Recent reports published by the United Nations and the World Health Organization suggest that the brain drain of healthcare professionals from the developing to the developed world is decimating the provision of healthcare in poor countries. The migration of these key workers is driven by a combination of economic inequalities and the recruitment policies of governments in the rich world. This article assesses the impact of the healthcare brain drain and argues that wealthy countries have a moral obligation to reduce the flow of healthcare workers from the developing to the developed world.
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The 2007 report of the United Nations Conference on Trade and Development states that the developing world’s healthcare system is suffering because a significant proportion of health professionals who are trained in these countries move abroad soon after qualifying.1
This brain drain affects all parts of society but is especially damaging when it affects healthcare systems, because it seriously disrupts their capacity to provide healthcare in countries with the greatest global disease burden.2 Indeed, a recent WHO report claimed that 1.3 billion people around the world have no access to basic healthcare and that the migration of healthcare workers has badly exacerbated this dire situation.3
In part, this migration of workers is caused by the freely made choices of people living in the developing world, and few would blame them for trying to find a better life for themselves and their families. But this is not the whole story, for a major cause of the so-called healthcare brain drain results from the unscrupulous and deeply hypocritical behaviour of Western governments which, while wringing their hands about the state of the healthcare in the developing world, systematically poach healthcare professionals from these very same countries.
THE FACTS OF THE BRAIN DRAIN
It has been estimated that at the turn of this century a staggering 81% of Haiti’s university-educated professionals had left the country to work abroad. The figure for Somalia was 58%, for Liberia 37% and for Laos 13%.4 The World Health Organization, meanwhile, has calculated that about 34% of Zimbabwe’s nurses and 29% of Ghana’s doctors work abroad, and a shocking 65% of Bangladesh’s newly qualified doctors leave the country every year to find employment elsewhere.5
In all, the WHO estimates that 25% of doctors and 5% of nurses trained in Africa are working in wealthy countries of the Organization for Economic Cooperation and Development.3 Moreover, 25% of all practising doctors, 10% of all practising nurses and 15% of all other healthcare workers in the UK, USA, Canada and Australia were trained in other countries.5–7
The result of these migrations of educated healthcare professionals from the developing to the developed world is evident for all to see. Hospital wards, rural health clinics, maternity units and even laboratories are hopelessly understaffed. This means that diseases go untreated, staff become overburdened with work and the overall standard of care decreases sharply.5 Indeed, so bad is the situation that the ratio of doctors to patients in sub-Saharan Africa is now estimated to be 20 per 100 000, and in developed countries is it about 220 per 100 000.8 This deficit is a particular problem in the sub-Saharan region of Africa because of the tuberculosis and HIV/AIDS pandemics that claim the lives of a large number of healthcare workers as well as patients.
It is, of course, true that some of the healthcare workers who move to the developed world return home at some point. However, the WHO claims that the numbers that do so are relatively small and that in any given year the net emigration of healthcare workers is much higher than the net immigration of these workers.3
It is also true that we cannot blame these imbalanced ratios purely on the migration of healthcare workers. Developed countries are more affluent and can obviously afford to train more healthcare professionals than developing countries can. But emigration is still a major factor in the imbalances noted above, and for this the West has some responsibility.3
PUSH AND PULL FACTORS
There are two main factors that explain why so many people move from the developing to the developed world. The “push” factors are indigenous factors that put pressure on those who can leave the “donor” country to do so. These include lack of basic services, high unemployment, bad housing, low wages, low career prospects, violence in the workplace and the threat of political instability and war.9 The “pull” factors, meanwhile, are those factors that make the “recipient” country seem attractive. These include good services, low unemployment, better remuneration, good career prospects, better working conditions and more job satisfaction.10
THE MUTUAL BENEFITS
Prima facie, three groups of people benefit from the movement of healthcare workers: the migrants themselves, the residents of recipient countries and the residents of donor countries.
The migrants clearly benefit because, by making the transition from the developing to the developed world, they can improve their general standard of living dramatically and they can look forward to a better life for themselves and their families. Thus, for example, the life expectancy of the children of a medical consultant moving from Sierra Leone to the UK could be expected to increase from 40 to 79 years of age and the consultant’s annual salary to increase from £300 to over £100 000!8 11 12
The recipient countries benefit because their economies are stimulated, they relieve short-term labour shortages and they save a lot of money by training fewer healthcare professionals than they would otherwise need.13 Indeed, the entire National Health Service in the UK has become totally dependent on the steady flow of highly skilled health professionals from the developing world to sustain the high levels of care and treatment provided for British patients.
Finally, the donor countries benefit because they receive financial remittances from workers living in rich countries, develop professional networks in the developed world and gain access to significant skills and expertise when the emigrant workers return home.13
Sadly, this mutually beneficial, symbiotic union hides a more malign, parasitic relationship. The problem is that this flow of medical professionals from developing countries is creating a huge burden on these donor countries, for several reasons. First, the economies of the donor countries lose out when their citizens emigrate because people are the engine of growth, and a net emigration of people usually dents economic development.14 Second, the donor countries must foot the bill for educating their healthcare professionals at the primary, secondary and tertiary level, but then they lose a return on their investment when their educated workforce emigrate.15 And finally, the bare fact that so many healthcare professionals leave these countries creates a large gap in the workforce that leaves the provision of healthcare in these countries in tatters.
It could be argued that the responsibility for the negative consequences of migration lie with those who migrate rather than with the recipient countries. But this argument does not hold water, because, even if we ignore the many historical injustices that have contributed to the economic imbalance between the developed and the developing world, there is also the disquieting fact that many Western governments actively recruit health care workers in developing countries.16 Moreover, the WHO makes it clear that the growth of professional recruitment agencies that enlist healthcare professionals in developing countries is partly to blame for the exodus of these professionals to the West.3 Bach also notes that that there is a clear link between recruitment and migration. For example, he points out that when the Canadian government attempted to recruit South African doctors directly, there was an immediate increase in the number of South African doctors moving to work in Canada.16 17
It should be clear, then, that we cannot simply blame healthcare migrants for the dire lack of healthcare professionals in the developed word. We must accept that part of responsibility for the damage wrought by the migration of these workers must be borne by the wealthy countries that recruit them and we must also accept that we have a duty to redress these injustices.
It is, of course, true that Western governments, private charities and individual health professionals spend a large amount of time and money trying to sustain the healthcare systems of poor countries, directly and indirectly. But doing so while simultaneously skimming off the cream of these countries’ educated workforces makes no economic, political or moral sense whatsoever. We really should not be giving with one hand just to take away with the other.
Some commentators have argued that the UN’s and the WHO’s assessments of the damage caused by the migration of healthcare workers is overblown. For example, Birdsall has argued that the deficit caused by the emigration of nurses from South Africa to the UK was balanced by a quadrupling of students enrolling on nursing courses in the following year.18 However, an increase in the number of applicants enrolling on courses does not necessarily translate into an increase in the number of trained nurses on the ground, because many of these trained nurses will end up emigrating themselves—which explains why there are still 32 000 nursing vacancies in South Africa.8 It should also be noted that even if the deficit could be plugged in this way, poor countries would still have to pay for the education of those who leave and would continue to lose out financially.
Nonetheless, some governments in the developing world, such as those in Cuba and the Philippines, intentionally train an excess number of nurses and doctors in the full knowledge that many of them will emigrate on completion of their qualification.8 This suggests that these governments see the export of human capital as a good investment rather than a waste of educational resources. The underlying economic idea behind this seeming paradox is that the remuneration that these workers will send back to their countries will exceed the costs of educating them in the first place. Thus, educating an excess of healthcare professionals provides a net economic benefit.
The problem with this neat solution is threefold. First, this policy does not solve the healthcare deficit in these countries. Hence, the Philippines still lacks nurses, even though it is a nurse-exporting country.8 Second, the evidence for this economic net benefit is inconclusive, because the gain from remuneration may not offset the loss of tax revenue that will occur when there is an exodus of large numbers of educated citizens. Third, even if there is a net inflow of money, it may be the case that the loss of human capital is still worse than the economic benefit. The reason for this is that the exporting countries become dependent on unstable exports to keep their economies ticking over. In essence, becoming dependent on exporting healthcare professionals is one with being dependent on cash crops such as cocoa, coffee and cotton. By becoming the healthcare factories of the world, these countries will become dependent on the vagaries of Western demand for health workers, and they may not develop their own industries, infrastructure and healthcare systems, either. Of course developing countries need to engage in some form of trade with the West. But they need to diversify their economies and avoid becoming over-reliant on one export product; otherwise they risk serious economic consequences if the demand for their export suddenly dries up.
A third argument in favour of migration runs along the lines that those who emigrate may one day move back home and bring with them the skills and knowledge that they have acquired.5 This seems initially quite attractive, because the rich world would in effect pay to provide the postgraduate skills that could then be used in the developing world in the future. However, this benefit is entirely dependent on large number of migrants moving back home after spending some time in the developed world, and there is no sign that they are doing this.
It has also been argued that any action taken by the industrialised nations to inhibit the immigration of healthcare professionals would be immoral, for it would represent an attack on these people’s right to move freely from place to place.19 This, of course, is true enough, because any immigration policy other than an open-door policy will inhibit the freedom of migrants to move. However, what this argument overlooks is the rights of sovereign states (and their native inhabitants) to determine who moves to within their borders. There must be some balance between the rights of people to move and the rights of people to choose whom they live with.
Finally, it could also be argued that the people and governments of the developed world have no right to inhibit the migration of their workers, either. However, this argument overlooks the fact that healthcare workers who are trained using taxpayers’ money have an obligation to those same taxpayers to provide a service to them. Poor people in poor countries do not pay taxes to train healthcare workers in order that they may leave the country to find a better life. They pay taxes in order to benefit directly from the knowledge and skills of those they train. Taxpayers have rights too.
The key point here is that those who receive benefits from a community have a moral duty not to behave parasitically towards their communities by taking a “free ride”. Free riding is deeply immoral, as it involves treating others as means to an end rather than as ends in themselves and because free riders often hide their intentions from the group and will thus be guilty of defrauding their associates. What is more, free riding is basically unfair because the principles of justice and equality require, at least prima facie, that each and every member of the community should receive an equal share of the benefits and burdens of the cooperative venture—which does not occur when individuals engage in this kind of behaviour. Thus, healthcare professionals who have had the costs of their training paid for by their communities should not emigrate after graduating unless they have repaid (or soon will repay) their debts to society.
WHAT IS TO BE DONE?
The global imbalance in healthcare is not going to change radically until there is a more equitable division of the spoils of capitalism, but there are many initiatives that could at least slow down the migration of health workers from poor nations to wealthier ones.
To begin with, the donor countries could direct more resources towards improving the pay and working conditions of their healthcare workers, and could respond to their legitimate complaints about the bureaucracy and corruption that blight many a developed nation’s government. In addition, these countries could attempt to address their free-rider problems, either by preventing trained professionals from emigrating before they had repaid the costs of their education or by allowing these professionals to emigrate immediately after graduating on condition that they repay their debts as soon as they begin to earn money in their recipient countries.20
Although such policies might well help to solve the free-rider problem, they also raise a number of problems of their own. For example, the donor governments would have to decide whether repayments would take the form of financial remittances, or the healthcare professionals in question would have to repay their debts by working in their countries of training for a set number of years before being allowed to emigrate.20 In addition, the donor countries would have to decide how much debt should be taken into account and they would have to find a fair way of quantifying the debt. Finally, these governments would have to be very careful not to trespass on the basic rights of their citizens. After all, the very idea that a group of people should have to work off their debts before being set free will sound suspiciously like a form of debt bondage, serfdom or even outright slavery to some. Moreover, such a system would involve fairly drastic limits on the international movement of people and this would need to be assessed carefully.
Nevertheless, as long as the repayment system accurately reflected the benefits received by the emigrant citizens and as long as the basic rights of the individuals involved were protected, I feel that such a system might offer the best solution to the free-rider problem.
In addition, recipient countries could play their part by recruiting and training more healthcare workers in their own countries, to avoid poaching any more workers from poor nations in the future. Recipient states could also direct more aid towards sustaining the healthcare systems of poor countries and could also send teams of experts to help train healthcare professionals in the developed world in an effort to improve their workforce.
To be fair, the British government has produced ethical guidelines to reduce the dependence of its health system on foreign immigrants21 and modified these guidelines when it was shown that private recruitment agencies were able to bypass them.22 However, it is unclear at present how effective these measures have been, and there are still plenty of countries not covered by the code, such as the Philippines, which is still haemorrhaging much-needed staff to the UK.13 What is more, many other governments have not yet taken any action to reduce the flow of healthcare workers from the developing world, and so the brain drain continues apace.
It is surely the responsibility of all wealthy, developed nations to ensure that we train enough healthcare professionals for our own needs. To continue to save money by training too few professionals and then topping up the deficit by raiding poor countries for their educated elite is deeply immoral. Ghana, India and Iraq, for example, cannot afford to lose these people and we have no right to take them. Indeed, it is high time that we reverse the process and give back to those who have given us so much. Rather than adding insult to injury, we should stop the poaching and begin to rebuild the healthcare systems of those countries we have helped to devastate.
This article was assessed by Professor Peter Singer before submission and I would like to thank him for his constructive comments and support.
Competing interests: None declared.
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