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SUMMARY OF EMAIL DISCUSSION ON HIF-net at WHO: 'BRAIN DRAIN'
22 July 2002 - 3 November 2003
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The notes below summarize the 41-message discussion on the brain drain of health professionals from developing to developed countries. Input came from 29 HIF-net at WHO members and additional messages were forwarded from 7 contributors to similar discussions in the BMJ and on AFRO-NETS.
FRAMING THE PROBLEM Brain drain was discussed in this forum as the loss of trained health professionals from poorer to richer countries, and from rural areas to urban areas of poor countries. The loss of the education investment alone costs poor countries 500m US dollars per year, according to one resource cited in the discussion. Another resource cited the total loss to Africa across all professions at 4 billion US dollars per year.
CAUSES OF BRAIN DRAIN in POORER Countries:
- Globalisation and trade liberalization: all countries are 'fishing from the same pond' and those with the better bait catch the fish.
- Lack of opportunities to have professional discussions with others in their own medical speciality.
- Attracted by better salaries in rich countries, further exacerbated by growing economic inequalities.
- Driven out by political upheaval, corrupt leaders, and/or civil unrest at home. This was mentioned specifically in Nigeria and Uganda.
- Driven out by poor working conditions, lack of facilities and/or opportunities to use specialized training.
- Some messages mentioned persecutions, humiliations and firings of medical professionals.
- Some countries have a surplus of medical staff and a shortage of postings, particularly desirable (urban) ones.
- Many available postings are rural where, as one contributor puts it, 'the level of income and career development is un-humane'.
- One contributor mentions that aggressive competition has crippled teaching, learning and professional information networking.
In RICHER Countries:
- Nationals in developed countries avoid medical professions because of underfunding by their governments, which in turn has spurred hospitals to aggressively and desperately recruit from wherever they can.
- Nurses in particular have left the profession in droves due to 'terrible working conditions, poor pay, and lack of respect'.
- Nursing, though practitioners are in high demand globally, remains low status with working conditions and salaries to match.
SOLUTIONS TO BRAIN DRAIN (counterpoints in brackets):
- Invest in more research and policy study about the causes of the drain and in educating policy makers about the causes.
- Rethink the nursing profession - compensate and treat according to their value.
In POORER Countries:
- Improve access to information and communication: e.g., video conferencing, email, online and CD libraries.
- Produce graduates whose qualifications are not recognised abroad, e.g., as one participant said is/was done in Tanzania. (However, others were against 'inferior' qualifications and said this would reduce the numbers of people who apply for healthcare training)
- Provide training and qualifications that are specific to health issues in poorer countries and rural health service, specialized to local needs.
- Create a special 'HIV nurses' qualification, with better pay conditions. (But, who would pay for that?)
- Contract medical students to repay their universities for their education if they leave the country before a minimum service. This is reported to be the case at Makerere University Medical School in Uganda, and in Singapore and Malaysia. The richer countries that accept 'brain drain' professionals could pay the fees.
- Poorer countries need political commitment to create and implement strategies to reduce the drain.
- Improve conditions of service, particularly in rural areas, including capacity building, salaries, social recognition, and networking and research opportunities.
- Fund nursing schools separately from hospitals (as in Zambia)
- Produce enough graduates to supply both local and international markets.
In RICHER Countries:
- Better policy planning for meeting their own health staff needs.
- Require reimbursement to poorer governments for brains drained.
- For each post, hire two 'imported' nurses for a fixed term, half of which is spent working in their home country. This could also be run via partnerships between medical institutions.
- Recruit from the health professional diaspora from poorer countries to return for short services stints in their home countries, funded by donors. This diaspora could also lobby for policy changes and donate funds to help their home countries
- Send health professionals to countries that need them on rotation.
OTHER ISSUES
- If the drain were stemmed or stopped, could poorer countries absorb the workers?
- Is it sensible to train more staff with public money than the country can afford to hire?
- What damage would be caused by the loss of foreign currency transfers to family back home?
- What is the value of the information and experience exchange that the drain creates?
- What are the ethics of restricting the movement of people?
- How much 'reverse' drain is there from richer to poorer countries? Should total flow be measured?
- A few discussants noted that the drain problem began in West Africa only in the 1970's. Before that time, in Nigeria, the vast majority of health professionals returned to Nigeria after post-graduate training abroad.
- With modern technology, can health professionals provide health care at a distance? (e.g., see the Teledoc telemedicine project in India, which just won the UN's World Summit Award for eHealth:
www.jiva.org/news_details.asp?news_id=95)
BRAIN DRAIN RESOURCES
(All the websites below were tested and okay on 7 December 2003)
"Global Market in Medical Workers: Exporting Health" by D Frommel in Le Monde Diplomatique, May 2002. "There is now an international trade in doctors and nurses, and every year poor countries lose both the 500m US dollars that it has cost them to train health workers recruited by the developed world, and the health workers, who could be crucial to a permanent improvement in conditions in the South."
"Developing evidence-based ethical policies on the migration of health workers: conceptual and practical challenges" in Human Resources for Health, Oct 2003 by B Stilwell et al. Free at
www.human-resources-health.com/content/1/1/8
"Pull factors in international migration of health professionals". Presentation by W Meeus and D Sanders, South Africa. March 2003.
www.hst.org.za/conf03/presentations/L0080.ppt
(or download the PowerPoint file from www.hst.org.za/conf03/program.htm).
"Brain Drain" by O. Gish in The Daily Nation, Pakistan. November 1997. http://meltingpot.fortunecity.com/botswana/616/oscar.html
"Health Personnel in Southern Africa: Confronting maldistribution and brain drain" by A Padarath et al. 2003.
www.equinetafrica.org/Resources/downloads/HRH%20Review.pdf
(a 600KB pdf file).
From A. Odutola's (work-in-progress) bibliographic listing of online resources on brain drain in Africa:
Brain drain and undocumented migrants of national importance www.hsrc.ac.za/media/1999/3/19990330.html
CONTRIBUTORS
SARR ADAMA. The moderator forwarded this message from the AFRO-NETS listserv
UZODINMA ADIRIEJE is Executive Coordinator of Afrihealth Information Projects, an NGO based in Lagos, Nigeria. Afrihealth Information Projects is a community-focused, not-for-profit humanitarian agency involved in information, education, intervention and research. Its areas of interest include reproductive health/family planning, maternal and child health, and population and environment. <[email protected]>
STEPHEN ALLEN is the course director for the E-learning Certification Programme in Global Health, UK, which is currently developing a programme of interactive, internet-based education/training in tropical medicine and public health for health professionals in Africa. He is a paediatrician and has 4 years experience as director of training with the Medical Research Council in Gambia. <http://www.tall.ox.ac.uk/globalhealthprogramme>
JOSEPH ANA is a GP Principal in Leighton Buzzard, Bedfordshire. He originally trained in Nigeria and is a member of the British Association of Urological Surgeons. He is a pioneer trustee-director of the Nigerian Medical Forum UK, the charity which initiated the publication of BMJ West Africa Edition in 1996. He is particularly interested in the setting-up and sustainance of continuing professional development schemes in Nigeria and West Africa for isolated doctors in rural medical/health institutions.
RANA JAWAD ASGHAR is Coordinator of the South Asian Public Health Forum. He completed his basic medical qualification in Pakistan, and postgraduate studies at the University of Bristol, UK and University of Washington, USA. He was a Fellow of Emerging Infectious Diseases at the University of Washington. He has carried out research and consultancy work at Stanford University, London School of Hygiene and Tropical Medicine, and WHO.
PETER BEWES is a retired trauma surgeon. From 1973-79 he was in charge of Kilimanjaro Medical Centre's Education Programme. From 1979-93 he was Consultant Trauma Surgeon at Birmingham Accident Hospital, joint editor (with Maurice King) o f Primary Surgery Vol. II - Trauma published by Oxford University Press, and assistant editor of the other two Maurice King books in the series. He is also author of Surgery, a manual for paramedics published by AMREF. From 1994-98 he was Director of Uganda's Continuing Medical Education Programme, and created around ninety clinical 'how-to' documents for hospital doctors in Uganda and elsewhere - all available for copying. He is keen to share his experience on how to set up a communications network with isolated doctors in Uganda, how to produce educational literature, and how to integrate information provision with on-site educational visits.
KURT BRAUCHLI works for the University of Basel, Switzerland, where he is developing the iPath telemed software. This forms the technical support for the West African Doctors Network. Kurt also helped to set up a histopathology lab and telepathology service in Honiara, Solomon Islands.
STEWART BRITTEN worked in Britain as a child psychiatrist, though also trained as an adult and child psychotherapist. His main interest is prevention of, and early intervention for, child mental health problems. He works with the British NGO HealthProm in Russia and Uzbekistan.
PETER BURGESS is VP and CFO of ATCnet, an organization of professional Africans committed to a new business model for sustainable socio-economic development and wealth creation in Africa. ATCnet's priority programs are the ATCnet Project for Universal Accountability, the ATCnet Community Cyber Networks program, the ATCnet Database on African Development and Enterprise and the ATCnet Database on the African Health and HIV-AIDS Crisis. <www.atcnet.org>
MICHAEL CARMEL is Chairman of 'Partnerships in Health Information'. He has had a posting in Kenya (c1970) and consultancies for UNESCO, WHO, and British Council in Africa, South Asia, and Western Pacific. He is the editor of 'Health Care Librarianship and Information Work', Library Association 1995. He is recently retired from the post of Director of South Thames Library and Information Services (STLIS). He is keen to develop active and mutually supportive North-South partnerships among health library services.
VITALIS CHIPFAKACHA works for the WHO in Botswana. The moderator forwarded this message from the AFRO-NETS listserv <www.afronets.org>.
DELA DOVLO is a medical doctor and HRH (Human Resources for Health) specialist, working independently from Accra, Ghana. He is also a member of the WHO/AFRO Multi-Disciplinary Advisory Group on Human Resources.
ATEF EL-MAGHRABY is a healthcare management consultant working in the Health Sector Reform Programme in Egypt. He has a solid career in health information management and human resource development in health. He currently works as part of the European Commission Technical Assistance Team (ECTAT) to provide technical support to MOH to plan and implement HSR in Egypt. His special interest is to establish a network of Health Reform Information Resource Centres.
MOHAMMAD NAGI HADI as SUDI works as a health communications specialist with the National Centre of Health Education and Information, Amran, Yemen.
RACHEL JENKINS is Director of the WHO Collaborating Centre at the Institute of Psychiatry, London.
BOB LEITCH works as an advisor for AMREF, Nairobi, Kenya.
LAURENCE F LEVY is a professor of neurosurgery, Departments of Anatomy and Surgery, University of Zimbabwe, Harare. The moderator forwarded Prof. Levy's 'Personal View' on brain drain in the BMJ to this list. Further responses to Levy in the BMJ were also forwarded to this list. These were from the following contributors: ADNAN A HYDER, assistant professor Department of International Health, Johns Hopkins University, United States; AHMED S LATIF, professor of medicine, University of Zimbabwe, Zimbabwe; DUMISANI NCOMANZI, house officer Kettering General Hospital, United Kingdom; JEAN P FISHER, clinical lecturer, Liverpool School of Tropical Medicine, United Kingdom.
EDWIN MAPARA is a medical doctor trained at the University Teaching Hospital, Lusaka, Zambia. He is currently studying at the London School of Hygiene and Tropical Medicine. He is a former chief medical officer of Athlone Hospital, a 175-bed district hospital in Lobatse, Botswana, where he established the Athlone AIDS Awareness Programme, a model which is now being replicated elsewhere in Botswana. Edwin has a special interest in HIV/AIDS and the use of health information materials - especially TALC clinical slides - for health education.
HARRY MEINARDI is honorary Executive Director for Epicadec. He is an epileptologist (neurologist/psychiatrist) interested in the promotion of epilepsy care in developing countries. Through his work, he is engaged in the production of information either for professionals or lay people.
BERTHA MO works in the US and holds postgraduate qualifications in medical anthropology and health education from the University of Berkeley, US. She recently left the Institute for Development and Research Cooperation (Canada) and is now working as a consultant.
FIORENZA MONTICELLI is HealthLink Editor of Health Systems Trust <http://www.hst.org.za>
, a non-governmental organization in South Africa. HealthLink <www.healthlink.org.za>
was established to meet the communication and information needs of health workers in South Africa. HealthLink services include: low cost E-mail and internet connectivity; access to medical libraries and drug information centres; and Web site publishing.
AKINTOLA ODUTOLA is an Anatomist, Surgeon and former foundation Provost of a College of Health Sciences in Nigeria. He is the Founder and Chair of the Centre for Health Policy and Strategic Studies (CHPSS) in Lagos, Nigeria. CHPSS works to promote better health for all in Nigeria through advocacy, research for reform, training in public health and information dissemination for personal and community health empowerment. The Centre is associated with the development, launch and maintenance of Datelinehealth-Africa.net <www.datelinehealth-africa.net>
<www.expage.com/chpsshomepage>
WELLINGTON A OYIBO is a medical doctor at the Department of Microbiology, Immunology and Parasitology at the Faculty of Medicine, Addis Ababa University, Ethiopia.
SUSAN PASQUARIELLA is Senior Knowledge Sharing Officer at the United Nations Population Fund (UNFPA), New York, USA. She manages the Population and Reproductive Health (POP/RH) Portal that UNFPA and the population community have recently established in the Development Gateway. <http://www.developmentgateway.org/pop>
ANDREW PATMORE works for an independent company based in Hastings, UK. He is currently assisting with an educational outreach programme in the poorer areas of South Africa with a charity called Computers for Charities
www.computersforcharities.org
LUCAS PINXTEN is a medical doctor with Johns Hopkins JHPIEGO in Indonesia. He previously worked for 7 years as a District Health Officer in Malawi. His interests include HIV/AIDS and public health responses to the pandemic.
CHRISTINE PORTER provided this summary and contributed to this discussion. She recently completed her MA dissertation, entitled 'Networking for Health-a r/evolution: Using new ICTs to support health professionals in developing countries'. She works as a consultant on using ICTs to support further education, health and development. Her core clients include Cornell University's eLearning subsidiary and an academic research funding and networking service <www.cos.com>
. She is interested in how new ICTs are, can and should be used by and for development professionals in the field. <http://myprofile.cos.com/c_porter>
PAGET STANFIELD is a retired paediatrician with a long experience in Africa, including work with the Makerere University, Uganda, and with AMREF. He has a longstanding interest in improving access to texts for medical and postgraduate medical students in very poor-resource situations, particularly in Maternal and Child Health. He is editor of the publication, Diseases of Children in the Tropics.
BARBARA STILWELL is a human resources scientist with WHO, based in the department of Organization of Health Services Delivery in Geneva. Her area of specialism is the management of change and the assessment and change in performance of systems. Her background is as a social psychologist and a family nurse practitioner.
KLARA TISOCKI is a clinical pharmacologist, who worked at the University of Zimbabwe Medical School in the past 6 years. She is interested in promotion of rational, evidence-based use of medicines and training of health professionals on how to find, critically appraise and apply high quality information for better health care.
MINH VO works with Solvay Pharmaceuticals, Belgium. Professional interests include pharmacy education and clinical research.
[HIF-net at WHO profile: Christine Porter recently completed her Masters dissertation, entitled 'Networking for Health-a r/evolution: Using new ICTs to support health professionals in developing countries'. She works as a consultant on using ICTs to support further education, health and development. Her core clients include Cornell University's eLearning subsidiary and an academic research funding and networking service <www.cos.com>. She is interested in how new ICTs are, can and should be used by and for development professionals in the field. <http://myprofile.cos.com/c_porter>]
[Note from moderator: Our warm thanks to Christine Porter for putting together this summary for us. Thanks also to all who have contributed to the discussion. This summary will be made available on the Web at
http://www.inasp.info/health/hif-net.html
- we shall make other summaries available there also. Meanwhile, we are working with WHO to provide a Web archive facility to organize all past messages on HIF-net at WHO, and provide easy public access. Best wishes, Neil PW]
'HIF-net at WHO': working together to improve access to reliable information for healthcare workers and health professionals in developing and transitional countries. Send list messages to
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