BRAIN DRAIN IN THE HEALTH SECTOR IN AFRICA: EXAMPLES FROM THE UNIVERSITY COLLEGE HOSPITAL UCH IBADAN

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BRAIN DRAIN IN THE HEALTH SECTOR IN
AFRICAEXAMPLES FROM THE UNIVERSITY COLLEGE
HOSPITAL (UCH) IBADAN, NIGERIA.
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I. INTRODUCTION

• Africa in Perspective
• Africa is home to nearly 800 million
• inhabits 300 million of the worlds poorest
• ranks very low in health status compared to other
  continents of the world
• more than 10 African countries have doctor
  population ratio of 130,000 or more
• WHO recommends 15000 people

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• University College Hospital, (UCH) Ibadan,
  Nigeria
• the first university teaching hospital in
  Nigeria, established in 1957
• currently one of the 20 teaching hospitals in
  Nigeria (NMA, 2005)
• a centre of excellence in neuro-surgery
• based on the caliber of its doctors and their
  medical practice.
• UCH started losing its doctors early in the 1980s
• initially the loss appeared gradually
  and insignificant
• by mid-1980s, the loss had become massive
• with migrants recruiting colleagues for host
  establishments.
• destinations - Europe, North America and the oil
  rich Middle East

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1.1 Statement of the Problem

• International emigration of physicians to
  developed countries have been blamed on push and
  pull factors including salary differentials, job
  satisfaction, organizational environment\career
  opportunities, governance, protection\risks, and
  social security and benefits.
• In addition to these, they are factors peculiar
  to Nigeria in general and the UCH in particular.

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• Streamlining salaries of all civil servants,
  including the doctors in 1974
• this resulted in frequent face-offs between the
  government and the doctors over salary and
  allowances
• enactment of Decree No. 5 in1978 banning private
  practice for doctors in the public service. This
  decree was subsequently included as
• Section 158 of the code of conduct for public
  officers in the 1979 Constitution
• termination of the superannuability of medical
  clinical supplementation of N3,000 per annum for
  honorary consultants, in 1982, without due
  consultation with the affected staff.
• re-enacted, in 1984, the ban on private practice
  by Decree No. 34
• proscription in 1985 of both the Nigerian Medical
  Association (NMA) and Nigerian Association of
  Resident Doctors (NARD) for strike actions
  against the ban on private practice by doctors

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• forced ejection of doctors from government
  quarters in 1985 for failure to call off strike
  action on governments demand
• non-review of doctors' call-duty allowance of
  N4,800 approved over two decades earlier, for
  work in excess of 40 hours per week
• economic crisis since the 1980s necessitating the
  adoption of the World Bank and IMF
  conditionalities requiring cuts in subsidies to
  the social sector including health.

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• the resultant poor funding exacerbated
• inadequate provision and non-maintenance of
  facilities
• poor salary and allowances
• un-conducive work environment
• adoption of the conditionalities also gave rise
  to massive devaluation of the naira and the
  consequent hype-inflation, resulting in reduced
  purchasing power of the naira and high interest
  rates on mortgage and other loans
• those who borrowed to build were unable to repay
  and those wanting to borrow could not . Medical
  professionals found themselves at the crossroads
  and consequently vote with their feet for greener
  pastures

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1.2 Objectives of the Study

• The paper investigates the impact of the medical
  brain drain on the health systems in Africa with
  examples from the UCH, Ibadan.
• Specifically, the paper examines
• the dimensions of the brain drain
• the measures to stem, restrict or prevent the
  brain drain
• the measures to reverse and turn the brain drain
  into brain gain
• the roles of governments and the universities and
• makes recommendations on the way forward.

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II. DIMENSIONS OF THE BRAIN DRAIN

• Dimensions include
• types,
• magnitude,
• causes, and
• consequences.

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2.1 Types of the Brain Drain

• Internal Brain Drain
• Three Types of Internal brain drain
• movement between public and private health
  sectors within the same economy.
• not considered a loss.
• movement outside the health sector within the
  same economy,
• definite loss to the health sector
• movement from one African health sector to
  another.
• may create problems for country of origin, but
  not a loss to the continent.

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2.1 Types of the Brain Drain

• External Brain Drain
• In this study, external brain drain means loss of
  Africas medical manpower to other continents.
• There are of two types
• Temporary Brain Drain
• migrants return to countries of origin after some
  years of absence.
• typifies medical the brain drain from the UCH to
  the Middle-East.
• a phenomenon attributable to religious and
  cultural differences.
• Permanent Brain Drain
• migrants absence becomes unusually prolonged,
• naturalizes in host country
• characteristic of migrants to Europe and
  North America

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2.2 Magnitude of the Brain Drain

• The magnitude of the brain drain among physicians
  of African origin appears staggering going by the
  statements and statistics below
• There are more Sierra Leonean medical doctors in
  Chicago than in Sierra Leone (Emeagwali, 1999).
• At least 60 percent of the doctors trained in
  Ghana during the 1980s have left the country
  (Mutume, 2003).
• Of the over 600 medical graduates trained between
  1977 and 2000 in Zambia, only 50 were still
  working in the Zambian public sector health
  service in 2000 (Bundred and Levitt, 2000).
• Only 10 percent of the 6,000 physicians trained
  in public hospitals every year remain in Kenya
  (Emeagwali, 2003).
• 120,000 of the over 640,000 African professionals
  in the United States alone, are medical doctors
  (from Nigeria, Ghana, Sudan and Uganda) (Dembele,
  2007).
• More than 25 percent of doctors trained in Africa
  work abroad (WHO, 2006).
• Emeagwali (1999) was quoted as saying that at
  the rate medical doctors are leaving Nigeria,
  there may eventually be more Nigerian doctors
  working outside Nigeria than within.

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2.2 Magnitude of the Brain Drain

• In the UCH, for instance
• Between the early 1980s and 1987, the UCH lost
  almost 40 percent of its consultant physicians
  (Mbanefoh, 1992).
• many departments became shadows of their past and
  utterly unable to carry out their statutory
  functions" (NMA, 1989).
• More fundamental is the ripple effect of their
  leaving. In UCH, for instance, the Department of
  Surgery
• had 23 lecturer/consultants in 1984
• by April 1989, only five were left in that
  Department
• consequently, its student intake fell from 279 in
  1984 to 124 in 1989
• Meanwhile, the hospital bed increased
  considerably by during the period under review
  (Mbanefoh, 1992).
• This same scenario was replicable in most other
  departments of the UCH and in other teaching
  hospitals in Nigeria.

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2.3 CAUSES

• Medical professionals emigrate for variety of
  reasons. Most of these reasons have already been
  outlined under the statement of the problem.
• What needs to be pointed out is the attempt by
  developed scholars to differentiate between the
  cause of internal and external brain drain.
• These studies point to fact that whereas salary
  differential is key to internal brain drain, in
  international brain drain salary differentials is
  just one of the push and pull factors.
• While not objecting to this view, it is
  important to point out that salary differentials
  is key to emigration decision of African
  professionals

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2.4 Consequences of the Brain Drain

• health of the nation
• direct financial costs
• indirect costs

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2.4 Consequences of the Brain Drain

• Health Consequence
• maternal mortality increased from 700 to 800
  deaths in 100,000 live births, and
• infant mortality also rose from 90 to 100 deaths
  in 1000 births between 1999 and 2004 respectively
  (Obiyan, 2007).
• Because the medical brain drain is occurring at
  the same time the continent was grappling with "a
  major health crisis of 'new' epidemics in
  HIV/AIDS and resurgence of 'old' communicable
  diseases such as tuberculosis, malaria, cholera,
  and increasing levels of disorders linked to
  changing lifestyles and degenerative diseases'
  (Sanders et al, 2003), the millennium development
  goals (MDGs) on health by the year 2015 may be
  difficult to achieve.

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2.4 Consequences of the Brain Drain

• Direct financial Costs
• it also has a huge direct financial cost
  implications to countries of origin
• it cost Africa 40,000 to train a medical doctor
  (Madamombe, 2006)
• Zimbabwe and Nigeria losses would exceed tens of
  millions of dollars per year from training
  doctors who rapidly emigrate (Schrecker and
  Labonte, 2004).
• the huge cost involved in recruiting expatriates
  replacements (Dolvo, 2003).
• Africa spends 4bn per annual to recruit 100,000
  expatriates as against 250,000 of its own
  (Emeagwali, 1999).

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2.4 Consequences of the Brain Drain

• Indirect Costs
• the lost opportunity of migrants' contribution to
  the gross domestic product (GDP) and taxes
• costs of illness/morbidity caused or aggravated
  by staff shortages
• costs arising from substituting less qualified
  staff

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IIl. MEASURES TO STEM/REVERSE THE BRAIN DRAIN

• 3.1 Delaying Strategy
• Extending years of training
• use of bonding
• compulsory service schemes (Dolvo, 2003).
• 3.2 Stemming Strategy
• Enhancement of salary and pension entitlements
• adoption of locally-relevant curricula and
  community-based training styles pioneered by two
  medical schools in Ethiopia and the University of
  Development Studies medical school in Northern
  Ghana
• entering into bilateral agreement with developed
  nations prohibiting the recruitment of health
  professionals from developing countries

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IIl. MEASURES TO STEM/REVERSE THE BRAIN DRAIN

• 3.3 Reverse Strategy
• Turning the Brain Drain into Brain Gain would
  include
• adoption of various tax measures ranging from
  one-time exit to bilateral taxes
• adoption of market-driven approach
• the return of medical doctors in the Diaspora.
• 3.4 The Diaspora Option
• does not insist on permanent relocation
• could entail short visits to continent
• to service particular needs and
• to complement the works of their colleagues in
  the continent

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3.4 The Diaspora Option

• The Diaspora programme
• Has been on for decades with modest impact
  described as
• sporadic
• exceptional
• limited in scope.

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3.4 The Diaspora Option

• Collaborative Efforts towards maximization of
  gains
• AfricaRecruit has since 2002 joined hands with
  the New Partnership for Africas Development
  (NEPAD) to achieve maximum benefits from the
  Diaspora programme using various medical and
  other networks with medical professionals as
  members
• the Digital Diaspora Network
• Africa Association of Scientists and Physicians
  of African Descent (ASPAD)
• the Constituency for Africa
• Africare
• the South African Network of Skills Abroad
  (SANSA)
• the Nigerian Association of Physicians in the
  Americas (NAPA).

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IV. ROLES OF GOVERNMENTS AND UNIVERSITIES

• 4.1 Role of Government
• 4.I.1 Funding
• Governments need to fund science and technology
  education and the university teaching hospitals
  adequately.
• Reduction in the current level of military
  spending
• 4.1.2 Special Salary and Allowance Package
• Governments should enhance salary and allowance
  packages for the medical professionals to make
  emigration less attractive.
• Even though researches point to the fact that
  salary is not key to international migration of
  professionals from the developed countries, for
  African professionals, salary is a major factor.

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IV. ROLES OF GOVERNMENTS AND UNIVERSITIES

• 4.1.3. Conflicts Free Continent
• Governments should minimize both internal and
  cross border conflicts.
• most countries in Africa are at war which creates
  a greater demand for doctors and causes their
  emigration.
• 4.1.4 Diaspora as Potential Economic Resource
• Remittances, though a potential economic
  resource, is not a good replacement for doctors.
  In a situation of scarcity, exporting skills
  would
• compromise the training of future doctors
• lead to collapse of the health systems
• undermine the health of the continent
• result in the continent's inability to meet the
  MDGs.

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4.2 Role of Universities

• 4.2.1 Curricula Review
• African universities should embark on medical
  curricula review with emphasis on preventive
  medicine and the adoption of community-based
  approach.
• current training in curative medicine is
• capital intensive,
• emphasizes mostly the diseases of the west
• results in poor African nations supplementing the
  medical education of wealthy west and
• facilitates emigration

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4.2 Role of Universities

• 4.2.2 Brain Sharing
• Brain sharing for purposes of training, research,
  teaching and service delivery is possible
  through
• technical cooperation, linkage and exchange
  programmes among medical institutions in Africa,
• workshops/conferences/seminars, and
• networking between and among the African colleges
  of medicine and teaching hospitals

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4.2 Role of Universities

• 4.2.3 Work and Academic Friendly
  Environment
• the universities must provide friendly working
  environment for their staff
• most African universities lack conducive
  professional and academic environments
• In science and technology education, teachers and
  students are expected to improvise
• theory of practical is gradually replacing
  practical
• ability to improvise requires the ingenuity of
  the very brightest and best
• their availability is constrained by their
  emigration

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4.2 Role of Universities

• 4.2.4 Acceptance of Returnees back to Faculties
• Interview with some medical returnees to Nigeria
  indicate that
• their universities were reluctant to accept them
  back as full-time staff rather some were offered
  adjunct or contract employment
• younger colleagues resist their re-absorption as
  full time staff
• because some of the migrants had resigned their
  appointment or had overstayed beyond the period
  approved, the universities do not accept them as
  bona fide staff
• Their non-acceptance on full time basis would
  mean that
• the universities may not get the best from them
  in terms of their participation in decisions and
  policies of the universities, and,
• the manpower starved universities may mot fully
  tap their wealth of experience and gain maximally
  from their return.

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4.2.5 Review of Salaries of Health Professionals

• There is need for upward review of remuneration
  packages of medical professionals.
• whereas salary may not be key to international
  migration in developed continents, salary is
  certainly a key push and pull factor in
  international migration of African professionals.
  
• A study by Mbanefoh (1992) shows that the UCH
  migrant doctors in the professoral cadre earned
  26 times their salary in the Middle East in the
  1980s and 1990s. The nurses and technologists
  salaries were 16 times higher, respectively.
• with accumulated mortgage debts and impending
  retirement, their options were very few.

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4.2.6 Building of the Database of the Diaspora

• Institutions should build a database of their
  health professionals in the Diaspora to know
  their number and utilize them as links between
  the home institutions and the Diaspora networks
  and overseas institutions.

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V. CONCLUSIONS AND RECOMMENDATIONS ON THE
WAY FORWARD

• 5.1 Conclusions
• In the last almost three decades, African
  continent has experienced loss of health
  professionals to countries of the west and oil
  rich Middle East nations.
• Their emigration are often blamed on the
  gradients of push and pull factors, ranging from
  salary, job satisfaction, organizational
  environment/career opportunity, governance,
  protection/risks, to social security and
  benefits.

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Recommendations on the way forward

• 5.2.1 Government
• In budgetary allocations, governments should give
  highest priority to science and
• technology education and the health sector.
  Military spending should be reduced to a level
  that would curtail the continent's appetite for
  wars.
• Governments should provide necessary
  infrastructure, good communication
• efficient power supply, and state-of-the art
  facilities for promotion and sustenance of
  knowledge networks in research, teaching,
  training, and service delivery are not only
  important but urgent

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Recommendations on the way forward

• Governments should resist the temptation to
  interfere with or frustrate professional
  associations by imposing policies that affect
  members without due consultation.
• Government should provide special salary and
  allowance package for medical staff.
• African governments should endeavour to minimize
  both internal and cross border conflicts.
• Even with all the benefits that the Diaspora
  option portends, it should be seen as short and
  medium term measures. Governments should make
  concerted efforts to facilitate the return of the
  Diaspora through the remediation of the
  conditions that led to their flight.

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Recommendations on the way forward

• 5.2.2 Universities
• universities should always source for state
  of-the-art equipment that would enhance teaching,
  research, training, and service delivery.
• virtual equipment for telemedicine which makes
  collaborative efforts between medical
  professionals in the different African
  institutions possible in handling difficult
  cases, is a case in point.
• the need for radical curricula review is greater
  now than ever
• the review should emphasize preventive and
  diseases of the south as against the current
  emphasis on curative and diseases of the west.
• Building of networks among the African health
  institutions and between the institutions and the
  Diaspora knowledge networks should be stepped up
  to facilitate effective and efficient tapping of
  the Diaspora knowledge, skills and talents.

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Recommendations on the way forward

• 5.2.2 Universities
• Institutions should build a database of health
  professionals as well as the alumni in the
  Diaspora to know their number and utilize them to
  serve as links between the home institutions and
  the Diaspora networks and overseas institutions.
• The various health institutions and science and
  technology institutions in the continent should
  harness and pull together their resources to
  create a synergy that would enable them overcome
  the challenges of scarcity of funds, human and
  material resources.
• the current duplications of centres of excellence
  in health institutions in nations and all over
  the continent is a dissipation of scarce human,
  financial and material resource. Rather only one
  or two institutions with comparative advantage
  over others should be so designated for not more
  than one specialization.

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• Thank You for Listening