Brain drain and health professionals
BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7336.499 (Published 02 March 2002) Cite this as: BMJ 2002;324:499
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Dear Sir,
I read The editorial by Pang et al as well as all the comments with great
interest. I am a Neurosurgical trainee from Nepal currently doing
Fellowship in US and intend to go back shortly. And I am aware of all the
'attractions' of the developed world plus advice from friends ' better
stay here'.I agree hundred per cent with the authors. At one point there
is the issue of freedom and right to seek better living conditions but at
the same time there is a question of responsibility and obligation to the
native country. If one or two persons emmigrate it may not be a problem
but when they leave in hundreds, it is something the native country should
be serious about. Freedom is a relative term conditioned by resources and
circumstances and so is happiness.Every developing country should have a
mechanism of getting their 'Brains' back ( there in fact are regulations
in Nepal to this effect but they are 'soft' enough to be bypassed easily)
and seeking help from the host countries is entirely justified. After all
"We get to make a living, we give to make a life(W.Churchil)" and helping
your underpriviledged people will always be rewarded sooner or latter.
Competing interests: No competing interests
Dear All
Many people feel to write the issues concerns most,and get noticed by us
doing so. Most of us do not believe the phenomenon brain drain,it is
Utopian concept developed by few, Communists and ultra
Nationalists.Create enviroment to work,train for that and see their are
reverses also.Many doctors spent some years in good clinic doing excellent
job in their native poor countries after they accumulated their skills
expertize and means to livlihood from wealthy nations.
If we talk global village what is this again?
Comptetive,fair and free world can demonstrate the benifit of sciences
including medical.Closed,dictated and publisized to be patriotic is not
solution any way.
If many Health Institutions loosing their good work forces,most important
cause is working envirinment is the first one to loose her/him.Thailand is
one country attracting its workforce back creating opportunities and other
can see how it works.
We are seeing politiacl boundries are not constant,it may not applicable
to acpture few good people in cage,if he or she want to fly.
Paras
Competing interests: No competing interests
Dear Colleagues
The issue of medical staff moving from Africa to the 'developed
world' is quite a complex one.
Should one penalise the individuals for making their own life
choices, based on their personal and professional needs? Does this not
infringe on their human rights.
Medics are very mobile, movement occurs from developed countries to
other developed countries and from city to city within a specific country
as well as from underdeveloped to underdeveloped countries.If you are
going to suggest penalties and compensation,where are you going to draw
the line?People have a right to make their own life choices without having
to face unfair intimidation.
Why limit your focus to medics?Surely your arguments apply to all
trained staff-engineers,tradesmen,teachers,etc.It will be a nightmare to
legislate and monitor.
I feel the onus is on the individual countries to analyse their own
problems and involve the relevant roleplayers in constructive discussion
and to come to imaginative solutions.I feel that win-win solutions can be
found without intimidation and without abuse of the human rights of
medical staff.
We are all part of a global village and we have to understand that
movement of people and ideas follow global currents that are not easy to
control.
Yours
Faz Mahomed
Competing interests: No competing interests
The editorial (1) describes how countries, as a result of brain
drain, are left with a reduced workforce to carry out crucial activities
for their development. We may ask ourselves where do these specialists go
to.
It is appropriate to analyze positive and negative aspects of brain
drain. A large number of specialists who emigrate from low- and middle-
income countries are attracted by international organizations helping to
define world health and development priorities. The World Health
Organization, for example, attracts the best health specialists to fulfil
its mandate to provide support and guidance to Ministries of Health from
191 countries. And it should do so, as it would be hard to imagine the top
United Nations body guiding health policies not to have the best
specialists. Or worse perhaps, not having specialists from low- and middle
-income countries with first hand country experience to argue their case.
Countries lose on one side but may be gaining on another. In the
field of health research, for example, migrating scientists from
developing countries can promote research activity in priority areas
relevant to their countries, thereby helping improve the allocation of
health research funding to these areas. Their work can be expected to have
repercussions in many low- and middle-income countries, including their
own. This, of course, lies on their commitment to contribute to improving
health conditions in their countries. An this is in itself a personal
choice.
(1) Pang T, Lansang MA, Haines A. Brain drain and health
professionals. BMJ 2002; 324:499-500.
Andres de Francisco, MD
Global Forum for Health Research
March 2002.
Competing interests: No competing interests
I read this article with great interest as well as all the comments.
Freedom of movement is supposed to be a human right, and the movement of professionals from place to place or country-to-country is not a new thing. The reasons for this professional migration have been studied for a long time now and are quite well known.
The brain drain is a phenomenon that is not likely to end anytime soon, given the nature of the world’s socio-political-economic makeup, why not try and make use of these professionals?
This was the question I put to a professor at an American university in a recent conversation I had on the very same subject. This professor was formerly a lecturer at an African university and I was interested in his views on the current capacity building efforts in Africa and what more could be done to address the problem of the lack of health professionals in Africa. He immediately brought up the subject of the brain drain and said governments in Africa should first address the issue of the brain drain and why they couldn’t keep the professionals in the first place.
I said given the fact that the conditions that create the brain drain are still in place, why are not finding a way to make use of the vast repository of knowledge these professionals have? Not only do they have knowledge about the countries they come from, many still have strong ties with the countries they left. Their first hand knowledge of their previous homeland and their presence in the west put them in a uniquely advantageous position. Perhaps we should view not as a brain drain but as "a relocation".
Professionals abroad have better access to new techniques, drugs or the latest developments in health and medicine, which may be relevant to for example a country in Africa. And being from there, these professionals would be better placed to analyse, assess or advise on how these could best be used in an African setting and make this knowledge available to their counterparts who are still at home.
Yet you rarely hear of any attempts to recruit such people for their knowledge. There are virtually no networks to tap this pool of talent. I should know I have been trying to do just such a thing in USA and the UK.
This was prompted by the recent developments in Anti-retroviral therapy, the controversy of their prices and how they were unavailable to third world markets. Price not withstanding, these drugs have been around for over a decade, why is it only just now African doctors are being trained in their use, and why did it never occur to anyone who is making policy that they could be used in Africa?
Clearly in this case, the health professionals who would have been best placed to advise on such drugs would be those who had access to them and had experience in using them, and of course they would be African health professionals based abroad.
Rather than viewing professional movement in a completely negative light, which is never going to bring them back, more effort needs to be made to find ways of using their knowledge
Competing interests: No competing interests
Dear Sir,
As a developing country national working in the developed world
academia, I welcome the editorial in your esteemed journal on the issue of
"brain drain".(1) However, I am concerned by the perspective taken in the
editorial and the proposed solutions.
Brain drain is a judgmental phrase in the first instance. Every
individual has the right to enhance their contribution to the society they
choose to live in, and to improve their quality of life. The implicit
assertion in the phrase and in the text, is that this is a "bad" phenomena
and the people involved are also somehow neglectful and irresponsible.
Such a biased beginning to a complex movement is not conducive to
objective debate.
Secondly, to consider the movement of health professionals from a
health perspective is only part of the analysis. Although mentioned in the
editorial, it is important to stress that very often the migration of
health professionals has little to do with their immediate pursuits and
much more to do with issues of securiy, economic gain, freedom of speech,
social and societal respect. For example, the lack of income and respect
of public health health professionals in many developing countries, will
continue to promote such migration to those countries where they can enjoy
both.
Thirdly, to suggest "negative" and "blaming" soultions such as
payment for compensation, and mandatory service is pursuing the older
traditions of control and rule. No amount of regulation will prevent
people from seeking their livelihood. What is critical is the development
of a supportive and attractive environment in the developing world for
such professionals to be retained. Their is a cost to quality and it needs
to be recognized.
Finally, the idea that WHO and some of its health partners should
consider "ethical guidelines" is a beginning but again restricts the study
of the phenomena to health. The education, social and human resource
sectors need to be engaged in the dialogue; new avenues for exploring this
issue need to be explored; and most important the people (those who drain)
need to be involved. No guidelines are likely to have an impact in the
face of ground realities that define the "push" and "pull" factors for
such movements.
It is time for a paradigm shift in the consideration of health
professional migration, and not for incremental adjustments based on the
health sector.
Thank you.
1. Pang T, Lansang MA, Haines A. BMJ 2002,324:499-500
Competing interests: No competing interests
Editor - The call for global solutions to the problem of medical
migration is welcome indeed, and Save the Children applauds the WHO,
INCLEN Trust and London School of Hygiene and Tropical Medicine for their
editorial on this issue. [1]
Through its longstanding health programmes in many developing
countries, Save the Children is acutely aware of the impact of medical
migration and the systemic factors which cause it. However, one factor not
touched on in the editorial is the increasing pressure on countries to see
health services as a potential source of export earnings, in the context
of increasing liberalisation of trade in services under the auspices of
the World Trade Organisation. [2]
The World Bank is the most outspoken proponent of this. In its recent
Global Economic Prospects 2002, the Bank explores service sectors in which
developing countries could make balance of payments gains, with the
following recommendation:
"Health services are another area in which developing countries could
become major exporters, either by attracting foreign patients to domestic
hospitals and doctors, or by temporarily sending their health personnel
abroad."
There may be countries where there is a genuine surplus of medical
personnel and where an excellent health record justifies seeking balance
of payments gains through exporting health services. Cuba is the most
obvious example, and the government there has established its own trading
agency Servimed to cater for foreign patients at home and abroad. However,
most developing countries are characterised by poor health outcomes and
chronic shortages of medical personnel. It is irresponsible to suggest
that they should become "major exporters" in the health sector rather than
marshalling all available resources to address their own health needs.
A binding international code for governments and multilateral
organisations may well be the best way of dealing with brain drain in the
long term. In the immediate future, however, the World Bank should desist
from promoting medical migration as an economic strategy for developing
countries.
John Hilary
Trade Policy Adviser
Save the Children,
17 Grove Lane,
London SE5 8RD, UK
j.hilary@scfuk.org.uk
[1] Pang T, Lansang MA, Haines A. Brain drain and health
professionals: A global problem needs global solutions. BMJ 2002; 324:499-
500
[2] Hilary J. The Wrong Model: GATS, trade liberalisation and
children's right to health. London: Save the Children, 2001.
Competing interests: No competing interests
Concerning migration of medical professionals, one key issue we
cannot overlook is the educational and training system for health
professionals in both, develop and developing countries. Western
medicine prides itself of being the most advanced. On doing so, it has
become self-centered and elitist. Medical training and technology are
important western exports. Medical and Nursing schools in many developing
countries were established by former colonial powers or shaped, by the new
independent countries, to reflect what was considered to be ‘civilized and
advanced’. Thus, many of our renowned universities and training
institutions look towards the West for guidance and inspiration. It does
not come as a surprise that, what we have been taught and encouraged to
emulate, is the health care system in the West. To become respectful
professionals -the system reminds us- we have to further ourselves by
pursuing a higher degree in a ‘Western country’.
If we want the brain drain to at least decrease we have to
reformulate training for health professionals in our countries. So far,
our universities graduate health professionals who want to become
successful and respectable by heading the most advanced ‘Cardiac
Transplant Center’ in a country where children continue to die of hunger.
To realize the dream, the newly graduate will memorize western textbooks
and study endless hour preparing for western exams. Once in the West,
Western science and technology will not prepare her/him to the realities
back in the country of origin. Every step of the way, this health
professional is encouraged to become Westernized.
A human being cannot become intellectual property and her/his freedom
of movement cannot be restricted. Thus, both developed and developing
countries together have to address the problems that lead to the brain
drain. I am of the idea that more western health professionals should
come to ‘the south’ and spend at least one year working side by side with
bright and dedicated health professionals in our ‘developing’ countries.
This way we can both learn from each other on a more ‘equal’ ground.
Learning first hand about the realities of the world can help the
West become less self-centered and elitist. I also believe that it is
time for the west to allow for more of its bright young minds to enter the
health profession instead of recruiting health professionals from our
countries. These health professionals should not be underpaid and
overworked as adverse working conditions will lead them to abandon the
carriers they trained for forcing the system to import more ‘brains’ from
the ‘developing world’.
Competing interests: No competing interests
Dear Sir
I was reading the article by Pang et al regarding “brain drain”. I
was surprised that there was no mention of medical graduates from the
Indian subcontinent, who form the largest body of overseas doctors in both
Britain and in the United States of America. They form up to 30% of the
medical workforce and make up for the shortfall in doctors produced in
these countries.
I trained in Indore, one of the 125 or so medical colleges in India.
Out of 135 students in my year, 18 students are currently in the United
States and four are in Britain. That means that about a sixth of class has
emigrated abroad. I am sure a similar number emigrate from other colleges
across India. It is very difficult to begin to realise the scale of the
brain drain occurring from India and the scale of the loss to India.
In India, medical education is heavily subsidised and the cost to the
student is nominal. The total tuition fees for a five-year medical degree
would be less than a hundred pounds. The cost to the Indian government is
however much more (between £12-15,000) and it can ill afford to loose many
of its brightest students to the lure of a career abroad.
This is why I was very interested to read that the author supported
some form of compensation to the developing countries that have invested
vast amounts of money in training these individuals. One must accept that
the reasons for leaving their homeland are complex and varied and are
mostly individual choices but the fact remains that while there is a one-
way traffic of intellectual ability from the east to the west, the brunt
of this effect is borne by the developing world in the form of economic
and intellectual loss.
Competing interests: No competing interests
Brain Drain: Leveling the Field
There is no way developing countries can successfully address the
question of brain drain and gain without unpacking the whole question of
imbalances created by colonial domination over the years. I specifically
refer to former colonies as victims in this scenario because it is them
who suffer most from migration of their skilled personnel than the
developed countries. In understanding contextual issues, bear in mind
pertinent questions: Whose interests were served by imperial/colonial ties
and what effects did they have? How fast can an average of a century of
colonial domination be reversed to the benefit of struggling nationals?
I think contributors who advocate for developing countries to address
'those problems that cause migration in the first place' run the risk of
missing the point - that the process of underdevelopment is not
coincidental or accidental. Furthermore, the process is still taking
place at a huge scale through relative deprivation, profit maximization by
drug manufacturing companies, withdrawal of medical patents and artificial
shortages of drugs in third world countries. Leveling the playing field
does not just require 'political correctness' but commitment, honesty, and
selflessness by developed countries. Unfortunately, these qualities may be
rare in this frenzy era of globalisation!
Competing interests:
None declared
Competing interests: No competing interests