Introduction

The World Bank estimates that there are currently 200 million people living in countries where they
were not born (Russel, n.d.). The global mobility of skilled workers has increased in recent years dueto the expansion of the knowledge economy, the progressive globalisation of markets and companies,
the growing demand for scarce skills, and wider political and economic issues. This increase inglobal mobility is a practical reality of the interdependence that affects us all and is not necessarily
a problem except where critical skills needed by source countries are lost and are not readily
replaced – a brain drain (Myburgh, 2002). Graph 1 shows that inevitably this is a phenomenon thatafflicts third world developing countries.
Graph 1: Countries losing talent

Source: General News of Saturday, 29 October (2005)

Graph 2 illustrates that health care professionals are no different from the rest of the skilled workforce.
As the health care labour market becomes more globalised because of common and reciprocal
qualifications, migration flows are likely to increase. Since the global demand for health care

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ATPS SPECIAL PAPER SERIES NO. 32

2

professionals far exceeds supply, developed countries are increasingly relying on migrant healthcare professionals to cope with domestic shortages.
Graph 2: Total migration compared to physicians, nurses and all professionals

1000
Total

100

PhysicianAll prof.

10

Nurses

1
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00

Number (thousands)

Graph 2. Total migration compared to physicians,
nurses and all professionals

Years

Africa is losing its best doctors and nurses in the greatest numbers at a time when it needs themmost. The out migration of African health professionals is a source of growing concern and isperhaps one of the most profound challenges facing health systems throughout the continent (Stilwell,2004). This, coupled with the inequitable distribution of those health personnel who are available,
the burdens of poverty and under- resourcing, infectious diseases and the threats of HIV/AIDS, arecausing public health systems on the continent to break down. The double crises of escalating
disease and personnel shortages have refocused our attention on medical migration.
This human resource crisis requires an urgent, collective, continental approach if we are to
successfully grapple with the challenges facing us. As nations bleed, Africa needs to militate against
this loss by developing networked structures of knowledge and innovation that span borders, sectors
and disciplines. In so doing, its entire people can appropriate and benefit from the enhanced
knowledge pools that may be easier to access, more affordable and more appropriate for the demandsof our continent.
This paper presents a framework for the systematic analysis of the causes and impacts of theemigration of African health care professionals. It also provides points of leverage for different policy
options, with special emphasis on knowledge and innovation networks, in keeping with the theme of
the conference. The outline of the document is guided by the interrelationships of the different
variables, each of which is systematically dissected and analysed.

2.

The Conceptual Framework

The international mobility of health care professionals derives from combinations of push and pull
factors. The consequent emigration of health care professionals results in a reduced number ofhealth care professionals in source countries. This impacts negatively on the ability of nations toprovide health care to its citizens as well as its ability to train new professionals and produce knowledge. All of these have economic consequences.

HEALTH CARE CAPACITY•Quality•Quantity
PULL

ECONOMICIMPACT•Macro•MicroBrain Drain
Stock of HCP

PUSH

KNOWLEDGE GENERATION•Research Capacity•Training

Figure 1: Conceptual framework for the analysis and management of the brain drain of African
health care professionals (HCPS)

3

3.

Emigration of Health Care Professionals - The
Brain Drain

The health professionals’ labour market is a global one with reciprocal qualifications for key healthprofessions internationally. This has facilitated the accelerated brain drain in this sector which has
now clearly become problematic for countries in Africa as out-migration of health professionals to
Europe and North America is denuding the region of scarce skills at a time when Africa can ill afford
to lose them. Developing countries are either unwilling or unable to meet health staffing needs fortheir expanding health services while source countries in Africa are unable to provide the resources
needed to retain their health workers. At the same time, source countries have their own increased
demand for services.

3.1

Volume and direction of flows

In general the migration of health professionals out of Africa appears to be substantial and on theincrease in relation to the stock of health professionals available. Most of the information available ison nurses (who indeed make up the largest professional group in African health systems) anddoctors, who though not numerically a large group, are probably the most expensive and arguably
the most influential cadre. Some studies also suggest that there is a considerable flow and exchangeof human resources between and within African countries.
Figure 2 illustrates the general movement of health personnel from areas of poverty and low social
development to more highly developed areas. The flows follow a hierarchy of wealth resulting in a
global conveyor belt of health personnel moving from the bottom to the top which also results inincreasing inequity.
3.1.1 Doctor FlowsThe losses are difficult to quantify accurately but existing data points to a difficult situation.
q Only 29.4% of graduates of Ghana Medical School were still on the medical and Dental
Council register in 1996 and for a specific 10 year cohort studied (1985-1996), 37.4% of
these were still on the register. The average cumulative annual loss was 50% loss in 4.5
years and 75% loss in 9.5 years (Dovlo, Nyonator, 1999). There are more Ghanian doctors
working outside Ghana than in Ghana.
q Frommel reporting on Zimbabwe (Frommel, 2002 cited in Stilwell et al., 2003) said that840 of 1,200 doctors trained in the 1990s were lost to that country.

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Ethiopia and Zambia have lost about 50% of their physicians (Frommel, 2002) The Zambian
public health system is said to have retained only about 50 of more than 600 doctors trainedsince independence though it is not clear whether the loss is entirely due to migration.
q UNECA estimates that Nigeria lost 21,000 doctors to the USA.
q In Sudan, an estimated 17 % of locally trained physicians and dentists left in the 1980s and1990s (UNECA, 2000 in Huddart et al., Meeus 2002).
q The migration of skilled people, from other African countries, primarily to South Africa,
Botswana and Namibia was sufficiently large to raise concerns about a regional brain
drain. Approximately 80% of South Africa’s rural doctors are from Kenya, Malawi and
Zimbabwe (Govender, 2004). In Namibia an estimated 90% of public sector doctors
outside the capital were foreigners.
q

Figure 2: Pattern of movement and migration of health personnel

3.1.2 Destination countries
The UK and USA appear to be major destinations. The proportion of foreign trained health workers
is particularly high in Anglophone countries, reflecting several years of net accumulation. The graphbelow shows that 23-34 % of physicians in New Zealand, the UK, Canada, the US and Australia areforeign trained.

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ATPS SPECIAL PAPER SERIES NO. 32

Graph 3: Stock of physicians foreign trainedOECD data shows that some 600 South African doctors are registered in New Zealand and 10% of
Canada’s hospital physicians are South African graduates (OECD 2002). Six percent of the total
health workforce in the UK is South African (OECD 2002). (see figure 3)
Of 489 students graduated from the Ghana Medical School between 1986 and 1995, 61% left
Ghana. Of these, 54.9% were said to be in the UK and 35.4% in the USA. Intra Africa migration(mainly to South Africa) was 6.2%. OECD (2002) data show that the highest stocks of foreign medical
graduates are in the English speaking member countries.

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Figure 3: Principal axes of international mobility on health professionals between the old commonwealth countries,
the United States and Cuba (by country of birth)

3.1.3 Nurses’ flows
The migration stream of nurses appears to be accelerating especially in the last decade and although
the percentage of foreign trained nurses may be lower than doctors in the workforce, the absolute
numbers are higher Over the three years from 2000 alone, more than 30,000 new registrants fromoverseas have been admitted to the UK nurses register (Bunchan, Parkin, & Scholski, 2003). Despite
shortages of their own, emigration from a number of African source countries to the UK continues torise as illustrated in Graph 4.

ATPS SPECIAL PAPER SERIES NO. 32

8Graph 4: New registrants on UK nurses from selected sub-Saharan African countries, 1998-2002

Martineau , Decker, Bundred (2002) report that 114 nurses constituting 60% of the 190 registerednurses in a Malawi tertiary hospital left the country between 1999 and 2001 and Meeus (2003)
reports approximately 18,000 Zimbabwean nurses left for the UK during 2000/2001 (Chikanda,
2001). DENOSA, the national nursing union in South Africa predicts that more than 300 specialist
nurses leave the country every month. All these figures are quite striking for the source countries even
if they represent small proportions in the recipient countries such as the UK.
Box 1: Other movements and distribution data - various sources

•
•
•
•
•

Some other movements and distributions data- various sources
South Africa to UK- 2.114 in 00/01 (nurses)
South Africa and Nigeria to USA- accounting for 7.45 of the 26.506 application for RN license between
1997 and 2000 (nurses )Nigeria to UK- rising trends of new registrants c. 180 in 98/99 to 430 in 01/02
Zimbabwe to UK- rising trend of new migration c. 50 in 98/99 to 460 in 01/02
Ghana, Zambia, Malawi, Kenya rising trend of new migration 98/99 and 01/02(nurses)

ource: Dovlo, 2004

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3.1.4 Destination countries
Some information exists on destination countries for nurses. Buchan et al. (2003) show that nurses
from Ghana are mainly recruited to the UK and to a lesser extent to the USA. Most South African
nurses also appear to go to the UK. However, between 1997 and 2000, South African and Nigeriannurses accounted for 7.4% of the 26,506 applicants for RN licensure in the USA. Nigerian nurses
registering in the UK also increased from 180 in 1998/99 to 430 in 2001/02; those from Zimbabwe
from 50 in 1998/99 to 460 in 2000/01 (Chikanda, 2001). Many other sub-Saharan African countries
show similar trends including some countries with relatively small stocks of nurses.
In the absence of specific data on migration of nurses, requests for “verification” are an indicator ofat least an intention to move that also shows the recipient countries for which requests were made.
Buchan and Dovlo (2004) show how Ghanaian verifications between 1998 and 2003 showedsignificant increases in requests to the UK as illustrated in Table 1.
Table 1: Ghana nurses verification: country verified for and year

Nurse migration is thought to be less permanent than doctor migration. The UK register of 1995
reports that more than half of foreign nurses did not stay longer than three years and 85% of departures
occur within four years of entry to the UK (Buchan; O’May, 1999)
3.1.5 Pharmacist flows
Recent Pharmacy Council of Ghana data (2000) showed that the number of Ghanaian
pharmacists seeking clearance (Certificates of Good Standing) to work overseas (mostly in UK) was
relatively small compared with nurses. However, the impact on pharmacy services is expected to bequite significant, given the small number of public sector pharmacists (only 162) in Ghana HealthService in 2002 (Dovlo, 2004). The recent steep rise in numbers (as seen with nurses) is a major
concern (Graph 5). Very little data were found on pharmacists from other countries in the subSaharan Africa region.

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ATPS SPECIAL PAPER SERIES NO. 32

Graph 5: Requests: confirmation of registration of Ghanaian pharmacists (1997-2000)

3.1.6 Flows of other health care professionals
Most of the data concentrates on nurses and doctors though it is recognized that all healthprofessionals with exportable qualifications were likely to migrate. In a recent study (Martineau et al.,2002) the majority of a cohort of physiotherapists graduating from the University of Pretoria wereleaving South Africa to the UK without even practising. Active foreign recruitment of health professionals
such as x-ray technicians and radiographers has been reported in Ghana, Kenya, South Africa,
Uganda, and Zambia using local papers, professional journals, and job fairs (Martineau et al.,2002). However, data on these healthcare professionals were much less available.
Health personnel from South Africa appear to make up the bulk of the total number moving andmigrating out of Africa, although smaller numbers lost from other African countries may represent alarger share of the overall personnel numbers from those countries. Because of the lower production
volumes of doctors in the smaller African countries, the loss of even a small number of doctors canhave a disproportionately large impact. The burdens of health personnel losses across the region
thus need to be mapped in relation to the capacity to produce and replace personnel.
The causes of medical migration are complex and are propelled by factors often termed ‘Push’ and‘Pull’ factors. Differences in the level of their influence in source and recipient countries create a
gradient that influences the decision to emigrate. Some of these are discussed below.

4.

Reasons for Migration

Pull factors result from influences arising from recipient countries which attract and facilitate themovement of health workers to that country. Push factors refers to influences that originate in thesource country that create an impetus to leave. Pull and push factors interact with each other andsome of these factors will be the converse of the other (for example, low pay in source country ascompared to higher pay in recipient countries). These factors can be either exogenous (outside thehealth system) or endogenous (directly related to the health system), (Briggs, 2000).

4.1 Pull factors
4.1.2 Endogenous pull factors
Remuneration
For individuals, the financial advantages of working in a country that pays considerably higher salaries
is a major pull factor and a number of studies reviewed cite the importance of pay. South African
nurses in the United Kingdom for example can earn (South African Rands) R256,000-448,000 ayear, and in Saudi Arabia, earn a tax-free salary of R228,000-360,000 per annum in contrast to an
experienced nurse working in an intensive care unit or theatre in South Africa who can only earn
between R84,000 and R96,000 per annum.
The two most often reported factors for working in the UK for nurses were professional development
and pay (Buchan, 2003). To the individual nurses (or any other professional for that matter) personal
financial gain outweighs larger national perspectives.
A recent WHO-AFRO study on migration indicated that reasons given by health workers wanting toleave Cameroon, for example, were better salaries (67.8%), better quality and opportunity for educationand training (66.6%), conducive working environment (64.2%), better management of healthcare(54.9%) and a peaceful social environment (48.4%).
Career development opportunities
In some studies career development is highlighted as an important pull factor (Sanders, 2003;
Dovlo, 2003) and gaining international fellowships for study abroad often becomes the first step inmigrating. There are many instances of fellowship recipients not returning to their home countries.
Only 30% of persons awarded WHO fellowships in Lesotho returned (Stephen, 2003). Whilst thisopportunity for international specialist training appears to be a pull factor for doctors, nurses may not

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ATPS SPECIAL PAPER SERIES NO. 32

necessarily seek additional qualifications and career development. For example, whilst UK employersof Filipino and South African nurses highlighted career development as an important secondary pull
factor, there was little sign of nurses making a temporary move to improve their skills for use backhome( Dovlo, 2003).
Meeus (2002) indicates that career development is used by several OECD countries as the attraction
for highly qualified persons whose training gives them familiarity with rules and conditions of therespective recipient countries. This goes beyond just the fact that foreign tuition fees received isgood for training institutions, and the acknowledgement that many such students do not return home(OECD, 2002). The scholarships tenable in industrialized countries for health professionals create
similar results.
Language traditions encourage and facilitate incoming migrants, given that training in many
developing countries takes place in the former colonial languages, and there exist migrant professional
communities from the source country,. In addition, perceptions of better technology and hence
professional satisfaction enhance the other pull factors (Commonwealth, 2001).
Demand driven recruitment
Demand is caused by under-production as well as the demographics of aging, advances in labour
intensive health technology, shifts towards nuclear family structures and changes in consumer
demand. This results in active recruitment and the facilitation and support of the emigration process.
q The US has 100,000 vacant nursing posts. By 2010 one million more nurses will be needed
to meet the needs of an ageing populationq Canada predicts a shortfall of 78,000 nurses by 2011, and Australia 40,000 by 2010
Employers have used international recruitment agencies which either help employers to recruit from
specific countries, or initiate the recruitment process themselves with “batch” recruitment.
The Department of Health in England has enacted a “Code of conduct on international
recruitment” which states that NHS employers should not “actively recruit nurses from developing
countries”. However, passive arrangements will mean that the code may not be entirely helpful inmoderating losses from developing countries.
Graph 6 illustrates the consistency in the perceptions of the different endogenous pull factors byhealth care professionals from different African countries.
Exogenous pull factors
Many of the countries that are able to offer a higher quality of life, freedom from political persecution,
freedom of speech and educational opportunities for children will naturally be attractive to healthpersonnel from many other countries. In addition, there is a greater likelihood of people emigrating
to countries where fellow citizens relatives and friends are already based (OECD, 2002).

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Graph 6: Factors affecting the motivation of health workers in five African countries

Better management ofhealth services

Continuing education,
training

Zimbabwe
UgandaSo uth africa
Ghana

Conducive w orking
environment

Cameroun

Better/realistic
remuneration
0

10

20

30

40

50

60

70

80

90

Percentage

Source: Awases M, Gbary A, Nyoni J. and Chatora R, Migration of health professionals in six countries: Report,
Brazzaville, WHO Regional Office For Africa, 2002

4.2 Push Factors
4.2.1 Endogenous push factors
Pay and benefits
Pay and other benefits for health workers are low in many sub-Saharan African countries. Studies by
Dovlo (1999) and Vijicic, Zurn, Diallo, Adam and Dal Poz (2002) for selected African source countries
illustrate some of the salary levels found in African countries which were generally very low compared
to remuneration in developed recipient countries (see Tables 2 and 3).
Table 2: Average monthly salaries of health professional in different African countries
Cadre
Junior Doctor(<5 years
Senior Doctor>10 years
Junior nurse<10 years
Senior nurse>10 years

Ghana

Lesotho RSA

Namibia

Malawi

ZambiaS.Leone$199.35

$1058

$1242

$1161

$1199

$200

$50

$272

$1430

$1818

$1445

$2670

$92.80$503pm

$661

$916

$761

$148.43

$865

$1030

$916

$1326

Source Dovlo 1999.

$200
$100

$40
$150

ATPS SPECIAL PAPER SERIES NO. 32

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These estimates (though based on actual salaries) are basic pay estimates and exclude otherbenefits and privileges. Changes in remuneration levels may have occurred since 1999 but thedifferentials between these pay levels and those of industrialized countries remain very significant.
The study by Vujicic et al. (2004) showed that nurse wages in recipient countries such as Australia
and Canada were 25 times the wage in Zambia, 14 times that in Ghana and twice that of South
Africa. The situation is similar with physicians.
Table 3: Monthly wages of nurses from source country and host countries in US dollars,purchase parity pay estimates (most recent data from each country)
Source country
South Africa
Trinidad & Tobango
Cote d’lvoire
Malawi
Sri Lanka
Philippines
Ghana
ZambiaUgandaMonthly wage
$1.486
$913
$530
$489
$407
$380
$206
$106
$38

Destination countries
United States
Australia
CanadaUnited Kingdom
FranceMonthly wages$3.056$2.832$2.812$2.576$2.133

Source: Vujicic et al ., 2004

However, the much lower differentials for South African nurses, for example, appear from other data
not to have mitigated the level of migration.
Pensions in many African countries reflect the low salaries earned during one’s working life and thus
retirement can be a difficult period. The relatively good social support systems in Namibia havebeen cited as reasons for better comparative retention of professionals compared with Lesotho(despite similar salaries) because the former provide more generous end of service payments,
subsidized housing and car ownership schemes (Dovlo, 1999).
Work associated risks
The ILO suggests that health work is one of the most dangerous jobs with many risks ranging fromviolence and sexual harassment, sickness, even death and infections, especially with the HIV.
Statistically, health care professions have to be classified among the most dangerous professions.
As economic and then working conditions in African countries deteriorate, health workers are awareof the increased hazards in their workplaces and a perceived lack of occupational protection may
well influence decisions to migrate.

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Lack of job satisfaction
Health workers may also become dissatisfied and therefore more open to migration for a variety of
non-financial reasons such as feeling demotivated by poor healthcare infrastructure and bad healthmanagement. Working environment problems are worsened by bureaucracy that seems to overwhelm
civil/public services in Africa. New recruitment of scarce professionals can take up to 30 months
from application to receiving first pay. Centralized public sector personnel management withrecruitment approval that involves several government departments contributes to this situation. For
example in 1998, the Ministry of Health and Social Welfare in Lesotho was unable to employ its
output of trainee nurses in 1998 despite having vacancies, because of the very lengthy process(Stephen & Kinoti, 2003).
Workload
The AIDS epidemic and its resultant workload increase may also contribute to the push. At a recent
meeting of Commonwealth African Countries on human resources (Commonwealth Secretariat,
2003) it was reported that fear of contracting HIV/AIDS and burnout from workload may be contributing
to losses from the health workforce from Botswana and Malawi. Similarly, nurses were also avoiding
or refusing postings to labour wards perceived as high-risk areas.
Workload increases in the African public sector are partly due to shortages of health professionals
from migration but also, particularly in southern Africa, to the increases in patient load created by the
AIDS pandemic. Workloads for Zimbabwean nurses, midwives and pharmacists were said to haveworsened significantly between 1995 and 2000.
Others countries (for example, Uganda) suggested in recent meetings that structural adjustment
policies and insistence by lending institutions on retrenchment of public service workers had led toserious workload and motivation problems (Lynos, n.d.).
4.2.2 Exogenous push factors
Social, political and economic factors
Social and political unrest have hampered some sub-Saharan Africa countries such as Sierra Leone,
Liberia, Congo (Kinshasa), Angola, Rwanda, Burundi, Cote d’Ivoire and Zimbabwe. Large numbersof ordinary citizens and professionals have become refugees. In South Africa, crime is thought to be
responsible for high white middle class migration (including many doctors). An estimated 96% ofemigrants from South Africa were said to have cited criminal violence as a reason for leaving thecountry (Economist, 1999).
Lack of educational opportunities for children
One of the reasons why many professionals migrate is not because of reasons that are relevant tothem, but because of aspirations they may have for their children.

5.

Why Doctors Stay

Despite the strong push and pulls factors experienced, some health workers give reasons for notleaving their countries, which are in line with stick factors suggested by Padarath et al. (2003). These
include high levels of morale, the presence of rewards and incentives, and placing a high value onfamily, social, cultural and patriotic values. The costs of migration (re-qualification, relocation,
language, time) may also be a barrier in some cases.
Once people have moved or migrated to work abroad, they may choose not to return because of avariety of “stay” factors (Padarath et al., 2003). These include the development of new social andcultural bonds, the risk of disruption to the education of children, reluctance to disrupt new lifestyles
and inadequate knowledge of job opportunities at home.
The conceptual framework in Figure 4, proposed by Padarath et al. (2003), illustrates the forces that
influence where health care professionals work. It provides us with an approach to understanding
the determinant of health personnel distribution and flows.

Figure 4: Factors influencing the availability and movement of health personnel

Figure 4: Factors influencing the availability and movement of health personnel

16

6.

The Stock of Healthcare Professionals

By far the most significant component of any health care system is its health personnel. Without afoundation of skilled human resources, health care systems cannot function adequately or effectively.
In the year 2000, the world had about 8.5 million doctors and 15.2 million nurses giving an averageworld density of 1.4 doctors and 2.6 nurses per 1,000 people.
Countries in the African region report major shortfalls of health professionals (especially in the public
sector), as opposed to those in Europe and North America. Africa averages only 1.4 of these skilledworkers per 1,000 in comparison to Europe’s density of 10.3, a seven fold increase (WHO, 2004).
Graph 7: Worker density by region

Source: (WHO, 2004)

A recent estimate suggests that sub-Saharan Africa is approximately 700,000 doctors and 700 000
nurses short of the staffing requirements necessary to meet the Millenium Development Goals

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ATPS SPECIAL PAPER SERIES NO. 32

18(Kurowsky, Wyss et al., 2004), and according to the WHO, 31 countries in Africa do not meet the“Health for All” standard of a minimum of one doctor per 5,000 people. The situation is continuously
deteriorating and sub-Sahara Africa is the only world region to show declines or stagnation in theratio of doctors to population between 1970 and 1997 (JLI, 2003; Sanders et al., 2003). In the late
1990s the doctor population ratio in Malawi, Mozambique and Tanzania was 1:30,000 or more andin Angola, Lesotho, Zambia and the DRC this ratio stood at 1:20,000. Hence, within Africa itself there
is considerable variation in health personnel availability.
Table 4: Doctor-population ratios for different African countries.
Country
AngolaBurkina Faso
Cntr. Africa Rep.
Chad
Ethiopia
Ghana
Kenya
Lesotho
MalawiMozambique
Niger
RwandaUganda1970
23 725
97 12044 74061 90086 120
12 9108 000
30 40079 58018 86060 09059 600NA

Number of People per Doctor
1990
1995-7NA
20 000 (1997)
57 32029 412 (1995)
25 93028 571 (1995)
30 03030 303 (1994)
32 65033 333 (1995)
22 97016 129 (1996)
10 130
7 092 (1995)
24 09514 285 (1995)
45 740NA
36 22528 571 (1997)
34 85028 571 (1997)
72 990NA
22 39920 000 (1996)

Source: WHO 2004)

These country-level indicators conceal the considerable inequities in health personnel within Africancountries. The main disparities of the internal distribution of staff occur between the public andprivate sectors, between urban and rural areas or between tertiary and primary levels of the healthsystem. This means that for a large number of people, the availability of health personnel is evenworse than the figures shown in Table 4.
Of all the countries in sub-Saharan Africa, South Africa has for long had the highest proportion ofprivate for-profit providers. Nigeria and Kenya also have substantial private sector services. In Kenya,
only 600 of its 5,000 registered doctors working in the public sector and only 12% of Nigeria’s 30,000
doctors are estimated to be working in the public sector (WHO, 2004).
Cameroon experienced a 75% increase in doctors working in the private sector between 1991 and2000 and similar increases were noted for nurses. In Zimbabwe the percentage of doctors working
in the public sector fluctuated between 40% and 47% between 1995 and 1998. The number ofA FRAMEWORK FOR THE STRATEGIC ANALYSIS AND MANAGEMENT OF THE BRAIN DRAIN

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pharmacists in Senegal’s public sector shrunk from 14% in 1993 (35 of 245) to only 5% in 1996
(WHO, 2004).
Attempts to assess the stock of health professionals from local health council data are also
complicated by a paucity of statistics as well as two additional factors. First, many who leave maintainlocal registration with councils and second, some who register no longer practice or practice on apart-time basis. The statistics quoted above therefore need to be interpreted in the light of these
possible discrepancies.

7.

The Impact of Migration on Source Countries

The impact of migration in source countries can be seen from various perspectives including theability of source country to deliver health services effectively, effects on training and innovation capacityof source countries, and impacts on the national economy at both macro and micro levels.

7.1

Impact on health service delivery

Every state has an obligation to create conditions that would assure its citizens of medical services
and attention in the event of sickness, and to prevent, treat and control diseases. Without adequate
numbers of trained health personnel, both the quality and quantity of health services that a healthsystem can deliver are reduced, limiting the number of people who receive care, and diminishingthe quality of care for those who are able to receive it. Recent studies reveal a significant negative
correlation between health worker density and mortality rates (Anand and Baenighausen, 2003), anda positive correlation between quality of care and healthcare outcomes, and the availability of healthpersonnel (Mercer, Da Poz, 2002).
Graph 8: Density of health workers by region

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Health systems in Africa face a variety of health personnel problems which include overall lack ofpersonnel in key areas of the health sector, an inequitable distribution of those who are available,
and a significant attrition of trained personnel from the health sector. The availability of health personnel in Africa is considerably worse than in other regions of the world as revealed in Graph 8, andis one of the stumbling blocks to the delivery of adequate healthcare (WHO, 2004).
Staff shortages in health facilities limit the number of people able to receive care, and diminish thequality of care for those able to receive it. Waiting times are often long and some facilities, especiallyrural ones close because they have no one to run them. Often, facilities are staffed with unqualified
personnel and even patients seen by qualified personnel are put at risk due to time constraints andprovider fatigue.
Health personnel shortages can also prevent a country from scaling up interventions to achievecertain health goals (Aids targets, Millenium Development Goals) and are limiting countries’ abilities
to meet tuberculosis targets (WHO, 2003) and immunization coverage targets (Brown, 2003). The
shortages are also directly related to high infant and child mortality (Chen & Boufford, 2004).
These are indirect measures of migration, because shortages, especially in public institutions may
also be caused by losses to the private sector. However, the effect of migration is not only in terms ofnumbers as the loss of a few highly specialised cadres that are scarce can lead to complete
collapse of a particular service in a country.
Moreover, migration of certain types of health personnel can have very significant ‘knock-on’ effects
which are often not captured as part of the costs and effects. These may include the overall malfunctioning of the health services and hence increases in morbidity and mortality. The loss ofinstitutional memory also results in a duplication of work and wastage of resources as a result of
reinventing disease management strategies and an inability to refine strategies based on experience.

7.2

Knowledge generation

The impact of the brain drain on associated areas of the health labour market such as academic,
research and medical school staff is also important. Whilst their relative numbers per se may besmall, the impact of their loss is much more widely felt. The brain drain of academic and experienced
personnel weakens the offer of research and health services by impacting on the future supply of
doctors not only in numbers but also on quality of trainees as well as the supervision and support ofremaining practitioners.
According to the most recent available data on the academic workforce in RSA (CSIR, 2005), there
is a sluggish growth amongst permanent academics, an increase in the proportion of academics
aged 55 and above, and a decline in the percentage of academics with doctorates at universities.

ATPS SPECIAL PAPER SERIES NO. 32

22

Concomitantly, student numbers continue to rise astronomically resulting in marked increases (33%)
in lecturer: student ratios (see tables 5 and 6).
Table 5: Permanent academic professionals at universities and technikons in 2000 and 2003
Permanent Research/ Instruction
Professionals
Universities
Technikons
Total
Student numbers
Universities
Technikons
Total

2000

2003

Change11 220
3 722
14 942
2000
387 361
202 792590 093

11 2633 713
14 976
2003
487 741230 052717 793+43-9+34
Change+100 380+ 27 260+127 700

2003
Total
%
4 1342
37.3
258
6.9
4 392
29.3

Change
Total
%
-335
-3.6
+56
+1.5
-279
-2.1

Source: CSIR report 2005

Table 6: Number and proportion of academics with PhD’s

Universities
Technikons
Total

2000
Total
%
4 469
40.91
202
5.4
4 671
31.2

Source: CSIR report 2005

Similarly, in Ghana the average age of Ghana Medical School lecturers was said to have risen from36 to 55 (Martineau et al., 2002). This is seen as a reflection of reduced intake of younger staff,
possibly due to emigration.
Data on the research and development (R & D) workforce in South Africa also show a significant
decline in both higher educational institutions as well as in government employ. The total number of
medical researchers in the South African public sector declined from 189 in 2002 to 136 in 2003. Of
these, 116 were based in the most urban provinces (HST, 2004).
Placed in an international context, South Africa also has less than one researcher for every thousand
members of the workforce compared with five in Australia and ten in Japan (CSIR, 2005). Given that“technology and innovation walk on two legs” these demographics represent a critical state ofaffairs. Although these data do not offer a historical or sociological basis for the explanation of thestate of the academic workforce, they suggest that the main challenge relates to promoting theretention of academics.

23

A FRAMEWORK FOR THE STRATEGIC ANALYSIS AND MANAGEMENT OF THE BRAIN DRAIN

Table 7: R&D workforce (1991 – 2001/2) full time equivalents
SectorHigher Education

Government (incl. Science Councils)

All Sectors

Categories
Researchers
Technicians
Support staff
Total
Researchers
Technicians
Support staff
Total
Grand Total

1991
5 984
289
260
6 533
3 629
2 384
3 437
9 450
15 983

2001/2
3424
217
231
4042
2134
1344
1842
5171
9 213

Source: (1991) SA science and technology indicators and R&D Survey 2001/2

Long-term analysis of South African scientific output shows that overall, total outputs as well as thosein ISI publications have been stagnating for the past 10-15 years (see Graph 9). However, in world
output, this has meant a decline in proportion of world share from 0.7% in 1987 to 0.49% in 2000.
Cumulatively Africa’s share of global scientific output has fallen from 0.5% in the mid 1980’s to
0.0.3% in the mid 1990s.
Graph 9: Trends in scientific output in South Africa

9000
8000
7000
6000
5000
4000
3000
2000
1000
0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

SA Kn o w le d ge b as e

SAPSE

ISI jo urna ls o nly