Covid accelerates Africa’s medical brain drain
Health professionals are among the most mobile categories of workers in the world. The permanent migration of medical skills from less developed to more affluent countries is not a new issue. A 2011 study of African-trained doctors from nine countries who subsequently emigrated (to Australia, Canada, the UK and the US) valued the continent’s negative Return on Investment at US$2.17 billion, effectively a subsidy paid by poor countries to rich ones.
The issue is being exacerbated by deliberate steps taken by developed countries to deal with anticipated shortages of medical personnel in the face of a surge in demand for health care brought about by the Covid-19 epidemic. This is deepening what was already an intractable problem. While it will only be possible to attach numbers to Africa’s loss of ‘International Medical Graduates’ (IMGs) with hindsight, the general trend is already apparent.
Africa, alongside other developing countries, has experienced a net medical brain drain for decades. A report for the UK’s House of Commons last year found that 38 percent of hospital doctors in the National Health Service (NHS) gained their qualifications outside the UK. 168 000 NHS staff (13.8 percent) reported a ‘non-British nationality’ but this figure understates medical migration by failing to include those who qualified abroad but are now British citizens by ancestry or naturalization. Africa’s biggest labour-sending country is Nigeria (8 241) which is fifth on the list of foreign recruitment sources after India, the Philippines, Ireland and Poland, followed by Zimbabwe (4 192), Egypt (2 095) and South Africa (1 719).
One of the UK’s responses to the pandemic was to actively recruit abroad. It is reported that 8 100 foreign-trained nurses joined the NHS between January and April this year and that the health service plans to recruit 1 000 foreign nurses per month for the next year. Policy measures were enacted to enable in-migration of IMGs. Medical personnel had their UK work permits automatically extended for a year, visa fees were reduced and relocation support increased.
Several US states, including New York, Massachusetts and New Jersey, waived strict regulations around the registration of foreign health care professionals while Utah scrapped the requirement that foreign-trained doctors have to repeat their residencies if they had previously practiced in Australia, the UK, Switzerland, South Africa, Hong Kong, China or Singapore. The US Department of State’s Bureau of Consular Affairs was mandated to expedite visa applications.
EU countries also relaxed regulations around the immigration of medical professionals. Italy, with the second highest Covid-19 death rate in Europe, adopted a decree enabling the temporary licensing of foreign-trained health professionals. Belgium, Germany, Ireland and Luxemburg all expedited current applications and Germany reduced the standard of its language requirements. A study for the Organization for Economic Cooperation and Development (OECD) pointed out most developed countries responded to the Covid-19 crisis by exempting health professionals (with a job offer) from travel bans.
The accelerated brain drain has not gone entirely unnoticed. In a letter to the South African Medical Journal last year, five medical professors at the University of Cape Town (UCT) complained that ‘it appears that the USA and UK intend to address the shortages of medical personnel, now exposed by the Covid-19 pandemic, by recruiting doctors, nurses, rehabilitation specialists and pharmacists from low- and middle- income countries’.
The tenor of much of the reporting on the issue has emphasized the risks that inadequate health staff levels pose to developed countries. Front-line medical staff are uniquely vulnerable to the virus and gaps will also be created by the need of many to self-isolate after being in contact with its victims. While the same issue bedevils less developed countries, the voices of those affected have been all-but drowned out by the raucous self-focus of media (and scholarship) in the developed world.
The impact of medical personnel shortages in developing countries has been documented by the World Health Organisation (WHO). The organization projects a shortfall of 18 million health workers by 2030, mostly in low and lower-middle income countries. There is a vicious cycle operating here. A surgeon in New York earns a average of USD431 669 per year while one in Zambia takes home only USD 12 200. The fact is that less developed countries tend to lose medical skills because they cannot pay adequately for them. But this loss exacerbates the health and socio-economic conditions which are part of the poverty matrix in the first place.
Given the global mobility of medical graduates, a snapshot of health migration is complex. Many health professionals, especially doctors, migrate for limited periods, often in pursuit of professional development. A 2013 survey of doctors in South Africa found that nearly half had worked abroad at some point. Nevertheless, the flow is mostly poor to richer countries. Of the 10 countries where medical migration rates exceed 50 percent (i.e. more than half of the medical graduate corps are working outside their country of origin) six are in sub-Saharan Africa: Liberia (75 percent), Zimbabwe (64 percent), Gambia (60 percent), Malawi (57 percent), Sierra Leone (54 percent) and Cape Verde (50 percent).
The deeper problem is that medical migration is baked into the system. The UK’s NHS has always relied on foreign trained staff, starting with Irish nurses at its inception in 1948 and later moving on to recruit immigrants from the Caribbean, India and Pakistan, and then Africa and the Philippines. It was reported that in the Rhondda Valley, in Wales, in 2003, 73 percent of general practitioners were from South Asia. In the US, 4 000 foreign medical graduates enter residency programmes every year. Few return to their countries of origin.
It does not appear possible to limit the damage to labour-sending countries without opening up politically and socially unacceptable gaps in the health systems of developed countries. The WHO’s 2010 Global Code of Practice on International Recruitment of Health Personnel mandates only voluntary compliance by governments and has been ineffective.
Above all, the issue is intensely political and leaders in labour-sending countries appear to be either ignorant of it or unwilling to make waves. But as Professors Johannes Fagan and Mahmood Bhutta write, in the South African Medical Journal: ‘when politicians and healthcare planners err by not training enough of their own healthcare personnel or do not create working conditions to retain staff, then they should pay the price, not patients and healthcare systems in poorer resourced countries’.
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