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Brain drain human resource crisis
Bryan Pearson, The Africa Report
October, 2006

At the heart of the breakdown in Africa’s health systems is the continual draining away of trained staff from the continent. The money, time and experience of these doctors and nurses is being lost, often for good. Bryan Pearson reports

There is a crisis within Africa’s health services and it has nothing to do with bacteria or viruses. It is a lack of suitably qualified people.

Ironically, while patient numbers have continued to rise inexorably, the number of doctors and nurses available to care for them is dwindling. Why? The lure of greener pastures overseas, and a lack of public sector funds to pay those who remain. This crisis jeopardises the aims of many of the major programmes, such as the Global Fund on HIV/AIDS, TB and Malaria and, unless assuaged, threatens to continue to undermine Africa’s public sector health services which, in many countries, have deteriorated badly in recent years.

The demographics for the personnel requirements to meet the predicted growth in health needs for the next couple of decades makes for sober reading. With populations living longer there is an untold need for extra geriatric care, etc. The recruitment trend is not a flash in the pan, it is the start of a long-term trend. Africa must find ways to make the pull of financial rewards less entrancing, as well as ways of addressing the push factor of poor working conditions at home, which send many overseas each year.

And yet, while much has been made of the exodus of key staff, what has often not been appreciated is that, in many African capital cities, there are dozens of unemployed and frustrated doctors and nurses. They don’t want to go and work in rural areas at the district level and there are no funds in the big cities to employ them.

Recognizing the dilemma, the World Health Organization recently urged the G8 members to dedicate 50% of all new developing country health funding to strengthening health systems. Of those funds, 50% should be dedicated specifically to training, retaining and sustaining the health workforce. It further urged the provision of direct financial support for health training.

WHO estimates that, to meet the investment costs of training an adequate health workforce by 2025, the average country with a severe shortage would need to increase its annual level of health spending by about $1.60 per capita. To pay the salaries of the scaled-up workforce as they finish training, a minimum increase of $8.30 per capita would be required. That is a total increase in spending of $10 per capita on the health workforce by 2025.

Brain drain is not a new phenomenon, but it is a rapidly escalating one. According to the International Organization of Migration, between 1960 and 1975 around 1,800 highly qualified Africans left the continent each year. For the period 1975 to 1984, this figure increased to 4,000 and, from 1984 to 1990, it went up to 12,000. By the end of 2000 it had increased to 23,000. All in all, more than one third of Africa’s intellectual resources now reside outside of the continent. In a free market it is perhaps inevitable and there is a firm sea change of opinion not to view it as negative, but simply as a challenge that need other answers. Certainly the exchange of ideas and skills is undoubtedly valuable to all parties, though returnees do find it difficult settling in back home again, with the paucity of resources often available to them compared to what they had become used to overseas.

In the health sector context, there were 20,000 nurses in Ghana in 1980. Today, the figure is about 10,500, despite nursing schools graduating around 600 new nurses each year. In 1980, there were 1,500 doctors (and a population of around 10 million), today there are roughly the same number of doctors – but the population has more than doubled. The medical schools have been graduating about 150 new doctors each year. According to Jacob Plange-Rhule, a Past President of the Ghana Medical Association, "We know that there are more than 600 doctors in the New York area alone. There are large numbers in other parts of the United States, the UK, South Africa and Europe." They go, he says, for economic security. "If you work as a doctor in Ghana for 25-30 years you retire on a national social security pension of around $50 per month. I know of retired specialists who now live in a single room in a house in their village. That cannot be something that anyone should experience… and that is a good enough incentive for anyone to leave Ghana for a greener pasture when he is strong and young enough to work and make reasonable savings."

Over the years, the Ghanaian government has made efforts to reduce the loss of staff, even going as far as giving out 368 cars to senior staff to try to ensure they stay. However the numbers of health professionals operating outside of the main cities of Accra, Kumasi and Cape Coast are lamentably few and well below what is needed if the health status of the country is to see the substantial improvement the government hopes for.

In Ghana, when a senior member of staff leaves a post to go overseas, they don’t call it brain drain, they call it "rupture". So thin and delicate are the management structures in the rural districts that a whole district structure can fall apart at the loss of one key staff member.

But nothing is simple. While all the angst over undelivered services and departing staff has been going on, a series of studies have been published which demonstrate that, economically, the brain drain is not all bad. The argument that the cost of training a doctor or nurse in an African university and hospital is in some way a subsidy that the country has been making to Britain, the US or wherever it is that the migrant has gone to, has been turned on its head. It now appears that remittances home, from those working overseas, on average far outweigh the investment in training them in the first place. Consequently, some countries are reviewing the whole training issue with an eye to using it as an export rather than trying to prevent people from leaving.

The trouble is that these benefits do not accrue immediately and, when they do, they exhibit themselves in the form of greater consumerism by relatives (remittance recipients) rather than in the form of greater spending by the ministry of health. If ministries are to pick up the bill for additional training, they are going to need more direct funding to make things happen or the situation will just get worse.

Governments are simply going to have to find additional resources and to try to make salaries more attractive. They are also going to have to look at introducing special rural incentives to redress the imbalance between health staff in the rural areas and those in the cities. And, if the funds cannot be found to achieve both of these objectives, then they are going to have to look at whether they can deliver services through the use of less costly staff. If the demands of globalization mean they are forever fighting a losing battle, then maybe the investment needs to be made in less-qualified and thus non-internationally mobile staff, who can be relied upon to efficiently provide the basics. This is a challenge for now and also one for evermore.

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