- © 2008 Canadian Medical Association
The concept of “ethical recruitment,” or headhunting foreign health professionals only in First World countries that can afford to lose them, has won widespread, international support.
Yet criticisms are emerging just as the incipient movement heads towards its watershed moment: a global forum on “human health resources” in Uganda in March. Michael Clemens, a Harvard-trained economist at the Washington-based Center for Global Development, says banning physician and nurse recruitment in Africa is unhelpful to Africans.
And he's got data to back his claims.
Clemens admitted in an interview that his views don't coincide with those of “97% of the people I talk to about this issue.” But there are compelling reasons why African health care workers would want to emigrate from their birthplaces and even benefits that accrue to their home nations as a result of their decisions to leave.
He points first to the obvious: Africans have clear incentives to leave. In addition to concerns they may have about safety or security due to the high crime rate in South Africa, nurses there can double or triple their salaries by moving to Australia. That's magnified for Ghanaian or Kenyan nurses, who can increase their wages by a factor of 10.
Then there's the less obvious: nurses who choose to stay in Kenya may essentially be choosing unemployment. In 2006, Clemens learned from Kenyan officials that 7000 nurses licensed to practise there were not working in their field due to a Ministry of Health hiring freeze. In his view, the opportunities that beckon African health care workers abroad are “a good thing” because such opportunities are in short supply back home. Moreover, health professionals who go abroad send huge amounts of money back to Africa.
Clemens contends there's a link between the number of doctors who leave a country and the number working within that nation. In support of that proposition, he cites the findings of an analysis undertaken on health professionals from the 53 African countries (Hum Resour Health 2008;6[1]:1 [epub ahead of print]). Using census data from the 9 countries to which African health professionals are most likely to emigrate, including Canada, Clemens and Gunilla Pettersson plotted the numbers of African-born individuals working in those countries as physicians (65 000 in the year 2000) and as nurses (70 000 in 2000) and found that the numbers leaving don't correlate with the numbers left behind — the nations losing larger numbers of health professionals are wealthier countries with larger numbers to lose.
Graphing the data, Clemens expected to see a downward slope: “I was sure that … I would measure the effect [of doctors leaving] and say, for every doctor who's outside, there are 5 fewer doctors at home, but no.”
Instead, he found a “very sharp, positive relationship.”
That correlation between the high number of doctors departing and the higher number working within a country was true for all 53 countries. In light of that, Clemens found himself increasingly offended by talk of countries “exporting” nurses or “poaching” physicians (CMAJ 2008;178[3]: 269-70; CMAJ 2008;178[3]: 270-71; and CMAJ 2008;178[4]: 379-80).
“You don't export a person, you export ivory,” he says, “You poach elephants.”
Taking issue with that analysis, though, is the Canadian physician who's arguably done more than anyone else to spotlight physician recruitment patterns. World Health Organization (WHO) Assistant Director General Tim Evans is incredulous at Clemens' findings and says dryly that the anecdotes he hears in Africa are “not captured in the econometric analysis.”
Evans recalls a 2004 instance in which, over the course of a weekend between a World Health Assembly meeting and a WHO gathering, a doctor emigrated from Ghana, forcing the country's Minister of Health to close the surgical wing of a hospital. “The foundation of human resources in Africa is so fragile that you lose the only anesthesiologist in a hospital and all of a sudden there is no capacity to run basic, emergency obstetric care,” Evans says. He doesn't accept that the outflow of physicians to the North has no adverse consequences.
Evans began working on the problem when he was at the Rockefeller Foundation in the late 1990s. “I remember being in Uganda in 1998 and asking, ‚Why are you only producing 30 physicians per year?',” Evans says. Uganda was training the same number of doctors that year as it had in 1969, though the country's population had nearly tripled.
With donors increasing their investments to the billion dollar range from the million dollar range, Evans feared there wouldn't be sufficient doctors or nurses to staff new programs. After he joined the WHO, the organization began promoting ethical recruitment and produced a 2006 report that concluded Africa was “at the epicenter of the global health workforce crisis.”
For Clemens, though, the paradoxical answer is to allow more health professionals to emigrate. He won't be in Uganda, though, to make that case when the WHO and a host of nongovernmental agencies focus their attention on the issue. In fact, the organizers didn't contact him. “If I had to guess, they probably just wish I would go away,” Clemens says.