The Ever Grim Story of Brain Drain
Latest statistics on emigration of health workers from Africa,
particularly Nigeria, to other continents is, indeed, grim.
OKUMEPHUNA CHUKWUNWIKE of the Abuja Bureau reviews the trend.
A recent report from the World Health Organisation (WHO) says that in
Africa alone, where health needs and problems are greatest, around
23,000 qualified academic professionals emigrate annually to Europe
and the Americas in search of better life opportunities. It also
added that as many as 18,000 nurses from a particular African country
work abroad, while elsewhere, an entire graduating nursing class was
recruited by a European country immediately after graduation.
Interesting stories indeed for The African continent.
Overall, there are estimated 750,000 health workers in the continent
who serve 682 million people. By Comparison, the ratio is 10 to 15
times higher in Europe and the Americas. To achieve the Millennium
Development Goals, the minimum level of health workforce density
according to WHO is estimated at 2.5 health workers per 1,000 people.
Out of 46 countries sampled in Africa, only 6 have a workforce
density of up to 2.5 per 1000 population.
Mohammed Yaro Budah, a pharmacist and Fellow of the Pharmaceutical
Society of Nigeria (PFN) captured the scenario: "I dare say that the
health sector has suffered the greatest brain drain compared to other
sectors. This has led to a dearth of specialists in the various
Indeed, Africa's health workforce density averages 0.8 workers per
1000 population; significantly lower than the other regions of the
world and the world median density of 5 per 1,000 populations,
observed the High Level Forum on Millennium Development Goals that
met in Abuja in December 2004.
From the North to the South and the East to the West of Africa, the
problem is the same. It is said that roughly 50 per cent of the total
population of doctors in Ghana are practising in the USA alone, while
between 70 and 100 doctors emigrate from South Africa every year.
The story is the same in Nigeria. Having the highest population in
the continent, Nigeria alone looses more health workers than other
African countries combined. Some estimates put the number of
Nigerians outside at one out of every five black doctor in the United
Kingdom. In the US it is about one out of every 10. The story is also
not different in other European and American countries.
The migration is already causing a lot of havoc to the country and
the growth of its health care system. Indeed, without urgent action,
there is a big risk that the financial support to Africa through the
new Global Health Fund to combat AIDS, Tuberculosis and Malaria may
suffer setbacks because of this trend.
For instance it is said that there has been a reduction in the number
of newly registered doctors from 1750 in the year 2000 to 800 in
2002, a 60 per cent reduction with all the implications for health
By 2002, Nigeria had a nurse population ratio of 1 to 20,700 people
compared with the WHO recommendations of 1 to 1,000. Also about eight
of doctors in Nigeria work in private hospitals, 9 per cent are
resident doctors, 10 per cent in public hospitals, 55 per cent are
not in the profession, while about 18 per cent work abroad.
A 2003 statistics of registered nurses in the UK showed that Nigerian
nurses topped the list. Nigerian doctors registered with the American
Medical Association by specialty for the same year were 15 per cent
pediatricians, 12 per cent general practitioners, 10 per cent
surgeons, seven per cent psychiatrists, six per cent obstetricians
and gynecologists, three per cent pathologists and 47 per cent for
other branches of medicine.
Stakeholders in the health sector have noted that the main reasons
for this migration of health workers to Europe and America include
low wages and salaries that they receive, poor working conditions,
inadequate incentive systems compounded by outdated regulations and
Furthermore, "challenges like political, social or economic crisis
are undermining optimal utilisation of available health workforce.
Structural adjustment policies have had major effects on development
of human resources for health as some conditions for loans' led to
the lay-off of personnel including health staff, freezing of
positions and non-recruitment of new personnel in the civil service",
said the WHO.
The migration is today a major health disaster in most African
nations. For instance, it is alarming and pathetic that Malawi, a
small poor African country has more of its doctors practising in
Manchester, England, than in all of Malawi. Other examples abound,
noted the High Level Forum.
The future is even grimmer, said the Forum. It noted that "there are
'demand' issues which encourage the exodus of African health workers
to wealthy countries. The investment in health in the western world
is predicted to increase ten-folds in the next 50 years. It is
estimated that England will need 25,000 doctors and 250,000 nurses
more than it did in 1997 by 2008. It is also estimated that a further
one million nurses will be needed over the next ten years to meet the
shortfall in the United States.
"There are also 'supply' issues which encourage African health
workers to look for more promising work opportunities abroad. The
biggest would have to be the low level of compensation provided to
most health workers in Africa. Cost of living adjusted wages
indicates that a registered nurse makes about $489 a month in Malawi.
By comparison, monthly pay for a nurse in the UK's National Health
Service is about $2576. In Ghana and Zambia, the average monthly
salary for a doctor is just over $400," noted the Forum.
The World Health Assembly through resolutions WHA 48.8 in 1996, WHA
49.1 in 1996 and WHA 54.12 in 2001, urged member states to undertake
co-ordinated health systems reforms, including reforms in medical
education and practice. It also suggests government-to-government
agreements to set up health-personnel exchange programmes as a
mechanism for managing their migration and to establish mechanisms to
mitigate the adverse impact on developing countries of the loss of
health personnel through migration. Receiving countries are urged to
support the strengthening of health systems especially in human
resources development in the countries of origin.
At the OAU Conference of African Ministers of Health, Sixth Ordinary
Session in October 1999 in Cairo, Egypt, the issue of brain drain and
its impact on the health sector was extensively debated. The
conference stressed the need to carry out research on the scope of
the problem of brain drain and its repercussion on the health budget
and called upon member states to ensure better utilisation of human
resources in the health sector.
In the same vein, the Abuja Declaration and the Abuja Framework Plan
of Action on HIV/AIDS, Tuberculosis and other related infectious
diseases in Africa adopted in 2001, called for acceleration of human
resource development on the continent. Also the improvement of
conditions of service of health personnel and the use of incentives
to prevent brain drain and promote return of health professionals.
How far these resolutions can go in the light of economic realities
of the African countries remains to be seen. A Nigerian born American
computer guru, Philip Emeagwali in his famous 2003 speech on how to
reverse the problem of brain drain in Africa painted the picture
graphically: "I also speak from my family experiences. After
contributing 25 years to Nigerian society as nurse, my father retired
on a $25 per month pension. By comparison, my four sisters each earn
$25 per hour as nurses in the United States. If my father had had the
opportunity my sisters had, he certainly would have immigrated to the
United States as a young nurse."
The 'brain drain' explains in part why affluent Africans fly to
London for their medical treatment.
Emeagwali then concluded that, "because a significant percentage of
African doctors and nurses practice in the US hospitals, we can
reasonably conclude that African medical schools are de facto serving
the American people, not Africa."
He advised African governments to ensure that those with skills are
encouraged and rewarded to stay, work and raise their families in
Africa. At the long run he pointed out, it would ensure large middle
class families thereby reducing the conditions that give rise to
civil war and corruption and ultimately promote revitalisation and
"It will be impossible to achieve a renaissance without the
contributions of the talented," he stated.
The contributions of the practitioners to the economy of Europe and
the Americas are enormous. According to the WHO report cited at the
outset, a typical Nigerian health professional in the US contributes
about $150,000 per year to the US economy.
Today it is widely believed that Africa's insufficient health
workforce will continue to be a major handicap in attaining the
Goals for reducing poverty and diseases
Recently the Minister of Health, Professor Eyitayo Lambo, raised an
alarm that African health development faces a double-edged crisis
'namely that its health systems are fragile and its human capacity is
inadequate'. He noted that while Africa has 25 per cent of the global
burden of disease, its share of the global health workforce is just
1.3 per cent thereby limiting its ability to deliver qualitative
health care especially in the public sector.
He observed that the situation called for more drastic actions by
government and the people, and stated that the federal government is
taking actions to redeem the situation.
But as Emeagwali posited earlier, there might be an urgent need for
the United Nations to impose what he called 'Brain Gain Tax' on all
the benefiting countries in Europe and Americas. He said: "I believe
controlling emigration will be very difficult. Instead, I recommend
the United Nations impose a 'Brain Gain Tax' upon those nations
benefiting from the 'Brain Drain'. Each year, the United States
creates a brain drain by issuing 135,000 HI-B visas to 'outstanding
researchers' and persons with 'extraordinary ability'.
"The US Internal Revenue Services (IRS), allows US taxpayers to make
voluntary contributions to election funds. Similarly, it could allow
immigrants to voluntarily pay taxes to their country of birth instead
of to the United States."
But despite all the arguments, the WHO regional office in Africa
believes that a lot can still be done to reverse the immigration of
African health workforce to the western world.
It is of the opinion that the tide can be reversed with improved
systems performance, better remuneration packages, adequate work
incentives, better training of health workforce, prompt and constant
payment of their salaries and arrears and others.
It also recommended that countries should urgently develop retention
strategies to prevent the brain drain especially in the area of
ensuring peace and security for their work and creation of an
enabling environment for the provision of health services.
"Countries should value their health workers and demonstrate this by
paying them a salary in keeping with what is expected of them.
Countries should, in addition, tap into the skills, expertise and
resources of their nationals in the Diaspora. Moral and ethical
considerations in the recruitment by developed countries of health
workers from developing countries should be put on the international
agenda," the office said.
The right atmosphere to make these professionals abide in Nigeria,
for instance, is still at issue, some say. "A great number of
Nigerian health professionals abound in the Diaspora who have
acquired great knowledge and skills and many are willing to return
home to share and invest in healthcare delivery once the enabling
environment is provided", said Mohammed Yaro Budah.
Perhaps, some day, given the right conditions, the brain drain will
turn to brain gain.
The Guardian, Thursday, May 5, 2005