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Developed nations receiving more physicians from poorer countries

Many African physicians who explore overseas educational opportunities do not return to their native countries.

Issue: Issue 5 2005

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A growing number of physicians and other health professionals are leaving developing nations for wealthier countries, creating a shortage of skilled health care workers in their homelands.

The migration is reportedly heaviest between sub-Saharan African countries and the United Kingdom. The result: a plethora of African-born physicians and nurses have emigrated to the United Kingdom, leaving a dire shortage of medical workers in Africa.

“People don’t move for money primarily; they move for their career objectives.” — John B. Eastwood

Migration is a virtual food chain in which progressively wealthier countries offer higher salaries and living standards than poorer nations. For example, physicians from Tanzania, Kenya and Nigeria move to South Africa. Meanwhile, many South African physicians migrate to the United Kingdom. Ironically, some British professionals migrate to Canada and the United States, and Canadians may, in turn, gravitate to the United States, according to an editorial in the May 28 issue of The Lancet.

The exodus is generating global concern. Last May, the 58th World Health Assembly asked its director-general to study the issue. Migration is on the 59th World Health Assembly agenda in 2006. The United Nations (UN) General Assembly is also scheduled to hold a high-level debate on migration next year.

“There’s no quick fix or someone would have found it,” said John B. Eastwood, MD, FRCP, of St. George’s University of London, lead author of The Lancet article. “There are no easy answers. It’s a terribly, terribly long-term thing.”

Winners and losers

A 1998 UN Conference on Trade and Development/World Health Organization study showed that 56% of migrating physicians move from developing to developed nations, while 11% go in the opposite direction. The ratio is even wider for nurses, The Lancet said.

Thirty-one percent of the United Kingdom’s physicians and 13% of its nurses were born outside that country. The workers’ shift to the United Kingdom has had some help, too: the U.K. government recently expanded its National Health Service (NHS) staff by 16,000, making room for foreign-born health care professionals. Half of that new staff qualified in other countries.

In 2003, the United Kingdom approved work permits for 5880 health workers from South Africa, 2825 from Zimbabwe, 1510 from Nigeria and 850 from Ghana. The United Kingdom’s NHS issued the permits despite the prohibition of NHS recruitment from those nations.

In stark contrast, about 5% of physicians practicing in Germany, 4% in France and virtually none in Italy are foreign-born.

Africa’s plight

The shortage of medical professionals in sub-Saharan African countries is severe and the problem is growing worse because of the HIV/AIDS crisis, The Lancet editorial said. For example, Tanzania has only two or three physicians for every 100,000 citizens. Ghana’s Ministry of Health reported that 60% of physicians trained in Ghana since the 1980s have left that country, with 200 physicians having left just in 2002.

“Africa is losing health workers, so to achieve the Millennium Development goals (by 2015), it needs another million health workers,” Eastwood told Orthopaedics Today. “So, what’s going to happen is that because Africa is short of health workers, highly paid health workers will come from places like the United States, United Kingdom and Europe, and that is not the way to build our health systems.”

Few migrating medical workers return home, and workers’ money goes into their home countries’ general economies, not the health care budgets specifically, Eastwood said.

“Of course, we suffer as well,” Eastwood said. “Our doctors go to Canada and the United States, or Australia and New Zealand. … Our suggestion is, ‘Don’t just train more doctors, but train more doctors in collaboration with the United States, Canada, Australia and New Zealand.’ But if we trained more, many would simply flow out [to other countries]. It wouldn’t be a very good investment. After all, it’s a walking resource. You can’t pin them down.”

Negative homeland effect

Bruce Browner, MD, former chairman of the International Committee of the American Academy of Orthopedic Surgeons, said that while it is “understandable” for African physicians and nurses to seek better salaries and living conditions outside their homeland, they do so to the detriment of their own nations.

“The net effect of this, and this is one of the consequences of free travel and increased freedom, is that people do gravitate up the food chain. But the impact on their own countries is that the best and brightest leave the country,” said Browner, who serves on the Orthopaedics Today Editorial Board.

For example, there are only 400 surgeons available to take care of approximately 210 million people living in the seven East African countries within the sub-Saharan region, he said.

The AIDS pandemic is not the only major health care threatening African nations either, Browner added.

For example, traffic accidents are expected to jump from ninth to third among Africa’s major health care problems by 2020. Tropical diseases, famine and war also threaten Africans’ health, he said, emphasizing the growing need for medical workers to help deal with Africa’s varied health crises.

A “human resource”

Jacob Plange-Rhule, MD, PhD, an orthopaedic surgeon who studied in the United Kingdom but practices in his native Ghana and collaborates regularly with Eastwood, said physicians are “a valuable human resource” that should not be squandered.

“I always look at human resources and development as an investment, and it’s one of the biggest investments a country can make,” Plange-Rhule told Orthopaedics Today. “Once you’ve made your investment in human capital, it’s a shame to sit and watch [physicians] leave. It’s akin to somebody making an investment and watching it being washed down the drain.

“Many of these people are very loyal to their countries and would probably stay in the country and train and work if they had adequate opportunities to train.” — Bruce Browner

“If you’ve made some investment in human capital, you need to go the extra mile to ensure that that capital stays within the country to make a difference,” he said.

Since most medical schools in sub-Saharan African countries offer courses in English, most of that region’s physicians move to the United Kingdom, Canada and the United States, Eastwood said. Still, a lack of medical training in the sub-Saharan nations contributes to migration.

In that region, 24 of 47 countries have one medical school each and 11 have no medical schools. Many African students who do get training receive it in developed nations, but very few of them return to their native countries, The Lancet reported.

“People don’t move for money primarily; they move for their career objectives,” including closer professional contact with their peers, Eastwood said. Some surgeons sense they will not have an opportunity to move ahead intellectually or professionally if they stay in their country.

“They feel a sort of urgency and ask themselves, ‘Where will I be 10 years from now? Will I still be practicing in some district hospital somewhere?’” he said.

And then there are the feelings of isoloation. “I met several people who said, ‘I migrated because in my specialty, I had no one to talk to [back home],’” he said.

Forging partnerships

Eastwood, who has collaborated with Rhule and other professionals from Ghana since the 1960s, suggested that partnerships between British universities and hospitals and their African counterparts may help squelch the migration trend. Links would enhance physicians’ sense of being in a community and improve patient care, he said.

“It doesn’t have to be expensive either,” Eastwood said. “It’s all about sending journals, making people [from other countries] members of the local societies, feeling you’re part of an international community, using the Internet … all sorts of things.”

Plange-Rhule also voiced strong support for international links, which he and Eastwood have nurtured for a decade.

“That sort of arrangement is one of the ways we keep people in their own countries in the developing world, because you know there’s a release valve that you can always open and travel up,” Plange-Rhule said. “It’s a way of refreshing yourself once in a while. You travel [to the partner country], renew ideas, dream up new research and come back rejuvenated to carry on the work of looking after the many people that attend your clinic every day.”

More training facilities needed

Browner, an orthopaedic surgeon at the University of Connecticut in Farmington, U.S.A., called for medical workers and educators from developed nations to help African countries establish more medical and nursing schools and thus retain more physicians and nurses.

“Of course, that doesn’t address our need and our tendency to recruit them in the G7 or G8 countries,” Browner said. “That won’t stop. Some would argue that if you produce more nurses and doctors in these countries, there will just be more for us to recruit.”

More African physicians and nurses would choose to work in their home countries if given the resources they need, he said.

“Many of these people are very loyal to their countries and would probably stay in the country and train and work if they had adequate opportunities to train,” Browner said.

Browner praised World Orthopaedic Concern, Health Volunteers Overseas, Doctors Without Borders, the International Red Cross and several other organizations for helping train health care workers in Africa and elsewhere.

However, aid organizations need more funding to better serve African countries, he said.

Likewise, “If the medical schools in the United States, Canada and Europe each adopted a medical school in another country, and there was some sort of interaction where faculty were rotating and people were raising money and sharing resources, it might become less overwhelming,” Browner said.

“I think people would be willing to do a lot more if there were opportunities and they had the resources.”

For more information:

• Eastwood J, Conroy RE, Plange-Rhule J, et al. Loss of health professionals from sub-Saharan Africa: the pivotal role of the United Kingdom. The Lancet. 2005; 365:1893-1900.