Ghana: Medical Skills Drai

AfricaFocus Bulletin

Mar 29, 2005 (050329)
(Reposted from sources cited below)
Editor’s Note
Among the most daunting barriers to addressing Africa’s urgent
health needs is the migration of health professionals to richer
countries. Skilled personnel representing investment by poor
countries end up filling in the gaps for the UK, USA, and other
countries. The problem is widely acknowledged. But a new paper
from Medact, based on the experience of Ghana and the UK,
argues that current policy responses are not only inadequate but
also based on many false assumptions.
The paper excerpted below, the lead author of which is a Ghanaian
medical doctor working in Kumasi, Ghana, argues that attempts to
control mobility to solve this problem are both ineffective and
questionable in terms of human rights. “The employment in wealthy
countries of health professionals trained in staff-short low-income
countries contributes to rising international inequity in health
care,” the authors say. “That effect should be central to the design
of policy responses to health professional migration … The
objective of policy towards migration should be, not limitation of
mobility, but equity in health care as soon as possible.”
For additional documents from Medact and Save the Children on this
issue, including a four-page briefing on how Africa helps subsidise
health care in the United Kingdom, visit
http://www.medact.org/hpd_brain_drain.php
For excerpts from an earlier Physicians for Human Rights report on
this issue, visit http://www.africafocus.org/docs04/acc0407b.php
All previous AfricaFocus Bulletins on health topics are available
at http://www.africafocus.org/healthexp.php
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The ‘Skills Drain’ of Health Professionals from the Developing
World: a Framework for Policy Formulation
Kwadwo Mensah, Maureen Mackintosh and Leroi Henry*
February 2005
* Kwadwo Mensah is a medical doctor and independent health
management consultant, Kumasi, Ghana; Maureen Mackintosh and Leroi
Henry are at The Open University, UK.
Medact http://www.medact.org
[Excerpts. For full paper, including tables and references, visit
http://www.medact.org/hpd_brain_drain.php]
Summary
This paper should be read in association with its companion paper
on migration and human rights (Bueno de Mesquita and Gordon 2005).
Human rights discussed there form part of the ethical and political
premises of this paper. This paper in turn examines policy towards
health professionals’ migration from economic and governance
perspectives. Our aims are conceptual and agenda-setting. In
essence, we argue that current policy responses to migration of
health professionals from low income developing countries
underestimate the pressures and mis-identify the reasons for rising
migration, overestimate the impact of recruitment policies on
migration flows while ignoring unintended side effects, and
mis-specify the ethical dilemmas involved.
The paper employs as its central case study the migration of health
professionals from Ghana, the home country of the lead author, to
the UK. This case is typical neither of migration flows nor impact,
and is not presented as such. Rather, Ghana-UK migration provides
a good example of many of the worst problems and contradictions in
the current situation and policy debate. We therefore employ it as
a test case, a source of insight, and a ‘place to stand’ in
constructing arguments that can be tested subsequently on a wider
field.
The paper puts forward the following propositions, with evidence
where available and with identification of gaps in evidence that
research could usefully address.
1.The employment in wealthy countries of health professionals
trained in staff-short low income countries contributes to rising
international inequity in health care. That effect should be
central to the design of policy responses to health professional
migration: the inequity ought to be tackled systematically and in
a co-ordinated way. The objective of policy towards migration
should be, not limitation of mobility, but equity in health care as
soon as possible.
2.The migration of health service professionals is an aspect of
rapid international integration and commercialisation of health
service labour markets, in the context of high levels of
international inequality. These processes are cumulative,
self-reinforcing, and hard to reverse; policy must work with, not
against their grain.
3. Coercive measures to prevent departure, taken in low income
countries that are losing staff, work poorly; worse, they can
intensify pressures to leave. Conversely, incentives to stay that
redress the key violations of decent working and living conditions,
and that value skills and commitment, do work, and lessen rather
than worsen inequalities; the implication is that health service
financing and governance needs to improve in countries that are
losing staff.
4.The UK Department of Health’s ‘ethical recruitment’ Code reflects
a welcome recognition of the detrimental impact of international
recruitment on the health systems of some developing countries. It
is however generally ineffective; it may impose increased migration
costs on staff from those countries; furthermore it is implicitly
discriminatory along the lines of ‘race’, affecting as it does
mainly African and Caribbean, hence predominantly black, staff.The
Code is thus neither an ethically satisfactory nor an effective
response to the detrimental impact of staff loss on low income,
staff-short health systems; a better recruitment policy response
would improve migration experiences and strengthen likelihood of
return.
5.The benefits of migration to migrants’ home countries are
substantial, but do not compensate for the health service impacts;
furthermore the problems suffered by migrants and by divided
families can be substantial.
6.The net effect of some types of health professional migration
such as that from Ghana is a perverse subsidy: a net flow of
benefits from poor to rich country health services. That perverse
subsidy is indefensible, contributing as it does to worsening the
huge inequality in health services between the UK and developing
countries, including Ghana. UK health service users benefit from
the services of people who would otherwise be caring for African
health needs, hence compensation should be paid to remove this
perverse subsidy from poor to rich.
7. It is possible to design compensation in such a way that it
overcomes most of the main objections usually presented, of which
by far the most important is that it constitutes a tax on migration
that undermines the right to migrate.
8.This would be best done within a political framework that
accepted that health professional migration blurs the boundaries
between countries’ of origin and destination countries’ health
services. In the case of the UK and Ghana these boundaries are
already permeable. The best way forward is therefore to build on
current links between institutions, professional associations,
trades unions and individuals so that, for example, Ghanaian and UK
professionals increasingly accept that they are colleagues in a
joint enterprise of health service development that can only be
done ethically if it explicitly addresses, over time, inequalities
of services and conditions.
This returns us to our initial point. The objective of migration
policy is not limitation of mobility but equity of health care as
soon as possible.

Health and inequality: ethical dilemmas, and the example of Ghana
Health inequality across the world is extreme. The populations of
low income countries from which some health professionals are
migrating to the UK, the USA and other high income countries, and
especially those in Sub-Saharan Africa, suffer appallingly high
levels of morbidity and mortality, associated with very severe
underfunding of the health services (public and private) that
should respond to those problems.
Table 1 shows just one snapshot of this intolerable inequity. The
African countries shown are those in the ‘top 25’ countries of
origin of overseas nurses registering in the UK in 2003/4.The
number of new nurse registrations is shown alongside the total
doctors on the UK register from those countries, and is compared
with Asian countries from which many health professional migrants
also come. A rich Commonwealth country of origin (Australia) and
the UK are shown for comparison1. The table also shows life
expectancy and total (public and private) health expenditure. In
Eastern and Southern Africa life expectancy has been cut
dramatically by HIV/AIDS. The inequality in life expectancy one
indicator of health care need is huge, dwarfed only by the extent
of relative privilege in rich countries indicated by the comparison
of African and Asian with Australian and UK health spending.
This is the economic and social context in which global labour
markets for health professionals are increasingly integrating, as
hiring of overseas-trained professionals by rich country health
systems increases. The dependence of the UK health service on
overseas-trained staff is nothing new. As Table 1 shows, over one
third of registered doctors are not originally from the UK, and not
far off half of newly registrant nurses are from overseas. The UK
population relies for its standard of health care on health
professionals trained elsewhere, and the consequences of this
‘skills drain’ for low income, staff-short health care systems and
the populations who rely upon them, is now widely recognised by
policy makers (House of Commons 2004, Department of Health
2004,Willetts and Martineau 2004). This paper argues that policy
still has a substantial way to go – in the UK and even more
elsewhere – in responding effectively to the ethical dilemmas and
obligations this dependence creates.
The paper employs the case of Ghana, and the migration of Ghanaian
health service personnel from Ghana to the UK, as our central case
study. From it, we generate arguments about the economic and
governance policy issues surrounding health professional migration.
We do not imply by our choice of case study that migration from
Ghana is ‘typical’ statistically or culturally, nor that it forms
a very large part of the total migration flow to the UK or the USA;
neither assertion is true. Rather, the widely cited Ghanaian case
focuses on a number of the most serious stresses and contradictions
generated by the current international labour market for health
professionals.
Ghana is a low income country with an absolute and rising shortage
of health care professionals and high and rising out-migration. It
has a growing economy and a government making substantial efforts
to improve health care. However the country is spending far too
little on health to achieve decent provision for its citizens.
Ghanaian health spending was $US12 per head in 2002 (Table 1), of
which $7 was public spending. The WHO’s Commission on
Macroeconomics and Health estimated the cost of a set of ‘essential
interventions’ at US$34 per capita per year, much of which would
need to be public spending, or $45 to include some additional
hospital services (Commission on Macroeconomics and Health 2001).
As Table 2 illustrates, the gulf in indicators of need and in
health professional staffing between the two countries is huge.
Insufficient health personnel form one of the main constraints
limiting health service capacity to deliver even basic services; in
crosscountry comparisons, health service staffing is associated
with better health outcomes after allowing for the effects of
higher income on health (WHO 2003, Chen et al 2004, Anand and
Baernighausen 2003). It follows that in Ghana, as in many other low
income countries, many people are denied the health care that is an
essential component of the right to health, and the failure is
worsened by out-migration. The Ghana Health Service (GHS) is still
achieving substantial immunisation coverage (Table 1) but that is
now under threat from declining staff numbers, and health the
‘skills drain’ of health professionals from the developing world 9
indicators such as infant mortality are showing signs of worsening;
surveys show facilities are ‘grossly understaffed’ (Nyonator et al
2004).The extreme inequalities of income, working conditions and
employment rights that are associated with struggling, underfunded
health services, so well illustrated by the Ghanaian case, are the
context of policy towards professional migration by health services
staff, and should be its key concern.
The Ghanaian government and health care authorities, like others in
comparable situations, face a dilemma. Ghana has ratified
international human rights treaties which impose binding legal
obligations to ensure that their people have decent health care and
safe working conditions4.On the other hand, overworked and
underpaid doctors and nurses are looking for alternatives, often
helped by international recruiting agencies that the Ghana
government, like many African governments, accuses of poaching
their much-needed medical staff (Itano 2002, House of Commons
2004). The Ghana Health Service has close current and historical
links with the UK NHS, and there has in the recent past been active
recruitment in Ghana for the NHS.
Ghanaian health care professionals who migrate and who return, of
whom the lead author is one, also face painful dilemmas and
contradictory pressures that policy towards migration must
confront. If the health care workers in developing countries seek
to demand their rights, then going on strike, for example, removes
the health care of other people. This is a dilemma of conflict
between rights, rooted in poor conditions of the health system.
Health service administrators in Ghana seek a working compromise
after industrial action – then after a couple of years, this
conflict reemerges. Some health workers, to avoid this spiral of
conflict, decide to leave.
Finally, policy makers in high income countries also face
dilemmas. There are strong economic and political pressures at
present in the OECD countries to recruit health workers from
overseas (Forcier et al 2004, Stilwell et al 2004). Responding to
these pressures is compatible with individuals’ wishes to
migrate. Trades unions and professional associations including the
Royal College of Nursing (RCN) in the UK for example support
individual nurses’ rights to travel and work overseas to develop
their practice and further their experiences (RCN 2002).
There is now a strong and welcome awareness not only among health
policy makers and aid donors, but also in the broader policy and
activist communities in the rich countries, and among health
service trades unions, of the damage done in some developing
countries by loss of large proportions of skilled health care
staff. We discuss below the policy approach that has widespread
support at present in the UK, which is often characterised as
‘ethical recruitment’, yet, we will argue, lacks a solid ethical
base.
The current Department of Health Code of Practice for international
recruitment of health care professionals in England and Wales
(Department of Health 2004) includes Ghana as a country from which
active recruitment is unacceptable because it will undermine local
health care delivery. If the underlying intention to reduce
recruitment were to be effective, the Code would amount to
selective restriction of individuals’ right to leave their country
purely on the grounds of profession and nationality; if it is
ineffectual, as it appears to be, then the underlying problems
should be addressed in other ways. The Code causes unease precisely
because it appears implicitly discriminatory along racial lines: it
implies (given the selected countries of origin) that migrants from
richer countries should be preferred to Caribbean and African
health professional migrants, an implication that can risk playing
into a racist agenda on immigration policy.
Finally, in considering the arguments for restitution payments, in
response to the benefits health professional migrants from low
income countries bring to rich country health services, Ghana
provides a highly relevant test case, illustrating the scale of the
subsidy from poor to rich involved. Ghana would provide, because of
its very particular set of characteristics including relatively
small size, a long political association with the UK and active
participation by its governments in the recent political debates on
health professional migration, an excellent setting for
experimentation in the way in which such restitution processes
might be designed and managed.
Ghana is thus, in this paper, a test case, a source of insight, a
‘place to stand’ in constructing the arguments that can be tested
subsequently in a wider field. The purpose of this paper is to make
a series of arguments about ways of understanding the migration
process as a basis for policy, and the policy implications that
emerge from these insights. We draw from, and reference, but do not
attempt to summarise the voluminous relevant literature to which we
hope to make a useful contribution.

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