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Medical Brain Drain in Developing Countries

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CHAPTER ONE

BACKGROUND

The loss of human capital from developing countries to developed countries is not a new phenomenon. It is commonly refer to as "brain drain" which broadly represents the migration of highly skilled professionals from one country or part of a country to another in search of a better prospect (Sako, 2002). The loss of highly skilled professional attributed to brain drain has been of interest internationally for over four decades (Giannoccolo, 2004). Concern over the international migration of health workers first came to limelight at the Edinburgh Commonwealth Medical Conference in 1965. This situation prompted the World Health Organisation (WHO) in 1970 to examine the global process and flows of doctors and nurses (Mejia, 1978). The report however made little impacts on migration of health workers which has continually been on the increase over the years (Levy, 2003, Pang et al. 2002)

The concept of the 'medical brain drain', that is the migration of doctors and other health professionals from developing economies to developed countries has been the subject of interest and research across a variety of fields including labour economics, human resource studies and human geography (Diallo, 2004, Buchan, 2004 and Stilwell et al., 2004)

The migration of medical personnel has been identified by WHO as the most critical problem facing the delivery of health service in developing countries (WHO, 2007), besides the emigration of doctors in particular to other countries have received a more considerable attention (Beecham, 2002)

The extent to which health professionals migrate to developed countries has continue to be on the increase in recent years and this has been attributed to an apparent response to demand from the developed countries where medical professional are in short supply to cater for demands due to demographic changes, aging population, growing income, feminisation of workforce amongst others (Pond and McPake, 2006).

Foreign-trained medical and nursing workforces are estimated to account for more than a quarter of health professionals of the Australia, Canada, the US, and the UK (OECD, 2002).The quest for highly skilled professionals has been on the increase in many developed countries. According to statistic report from the Global Atlas of Workforce cited in Pond and McPake, (2006), the United Kingdom (UK) was ranked among the least staffed of high income countries with 166 doctors and 497 nurses per 100,000 populations - the second lowest doctors' density and the fourth nurses' lowest density among the Organisation for Economic Cooperation and Development (OECD) countries. Moreover, as at the year 2000, the UK health system currently require about 10,000 physicians and 20,000 more nurses to meet the demand of the NHS plan (Department of Health, 2000). Between the year 1999 and 2004 when the targets was achieved earlier than expected, a new target was set to increase the number of nurses by 35000 (10%) and physicians by 15000 (25%) between 2001 and 2008. In order to achieve the new target, several methods were adopted to recruit doctors and nurses from other country to fill the shortage within the NHS. However, the approach created a surge in the international recruitment of health worker (Department of Health, 2004).

Conversely, the poor economy condition in the developing countries coupled with poor remunerations, lack of infrastructural facilities, and low morale, emigrating to developed countries by doctors' is seen as an opportunity for a better prospect.

Furthermore, the continuous rise in disease prevalence, emigration, productivity losses, and shortage of doctors in Sub-Saharan Africa, has resulted in health resource crisis (Aluwihare, 2005). Insufficiency in human capacity for health care delivery in developing countries have been identified as a significant factor that is responsible for the inability to achieve the target set by WHO for the treatment of 3 million HIV infected people by year 2005. (This initiative was tagged '3by5') (WHO, 2005). This has also been identified as a major constraint limiting the progress of Millennium Development Goals (MDGs) Initiatives (IOM, 2005).

In response to the migration of health professionals to developed countries and the undermine effect to the economy, social and health status of exporting countries, the Commonwealth Ministers of Health agreed to uphold and keep the Commonwealth values of cooperation, sharing and supporting one another, thus a consensus approach to deal with the problem of international recruitment of health workers was adopted.

The Code of Practice for the International Recruitment of Health Workers is intended to provide a framework to governments within which international recruitment should be carried out (Commonwealth Code of Practise, 2003).

Similarly, Department of Health (2004), presented a revised policy on "code of practise for international recruitment of health care professionals" this demonstrated the concerned of the UK government in protecting the health care system of developing countries. The revised code of practise for recruitment addresses role of private employer and agencies in the international recruitment of health professionals from developing countries (Eastwood et al., 2005).

Nevertheless, developing countries have made some effort in preventing the emigration of physician to developed countries. In spite of this, addressing factors that encourage emigration, such as large disparity in remunerations, standards of living, opportunities for career development amongst host other benefits are usually difficult to come by. At the 1998 UN Conference on Trade and Development, WHO study indicated that 56% of doctors from developing countries migrate to developed nations, while only 11% migrate in the opposite direction; the imbalance is even greater for nurses. (Chanda, 2002).

As a result, further effort is being deployed by developing countries to search for means to manage the migration of the health workforce to developed countries (Hussey, 2007).

Despite measures, it may be difficult to totally prevent health professionals from migrating. As the large scale of medical brain drain from developing countries is now having a negative impact on the development process of the health system of those countries, it is however imperative for stakeholders to develop a consequential means to curtail the continual movements of health professionals.

Nigeria Health Services

Historical Background

Nigeria, the most populous black nation in the world with a total population of 140 million people (2006 census). As a country with mono-cultural economy, the major source of foreign earnings is from crude oil. The poor level of resources allocated to the health care sector is one of the main factors responsible for the deplorable health condition in the country (Campbell, 2007).

The public health service in Nigeria started in 1946 with a 10-year colonial administration plan; the development came about when treatment was required for soldiers of the West African Frontier Force and the colonial administration staff. In 1975 attempt was made to adopt primary health care under the Basic Health Service Scheme (BHSS). The BHSS aimed to improve the accessibility to heath care in terms location, affordability, increase access to disease prevention and distribution of services, and provision of adaptable health services based on local need and socially acceptable method of technology (Hodges 2001).

The Current Health Care System in Nigeria

Over the last two decades, the health care system in Nigeria's has deteriorated - a fact ascribed to the country's poor governance and leadership which was more pronounced during the military era. This was reflected in budget allocations and the fiscal requirements of the Structural Adjustment Programmes. The deficient of reliable data makes it difficult to provide a detailed assessment of the degree of financial commitment to the health sector (Ali-Akpjiak and Pyke, 2003).

According to World Bank source, Nigeria public spending per capita for the health sector is less than $5 USD and is as low as $2 USD in some parts of the country. This is far below the $34 USD recommended by WHO for developing countries within the Macroeconomics Commission Report. Nevertheless the Federal Government recurrent budget on health showed an increasing trend from 1996 to 1998, a decline in 1999 and started to rise again in 2000, available evidence shows that most of the recurrent expenditure is spent on personnel. The Federal Government recurrent expenditure on health as a share of the total Federal Government recurrent expenditure which stood at 2.55% in 1996, 2.96% in 1997, and 2.99% in 1998, declined to 1.95% in 1999 and 2.5% rose in 2000. Beyond budgetary allocations, there is a wide gap in the available between the budgetary figures and the actual amount of funds released from the treasury for health activities (WHO 2009a).

The decline in the Nigeria health sector was accompanied by collapse of institutional capacities, poor remuneration and lack of conducive environment, dilapidated equipment and infrastructure have over the years, job dissatisfaction and low motivation, have led to increase migration of health professionals to seek employment in overseas countries. In a bid to curtail the impasse, Nigeria has subscribed to the Commonwealth Code of Practice for the International Recruitment of Health Workers for which a framework of responsibilities is presently being developed (WHO 2009b).

Demographic and Health Indicators

The demographic data in Nigeria are not very reliable. Data gathered from various exercises such as census, vital registrations and surveys are often inconsistence and sometimes contradictory. Nonetheless, there is evidence that the key indicators have either remained constant or worsened (WHO 2005).

Life expectancy declined from 52.6 years for male and 58.8 years for female in 1991 to 45 years and 46 years for both Male and Female respectively in 2004. The infant mortality rate (IMR) in 2004 is 103 per 1000 live births when compared to 87.2 per 1000 live births in 1999. Fifty percent of deaths under 5 years of age have been attributed to malnutrition.

The maternal mortality rate (MMR) of 800 per 100,000 births is the second highest in the world after India. This has been attributed partly to shortage of skilled medical personnel. For instance only 41.9 % of primary health facilities is provides antenatal and delivery services. Moreover 57.3% of such health facilities operate without a doctor, midwives or senior community extension worker. The Nigeria health system is one of the worst in sub-Saharan African with a disability life adjusted expectancy of 38.3 years and ranked 187 in the world (WHO 2005)

Health Workforce in Nigeria

Among the several challenges facing the health system in Nigeria is the lack of competent health care professionals. This has been attributed to inadequate infrastructures and poor remunerations packages, making a sizeable numbers of doctors, nurses and other medical professionals vulnerable to be lured away to developed countries in search of a fulfilling and lucrative employments (Stilwell and Awofeso, 2004, Raufu, A., 2002)

There are 52, 408 Nigerian Doctors registered with the Nigeria Medical Council as at December 2007, There are 128,918 nurses and 90,489 midwives on the register, although only a fraction of these pay the required practicing licensing fee. There are 13,199 pharmacists, 840 radiographers, 1,473 physiotherapists, 12,703 medical laboratory scientists, and 19,268 Community Health Officers. All these health workers are required to pay annual practicing licensing fees; however the lists have not been pruned for those have migrated out to foreign countries, deaths, retirements or those that have left the profession for another career entirely.

Health workers are poorly distributed and most are in favour of urban areas, southern, tertiary health care services delivery, and curative care. For some cadres of health workers such as doctors and nurses, more than 50% have their place of work in the South Western part of the country with vast majority residing in the commercial city of Lagos (Labiran et. al, 2008).

Medical Brain Drain in Nigeria

Among the countries in sub-Saharan African, Nigeria is a major "export" of health professionals. An estimated number of 20, 000 health professionals emigrate from Africa annually. A trend that poses threat to sustainable health care delivery in Nigeria. Statistical data on Nigerian doctors who are legally migrating overseas are scarce and unreliable, this is largely due to the fact that most wealthy nations like Australia currently makes it very difficult for overseas trained doctors to practise in their country primarily on the basis of medical skills. However, hundreds of doctors trained in Nigeria continue to emigrate to developed countries annually (Stilwell and Awofeso, 2004). Better remunerations and medical facilities among other factors are cited as one of the major reason for flight of Nigerian doctors (Raufu, 2002) and also there are limited incentives and encouragement for overseas based Nigerian doctors that is willing to relocate back to the country (Stilwell et al., 2004).

Purpose of the study

In sub-Saharan African, there is has been a significant rise in disease burden, loss of productivity and the emigration of medical doctors to developed counties have resulted in the in dearth of the most required health resource (Aluwihare, 2005). Most studies on medical brain drain have examined the subject from the perspective of recipient developed countries and little attention has been paid to the donor developing countries. Thus, "scarcity of data from developing country makes it difficult to fully describe the impact of migration on countries of origin" (Hagopian et al., 2004). Most studies on doctors migration from Sub-Saharan African have tended to focus on numbers, without exploring the underlying reason for migration, assessing the potential negative impact of migration on the health care systems, or considering means to alleviate the problem. In actual fact, information regarding the extent of migration is usually obtained through data from countries of destination (Stilwell et al 2003).

The migration of medical doctors from Nigeria and other countries in sub-Saharan African generates three areas of major concern. The first is a loss of the basic health services available to the citizen. for instance, Ghana, faced with a ratio of nine doctors to every 100 000 patients and no more than 22 paediatrician are licensed to practise in country and no more than 10 specialists of any kind practising in the remote area. Similarly, Nigeria lack adequate doctors to care for the sick especially patients residing in the rural communities

The second effect doctor migration from Nigeria is that it prevent the health sectors the ability to organize and expand. Public health institutions heavily depend on doctors to lead, develop and promote them as they work to advance health care delivery. As obtained in US, doctors are well positioned to serve their organisation by actively involved in managing resources and articulating priorities. It is therefore speculated that as the numbers of available medical doctors in developing countries reduces.

The third challenges are that doctor's migration depletes a significant element of the middle class in developing countries. As in the developed countries, medical doctors in African comprise of an important segment of the social and economic make up of the middle class. They are generally accorded a lot of respect in the society, as being above corruption, they advocate for improvement in quality of education of public schools and they play a vital role in political (Hagopian et al., 2005). In Nigeria, over 70.2% of the population lives on $1 per day (WHO, 2006)

Research aim and objectives

The aim of this study is to analyse the causes of medical brain drain from developing countries, benefits and burdens associated with brain drain based largely on the views of Nigerian doctors practising in UK.

The objectives are:

  • To identify the factors that influence the decision of medical doctors to migrate to developed countries migration
  • To identify the impacts of migration on healthcare in developing countries

CHAPTER TWO

LITERATURE REVIEW

Concept of Brian Drain

Brain drain has been defined by many analysts in different ways. It is not surprising the social phenomenon has been examined and analysed from different perspective, based on their general orientation and or awareness of the subject.

Brain drain will be conceived in this study as the loss of medical professionals or significant number of human capital within the health care system to other sector of the economy or country.

Migration of skilled professionals differs from one country to another and from time to time it is however misleading to generalise the possible impacts of migration in developing countries. Moreover, it can be argued that various studies have attempted to measure the phenomenon from different perspective. Single analytic measurement cannot be used to justify all migration although migration of highly skilled professionals from developing countries has been attributed to various factors which political, social and economical factors account for a significant reasons behind the phenomenon (AUN report, 2002).

The migration of highly skilled workers can justify the use of the term "brain drain" however the expression should be used cautiously. Replacing 'drain' by a more common and value expression such as 'migration' may generate alternate meaning. The difference in the word may be heightened by saying while all brain drains constitute brain migration notwithstanding, brain migration may not necessarily refer to brain drain.

Brain drain denote the de-facto transfer of resources spent on impacting education and developing both technical and professional skills of the drained brain in question by the parent (donor) country to the (recipient) country of transfer. The developed countries thus save financial resources on education and professional training and invariably obtain the service of professionals such as doctors, nurses, engineers, scientists who earn more than their colleague in developing countries with a better comfortable living environment (Glaser and Habers, 1978).

Several efforts have been made to define the concept of brain drain, most especially by international organisation. According to United Nations Educational, Scientific and Cultural Organisation (UNESCO report, 1969), "the brain drain could be defined as an abnormal form of scientific exchange between countries, characterized by a one- way flow in favour of the most highly developed countries". Approximately four decades later, the definition of brain drain has undergone no significant change with a lot of highly skilled workers still leaving the shores of developing countries in pursuit of greener pastures in the developed nations. Medical doctors, engineers and scientists usually tend to predominate or account for a larger proportion among the migrants. Their higher the level of skills or professional qualification, make them more susceptible to migration.

Gillis, et al. (1987) suggested two main reasons why brain drain is detestable to most developing countries. The first is that the calibres of people that migrate represent one of the scarce human resources in these developing countries and secondly the amount of resources, financial cost and time involve in educating these group of people is expensive and heavily subsidise by the government. Such migration to foreign country therefore becomes expensive and costly to the donor countries. In most cases the developing countries completely loose these highly skill professionals to the developed countries (Edokat, 2000). This phenomenon has generated a lot of arguments that have been advanced for or against brain drain; however this is not a concern for this study. All that can be concluded is that migration of highly skilled workers from developing countries to develop countries creates a vacuum in the former countries (Edokat, 2000).

Types of brain drain

Primary external brain drain - occurs when trained professional or skilled human resources emigrate from their country of origin to work in developed countries such as America, Europe and Australia.

Secondary external brain drain - occurs when a trained professional or skilled human resources leave their country or any other less developed country to work in a another developing country such as Botswana, South Africa, Zimbabwe and Namibia.

Internal brain drain - occurs when a trained professional or skilled or skilled human resources seek for employment in a field not related to his to his/her expertise or when such individual migrate from the public sector to private sector or to another sector within a particular country. While this may pose a problem for a country, it is however not a loss of human resource to the country or the continent.

Brain Drain Theories

These theories are based on general migration approaches. In brain drain discussion, these approaches have been referred to briefly or summarized. Occasionally specific remarks will be made to provide more clarity regarding the theories.

It is however important to state that nearly the theoretical outlook consists of specific mix of different theories or based on the nature of the dominating factors. On the other hand, the scientific approach in which the theories were founded. Another approach in the use of division based on the level - Micro, Meso or Macro. These groups cover greater number of theoretical approaches (Oderth, 2002).

This level has been defined as:

Micro level - the decision making of individual is affected by his or her motives, circumstances and access to information.

Meso level - an aspect of social ties that affects migration such as the effect of network of friends and relatives on migration

Macro level - opportunities and constraints available at societal level which include political, socio-cultural and economical factors

There is no Grand theory linked with research on brain drain although attempts have been made to integrate the subject with economic and social theory, spatial analysis and social science (Kangasniemi et. al., 2004). The study of brain drain and other behaviour by demographers was able to draw insights from other disciplines such as statistics, history, economy, medicine and anthropology (Oderth 2001). A common example is the push and pull model of labour mobility. The model states that "individual migration decision is a combination of family, economic, social and political factors". Categories of factors identified to be affecting migration include: 1) Factors at the point of origin, 2) Factors at point of destination, 3) Intervening obstacles and 4) personal circumstances. The push and pull model has been widely used by scholars in studies. Economic factors of employment and material benefits are regarded to have the strongest influence on migration decision (Oderth 2002)

Despite the frequent use of the push and pull model approach in migration literature, the approach has been seen as too mechanical and 'rational choice' based and with less consideration for intervening obstacles or institutional and structural constraints (Massey et al, 1993). Most migration tends to be unidirectional from poor to rich nations. The rate of emigration also differs vary considerately between countries and regions on similar economic level and the poorest or the less educated people hardly ever move. A major challenge for the migration is lack of insights in the interconnectedness of all the processes (Kangasniemi et. al., 2004)

Another model is the migration system approach - it involves formation of a link that encourages migration between a sender and receivers which are strengthened over a period of time. Such links include economic, political and cultural interaction often based on historical activities. Once a link has been created between the migrant places subsequent migration is facilitated through the links.

The migration system approach emphasis that social network of the migration provides the intending migrants with information and assistance to ease migration. An important feature of such system is that immigration to a country is directed to specific regions. Such migration is partly dependent on specific areas (Gillis, et al. (1987)).

The scope of medical brain drain

The World Health Report (2006) estimated that an approximately 817,992 (138%) health workers would be required In Africa to achieve the coverage of basic health interventions.

The rate at which doctors and other health professional migrate differs from country to country. Nevertheless, the pattern of migration shares certain similarities. The severe shortage of doctor's particularly in rural health facilities has critical negative effects on accessibility and equitable distribution of health care in sub-Saharan African (Ovberedjo, 2007).

Studying a specific group of employments from a pool of migration statistics revealed a substantial net loss of human capital among certain key profession in sub-Saharan African. An obvious and highly skilled professional to emerge from such analysis are medical doctors (SOPEMI, 2008). This particular phenomenon can be described as "Medical Brain Drain". However, to what extent doctors migrated from sub - Saharan African to developed countries?

This section will review the scope of migration among doctors in sub - Saharan African. Medical brain drain is important and deserves consideration because it is obvious that any decrease in the labour supply among doctors in any country is bound to generate a significant negative impact on the health system of that particular country.

In year 2000, statistical data revealed an average of 18.2% of employed doctors working in OECD countries were foreigners. The United States has the largest number of doctors (about 200,000) born and trained in foreign countries followed by the United Kingdom which account for almost 50,000 and France about 34,000. Health worker in India and Philippine formed a greater percentage of the immigrant health workforce OECD countries. In addition, doctors from India account for 56,000 of foreign born doctors practising in OECD countries while nurses of Philippine origin account for about 110, 000. These represent about 15% each of the total (SOPEMI, 2008).

The French and the Portuguese African speaking countries contribute some of the highest emigration rate to OECD countries for medical doctors some of other African countries such as Guinea Bissau, Sao Tome and Principe, Senegal, Carpe Verde, Congo, Benin and Togo rank between 17th and 23rd places with emigration rate of 40%, while the English speaking countries in African such as Malawi, Kenya and Ghana have lower emigration rate ranked 25th, 28th and 38th respectively. South African and Nigeria were the only two countries in sub-Saharan African among the top 25 countries with foreign doctors and nurses practising in the OECD countries. This was due to the fact that most African countries have smaller population of workforce (SOPEMI, 2007).

Statistical data from the American Medical Association (AMA) Physician Master file shows that 5, 334 non-federal trained doctors trained in Africa medical schools were licensed to practise medicine in the United States in 2002. Nigeria account for 2,158, while South Africa 1,943 doctors. Another 478 doctors are from Ghana medical schools. Other countries contributing to the list in sub-Saharan African include Ethiopia - 257 physician, Uganda - 153 doctors, and Kenya - 93 doctors. The total number of 5,334 represents 6% of the total number African doctors (Hagopian et al. 2004).

After United States, the United Kingdom and Canada are the most common destinations in developed countries for African Physicians, with a total of 3,451 and 2, 151 African trained doctors are recorded to be practising in United Kingdom and Canada respectively. Moreover figures in the UK include only doctors who arrived after 1992 thus the number may probably be higher, other destinations for African-trained doctors include Australia, New Zealand and the Gulf States (Hagopian et al. 2003)

Migration of doctors also occurs between countries within African continent. For instance, countries such as South Africa, Senegal and Botswana "export" doctors to developed countries and likewise import doctors from other African countries to cater for shortfall in medical personnel (EQUINET, 2003).

Causes of Brain Drain

The factors guiding individual choice of migration is in essence personal and thus susceptible to the prevailing personal circumstances. Nonetheless, the economic and social context of such decision deserves an important consideration. Moreover, the disparity between the economic and social development status of different sectors within a particular country and of different countries within African has countries has broaden over the year (Stilwell, 2004).

Brain drain of doctors and other highly skilled professional from Africa has been blame on unfulfilled dream at country of origin caused by strife, corruption and misuse that mark Africa's post-colonial history (Bridgewater, 2003 cited in Mbanefoh, 2007). Also according to Dovlo (2003), causes can be linked using six gradients which include job satisfaction, salary, career opportunity, governance, social security and benefit, protection and risk. Furthermore the dualistic nature of the world economy has been found to be a major contributing factor to brain drain, as highly skilled medical professionals particularly doctors try to escape the endemic poverty by migrating to wealthy, developed and technologically advanced countries of the world (Mbanefoh, 2007).

Factors guiding individual decision to emigrate are a result of the interplay of economic, cultural, social, political and legal forces. Others factors encouraging cross-border migration are usually considered under two main categories: "Push" factors (Supply) and "Pull" factors (Demand) (Kline, 2003). Over time the pattern of migration is facilitated through networks that provide prospective migrants with information about job opportunities in countries of destination as well as offer various support to help adjustment after migration (Matin, 2003).

"Push" factors (Supply) - these are conditions that make a doctor to be dissatisfied with work and professional careers in their country of origin. The factors may be evident both in the developed and developing countries facilitating the migration of health care professionals from one country to another which is perceive to offer better opportunities in some way. However, these factors are more prominent in developing countries, and they greatly influence the decision of doctors to emigrate in these countries.

"Pull" factors (Demand) - these are conditions in countries of destination that motivate workers to migrate. In the same manner as "push" factors, "pull" factors can also influence the migration of doctors from one developed country to another developed country. However, the pull factors has a more pronounced influence on individuals in developing countries for instance, there is surge in migration of nurses to Canada after the review of cost of living, salaries of nurses became double of what is earned in South Africa, four times more than what is obtained in Ghana and 25th than those in Zambia. Similarly, health care professional will only decide to emigrate if they perceive condition of service is a more superior (or better) to what is available in their home country (Clarke et al, 2006)

Push and Pull Factors in Health Care Migration

Push factors

 

  • Inadequate compensation
  • Lack of career opportunities
  • Lack of opportunities for children
  • Poor quality of life
  • Poor working condition/Job dissatisfaction
  • Work related hazard (HIV/AIDS, tuberculosis, Hepatitis etc)
  • Political instability/War/ ethnic strife/ insecurity etc

 

Pull Factors

 

  • Safer work environment
  • Greater career opportunities
  • Better compensation
  • Better quality of life
  • Greater career opportunities
  • Political stability
  • Better working condition/greater job satisfaction

 

Impact of medical brain drain

The impacts of migration health professional are majorly borne by the developing countries that lost a significant numbers of doctors and other healthcare professionals to the developed nations. According to WHO (2002), "health personnel are the people that makes things happen". The loss of these groups of professionals to the developed countries greatly affects both the quality and quantity of health services that is available to the people. Access to effective care is limited and the very few that managed to access the available local facilities; they are welcomed with poor services which could further complicate their present condition.

The impacts of medical brain drain cut across various sectors of the economy, usually effects of migration of doctors and other health worker from developing countries to the developed nations leave behind largely negative impact on the health system, economy, and even the financial sector of their country of origin. Nevertheless, migrations of doctors to high income have either directly or indirectly contributed positively to specific sectors in the developing countries.

Impact on Health system

The apparent effect of shortage of doctors and other health care professionals is that it leads to an early closure of health facilities thereby limiting access to required basic health care. For effective functioning of the health system, a balanced mix of health professionals is required and should be adequately deployed for equitable coverage (Stilwell, 2003).

A survey of some African countries by Dovlo (1999) shows vacancies level in public health sectors to range between 7.6% - for doctors in Lesotho and 72.9% - for specialist in Ghana. Such vacancies usually translate to inadequate health service coverage with the health need of some population group remain unmet. Emigrations of doctors usually leave a vacuum in the health system and with shortage of health professionals, there is high tendency of finding unqualified health personnel performing tasks and roles for which they have received little or no training (Physician for Human Right, 2004). For instance, in Malawi undertrained staff were deployed to work as ward attendant at some health facilities (Aitken and Kemp 2003), likewise in Ghana, shortage of physician have lead to inadvertent employments of unqualified medical personnel in communities with desperate need (Hagopian 2005) or better still retired physician and surgeon who lacked skills in current medical practises are relied upon for services in some health facilities (Physician for Human Right, 2004)

Furthermore, There is increased exposure of people to the risk of wrong treatment, misdiagnoses, and poor quality of service while waiting so long to see a doctor who is overworked, contributing to stress, fatigue and perhaps medical errors, in addition, in a very busy health care facilities, little time is spent with each patient, which could limit their ability to fully explore the patient's clinical condition.

Incessant migration of healthcare professionals to the developed countries increases staff turnover rate thereby resulting in loss of institutional memory. There is continuous reinvention of strategies to manage diseases and illnesses, which is been attributed to shortage of key health professionals and resulting in lack of lack of continuity and formation of gaps within the institution. Loss of institutional memory affect organisation or sector of the economy which limit the ability of health system to build and retain strategies based on experience (Physician for Human Right, 2004).

At a macro level, shortage of doctors can cause delay in scaling up interventions goals which include the millennium Development Goal (MDG) (WHO, 2002). The World Bank estimated that Tanzania and Chad would need to increase by three to four folds by 2015 in order to be able to render the basic health service in alignment with the MDG (Chen, 2004).

A major limiting factor affecting the scaling up AIDS treatment in Botswana is shortage of health worker. Botswana government desperately had to recruit doctors from other countries such as India and china to cater for the shortfall (Dugger 2003). Similarly, in South African, the implementation of the National AIDS treatment and care strategy was faced with the same impediment after the first year of its commencement (Wilson et. al., 2006). Importantly, prioritising and scaling up AIDS treatment and other interventions without adequate health professionals may result in a serious negative consequence.

The major impact of the brain drain is felt among the user of the health service in the remote rural areas, as these groups of are considered lowest in the distribution order of health professionals preferred working location. Any vacancies in the urban area as a result of migration overseas usually result in re-shuffle by doctors from the rural area. The increase erosion of health professionals creates a downward effect and the poor job satisfaction further facilitates health workers to consider emigration (Martineau et al 2004).

Impact on the economy

The economy impacts of medical brain drain can be subdivided into the cost and benefits. Cost - The cost of migration of doctors from developing countries are evident. First there is loss of human capital creating a negative spill over effect on the other staff that was left behind (Patel 2003). However these effects are not of significant in cases of temporary migration and in countries with surplus of medical professionals such as Philippines and India. United Nation Conference on Trade and Development survey found out that each migration of doctors and other health professionals represent a financial loss of about US$184,000 to Africa while leaving unfilled vacancies behind. Furthermore, it has been estimated that Africa spends US$ 4billion per year on salaries of 100,000 foreign experts which could have been invested in the development of the health system and other important sector of the economy (Pang et. al., 2002)

According to The World Health Report (2006), a total of 18,556 medical doctors trained primarily in 10 sub-Saharan African counties (South African, Zimbabwe, Uganda, Cameroon, Ethiopia, Ghana United Republic of Tanzania Angola Nigeria Mozambique are registered and practising in eight OECD countries (Portugal, Canada, Finland, Australia, France, United Kingdom Germany and United States of America).

The cost of training a medical doctor varies across each country in sub-Saharan Africa; however an average of US$ 65,000 was estimated as the cost of single medical doctor. Estimating the cost of tertiary education to be approximately US$ 48,169 and the cost of primary and secondary education to be US$ 6865 and US$ 10, 963 respectively. South Africa government spends an estimate of US$ 97, 000 to train a medical doctor, thus making an overall loss of approximately US$ 1 billion to investment in medical education which is a third of development aid to South Africa over a period of 1994 - 2000 (Alkire and Chen 2004).

Considering the cost of education and loss return on investment, a total of US$ 517,931 was spent by Kenya per doctor and US$ 338,862 per nurse (Kingra et. al., 2003). An estimate of US$ 60 million is also spent by Ghana on the training of medical personnel (Martineau et al 2002). According to Chen and Bufford (2005), African looses an estimate of US$ 500 million annually for all skilled workers that emigrated from Africa.

Further evaluation of this phenomenon shows a net loss of human capital. According an African proverb, "it takes a village to raise a child", in the same manner training of medical doctors require a considerable amount of resources, money, care and other ancillary support. The gradual erosion of the middle class and upper class of the society leaves a social gap which is neither politically economically or culturally healthy for developing countries. Such exodus of skilled professionals deprives African of a solid middle class, a condition that contribute to erosion of democracy (Physicians for Human Rights, 2004). The flight of medical professionals continually put health system in sub-Saharan Africa countries in a state of unending instability and lop-sidedness.

Benefits - The benefits of migrating from developing or source country usually include, long term professional networks, improved training facilities and also skills acquired may of benefit to the source country upon return (when migration is temporary). Better financial returns in terms of wages, salaries and other emolument and also an increase in financial remittance to home country (World Bank, 2006, Pang et. al., 2002)

In addition, migrants stand to benefit from further education in view of migration opportunity alongside higher wages. However recent studies show that benefits may be limited and subject to immigration policies (Martine, 2009, Schiff, 2005).

Migration can also be a source of avenue to relieve pressures from providing employments and other benefits for some categories of skilled worker. For instance a Ghanaian official was cited pointing out that, if all 1,500 doctors practising in other countries were to return home, the government may only be able to accommodate 200 (World Bank 2002, Martine 2009).

Remittances

Remittances from migrants constitute an important means through which medical brain drain can be of beneficial effects to developing countries. It is evident that remittances from overseas migrants usually make up a considerable contribution to the Gross National Product (GNP) and also a source of revenue to many developing countries (Docquiliers, 2006).

It is also been proven that remittances help to improve the economic activity, as well alleviate poverty. For instance, nearly 50% of Indian medical doctors practising in UK remit an average of 16% of their income their home country (Kangasniemi et. al., 2004).

The financial cost of brain drain to developing countries is partly make up for by remittances that doctors working in high income countries send to their families back their home countries. For instance Ghanaian doctors in Diaspora contribute about US$ 10milllion in remittance. Remittances from doctor are only a fraction of the total remittance that is received from migrants (Physician for Human Rights, 2004).

Nonetheless, due to the fact that most doctors migrate alongside their families they tend to integrate quickly into the society of their host countries and, the amount they remit is likely to reduce over time (Faini, 2003). Other means of remitting money from overseas is when migrants contribute to their home country by way of investments, business partnerships and also through remittance of foreign currencies.

Additional skills and knowledge acquired abroad are transferred to their country of origin whenever they returned home. Also among doctors who migrate permanently, some may temporarily return to contribute their skills or may contribute skills and resources through professional networks in Diaspora to the health system of their home countries (Pang et. al., 2002)

Other benefits accrued to doctors working in developed country include practising in better and much safer working conditions, exposure to use of modern technologies and equipment, opportunities for research and updates with current developments in their profession. Moreover there is a better respect for the civil and political rights of the doctors and their families. Remittances although beneficial to the economy but cannot make up the human capital loss of medical professionals and most often such remittances are sent to family members with none invested in the health care sector especially in the absence of proper functioning health system (Martineau et. al., 2004, Hagopian et. al., 2004, Clarke et. al., 2006).

Impact of health policies

The importance of migration among health professionals to the overall effectiveness of the health system in the developed countries cannot be effectively accessed; this has been attributed to limitations in the available data. However there are two key indicators of relative importance to migration and international recruitment of health professionals to a country: by monitoring the inflow of health professionals into a country from their country of origin or by assessing the actual numbers of health in the country at a particular point in time Both the developed and developing country do not currently have any structure in place to accurately monitor the supply and inflow of migrant health professionals. This has limited the capacity to be able to assess in empirical and in clear term the impacts of policies on medical brain drain (Buchan, 2003).

Although, regarding international migration of doctors, OECD member countries generally prefer long-term policies that enable national self sufficiency to cater for their physician workforce however such policies often entail short to medium term policies to attract doctors from other countries either on a temporary or permanent basis. In order to sustain the adequate supply of doctors in OECD countries, immigration of foreign doctors was considered an important alternative in countries such as Canada, Australia, United States New Zealand and United Kingdom. Conversely, migration of doctors has been perceived in Canada, Sweden and New Zealand to have negatively affected the supply of doctors in their country (OECD, 2002)

Consequently, an international agreement regulating the migration and employments of doctors was formulated among the OECD countries to regulate the migration of doctors from abroad. One of such agreement that provides temporary immigration for doctors in an OECD country is the General Agreement on Trade in Services (GATS) (Forcier et al, 2004). This comprises of set of legally enforceable rules and regulations that governs trade and services. Mode 4 of GATS agreement addresses the movement of people, and in relation to trade in health services, it also focus on migrant health professionals and the provision of health services within the OECD countries on temporary basis. The possible effect of GATS on health care is controversial however in term of migration of health professionals, such agreement may be of benefit to some countries that often send health workers abroad. On the other hand, the challenges with GATS is that there is no clear definition of "temporary movement" and this may likely affect some migrant from source countries restricting the period for which health professionals can obtain a visa (Stilwell et al 2004).

Given the limited success of GATS on doctors' migration, OECD countries subsequently adopted specific policies to encourage the immigration of foreign doctors, while making attempt to minimise the negative effect on the home country. Three types of policies were adopted by the OECD countries to encourage migration of foreign doctors. These include international recruitment campaigns of health workers, easing immigration requirement and setting up special programme that encourage shared learning between different health care systems (Adlung and Carzaniga, 2001).

Requirement for physician migration is reduced in some OECD countries. For instance, the Immigration Act Regulation in Canada favours the migration of doctors and further efforts are been put in place to facilitate the licensure of foreign trained doctors. Similarly, there is relaxation of immigration requirement and conditions for foreign trained doctors in Australia and United States especially to those willing to practise in rural areas. In Ireland, there is existence of mechanism to fast track working visas for foreign doctors (Forcier et al, 2004).

In addition, the Department of Health launched an International Fellowship Programme in January 2002 to attract experienced specialists from abroad to fill in selected posts in the NHS for periods of one to two years (Department of Health, 2002). Although available information do not indicate the actual number of specialist that was recruited but over 400 application were received. Over 100 psychiatrists were recruited from other countries (largely from India) and were appointed as consultant to the NHS (Patel, 2003).

The Department of Health in England released an updated code of practice on International recruitment of health worker, it aimed at dissuading NHS employers from recruiting health workers from developing countries, unless an agreement has been made between the two governments (Department of Health, 2004). However, various alternative recruitment routes still exist and are not restricted by the code of practise. These include applicants coming to the United Kingdom for academic purpose rather than employment, staffs which are actively recruited by non NHS employer and individual health workers taking the lead to apply for jobs in the United Kingdom, and some staff actively being recruited by non-NHS employers (Buchan 2004).

Nonetheless, the Commonwealth countries also adopted Code of Practice for the International Recruitment of Health Workers which is to discourage unethical recruitment of doctors and other health workers from countries which are experiencing shortages. it set out guiding principles for international recruitment of health workers and emphasise mutuality of benefit between the host and home countries. However, few countries among the OECD nations have implemented policies to limit the level of emigration of doctors and there is lack of detail information about the effectiveness of existing policies (Forcier et al, 2004).

CHAPTER THREE

RESEARCH METHOD AND METHODOLOGY

Research design

The most suitable research design was selected to meet the aims and objectives of the study. The purpose of the study was to conduct a series of interviews to identify the factors that influence the decision the migration of medical doctors to developed countries and the impacts of migration on the health care system in developing country. The focus is analysing the causes and impacts of medical brain drain largely based on the view of Nigerian doctors practising in the United Kingdom.

Traditionally, science is uniquely quantitative (Streubert and Carpenter, 1999), however the general idea of research is about positioning the researcher in the experiential world and a more practical level it involves relating research question to available data (Punch, 2000). Basically research design is divided into major categories: quantitative and qualitative research method.

Quantitative research method entails conceptualization of problems in term of experimental comparison, which is based on some intervention or treatment and usually with a clear outcome or variables in mind. It involves the collection and analysis of numerical data and depends on numbers for its conclusion and statistical techniques are often employs for its analysis (Pontin, 2000).

Qualitative research methods are tools used in understanding and describing the world of human experience. The concept and theoretical elaboration of qualitative research emerge was derived out of words in the collection and analysis of data. Qualitative research design has been selected as the most appropriate method for this study. The reason for adopting this method is due to it creditable nature of analysis and it provides systemic for gaining insights into other persons' views of the social world, 'putting oneself into someone else shoes' (Pogar and Thomas, 2008).

"Qualitative" as described by Pogar and Thomas, (2008) refers to the nature of data or evidence collected. Qualitative data entail detailed description based on language or recorded pictures by investigator. "Qualitative research method is a research strategy that often emphasise word rather than quantification in the collection and analysis of data. As a research strategy it is inductive, constructionist, and interpretivist" (Bryman, 2008), whereas quantitative researcher does not always subscribe to all the three features. In addition, It can be described as a method of naturalistic enquiry which is often less obstructive than quantitative investigations and does not manipulate research settings. The research method in qualitative research aims at studying people in their natural social setting and to collect a natural occurring data. Demonstrable advantages of qualitative research over quantitative method have been shown in situations in which there is a little pre-existing knowledge (Bowling, 2002).

Furthermore, Muir Gray (2001) emphasise the usefulness of qualitative research in gaining understanding of health and health services, it also complement and support a quantitative research. The research method is often used in generating hypothesis to solve a problem which be subjected to a test using either a quantitative methods or combination of qualitative and quantitative method (Muir Gray, 2001). Nonetheless, there may be some challenge delineating the nature of qualitative research usually when the link between the theory and research is ambiguous. In qualitative research, theory is usually an outcome of investigation rather than having theory that precedes it (Bryman 2008).

Sample

One of the most important decisions required for any research activities is to determine the type of participants essential for the study. As it is usually impossible to sample a whole population, thus researcher select a sample of research subject that represent the whole research population (Polit and Hungler, 1995). Polgar and Thomas (2008), defined sample as a subset of a population while sampling involves the selection of a sample from a population. Sampling method according to Brink and Wood (1998) is a process of selecting the sample form a population in order to obtain information regarding a phenomenon in a way that represents the population of interest. Essentially, if a sample is representative of the study population, A generalise valid sample result to the population can be obtained without going through the expense of studying the whole population.

Hesse-Biber (2005), argued that the logic of qualitative sampling is concerned with in-depth understanding, working with small sample which is usually a function of the purpose of the study; in light of its sampling frames and of practical constraints. The overall goal of qualitative sampling is to examine the "process" or "meanings" of individual attribute to their given social situation, not necessarily to make generalisations.

Although, sampling in quantitative research may be probabilistic (if representativeness is important) or purposive (if the focus of the research is to study the relationship between two variables) while qualitative research is often a non probability sampling which is generally restricted to the following method - convenience sampling, purposive sampling, snowball sampling and theoretical sampling (Punch, 2000). The aim of all qualitative method is method is to understand complex phenomena and generate hypothesis, rather than apply the findings to a wider population (Bowling, 2002)

Sample size

Samples in qualitative studies are usually small, non random samples; this is due to the use of different consideration in the selection of participants. A critical step in qualitative sampling is the choice of settings with high potential for information richness (Polit and Beck 2000). For instance simple or very detailed studies, single figures may be required; for complex questions large samples and a variety of sampling techniques may be considered. However, in practise, the number of participant required becomes apparent as the study progress Marshall (1996).

Another important point is that in qualitative studies, individuals are not always considered the unit of analysis. Glaser and Strauss (1967) cited in Polit and Beck, (2000) noted that incidents or experiences are often the basis for analysis. A participant with rich information can therefore contribute dozens of incidents and likewise a small number of participants can generate large samples for analyses (Polit and Beck 2000).

A total of numbers of eight medical doctors that are of Nigerian origin practising in the UK were recruited for telephone interviews to determine their views about migration of doctors from developing countries to developed countries. Doctors of Nigerian origin were selected by the researcher because of easy accessibility and also the time constraint to undertake this research. Moreover, selection of this particular group of medical professional is special interest to the researcher due of the trend of medical brain drain in Nigeria.

The inclusion criteria for selecting interviewees were that the participant must be a medical doctor of Nigerian origin, received his/her medical training in Nigeria and practising medicine in the UK. Nigerian doctors who are engaged in other professional activities in UK were excluded from the study.

A purposive sampling method was used in this study because the research is limited to Nigerian doctors practising in UK. According to Bowling (2002), purposive sampling method aims at sampling a group of people or settings, with particular characteristics. Also it consideration often apply to sampling of cases in which research will be conducted and then to people within those cases. This sampling method is essentially strategic and an entails establishing a good correspondence between the research questions and sampling. It is otherwise known as judgement sampling where the respondents are selected because their knowledge and experience is valuable to the research process (Bryman, 2008). The sampling method can be used in detecting cases within an extreme condition as for certain characteristics or cases within a wide range situation in order to maximize variation (Hesse-Biber, 2005).

As stated in Bryman (2008), "most writers on sampling in qualitative research based interviews recommend that purposive sampling is conducted". This form of sampling is essentially strategic and entails an attempt to establish a cordial relationship between the research questions and sampling, In other words, the researcher samples on the basis of wanting to interview who are relevant to the research questions. Purposive sampling provides information-rich cases for in-depth study and analysis (Paton 1990).

However a common disadvantage of this sampling method was that it require an in-depth interviewing, time-consuming data analysis and a rich insight is required in order to understand the social phenomena unlike statistical information (Bowling, 2002).

In addition to purposive sampling, a snowball sampling method was employed to recruit other participants for the interview based on recommendation from the initials participants. This is a technique used where no sample frame exists and cannot be created. It involves the researcher asking an initial group of respondents to recruit others they know are in the target group (Bowling 2002). Snowball sampling in not sample technique that is employ in quantitative research but within qualitative research (Bryman, 2008). The advantage of snowball sampling is that the initial participants recommends and encourage cooperation and facilitate access to other participants, it is more cost effective and practical and in addition it gives the researcher opportunities to specifies the characteristics that is require of the new participants although the limitation of this approach is that sample may be unrepresentative because sample may be restricted to rather small group or network of contacts (Sapsford and Jupp, 1996)

Data Collection

In qualitative studies, data collection is more flexible than in quantitative studies and decisions about what information to collect usually evolve in the field. Qualitative researchers are often prepared for problematic situations that may arise in the process of data collection however the best prearrange plan for data collection sometimes fall through. Essentially, the primary method of collecting qualitative data is majorly through self report, by interviewing other study participants (Polit and Beck, 2008)

Interviewing remains the principal mode of data collection in qualitative research (May 1991). It is a data collection method in which one person (the interviewer) asks question from people (a responder). Interviews are either conducted by telephone or face-to-face (Polit and Hungler, 1991). The most widely used interview formats are either by semi-structured or open interview methods. In the context of quantitative research study, they are used majorly in preparation of a standardized data collection and the development of data collection tools whereas qualitative interviews play a significant role imparting of expert knowledge about the research field in question, the recording and analysis of the informants' subjective perspective, or collection of data relating to their biography. In actual fact, as a means of acquiring information, interviewing is an element so significant to qualitative methodology (May 1991). Research areas in which qualitative interviews are frequently used include studies of gender-related questions, studies of social and political orientations of different population groups, or studies of access to professions and of professional socialization (Ficks et al, 2004).

According to Pontin, (2000), three types data are characteristically generated from interviews, these include: peoples experience and account of events; their attitude, perceptions and opinions about phenomena; and biographic and demographic details. This study aim to reflect the doctors' views of Nigerian doctors in terms of reasons, experience, attitude, perception and opinion on "Medical Brian Drain"

Initial access to Nigerian doctors practising in the UK was through an email to the secretary of Medical Association of Nigerian Specialties and General Practitioners (MANSAG) in the British Isles to seek for volunteers that would be willing to partake in the telephone interviews. Initially, three participants were recruited with the assistance of MANSAG secretary while other participants who participated in the studies were recruited using a snowballing method based recommendation from the initials three participants. These resulted in the selection of eight eligible Nigerian doctors who were willing to participate in the telephone interview. Those fitting the criteria were doctors who trained in Nigeria and are currently practising the medical profession in the UK.

Individual consent was obtained through an email indicating their interest to participate in the telephone interview. This approach was used as an alternative means of obtaining a writing consent however this method was considered following approval by the Swansea University School of Health Science Research Ethics Committee. Interviews were conducted at scheduled time and of the day which were co


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