No. 2: The Brain Drain of Health Professionals from Sub-Saharan Africa to Canada

Significant numbers of African-trained health workers migrate every year to developed countries including Canada. They leave severely crippled health systems in a region where life expectancy is only 50 years of age, 16 per cent of children die before their fifth birthday and the HIV/AIDS crisis continues to burgeon. The population of Sub-Saharan Africa (SSA) totals over 660 million, with a ratio of fewer than 13 physicians per 100,000. SSA has seen a resurgence of various diseases that were thought to be receding, while public health systems remain inadequately staffed. According to one report, the region needs approximately 700,000 physicians to meet the Millennium Development Goals. Understaffing results in stress and increased workloads. Many of the remaining health professionals are ill-motivated, not only because of their workload, but also because they are poorly paid, poorly equipped and have limited career opportunities. These, in turn, lead to a downward spiral where workers migrate, crippling the system, placing greater strain on the remaining workers who themselves seek to migrate out of the poor working conditions. The ultimate result is an incontestable crisis in health human resources throughout SSA, the region suffering most from the brain drain of health care professionals. The situation in SSA has become severe enough that the final report of the Joint Learning Initiative on Human Resources for Health – a two-year global initiative sponsored by a number of donors studying various aspects of human resources for health performance – has concluded that the future of global health and development in the 21st century lies in the management of the crisis in human resources for health. There is a considerable body of literature attesting to the fact that the migration of skilled professionals from developing to developed countries is large and increasing dramatically. While different experts espouse different reasons for the increase, all agree that it is happening. Developing countries are hit hardest by the brain drain as they lose sometimes staggering portions of their college-educated workers to wealthy countries which can better weather their relatively smaller losses of skilled workers. Highly skilled professionals account for 65 per cent of migrants moving to industrialized countries. The International Organization for Migration (IOM) estimates that about 20,000 Africans leave Africa every year to take up employment in industrialized countries. We do not know how many of these are health care professionals (largely because of inadequate systems for gathering such statistics in African countries).11 The World Health Organization (WHO), however, found that a quarter to two-thirds of health workers interviewed in a recent study expressed an intention to migrate. Historically, and specific to the SSA context, the brain drain has meant not only the exodus of human capital but financial resources as well, as African health care professionals left countries with their savings and reinvested very little of their foreign earnings back into the region. There is only recent evidence suggesting that, while the numbers of professionals leaving continue to increase, émigrés are slowly reinvesting some of their earnings back into their countries. Other research raises doubts about the value of such reinvestments, however, particularly when they are in the form of remittances that are generally private welfare transfers back to family members and are often used for consumption rather than for savings. In recognition of the enormous challenge posed by the international migration of health personnel to health systems in developing countries, the World Health Organization has proclaimed 2005-2015 the decade on human resources for health (HRH)

Causes, Consequences, and Policy Responses to the Migration of Health Workers: Key Findings from India

Background: This study sought to better understand the drivers of skilled health professional migration, its consequences, and the various strategies countries have employed to mitigate its negative impacts. The study was conducted in four countries—Jamaica, India, the Philippines, and South Africa—that have historically been “sources” of health workers migrating to other countries. The aim of this paper is to present the findings from the Indian portion of the study. Methods: Data were collected using surveys of Indian generalist and specialist physicians, nurses, midwives, dentists, pharmacists, dieticians, and other allied health therapists. We also conducted structured interviews with key stakeholders representing government ministries, professional associations, regional health authorities, health care facilities, and educational institutions. Quantitative data were analyzed using descriptive statistics and regression models. Qualitative data were analyzed thematically. Results: Shortages of health workers are evident in certain parts of India and in certain specialty areas, but the degree and nature of such shortages are difficult to determine due to the lack of evidence and health information. The relationship of such shortages to international migration is not clear. Policy responses to health worker migration are also similarly embedded in wider processes aimed at health workforce management, but overall, there is no clear policy agenda to manage health worker migration. Decision-makers in India present conflicting options about the need or desirability of curtailing migration. Conclusions: Consequences of health work migration on the Indian health care system are not easily discernable from other compounding factors. Research suggests that shortages of skilled health workers in India must be examined in relation to domestic policies on training, recruitment, and retention rather than viewed as a direct consequence of the international migration of health workers

No. 2: The Brain Drain of Health Professionals from Sub-Saharan Africa to Canada

Significant numbers of African-trained health workers migrate every year to developed countries including Canada. They leave severely crippled health systems in a region where life expectancy is only 50 years of age, 16 per cent of children die before their fifth birthday and the HIV/AIDS crisis continues to burgeon. The population of Sub-Saharan Africa (SSA) totals over 660 million, with a ratio of fewer than 13 physicians per 100,000. SSA has seen a resurgence of various diseases that were thought to be receding, while public health systems remain inadequately staffed. According to one report, the region needs approximately 700,000 physicians to meet the Millennium Development Goals. Understaffing results in stress and increased workloads. Many of the remaining health professionals are ill-motivated, not only because of their workload, but also because they are poorly paid, poorly equipped and have limited career opportunities. These, in turn, lead to a downward spiral where workers migrate, crippling the system, placing greater strain on the remaining workers who themselves seek to migrate out of the poor working conditions. The ultimate result is an incontestable crisis in health human resources throughout SSA, the region suffering most from the brain drain of health care professionals. The situation in SSA has become severe enough that the final report of the Joint Learning Initiative on Human Resources for Health – a two-year global initiative sponsored by a number of donors studying various aspects of human resources for health performance – has concluded that the future of global health and development in the 21st century lies in the management of the crisis in human resources for health. There is a considerable body of literature attesting to the fact that the migration of skilled professionals from developing to developed countries is large and increasing dramatically. While different experts espouse different reasons for the increase, all agree that it is happening. Developing countries are hit hardest by the brain drain as they lose sometimes staggering portions of their college-educated workers to wealthy countries which can better weather their relatively smaller losses of skilled workers. Highly skilled professionals account for 65 per cent of migrants moving to industrialized countries. The International Organization for Migration (IOM) estimates that about 20,000 Africans leave Africa every year to take up employment in industrialized countries. We do not know how many of these are health care professionals (largely because of inadequate systems for gathering such statistics in African countries).11 The World Health Organization (WHO), however, found that a quarter to two-thirds of health workers interviewed in a recent study expressed an intention to migrate. Historically, and specific to the SSA context, the brain drain has meant not only the exodus of human capital but financial resources as well, as African health care professionals left countries with their savings and reinvested very little of their foreign earnings back into the region. There is only recent evidence suggesting that, while the numbers of professionals leaving continue to increase, émigrés are slowly reinvesting some of their earnings back into their countries. Other research raises doubts about the value of such reinvestments, however, particularly when they are in the form of remittances that are generally private welfare transfers back to family members and are often used for consumption rather than for savings. In recognition of the enormous challenge posed by the international migration of health personnel to health systems in developing countries, the World Health Organization has proclaimed 2005-2015 the decade on human resources for health (HRH)

Is the Alma Ata vision of comprehensive primary health care viable? Findings from an international project

BACKGROUND: The 4-year (2007 2011) Revitalizing Health for All international research program (http://www. globalhealthequity.ca/projects/proj_revitalizing/index.shtml) supported 20 research teams located in 15 lowand middle-income countries to explore the strengths and weaknesses of comprehensive primary health care (CPHC) initiatives at their local or national levels. Teams were organized in a triad comprised of a senior researcher, a new researcher, and a 'research user' from government, health services, or other organizations with the authority or capacity to apply the research findings. Multiple regional and global team capacityenhancement meetings were organized to refine methods and to discuss and assess cross-case findings. OBJECTIVE: Most research projects used mixed methods, incorporating analyses of qualitative data (interviews and focus groups), secondary data, and key policy and program documents. Some incorporated historical case study analyses, and a few undertook new surveys. The synthesis of findings in this report was derived through qualitative analysis of final project reports undertaken by three different reviewers. RESULTS: Evidence of comprehensiveness (defined in this research program as efforts to improve equity in access, community empowerment and participation, social and environmental health determinants, and intersectoral action) was found in many of the cases. CONCLUSION: Despite the important contextual differences amongst the different country studies, the similarity of many of their findings, often generated using mixed methods, attests to certain transferable health systems characteristics to create and sustain CPHC practices. These include: 1. Well-trained and supported community health workers (CHWs) able to work effectively with marginalized communities 2. Effective mechanisms for community participation, both informal (through participation in projects and programs, and meaningful consultation) and formal (though program management structures) 3. Co-partnership models in program and policy development (in which financial and knowledge supports from governments or institutions are provided to communities, which retain decision-making powers in program design and implementation) 4. Support for community advocacy and engagement in health and social systems decision making These characteristics, in turn, require a political context that supports state responsibilities for redistributive health and social protection measures.IS

Health worker migration from South Africa: causes, consequences and policy responses

BackgroundThis paper arises from a four-country study that sought to better understand the drivers of skilled health worker migration, its consequences, and the strategies countries have employed to mitigate negative impacts. The four countries—Jamaica, India, the Philippines, and South Africa—have historically been “sources” of skilled health workers (SHWs) migrating to other countries. This paper presents the findings from South Africa.MethodsThe study began with a scoping review of the literature on health worker migration from South Africa, followed by empirical data collected from skilled health workers and stakeholders. Surveys were conducted with physicians, nurses, pharmacists, and dentists. Interviews were conducted with key informants representing educators, regulators, national and local governments, private and public sector health facilities, recruitment agencies, and professional associations and councils. Survey data were analyzed using descriptive statistics and regression models. Interview data were analyzed thematically.ResultsThere has been an overall decrease in out-migration of skilled health workers from South Africa since the early 2000s largely attributed to a reduced need for foreign-trained skilled health workers in destination countries, limitations on recruitment, and tighter migration rules. Low levels of worker satisfaction persist, although the Occupation Specific Dispensation (OSD) policy (2007), which increased wages for health workers, has been described as critical in retaining South African nurses. Return migration was reportedly a common occurrence. The consequences attributed to SHW migration are mixed, but shortages appear to have declined. Most promising initiatives are those designed to reinforce the South African health system and undertaken within South Africa itself.ConclusionsIn the near past, South Africa’s health worker shortages as a result of emigration were viewed as significant and harmful. Currently, domestic policies to improve health care and the health workforce including innovations such as new skilled health worker cadres and OSD policies appear to have served to decrease SHW shortages to some extent. Decreased global demand for health workers and indications that South African SHWs primarily use migratory routes for professional development suggest that health worker shortages as a result of permanent migration no longer pertains to South Africa

Implementation, effectiveness and political context of comprehensive primary health care: preliminary findings of a global literature review

Primary health care (PHC) is again high on the international agenda. It was the theme of The World Health Report in 2008, thirty years after the Alma-Ata Declaration, and has been the topic of a series of significant conferences around the world throughout 2008. What have we learnt about its impact in improving population health and health equity? What more do we still need to know? These two questions framed a four-year international research/capacity-building project, “Revitalizing Health for All” (RHFA), funded by the Canadian Global Health Research Initiative, which began in 2007. The findings of a global literature review conducted by this Initiative, and focusing on comprehensive primary health care - and how it has been implemented since Alma Ata are presented. The way in which the political context has affected the comprehensiveness of PHC is considered - along with a series of proposed future PHC research areas.Web of Scienc

Reflections on the ethics of recruiting foreign-trained human resources for health

<p>Abstract</p> <p>Background</p> <p>Developed countries' gains in health human resources (HHR) from developing countries with significantly lower ratios of health workers have raised questions about the ethics or fairness of recruitment from such countries. By attracting and/or facilitating migration for foreign-trained HHR, notably those from poorer, less well-resourced nations, recruitment practices and policies may be compromising the ability of developing countries to meet the health care needs of their own populations. Little is known, however, about actual recruitment practices. In this study we focus on Canada (a country with a long reliance on internationally trained HHR) and recruiters working for Canadian health authorities.</p> <p>Methods</p> <p>We conducted interviews with health human resources recruiters employed by Canadian health authorities to describe their recruitment practices and perspectives and to determine whether and how they reflect ethical considerations.</p> <p>Results and discussion</p> <p>We describe the methods that recruiters used to recruit foreign-trained health professionals and the systemic challenges and policies that form the working context for recruiters and recruits. HHR recruiters' reflections on the global flow of health workers from poorer to richer countries mirror much of the content of global-level discourse with regard to HHR recruitment. A predominant market discourse related to shortages of HHR outweighed discussions of human rights and ethical approaches to recruitment policy and action that consider global health impacts.</p> <p>Conclusions</p> <p>We suggest that the concept of corporate social responsibility may provide a useful approach at the local organizational level for developing policies on ethical recruitment. Such local policies and subsequent practices may inform public debate on the health equity implications of the HHR flows from poorer to richer countries inherent in the global health worker labour market, which in turn could influence political choices at all government and health system levels.</p

Managing health professional migration from sub-Saharan Africa to Canada: a stakeholder inquiry into policy options

BACKGROUND: Canada is a major recipient of foreign-trained health professionals, notably physicians from South Africa and other sub-Saharan African countries. Nurse migration from these countries, while comparatively small, is rising. African countries, meanwhile, have a critical shortage of professionals and a disproportionate burden of disease. What policy options could Canada pursue that balanced the right to health of Africans losing their health workers with the right of these workers to seek migration to countries such as Canada? METHODS: We interviewed a small sample of émigré South African physicians (n = 7) and a larger purposive sample of representatives of Canadian federal, provincial, regional and health professional departments/organizations (n = 25); conducted a policy colloquium with stakeholder organizations (n = 21); and undertook new analyses of secondary data to determine recent trends in health human resource flows between sub-Saharan Africa and Canada. RESULTS: Flows from sub-Saharan Africa to Canada have increased since the early 1990s, although they may now have peaked for physicians from South Africa. Reasons given for this flow are consistent with other studies of push/pull factors. Of 8 different policy options presented to study participants, only one received unanimous strong support (increasing domestic self-sufficiency), one other received strong support (increased health system strengthening in source country), two others mixed support (voluntary codes on ethical recruitment, bilateral or multilateral agreements to manage flows) and four others little support or complete rejection (increased training of auxiliary health workers in Africa ineligible for licensing in Canada, bonding, reparation payments for training-cost losses and restrictions on immigration of health professionals from critically underserved countries). CONCLUSION: Reducing pull factors by improving domestic supply and reducing push factors by strengthening source country health systems have the greatest policy traction in Canada. The latter, however, is not perceived as presently high on Canadian stakeholder organizations' policy agendas, although support for it could grow if it is promoted. Canada is not seen as "actively' recruiting" ("poaching") health workers from developing countries. Recent changes in immigration policy, ongoing advertising in southern African journals and promotion of migration by private agencies, however, blurs the distinction between active and passive recruitment