in low-income countries, with some 84% concentrated in Sub-Saharan Africa and South Asia where the brain drain is most prominent [3]. Evidence shows that at least 7 million of these lives could be saved each year with proven cost-effective interventions that are readily available to the world's wealthy, but out of reach for the vast majority of the world's poor [4]. Strengthening capacity in countries to deliver an essential package of maternal, newborn, and child health (MNCH) interventions depends largely on the availability, training, appropriate distribution, and retaining of adequate numbers of health workers. Ensuring that skilled personnel are present at all deliveries and that these personnel have access to emergency care where necessary is the most effective means of saving mothers' lives [3].

The FIGO General Assembly, held in Kuala Lumpur in 2006, noted that the shortage and uneven distribution of human resources, and the neglect of care that only women need, inhibit and prevent access to care.

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3. Brain drain and the Millennium Development Goals 

Improving maternal health, Millennium Development Goal (MDG) 5, is often referred to as the heart of the MDGs; progress here is critical to achieving the other MDGs. If MDG 5 fails, the other MDGs will too. The policy and program changes required to achieve MDG 5 will directly support MDGs 3 to 7—women's empowerment, child health, HIV and other diseases, and the environment—and indirectly determine the achievement of poverty reduction (MDG 1) and education (MDG 2) [5].

At least 2.3 trained healthcare providers are needed per 1000 people to reach 80% of the population with skilled attendance at birth and child immunization [6]. However, in low-resource countries only 57% of women give birth with a skilled attendant present. About 35% of pregnant women have no access to or contact with health personnel before delivery. Thirty-six countries in Sub-Saharan Africa have severe shortages of health workers. Rural and poor women often have no access to maternal health services or cannot afford them [7].

The numbers of migrating accredited healthcare professionals (e.g. doctor, midwife, or nurse) have significantly increased in the past few decades, and patterns of migration have become more complicated and involved more countries. The migration of health workers from countries that are already experiencing a crisis in their health workforce is further weakening already fragile health systems, and is a serious impediment to achieving the health-related MDGs [1].

There is a growing international consensus that investments in saving the lives of women and children have the potential to bring substantial long-term development returns, not only to the lives of the vulnerable, but also to global and national economies [4].

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4. Causes and determinates of migration 

The migration of healthcare workers is attributed to several factors, including unreasonably low wages paid to national health professionals; political instability and poor socioeconomic conditions; brutal regimes; internal and regional armed conflicts; wars; fractionalization and religious and ethnic drives (e.g. in Ethiopia, Sudan, Angola, Zaire, and Iraq); employment of health professionals in fields other than those of their expertise; low level of development and frustration of practicing in the native country; and proximity and historical links to larger and more developed countries. Over half of the doctors in several source countries cite “lack of promotion” and “no future” as prime motivations for migrating [1].

The highest brain drain rates are observed in the small developing islands of the Pacific and the Caribbean and in the least developed countries such as Sub-Saharan Africa (13%), Latin America and the Caribbean (11%), and the Middle East and North Africa (10%). The lowest rates are from large and landlocked low-resource countries.

In high-income countries, predominantly in the northern hemisphere, a growing aging population and increasingly high-tech health care are increasing the demand for healthcare workers. Furthermore, poor planning and underinvestment in health workers' education has left high-income nations with too few health workers to meet the demand [1].

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5. The changing face of the brain drain 

“Brain gain” occurs when many trained and talented health workers seek entrance into a country, which creates a brain drain in the source country. “Brain circulation” or “brain exchange” described the situation that occurred in Canada when many highly-skilled Canadian health workers moved to the United States, while simultaneously many qualified immigrants moved to Canada. Moreover, because this movement is global, it affects high-income as well as low-income countries.

New forms of communication, transportation, geopolitics, intercultural relationships, and commerce have made the brain drain, in some situations, temporary (with occasional returns to the country of origin), and multidirectional instead of unilateral. The increased ability to interact at a distance through conferences and interactive teleconferences, and the transmission of technology to the source country help to maintain umbilical links with the country of origin, in contrast to the past when a break with the source country was almost total.

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6. Economic and social implications of the brain drain 

The cost of the outflow of health workers can be considerable. When low-income nations pay to educate their healthcare workers only to have them leave the county, they are, in effect, subsidizing a wealthier nation; this makes the rich nations richer and the poor nations poorer and is a curse for economic development. Low-resource nations spend US$ 500 million each year to educate health workers who leave to work in North America, Western Europe, and South Asia [8].

The unemployment rate of skilled workers who had migrated to Canada was 34%, bringing a significant cost to the government and calling into question the existence of any net “gain” to Canada or the country of origin. When health professionals migrate they are often the best and brightest. Long-term economic growth and social development driven by talented professionals cannot be achieved in the source county. Importing expertise from high-income countries to compensate for the brain drain costs low-income countries a huge budget [9].

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7. Health implications of the brain drain 

When health professionals migrate to high-income countries the poor may be forced to seek medical treatment from traditional healers, while the wealthy may travel outside the country for their routine medical checkups; this aggravates the inequity in access to healthcare services in such countries.

In Canada, 1 in 11000 women will die from complications of pregnancy and childbirth. In Niger, where high fertility combines with poverty and a shattered healthcare system, pregnancy-related causes will kill 1 in 7 women [10]. These deaths could be cut by nearly three-quarters if women had better access to core strategic interventions, including skilled care during pregnancy and childbirth, emergency obstetric care, immediate postnatal care, and family planning [11].

The worldwide shortage of healthcare workers—coupled with a disproportionate concentration of health workers in high-income nations and urban areas, and migration of health professionals to these nations—stands in the way of achieving key public health priorities such as reducing child and maternal mortality, increasing vaccine coverage, and battling epidemics such as HIV/AIDS. The migration of 1 or 2 specialists in a given field, in some countries, may strip the country of half or all of its skill base in that field [8].

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8. Current health workforce disparity and needs 

Migration of health workers has contributed to the current disparity in the health workforce between high- and low/middle-income nations (Table 1). While high-income countries have only one-third of the world's population, they contain three-fourths of the world's physicians and 89% of the world's migrating physicians. Some 180000 (25%) of the USA's physicians are trained abroad, with 64.4% of them from low- and lower/middle-income nations. Some 90000 nurses (40% of the overall US nurse workforce and 14% of recently licensed nurses) are trained abroad, and the number is increasing at a rate faster than for new US-educated nurses [12].

Table 1. Global health workforce, by density.

Note: All data for latest available year. For countries where data on the numbers of health management and support workers were not available, estimates have been made based on regional averages for countries with complete data.

Source: World Health Organization. The World Health Report 2006. Working together for health. Geneva: WHO; 2006. Available at: http://www.who.int/whr/2006/whr06_en.pdf. Accessed September 26, 2008.

Thirty-seven percent of the world's healthcare workers live in the Americas, predominantly in the United States and Canada, yet these countries carry only 10% of the global disease burden. Africa bears 24% of the global burden of disease but has only 3% of the healthcare workforce and 1% of the world's financial resources [1].

In Sub-Saharan Africa, 1.3% of the world's health workers provide health services to 13.8% of the world's population. Africa needs 1 million health workers for this region alone [13]. The shortage of health professionals in Africa proved to be the bottleneck that hindered the utilization of global funds for improvement of healthcare systems [1]. As discussed in the World Health Report 2006 [1] and emphasized in the WHO Report 2007 [14], today many national health systems are weak, unresponsive, inequitable, and even unsafe. WHO has identified 57 countries that cannot meet a widely accepted basic standard of healthcare coverage by physicians, nurses, and midwives; 36 of these critical countries are in Sub-Saharan Africa. WHO estimates that it will take an additional 2.4 million physicians, nurses, and midwives to meet the needs, along with an additional 1.9 million pharmacists, health aides, technicians, and other auxiliary personnel. Most of the demand is concentrated in industrialized countries because of largely demographic reasons.

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9. Measures to combat migration of the health workforce 

9.1. Improving the health workforce database 

Evidence needed to monitor and evaluate the phenomenon and provide decision-makers with a solid basis for making policy is weak, incomplete, not comparable, or often nonexistent, particularly in low-resource countries. Several publications have highlighted the chronic shortages of health personnel in Africa and claimed that these are due partly to migration; evidence to sustain these claims is often anecdotal [15]. Adequate information helps analysis, promotes well-tailored actions, and monitors improvement of retention and access.

9.2. Improving wages, health resources, and working conditions 

One obvious key to retention is improved wages. Both financial and nonfinancial incentives influence workers' motivation, ability, and willingness to act productively and efficiently, as well as their willingness to remain in their jobs [16]. In Ghana, Uganda, and South Africa, local students receive scholarships for healthcare training on the condition that they agree to return to the district. Trainees from rural areas were 3–8 times as likely as those from urban areas to practice in rural regions after graduation. Zambia has provided a hardship allowance, an education allowance for children, housing, and some funding for postgraduate training for physicians who agree to serve in a rural area for 3 years.

Many African countries have begun providing health workers with resources for care of their patients, such as in Ondo State, Nigeria, which increased nurses in rural areas from 28% to 66% over a 3-year period. In rural Haiti, Partners in Health has been successful in retaining healthcare workers by providing Haitian physicians with the tools to care for fellow Haitians in a decent, competent, and effective manner. Necessary improvement in basic working conditions by increased spending on the healthcare system per capita in source countries may improve retention.

9.3. Payback from recipient countries and migrant health professionals 

High-resource countries that benefit from the migration of health professionals may compensate the source countries with funds and resources. Migrant health professionals could remit money to their country of origin as a form of tax that could be used to finance development programs and contribute to the welfare of the rest of the society, as experienced in the Philippines. This may be particularly useful to source countries that produce health professionals above their actual requirements, as in some Latin American countries and in Egypt.

9.4. Task shifting 

In some countries, where the underproduction of healthcare workers is a major problem, initiatives have targeted task-shifting and the assembly of new cadres of workers. In Lusikisiki, South Africa, HIV/AIDS patients are attended by physicians only in complex cases, nurses prescribe antiretroviral drugs, and pharmacy assistants have filled gaps in care [17]. In some instances, African substitute doctors are as successful as doctors at performing surgical interventions; their higher retention rates probably stem from lack of skills and licensure specific to Western health practice.

9.5. Securing additional investment in the health workforce 

In many countries, including high-resource countries, there is insufficient overall investment in the health workforce. The USA is currently facing a shortage of 125000 nurses, and this figure could rise to as high as 1 million in 10 years. Canada has predicted that its shortage of nurses will reach 195000 in 2011 and 282000 in 2016 [18]. Evidence-based practices are required to establish the financial basis for better retention policies, wage ceilings, contracting arrangements, and use of donor aid to improve the capacity of the health workforce.

9.6. Locally relevant medical training and research 

A medical school with locally relevant orientation in Sub-Saharan Africa or South East Asia would assign the highest priority to endemic problems with significant mortality such as malaria, HIV, sexually transmitted infections, multidrug resistant tuberculosis, bilharzia, malnutrition, and childhood diarrhea. It would place special emphasis on clinical examination skills by training students to use evidence-based locally-adapted guidelines, simplified diagnostic and therapeutic procedures, and generic medication for endemic and common diseases. There would be less emphasis on modern western expensive diagnostic and therapeutic tools. Graduates would be qualified doctors who are community oriented.

Such programs have increased graduates' marketability in source countries and decreased it abroad, as experienced in Cuba, Gambia, Venezuela, Cameron, Nigeria, Ethiopia, and South Africa [19].

Postgraduate training programs in obstetrics and gynecology would encourage doctors to stay in the country, and provide health care, education, and leadership in clinical and health services; this has been experienced successfully in Ghana, where doctors felt well respected, needed, and wanted to help Ghanaian people [20].

Many doctors migrate in search of opportunities to conduct research for increased professional prestige. Universities in Mali, Pakistan, and other source countries have attracted researchers, despite lower salaries, by offering them teaching and research opportunities in locally relevant medicine [21], [22]. Increasing the need for locally-oriented research, guidelines, textbooks, and websites, locally relevant medicine could eventually generate regional “magnet centers” that use international financial contributions and require local expertise [21].

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10. International initiatives to manage the pressures of the international health workforce market 

Resolution WHA 57.19, adopted by the World Health Assembly in 2004, urged member states to develop strategies to mitigate the adverse effects of migration of health personnel and to frame and implement policies and strategies that could enhance effective retention of health personnel, and requested the Director-General to develop a code of practice on the international recruitment of health personnel. In response, the Secretariat designed a comprehensive four-pillar approach including: improvement of data on migration of health workers; development of innovative policy responses; evaluation of the effectiveness of international interventions; and international advocacy for workforce issues. There has been a call for immediate and sustained action to resolve the critical shortage of health workers around the world, particularly in low-resource countries that are most affected by migration of their already scarce health workforce [23].

The pressures of migration are fueled by the growing demand from national health systems in wealthy countries, as well as by the growing trade and private commercial investment in health services. In these circumstances, there is a need to find ways to stabilize the health workforce market and reduce the negative impacts of the high mobility of health professionals, thereby improving retention.

Individuals have the right to leave any country, including their own [24], in search of better opportunities, but health workers trained with public resources have obligations as defined by individual countries.

The first Global Forum on Human Resources for Health, held in Uganda in 2008, identified 6 strategies for action [16]. These included building coherent national and global leadership for health workforce solutions; ensuring capacity for an informed response based on evidence and joint learning; scaling up health workers' education and training; retaining an effective, responsive, and equitably distributed health workforce; managing the pressures of the international health workforce market and its impact on migration; and securing additional and more productive investment in the health workforce. It also called on WHO to accelerate negotiations for a code of practice on the international recruitment of health workers.

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11. Conclusion 

The brain drain further weakens already fragile health services in low-income countries, particularly in maternal and neonatal health. Concerted efforts from all concerned parties are needed. The role of professional organizations in training, accreditation, task-shifting, and setting policies for retention of the health workforce is emphasized.

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