stemming the impact of health professional brain drain
TRANSCRIPT
[Journal of Public Health in Africa 2013; 4:e4] [page 19]
Stemming the impact of healthprofessional brain drain fromAfrica: a systemic review of policy optionsEdward ZimbudziDepartment of Nephrology, MonashHealth, Monash Medical Centre, Clayton,Melbourne, Victoria, Australia
Abstract
Africa has been losing professionally trainedhealth workers who are the core of the healthsystem of this continent for many years. Facedwith an increased burden of disease and cou-pled by a massive exodus of the health work-force, the health systems of many Africannations are risking complete paralysis. Severalstudies have suggested policy options toreduce brain drain from Africa. The purpose ofthis paper is to review possible policies, whichcan stem the impact of health professionalbrain drain from Africa. A systemic literaturereview was conducted. Cinahl, Science Directand PubMed databases were searched with thefollowing terms: health professional braindrain from Africa and policies for reducingimpact of brain drain from Africa. Referenceswere also browsed for relevant articles. A totalof 425 articles were available for the study butonly 23 articles met the inclusion criteria. Thereview identified nine policy options, whichwere being implemented in Africa, but themost common was task shifting which hadsuccess in several African countries. Thisreview has demonstrated that there is consid-erable consensus on task shifting as the mostappropriate and sustainable policy option forreducing the impact of health professionalbrain drain from Africa.
Introduction
Brain drain occurs when a country becomesshort of skills due to emigration of workerswith specialized skills.1 Highly skilled healthworkers often migrate from poor to rich coun-tries. In Africa, a sizeable number of healthprofessionals migrate to developed countriesleaving behind systems with acute staff short-ages resulting in exacerbation of healthinequalities that already exist. Brain drain ofhealth professionals has resulted in an unevendistribution of health staff across the globe,with countries carrying the highest burden ofdiseases having the lowest numbers of healthworkers while those with relatively low need
have the highest numbers.2 The greatestshortage of health workers is believed to be inSouth East Asia and the largest relative need tobe in Sub-Saharan Africa where an increase ofalmost 140% is required to achieve adequatestaffing levels.3
The developing world is likely to lose morehealth staff in the future as the demand forskilled health professionals by rich countries isset to increase due to their ageing popula-tions.4 This implies that the distribution ofhealth workers is most likely going to be fur-ther skewed in favor of the developed world.Latest figures suggest that Africa carries 25%of the world’s disease burden, yet has only 3%of the world’s health workers and only 1% ofthe world’s economic resources.2 Given thesedisturbing statistics, there is an urgent need tocorrect this rather unethical and social injus-tice which has been allowed to occur for manyyears.
In order to manage the outflow of healthstaff from Africa, there is need to prescribe anumber of policy initiatives at regional, inter-national and global levels and to also fullyimplement the recommendations of severalstudies done on health professional braindrain from Africa. It is vital for these policiesand recommendations to be directed to thehealth workers who are the integral compo-nent of the health system. For instance, pour-ing money in the health system of Africancountries may not yield any desired change ifhealth workers are not available, motivated,skilled and supported. The purpose of thispaper is to review possible policies, which canstem the impact of health professional braindrain through a systemic review of most recentliterature on brain drain from Africa and toalso explore on instances when these policieshave been applied practically.
Methods of research
Electronic searches were conducted inPubMed, Cinahl and Science Direct with thesearch themes health professional brain drainfrom Africa and policies for reducing impact ofbrain drain from Africa. References of identi-fied articles were also browsed for relevant lit-eratures. The search was limited to peerreviewed publications, which were written inEnglish language.
Articles published from January 2005 toJune 2012 were included in the study. After theinitial search, articles were screened for rele-vance by reviewing the abstracts and titles.Studies were selected for full text appraisal ifthey suggested policies for stemming theimpact of health professional brain drain fromAfrica.
The Appendix summarizes the type of data
collected during the review. The data abstrac-tion form was used as a quick guide to deter-mine eligibility of articles considered for thisreview besides its primary role as a data collec-tion tool. The form was completed for all arti-cles, which met the inclusion criteria. Due tothe inclusion of mixed methodology papers, anarrative synthesis approach was utilised tosummarise and synthesize results. For the pur-pose of this study, authors were not consultedif there was any missing data on papersreviewed. All collected data was entered into adatabase managed by the researcher.
Results
The flow chart in Figure 1 shows the resultsof the search and study selection. A total of 425studies were available after the initial search.The titles and abstracts of these studies werescrutinised for eligibility and 325 articles wereexcluded because they were not relevant to thestudy. The remaining 100 papers werereviewed and 77 were rejected due to unavail-ability of the full article or duplication. A totalof 23 articles met the inclusion criteria andwere included in this paper.
Description of policies included inthe studies
Overall, nine policies to reduce health work-er brain drain from Africa were identified andthey were implemented by countries mostly inthe Sub-Saharan region. These policies weretask shifting, remuneration, regulatory mecha-nisms, compensation, bonding, political stabil-ity, importing health staff, training more staff
Journal of Public Health in Africa 2013 ; volume 4:e4
Correspondence: Edward Zimbudzi, Departmentof Nephrology, Monash Medical Centre, Clayton,VIC 3168, Australia.Tel. +61.3.95943618 - Fax: +61.3.95946907.E-mail: [email protected]
Key words: health professional brain drain,Africa, policy options, health workers.
Conflict of interests: the author declares no con-flict of interests.
Received for publication: 5 July 2012.Revision received: 7 April 2013.Accepted for publication: 27 May 2013.
This work is licensed under a Creative CommonsAttribution NonCommercial 3.0 License (CC BY-NC 3.0).
©Copyright E. Zimbudzi, 2013Licensee PAGEPress, ItalyJournal of Public Health in Africa 2013; 4:e4doi:10.4081/jphia.2013.e4
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most common was task shifting which had
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most common was task shifting which hadsuccess in several African countries. This
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success in several African countries. Thisreview has demonstrated that there is consid-
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review has demonstrated that there is consid-erable consensus on task shifting as the most
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erable consensus on task shifting as the mostappropriate and sustainable policy option for
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appropriate and sustainable policy option forreducing the impact of health professional
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reducing the impact of health professional
and recommendations to be directed to the
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and recommendations to be directed to thehealth workers who are the integral compo-
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health workers who are the integral compo-nent of the health system. For instance, pour-
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nent of the health system. For instance, pour-ing money in the health system of African
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ing money in the health system of Africancountries may not yield any desired change if
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countries may not yield any desired change ifhealth workers are not available, motivated,
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health workers are not available, motivated,skilled and supported. The purpose of this
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skilled and supported. The purpose of thispaper is to review possible policies, which can
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paper is to review possible policies, which canstem the impact of health professional brain
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stem the impact of health professional braindrain through a systemic review of most recent
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drain through a systemic review of most recentliterature on brain drain from Africa and to
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literature on brain drain from Africa and toalso explore on instances when these policies
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also explore on instances when these policieshave been applied practically.
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have been applied practically.
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collected during the review. The data abstrac-only
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[page 20] [Journal of Public Health in Africa 2013; 4:e4]
and remittances. Figure 2 demonstrates thefrequency these policies were discussed andimplemented in the studies reviewed. Table 1gives a detailed summary of the policies iden-tified by each and every study included in thisreview and where the respective policies havebeen implemented.4-26
Task shiftingTask shifting has been a popular policy in
reducing the impact of health worker braindrain from African countries. Several Africangovernments have been meeting specifichealth needs by establishing new cadres thatare better retained in rural and hardship areasbecause their qualifications are not recog-nised internationally.12 These cadres haveplayed a pivotal role in initiating and deliver-ing antiretroviral treatment (ART).5,9,12 Taskshifting has also been successfully used in psy-chiatry where psychiatry nurses have per-formed the psychiatrists’ roles well.22 In
Mozambique, a follow up study on task shiftingrevealed that 90% of non-physician cliniciansin obstetric care were still working at a districthospital while almost all of the doctors hadleft.13 Most of the articles which discussed taskshifting have revealed that moving away fromthe traditional doctor-centric model hasincreased the efficiency and quality of healthservices.9,14,15,27 Constraints of task shiftinghave also been reported and these include lackof standardisation between training pro-grammes and resistance from professionalstaff.
RemunerationMany health workers migrate due to poor
remuneration and improving the health work-ers’ salaries may reduce health professionalbrain drain. Many African countries have notsuccessfully managed to tap into the benefitsof remuneration because of the difficulties insustaining decent salary packages. This review
identified one study where an occupation-spe-cific dispensation model to remunerate healthworkers was implemented in South Africa.6
This resulted in the adjustment of nurses’salaries from 2008.
Regulatory mechanismsRegulatory mechanisms such as recognis-
ing overseas qualifications have beenembraced by South Africa.7 This can potential-ly facilitate the immigration of health profes-sionals willing to work in Africa. Another studyreviewed reveals that some African countriesare using the voluntary World HealthOrganisation Global Code of Practice to guidetheir national action and multilateral coopera-tion. In this regard, Kenya has entered intobilateral agreements with Namibia, Lesothoand Rwanda regarding collaborative healthworkforce training with the hope of promotingcircular migration of health professionals.8
Review
Table 1. Details of studies included in the review.
Reference Policies/recommendations Country
Mullan et al., 20075 NPCs were operating in 25 of the 47 Sub-Saharan African countries surveyed Sub-Saharan AfricaPillay et al., 20086 Improving health worker salaries by adopting an occupation-specific dispensation model South Africa
to remunerate health workers. Implementation began with adjustments of nurses salaries in 2008 Chopra et al., 20087 Policies suggested include introducing regulatory mechanisms that recognise overseas qualifications South Africa
and involving the communityTaylor et al., 20118 Embracing the voluntary WHO Global Code of Practice by committing to bilateral agreements Kenya, Namibia,
regarding collaborative health workforce training and promotion of circular migration. Lesotho, RwandaGerein et al., 20069 Task shifting or substitution where the roles of a lower level cadre were enhanced resulting Burkina Faso,
in increased efficiency and quality of health services Malawi, Mozambique,Tanzania, Zambia
Eastwood et al., 200510 Suggests direct financial compensation to source countries, restriction of freedom of movement Ghana, Southand use of auxiliary cadres. Implementing a Certificate of need whereby newly qualified graduates Africaare required to serve in areas of need before migration and also bonding schemes
Manafa et al., 200911 Production of lower level cadres MalawiZachariah et al., 200912 Discusses task shifting in ART management where nurses have successfully initiated and managed Malawi, Lesotho,
ART at rural primary health clinics South AfricaPereira et al., 200713 Engagement of non-physician clinicians in obstetric care MozambiqueBedelu et al., 200714 Evidence suggest that use of nurses and community cadres improved overall ART outcomes South AfricaShumbusho et al., 200915 Nurses were able to effectively and safely prescribe ART when given adequate training, mentoring and support RwandaOberoi et al., 200616 Zimbabwe importing up to 300 Cuban doctors per annum to meet demand ZimbabweMills et al., 201117 Suggests investment in training of health care workers in source countries by recipient countries Sub-Saharan AfricaKirigia et al., 200618 Considers reimbursement by source countries KenyaWright et al., 200819 Discusses compensatory schemes from recipient to donor countries AfricaWasswa et al., 200820 Training more health care workers EthiopiaDovlo et al., 200721 Implementing use of health extension workers and community health nurses Ethiopia, GhanaOlowu et al., 201022 Reinforces the success stories of remittances send from recipient countries Cape VerdeJenkins et al., 201023 Discusses task shifting where psychiatric nurses performed psychiatrist roles successfully AfricaBenedict et al., 201224 Bonding of health professionals to government institutions after graduating ZimbabweOyere et al., 200725 Reiterates importance of political stability in stemming brain drain KenyaRecord et al., 20064 Introducing temporary migration scheme and resolving incidence of market failure MalawiVan Rensburg et al.26 Discusses the task shifting in South Africa’s Free State programme South AfricaNPCs, non-physician clinicians; WHO, World Health Organization; ART, antiretroviral treatment.
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NPCs were operating in 25 of the 47 Sub-Saharan African countries surveyed
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NPCs were operating in 25 of the 47 Sub-Saharan African countries surveyed
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Improving health worker salaries by adopting an occupation-specific dispensation model
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Improving health worker salaries by adopting an occupation-specific dispensation model
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to remunerate health workers. Implementation began with adjustments of nurses salaries in 2008
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to remunerate health workers. Implementation began with adjustments of nurses salaries in 2008 Policies suggested include introducing regulatory mechanisms that recognise overseas qualifications South Africa
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Policies suggested include introducing regulatory mechanisms that recognise overseas qualifications South Africa
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Embracing the voluntary WHO Global Code of Practice by committing to bilateral agreements
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Embracing the voluntary WHO Global Code of Practice by committing to bilateral agreements
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regarding collaborative health workforce training and promotion of circular migration.
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regarding collaborative health workforce training and promotion of circular migration.Task shifting or substitution where the roles of a lower level cadre were enhanced resulting
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Task shifting or substitution where the roles of a lower level cadre were enhanced resulting in increased efficiency and quality of health services
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in increased efficiency and quality of health services
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Suggests direct financial compensation to source countries, restriction of freedom of movement
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Suggests direct financial compensation to source countries, restriction of freedom of movement
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and use of auxiliary cadres. Implementing a Certificate of need whereby newly qualified graduates Africa
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and use of auxiliary cadres. Implementing a Certificate of need whereby newly qualified graduates Africa
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are required to serve in areas of need before migration and also bonding schemes
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are required to serve in areas of need before migration and also bonding schemesProduction of lower level cadresNon
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Discusses task shifting in ART management where nurses have successfully initiated and managed Malawi, Lesotho, Non-co
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Discusses task shifting in ART management where nurses have successfully initiated and managed Malawi, Lesotho, Non-co
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ART at rural primary health clinics
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and Rwanda regarding collaborative healthworkforce training with the hope of promoting
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circular migration of health professionals.
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CompensationSeveral studies have undoubtedly revealed
shocking statistics on how much revenueAfrican countries are losing to developed coun-tries through the migration of trained healthprofessionals. A Kenyan study reports lost rev-enue from investment for nurses of betweenUSD 205750.00 and USD 4, 515869.00 pernurse.18 Logically and ethically, recipient coun-tries would need to reimburse the source coun-tries for costs incurred in producing healthprofessionals. In this review, there was no suc-cessful reimbursement programme identified.In fact, the United Kingdom, Canada andAustralia did not sign the CommonwealthSecretariat’s Code of Practice for Internationalrecruitment of health workers due a clauserelated to the possibility of compensation.10
Some recipient countries have been viewingthe aid they give to the source countries assome form of compensation, but countriessuch as Ghana who spend USD 9,000,000annually on medical education have witnessedthe reversal of the flow of aid.28
BondingBonding occurs when health professionals
are asked to work for the government institu-tions after they graduate usually for a periodequal to the number of years they trained. Thechallenge of this policy is that the governmentshould be in a position of absorbing all thegraduates when they qualify. This review iden-tifies Zimbabwe as one of the African coun-tries to successfully bond some of its healthprofessionals,24 but faced with a strugglingeconomy, Zimbabwe has not been able toemploy all of the nursing graduates. Ghanaalso tried bonding to retain nurses, but withlimited success.10 The government of SouthAfrica introduced the Certificate of Need wherenewly qualified graduates serve in areas ofneed before they are cleared to migrate.10
Political stabilityAlthough political stability is a very impor-
tant catalyst in health care workers migration,only one study in this review discussed theimportance of political stability in staff reten-tion. In Kenya, a slight reduction in brain drainwas noted in 2002 and this was associated withthe election of President Kibaki. There wasevidence of a lot of Kenyan health profession-als returning home after the 24 years rule byPresident Moi.1
Importing health staffImporting health staff may provide the
much-needed immediate relief from healthprofessional shortages. In Zimbabwe forinstance, of the 1200 physicians trainedbetween 1990 and 2001, only 360 remained inthe country by 2006.8 Zimbabwe responded to
this by importing 300 Cuban doctors annuallyto meet demand.16
Training more staffThe impact of health professional brain
drain may potentially be reduced by trainingmore staff. Three studies in this review dis-cussed the policy of health professional train-ing. One study emphasized the need for desti-
nation countries to be involved in traininghealth professionals in source countries17
while the other study cautioned against marketfailure whereby the costs of training medicalstaff lays with the state, but the benefits ofworking abroad are privately accrued.4 Anotherarticle discusses Ethiopia’s plan to train extra9000 doctors to fill the gap left by migration.20
Review
Figure 1. Flow chart of search strategy for review of literature on health professional braindrain from Africa.
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also tried bonding to retain nurses, but with
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also tried bonding to retain nurses, but withThe government of South
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The government of SouthCertificate of Need
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Certificate of Need where
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wherenewly qualified graduates serve in areas of
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newly qualified graduates serve in areas ofneed before they are cleared to migrate.
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need before they are cleared to migrate.10
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RemittancesTheoretically, remittances from African
expatriates abroad have the potential tostrengthen the economy and if they areploughed back into the health systems, Africais set to benefit. However, on the ground, mostof the money from health workers abroad isnot channelled into the formal banking systemand it is almost impossible for some Africancountries to fully utilise these funds for thebenefit of the majority of the people. Thisreview only identified one country whereremittances were making a difference to theeconomy. Remittances are contributing 20% ofCape Verde’s gross domestic product.22
DiscussionSeveral studies included in this review have
demonstrated the success of task shiftingunder different settings such as HIV/AIDScare,11,12,14,26,27 obstetrics13 and psychiatry.23
Countries practising task shifting have beenable to sustain these programs. Interestingly,the use of lower level cadres has been associ-ated with improved health outcomes.14 Incomparison with other policies, which havebeen implemented by African countries toreduce health professional brain drain, theconcept of task shifting seems to be feasible.The success of task shifting can be attributedto the fact that this policy does not infringe onthe rights of workers and in most cases it iscommunity owned. Some studies have howev-
er hinted that some lower level cadres underthe task shifting schemes are being luredfrom the public health system by non-govern-mental organisations11 thereby underminingthe gains from this policy.
This review has several limitations. All thearticles in this study were reviewed by oneresearcher whereas ideally, two reviewersshould have independently assessed each arti-cle for inclusion and exclusion to reduce bias asingle reviewer might introduce. Furthermore,there was an insufficient number of high qual-ity papers which discussed policies gearedtowards reducing the impact of health profes-sional brain drain from Africa. Only 5.4% ofarticles from the original search ended upbeing included in this review.
This review might also have been limiteddue to the methods utilised. Non-English pub-lications were excluded in this study raisingthe possibility of having missed relevant arti-cles. Besides this, potential studies wereexcluded because they did not have full textarticles readily available. Although the possi-bility of bias in the method of identifying andselecting studies for review was reduced byusing a comprehensive search strategy, thereis a possibility of publication bias since thisreview included only published articles. Tocounteract this, unpublished data could havebeen reviewed as well. The review also did notassess the quality of the included studies.
This review had a lot in common with otherstudies on health worker brain drain fromAfrica. Firstly, other systemic reviews have alsobeen unable to find substantial amount of rel-
evant literature on successful policies that canreduce the impact of health worker brain drainfrom Africa7 and in addition to this, most of thedata available tend to come from high-incomesettings and may not apply to developing coun-tries. Most importantly, among the policyoptions identified by other systematic reviews,substitution or shifting tasks between differ-ent types of health workers is a common policybeing applied by several low income coun-tries.7,27
Conclusions
This review has demonstrated that there isconsiderable consensus on task shifting as themost appropriate and sustainable policy optionfor reducing the impact of health professionalbrain drain from Africa. The paper has alsorevealed that implementing this policy insource countries is feasible given that it costsless to train lower level cadres. Very few stud-ies which focused on policy options for reduc-ing brain drain from Africa were identified, butapparently a lot of work has been done on braindrain. Future studies should therefore try toincorporate unpublished articles to increasethe likelihood of capturing representative data.
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review included only published articles. Tocounteract this, unpublished data could have
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This review had a lot in common with other
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studies on health worker brain drain fromAfrica. Firstly, other systemic reviews have also
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e review included only published articles. To
ies which focused on policy options for reduc-
use ies which focused on policy options for reduc-ing brain drain from Africa were identified, but
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for reducing the impact of health professional
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revealed that implementing this policy in
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less to train lower level cadres. Very few stud-only
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