Brain Drain

The term 'brain drain' refers to the net migration of skilled people from one place to another. The 'brain drain' in health is a part of a global health workforce crisis because of the net migration of health professionals from resource-poor countries to resource-rich countries. The health brain drain is a major problem for sub-saharan Africa in particular but it does affect many developing countries, and it affects them in different ways. The main recipient countries for health workers are the USA who absorb by far the most workers, and also Canada, United Kingdom, and to a lesser extent, New Zealand and Australia.

This document outlines of some basic issues concerning the brain drain and Australia. It is based on a speech made by Sally Kingsland at the PHM Vic Launch on 24 March 2005.

Why is it a problem?

It would be quite reasonable to ask why we might see migration as a problem. Why should we be concerned if individuals make a personal choice to move from one country to another, particularly if they may be happier in the new country where they are genuinely needed for work? Immigrants are likely to have better opportunities to send remittances home to family which is a major source of income world wide.

There are several issues to be considered here. One is huge investment made by the home country in training each health professional that is then lost to another country. There is a massive net wealth transfer to recipient countries through this hidden transfer of wealth. For example, South Africa, (who itself recruits doctors from Cuba), in 2000 had 600 medical graduates registered in New Zealand. It cost South Africa US$37 million to train those doctors. (Editorial, Lancet 2000; 356:177)

There are some countries which train surplus health workers who they expect to emigrate, this includes countries such as the Phillipines and China, however those are not the countries we consider here. We are discussing countries such as Ghana who have more doctors who were trained in Ghana working outside the country than they have working in the country.

The migration of health workers also widens the gap of service provision between the countries experiencing a drain of health professionals and the recipient countries. For example, in rich countries such as Australia, we have one doctor for approximately 500 people. Compare that to the 25 poorest countries in the world where the number of people per doctor is approximately 25 000. (WHO target 1:1000)

Sometimes the gaps left by emigrating health professionals who were trained in-country are filled with well-meaning health professionals from rich countries. However they are employed at a higher cost to the society and usually those gaps actually are not filled at all.

Magnitude of the problem

Some statistics from sources including Fatal Indifference by R Labonte, T Shrecker, D Sanders and W Meeus. (available as an open e-book).

• Half of Pakistan’s medical graduates in any year leave the country and go to the West; very few return (Chanda, 2001: 23).

• Over 21 000 Nigerian doctors are practising in the US, while there is an acute shortage of physicians in Nigeria;

• Zimbabwe lost almost three-quarters of all of its doctors to emigration during the 1990s (Chanda, 2001: 22).

• Over 35 per cent of trained health professionals from Africa’s poorest 20 countries left for (and often were actively recruited by) countries in North America and the EU (CMH, 2001: 76).

• Zambia has lost 75 per cent of its physicians in recent years, often to South Africa as well as to developed countries (Globe and Mail, 5 January 2002).

In particular, the loss of heath professionals is hindering the fight against HIV/AIDS and tuberculosis which is a primary reason that it is starting to gain attention around the world. (As stated by Director General of the WHO – Dr Lee Jong-wook)

What drives the brain drain?

There are some powerful influences on stakeholders that create the brain drain. These include pressure on health providers in rich countries who are desperate (by their standards) for more workers, particularly in rural areas. Recruitment agencies who facilitate migration have a lucrative business and an obvious incentive to increase migration. And the health professionals themselves experience a number of forces relating to emigration which have been catagorised into 'push factors' and 'pull factors'.

Push factors
-Poor working conditions –Low pay (Southern African countries US$500-$3500/month v US$5,000-$10,000 in recipient countries – WHO 2000) -Poor infrastructure -possibly Inappropriately trained – tertiary level not PHC (Sanders et al. Global Public Health) -Fewer promotional opportunities -Lack of decision-making powers -Civil war -At a higher risk of HIV than most professions (the high death rate of health workers in Africa in particular is another factor contributing to the declining health workforce)

Pull factors
-Workforce shortages in countries with better economic/social opportunities -Active recruitment by recipient countries Situation in Australia

Situation in Australia

The situation in Australia is similar in many ways to that of other recipient countries such as UK, USA, New Zealand and Canada in particular.

Common to all these countries is a workforce shortage in rural, remote and outer urban areas. This is occurring for two reasons: 1) not enough workers 2) health professionals overall have a preference for working in inner urban areas.

These factors have created a heavy reliance on overseas trained health workers, particularly as temporary residents to work in what are termed “areas of need”. For example, around 4 to 5,000 overseas trained nurses, and 1000 overseas trained doctors are recruited to Australia each year, many of them are from developing countries. (Whelan et al. Harvard Health Policy Rev. In the 90s, it was ~1000/year)

A significant problem in researching brain drain issues is the lack of data. Often we only know where the workers were born, not trained. Also, there is some data on overseas trained doctors but much less for nurses and even less again for allied health professionals and technicians.

What is being done? What can be done?

It was stated in the 2003 World Health Report that “the most critical issue facing health care systems is the shortage of the people who make them work”. We can see that within this workforce crisis, the brain drain exacerbates the problem in the majority world, to the benefit of countries like Australia. The World Health Assembly in 2004 made a call for action on mitigating the negative effects of health workforce migration. There is some indication that 2006 will be a year that WHO focusses on this issue.

It needs to be noted that the situation is different in every country so a single global answer isn't going to be found, we need to find solutions that work in each situation.

Action in Australia - where to from here?

It becomes clear at this point that an ethical position must be taken. We need to find a balance between individual choice and free movement and ensuring some kind of global equity. The strategies discussed here aim to create a win-win situation in both donor and recipient countries.

Strategies to address brain drain issues can be roughly divided up into those which are implemented in the donor countries, and those which are implemented in the recipient countries only the possiblities for recipient countries like Australia are outlined here.

One clear way for Australia to reduce its contribution to the negative effects of the brain drain is to train sufficient people to make up our own health workforce and ensure appropriate distribution within the country.

According to our national health workforce strategy (created by the Australian Health Ministers) this is indeed Australia's aim. But regardless of the steps being taken now to address workforce shortages in future years, it is widely accepted that we will be reliant on overseas trained health workers for some time. (Joyce MJA 04)

Australia is a signatory to the Commonwealth Ethical Recruitment Code and various states, such as NSW and Victoria, follow some ethical recruitment guidelines. However, as researchers at UNSW suggest (Scott et al MJA 2004; 180 (4): 174-176), we need a national code of conduct for ethical recruitment which differentiates between donor countries. It has been suggested elsewhere though that ethical recruitment alone is limited in its effects; as has been seen in the UK where rate of in-flow has increased despite the introduction of ethical recruitment guidelines.

The UNSW researchers also suggest that we must selectively limit proactive approaches by recruiters in developing countries.

Exchange programs have also been suggested as a way that workers can come to a recipient country to gain experience eg 20 nurses donor to recipient, 1 or 2 more senior nurses go over in exchange. Addresses training opportunities in both countries,

Compensation to donor countries has also been raised as a possible strategy as has supporting developing countries improve the conditions and opportunities for workers within their country. This option needs further development and consideration.

An Australian Government Productivity Commission Health Workforce Study was announced on 15 March 2005. It is the goal of the new PHM Vic Brain Drain Working Group to make a submission focussing on some of the issues raised here.

PHM Victoria Brain Drain Working Group

Please contact Sally to get involved with the working group.

Next 'Brain Drain' Working Group meeting:

6:45-8:00pm Tuesday 26 April, 2005
La Trobe City Campus (near Queen Vic Markets)