Apr 8, 2008

HEALTH MATTERS: Abysmal conditions drive out African health professionals

By LJ Anderson / Daily News Columnist

Physicians and nurses leave African countries for a host of reasons including, but not limited to: lack of jobs, poor pay, unacceptable working conditions, political instability, lack of health care infrastructure, and limited professional advancement. Those who leave - and when present, their recruiters - are often blamed for abandoning underserved populations at home, but substandard health care systems fueled by poverty are at the heart of this medical exodus.
Economist Michael Clemens, Ph.D., compiled the first detailed count of African-born doctors and nurses living outside of Africa from destination country census data. Almost 30 percent (65,000) of African-born doctors, and 11 percent (70,000) of African-born professional nurses were living abroad in 2000. The proportion varied greatly by source country. As a research fellow at the Center for Global Development, an independent, nonprofit think tank in Washington, D.C., Clemens' areas of expertise include the effects of skilled-worker emigration on developing countries.


Q: What types of health workers emigrate, and where do they go?

A: It is almost universally the highly skilled - physicians, registered nurses and nurse practitioners. The nurse registrar of Kenya showed me a chart of transcript requests from the United Kingdom, and almost 95 percent were from registered nurses. For physicians the principal destination countries by far are the U.K., United States and France and, after that, Canada, Australia, Portugal, Spain, Belgium and within Africa, to South Africa. Trade statistics are easy to measure - such as a cocoa bean - but there is no single way to measure immigrants. Is an African doctor a person who was born in Africa who is a doctor? Is it someone who trained in Africa no matter where they were born? Is it someone who is a citizen of an African country no matter where they trained or are working? In the research that I've done, I've shown it by country of birth.



Q: What incentives would be needed to encourage health professionals to stay in Africa?

A: The World Health office in Brazzaville, Congo, did a survey three years ago of about 2,000 doctors and nurses in six African countries. (One of the questions was) "Are you thinking of leaving and if so, where would you go and why?" On par or above remuneration, especially for physicians, was professional advancement - a chance to use modern techniques, do a residency abroad, acquire other skills, and use modern equipment and pharmaceuticals. People talk about migration as if it is driven by wage differentials, but there can be large wage differentials without people leaving. For medical professionals, there's a chance to use skills in a setting where they are valued. It can also be incredibly difficult to work at home. If you are willing to work as a nurse in northern Mozambique - parts of which are 1000 miles from the capital, have land mines and poor schools for your children, there is a 10 percent rural hardship allowance. Incentives are absent in the system - not just to work in areas with poor people but even the incentive to show up at work. In 2006 the head of the Kenyan nurses' association told me that he had 7,000 registered nurses who were not working (due to a) hiring freeze of doctors and nurses. He laughed when I mentioned the exodus of health professionals. "These people should get jobs wherever they can."


Q: What countries have the most health professionals leaving?

A: When I counted up doctors and nurses in censuses of the (destination) countries in order to measure health professional drain, I found that the (African) countries with the most doctors per capita abroad were the ones that have the most doctors at home per capita - and that's true for the entire continent. Countries where few doctors have left - like Niger with 9 percent of its doctors abroad - also have the least doctors at home, and places like South Africa with the most doctors abroad have the most doctors at home.
A lot of people consider migration bad when you have a tremendously underserved population. The thing I want to push back on is, would that Kenyan nurse working in London, for example, be taking care of Kenyans had she been stopped from leaving? In the vast majority of cases, the answer is no. The migration is a reaction to a situation in all African countries, and migration is not the problem. Poverty is the No. 1 reason for the weakness of the health system - very poor basic education, terrible working conditions in the public health service, absence of a private sector, and 11 of the sub-Saharan African countries have no internationally accredited medical schools. Nurses are unwilling to work in the public sector because conditions are absolutely abysmal.


Q: What role does recruiting play in this migration?

A: As an example, the Philippines sends more nurses to the world than any other country. Here's a country that has embraced (recruiting) as a way for Filipino women to advance their careers and lives, and they have more nurses per capita than Austria or Great Britain. Recruiting per se can lead to more nurses in (source) countries. Professionals respond to incentives, and you can set up a system that prepares people to work abroad. It could be a way out of poverty if African countries were willing to look at other developing countries as a model. Recruiting is not the problem per se, and can be a lever by which to build the health care system.


LJ Anderson writes on health matters every Tuesday. She can be reached at lj.anderson@yahoo.com.