Africa’s medical deficit

December 13, 2006

A permanent drain of trained health personnel

Africa's medical deficit

The African continent is facing 25% of the world's morbidity rate

with only 3% of its healthcare personnel. This is the result of years

of neglect and underinvestment by African governments and the

international community, plus harsh IMF restraints on nations'

budgetary expeditures.

By Karl Blanchet and Regina

Each year 20,000 healthcare personnel — doctors, nurses and midwives —

emigrate from Africa to Europe and North America: more Beninois

doctors now work in France than in Benin. Yet because of the

disastrous health situation in Africa, a million more health workers

will be needed there by 2015 to achieve Millennium Development Goals

(1).

African healthcare personnel have become a pillar of strength for

health systems in the North. Europe, the United States and Canada

have neglected to train and retain adequate numbers of doctors,

nurses and midwives to meet the growing needs of their ageing

populations, and are forced to recruit from abroad. Britain will need

25,000 more doctors and 35,000 nurses between now and 2008, according

to estimates; the US will need a million more nurses between now and

2010.

Recruitment from abroad seems to be a cost-effective and simple

solution to a shortage of healthcare workers. In seeking personnel

from Africa, rich countries save on the cost of training, which is

about 10 times higher at home than in Africa. Another advantage is

that African health workers are more flexible — prepared to work for

less money and more willing to work night shifts and overtime.

This migration of qualified professionals represents a major loss to

their countries of origin in healthcare capacity and economic and

social costs. It is enough to measure the training costs: since 1999

Ghana has lost $67m in health system investments because health

workers emigrate once they have completed their training.

Easy prey

These workers are easy prey for northern economies. The continual

drain of human resources from Africa, combined with decades of harsh

economic policies, has led to chronically underfunded health systems.

Staff in such countries are paid meagre salaries (the purchasing

power of a Nigerian doctor is 25% lower than that of a doctor even in

eastern Europe). They work in insecure areas and have heavy

workloads, but lack the most basic resources, including insufficient

drugs or medical equipment; they have little chance of career

advancement.

The impact of this chronic underfunding, together with high levels of

emigration and the worsening impact of the Aids pandemic (2), has led

to a rapidly mobile health workforce ready to seek better

opportunities elsewhere. It is easy for recruitment agencies and

diaspora networks to entice health professionals from Africa to

developed countries with offers of higher salaries and better working

conditions, selling a new employment paradise in the North. But

healthcare professionals also move from rural areas to the cities and

from the public to the private sector, seeking to optimise the

quality of life for themselves and their families, and making the

most of their work opportunities.

This brain drain has terrible consequences for Africa, where two out

of three children die from diseases that could easily be treated or

prevented. Of the 1,200 doctors trained in the 1990s in Zimbabwe,

only 360 remain; 600 out of the 800 doctors trained in Ghana between

1993 and 2002 have emigrated and 66% of them now work in Europe or

the US. The infant mortality rate in Ghana is 1 in 10, against 1 in

200 in France; there are nine doctors for 100,000 people against 335

for 100,000 in France.

Dr Abdoulaye Bagnou, coordinator of the prime minister's cabinet in

Niger, says that his country has lost all its experts in certain

areas. " We can't choose the right equipment. We have difficulties

planning and cannot get support from technicians. This effects our

capacity and we can't recruit new staff. The World Bank and the

International Monetary Fund control our expenses. "

Affirmative action

Several African countries have decided to take action and their

initiatives show that it is possible to reverse the brain drain and

improve health systems by investing in healthcare personnel. In

Uganda, the ministry of health started meal payments for doctors in

1996, followed by a 60% increase in salaries in 2001. Malawi managed

to convince Britain's Department for International Development, the

World Bank, the Norwegian Agency for development cooperation and the

Global Fund to fight aids, tuberculosis and malaria to fund a major

increase in personnel. This means 40-50% higher salaries, new cadres

of health workers, modified training modules more suited to context,

and six times as many graduates in medicine and nursing.

Ghana is another dynamic country. With the help of the International

Organisation for Migration, it launched a recruitment programme to

offer financial incentives for health personnel who return home after

working abroad. Recruitment offices were set up in Ghana's chief

embassies to improve contact with likely candidates. Ethiopia is

desperate to make changes. It has morbidity and mortality rates among

the highest in the world, and an acute and chronic shortage of

doctors and nurses. Twenty thousand women without nursing

qualifications have been trained in maternal and child health and

will soon be sent to rural areas in an attempt to make 19 health

schemes work. In Zambia, healthcare personnel are being offered such

incentives as financial bonuses, housing loans and contributions to

their children's education, to encourage internal migration towards

more remote areas. In 2005, 66 doctors accepted these.

Failure to coerce

Research by Save the Children UK and Medact (3) shows that many of

these positive retention policies were introduced because of the

failure of coercive reforms in the 1990s. These included taxing those

migrating to work abroad, withholding diplomas from health workers

until they completed their agreed bond time of one or two years, and

failing to add their names to public payroll lists until they

completed two years' work in rural areas. The result of these

measures was to encourage migration and increase tensions between

health workers and government; many countries have had to deal with

staff strikes and more absenteeism.

In most inefficiently resourced African health systems, ineffectively

supported health workers have to charge fees just to have some

resources to keep the basic health services functioning. This has led

to tension and eroding trust between health workers and poor

communities who either avoid seeking care or wait until they are

seriously ill to do so, leading to high levels of unnecessary deaths

among women and children.

Some rich countries have adopted codes of good conduct, but these

have until now had limited impact. The codes prohibit recruitment

from target countries and protect the rights of personnel within the

host country. All African countries are on this list of targeted

countries. But codes of good conduct have not been made law in

Britain and some other Commonwealth countries and their application

is dependent on government goodwill. In practice, codes of conduct

have not prevented developed countries from continuing to recruit

African personnel through private agencies.

Need to invest

When launching the World Health Report " Working Together for Health "

in April, Louis , the European commissioner for development

and humanitarian aid, said: " It is essential to invest in health

worker training " . He added that it was necessary to put more

resources behind effective human resource strategies and highlighted

the contradiction between member states who pretended they were

increasing development budgets while draining poor countries'

resources for their own needs. He warned that if long-term

strengthening measures were not taken immediately in sub-Saharan

Africa's health sector, international community investments in health

would have only limited effects.

According to the Commission for Africa, between $1bn and $6bn will be

necessary from 2006, and as much as $7.7bn from 2010, to make up for

the lack of African health professionals. To date few donations have

been pledged to help developing countries fill their personnel gaps.

Training this additional pool of healthcare workers is essential,

even though it will take six to eight years to produce results.

Urgent short-term measures are necessary: successful measures include

increasing salaries and introducing financial incentives for service

in remote areas. It is vital to convince the IMF, the European Union

and other international institutions to loosen economic regulations

to allow African countries to improve their expenditures on health.

Dr Ntaba, Malawi's minister of health, said: " I would like to bring

to the attention of the international donors that it is impossible to

deliver quality care with $12 per person per year (4). It is poverty

that underlines this situation. If donors respect their promises,

they should spend 0.7% of their GDP. This would have a significant

impact on poverty in developing countries.

It is unrealistic to analyse the present human resource crisis

without relating it to poverty issues. To be able to attain the

Millennium Development Goals, we urgently need significant

investments in both human resources and poverty reduction strategies. "

http://mondediplo.com/2006/12/12africa

--- End forwarded message ---

December 13, 2006