The Current Thinking
In the recent UK General Election, parties vied for polling superiority on numerous platforms from health and education to immigration. The issue of the ‘brain drain’ is topical to all these manifesto themes. The flood of migrant health professionals, from developing countries to developed countries, questions the balance of an individuals’ right of freedom of movement and labour against the rights and necessity of a population to have access to health services. Currently, there is an inverse care relationship (1) where those countries most in need of health services are the most understaffed. The state is responsible under international treaty obligations (CESCR General Comment 14 based on art 12 IESCR) to make health care available, accessible, acceptable and of good quality. However, international treaty articles pertaining to the freedom of movement (borne out in article 12 of ICCPR as well as article 13 UDHR) define another perspective on health migration rights. In order to respect, protect and fulfill the rights of the individual and of the communities affected by health worker migration a balance needs to be achieved on an international basis.

“Protection for developed countries at the expense of the developing world must come to an end. It is both immoral and hypocritical... “Mr. Howard (2) expressed this unlikely Tory view recently, highlighting the growing imbalance in the developing-developed world relationship.

Rising dissatisfaction with the unequal symbiosis between poor and rich led Dr Igodogho, deputy director of ActionAid International Nigerian Programme, to speak openly about the devastating effect the brain drain was having on health services in Africa. He points out, of his graduating class of 137, only 47 are left in Nigeria; the remainder dispersed to richer nations around the globe. (3)

UNISON general secretary, Dave Prentis, has emphatically pointed out that “it is morally wrong to take nurses and doctors from countries where their services are desperately needed". (4)

So how do we balance the right to travel and work abroad, with the needs of a population to attain basic human rights, including a right to health?

How does the migration work?
In order to understand how to satisfy the needs surrounding health professional circulation it is important to quantify the causes. Many documents rely on the ‘push’ and ‘pull’ classification of health migration. Push factors include the desire to abandon poorly resourced, poorly renumerated and often dangerous working conditions of many developing world health services. Pull factors include the attractive prospects presented by the developed world, such as greater job prospects, higher wages, and the lure of active recruitment and advertisement. The flow, in other words, is essentially from poor to rich. This translates to a significant rural to urban migration, public sector to private sector shift and a developing world to developed world exodus.
A Lowell and Findlay ILO paper estimates that 80% of Zimbabwe medical graduates have emigrated since the country’s independence in 1980. (5) South Africa loses 300 nurses a month overseas. (6)

Implications
Higher nurse staffing levels improve health outcomes (7). A recent estimate suggests “sub-Saharan Africa is approximately 700,000 doctors and 700,000 nurses short of the staffing requirements necessary to meet the Millennium Development Goals” (1). And yet, labour from the most underserved areas of the world continues to emigrate, in order to fill shortfalls in developed world health care services. The drain is immoral and unsustainable, resulting in poorer health in the developing world, which has vast consequences for the developed world. See Related Links.

In Countries, such as Mozambique, where the ratio of doctors per head of population is 1/30 000, or in Malawi, where the figure is 1/100 000, health workers are trapped in a vicious cycle. The reduced workforce is required to cope with ever higher work loads. When this is put into the context of HIV/AIDS, as illustrated in Malawi where 40% of the average annual output of nurses from training die prematurely, in all likelihood all due to the HIV/AIDS epidemic, remaining health workers' are overburdened and afraid (8).

A Save the Children and Med act Joint publication, labels the brain drain “An unjust subsidy”, highlighting the cost of training health graduates, their lost productivity and the lost health benefits to their native population as part of the price to underserved source nations. Why is this continuing?

Existing mechanisms to band-aid the drain
Willets and Martineau have identified 15 codes of practice targeting ethical international recruitment. Since the introduction of the first ethical guidelines, (9) the outflow from South Africa has more than quadrupled. The DoH advises against recruitment from a list of vulnerable nations and yet in 2002/2003 one in four new nurse registrants were from this list. (10)

The current DoH code of practice permits individual health professionals to pursue careers abroad. The Ethical codes in place are not all encompassing, leaving many private agencies free to continue to recruit from poor health source countries. “Eric Goemaere, the MSF head of mission in South Africa voices his frustration that ‘despite the UK's Code of Conduct on International Recruitment private agencies continue to recruit viciously throughout South Africa’"(8).

We now know that the code of practice in ethical recruitment pioneered by England and the UK has been unsuccessful. Further aggravating the ethical minefield of international recruitment the Guardian recently uncovered the fact that Foundation hospitals are to be exempt from rules limiting the poaching of overseas ‘nurses and other medical staff’. A draft code of practice alleged to be seen by the Guardian, says foundation trusts will be treated like private hospitals and merely "invited" to adopt ethical recruitment policies, without any sanction if they choose to ignore them. (11)

Potential Solutions

Listed here are potential solutions to the “be-heading” of health services, however, no single intervention is a cure and multiple strategies will be needed to reduce the exodus.

1) Strengthen health systems in countries of origin to reduce the factors impelling evacuation from impoverished, overburdened health systems.
2) Restitution: compensation for the costs incurred in training and loss of work hours to source countries.
3) Better human resource planning in destination countries. Rather than train numbers that require international recruitment top-ups, train sufficient numbers to meet health requirements at home as a minimum.
4) Managed Migration. Advocate exchange programmes.
5) Encourage ethical recruitment by destination countries.
6) Bonding. Required service to home countries in order to recoup some of the costs of training
7) Auxiliary worker training, thereby relying on non-exportable health employees to act as a reliable health care buttress.
8) Increase the policy role of International Organisations, such as the WHO and the World Health Assembly.

Conclusion:
The Foundation of any solution to the health care exodus must be to head the words of Mr. Johnson the BMA chief executive, who has recommended the government commit itself to becoming self-sufficient in doctors and nurses within the next decade. "If one considers the absolutely catastrophic effect that the current polices are having on the developing world, it seems quite immoral to consider any other course of action." Overall, it is estimated that by 2008, the UK will need 25,000 more doctors and 250,000 more nurses than it did in 1997.” (6) Isn’t it time to stop the poorest countries subsidizing the rich?

Charlotte Chamberlain
Organising Health Care Editor
charlotte.chamberlain@almamata.net

Glossary
CESCR: Committee on Economic, Social and Cultural Rights
IESCR: International Covenant on Economic, Social and Cultural Rights
ICCPR: International Covenant on Civil and Political Rights

References
1. Rowson, 2004, ‘The Brain Drain: can it be stopped?’ Health Exchange, Aug 2004, p21-23

2. ‘Howard Says Developing World Government must Reform’, Wed 09 March 2005, last updated 12 April 2005,
http://www.politics.co.uk/election-2005/howard-says-develkoping-world-governments-must-reform-$798591.htm

3. NHS Recruitment from the Third World: ActionAid International, Brain Drain Devastating African Health Services, Tuesday 22 Feb 2005, last updated April 12, 2005,
http://www.politics.co.uk/issueoftheday/actionaid-international-brain-drain-devastating-african-health-services-$7858945.html

4. ‘NHS recruitment from the Third World: UNISON- stop taking health staff and start training’, Tuesday 22 Feb 2005, last updated 12 April 2005,
http://www.politics.co.uk/issueoftheday/unison-uk-should-stop-taking-health-staff-and-start-training-$7858572.htm

5. Lowell and Findlay (2001 and 2002) Migration Of Highly Skilled Persons From Developing Countries: Impact and Policy Responses. Geneva International Labour Organisation

6. Save the Children and MedAct Joint
Briefing, ‘Whose Charity? Africa’s Aid to the NHS’ accessed via the MedAct homepage.

7. Mercer and Dal Poz, 2003, Human Resources for Health: Developing Policy Options for Change. Towards a Global Health Workforce Stratey. P Ferrinho and M Dal Poz. Antwerp, ITG Press

8. K Kober MSc, W Van Damme MD, 2004, ‘Scaling up access to antiretroviral treatment in southern Africa: who will do the job?’ Lancet 03 July, 2004; 364:No 9428,p 103-07

9. Guidance on International Nurse Recruitment. Department of Helath, London, 1999. Available from: URL:
http://www.dh.gov.uk/assetRoot/04/03/47/94/04034794.pdf

10. J Buchan and D Dovlo, 2004, International Recruitment of Health Workers to the UK; a report for Dfid 2004, London, Department for International Development Resource Centre,
http://www.dfidhealthrc.org/shared/publications/reports/int_rec/int-rec-main.pdf

11. Carvel, J., Nurse poaching rules eased. The Guardian, 26 July 2004: p.
http://society.guardian.co.uk/NHSstaff/story/0,7991,1269201,00.html accessed March 2005.