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Efforts under way to stem 'brain drain' of doctors and nurses
Clare Nullis-Kapp
Cape Town
The migration of skilled professionals to industrialized countries is one of the factors behind the chronic shortage of health workers in many developing countries. Last year the problem was highlighted at the World Health Assembly; 2005 may be the year when a series of initiatives to address the problem start to gather momentum.
International recognition that the growing shortage of health workers poses a major threat to fighting diseases such as HIV/AIDS and tuberculosis has prompted a flurry of measures to stem the exodus of health professionals from developing countries.
The initiatives such as ethical recruitment codes to try to limit damage inflicted by the 'brain drain', and exchange and training programmes and projects to tap the resources of what has become known as the 'diaspora' of migrant health workers remain fragmented but at least mark a start in the search for solutions to the crisis.
"I hope that 2005 will finally be the year when we achieve some concrete results," said Davide Mosca, the International Organization for Migration's (IOM) regional medical officer for Africa and the Middle East.
"Everything has been analysed. We now need action. If we don't address this problem it will be a disaster. It is increasingly difficult to find doctors in many countries and impossible to retain them," Mosca, who is based in the Kenyan capital, Nairobi, told the Bulletin.
This year's World Health Assembly in May is expected to discuss how to limit the adverse effects of the migration and to promote fairer recruitment tactics by developed countries as a follow-up to a resolution passed in 2004. It will also hold preliminary discussions on an international code of practice, according to Dr Pascal Zurn, a health economist at WHO's Department of Human Resources for Health in Geneva.
The Commonwealth set a precedent for action in 2003 when it agreed on guidelines "for the international recruitment of health workers in a manner that takes into account the potential impact of such recruitment on services in the source country". But the code of practice has been signed primarily by developing country members rather than importers of health workers such as Australia, Canada and the United Kingdom, who are reluctant to make a formal commitment to provide compensation or reparations.
Thus, negotiations on any international code will be protracted, Zurn and Mosca cautioned. In the interim, WHO, IOM and the International Labour Organization plan to step up their collaboration to gathering statistics and other information to gain a better understanding of the dynamics of health worker migration, which is often clandestine.
"Once you know what is going on, you can find appropriate solutions," said Zurn.
Even countries such as India and the Philippines, which have long encouraged the export of health and other skilled workers because of their return remittances, are increasingly complaining of domestic shortages especially in the public sector in rural areas. In Africa, it is estimated that an additional one million health workers will be needed over the next decade to deliver basic health interventions.
The extent to which eastern European countries, especially those which recently joined the European Union, can provide medical staff for the West and thus ease pressure on developing countries, is uncertain, according to Galina Perfilieva of WHO's Regional Office for Europe.
The United Kingdom, which absorbed more than 13 000 foreign nurses and 4000 physicians in 2002, according to figures presented to an IOM seminar last June, is widely regarded as setting the standards for bilateral agreements on ethical recruitment.
Health minister John Hutton announced on 9 December last year that the United Kingdom would toughen its code on international recruitment, which restricts recruitment from over 150 developing countries. The revised code, which will enter into force at the end of this year, prevents hospitals from actively recruiting nurses and other health-care professionals from developing countries and extends the obligations to the private sector as well as the UK National Health Service (NHS), thus closing a major loophole.
"The revised code will mean the independent sector acts more ethically, but takes account of the right of individuals to move of their own volition," Hutton said when he announced the measure.
Separately the United Kingdom also announced a £55 million (US$ 103 million) Emergency Human Resource Programme to attract and retain health workers, expand training and send volunteers to Malawi as part of a £100 million (US$ 187 million) health package to this country, which is one of the worst hit by shortages.
A memorandum of understanding between the United Kingdom and South Africa is often cited as a good role model for managing migration. It provides for exchange programmes to allow South African health professionals to gain experience by working for a specified period in organizations providing NHS services and for UK clinical staff to work in rural parts of South Africa.
At a meeting with her UK counterpart last August, South African Health Minister Manto Tshabalala-Msimang also cited the success of a bilateral hospital twinning scheme. The twinning between the Oxford Radcliffe NHS Trust and South Africa's Kimberley Hospital, for instance, has allowed 30 South African nurses to be placed in Oxford for theoretical and practical training, while senior nurses from the UK have worked in Kimberley as mentors.
Even so, the South African health ministry describes the continued loss of skilled professionals partly offset by immigration from other southern African countries as an "Achilles heel" and it is stepping up efforts to attract more South Africans to return home.
The IOM's Mosca said that many professionals would like to return home but fear losing their residence status in the country where they have been working. He said IOM wanted developed countries to have an open-door policy to allow migrants to go home, but giving them freedom to change their mind. This would then give professionals more confidence to return to work at home without fear of jeopardizing their legal status in the country where they were employed.
The IOM has a programme on Migration and Development for Africa (MIDA), which tries to encourage mobility of people and resources. Launched in 2001, it encourages temporary or long-term return of skilled workers in general as well as "virtual returns" through video link-ups to allow skilled members of the diaspora to teach at home.
Mosca said MIDA projects aiming to capitalize on the resources of the diaspora have been launched in a number of countries including Burundi, Democratic Republic of the Congo, Ghana, Somalia, the United Republic of Tanzania and Zimbabwe. The USA, which is the single largest market for migrant health workers, has many active diaspora communities anxious to help transfer knowledge and technology through such projects, he said.
The GhanaNetherlands Healthcare Project, one of the MIDA initiatives, is cited by research consultant Christiane Wiskow in an unpublished paper prepared for WHO as an example of a success story. Its objectives are to transfer knowledge, skills and experiences through short-term assignments and projects and practical internships for Ghanaians and to develop a centre for the maintenance of medical equipment in Ghana. It is meant to allow Ghanaian health professionals in the diaspora to offer services, conduct research and implement projects in their home country.
There are more Ghanaian doctors working outside Ghana than in the country itself, according to a paper by Frank Nyonator, Delanyo Dovlo and Ken Sagoe. The paper says Ghana has a doctorpopulation ratio of 1:17 489 compared with 1:300 for the United Kingdom. In the past decade the country has lost 50% of its professional nurses to Canada, the United Kingdom and the USA.
It recommends increasing training opportunities; retaining workers through better salaries, cheap mortgages, car loans, educational subsidies, incentive payments and pensions; extending the retirement age from 60 to 65; and recruiting more personnel who are older and therefore less likely to emigrate because of family ties.
Similar recommendations were made in a report published last year on the global nursing workforce by James Buchan and Lynn Calman prepared for the International Council of Nurses. The report also urged better advance workforce planning and far greater involvement by nurses in decision-making as one way to stem the drift out of the profession. 