Health worker migration - can it be stemmed?

There is a universal shortage of 4.3 million healthcare workers, but the crisis is most severe in Africa, according to the World Health Organisation's (WHO) World Health Report 2006, launched on Friday. The shortfall occurs worldwide, but is "most severe in sub-Saharan Africa, which has 11 percent of the world's population and 24 percent of the global burden of disease, but only 3 percent of the world's health workers", the report noted. "Not enough health workers are being trained or recruited where they are most needed, and increasing numbers are joining a brain drain - migrating to better-paid jobs in richer countries," WHO Assistant Director-General Dr Timothy Evans said at the launch of the report. Attracted by better pay and working conditions, "one in four doctors and one in 20 nurses in seven surveyed ... [developed] countries were trained in Africa", Barbara Stilwell, coordinator of the Human Resources for Health Department at WHO, told IRIN. "English-speaking countries, such as the USA, UK, Canada and Australia, have the lion's share of healthcare workers from Africa." Danielle Grondin, director of the Migration Health Department of the International Organisation for Migration, said stemming the exodus of healthcare workers raised complex ethical and financial questions. "This is a very difficult issue. Stopping migration is impossible: we live in a globalised world and freedom of movement is a basic human right, also for healthcare workers." It was difficult to reconcile the extremes of "poaching practices by rich countries", where professionals were aggressively recruited from poorer countries, and "respecting the fundamental human right" and choice of the individual to pursue a better way of life, she pointed out. "There are recruiting agencies that are very unethical - we have seen cases where recruiters go in [to an African country] and recruit 100 percent of a graduating class," Grondin said. "But the majority want to leave on their own accord." According to Stilwell, a number of factors were driving healthcare workers abroad: "pay is very important - in many African countries payments are bad and often late". But it wasn't simply about fatter pay cheques. "It is time to move away from that stereotype; sometimes, what makes people want to leave is the freedom to do their work," Grondin remarked. Stilwell added, "Working conditions, such as safety and level of violence, are also important - one South African nurse said she was afraid because patients would come in with guns and demand treatment." Migration was usually a response to uneven development at a global level. 'Push factors', such as poor working conditions and low wages, reflected the migrants' desire to leave, whereas enticing alternatives in destination countries acted as 'pull factors'. Governance issues were key in the source country as well as the destination country, Grondin said. Also important were "the ability to properly take care of patients requires proper facilities, proper hospitals, opportunities to further education and upgrade skills, and even education opportunities for their children". A recent WHO survey in six sub-Saharan African countries (Cameroon, Ghana, Senegal, South Africa, Uganda and Zimbabwe) revealed that the main reason for healthcare migration, ahead of 'conflict and social unrest', was 'further professional training'. Retention was an issue that both destination and source countries should deal with. Source countries "should look at their own governance situation and try to improve it", Grondin remarked. According to Stillwell there was a "lack of investment in public health sectors and [despite the need for them] there are not enough jobs to absorb the amount of healthcare workers". "African countries, especially South Africa, have become particularly concerned over the 'perverse subsidy'," Stillwell commented, referring to the return on investment lost when the government paid for medical education but students left for better paying jobs abroad as soon as they graduated. "They end up unwillingly providing the wealthy countries to which their health personnel have migrated with a kind of perverse subsidy," the report noted. According to Grondin, "South African medical schools report that a third to a half of their graduates emigrate to the developed world every year." Stilwell said international codes of practice for responsible recruitment have become essential. Grondin agreed: "The key is ethical recruitment. Recruitment should not be done through the migrants themselves but through institutions [hospitals and governments], so that there is more control [and] better planning." "South Africa is a good example," she said. "The country has drawn up a bilateral trade agreement with the UK ... [with] provisions that, among others, make return to South Africa easier, and this seems to be working."