Eight facts about health workers and the brain drain

Migration is a much debated subject around the world. We are investigating the impacts that migration on countries, migrants, business and more. Today we hear from Martin Drewry, Director of Health Poverty Action on the issue of brain drain. Read more of the series Migration Matters.

Doctor Kouakoussui gives advice to a patient at PMI hospital. Côte d'Ivoire.
Doctor Kouakoussui gives advice to a patient at PMI hospital. Côte d’Ivoire.
Ami Vitale / World Bank

Migration: a simple concept with incredibly complex ramifications. Is there any other topic that gets people as riled up? Certainly not many.

Recent debates have highlighted some of the sensitivities.  But with the health worker crisis growing, we have a duty to have an honest and nuanced debate, no matter how tricky this may be.

For my part, as director of an international development organisation working on health in 13 countries (in Africa, Asia and Latin America), I can offer information on the connection between migration and health – or, to be more specific, migration and health workers. Here are eight ‘useful things to know,’ some obvious and some less so:

  1. Low income countries are massively short of health workers.

Can you imagine arriving at a hospital with your sick child, only to find no staff there?  Sure, busy and over-worked staff feels (sadly) familiar enough to lots of us, but not no staff. Yet in low-income countries many people genuinely face this. Across the world, extremely poor countries have a shortage of health workers that goes way beyond words like ‘severe’.  It is costing a catastrophic number of lives, and fuelling widespread disease.

A health system can’t work adequately without sufficient health workers. According to the World Health Organization (WHO) 83 countries have less than 23 doctors, nurses and midwives per 10,000 people. They are the world’s poorest countries, and this shortage is described by the WHO as ‘one of the most critical constraints to the achievement of health and development goals‘.

  1. Large numbers of health workers migrate from poor to rich countries

In 2006 it was estimated that 25% of all doctors and 5% of nurses that were trained in sub-Saharan Africa were working in OECD countries. While recent data does suggest that in some of these countries the influx of internationally-trained health workers has stabilised or declined, overall migration of health personnel to OECD countries is increasing.

Many of these are trained at public expense. This means, essentially, that wealthy countries are benefitting from the funds poor countries are investing in training health workers.

  1. One reason health workers migrate is because of their living and working conditions

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As you can probably imagine, health workers in low-income countries have a lot to deal with. Very low salaries, poor local living conditions, extremely high workloads, limited equipment and medical supplies, a lack of training opportunities – and, of course, many more poor people with diseases of poverty.

Working in wealthy countries offers them the opportunity to reverse this situation, live more comfortably, and have generally better economic prospects for themselves and their families.

  1. Health workers migrate because wealthy countries actively recruit them

Known as a ‘pull factor’ to experts on migration, many rich countries actively recruit health workers from low-income countries.

Critics have called this practice unethical because wealthy countries are, in effect, enticing health workers away from countries that are in dire need of the meagre number of health workers they are able to train. In doing this, wealthy countries are avoiding the cost of training staff themselves.

In 2007 in the United States there were 270 agencies specialising in the recruitment of nurses from abroad. The US is not the only perpetrator, though. Europe too is guilty of high levels of international recruitment. The UK, for example, is currently one of the largest destination countries for migrant health workers. Despite an ethical recruitment code, 26.63 are of doctors working currently are from outside the European Economic Area, 21% of UK doctors are recruited from middle and low-income countries, which means the UK benefits from the funding many poor countries put in to training much needed health workers.

Although international migration has been described as an inevitable aspect of globalisation, wealthy countries should accept much of the responsibility for the migration of health workers.

  1. For some poor countries, it is thought that they may lose more through lost training costs than they gain in aid for health.

Kind of puts it in perspective, doesn’t it?

  1. The WHO has a code on the ethical recruitment of health personnel…

But it lacks teeth.

The World Health Organization Global Code of Practice on the International Recruitment of Health Personnel was adopted by all WHO member states in 2010. It does provide an impetus for action, but the Code itself has limits and is voluntary, needing political will to implement it.

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Some countries also have their own ethical codes, but they have their faults too. The UK’s code, for example, does not cover the private sector except for those providing services directly to the NHS, limiting its impact somewhat.

  1. The situation is complicated.

You knew this already.  And it keeps shifting. The lines between source and destination countries have become increasingly blurred, partly as a result of the economic crisis.  In the last 20 years Spain has gone from source country to destination country, back to source country again.

And of course migration is politically sensitive. Acknowledging the inequitable global distribution of health workers caused (in part) by migration is often construed as fuelling the anti-migration agenda – but although restricting immigration may be the obvious option, it’s not necessarily the best, and in some instances has actually had unintended consequences. Acknowledging the problem of health care inequalities as a result of migration must not result in simplistic calls for tighter restrictions.

So, the issue is definitely complex, but this doesn’t mean we should ignore it as…

  1. The health worker crisis is about to get a lot worse.

In the European Union (EU) the number of people employed by the health care sector has been on the rise for several years. But it is not rising fast enough. Technological advances leading to aging populations, along with insufficient numbers of health workers being trained to replace those who retire, is leading to a crisis. Globally this will be a 12.9 million shortage of health workers sized crisis.

Today the world is short of 7.2 million health workers and it is having dire consequences, by 2035 the shortage is predicted to be 12.9 million. Unless we act now we are in danger of reversing the progress we have made in global health.

The health worker brain drain is one topic within a myriad of issues when it comes to migration – and within the broader debate it will doubtless bump up against other considerations. But, in view of its impact on poverty and global health, and despite the complexities, the inequitable distribution of health workers is an issue the world simply must address.

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Humanosphere will sometimes post articles from authors from around the globe. Although these folks are not regular contributors, we hope you enjoy this change of pace.

  • shannon

    i see eight facts. where are the other two?

    • I apparently flunked counting when I was a child. Error corrected.

      • shannon

        bummer, I was interested in the other two!

  • Michael Clemens

    Indeed this issue is complex. This piece does not reflect how complex it is, and the multiple opinions expressed here are certainly not “facts”. I’ve met African nurses who earn US$110 per month. Working for the NHS in rural UK they same person would easily make more than thirty times that amount. The author of this piece declares “guilty” the people who would dare help that nurse realize her dreams an ambitions, by telling her about jobs available (that’s what a recruiter does). Calling them “guilty” as this author does, is certainly not “fact” but represents an ideology, a view of the world in which people born in rich countries have unquestionable rights to monopolize information about all the high-paying professional jobs on earth, and not provide it to poor people.

    Recruitment bans withhold information from real people. Denying information about high-paying jobs abroad to people born in poor countries–as recruitment bans demand–is profoundly unethical. That, like the author’s claim, is an opinion. But I don’t call it “fact”.

    The “fact” of the matter is that there is no evidence at all–none–that recruitment limits like the ones this author “factually” espouses have 1) meaningfully lessened health worker shortages anywhere on earth, or 2) caused any measurable improvement in health outcomes anywhere on earth. The author has no evidence of that at all because none exists. The author has opinions that those outcomes must have happened, but that is all. What certainly will happen if recruitment bans are given “teeth”, as this author wishes, is that large numbers of people born without the professional opportunities that this author enjoys by birthright will never have the chance to achieve them. Add that to the “fact” list.