Health Worker Migration: Disease or Symptom?
Michael A. Clemens
Do health workers who leave developing countries, and the organizations that hire them, cause death? Enormous concern has arisen around this issue. Many analysts assert that health worker migration from poor countries kills large numbers of people. If this is true, others reason, the international recruitment of African health workers is an atrocity, a crime against humanity.
We should take these claims seriously. If health worker migration by itself were a substantial cause of death, then stopping health worker migration - by itself - would save lives. Allowing it would have plain ethical implications. Measures that have been proposed to limit health worker migration include restrictions on the international recruitment of health workers, and promoting health worker self-sufficiency in destination countries. Such measures are coercive; they work to interrupt health workers' ability to find jobs abroad, without those workers' permission.
But migration is simply a choice about where to live. Stopping health worker migration by itself means restricting health workers' choices about where to live, against their will. That has ethical implications too, especially because many of those who advocate limiting health worker migration enjoy freedom of movement and spectacular wealth that many developing-country health workers could never hope for. We should not consider forcibly restricting the freedoms of others without overwhelming evidence that doing so directly saves many lives.
What hard evidence do we have that health worker migration is an important cause of death? The main evidence in most writings on health worker migration is that places with more health workers have lower rates of mortality. Here's an example from one report that advocates measures to limit health workers' mobility:
Source: Joint Learning Initiative, Human Resources for Health: Overcoming the Crisis, page 26.
But the fact that places with more health workers have lower death rates does not mean necessarily that the number of health workers determines a country's mortality rate. Places with more cancer patients use more chemotherapy, but that does not mean that chemotherapy causes cancer. In order to believe that health worker migration is a substantial cause of death, we need to know much more than the fact that places with lots of migration have lots of death. We need to know that if there were less migration, and if all else were equal, there would be many fewer deaths.
To believe that, you would need to believe two things.
The first thing you would need to believe is that migration is an important cause of health worker shortages. Right away there's a problem. To say that a Malawian doctor is absent from Malawi "because" she is in Britain is like saying that a bowl of soup is salty "because" you put salt in it. It's literally true, but it doesn't tell you anything you didn't already know. Most importantly, it tells you nothing about why she decided to leave.
The reasons for her decision should be the focus of our attention. We can ignore the reasons and focus on stopping migration itself if we feel comfortable changing her choice without giving her a reason to change her choice - that is, coercing her decision. But in that case, either we must claim special authority to coerce others to live in circumstances often far more difficult than our own, or we should feel comfortable with others coercing our own decisions about where we live. If neither of these is palatable, the goal of policy toward migration should be to influence the underlying reasons for migration decisions.
Those reasons are transparent. The World Health Organization surveyed more than 2,000 health professionals in six African countries in 2003, asking them if they were thinking of emigrating and why. Roughly half declared an intention to emigrate. Common, unsurprising reasons included: "better remuneration", "better living conditions", and "to save money". But in many countries a more common answer was "to gain experience" or "upgrade qualifications". Roughly as common were the responses: "lack of facilities", "poor management", "safer environment", and "violence and crime".
These are the underlying causes of migrant health workers' absence from the country they chose to leave. Changing these causes is both more effective and more ethical than focusing on stopping movement itself, via recruitment bans or "self-sufficiency". Focusing on underlying reasons is more effective because it treats the disease rather than the symptom. And it is more ethical because it gives potential migrants a reason to change their minds, rather than coercing their actions.
There is a second thing you would need to believe in order to believe that less health worker migration per se would mean substantially fewer deaths. Even if you believe that migration per se is the "cause" of health worker shortages, you would also need to believe that health worker shortages at the national level are an important cause of death relative to other causes of death.
Health outcomes are determined by a constellation of forces. Most health professionals who migrate internationally are very highly skilled clinical care professionals with several years of advanced education. But health workers like these play a limited role in determining the health outcomes that are most grave in the most afflicted countries.
Diarrhea kills a child in northern Mozambique. We could list many potential "causes" of that sad event: lack of proper sanitation, lack of a distribution network for cheap electrolytes, lack of parental education, lack of rural-service incentives for health professionals, the skill mix of the national health workforce, and a long list of others. Very far down that list would be the number of physicians who live within the national borders of Mozambique. Adding one physician within those borders by preventing his migration - adding one secondary or tertiary care worker more likely to work in the capital Maputo than in the rest of the country - would have been highly unlikely to prevent what befell that child.
That's not a call to inaction. There are many, many things that policymakers can do to build a human resource base for health and development without restricting international movement. I have discussed these options elsewhere. They include real incentives for service in underserved areas, pay that is tied to performance, innovations in how health workers' training is financed, changes in the skill-mix of the health workforce toward prevention and very basic primary care, disassembling legal barriers to effective deployment of existing health workers, supporting temporary return by émigré health workers, and supporting regional centers of excellence in care, prevention and research.
The migration of health workers is a symptom rather than a disease. The disease that causes this symptom is often the very poor working conditions that these professionals face at home, relative to the excellent conditions that their rich-country colleagues take for granted. If our interest is in building the capacity of developing-country health systems to prevent suffering and death, we should move away from thinking of migration as the problem. Seeing migration as the problem leads us to "solutions" that involve stopping migration itself, forgetting that migration is merely a choice of where to live, a choice that very few of us would accept losing without our consent.
Building up developing-country health systems means asking health workers what they would need in order to stay and what they would need to be effective, as well as reconsidering the incentives created by current public systems of health-worker training and employment. In short, it means thinking of health workers less as human resources and more as human beings.
Michael A. Clemens is a research fellow at the Center for Global Development.
The manner in which a problem is understood and defined determines the solutions proposed. Health worker shortage in developing world especialy in rural areas, difficult areas and under developed areas is more often than not under stood as a problem of health workers delberate decision to not work in these areas after their basic training. The article has very effectively argued that such behaviour is symptom and not the disease. One need to explore the root causes of the behaviour to address the issue. Improving over all working conditions, living conditions, considering the carrier related issues and designing proper salary and incentives could reverse the current trends of shortage of health staff in such areas where most persons would not like to work.
— Dr Daya Krishan Mangal on 2010-01-26
A nice effort is made above to point out the cause and effects of physicians migrating from developing to developed countries.
Yes all said are true. But
1. If all the physicians that migrated had not done so how much lives they might have saved. Because most of the lives that are lost in developing countries are saved by paramedical workers who are still there in the country (if they are properly utilized) and not the highly skilled physicians.Nepal lost about 400 people with diarrhoea during August to October 2009 and the physicians were blamed for it. Because they did not have transport to reach to the epidemic sites. Whereas when there was epidemic of similar disease (Cholera) during Jule-August in 1989 in districts almost five times of this it was managed effectively mostly by paramedicals mobilizing the support of local community people.
2. Suppose all these people are in their country can the government or the private sector give them reasonable encouragement to work happily there? May not be? Can we say that it is their country, so they should work whatever situation exists there?
3. Compare the level of satisfaction of two colleagues graduating at the same time one working with full patriotism in his home country and another in a developed country? Whom should we blame this unhappiness, the one in developed or in developing country for the wrong decision?
4. Those living in developed countries, is it not that many of them are playing a key role in raising the economic status of their home country, if not many of their close relatives?
In view of these reasons I am fully in favour of migration.
— Dr.Benu B Karki on 2010-01-26
I was surprised when i read this article. I never thought of it until now. Now I agree with this thought. The same thing is happening in our country, Nepal. It reinforces me to analyze to find out root cause of problems more details. I want to disseminate this information by editing in our context if you give me permission.
— Dr. Madhab Prasad Lamsal on 2010-01-27
Dr. Mangal, Dr. Karki, and Dr. Lamsal: Thank you very much for these thoughtful and nuanced comments. I am so happy to see this discussion focused on the root causes. When I visited Kenya three years ago, the head of the National Nurses Association informed me that over 6,000 of his Registered Nurses were unemployed, primarily because the country was in fiscal shambles and the health ministry faced a hiring freeze. Yet the ban on recruitment of African nurses by the British National Health Service applied to those nurses too. This is the kind of sad situation that results when the deeper diseases are not addressed. I would welcome other comments offering related stories from your own rich experience.
— Michael Clemens on 2010-01-27
More health workers less death. Agreed. But highly skilled professionals go to other countries. If such health workers do not migrate then they are not going to serve the rural people. For any developing country, the main issue is migration within the country of health workers who are simple medical graduates. They opt for urban areas.The country should focus on producing more basic graduates who should be selected from the rural administrative units by the people. All types of methods should be thought to attract them and retain them in the villages. Focus on high skilled physicians should be less. The policy makers should see that more mbbs doctors are produced. In this regard Medical Council of India is now thinking of producing “bachelor in rural medicine & surgery” in lesser years than mbbs to tackle this shortage of health workers. Another method is that we should train all those who serve people ( non medical quacks) which will enable them to treat common ailments. Reason is- they are available,acceptable,accessible and affordable. And we can have some restriction on migration to other well-off countries. They can go only after a nod from top officials of the country and the developed country should be ready to help the country in some manner to make up the loss of health worker.
A burning issue and it needs much discussion and debate to find out solution.
— Dr.Sadhu Charan Panda on 2010-01-28
Dr. Panda, You raise the excellent point of focusing limited training resources on producing more basic graduates. This is exactly what I meant when I urged governments to revisit the skill-mix of the national health workforce. This could be done with greater emphasis on non-physician paraprofessionals, or on adjustments to the way physicians themselves are trained, as Eyal and Hurst argue here:
http://phe.oxfordjournals.org/content/1/2/180.abstract
— Michael Clemens on 2010-01-28
In the past 13 months, the overall head of surgery at Chris Hani Baragwanath Hospital, Soweto and the head of anaesthetists at Charlotte Maxeke Hospital, Johannesburg, were among many senior medics who left South Africa for the USA. Baragwanath is the biggest hospital in the southern hemisphere. More and more junior medics are filling senior positions without the experience and skill to do so. Children are dying who could have been saved. We know many by name. By all means exchange knowledge, even exchange surgeons, but please stop poaching Africa’s best. They are needed here. See http://www.firechildren.org for details of Africa’s first burns charity if you want to know more about us.
— Children of Fire on 2010-01-31
To Children of Fire: It is a horrible tragedy that children have to die who could have been saved. I am very sorry for them, their families, and for you that you have to witness such sadness. What I do not understand is why you appear to believe that trapping physicians in South Africa against their will is the best solution to that sad problem. Stopping their free choice to emigrate, without changing anything else *is* trapping them against their will. Trapping, or “poaching”, are things that are done to animals, not to human beings. Health workers are human beings. It is difficult to believe that nothing can be done to improve health care in South Africa, and save the named babies you speak of, besides corralling people by force. Promoting private education of doctors would be a good first step, because then those who choose to emigrate would not take so much public investment in their training with them. That would expand the resources of the Department of Health to finance training for others who did wish to stay, and take other steps to improve the quality of patient care. But fundamentally what I disagree with about your comment is that you show absolutely no interest in *why* those doctors are leaving, that is, no interest in changing the underlying problem. Much could be done, in South Africa and in every other country, to improve the health system and its incentives for the people who work in it, aside from trapping potential emigrants against their will. It is likely that there are parts of South Africa you would prefer not to live in, and if someone informed you that they were going to force you to live there against your will because they believed it would do social good, you would feel that your rights had been grievously violated. Certainly there are babies dying right now in townships that could be saved if the government were willing to force richer South Africans em masse to go live in the townships and work to save those children, but the government is not willing to do that and should not be willing to do that. Why then are you willing to force doctors who don’t want to live in South Africa to live there, against their will, by asking others abroad not to hire them?
— Michael Clemens on 2010-02-01
I completely agree with Dr. Panda that the focus needs to be more on basic training and paraprofessionals. These people, hypothetically, would be more “local” and have a better understanding of the local culture, language, and health habits. Additionally they would resolve many problems regarding trust between Western doctors and patients in developing countries.
However, diseases such as pneumonia, heart disease and COPD, which are leading causes of death in developing countries, do require higher trained professionals and higher levels of equipment than a basic paraprofessional could handle.
The question then becomes one of appropriately splitting resources between basic paraprofessionals and highly trained MDs. What is the right balance? 60-40? 70-30? 50-50?
While this statement is overused and solves no problems, it is most appropriate here: More research needs to be done.
— Christina Amutah on 2010-02-08
I agree with u Christina on the issues of COPD, CHD etc that requires skilled professionals. Let’s discuss about CHD. It is increasing rapidly in countries like India.When AMI occurs first one hour is critical and at best 4 hours. With this background concept of ICCU came up. Care of such patients needs cardiologist, trained paramedics and infrastructure. As we are talking of capacity building paraprofessionals at village level we can increase the skill of existing doctors with M.D.(General Medicine or Paediatrics) to manage AMI. Similarly nurses can be trained. They will be available at subdivisions and district HQs and in each block. Within 50 km radius provision of ICU should be there. Similarly we can increase the skill of physicians in Diabetology, HIV/AIDS management.
Regarding proportion of paraprofessionals and Trained MDs in my opinion it should be 70:30. This is about care of patients. But intensive public health measures from village level should be conducted by nonmedical public health professionals to change the life styles so that burden of such diseases come down. Such comprehensive approach and needbased production and distribution of health workers will will be a grand success.
— Dr.Sadhu Charan Panda on 2010-02-08
Human rights - doctors have a right to be paid and medical practice is not a charity but business.
Suggestion to prepare paraprofessionals is a violation of human rights as paraprofessionals will deliver paraprofessional services and this will invest greatly in health care deliveries inequity and low standards of care.
To deliver basic services of care - standards of care you need to have professionals, to deliver paraprofessional low(inferior) services - you need paraprofessionals and this is violation of human rights.
The same situation is with clinical protocols/ Clinical protocols can be basic protocols, not advanced or maximum, however, clinical protocol cannot be changed for TB treatment or HIV because people are poor and cannot afford to pay.
The answer behind this debate is in universal health care - free for poor. That’s why this is a political question. Politicians should agree to give country GDP for universal health care, pay professionals and develop financial methods for additional incomes.
Otherwise all talks about doctors shortage and suggestions about paraprofessionals for poor is a double standard in health care.
Many countries such India and others can afford universal health care - basic and invest more money for people. History has such lessons.
— Tatiana S on 2010-02-16
In Nigeria most PHCs are run by Community Health extension workers, yet you find unemployed doctors and even nurses in urban areas. The new trend is having doctors opting out of clinical practice for public health within the context of NGOs. So I quite agree with Tatiana for us to solve inequality in the healthcare system, policies should favour universal access to healthcare, pay professionals and develop a proper mechanism for healthcare funding for sustainability.
— Ikwo O on 2010-02-17