Stemming the Tide of African Health Worker Migration

Stemming the Tide of African Health Worker Migration

Cross-posted from the Global Health Magazine blog.

How did Malawi control its brain drain?

The British Medical Journal issued a report last month estimating that nine African countries have lost $2 billion worth of investment in training and educating doctors who have subsequently migrated abroad. It needn't be this way. Doctors, nurses and other health professionals do not have to give up home, family and country to earn enough money to give themselves and their children a future, even a modest one. And it needn't cost low income countries billions of dollars to train the doctors and nurses who then leave for greener pastures.

BMJ is correct in saying that rich countries should do their share by investing more in training health workers rather than ‘importing' them from abroad. As a supporting opinion piece in the same issue argues, a ‘whole of government' approach in the developed world is needed to align the multiple angles of this dilemma. It is a dilemma, in fact, because morally, the choice of career, training, and mobility belongs to the individual after all.

A hospital team at Nandi Hills District Hospital, Kenya. Credit: MSH.

And, in fact, it is the perspective of the individual, in this case the African health worker, that is often overlooked and may provide clues to another, albeit more modest, approach to the issue.

MSH's research on leadership, management and sustainability of the health workforce, has revealed two facts: (1) People go to medical or nursing school to treat the ill and heal the sick; (2) When these same people are assigned to health facilities, they find their hopes dashed due to lack of supplies, medication, chronic staff shortages, low morale and poor working conditions.

A recent blog from a Kenyan doctor eloquently illustrated these issues. In regard to her anger, she wrote:

"I can't quite decide if it is the night I performed two caesarian sections with the anesthetist shining the light from his Nokia phone because the generator did not function and the operation had started... Or maybe it is the fact that over 60 percent of nurses in Southern Africa are HIV positive because of a lack of gloves. Or maybe it is the incidents of nurses being raped in night time hours, sometimes by patients."

The truth is there are poor working conditions in many parts of the health system in Africa, and when this is added to low salaries, salaries that can't even support the family, then people are forced to consider other options such as migration.

Malawi presents a hopeful alternative. As part of its national Emergency Human Resource Program (EHRP) from 2004 to 2009, the government, with support from the UK's Department for International Development (DFID) and other development partners, increased salaries of 11 cadres by 52 percent. They also increased the production of health workers by 53 percent and created a sense of accomplishment and commitment. Working conditions improved. Health workers were more respected. Leadership was strong.

At the end of five years, they had increased the impact on all health indicators (i.e., prevention of mother-to-child transmission of HIV, safer deliveries of newborns, immunization rates, antenatal care and antiretroviral treatment). This only increased the sense of pride they all shared.

But most interesting was the decline in migration. In 2002, 59 percent of Malawi's doctors and 16 percent of their nurses were working out of the country. In the year 2003 alone, 108 nurses migrated out of Malawi. At the end of the EHRP in 2009, migration had slowed and only 16 nurses migrated. While the figures are not available, it is agreed that the rate of physician migration has also slowed significantly.

In focus group discussions with a variety of staff, the majority stated that the salary increase was a significant factor in their decision to join or return to the health service, and that their commitment was ‘until retirement ‘or ‘as long as they were able.' But, the other factor in their decision, were the improved working conditions.

Yes, there is a cost to Malawi's success story. During the five years of the EHRP, the up-front cost of the salary increases for 11 cadres of staff was $34.1 million. Some of that money reverts to the government in the form of payroll tax. Since then, the pay increases have continued, with the government taking more responsibility through increasing its health expenditure.

Is this worth it? When you consider the costs of migration, isn't it better to concentrate on the costs of retention and improving the conditions and safety of health facilities and in the process provide better health care as well as a viable opportunity for people to reach their dreams at home?

Mary O'Neil, EdD, is Principal Program Associate for Human Resources for Health at Management Sciences for Health.


Stacia Nordin
Thank you for highlighting this issue. It is so important that staff (including ourselves!) are engaged in fulfilling work and that we are equipped with the tools we need to do our job such as skills, continuous professional development, resources appropriate to the job, and, a salary that fits the tasks. BUT, as much as I agree with you on those issues, I disagree with outsiders paying people's salaries / standard job resources without an ongoing plan for the government to continue on this path. Outside assistance should support the government to find ways to build a supportive work environment; outside assistance should not do what the government should be doing (unless there is a crisis situation that requires short term support, and this is not the case in Malawi). The staffing situation in Malawi is now right back to where it was (compared to the DFID project you refer to), if not even further behind since the government got used to other people doing for them. Of course Malawi will let other nations come in and pay the salaries that they should be giving to their front line staff and improving their working conditions, that way they can put their money into their own interests that get them re-elected and everyone is happy! I hope that development stops doing for other nations and helps nations do for themselves. If not, development aid will be here, forever. Here is a posting from a local independent news cast the other day in Malawi: (paraphrased) ''Zodiac Broadcasting Service has established that five health centers in Mangochi have no medical personnel, a development authorities say is compromising health service delivery in the district. Acting district health officer for Mangochi Ekwako Muliya says the district has a 75% vacancy for nurses, 54% for medical assistants and 36% for clinical officers. Meanwhile, executive director for Malawi Health Equity Network (MHEN) Martha Kwataine says with such trends, Malawi should forget about attaining Millennium Development Goals on health.'' Here is another post recently on independent Zodiak Broadcasting Station: (paraphrased) ''The Malawi Health Equity Network has warned that a budget which is not dependent on donors cannot work for the country’s health sector. The NGO’s director Martha Kwataine said without donors Malawi’s health sector cannot perform effectively because donors contribute 90 percent of money for drugs and 52 percent for salaries.'' So we have a long way to go to get out of areas that we have no business in, and instead having the government use its meagre funds for basic services before putting funds into fancy meetings, cars, planes, high salaries and allowances for political leadership, homes and swimming pools (which is the newest fad according to the media anyway). You have all my respect for attempting to assist Malawi and other nations, but I beg that we remember our place as outsiders is not to do for others what they can really do, and what they really should do, for themselves. Also recently on Malawi's independent radio, Capital FM (paraphrased): ''Government employees were given a 7% salary increment which was described as too little considering the rising cost of living. The civil servants through their trade union have for the past months engaged in talks with authorities to consider hiking the 7% increment but to no avail. The Civil Servants Trade Union (CSTU) leadership however remains optimistic that Government will sort their issues out in the coming year.'' Let's hope that their talks end up with favourable salaries that are in line with other parts of the budget plan.
Mary O’Neil
Dear Stacia, Your point of view provides an important perspective regarding the role that government can play in its own country. It is true that in many countries, like Malawi, there are severe shortages of health workers. Vacancy rates are high and many facilities are closed. My comments, as an outsider, were merely to highlight the importance of the issue of retention which I find is often overlooked in the discussion about migration. You are right, these are steps that only countries can do on their own in the final analysis. I appreciate your comments and your thoughtfulness on these issues. Mary O’Neil
Jenie Lates
Thanks Mary for the good article! Hope you are well and greetings from Namibia! Jennie

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