Brain Drain Bibliography

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Abbreviations

BMJ - British Medical Journal (free access)

Bull WHO - Bullentin of the World Health Organisaton (free access journal)

HR - Human resources

HRH - Human resources for health (also the name of a free journal)

MJA - Medical Journal of Australia

OTD - Overseas Trained Doctor

SHP - Skilled health professional

WHO - World Health Organisation

Australian Health Workforce

O'Dea, Kilham. The inverse care law is alive and well in general practice. MJA 2002 177 (2): 78-79
Simple overview of some workforce issues relating to GPs in particular. Raises the concern of Aussies that other countries are also competing for our doctors and the doctors that we would poach from developing countries.

Birrell. Australian Policy on Overseas-Trained Doctors. MJA 2004; 181(11/12):635
This is more about policy on OTDs within Australia but contains some useful information. In 1997-98 most OTDs to Australia were from UK and Ireland, by 2002-03 it had dropped to under 50%. Figure 6 shows all persons aged 15-64 holding a medical degree who entered Australia between Jan 96 and August 2001 including birthplace and occupation in 2001.

Australia and Brain Drain

Scott, Whelan, Dewdney, Zwi. Brain drain or ethical recruitment? MJA 2004; 180:174-176.
Authors are from UNSW and involved with PHM. This is an important article to read.

Australian Government Funded Medical Recruitment
http://www.health.gov.au/internet/wcms/Publishing.nsf/Content/health-medicare-health_pro-otd-advert.htm
"Under its Strengthening Medicare package, the Australian Government has introduced an international medical recruitment initiative to increase the number of appropriately qualified overseas trained doctors providing Medicare services in districts of workforce shortage across Australia. Under this strategy, employers and overseas trained doctors will not be charged a recruitment fee by medical recruitment agencies contracted by the Australian Government."

Economics of the Brain Drain

Martineau, Decker, Bundred. "Brain drain" of health professionals: from rhetoric to responsible action. Health Policy 2004; Volume 70 Issue 1 Pages 1-10
This article has important information on financial costs of the brain drain focussing on Africa.

See Pang et al. under Solutions section.
Estimated cost of loss of one African to African country is $184 000. Paradoxically, Africa spends about $4billion on salaries of foreign experts.

Human Resources and Health - Policy

Draft outline of the World Health Report 2006
Proposed title: "Working for Health". Read the outline and comments.
Proposed core messages:

1. Health workers are crucially important for producing good health through the performance of health systems; they constitute a significant share of the labour force and perform key social roles in all societies.
2. Health for All, Primary Health Care and Millennium Development Goals are not achievable without an appropriately prepared, deployed and supported health workforce
3. Good health depends also on good governance and stewardship of the health labour market, and country leadership is the key to sustainable HRH development.
4. Significantly increased and strategically placed investment of international and domestic funds in education, planning and management of the health workforce is crucial for achieving equity-oriented national health goals.

http://www.who.int/hrh/about_whr06/en/

Narasimhan et al. Responding to the global human resources crisis. Lancet 2004; 363:1469-1462.
A must-read introduction to the current state of affairs, particularly from a policy/multilateral point of view. Takes a global perspective and is written by authors from many countries and institutions including Rockerfeller, universities and World Bank.

Adams RH. International Migration, Remittances and the Brain Drain: A study of 24 labor-exporting countries. 2003, World Bank.
Creates a new data set based on estimates of migration to the USA and level of educational attainment. They find that closer geographical proximity to the USA will result in a higher proportion of people with tertiary education migrating. The aim of the paper is to help determine whether the so-called brain drain is having a negative or positive effect on the developing country economies. They seem to consider brain drain to have occured only when a proportion of more than 10% of the 'best educated' people leave the country although they find that 88% of all migrants to the OECD have secondary education or higher. This is not a paper that focuses on skilled health professionals.
http://econ.worldbank.org/external/default/main?pagePK=64165259&piPK=64165421&menuPK=64166093&theSitePK=469372&entityID=000094946_03062104301450

The Millennium Development Goals and Migration. 2005, International Organization for Migration.
Highlights a gap in attention given to the influence of migration on the achievement of the MDGs. Migration can impact on both the health of migrants and health of population of origin country when health professionals are the ones migrating. From a health sector perspective, the document analyses migration and Goal 6 (Combat HIV/AIDS, malaria and other diseases). It looks in particular at the movement of people and HIV/AIDS and the individual and public health of population left behind. Unfilled positions in health vary going up to 73% of unfilled specialist positions in Ghana.
http://www.iom.int/iomwebsite/Publication/ServletSearchPublication?event=detail&id=4151

Efforts underway to stem brain drain of doctors and nurses News. Bull WHO 2005; 83(2): 83-85
Summary of where WHO etc are at with regards to brain drain.

Bundred & Levitt. Medical migration: Who are the real losers? Lancet 2000; 356(9):245-46
Covers broad range of issues including compensation, costs of training, proposed solutions, good for case studies on Uganda, Sth Africa, geographical distribution.

Human Resources and Health - Research

Human Resources and Health Outcomes. Anand S, Baernighausen. December 2003, Joint Learning Initiative
Cross-sectional study looking at the association between factors such as nurse and doctor density and IMR, MMR and U5MR.
Read the article as the Report or Lancet article

Baer, Gesler & Konrad. The wineglass method: tracking the locational histories of health professionals Soc Sci Med 2000; 50: 317-329.
Motivated by the underlying concern of health prof shortages in underserved areas of the USA, this paper presents a space-time continuum model for evaluating the effects of programs to recruit and retain health professionals on their geographical dispersion.

Strategies/Solutions (other than just ethical recruitment)

Kupfer et al. Strategies to discourage brain drain. Bull WHO 2004; 82:612.
Lively debate on strategies to encourage health professional return to country after undertaking research training abroad - uses an example of a program in the USA.

Medical migration and inequity of health care. Editorial Lancet 2000; 356(9): 177
Among other things, raises UK's agreement with Ghana regarding nurses.

Pang, Lansang, Haines. (Editorial) Brain Drain and Health Professionals. BMJ 2002; 324: 499-500.
Around 23 000 professionals emigrate from Africa per year, 18 000 Zimbabwean nurses work abroad, 1/3-1/2 of Sth African medical graduates emigrate. Raises the issue of 'brain waste' where professionals end up working in less skilled employment. Thailand and Ireland are achieving 'brain gain' by offering incentives for workers to return.
Proposed solutions: “a systematic approach using the convening power of international organizations”

• Demand compensation from departing workers
• Delay departure with compulsory service
• Increase wages in public sector
• Permit dual practice in public and private sectors
• Educational benefits for children
• Training paramedics to take the place of Drs whose qualifications not recognised O/S
• Aim to provide stimulating work environment with vibrant intellectual community
• Training provided in areas of importance to country
• Reimbursement to 'drained' countries
• Bilateral agreements
• More research on evidence of the impacts on health
• Recognition of intellectual property in the form of humans
• WHO convene a forum of international organisations and governments such as IOM, UNESCO, UNDP, WB, WMA (World Med Assoc), Council of International Organizations of Medical Societies to create declaration and international code of ethical recruitment.

Ethical Recruitment

Willets & Martineau. Ethical international recruitment of health professionals: Will codes of practice protect developing country health systems? Report, Liverpool School of Tropical Medicine. January 2004.
Available at: http://www.liv.ac.uk/lstm/research/documents/codesofpracticereport.pdf
Report of a prospective study into the develoment, implementation, value and limitations of ethical recruitment through voluntary codes of practice. Provide some good recommendations (p14, 16) on how codes of practice can be better utilised.

A Code of Practice for the International Recruitment of Health Care Professionals: WONCA Melbourne Manifesto
Adopted at the 5th Wonca World Rural Health Conference 2002
Available at: http://www.globalfamilydoctor.com/aboutWonca/working_groups/rural_training/melbourne_manifesto.htm or search around on the net for a pdf version.

Country Specific References

Africa

See Medical Migration: Who are the real losers? listed in HR&Hlth - Policy section above.
Good for case studies on Uganda, Sth Africa

Carribean

Walt G et al. The historical development of human resource policies in the health sector of four Carribean territories: imitated or created? Health Policy 2002; 62: 85-101.
In depth look at the historical health system and policy factors that lead to and then responded to the out-migration of doctors and nurses in Trinidad and Tobago, Suriname, the Bahamas (all ex-colonies) and Martinique (now an autonomous part of France). It also examines the tensions b/w public health, hospital services and private sector policies. The authors identify 'push' and 'pull' factors for brain drain including colonial relationships, lack of HR management, poor remuneration etc. Great value of this paper is the clear links made between health policy and the movement/morale of doctors and nurses. They conclude (among other things) that the medical profession played a dominant role in HR policy development.

Pacific Islands

Watters, Scott. Doctors in the Pacific. MJA 2004; 181(11/12): 597-601
Discussion and comparison of physician workforce and country context in the pacific including training methods and number of specialists. Very much hospital and specialist focused.

Duke, Tefuarani, Baravilala. Getting the most out of health education in PNG. MJA 2004; 181(11/12): 606-607
Medical training and factors causing brain drain.

Brown, Connell. The migration of doctors and nurses from South Pacific Island Nations. Social Science and Medicine 2004; 58:2193-2210. A survey of 251 Drs and nurses who either a) had migrated and were living in Auckland or Sydney (regardless of whether planning to return home, b) had returned to home country (Fiji, Samoa, Tonga) or c) had never/not yet left country to work abroad. Key determinants analysed using econometric analysis included income and non-income factors such as education opportunities for children and owning a business.

Kevau, Vince, McPherson. Tailoring medical education in PNG to the needs of the country. MJA 2004; 181(11/12): 608-610
Looks at graduates of bachelors and post graduate medical studies from UPNG and the Fiji School of Medicine. Brief discussion of type of education and what has happened to graduates since.

Baravilala, Moulds. A Fijian perspective on providing a medical workforce. MJA 2004; 181(11/12): 602
Short article on the difficulty in the attempt to make Fiji and neighbouring islands self-sufficient in their medical workforce when the physicians are 'draining' away to Australia and NZ where the shortage of workers creates a massive vacuum. Authors state that the first step must be a recognition in Australia of the problem.

UK

Buchan, Dolvo. International Recruitment of Health Workers to the UK: A report for DFID. 2004, DFID Health Systems Resource Centre
Exploration of the issues for the UK regarding international recruitment.
Available at: http://www.dfidhealthrc.org/shared/know_the/publications.html#dfidrep

Links to Useful Resources

Global Health Trust
The aim of the Global Health Trust is to advance global health equity through strengthening the production, deployment, and empowerment of human resources for health in low-income countries. The work has been launched through a Joint Learning Initiative, a multi-stakeholder participatory learning process, to better understand the role of workers in health systems and to identify new strategies to strengthen their performance.
http://www.globalhealthtrust.org/

ELDIS - Human resources for health
This human resources for health dossier is an information resource and tool for advocacy for the importance of human resources in making improvements in health service delivery for poor people. It offers practical up to date information about how to address human resource problems and issues, drawing upon evidence about what works, and identifying innovations in approaches, policy and practice.
http://www.eldis.org/healthsystems/dossiers/hr/index.htm

Management Sciences for Health - Human Capacity Development
Human capacity development (HCD) is a comprehensive process of creating the political will, capabilities, and management systems to enable governments and organizations to respond effectively to the human resource crisis.
http://www.msh.org/what_MSH_does/hcd/index.html

World Health Organisation - Human Resources for Health
Includes links to the draft outline of the World Health Report 2006 Working for Health and the free online journal Human Resources for Health.
http://www.who.int/hrh/en/

Bulletin of the World Health Organisation
The Bulletin of the World Health Organisation included brain drain articles in Number 4, Volume 83 (2005) and was the special theme for Number 8, Volume 82, (2004).
http://www.who.int/bulletin/en/