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Should I stay or should I go?

Fiona Fleck

Geneva

The answer for most health-care workers in developing countries is easy: go. Higher pay and better working conditions are luring more and more health personnel abroad leaving their native health systems stripped of staff.

There has been an alarming surge in the number of health workers leaving their own countries to benefit from better pay and working conditions offered by richer countries, according to WHO and The World Bank. Whilst this has increased the flow of remittances — and in some cases, expertise — back home, it has also triggered staffing crises in many countries.

According to The World Bank, remittances wired by migrant workers through the banking system alone totalled US$ 90 billion in 2003, up from some US$ 88 billion in 2002 and US$ 72.3 billion in 2001. The International Organization for Migration (IOM) estimates that at least as much again is remitted outside the banking system. In the United Kingdom 50% of newly registered nurses came from abroad in 2002, compared with 25% in 1998.

"It's not surprising when salaries in Zambia, for example, are 25 times lower than in the UK," said Barbara Stilwell, Programme Coordinator from WHO's Human Resources for Health department.

WHO and World Bank officials warned governments in January that the health staffing gap in developing countries had become a major obstacle to achieving the UN Millennium Development Goal to reduce poverty by 2020. A World Health Assembly resolution followed in May calling on WHO's 192 Member States to better manage the migration of health workers in order to avoid damaging health services in poor countries.

Some receiving countries, like the United Kingdom, have begun to recognize the damage wrought by their recruiting strategies and are adopting ethical recruitment policies in line with those of the Geneva-based International Council of Nurses, a federation of national nursing associations representing millions of nurses worldwide. The UK's National Health Service now discourages recruiting from certain developing countries in order to safeguard their health-care systems, for example.

In some donor countries, improving the organization of health staffing services could help address staff shortages, explained Stilwell. Malawi, for example, has nursing vacancies and yet has 1200 unemployed nurses. In other countries such as Ghana, however, the situation is different. Ken Sagoe, Director of the Ghanaian health service's Human Resource Development Division, told news web site, Ghanaweb, that Ghana had lost 1032 nurses and 166 doctors last year and nine health centres had been without a medical officer since January.

India was one of the first developing countries to suffer a drain of health workers and was the largest source country for doctors in the 1970s, many of whom have stayed on in the United Kingdom, Canada and the United States. Binod Khadria, Professor of Economics at the Jawaharlal Nehru University in New Delhi, India, wrote in a recent paper that 56% of the All India Institute of Medical Sciences' graduate doctors left the country between 1956 and 1980. According to Khadria, however, the trend has reversed to some extent over the last decade with an influx of Indian doctors who had trained in the former Soviet Union but were returning and the increase in "medical tourism" in which patients from developed countries seek to undergo medical procedures in India at reduced cost.

A recently published article in American magazine, Science (2004;304:1286-88) describes how an increasing number of doctors and scientists who left Africa and Asia for the United States are involved in joint research projects aiming to help those they left behind.

Jean-Philippe Chauzy, IOM spokesperson in Geneva, said properly managed migration was key to ensuring that countries both receiving and sending health workers could benefit. By regulating migration, the Philippines, which produces the most migrant workers (9% of the population works abroad), benefits from some US$ 8 billion annually in remittances and better legal protection of its overseas workers, he said. "The question nevertheless remains as to whether the benefits of migration fully compensate for the costs to the sending country, such as brain drain, the social disruption of families and the costs of training health workers," said Chauzy.

The Philippines is also the largest source of registered nurses working overseas. According to a paper by Dr Stephen Bach of King's College, London, United Kingdom, published by the International Labour Organization in June last year, the system is so successful, that there are examples of doctors retraining as nurses. Dr Bach said that over 70% of Filipino nurses leave the country contributing to an outflow of 15 000 nurses a year bound for more than 30 countries but that health officials now say the country is suffering shortages and imbalances in specialities.

Sub-Saharan Africa suffers more from staff shortages than any other region, not least because of the need for doctors and nurses to help combat human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), malaria and tuberculosis epidemics, said Stilwell who added that fewer doctors are trained in Africa than other regions and many of those who graduate leave to work in Europe. During the 57th World Health Assembly in May, some African countries said they would seek compensation from developed countries for losing the investment made on educating nurses who then work abroad. The issue is to be discussed during the 15th International AIDS Conference which began in Bangkok on 12 July. During the conference the first progress report on WHO's "3 by 5" initiative, which aims to treat three million people with antiretroviral drugs by 2005, singled out the shortage of trained health-care workers as a major obstacle to progress.