GUJHS. 2006 March; Vol. 3, No. 1
Throughout the 20th century, there have been a substantial number of highly skilled and educated professionals emigrating from their home countries in search of better economic and social opportunities in other countries. In the 1960s the term “brain drain” was coined in response to the large number of trained scientists, physicians and university teachers leaving developing countries (Carrington & Detragiache, 1999). Understanding the reasons for migration from the source country is critical to understanding how to effectively deal with the resultant issues. These issues have been called the “push” factors that promote the migration of health workers from developing nations. Additional factors are said to “pull” workers to developed countries such as higher wages, better quality of life, safer working conditions and greater opportunities to improve their education and expertise (Kline 2003). Usually, the recipient countries have an immigration policy that allows trained professionals to enter and receive work permits and even apply for citizenship (Kline, 2003). The reasons are often simple economic motives—limited career opportunities, low salary and limited advanced educational opportunities.
This paper concentrates on how the brain drain affects health care personnel on a global scale. For instance, health care workers in developing countries are worried about poorly funded and ill-managed health care systems. A recent data analysis appearing in the OECD’s annual report showed that 60% of the physicians trained in Ghana leave the country, whereas 65% of the United Kingdom’s medical staff are foreigners (Garson, 2004). Reducing the brain drain by getting professionals in developing countries to remain in their home countries is a plausible goal and many countries have demonstrated possible ways to work toward this goal. Currently, a number of countries are working together in order to create a global framework that deals with the policy of health care professional migration (McKinnon, 2003). The successful projects such as the reforms initiated by the International Organization for Migration (IOM) look at the situation from a multilateral perspective, covering issues of economics and politics. However, countries trying to regulate migration patterns face opposition. Two critical counter-arguments that cannot be ignored are the disruption of economic stability within developing countries and the infringement upon the basic human right to migrate.
Implementing Ethical Recruitment Codes
According to the World Bank database, the mortality rate for children under five in developing nations is 150 deaths per 1000, whereas in developed nations, namely the OECD countries, it is 7 deaths per 1000 (2005). In addition, in developing countries there is an estimated one physician per 1,000 people, whereas in developed countries there are five physicians per 1000 people (World Bank, 2005). These statistics demonstrate the inequality of health care that exists among nations and stress the ethical dilemma of whether developed nations should be taking medical resources from countries that are desperately in need of health professionals.
In May 2003, countries of the British Commonwealth, ranging from Canada to small island states such as Malta, adopted an International Code of Practice for the International Recruitment of Health Workers. The main section of this Code focused on discouraging physician recruitment from developing countries with their own shortages. Another critical issue that the Code addresses is the possibility of financially compensating the developing countries for the costs of education and training. However, the Commonwealth countries have yet to implement this policy because they are experiencing difficulty in evaluating the countries’ net losses. Overall, the Code lists a number of principles that are designed to guide international recruitment. Representatives within the Commonwealth are trying to extend the list of signatories to the Code and discussed this effort at the 2003 World Health Assembly (Garson, 2004).
As of 2004, the OECD countries have not signed the Code, but have started to create regulations and have entered bilateral agreements that restrict the length of stay for foreign physicians (Garson, 2004). For example, the United States implemented a “cultural exchange visa” that limits the stay of foreign health care workers such as doctors, nurses and medical professors or instructors. After their visa expires, workers are required to go home for two years until they are able to apply for re-admittance (Forcier, Giuffrida, & Simoen, 2004). This policy ensures the return of health care workers to their own countries and encourages them to share knowledge and expertise with their colleagues back home. In the future, this policy hopes to promote a “brain exchange” rather than a “brain drain” (Forcier et al., 2004).
Furthermore, “brain exchange” can be augmented if host countries assist developing nations in sustaining their domestic supply of physicians. For instance, host countries can provide financial support for foreign students, allowing them to study overseas and work for a pre-determined number of years (Forcier et al., 2004). However, similar to the effect of the “cultural visa,” the arrangement would foster the return to their homeland. Host countries can also aid developing countries in sharing medical technology advances that may be difficult to learn about in isolated areas. The “brain exchange” can also encourage physicians from host countries to spend a sabbatical year abroad, thereby giving participants the opportunity to fully immerse themselves in the current problems of the developing world (Forcier et al., 2004).
In addition to recruiting foreign workers under such policies and programs, the OECD countries must focus on long-term policies to restore and sustain their own physician workforce. Instead of ignoring their own internal problems that exist in the health care industry, the OECD nations must evaluate their own situation with the hope of creating and retaining a new workforce rather than depending upon developing nations for needed professionals. In January 2005, U.S. President George Bush signed a proposal that provided $147 million for the recruitment and retention of nurses within the United States. The legislation is called the Nurse Reinvestment Act and some of the funding is targeted to provide student loans and scholarships and nurse diversity programs (Duckett, 2004). Similar to the United States’ legislation, in 2004 the Canadian government began reforming their nursing programs and to work closely with the Canadian Nursing Advisory Committee in order to negotiate commitments such as providing nurses with a pension, regular vaccinations and quality health insurance (Scally, 2004).
Impact of Migration on the Labor Market
From an economic standpoint, the brain drain significantly affects the developing world. These countries have spent both time and money educating the health care workers that subsequently emigrate. While some health care workers return to their homeland, most stay abroad and are soon followed by their families. As Dr. Barker of the UN Economic Commission of Africa warned his foreign colleagues, “in 25 years, Africa will be empty of brains” (Tebeje, 2005, ¶ 1). His comment demonstrates the increasing alarm over Africa’s flight of human capital. According to a report by the IOM, 20,000 health care workers have been emigrating each year since 1990, with only a small percentage of workers returning to Africa (2004). The United Nations has recognized Africa’s alarming emigration statistics, stating that the emigration of African professionals to the West is one of the greatest obstacles to Africa’s economic development (Tebeje, 2005).
In order to solve this problem, the IOM, with the help of the WHO, launched the Migration for Development of Africa (MIDA) initiative. To begin the MIDA program, the IOM and the WHO developed a database of health professionals in Africa in order to numerically determine the shortage of workers. According to the IOM’s website for MIDA, “the overall objective of the MIDA program is to assist in strengthening the institutional capacities of African governments to manage and realize their development goals through the transfer of relevant skills, financial and other resources” (International Organization for Migration [IOM], 2004, ¶ 4). In addition, MIDA works with African and host countries and diaspora members in order to facilitate networks of communication among governments. MIDA has successfully launched pilot projects in several African countries that attempt to negotiate contracts between hospitals and their workers. In November of 2004, MIDA organized an international “stakeholder roundtable” to discuss the implementation of governmental policy changes in each African country designed to ease brain drain pressures (IOM, 2004). Some of the members of the “roundtable” included the New Partnership for Africa’s Development (NEPAD), the African Union (AU), several NGOs, and WHO and UN representatives. The success of MIDA throughout Africa demonstrates the ability of countries and international organizations to work together in order to achieve the common goal of reducing the brain drain (IOM, 2004).
International and Local Government Intervention
With the help of international organizations such as the UN and WHO, individual countries have been encouraged to make changes in their health care system in order to help retain their workers. Many African countries are encouraged to implement changes in local hospitals to reduce the brain drain in their countries. For example, the Zimbabwean government worked with representatives of the WHO and developed a plan to increase the retention of skilled health personnel (Chikanda, 2005). Some of the changes included the provision of housing and transportation allowance, salary reviews, fellowship and scholarship programs and free advanced training seminars. Another critical change that has increased retention of health care workers in Zimbabwe and other developing nations has been enforcement of safety measures that prevent unnecessary exposure to infectious diseases such as HIV. Hospitals in Zimbabwe now provide protective clothing and have increased the use of sterilized equipment by health professionals (Chikanda, 2005).
Another problem that the brain drain causes is the cycle of migration and recruitment that occurs in some countries. For example, South Africa is one of the middle-income countries that is most affected by the brain drain, losing over 50% of their health care workers each year. South Africa is then forced to recruit expensive foreign expertise, which in turn creates a nearly unstoppable vicious cycle. In order to alleviate the detrimental impacts of medical staff shortages, in 1993 the IOM introduced a program called “The Return of Talent” which with the offering economic and social incentives induced fifty-two doctors that year to return home (Forcier et al., 2004). This program is an initial step in promoting the retention of medical staff. Currently, South Africa is also trying to sustain and increase domestic physician supply by modifying the educational curriculum, adding mandatory fieldwork experience in rural areas for one year after graduation. Other incentives offered by the South African government include physician housing, social advantages, improved pay and job security. For the first time, doctors are reconsidering their job options abroad and choosing to stay at home. South Africa has demonstrated that motives for emigration can be tempered if governments are willing to work with the needs and desires of health care workers (Forcier et al., 2004).
Oppositions to Regulating Migration
Even though there has been significant progress in dealing with the problem of brain drain, there are also several strong arguments that oppose interfering with the brain drain process. One of the key counter-arguments involves the economic incentives for the brain drain. A recent editorial in Africa Health stated that the total annual remittance from trained professionals working overseas to their home countries now amounts to more than the total aid given by developed nations every year. Thus, in most cases, the increasing export of health professionals actually economically benefits the developing country in the end (Rowson, 2004).
In Africa the brain drain is a problem, but in the long term some argue that emigrants help create new markets for African products and bring back sufficient financial resources and new political and technological ideas. Even if medical professionals do not return permanently, they can still make a dramatic impact with intermittent returns because of their involvement in developing projects, charities and business ventures. An example is a man from Ghana who went to the United States to work for Microsoft. He later returned to Ghana with his accumulated fortune and founded a university. In addition, he also started his own software company (Herbert, 2004). This story demonstrates why some African policy makers are now looking upon the brain drain as a human network through which new ideas, capital and technology can flow back to the continent. Many countries even depend on the remittance from overseas workers for economic stability and view the exportation of medical professionals as a marketable commodity (Herbert, 2004).
The Philippines is the prime example of a country that specifically trains nurses for the purpose of sending them abroad (Buchan & Calman, 2004). Therefore, the export of nurses is one of the country’s innovative ways of supporting its economy. In the Philippines, it is customary for nurses that leave to work overseas to send money home, thereby strengthening the local economy. Recently, the Philippines has been feeling the affects of other nations addressing the brain drain. For instance, both the United States and the United Kingdom have enacted stricter immigration laws, decreasing the number of Philippines nurses allowed to work in their countries. In turn, this is affecting their economic stability due to a decreased amount of money that is being sent back home (Buchan & Calman, 2004).
Ethical Dilemmas: The Issue of Human Rights
Another key issue that challenges those interfering with the brain drain is the matter of individual human rights. The people who oppose reforming the migration process state that it is a contradiction to the right to freedom of movement. Article 13 of The Declaration on Human Rights makes two key points concerning migration:
(1.) Everyone has the right to freedom of movement and residence within the
borders of each state.
(2.) Everyone has the right to leave any country, including his own, and to return to his country (1948).
Article 13 clearly shows that any person has the right to leave his or her country without harassment by his or her local government. The Declaration on Human Rights is not the only international document that supports the migration of skilled professionals. The preamble to the WHO Constitution is another example that supports an individual’s right to migrate. The preamble states, “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being” (World Health Assembly, 1946, ¶ 3 ). According to the WHO Constitution, emigrants who leave their country due to poor health conditions are justified in their decision to migrate. Not only is individuals’ rights to health mentioned in the WHO Constitution, but also in 20 Constitutions in the Western Hemisphere which include language that invokes a right to seek better health care (Mackintosh & Mensah, 2005).
In 1978 the Declaration of Alma Ata stated:
“Health… is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector” (International Conference on Primary Health Care, 1978, ¶ 1).
With all these declarations, it is important that all countries follow their own declarations and recognize that their people have the right to a healthy lifestyle. Furthermore, if the population within a country is not satisfied with their health care systems, then they have the right to seek a higher standard of living. Even though Human Rights legislation does exist, the international legal regime is weak and largely ineffective, as it lacks the mechanism for enforcement of its policies and thus can rely only on the voluntary cooperation from participant states. The above policies were not originally designed to encourage emigration, but rather were used to provide a general standard for the overall health goals within individual countries. Therefore, countries must focus on improving their quality of life in both human rights and health care system standards if they want to avoid the problems of migration (Mackintosh & Mensah, 2005).
The Future of the Brain Drain
On a global level, the migration of health care workers undermines all of the international efforts to reach the Millennium Development Goals by 2020 because it reduces the medical staff of developing nations to a point where their own health care systems are not able to treat their own citizens (Rowson, 2004). The migration trend is increasingly global and demonstrates the contentious North-South debate, where the developed countries have been accused of exploiting the workers in developing nations. Further, the recipient countries are only addressing their labor problems on a short-term basis by avoiding pressing issues of health care reform that may be politically difficult to address. International cooperation that effects program and policy change continues to be the most effective way of minimizing the brain drain. However, there are strong arguments against the reduction of brain drain that must be addressed in order to reach an agreement concerning the rights of migration. For over forty years, countries have been debating the local and global impact of the brain drain. The programs and policy changes that our international community makes today will affect the future of the brain drain.
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