Developed world is robbing African countries of health staff
BMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7497.923-b (Published 21 April 2005) Cite this as: BMJ 2005;330:923All rapid responses
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The article mixes facts and figures from Africa with mention of
representation of delegates from all parts of the 'developing world'. The
fact is that healthcare standards and availability in India, the fourth
largest and second fastest growing world economy are very different from
Mozambique, the second poorest nation on Earth. Also,it's naive for somebody
familiar with NHS to assume that healthcare flows out of a standalone
doctor. A doctor needs a basic infrastructure of equipment, examination
room, basic lab facilities, medicines and a patient who is not dying of
hunger to do his work. In the absence of these,he can be as effective as an
intelligent samaritan.
Furthermore, there are centres of oversaturation with
doctors in Indian subcontinent in places where secondary and tertiary care
hospitals exist. Even in rural primary health centres,there are enough
doctors posted although poor funding affects their attendance. Further
enhancement of healthcare can occur by infrastructure investment and not
by a doctor coming to stand in the midst of people. A case in point is also
the article on p 920 of the same BMJ issue which tells us about the £0.8
bn drive in India to raise a cadre of 250000 women health activists which
is what is needed in India and not more doctors who are now permitted to
join administration, management etc due to absence of infrastructure. UK has
one of the largest percentage emigrant populations in the world but nobody
thinks their coming back to work in UK would make up for shortages that
exist in specific areas. If an engineer is not equal to a bridge a doctor
is not equal to healthcare either.
Competing interests:
None declared
Competing interests: No competing interests
Dear Editor,
Rebecca Coombes reported on a recent BMA conference concerned with
the ‘developed’ world robbing African countries of health staff (23
April). She rightly emphasizes the unwillingness of richer countries to
train sufficient numbers of their own doctors and nurses as creating an
international market in health human resources; one that is understandably
very attractive to personnel from relatively poor countries. This outflow
of human resources from those countries with the highest disease burden is
one example of how healthcare knowledge and capacity to apply that
knowledge is being severely undermined. Another example is the TRIPS
(Agreement on Trade-related Aspects of Intellectual Property) agreement
that effectively diminishes access to medications by those who are least
able to pay, but again, often in greatest need.
What the debacle over the attempts of a consortium of 39
pharmaceutical companies to prevent South Africa from making generic drugs
available to people with HIV/AIDS demonstrated, was that moral outrage can
be productively channelled. We need just such an outrage and a similarly
effective channel to respond to the plundering of human health resources
in Africa. However, as long as highly incentivised outflows, and highly
restricted inflows of healthcare and health knowledge continue, much more
focus must be given to developing local solutions. For instance, in
Malawi cadres of Clinical Offices and Clinical Assistants provide an
important health force, and one that isn’t offered the mobility conferred
by an internationally recognised medical degree. In Ethiopia, local
extension workers (who are not ‘health professionals’) provide crucial
front line healthcare (Mc Auliffe and MacLachlan , in press). A recent
study in Bangladesh found that again the use of local human resources –
most of whom were not health professionals – dramatically increased child
survival (Pyle and Hossain, 2004). An achievement beyond the ability of
many other projects apparently ‘better resourced’ with health
professionals.
Gustavo Gutierrez's liberation theology sought to create
consciousness among poor people, not only of the factors responsible for
their impoverishment, but also as a means of empowering them to overcome
those oppressive forces. The gravity of globalisation, while pulling
professional health workers further from those most in need of them, is
also creating the necessary conditions for exploring new ways to deliver
healthcare; ways that are possibly less expensive, more community focused,
more empowering and, dare we suggest, possibly more effective. We will of
course always need some highly skilled specialist doctors and nurses, but
we may need fewer of them, both ‘here’ and in Africa, if these health
delivery experiments, borne out of desperation, continue to challenge the
roles of conventional ‘Western’ health professionals.
Eilish Mc Auliffe & Malcolm MacLachlan
Centre for Global Health, Trinity College Dublin.
(Malcolm.maclachlan@tcd.ie)..
No competing Interests
References
Mc Auliffe, E. and MacLachlan, M. (in press) Turning the Ebbing Tide:
Knowledge Flows and Health in Low-income Countries. Higher Education
Policy
Pyle, D.F. and Hossain, J. (2004) USAID-Municipality-Concern
Worldwide Bangladesh Child Survival Partnership Program. Washington, DC:
USAID/GH/HIPN.
Competing interests:
None
Competing interests: No competing interests
A lot of doctors from developing countries, leave their homeland and
practices, with the lofty aim of acquiring knowledge and going back to
practice in their countries, that is excluding those running from
persecutions.
While working in your country you were used to fashioning out a chest
drain out of a discarded drip set, you have to buy the catheter for that
patient if not he cant go to theater, and you have to buy drugs on a
number of occasions when your salary hardly lasts a week, but amidst all
these your zeal was to better the lot of your patient.
Then you get the opportunity to either study or work in the west, and you
actually start to enjoy your work, although you work longer hours you look
forward to going into work, it seem like magic but all those things you
only read in books are practiced right in front of you, you can get a
chest x ray within an hour, when it use to take you 2 to 3 days to get
one, and then you dont have to think of what to do when your salary runs
out before the end of the month. You start to re-evaluate your life, you
look at the priorities of the society you left behind, often its not so
poor that it cannot afford these things, but a total lack of political
will, greed and corruption had stopped any form of growth in health care,
and even the senior doctors are so oblivious of what the world is about
that you feel, there is really no hope.
African countries in particular need to start all over, Africa has to be
able to combine the 21st century with the 19th century because that is how
African development and its diseases are evolving. Western Governments can
help in technology transfer, not to build MRIs but to make water for
injections, life saving fluids and medications and to have some form of
maintenance system build into supply of modern technology to African
countries.
I strongly believe the greatest deterrent at the end of the day to people
returning, has to do with inability of African Governments to provide
minimum standard of modern healthcare, and not necessarily financial.
Competing interests:
None declared
Competing interests: No competing interests
The migration of doctors from developing countries to the developed
world is multifactorial and in my opinion the developed countries are the
one to blame more than the developed countries. One thing everybody
reading this article has to understand is that all poor people in the
world know how good it is to be rich but most of the rich people don’t
know what being poor feels like.
The politicians have made it very sad for professions to live in
their own country. The cake of the country is no longer equally shared and
this is like a slap on the face of the professions in developing
countries. Politicians are looting everything that can be taken and a small
class of people who regard themselves as rulers have turned up to be
millionaires in the midst of a poor majority. Being a professional you are no
longer respected and cared for the ruling class goes abroad even when they
have flu. In East Africa for example, which consists of Tanzania, Uganda
and Kenya, the salary of a doctor is in the ratio of 1:5:8 respectively.
Tanzania is paying the least amount of money despite being economically better than Uganda. Doctors are human beings they have their basic human
needs and you will agree with me that only a few people will opt to stay and
work in such deprivation while you know very well you can be a hotcake
somewhere else. I believe anywhere in this world can be home provided you
are comfortable.
It’s the bitterness of being neglected, underpaid, being labelled
corrupt and recognised that make people move out and go to practise in a
place where they will have peace of mind.
Movement abroad is not the only thing depriving Developing countries of
‘’practising doctors’’. There is unequal distribution even of the few
doctors who are in the developing countries. For example in Tanzania the
doctor/patient ratio is 1:29,000 but within the country the
doctor/patient ratio in Dar es Salaam the capital is 1:6,000 while in
Rukwa one of the regions bordering DRC has a ratio of 1:300,000(MOH
Tanzania). How can you blame the Western countries for people who are
missing health services in Rukwa region? It’s also very interesting to
note that a lot of Doctors are not practising medicine. The ratio of
1:29,000 given for Tanzania can be even higher when the absolute number of
practising doctors is considered. A big number of Doctors are involved in
non-medical things like business and supervising projects. I think it's
better for a doctor to be practising in America or Europe where he/she
will be using his/her valuable knowledge to serve people of this world
rather than being involved in no professional activities.
People in the medical profession have been waiting so much for the so
promised good life, which they have realised will never come.
Whenever you talk to senior people in the profession they sound
confused and encourage young people to leave as an immediate solution to
the problems in the motherland. The world has turned out to be a village
with free movement of capital and investments that I expect
to have a
big positive pull on the movement on the movement of labour. The
population of medical professions like other fields have to enjoy the
global village and move as they please in the world to find comfort,
reward and peace of mind.
By J.I. KOOLA MD
P.O BOX 923,MOSHI. TANZANIA. Email jametz94@gmail.com
Competing interests:
None declared
Competing interests: No competing interests
Is it surprising that an individual (resident in any country) should
be bright enough to become a doctor and then not recognize that his/her
country is a sinking ship? Whether the reason is economic stagnation, bad
governance, or social/ethnic/religious unrest is not really important.
That doctor votes with his feet and leaves.
Should a developed country bar him/her from entering and practicing,
that would seem to be cutting off our nose to spite our face. We need
doctors (at least some experts say so), and economics as well as nature
(abhoring a vacuum) would seem to agree - why turn the emigrant doctor
away because he has left his home?
Medicine has a long tradition of itinerant practitioners. To condem a
doctor from bettering his lot in this world is to impose a worse fate on
his homeland - there's no point in working hard, studying to become a
doctor, if it's not a way out. "I'd be better off as a football or
cricket sportsman, and make more money"! Should we condem our sports
clubs from recruiting abroad too? How insular!
Yours,
WGBartlett, MD, FRCS, FACPM, MPH
Competing interests:
None declared
Competing interests: No competing interests
Socioeconomic imbalances have a habit of exacerbating themselves: we
call them virtuous and vicious cycles. And it is near impossible to change
the one into the other.
The world is increasingly one integrated system and costs and
benefits are not directly linked. Those who benefit are not those who pay.
Conscience may persuade some – some of the time – to pay for the value
they receive. These discussions serve as part-payment, a salve to
conscience, but no pragmatist expects or believes that the brain drain
will be reversed.
The convenient solution is to introduce friction to the free movement
of health professionals: the health professionals pay, the benefiting
countries say, “See we have made it difficult for them.” And the losing
countries are left with nothing.
The entire argument seems misplaced. Seen as a unit, the whole world
suffers from a dearth of health professionals.
Poor countries – Developing countries – need more health, not more
healthcare or more health professionals. Below a recognised threshold,
health equates with income, both direct and indirect (the entire focus of
public health initiatives: potable water, sewerage systems,
electrification, telephones, roads, mass immunisation, etc.) and yet still
the health of nations focuses on the movement of health professionals.
A cardiothoracic surgeon or interventional radiologist can do nothing
for the health of a nation sitting on a dune in the Karoo or looking off a
cliff in the Himalayas. Implants of NGF producing cells for Alzheimer’s
are irrelevant to a population dying of cholera for lack something simple
and inexpensive: potable water.
The health of a nation has very little to do with the movement or the
numbers or the training or the remuneration of health professionals:
America and Cuba are the proof of that.
I am in favour of dialogue and I will award myself Brownie points for
this piece; I know that it will make no difference to the health of any
nation, but I will feel better and that will certainly be good for me.
Competing interests:
health professional
Competing interests: No competing interests
There is no justification in blaming the developed world for brain
drain neither in Africa nor in any other developing country.
BMA'S best option would be to ask the politicians.It might be of interest
to you to know that as a surgeon thousands of times i have paid money out
of my own pocket to buy a catheter and urinary bag so that end of the day
i can as an absolute minimum leave the operating theatre.
The theatre green and basic trays were donated to me as a person.
Competing interests:
None declared
Competing interests: No competing interests
The solution to African health professional brain drain lies on the
African countries. There is no need blaiming the developed countries of
the West.In many African countries, and particularly in my country,
Nigeria,there is now a near collapse of the public healthcare system. This
is due to the poor management and lack of political will and interest in
health. All levels of health care are affected,particularly the PHC and
even research at the teaching hospitals is rudimentary or non -
existent.Our politicians and highly placed government officials who
should provide solutions rather seek medical attention in hospitals abroad
even for common symptoms. The health care professionals are often
frustrated and if an opportunity comes, such as employment abroad there
is a 100% chance that the offer will be accepted.In my opinion,one long
term solution to this problem , apart from improving the working
conditions of the professionals,is a redirection of the health piororities
to suit the common health problems in Africa ie emphasis on preventive
health. Also the training of doctors, even at postgraduate levels should
be more towards primary and secondary care which will eventually form a
strong base for the apex hospitals.Development in health should then be
from "bottom -up" and not the more "super-specialty" emphasis that now
exist in an attempt to keep up with the developed countries
Emmanuel Monjok MD; MPH
Competing interests:
None declared
Competing interests: No competing interests
The real cause of the increasing migration of healthcare
professionals from poorly developed African countries to the develped
economies of the West lies in the African countries rather than in the
recipient countries. Healthcare professionals are certainly among the best
minds anywhere,particularly in those African countries and fully
appreciate the hard fact that their services are in much greater need at
home than in the Western countries. The key issue is that the economies of
those African countries have been thoroughly run aground by politicians,
such that the healthcare systems are not sustainable within the context of
conventional healthcare delivery concepts.
For example, in my country, Nigeria about 70% of care is delivered by
the private healthcare institutions to an improvished population whence
patients are incapable of meeting the real costs of care. These
institutions operate within an economic system that has outstripped the
capability of the private care institutions to exist and offer services.
As a consequence, hospitals and clinics are closing down at an alarming
rate, throwing investors who are the professinal practitioners themselves
into debt. Professionals cannot be paid salaries for months on end.
Experienced and highly trained professionals who have retired from highly
meritorious careers in the public service are unable to practise in the
private sector because of an economic atmosphere that disallows the
development of medical institutions.
The public healthcare delivery systems deserve much better management and
transparency. Besides, we are talking of national economies that import
virtually all the hardware and almost all the consumables, from water for
injection to CT scanners for the operations of the healthcare systems.
In short, the solution to the brain drain lies in those African countries
rather than in the West. Politicians in power in the African countries
need to address the entire system such that experienced professionals are
able to remain at home to continue to give service whilst the younger ones
are properly guided into careers for personal development and a secure
future in the professionsin their own countries.
Dr Abayomi Ferreira FRCSE
Competing interests:
None declared
Competing interests: No competing interests
Who is responsible for brain drain?
In present day money-driven society, brain drain occurs from under-
developed and developing countries. Poor economy, bad governance, low
employment rate; sometimes; aided by unfair selections to jobs and lack of
recognition of one's professional skills (in terms of money, job security,
respect and awards) in these countries are good catalysts for brain drain.
One of the factors responsible for this situation is also a rise in number
of seats in professional colleges disproportinate to job oppurtunities. It
indirectly favours the developed countries as the cut-throat competition
ensures availablity of quality health professionals at cheap rates. This
brain drain starts in the name of skill level-enhancement. A health
professional with 'foreign experience' tag whether in terms of degrees or
work experience definitely fetches the 'more price' in the home (under-
developed or developing) country .
A health professional; who has enjoyed the work culture and
facilities abroad; has to reconsider the issue of returning to home
country . Hence, the majority of the 'foreign-goers' favour to continue in
the developed countries. The minority of professionals returning to native
land often get frustrated as they may get the expected money but not the
work culture and facilities in most of the cases.
Still, the charm of foreign land and money occupies the highest seat
in the well-trained minds and it even sometimes forces the mediocre-mind
professionals to somehow manage the 'things' - just for the sake of
getting into the 'dream land'.
Change is the first law of nature. I recall reading an item in the
newspaper with its rather bitter heading - brain drain is better than
brain in drain. Who will diasgree ? Honestly speaking, admitting the
existence of the problem is the very first step towards its solution.
Competing interests:
Pharmacy Teaching in India
Competing interests: No competing interests