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Health Policy and Development Journal, Vol. 6, No. 3, December, 2008, pp. 153-163 THEME TWO: HUMAN RESOURCES FOR HEALTH Globalization, migration and brain drain: a reality check Maurizio Murru Visiting Senior Lecturer, Uganda Martyrs University. E-mail: maurimurru@gmail.com Code Number: hp08018 Abstract Migration is an old phenomenon in human history. It takes place for various reasons, which have been roughly grouped into "push" and "pull" factors. Migrants have always faced harsh conditions either in transit or on arrival, from the environment and the citizens of their destinations. Of recent, migration has increased due to globalization, which has increased the access of people in sending countries to "pull" factors through the media. However, more recently, stiff regulations have been put in place by the receiving countries to curb immigration, partly as part of the global "war on terror", but partly as a political measure to contain intolerance of foreigners in their societies. In a special way, international migration of skilled labour has come under increased scrutiny over the recent years. It has been argued that for the sending/losing countries, it leads to a brain drain and depletes national resources spent on training. It also denies the remaining population the opportunity to benefit from their highly skilled compatriots usually educated at the public's cost. Proponents argue that it is the right of individuals to look for the working conditions acceptable to them, in order to earn acceptable income for themselves and their families. They argue that, moreover, migrant workers send back remittances to their relatives. In fact, in some countries like Uganda, remittances are the leading source of foreign exchange. Such countries have therefore started policies to export skilled labour or to support the return of remittance with a view tap into the wide base of remittances for public use. This paper discusses the pros and cons of migration and concludes that international migration is inevitable but should be managed in a way that is beneficial for both the sending and receiving countries. It ends on a prophetic note that current intolerance to foreigners will end spontaneously in the course of a generation. Introduction Migration is as old as humanity. During the last decades it increased in intensity, importance and complexity. It takes places due to various reasons such as the quest for better living and working conditions (the so-called "pull" factors), the escape from violence, persecution and adverse conditions e.g. environmental catastrophes (the so-called "push" factors), and the smuggling and trafficking of human beings. The arrival in any country of an increasing number of foreigners intending to settle there causes mixed and contrasting reactions, often emotional and hostile. The encounter of different cultures, when mediated by a high and increasing number of people, raises problems whose management is difficult and, often, postponed. Irresistible and interconnected forces (demographic, political, economical etc) blow the waves of migration. They will keep doing so in spite of the cultural, psychological, political, legal, administrative and organizational problems encountered in the receiving countries. Various aspects of globalization contribute to increase migration. Travelling is easier than in the past. Television images, reaching even far away villages of poor countries, increase awareness about the enormous differences in life conditions around the globe. They feed dreams of a better life. The mesmerizing environment of the rich world is often perceived as a sort of paradise on earth that everybody can enjoy by simply being there. The relatively easy worldwide connections, by phone and e-mail, allow the formation of networks facilitating international movements of human beings. More often than not, their motives are suspicious. Nonetheless they are effective. Income differences The enormous differences in income existing between rich and poor countries are a powerful incentive to migration. According to UNDP (United Nations Development Programme), in 1975, the GDP (Gross Domestic Product) of high income countries was 41 times higher than the one of low income countries and eight times higher than the one of middle income countries. Today the GDP of high income countries is 66 times higher than the one of low income countries and 14 times the one of middle income countries (UNDP, 2005). Such disparities which have dramatically increased in the last 30 years, keep growing and will keep being a strong incentive to international migration. Demographic trends The different demographic trends in rich and poor countries, also, contribute to migration. In rich countries the population is ageing, fertility rates are low and, often, decreasing. In poor countries the population is young and fertility rates are high. The average fertility rate in Sub Saharan Africa is 5.4, in Arab countries 3.8, in Latin America and in the Caribbean countries 2.5 and in Europe 1.4 (GCIM, 2005). In rich countries, 18% of the population is below 15 years of age compared to 31% in poor countries (World Bank, 2006). Moreover, by 2025, rich countries will loose about 20 million workers. Within the same period, in poor countries, the new comers into the labour market will be about one billion. Without immigration it will be impossible for rich countries, to maintain their level of life, their economic growth, their pension systems, the quantity and the quality of their services (World Bank, 2006). Given the slow pace of economic development in the poor countries, their economies will not be able to provide employment for the newcomers. Therefore, they must move to somewhere. The economy alone will therefore be an inevitable "push" and an inevitable "pull" for international migration. Democracy, good governance, respect for human rights The 1951 Convention on Refugees defines as "Refugee" any person who " … owing to well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country; or who, not having a nationality and being outside the country of his former habitual residence […], is unable or, owing to such fear, is unwilling to return to it" (United nations, 1951). For several years now, the process of obtaining the status of "refugee" (if successful) - starting from seeking asylum - has become longer and more complicated. Attempts are made to distinguish the so called "economic refugees" (those who leave their countries to escape poverty), from the "genuine refugees" (who, at least in theory, are protected by the 1951 Geneva Convention). However, this is a daunting task since, as a matter of fact, many of the poorest countries are also characterized by political instability and are ruled by despotic regimes of dubious legitimacy. Often, they have uncertain rule of law, corrupt and inefficient administration and frequent violations of human rights. Such regimes constrain their citizens in conditions that the World Bank defines as "inequality traps" (World Bank, 2005). It is not surprising that an increasing number of individuals in those countries wish and try to escape from such "traps". Intolerance is universal Often, and with good reasons, attention is drawn to the intolerance and to the harsh treatment encountered in rich countries by many migrants, regular and irregular. However, it is worth mentioning that migrants are often faced by intolerance and harsh treatment even in poor countries. It may be at national level or even within population sub-groups in the same country. In 1983 the Nigerian government expelled, overnight, between 20,000 and 30,000 nationals of neighbouring countries (especially Ghana). The majority of them had lived and worked in Nigeria for decades. Many of them were forced to abandon their homes and were robbed on their way to the border and at the border. In 2006 Tanzania (in the past often praised for her openness to foreigners), closed her borders and sent back thousands of Burundians trying to escape the violence and instability in their country. The Tanzanian Government called them "economic migrants", a term often criticized in poor countries whenever used by governments of rich countries. For several years, now, Ivory Coast expels and / or violates the rights of many longstanding immigrants. They were lured into the country as cheap labour when the world market paid a high price for cocoa (of which Ivory Coast was the world's major producer up to 1990). They became a burden (or were perceived as such) when world prices plummeted. In 2006 the Niger government announced the expulsion of thousands of families of Arab descent who settled in some northern areas of the county several decades ago. The list could continue, but the point is clear: human beings can display intolerance and cruelty everywhere and the life of migrants can be tough everywhere. The numbers Because of its complexity, it is virtually impossible to quantify migration, in its various aspects, with a satisfactory degree of accuracy. Migration statistics are still approximations even if efforts are being made to improve them. According to available data, migrants were about 82 million in 1970, 175 million in 2000 and 200 million in 2005 (GCIM, 2005). This figure includes about 8.4 million refugees. About 49% of all migrants are women. The majority of migrants are concentrated in relatively few countries. The United States, alone, hosts about 35 million. About 70% of the increase in migrants in the last 20 years took place in only two countries: Germany and the USA (World Bank, 2006). The US is the favourite destination of most migrants and their laws favouring family reunion strongly contributed to the mentioned increase. The increased number of migrants in Germany is essentially made up of people coming from Eastern European Countries after the collapse of the Soviet Union. Table 1 shows the number of migrants per continent and the percentage that they make of the total population. In the USA, having the highest number, immigrants form 12.4% of the total population. In the other countries this percentage ranges from 73.8% in the United Arab Emirates to 0.6% in India. In poor countries like Burkina Faso and Ivory Coast, migrants are 9.7% and 14.6% of the total population respectively. In 1970, countries where migrants reached 10% were 48; in 2000 they were 70 (GCIM, 2005). The number of immigrants would be higher if receiving countries had more liberal policies. In the majority of receiving countries, rich and poor, public opinion is, on the whole, hostile to immigrants. According to recent polls, in the USA migration is seen as a threat second only to terrorism (and often connected to it); in the OECD countries more than 90% of the population is hostile to migrants (Pritchett, 2006). France, the UK and other countries have introduced restrictions to the immigration of non-specialized workers. On the contrary, there is a widespread tendency to ease the immigration rules for some categories of highly educated, specialized workers such as engineers, doctors and nurses. People also migrate from rich countries Although the majority of migrants move from low income to high income countries, people also migrate, in increasing numbers, from rich countries. In 2004, over 150,000 German citizens left their country looking for a job abroad, the highest number since 1888 (The Economist, 2006a). About 200,000 UK citizens left their country in 2005 (The Economist, 2006b). The UK citizens permanently working abroad are about 5.5 million, or, 9.2% of the total UK population (IPPR, 2006). This means that there are more UK emigrants abroad than immigrants into the UK. As for the volume of migrant remittances, France comes fourth after China, India and Mexico (World Bank, 2006). Irregular migration The so called "irregular migration" is an even more complex phenomenon. Problems start from the very definition: Is "irregular", the same as "illegal" or "not documented"? The term "illegal" is widely used but conceptually flawed and tainted with negative connotations, more or less explicitly associated with criminality. An irregular migrant enters a country without the due authorization or stays after such authorization has expired. Many international organizations dealing with migration abandoned the term "illegal" long ago and adopted, instead, the one of "irregular". However, the European Union maintains this vexing term in several of its documents. Smuggling and trafficking of human beings are included within the framework of irregular migration. Even if the two phenomena are different, the terms are often used interchangeably by some people. On the one hand, human trafficking is the forced transfer of individuals from one country to another through threats, coercion and with illegal aims like forced prostitution and forced labour. It is, therefore, something that goes against the will of the victims and violates their basic rights. On the other hand, human smuggling is the transfer of consenting individuals who want to move from one country and enter another one without having the authorization to do it and, to this end, seek the help of more or less structured, clandestine organizations (United Nations, 2000). The distinction is, nevertheless, usually ignored because the two phenomena often overlap. According to data published by the USA Department of State, there are between 600,000 and 800,000 victims of human trafficking every year and about 12 million people are exploited in some forms of forced labour (US Department of State, 2005). According to the Global Commission on International Migration (GCIM), every year, about 2,000 irregular migrants lose their lives (GCIM, 2005). However, these are very likely to be underestimates of the reality. How many migrants are irregular? As expected, data on irregular migration are scarce, confused and unreliable. Their ranges point to their unreliability: the most recent estimates of irregular migrants worldwide vary from 3 to 30 million per year; in Europe alone, new irregular immigrants vary from 400,000 to 830,000 per year. In India the irregular immigrants are estimated to total 20 million, in Europe between 10 and 15 million, in the USA 10 million and in Russia between 3.5 and five million (GCIM, 2005). It is important to remember that the majority of irregular migration does not take place between low and high income countries but within low income countries and that data on this phenomenon are hard to come by. According to United Nations estimates, there are several million irregular immigrants in countries of South East Asia and between three and five million in South Africa. Perceptions and reality The importance of irregular migration is linked more to politics and perceptions than to sheer numbers. Its threat to state security is exaggerated and mainly based on emotional misinformation often exploited by politicians looking for cheap popularity. The main victims of irregular migration are the irregular immigrants themselves. They often live in precarious situations, deprived of the most basic services like health and education. The most disgusting aspect is that many irregular migrants are shamefully exploited by "honest" citizens of receiving countries through underpaid work, blatant discrimination, sexual exploitation and exorbitant rent for squalid rooms of a few square meters. Migration and economy According to economists, the economic effects of migration are positive for the countries and for the individuals involved (World Bank, 2006; IOM, 2006). In receiving countries, migrants mitigate the lack of manpower in those sectors where it exists (for instance, the health sector in several rich countries). They are frequently employed in jobs rejected by local people, such as security, cleaning, gardening and routine work in industries. They contribute to production and consumption by so doing contribute to an increase of the GDP. Since they are usually underpaid, their presence also contributes to curbing inflation by decreasing salary pressure. Though this last one is a positive macroeconomic effect, it can have negative aspects for those local workers employed in the same jobs as the immigrants, hence the resentment. In their countries of origin, the departure of the migrants decreases the unemployment rate, makes available additional financial resources through their remittances, and avails new ideas, knowledge and skills when the migrants go back. The main benefits of migration are felt by many of the migrants themselves and by their families. The history of mass migrations, from the end of the XIX century, from several European countries (Ireland, Italy, Norway, Sweden), confirms what is written above, that enormous migratory movement favoured the economic growth of the USA and of the countries of origin through all the mechanisms mentioned (Clemens, 2006). Many economists think that were the circulation of human beings to be liberalised in the same way as that of goods and capital, the benefit for the world economy would be about 25 times higher (World Bank, 2006). According to some World Bank projections, if high income countries allowed a 3% increase of immigration, this would produce, from now to 2025, an annual gain of about US$ 300 billion for poor countries and about US$ 51 billion for rich countries (World Bank, 2006). These hypotheses are also contained in a recent book that stirred a lot of discussion among politicians and economists. The author, Philippe Legrain, an economics journalist who also worked for the World Trade Organization, echoes the mentioned projections and maintains that migration is not an optional course but a need for the survival of the world economy (Legrain, 2007). These theories have a weak spot though: they are based on complex calculations but on simple hypotheses. They ignore the complex and intertwined factors associated with migration such as culture, religion, social and individual psychology, and international economic trends. When Poland and nine other countries entered the European Union in 2004, the UK absorbed in a few months, without serious problems, about 500,000 migrants coming from those countries. This may have proved unthinkable had those immigrants been black and Muslims instead of being white and Christian. And, in any case, even if economists pointed out how that influx benefited the British economy, promoting a considerable increase of GDP, Her Majesty's government, a few years later, imposed severe restrictions to the immigration from Bulgaria and Romania when they entered the European Union. The fragility of the mentioned economic theories lies mainly in the fact that they consider society as if it were a hard system, perfectly predictable in its reactions. On the contrary, all societies, being made of human beings, are soft and flexible systems, often unpredictable. They often defy logic. Or, better still, they use a logic that often is not the same as that used by economists. It is, nevertheless, necessary that politicians and citizens know those economic theories and ponder about them. They point to a direction that, although complex, seems to be unavoidable. Migration and Development The impact of migration on poverty reduction and development has only been studied in recent years. Every year, the Center for Global Development (CGD), publishes the Commitment to Development Index (CDI), a sort of league table ranking the world richest countries on the basis of a complex index suggesting their actual commitment to global development. The CDI is obtained by combining the performance of the rated countries in seven areas deemed important for global development namely, official development aid; trade policies; direct investment in poor countries; environmental protection policies; contribution to international security (mainly contribution to UN peace keeping missions); research and capacity transfer; and, last but not least, migration policies (CGD, 2006). Migration policies include not only the way countries welcome foreign workers, protect and guarantee their rights but, also, how friendly a country is towards foreign students. Migrant remittances Migrant remittances to their countries of origin amounted to about US$ 31 billion in 1990 and about US$ 170 billion in 2005 (ILO, 2006). As all the statistics concerning migration, even this one is an approximation. Significant amounts of money are transferred through informal channels: they cannot be accurately quantified. They can only be guessed. According to World Bank estimates, the amount escaping official statistics could equal 50% or more, of the official figure (World Bank, 2006). This would make remittances equal to about US$ 250 billion per year. Official Development Assistance (ODA), was US$ 106.5 billion in 2005 (OECD, 2005). For many poor countries migrant remittances exceed the amount received as ODA. It must also be realised that remittances go directly to the migrants' families at the grassroots while a considerable proportion of ODA is trapped within the bureaucracy and does not trickle down to the grassroots, to translate into direct benefits for recipient countries' people. Between 30% and 45% of remittances follow a south-south circuit. This means that they are sent to families in poor countries by relatives who have migrated to other poor countries. This because of an often ignored fact: that about half of the people emigrating from poor countries go to other poor countries (World Bank, 2006). According to an article published by The Economist, migrants' remittances play a crucial role in sustaining the economies of many countries of the former Soviet Bloc. They represent about 10% of GDP in Albania, Armenia and Tajikistan and about 20% of the GDP of Bosnia and Moldova. About 15% of the population of Ukraine and 20% of the one of Kazakhstan are migrants. Their remittances and their ideas, when they go back, are transforming their countries of origin (The Economist, 2007). The cost of money transfers through official channels (specialized agencies, banks) is still considerably high. In some cases it can reach 25% of the amount transferred (CGIM, 2005; World Bank, 2006). However, as much as migrant remittances are a useful and important factor, are not a magic bullet and are not a substitute to adequate national and international development policies. Remittances need sound domestic economic policies to be used even more effectively. Brain drain In the last two decades whereas, as a factor of globalisation, international barriers to the circulation of goods and capital have been substantially reduced, the barriers to the circulation of human beings have not been reduced with the same speed. On the contrary, the tendency in many countries seems to be set on a trend of more rigid and strict regulations. One exception, with significant consequences, concerns the so called "focused migration", that is, the promotion, by many rich countries, of the immigration of individuals with high degrees of education in specific sectors. There are numerous measures intended to promote the so called "brain drain". It is estimated that about 10% of the university graduates of poor countries work in rich countries. This percentage goes up to 50% for the graduates in technical and scientific fields (Lowell and Gerova, 2004). A lot has been written on this aspect. The traditionally more common view is that migration deprives poor countries of their best human resources, thus hindering their development. Furthermore, it is rightly underlined, that poor countries' governments paid for the education of these "selected migrants" but rich countries enjoy the results, a sort of subsidy from the poor to the rich. The situation is particularly serious in some countries, like, for instance, Cape Verde, Gambia, Seychelles, Somalia, with more than 50% of their graduates migrating, up to the stunning 82.5% from Jamaica (Kapur and McHale, 2005a). It is obvious that these countries are unduly deprived of useful, probably vital, resources. As always, however, the problem is more complex and one sided judgements are not as correct as they seem. In many cases, the selected migrants come from countries where, for economic and political reasons (poor governance, nepotism, corruption, violence, ethnic, regional, religious discriminations) they could not have fully developed their potential. All too often, their potential and theoretical contribution to the development of their countries is mistaken for the contribution that would have been really possible. Various proposals are advanced to limit, if not to stop, the "stealing" of the best brains from poor countries by the rich ones. Such proposals range from forbidding the employment, in rich countries of some categories of workers coming from poor countries (like doctors and nurses) to the delivery of short term visas to qualified professionals so that they are somehow forced to go back to their countries. Apart from the practical problems in effectively applying such measures, their proponents seem to neglect the fact that they constitute an unjust limitation to the individual freedom of pursuing better conditions of life for themselves and for their families. Brain drain is a symptom, not the disease It is right to formulate policies to compensate poor countries and motivate highly educated migrants to go back. But this is another complex chapter. In the great majority of cases, brain drain is just one symptom of more serious diseases: poverty, inequalities, under-development. Decades of history suggest that development is, mainly, an endogenous process. From outside, in the best case scenario, it can only be stimulated, facilitated, strengthened. It has even been proposed that rich countries should invest in the education sectors of poor countries. On the face of it, this looks like good reasoning: if rich countries need to employ diploma and degree holders from poor countries, let them contribute to their training. If the UK needs Ugandan nurses, the UK should invest in Ugandan nursing schools. However, this is far from being enough. Nobody enters a nursing school (or a faculty of medicine) without an adequate level of basic education. Therefore, it is necessary to invest in the entire education system of poor countries to enable many candidates to qualify for the medical and nursing schools: right from the primary to the tertiary cycle. This is a very long term investment. Its results will be seen after 15 to 20 years. However, currently, the aid going to the education sector of poor countries is not significant. The World Bank, the biggest donor in this sector, invested about US$ 2 billion, in countries in Africa, Asia, Latin America and Eastern Europe in 2002. In that same year, those countries invested US$ 250 billion (World Bank, 2002). For sure, more funds are needed, as well as solid, wide-ranging and long-term policies and strategies. Other measures are suggested to counteract or to maximise national benefits from the brain drain. They have included imposing taxes on remittances by the countries of origin (with the collaboration of the receiving countries); ensuring the transferability of pension benefits from the receiving countries to the countries of origin; granting double nationality (that favours a more free and frequent circulation with economic benefits for both receiving countries and countries of origin) more easily; stipulating bilateral or regional agreements providing for, among other things, increased aid from the receiving countries to the countries of origin of the highly specialized migrants. Health systems and brain drain For several years, now, the health systems of poor countries have been severely affected by brain drain. Many think that, in the framework of international migration, health systems deserve a special attention (Bach, 2006). Rich countries' populations are ageing and need more and more services that their health systems will be unable to provide due to lack of personnel. Human Resources for Health (HRH) are particularly scarce even in poor countries. Sub Saharan Africa, with about 10% of the total world population, has a mere 2.8% of the total world health workforce and accounts for the tiny 1% of the world health expenditure (WHO, 2006). The UK suffers from a severe shortage of nurses and is one of the main destinations of migrant health workers from poor countries. In 2002 the number of foreign nurses registered in the UK (16,155) was higher than the number of nurses trained in the UK (14,358) and, between 1999 and 2002, the number of foreign nurses employed in the UK more than doubled, reaching 42,000 (Aiken et al., 2004) and 65,000 at the end of 2006 (WHO, 2006). According to the WHO, about 23% of the medical doctors who graduated in Sub Saharan African countries work in OECD countries; the percentages range from the minimum of 3% in Cameroon through 16% in Uganda, 17% in Ethiopia, 19% in Angola, 29% in Ghana, up to the maximum of 37% in South Africa (WHO, 2006). According to other sources, the proportion of medical doctors graduated in Sub Saharan Africa and working abroad (mainly, but not only in OECD countries) is 28%: from 1% in Guinea Bissau, to about 50% in several countries (Cape Verde, the Democratic Republic of Congo, Equatorial Guinea, The Gambia, Ghana, Kenya, Liberia, Malawi, Sao Tomé and Principe, Senegal, Swaziland, Tanzania, Zambia and Zimbabwe) up to 70% in Angola. As for Mozambique, the proportion is estimated at about 75%, but this includes many individuals of Portuguese origin who left the country after independence (Clemens, 2006). According to many, rich countries employing health workers trained in poor countries act unethically as they deprive poor people, especially in rural areas, of essential human resources. Although containing some truth, this position can be questioned. Health systems of poor countries are severely under-funded (they receive between 1% and 2% of what health systems in rich countries receive). Consequently, they are in real dire straits: dilapidated infrastructure, lacking or having obsolete or faulty equipment, chronically short of medicines, low and irregularly paid salaries. In such conditions, it is difficult for health workers to make full use of their knowledge, skills and competence. Furthermore, if the migrant health workers remained in their countries, only a tiny fraction of them would work in rural areas. Many would work in urban areas, possibly in private clinics, serving the richest segments of the population. In Uganda, for instance, the poorest districts have about 26% of the health workers deemed necessary while the richest ones have more than they need, reaching even 263% of what is deemed necessary ((MOH Uganda, 2005). A striking example of maldistribution of health personnel concerns doctors: of the 648 doctors working in government health units in 2003, 111, or, 17% of them, worked in the main hospital of the country, Mulago, situated in the capital Kampala (MOH Uganda, 2004). In 2004, President Yoweri Museveni stated the intention of his government of favouring the migration to rich countries of highly educated Ugandans, especially health workers. The reason given was that migrants remittances are a useful tool to fight poverty (Maniple, 2004). According to the World Bank, in the last few years, remittances of Ugandan migrants have reduced poverty in the country by about 11% (World Bank, 2006). In the Philippines, for several years now, the government trains health workers "for export": it encourages them to migrate, and through facilitation and favourable conditions, to send back remittances through official channels and to come back after several years. In 2004 the remittances of migrants were US$ 8.5 billion, or, about 10% of the GDP of the Philippines (WHO, 2006). In the same year, the Philippines received US$ 462.8 million in ODA (UNDP, 2006). This paper does not argue that poaching health workers in poor countries by rich countries is a good thing or should be encouraged (especially when unscrupulous private recruiting firms are involved). However, it simply suggests that migration reality is complex and should be examined in all its aspects. Measures to curb the fleeing of African health workers Various measures have been suggested and tried to limit the migration of health workers to rich countries from poor especially from African, countries. They range from bilateral agreements between countries of origin and of destination, and the introduction of quotas, to different types of compensation by rich countries. We already mentioned the possible funding, by rich countries, of the education sectors of poor countries. Some countries, like South Africa, started to train new cadres of paramedical personnel capable of carrying out many nursing tasks but less qualified than nurses: they are very useful within the country, but, because of their low academic level, are excluded from the international market. Rich countries have been urged to better plan and stimulate their own production of health personnel. This does not seem to be happening yet and is not likely to happen soon. It is estimated that, in the next four years, the British health system will have a gap of 14,000 nurses, 1,200 family doctors and 1,100 hospital doctors. At the same time, it will have a surplus of 3,200 specialists and 16,200 laboratory technicians, physiotherapists and other similar professional cadres (McSmith, 2007). In the last few years several codes of conduct have been formulated to try to regulate the employment of health personnel coming from poor ones in rich countries. They are addressed to national authorities, professional associations and recruiting agencies. Private recruiting agencies have multiplied in the last few years. In the USA, they receive between US$ 5,000 and US$ 10,000 for every nurse they "provide". This is a business worth several million US dollars per year (Brush et al., 2004). The existing codes of conduct are not binding for private recruiting agencies. This means that, most often than not, they are not respected. A telling example comes from the UK, where a Code issued in 1999 forbids to the National Health System (NHS) to employ health personnel coming from poor countries. This code was revised and made even more stringent in 2004 (DOH UK, 2004. The private sector, however, is allowed to employ health personnel coming from poor countries, and keeps doing so. Once they are in the system, these health workers can be employed even by the NHS (Aiken et al., 2004). A measure often suggested to keep the health personnel in their home countries is paying them higher salaries. Whereas this seems obviously workable, once again reality is stubbornly more complex. An article published by "Le Monde Diplomatique" in December 2006, suggests this measure and, as a good example, quotes Uganda (Blanchet and Keith, 2006). As a matter of fact, between the financial years 2003/2004 and 2004/2005, the Government of Uganda raised the salaries of health workers by 51.7% (MOH Uganda, 2006), certainly a sensible measure and a significant increment. However, among the consequences, there was a massive exodus of health workers from the private not-for-profit (PNFP) health facilities to the Government health units. The former were unable, for lack of funds, to raise their salaries to keep pace with the government. Yet, in Uganda, PNFP are responsible for about 40% of health services delivered. If one looks at the consequences of this sensible measure on the health system as a whole, the conclusion cannot be positive, as it deprived a significant proportion of health units mostly located in rural areas of nurses and doctors. The heart of the matter Other measures, like greater chances for further education, incentives to work in rural areas, better integration with served communities, and other similar incentives (PHR, 2006), resemble more of good will exercises, limited and fragmented, than true solutions. They all seem to neglect the heart of the matter. And the heart of the matter is that migration is not a phenomenon due to one single cause. It has its roots in numerous intertwined and complex causes. Therefore, when it leads to problems, these have to be analysed and faced in their entirety. Coming back to African health systems, it would be of only marginal benefit to keep health workers stuck in dilapidated health systems. It is necessary to strengthen such systems. Huge amounts of funds are needed, together with wide-ranging and long-term policies and strategies. According to a recent study, about 77% of the families of newly graduated Zimbabwean doctors suggest they should try to emigrate24. This is not surprising, when the Zimbabwe health system, as the rest of the country, is in a sorry state of collapse. Equally not surprising is the fact that this country has the highest percentage of migrated nurses of all African countries: 34% (WHO, 2006). Positive effects of brain drain The positive effects of brain drain are often neglected and yet they could be harnessed even more. They go beyond remittances. There are more and more associations of migrants from the same country that, although acting abroad, have an economic, cultural and political impact in their home countries, promoting investments, the circulation of ideas and innovations (Pritchett, 2006). Some of these Associations send back home collective remittances for the construction of public infrastructure such as roads, schools, health units. This phenomenon is not yet significantly widespread but it is rapidly expanding (WHO, 2006). In many international organizations, especially, but not only in the UN System, many high ranking officers come from poor countries. Their ability to lobby in favour of their countries of origin is politically and practically important and it would deserve to be assessed. Some analysts also argue that departure of highly educated people creates room for others to emerge and fill their positions, thus ultimately increasing the national stock of competent people (Kapur and McHale, 2005b; The Economist, 2005). However, this is dependent on an advantage that so far only remains a remote possibility for many countries i.e. the return home, after several years, of highly educated migrants. They would bring back new ideas, financial resources, contacts and networks potentially useful in various fields like tourism, transports and communications. Obviously, such coming back must be voluntary and attractive. Countries like China, India, Ireland, Mexico, Taiwan, have successfully introduced policies to favour the return of their highly educated migrants. Other countries, like Afghanistan, Rwanda, Sudan, tried to do the same, so far with more limited success. Conclusion Migration is a phenomenon as complex as it is unstoppable. Managing it adequately will require hard work, commitment, research, reflection, understanding and, most of all, political courage. Global cultural transformations will be necessary. And they will take place. They too are unstoppable, although, understandably, slow. The short-sightedness of numerous politicians the world over, international terrorism, the so-called "war on terror", ignorance and narrow mindedness, the current global economic crisis, the actual and real problems posed by the integration of massive waves of immigrants, will make the next decades difficult for current and intending migrants. Long-term optimism is of little consolation today. In the short term (a short term being longer than the life span of many individuals) the world will go through difficult, sometimes, atrocious, processes. In the long term all this could (should) lead to a better world made of really multicultural societies, better integrated, open-minded, tolerant, capable of living and prospering on the basis of common, shared values and interests. References
© Copyright 2008 - Department of Health Sciences of Uganda Martyrs University The following images related to this document are available:Photo images[hp08018t1.jpg] [hp08018t2.jpg] |
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