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Fwd: Exporting health
by Threehegemons
21 May 2002 02:24 UTC
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Interesting article from Le Monde Diplomatique about the global movement of 
health care workers.

Steven Sherman

   Le Monde diplomatique 


   May 2002


                         Exporting health

    There is now an international trade in doctors and nurses,
    and every year poor countries lose both the $500m that it
      has cost them to train health workers recruited by the
      developed world, and the health workers, who could be
     crucial to a permanent improvement in conditions in the

                                         by DOMINIQUE FROMMEL *

     The United Kingdom began to recruit doctors from abroad
     in December 2001; it had realised that, for the National
     Health Service to work properly, it would need 8-10,000
     more doctors by 2004. Earlier in the year South Africa
     had asked Canada to stop recruiting South African doctors
     to make up for a shortfall of general practitioners in
     rural Canadian areas; South Africa had recruited 350
     Cuban doctors (1) to cover for the exodus of locally
     trained staff. Ireland hired 55 anaesthetists from India
     and Pakistan in 2000.

     Even Sweden, with its welfare system, has had to recruit
     30 Polish doctors. In the United States 23% of doctors
     qualified abroad; in the UK about 20% of doctors are
     Asian in origin; in France 8,000 doctors trained abroad,
     4,400 outside Europe. Many of these are on night call in
     children's and maternity wards, and X-ray departments of
     state-run hospitals. But they do not qualify for the same
     conditions or salaries as do their French colleagues.

     The Gulf states employ 20,000 doctors, mostly from the
     Indian subcontinent, though such South-South migration is
     usually temporary (2). This talent drain has serious
     consequences. By 2000 only 360 of 1,200 doctors who had
     been trained in Zimbabwe in the 1990s were still working
     there. Half of the doctors who qualified in Ethiopia,
     Ghana and Zambia have left home, and many of them no
     longer work in medicine in their host country. The
     available statistics about voluntary immigrants and
     refugees, and nationals born abroad, are not detailed
     enough to get an accurate picture of migratory movements

     The shortage of nurses is even more acute. In 2000 the UK
     hired more than 8,000 nurses and midwives from outside
     the European Union, to join 30,000 overseas nurses
     already working in state and private hospitals. Forecasts
     for the US, France and the UK predict a shortfall of tens
     of thousands of qualified staff by 2010.

     Science has always gained from the circulation of people
     and ideas, and medicine is no exception. In the Middle
     Ages, doctors travelled to study in the famous schools of
     Alexandria, Cordoba, Bologna or Montpellier. Later they
     sailed with explorers. After Louis Pasteur's medical
     discoveries, they travelled all over the world and
     founded tropical medicine. Now only a few doctors still
     work in Christian missions and Western experts have not
     replaced them. Nor have NGOs. The flow of doctors and
     nurses has changed direction since former colonies gained
     independence. Increased demand in industrialised
     countries partly accounts for this. The structural
     adjustment plans imposed by international funding
     agencies at the beginning of the 1980s, and their
     disastrous effect on health budgets, are also

     People do not emigrate just because they are poor and
     need to earn, or because behaviour patterns change. They
     mainly leave because they think countries in the North
     offer qualified professionals a life and career
     opportunities on a par with their education. Many factors
     are more important than material benefits (4) political
     instability, ethnic discrimination, professional
     dissatisfaction (with bureaucracy, salary arrears,
     autocratic management, isolation), the gap between
     learning and achievement, family life.

     The reasons why doctors lose interest in their work are
     complex. One, which affects both rich and poor countries
     and is often glossed over, is a crisis in medical
     thought. Consciously or not, doctors believe that
     medicine is the solution to human problems. This mirage,
     which is often given as the reason for entering the
     profession, soon disappears when material resources run
     short, and leads to frustration and anger. For most
     doctors in developing countries, there is no scope for
     laboratory tests to confirm a diagnosis. The right
     pharmaceuticals are not available. Minimum standards of
     hygiene are not possible. Those who are lucky enough to
     consider emigrating must resolve a dilemma between
     loyalty to their country, and their duty to care for the

                            Vain hopes

     In its Health for All by the Year 2000 initiative (5),
     the World Health Organisation (WHO) set targets for
     developing countries. It aimed to provide a doctor for
     every 5,000 people and a qualified nurse for every 1,000
     people, with improved access to treatment, particularly
     in rural areas. But market forces, unrealistic funding
     agencies and negligent governments have shattered these
     hopes. The world average now is one doctor for 4,000
     people: but that is one for 500 in Western countries, one
     for 2,500 in India and one for 25,000 in the 25 poorest
     countries. Free circulation of doctors, nurses and
     paramedics has created a health gap in developing

     The international bodies responsible for deciding policy
     on health and fighting social inequality have little to
     say about this. Since 1979 neither the WHO nor the United
     Nations Development Programme (UNDP) have published
     reports on the consequences of this trend for deprived
     populations (6). The World Bank has produced many studies
     celebrating the benefits of free markets, but it has not
     assessed the flow of funds resulting from exchanges of
     human capital. It no doubt prefers to disregard UN
     resolution 2417 on the "outflow of trained professional
     and technical personnel from the developing countries",
     which bans poaching of specialist professions (7). A
     country's health service does not contribute directly to
     its gross domestic product.

     A WHO document, Health for All in the 21st Century,
     published in 1995, focuses on resources required for a
     global health policy. But it makes no attempt to control
     the movement of medical skills (8). And the WHO does not
     take account of missing doctors and nurses when
     calculating average lost years of good health an index
     that factors in premature death and disability. Nor does
     the UNDP take the brain drain into account in its human
     development index for each country. It may be impossible
     to quantify the suffering of people deprived of
     healthcare, but it is very clear just why infant and
     maternal mortality has stopped declining.

     Now that public opinion is critical of the global market,
     the WHO director general has set up a commission on
     macroeconomics and health to propose a new approach to
     investment (9). In its report the commission challenges
     the usual argument that health inevitably improves with
     economic growth, stressing rather that improved health is
     essential to development and social progress in
     low-income countries. It calls for a new pact for health
     to redefine relations between donor and beneficiary
     countries. But it scarcely mentions the medical staff
     required to put proposals into practice. To achieve its
     objectives, the global fund to fight Aids, tuberculosis,
     and malaria will need teams of doctors and social
     workers, in particular to be responsible for monitoring
     patients treated with antiretroviral drugs.

     It is never easy to evaluate the cost of training
     doctors, which varies in different parts of the world. It
     is equally difficult to assess the impact on health
     services and development. But we can assume that it costs
     about $60,000 to train a general practitioner in the
     South and $12,000 for a paramedic. On this basis,
     developing countries are subsidising North America,
     Western Europe and Australasia at about $500m a year
     (10). The World Trade Organisation (WTO), always quick to
     defend the prerogatives of multinational pharmaceutical
     groups, seems incapable of understanding how important
     doctors are to prescribing drugs. Is the WTO counting on
     street market traders to boost prescription drug sales

                         Two way benefits

     Is there an inexpensive way of discouraging rich
     countries from poaching scientists from poorer countries
     (12)? Several solutions are possible. The first, far from
     new, has recently attracted attention (13): host
     countries should compensate those countries that
     originally trained their doctors and nurses. But it would
     be hard to apply such a measure without strict
     international rules. Poor countries could obstruct
     emigration, or delay it, introducing compulsory community
     service before qualification. Host countries could demand
     higher qualifications. But banning emigration will not
     prevent the deterioration of treatment and government
     decisions have little real effect on migration.

     The second solution, more far-reaching, would be to
     bolster the medical profession's image in developing
     countries. At present doctors cannot effectively deal
     with the needs of patients because their training is
     based on a universal concept of curative, scientific
     medicine that gives marginal importance to public health
     education. Before doctors can acquire the intellectual
     and practical tools they need to identify with the
     development of their countries, they must break with the
     ideology behind the training founded by former colonial
     powers (14).

     The new perspective would give priority to preserving
     health rather than treating disease. It would focus more
     on the community, less on individuals. It would demand
     teamwork between different disciplines to reconcile cure
     and prevention. Hospitals, which only benefit a minority,
     would have to stop being the only places where quality
     treatment can be dispensed. This change would oblige
     management and practitioners to justify their acts to
     society rather than just to international funding

     But the switch from a universal approach to an integrated
     one, based on recognising regional differences and
     optimising local resources, would be likely to endorse
     the principle of two-tiered healthcare, one for rich
     countries, and another for poor ones. And though the West
     might stop recognising Southern professional
     qualifications, making it more difficult for health
     professionals to emigrate, the brightest students would
     leave anyway. Some 75% of graduates from the All India
     Institute of Medical Sciences continue their studies in
     the West (15). It seems likely that, with the
     international community disregarding their scientific
     work, the status of doctors who opt to stay at home would

     There is no single answer to the problem. The countries
     of the South are not all the same, and co-operation must
     take account of their diversity and what is at stake
     short and medium term. Some countries (Cuba, Egypt,
     Spain, Italy, Israel and the Philippines) train more
     doctors than they can employ. Others (US, Canada and the
     UK), train too few to keep doctor-patient ratios at a set
     level. Limiting individual mobility will not prevent
     emigration by health workers.

     Another solution seems more promising: finding ways to
     encourage qualified staff to stay put or even return
     home. This gives everyone equal access to healthcare and
     encourages investment in education and health. Increasing
     availability of information and communications technology
     provides scope for new methods, such as distance learning
     workshops and interactive networks.

     The workshops act as virtual medical schools, backed by a
     university in the South and a teaching hospital in Europe
     or North America. The hospital is responsible for keeping
     course content up to date and giving students access to
     specialist libraries. Interactive networks connect
     expatriate doctors to colleagues at home. Such networks
     give a new shape to an intellectual and scientific
     diaspora, fostering North-South collaboration, promoting
     abroad the work of those who stay at home, and finding
     ways for emigrants to return temporarily or permanently.

     There are already more than 40 networks, operating in 30
     countries. Their membership ranges from dozens to
     hundreds (16). By restoring links with home, while
     remaining abroad, expatriates can contribute to their
     countries' development. The UNDP and the International
     Organisation for Migration are funding the Tokten
     (transfer of knowledge through expatriate nationals)
     programme to encourage return. But so far it has had only
     a limited effect on health services.

     It is difficult to predict population and economic
     growth, and harder to forecast human resources
     requirements; and the brain drain is not the uniform
     result of a single policy affecting the world. Human,
     cultural and social differences in developing and
     developed countries have to be considered. The fate of
     doctors and nurses should be decided neither by
     directives on world trade by rich countries and the WTO,
     nor by uncoordinated laws passed by poor countries.

     It is time for the WHO to honour its mandate and define a
     healthy world based on solidarity and ethical values. The
     WHO could prompt a debate on the future of trading in
     public services, involving all UN agencies, economic
     development and funding agencies, and experts in
     international law. The objective would be to draw up a
     convention on international recruitment. It would
     stipulate the conditions under which developed countries
     may recruit health workers in countries that are
     short-staffed (17). This would complement international
     agreements on qualifications and consolidate the right to
     good health recognised by the Declaration of Human

     * Doctor, former lecturer at the universities of
     Minnesota, Paris, Addis Ababa and Calcutta

     (1) Cuba trains more doctors than it needs. It has
     agreements with several African countries, some of which
     include financial compensation.

     (2) On changes in migration policy, see Joaquín Arango,
     "Expliquer les migrations: un regard critique", Revue
     internationale des Sciences Sociales, Unesco, Paris,
     September 2000.

     (3) See Sabine Cessou, "Fuite des cerveaux: L'Afrique
     part en croisade", Marchés tropicaux, Paris, 23 February
     2001, no 2889. Stephen S Mick, Shoou-Yih D Lee, Walter P
     Wodchis, "Variations in geographical distribution of
     foreign and domestically trained physicians in the United
     States: 'safety net' or 'surplus exacerbation'", Social
     Science and Medicine, Blackwell, Oxford, vol 50, January

     (4) See Marc-Eric Gruénais and Roland Pourtier (ed), "La
     santé en Afrique", Afrique Contemporaine, Paris, n° 195,
     July-September 2000, in particular Marie Badaka,
     "Profession: médecin".

     (5) Health for All was adopted in 1977 and launched at
     the Alma Ata conference in 1978.

     (6) Alfonso Mejìa, Helena Pizurki, Erica Royston,
     "Physician and Nurse Migration: Analysis and Policy
     Implications", WHO, Geneva, 1979.

     (7) General Assembly, 23rd session, Resolution 2417
     (XXIII) "Outflow of trained professional and technical
     personnel at all levels from the developing to the
     developed countries, its causes, its consequences and
     practical remedies for the problems resulting from it",
     1745th plenary session, 17 December 1968.

     (8) WHO, Regional Office for Europe, Health 21 - "Health
     for all in the 21st century", WHO, Copenhagen, 1999.

     (9) Report of the Commission on Macroeconomics and Health
     (led by Jeffrey S Sachs) Investing in health for economic
     development, WHO,Geneva, 20 December 2001. See also
     Amartya Sen, "Health in Development", WHO Bulletin,
     volume 77, September 1999.

     (10) Sophie Boukhari in "Diplômés aux enchères", Courrier
     de l'Unesco, Paris, September 1998, estimates the annual
     cost of the brain drain as a whole as $10bn.

     (11) See Jeanne Maritoux, Carinne Bruneton, Philippe
     Bouscharin, "Le secteur pharmaceutique dans les États
     africains francophones", Afrique Contemporaine,
     July-September 2000, n° 195. In West Africa 25% to 40% of
     drugs are peddled on markets.

     (12) The US Bureau of Labour Statistics forecasts that
     growth in healthcare services will increase by 30%
     between 1996 and 2006, accounting for 3.1m jobs,
     numerically the largest increase in all sectors in the US
     ("Occupational statistics outlook", Statistics Handbook
     1998-1999). In France, 35,000 to 80,000 new hospital jobs
     are due to be created by 2004.

     (13) Peter E Bundred, Cheryl Levitt, "Medical Migration:
     Who are the real losers?", The Lancet, London, vol 356,
     15 July 2000.

     (14) In industrialised countries, the content and funding
     of medical training have also drawn criticism. See, in
     particular, Arnold S Relman, "The crisis of medical
     training in America. Why Johnny can't operate", The New
     Republic, Washington DC, 10 February 2000.

     (15) Sanjoy Kumar Nayak, "International migration of
     physicians: Need for new policy directions. (Interpreting
     new evidence with reference to India)" European
     Association of Development, Research and Training
     Institutes (EADI), 8th General Conference, Vienna, 11-14
     September 1996.

     (16) Jacques Gaillard, Anne Marie Gaillard, "Fuite des
     cerveaux, retours et diasporas" , Futuribles, Paris, n°
     228, February 1998. Jean-Baptiste Meyer, "Expatriation
     des compétences africaines: l'option diaspora de
     l'Afrique du Sud", Afrique contemporaine, n° 190, 2nd
     quarter, 1999.

     (17) Tikki Pang, Mary Ann Lansang and Andy Haines make a
     similar proposal in "Brain drain and health
     professionals" British Medical Journal, London, vol 324,
     2 March 2002.


                                   Translated by Harry Forster


       ALL RIGHTS RESERVED © 1997-2002 Le Monde diplomatique


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