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 fields."

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 care.

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 management approaches.

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 renaissance.

"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 Millennium Development 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