Managing medical migration from poor countries

Introduction

In the past, the migration of skilled health professionals from poorer to richer countries was essentially a passive process. Movement was driven mainly by the political, economic, social, and professional circumstances of the individual migrant. In recent years, however, demand for health workers in many countries in the Organisation for Economic Cooperation and Development has been greatly increased by changes in population dynamics. In response, some of these countries are relying increasingly on imported labour, with potentially damaging consequences for the healthcare systems in many developing countries, especially Africa. Indiscriminate poaching of health professionals is also likely to damage receiving countries in the long term. In this article I explore the policy options likely to minimise the consequences of migration of health workers.

Why do health workers emigrate?

Studies focusing on why skilled health professionals emigrate have identified two broad categories: the “push” and the “pull” factors.1 2 Among the push factors are low wages, poor motivation, persistent shortages of basic medical supplies, dangerous working conditions, outdated equipment, lack of supervision, and limited career opportunities.2 3 Involuntary factors such as human rights violations, ethnic and religious tensions, political persecution, wars, and economic collapse also play a part.4 Economic reasons, access to professional development opportunities, and job security are among the most important pull factors.

Empirical evidence on the size of the problem is only now emerging.5 6 For instance, in Ghana over 60% of all doctors trained locally in the 1980s had emigrated by 1999.7 In 2001 alone, it lost over 2972 nurses compared with 387 nurses in 1999.8 The vacancy rate for nurses in 2002 was 57% compared with 25% in 1998. Similar losses are reported in other parts of the developing world.6 7 9

Too few doctors who come to the West ever return home

Credit: IAN HOOTON/SPL

Winners and losers

The mass emigration of skilled health professionals is not a neutral event. At present the costs and benefits are unevenly distributed.4 10 The host countries benefit from short term relief of labour shortages, increase in available human capital, stimulation of capacity for innovation, savings in educational costs, and increased global competitiveness.11 The potential benefits to the origin countries include financial gains through remittances, skills transfer, and possible investment if workers return.12 However, all these are trivial compared with the losses, which include loss of public educational investment, loss of intellectual capital, reduced range of available services, chronic understaffing of health facilities, and poor healthcare services.3 13 In extreme cases, a widening of the population health gap may result in reduced productivity, loss of national economic investment, and potential damage to economic development.1 2 13

Affected developing countries face difficult choices. They can neither control the outflow of skill nor ignore its consequences on the larger community.14 The right of the individual health worker to emigrate has to be balanced against the consequences of such migration on the welfare of the larger society. This problem has rekindled an old debate between those who view skilled migration as the rational expression of the right of individuals to maximise their utility and those who view it as concealed exploitation of poorer countries by the richer countries.15 16

What went wrong?

Changing population dynamics within industrialised countries have created an ageing population with increased demand on health services.17 The problems arising from factors such as low fertility, increased longevity, a trend towards early retirement, and an ageing workforce are likely to deepen over the next half century.18 19 This difficulty is compounded by a persistent shortage of health professionals, especially nurses. The US, for example, expects a nursing shortfall of around 500 000 by 2015.20 In addition, globalisation and the rapid commercialisation of health services has increased competition for skilled labour.13

In response, some governments (developed and developing) have entered into bilateral agreements for the supply of healthcare professionals from specific countries for specified durations.10 Others, like Canada, Australia, and the UK have opted for a two pronged approach. A short term plan of “ethical” international recruitment and a long range plan to train more new doctors and nurses.21 22 23 More generally, however, many countries have instituted emigration policies that favour direct recruitment of foreign health professionals—for example, the US H-1C visa programme targeting nurses, Australia's migration occupations in demand list, the UK's shortage occupations list, and Germany's green card system.3 24 In effect, many countries are using selective immigration as an instrument of industrial policy.10 In the words of the German interior minister Otto Schily: “There's competition among the industrialised countries for the best minds. That's why we have to direct our immigration law more strongly towards our own economic interests.”25

Challenge of ethical recruitment

It is tempting, therefore, for destination countries to ignore the consequences of indiscriminate poaching on the health of the origin countries. This strategy, however, is unlikely to serve the long term interests of either the origin or the receiving countries. The consequences of further deterioration of the already frail health systems in affected countries may go beyond health to other sectors of the economy.15 16 25 The potential for economic decline, political instability, and mass emigration is real. More drastic measures than those used recently by Italy and Australia may be necessary to halt migration into developed countries.

Fortunately, concern about the harmful effects of indiscriminate poaching is growing.26 The adoption of a code of ethical recruitment by the UK Department of Health and Commonwealth countries are notable (albeit feeble) attempts at minimising the damage.27 28 So far, however, the effect of the existing codes on recruitment has not been systematically examined.29

Strategies and solutions

Clearly, the shortage of health professionals has no simple solution. The problem is global and therefore requires a global solution. The goal is to meet the legitimate labour needs of the developed countries without damaging the health systems of the developing countries. However, effective international cooperation on the management of skills migration cannot be achieved without comprehensive and accurate data on stocks and flows of health workers. This is difficult to obtain because countries are not specifically required to track healthcare staff. A recent review by WHO noted that existing data on the migration of health workers are neither complete nor fully comparable, are often underused, and are not as timely as required.30 Furthermore, the lack of standardised definitions and data instruments make it impossible to distinguish between local shortfalls in producing skilled workers, internal brain drain to other sectors of the same economy, and emigration.

The need for consistent and comparable international migration data is obvious. Institutions like the International Labour Organization, the World Trade Organization, and WHO must take a lead in harmonising the development of comparable instruments for collecting data. This is necessary for crafting equitable policies to govern ethical recruitment. Unfortunately, however, it may take years for the necessary consensus to emerge.

The absence of a consensus should not be used to justify governmental inaction. A well designed global cross sectional survey of health professionals could provide the basis for a preliminary analysis of the scope, magnitude, and direction of these flows. Such information would facilitate comparative analyses of the factors that influence emigration of health workers; the economic, social, and political determinants of changes in policies in both origin and receiving countries; and the influence of immigration policies on skilled migration in both origin and receiving countries.

Evidence from such a survey could form the basis for international action. It is, however, unlikely that any single policy will be sufficient. Firstly, the factors influencing the decision to emigrate are complex. Secondly, the countries involved vary greatly. Some produce more health professionals than they can absorb (Egypt, Cuba, Spain, Israel, and Italy) while others (US and UK) produce fewer than they need.5 15 31 Between these extremes are countries that both send and receive health workers in a pattern that reflects their level of social, political, and economic development.

Successful international action will require a global framework for the management of skills migration. It is critical to engage the active participation and cooperation of all the major players: major developed countries, major developing countries, multilateral agencies, and representatives of the health professions. The goal of such a framework will be to:

• Link international migration to the health policy goals of individual countries.

• Develop a set of rules or guidelines to govern the recruitment of health workers.

• Develop guidelines for bilateral and multilateral compensation agreements.15

• Identify countries from which recruitment may be less harmful.

• Monitor and document the production of the extra workforce to meet the needs of receiving countries without injuring the health systems of origin countries.

• Safeguard the rights of recruits in the host country.

Setting up such a framework will be complicated. It is, nevertheless, necessary if we are to uphold the principles of fairness. The codes of practice developed by the UK and the Commonwealth will provide a good starting template.26 27 Although the international community needs to guarantee an equitable environment for the administration of ethical recruitment, steps can be taken independently by both origin and receiving countries (box). Prompt action is essential for everyone's health.