Brain Games

Harare – The number of doctors leaving Africa to go and work in the United States increased by 38 percent between 2002 and 2011 at a time that the continent has a very abysmal physician-patient ratio.

In 2011, there were no less than 10 000 doctors trained in Africa working in the US, a figure 38 percent higher than it was in 2002.

According to the “Physician Emigration From Sub-Saharan Africa to the United States: Analysis of the 2011 AMA Physician Masterfile” study published recently by respected online journal, PLOS Medicine, a good number of doctors started migrating across the Atlantic following implementation of structural adjustment programmes championed by the World Bank.

The findings of the study, while focusing on medical experts, will raise more questions on the broader policy options open to Africa within the general context of the brain drain debate.

That there were 10 819 physicians who were born or trained in 28 African countries working in the US by 2001 means that the continent – despite its low standards of living ‑ is effectively subsidising education, healthcare and development in the world’s largest economy.

That figure is higher than the total number of doctors working in Ethiopia, Ghana, Liberia, Tanzania, Uganda, Zambia and Zimbabwe combined.

The study authors say, “The large-scale emigration of physicians from Sub-Saharan Africa (SSA) to high-income nations is a serious development concern.

“Migration trends among SSA-trained physicians increased from 2002 to 2011 for all but one principal source country; the exception was South Africa whose physician migration to the US decreased by eight percent.”

They go on to say, “On average, SSA-trained physicians have been in the US for 18 years. They practiced for 6.5 years before US entry, and nearly half emigrated during the implementation years (1984-1999) of the structural adjustment programmes  which resulted in deep cuts to public healthcare services, were implemented in developing countries by international financial institutions as conditions for refinancing.

“Physician emigration from SSA to the US is increasing for most SSA source countries. Unless far-reaching policies are implemented by the US and SSA countries, the current emigration trends will persist, and the US will remain a leading destination for SSA physicians emigrating from the continent of greatest need.”

The study says high-income countries are actively encouraging trained personnel from Africa to come to their shores to improve healthcare delivery there.

The result, according to the editor’s summary of the study, is that many African countries have experienced a decline in the number of physicians serving their populations.

The starkest example is that of Liberia.

“Since 1970, as a result of large-scale emigration and limited medical education, there has been negligible or negative growth in the density of physicians in many countries in Sub-Saharan Africa.

“In Liberia, for example, in 1973, there were 7.76 physicians per 100 000 people but by 2008 there were only 1.37 physicians per 100 000 people; in the US, there are 250 physicians per 100 000 people.”

The study says 77 percent of Liberia’s doctors are in the US.

It is noted that the “emigration of physicians from Sub-Saharan Africa is a growing problem and is likely to continue unless job satisfaction for physicians is improved in their country of origin. Moreover, because the (study) only lists physicians who qualify for a US residency position, more physicians may have moved from Sub-Saharan Africa to the US than reported here and may be working in other jobs incommensurate with their medical degrees”.




Tackling the Problem


The causes of migration are simple: lower salaries for medical personnel in Africa than in the US, poorly-equipped hospitals and training institutions, and less room for professional growth by way of advanced training among others.

Professor Mohamed El-Khawas of the University of the District of Columbia notes, “Some Africans prefer to migrate to former colonial powers because of their familiarity with the language and culture.

“Other factors influencing destination choices are geographical proximity and having support networks in the host country to help with adjustment to the new life and with finding temporary employment. 

“Thus, immigrants from Angola, Cape Verde, and Guinea-Bissau are found in Portugal. Those from Algeria, Morocco, and Tunisia usually settle in France.

“Others choose the United States as a destination not because of its colonial past but because of its strong economy and the availability of employment.” 

El-Khawas goes on to say: “The United States, the largest recipient of new immigrants, tends to attract talented and educated migrants. Africans are said to be the most educated ethnic group in the United States. In fact, there are more African scientists and engineers working in the United States than there are in Africa.”

While many of Africa’s political leaders tend to complain about brain drain and make platitudes about brain grain, very little is done on the ground to address the problem.

Countries like The Philippines have modelled themselves as exporters of physicians; instituting policies that ensure the country actually trains doctors to feed European and American healthcare sectors.

At the turn of the millennium, Malawi implemented an Emergency Human Resources Programme (EHRP) to increase the number of locally-trained professionals. The country also increased salaries by up to 52 percent in specialised fields and opened up more opportunities for domestic advanced training.

One report says, “Between 2004 and 2009, the EHRP increased the number of healthcare workers by 53 percent, raising the (doctor-patient ratio) density from 0.87 to 1.44/1 000 population.

“However, these gains are vulnerable, as donors are now shifting their support elsewhere. India is considering requiring physicians to certify that they will return home before they may receive a visa to train and practice in the US.

“Simply increasing the wages of physicians in LMICs is not effective, as many more factors such as working conditions, housing, and career advancement play a role in their departure. The  nurse and midwife strike in Liberia, motivated in large part by wage demands, exemplifies the challenges of retaining physicians through selective salary increments when these are not matched by corresponding improvements for other health workers.”

The report says Africa cannot – at present or in the near future – match the remuneration levels obtaining in the US, but there are other strategies that can be employed to improve the situation.


These include:

* placing greater emphasis on non-wage retention strategies, including improving working and living conditions;

* diversifying the skills mix to harness the potential of non-physician clinicians and community health workers; the credentials awarded to these cadres are typically recognised only in their own country, making them less vulnerable to international migration;

* circular migration, ie, promoting a triangular flow of talent and skills by encouraging some migrant health workers to return to their home country.

Furthermore, governments in Africa should attach more importance to innovation, giving people room to advance themselves because the continent’s bureaucracies are unable to match American salaries and general working conditions at present.

As such, governments can connect enterprise and universities in research and development and ensure effective protection of intellectual property rights while bolstering the market environment so that talent and skill are rewarded and as such retained.

In the best case scenario, experts from other continents should start migrating to Africa.

Reacting to the “Physician Emigration From Sub-Saharan Africa to the United States” study, Giorgio Cometto of the Global Health Workforce Alliance, also called on high-income countries to invest more in domestic medical training so that they do not have to resort to taking the few doctors that the continent has.

Other experts emphasise that Africa cannot meet its development objectives if it continues to bleed talent like it is right now.

“It will be impossible to achieve an African renaissance without the contributions of the talented Africans residing outside Africa,” says Ravinder Rena of the Eritrea Institute of Technology. 

Joan Dassin of the Ford Foundation concurred saying: “If you do not have qualified people on the ground with strong local roots to carry out development projects, it is not likely they (African countries) will move forward in a sustainable way.”


September 2013
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