Doctors and the Brain Drain

[Angel]

Doctors and the Brain Drain

Doctors trained in developing countries often choose to work elsewhere. Wais Ahmed considers the implications for the countries they leave behind


A doctor treating a patient with malaria in Sudan

Destitution is still one of the biggest challenges that the developing world faces despite great achievements made in social, scientific, and economic development in the past century. Live 8 was the biggest political-humanitarian musical show ever to contribute to the relief of poverty in Africa, but to what long term effect?

The United Nations Conference on Trade and Development reports that over the past 27 years the West has devoted almost $500bn to alleviate poverty in Africa, but in this time poverty has worsened.1 Debt relief and economic aid may not be the magic bullets for these problems. What effect does the exodus of developing world professionals to the West have?

This exodus is particularly important with regard to the health sector. The estimated 35 million health professionals worldwide are not equitably shared between countries, largely because of international migration of health professionals.2 Better quality of life, higher salaries, access to advanced technology, and stable political conditions in developed countries attract talent from less developed areas. This brain drain has an impact on the health systems of the developing world.

Writing in the Student BMJ, fourth year medical student Karen Milford in Pretoria, South Africa, refers to the recruitment of South African health professionals by countries such as the United Kingdom and Canada as poaching.3 Is the term justified?


Effects on developing countries

International migration first emerged as a major public health concern in the 1940s, when many European professionals emigrated to the UK and USA.4 In the 1970s, the World Health Organization published data showing that an estimated 90% of all migrating physicians were moving to just five countries: Australia, Canada, Germany, the UK, and the USA.5

It is essential to understand brain drain at a global level and not underestimate the extent to which scientists born in countries with low opportunities have an impact on their homeland communities. Imagine living in a war-torn, poverty stricken, economically fragile region of the world. A handful of medical professionals is generated at great expense in spite of the country’s limited resources, at the expense of opportunities for others. You will feel the injustice towards current and future generations when a developed country snatches these invaluable contributors to healthcare.

Consider Afghanistan. It has been engulfed in war and poverty for the past 28 years. One in six mothers die during childbirth.6 Yet there is constant migration of professionals to developed countries. The crippled healthcare and education system means a scarcity of medical facilities in Afghanistan. It takes days of travel to see a doctor. These countries are not only losing their investment in the education of health professionals but also the contribution of these workers to health care.

Policies of the developed world discourage family immigration because it does not coincide with the economic necessities of migration policy. Under the UK law, dependent children over the age of 18 do not qualify for family reunion.7 When a member of a family migrates, it often leads to the break-up of the family, creating financial and psychological instability. The developing world also discourages family migration to encourage people educated overseas to return to their homeland.As much as half of the foreign born graduate students in France, the UK, and the USA remain there after completing their studies. Among doctoral graduates in science and engineering in the USA in 1995, 79% of those from India and 88% from China remained in the USA.8 Call it “poaching’’ or brain drain, the consequences are equally detrimental to already desolate developing countries.

Migration of the scientific work force seems to be happening at all levels, from undergraduate students to top level, internationally established scientists. Developing countries, especially in South Asia, are now the main source of healthcare migration to developed countries.9 This trend has led to concerns that the outflow of healthcare professionals is adversely affecting the healthcare system in developing countries and, hence, the health of the population. There is a need to review the social, political, and economic reasons behind the exodus, and to provide security and opportunities for further development locally.


Reversing the trends

Scientists who have emigrated for whatever reason are recoverable and can play a part in developing opportunities at home. However, this requires the opening of diverse and creative conduits. Today’s policy makers, scientists, and economists were yesterday’s students. By understanding the situation now, we can shape tomorrow’s future for millions. Tackling the issue requires efforts at all levels of professionalism. Currently, source countries must work on improving staff attraction and retention. The health system must be financially, technologically, and politically supported to retain skilled personnel.

Innovative graduate opportunities and programmes could be developed with the help of foreign professionals. For example, World Bank credits and transfer of technology in areas of research and development should be encouraged. Foreign scientists from developing countries who are involved in research and development produce 4.5 more publications and 10 times more patents than their counterparts at home. 9 This vast difference in productive capacity should be reviewed and conditions in which science and technology are able to prosper should be implemented. This requires political decisions, funding, infrastructure, technical support, and knowledge sharing among the international community.

Medical students should be encouraged to work as volunteers in developing countries. Not only will this bring invaluable experience back to the UK’s National Health Service, but it will encourage them to transfer their skills to these poor communities. They should be encouraged with greater financial rewards to spend their electives in the developing world.

Developed countries should also reduce the restrictions on volunteers (doctors and students) who work in developing countries and give them financial support as well as good job prospects when they return. The obstacles must be removed and doctors working overseas must be appraised.
Currently, general practitioners who work outside the UK are removed from the primary care trusts’ performers’ list (the list of family doctors licensed to practice in an area in the UK) because they are unable to attend face to face appraisals. To return to the UK to work, these doctors must reapply to the trust, a process that takes up to two months. They are more likely to be financially stranded and as a consequence are pressured to opt out of returning to volunteering in developing countries.

While it may be reasonable for those poor countries that are losing their health professionals to richer countries to complain about poaching, they must also accept their own responsibilities as employers by improving strategies for attracting and retaining staff. The Chinese government is introducing overseas intellectual resources into China to attract prominent professionals in the technology, finance, and health sectors. China reports that the number of “Haigui” (sea turtle)—the nickname for returned Chinese students—is growing rapidly in Shanghai, an example for the developing world to follow.10


Policies and effects

The mass recruitment of health professionals by industrialised countries has a negative impact on health services in poorer countries. The problem is not helped by oversimplifying the debate to one of heartless employers in the West poaching employees from developing countries. Recognition of the complexity of stakeholder interests, both within and between countries, is necessary for progress. Work should proceed simultaneously on several fronts.

Currently, decision makers in source countries are searching for policy options to slow down and even reverse the outflow of healthcare professionals. But is this possible? Perhaps not, bearing in mind the current political and economic situations of the source countries and globalisation. As Lenin said in 1916, “Capitalism is a system that is worldwide in its economic scope but divided politically into competing states that develop economically at different rates and results into Imperialism, the Highest Stage of Capitalism.”11 These economic differences in wages, knowledge, standard of life, technology, and opportunities will exist until global resources are equitably shared all over the world.

Although the developed world is attempting to do its share in regard to the brain drain, much more could and should be done. In September 2001, the UK government issued a detailed code of practice, which iterated that NHS trusts should not target recruitment at developing countries unless the Department of Health had a formal agreement with a particular country. The UK government has signed agreements with Philippines, India, and Egypt. In Egypt, the agreement extends to the improvement of Egyptian health care where Egyptian doctors can work in England to gain additional experience and return to their country.12

The UK Home Office stipulated in April 2006 that foreign medical nationals who graduated in the UK strictly fall under the work permit system on completing foundation training, so that they return to their countries of origin.13 In November 2007, the Court of Appeal ruled against the Department of Health’s guidance to limit access of international medical graduates to junior doctor specialty training posts.14 It will be interesting to observe the long term consequences of such policies on brain drain and consequently on poverty and health in developing countries.

Though it may seem counterintuitive, the brain drain may have positive economic effects for developing countries. The World Bank’s report, Global Economic Prospects, estimates that of the close to 200 million people that are living outside their home countries, their remittances reached about $225bn in 2005; it shows a direct link between migration and reduction of poverty.15 Regardless of the type of migrant, educated or not, the money sent back does alleviate poverty in their former homes. In Bangladesh, remittances are the second biggest source of foreign revenue.16 The transfer and management of remittances are thus factors that can be leveraged in forming policies that have implications for the issue of brain drain.


Is it poaching, then?

Let us return to the question posed at the beginning: is “poaching” the appropriate term? Superficially, brain drain seems to escalate poverty in the homeland. However, it gives access to better education and resources to the migrant, who otherwise might not have such opportunity, and a small but substantial amount of money is pumped back into the country in the form of remittance. Though the remittance clearly does not outweigh the benefits of health professionals staying in their native countries, the term “poaching” is far too harsh.

Regardless of whether we refer to this phenomenon as poaching or brain drain, the dynamics of migration will ultimately run their natural course. It is in this constantly evolving complexity of our world that we must work to strive for a more equitable global society. The issue of brain drain may be what tips the balance in enabling developing countries to lift themselves out of poverty.

Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed.
Wais Ahmed fifth year medical student Imperial College London
Email: wais.ahmed@imperial.ac.uk
Student BMJ 2008;1:11-12 | 16

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Source: studentBMJ