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Ghana: Medical Skills Drain

AfricaFocus Bulletin
Mar 29, 2005 (050329)
(Reposted from sources cited below)

Editor's Note

Among the most daunting barriers to addressing Africa's urgent health needs is the migration of health professionals to richer countries. Skilled personnel representing investment by poor countries end up filling in the gaps for the UK, USA, and other countries. The problem is widely acknowledged. But a new paper from Medact, based on the experience of Ghana and the UK, argues that current policy responses are not only inadequate but also based on many false assumptions.

The paper excerpted below, the lead author of which is a Ghanaian medical doctor working in Kumasi, Ghana, argues that attempts to control mobility to solve this problem are both ineffective and questionable in terms of human rights. "The employment in wealthy countries of health professionals trained in staff-short low income countries contributes to rising international inequity in health care," the authors say. "That effect should be central to the design of policy responses to health professional migration ...The objective of policy towards migration should be, not limitation of mobility, but equity in health care as soon as possible."

For additional documents from Medact and Save the Children on this issue, including a four-page briefing on how Africa helps subsidise health care in the United Kingdom, visit http://www.medact.org/hpd_brain_drain.php

For excerpts from an earlier Physicians for Human Rights report on this issue, visit http://www.africafocus.org/docs04/acc0407b.php

All previous AfricaFocus Bulletins on health topics are available at http://www.africafocus.org/healthexp.php

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Many thanks to those of you who have recently sent in a voluntary subscription payment to support AfricaFocus Bulletin. And a reminder to all that this information service depends on support from subscriber. See http://www.africafocus.org/support.php for details.

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The 'Skills Drain' of Health Professionals from the Developing World: a Framework for Policy Formulation

Kwadwo Mensah, Maureen Mackintosh and Leroi Henry* February 2005

* Kwadwo Mensah is a medical doctor and independent health management consultant, Kumasi, Ghana; Maureen Mackintosh and Leroi Henry are at The Open University, UK.

Medact http://www.medact.org

[Excerpts. For full paper, including tables and references, visit http://www.medact.org/hpd_brain_drain.php]

Summary

This paper should be read in association with its companion paper on migration and human rights (Bueno de Mesquita and Gordon 2005). Human rights discussed there form part of the ethical and political premises of this paper. This paper in turn examines policy towards health professionals' migration from economic and governance perspectives. Our aims are conceptual and agenda-setting. In essence, we argue that current policy responses to migration of health professionals from low income developing countries underestimate the pressures and mis-identify the reasons for rising migration, overestimate the impact of recruitment policies on migration flows while ignoring unintended side effects, and mis-specify the ethical dilemmas involved.

The paper employs as its central case study the migration of health professionals from Ghana, the home country of the lead author, to the UK. This case is typical neither of migration flows nor impact, and is not presented as such. Rather, Ghana-UK migration provides a good example of many of the worst problems and contradictions in the current situation and policy debate. We therefore employ it as a test case, a source of insight, and a 'place to stand' in constructing arguments that can be tested subsequently on a wider field.

The paper puts forward the following propositions, with evidence where available and with identification of gaps in evidence that research could usefully address.

1.The employment in wealthy countries of health professionals trained in staff-short low income countries contributes to rising international inequity in health care. That effect should be central to the design of policy responses to health professional migration: the inequity ought to be tackled systematically and in a co-ordinated way. The objective of policy towards migration should be, not limitation of mobility, but equity in health care as soon as possible.

2.The migration of health service professionals is an aspect of rapid international integration and commercialisation of health service labour markets, in the context of high levels of international inequality. These processes are cumulative, self-reinforcing, and hard to reverse; policy must work with, not against their grain.

3. Coercive measures to prevent departure, taken in low income countries that are losing staff, work poorly; worse, they can intensify pressures to leave. Conversely, incentives to stay that redress the key violations of decent working and living conditions, and that value skills and commitment, do work, and lessen rather than worsen inequalities; the implication is that health service financing and governance needs to improve in countries that are losing staff.

4.The UK Department of Health's 'ethical recruitment' Code reflects a welcome recognition of the detrimental impact of international recruitment on the health systems of some developing countries. It is however generally ineffective; it may impose increased migration costs on staff from those countries; furthermore it is implicitly discriminatory along the lines of 'race', affecting as it does mainly African and Caribbean, hence predominantly black, staff.The Code is thus neither an ethically satisfactory nor an effective response to the detrimental impact of staff loss on low income, staff-short health systems; a better recruitment policy response would improve migration experiences and strengthen likelihood of return.

5.The benefits of migration to migrants' home countries are substantial, but do not compensate for the health service impacts; furthermore the problems suffered by migrants and by divided families can be substantial.

6.The net effect of some types of health professional migration such as that from Ghana is a perverse subsidy: a net flow of benefits from poor to rich country health services. That perverse subsidy is indefensible, contributing as it does to worsening the huge inequality in health services between the UK and developing countries, including Ghana. UK health service users benefit from the services of people who would otherwise be caring for African health needs, hence compensation should be paid to remove this perverse subsidy from poor to rich.

7. It is possible to design compensation in such a way that it overcomes most of the main objections usually presented, of which by far the most important is that it constitutes a tax on migration that undermines the right to migrate.

8.This would be best done within a political framework that accepted that health professional migration blurs the boundaries between countries' of origin and destination countries' health services. In the case of the UK and Ghana these boundaries are already permeable. The best way forward is therefore to build on current links between institutions, professional associations, trades unions and individuals so that, for example, Ghanaian and UK professionals increasingly accept that they are colleagues in a joint enterprise of health service development that can only be done ethically if it explicitly addresses, over time, inequalities of services and conditions.

This returns us to our initial point. The objective of migration policy is not limitation of mobility but equity of health care as soon as possible.

...

Health and inequality: ethical dilemmas, and the example of Ghana

Health inequality across the world is extreme. The populations of low income countries from which some health professionals are migrating to the UK, the USA and other high income countries, and especially those in Sub-Saharan Africa, suffer appallingly high levels of morbidity and mortality, associated with very severe underfunding of the health services (public and private) that should respond to those problems.

Table 1 shows just one snapshot of this intolerable inequity. The African countries shown are those in the 'top 25' countries of origin of overseas nurses registering in the UK in 2003/4.The number of new nurse registrations is shown alongside the total doctors on the UK register from those countries, and is compared with Asian countries from which many health professional migrants also come. A rich Commonwealth country of origin (Australia) and the UK are shown for comparison1. The table also shows life expectancy and total (public and private) health expenditure. In Eastern and Southern Africa life expectancy has been cut dramatically by HIV/AIDS. The inequality in life expectancy one indicator of health care need is huge, dwarfed only by the extent of relative privilege in rich countries indicated by the comparison of African and Asian with Australian and UK health spending.

This is the economic and social context in which global labour markets for health professionals are increasingly integrating, as hiring of overseas-trained professionals by rich country health systems increases. The dependence of the UK health service on overseas-trained staff is nothing new. As Table 1 shows, over one third of registered doctors are not originally from the UK, and not far off half of newly registrant nurses are from overseas. The UK population relies for its standard of health care on health professionals trained elsewhere, and the consequences of this 'skills drain' for low income, staff-short health care systems and the populations who rely upon them, is now widely recognised by policy makers (House of Commons 2004, Department of Health 2004,Willetts and Martineau 2004).This paper argues that policy still has a substantial way to go in the UK and even more elsewhere in responding effectively to the ethical dilemmas and obligations this dependence creates.

The paper employs the case of Ghana, and the migration of Ghanaian health service personnel from Ghana to the UK, as our central case study. From it, we generate arguments about the economic and governance policy issues surrounding health professional migration. We do not imply by our choice of case study that migration from Ghana is 'typical' statistically or culturally, nor that it forms a very large part of the total migration flow to the UK or the USA; neither assertion is true. Rather, the widely cited Ghanaian case focuses on a number of the most serious stresses and contradictions generated by the current international labour market for health professionals.

Ghana is a low income country with an absolute and rising shortage of health care professionals and high and rising out-migration. It has a growing economy and a government making substantial efforts to improve health care. However the country is spending far too little on health to achieve decent provision for its citizens. Ghanaian health spending was $US12 per head in 2002 (Table 1), of which $7 was public spending. The WHO's Commission on Macroeconomics and Health estimated the cost of a set of 'essential interventions' at US$34 per capita per year, much of which would need to be public spending, or $45 to include some additional hospital services (Commission on Macroeconomics and Health 2001).

As Table 2 illustrates, the gulf in indicators of need and in health professional staffing between the two countries is huge. Insufficient health personnel form one of the main constraints limiting health service capacity to deliver even basic services; in crosscountry comparisons, health service staffing is associated with better health outcomes after allowing for the effects of higher income on health (WHO 2003, Chen et al 2004, Anand and Baernighausen 2003). It follows that in Ghana, as in many other low income countries, many people are denied the health care that is an essential component of the right to health, and the failure is worsened by out-migration. The Ghana Health Service (GHS) is still achieving substantial immunisation coverage (Table 1) but that is now under threat from declining staff numbers, and health the 'skills drain' of health professionals from the developing world 9 indicators such as infant mortality are showing signs of worsening; surveys show facilities are 'grossly understaffed' (Nyonator et al 2004).The extreme inequalities of income, working conditions and employment rights that are associated with struggling, underfunded health services, so well illustrated by the Ghanaian case, are the context of policy towards professional migration by health services staff, and should be its key concern.

The Ghanaian government and health care authorities, like others in comparable situations, face a dilemma. Ghana has ratified international human rights treaties which impose binding legal obligations to ensure that their people have decent health care and safe working conditions4.On the other hand, overworked and underpaid doctors and nurses are looking for alternatives, often helped by international recruiting agencies that the Ghana government, like many African governments, accuses of poaching their much-needed medical staff (Itano 2002, House of Commons 2004). The Ghana Health Service has close current and historical links with the UK NHS, and there has in the recent past been active recruitment in Ghana for the NHS.

Ghanaian health care professionals who migrate and who return, of whom the lead author is one, also face painful dilemmas and contradictory pressures that policy towards migration must confront. If the health care workers in developing countries seek to demand their rights, then going on strike, for example, removes the health care of other people. This is a dilemma of conflict between rights, rooted in poor conditions of the health system. Health service administrators in Ghana seek a working compromise after industrial action - then after a couple of years, this conflict reemerges. Some health workers, to avoid this spiral of conflict, decide to leave.

Finally, policy makers in high income countries also face dilemmas. There are strong economic and political pressures at present in the OECD countries to recruit health workers from overseas (Forcier et al 2004, Stilwell et al 2004). Responding to these pressures is compatible with individuals' wishes to migrate. Trades unions and professional associations including the Royal College of Nursing (RCN) in the UK for example support individual nurses' rights to travel and work overseas to develop their practice and further their experiences (RCN 2002).

There is now a strong and welcome awareness not only among health policy makers and aid donors, but also in the broader policy and activist communities in the rich countries, and among health service trades unions, of the damage done in some developing countries by loss of large proportions of skilled health care staff. We discuss below the policy approach that has widespread support at present in the UK, which is often characterised as 'ethical recruitment', yet, we will argue, lacks a solid ethical base.

The current Department of Health Code of Practice for international recruitment of health care professionals in England and Wales (Department of Health 2004) includes Ghana as a country from which active recruitment is unacceptable because it will undermine local health care delivery. If the underlying intention to reduce recruitment were to be effective, the Code would amount to selective restriction of individuals' right to leave their country purely on the grounds of profession and nationality; if it is ineffectual, as it appears to be, then the underlying problems should be addressed in other ways. The Code causes unease precisely because it appears implicitly discriminatory along racial lines: it implies (given the selected countries of origin) that migrants from richer countries should be preferred to Caribbean and African health professional migrants, an implication that can risk playing into a racist agenda on immigration policy.

Finally, in considering the arguments for restitution payments, in response to the benefits health professional migrants from low income countries bring to rich country health services, Ghana provides a highly relevant test case, illustrating the scale of the subsidy from poor to rich involved. Ghana would provide, because of its very particular set of characteristics including relatively small size, a long political association with the UK and active participation by its governments in the recent political debates on health professional migration, an excellent setting for experimentation in the way in which such restitution processes might be designed and managed.

Ghana is thus, in this paper, a test case, a source of insight, a 'place to stand' in constructing the arguments that can be tested subsequently in a wider field. The purpose of this paper is to make a series of arguments about ways of understanding the migration process as a basis for policy, and the policy implications that emerge from these insights. We draw from, and reference, but do not attempt to summarise the voluminous relevant literature to which we hope to make a useful contribution.


AfricaFocus Bulletin is an independent electronic publication providing reposted commentary and analysis on African issues, with a particular focus on U.S. and international policies. AfricaFocus Bulletin is edited by William Minter.

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