Washington, DC — Sub-Saharan Africa bears the greatest burden from the international movement of trained medical doctors to wealthy countries, according to a study published in Thursday's New England Journal of Medicine.
Nine of the 20 countries in the study with the highest proportion of doctors emigrating are in Africa south of the Sahara. Nearly 14 per cent of physicians from African countries that have over 1000 doctors are practicing in Canada, the United States, the United Kingdom and Australia. Thirty per cent of Ghana's doctors have emigrated to one of the four recipient nations.
Fitzhugh Mullan, the study's author, culled data from a variety of sources and used a common metric to compile a relative measure of physician emigration from 120 countries. Although international alarm at the size of what is often called the 'brain drain' of health professionals from poor countries is growing, Mullan's work is the first published study to quantify the problem.
He found substantial reliance on international medical graduates, averaging just over 25 percent for the four countries, ranging from 23.1 per cent in Canada to a UK figure of 28.3 per cent. The percentage of international doctors who come from lower-income countries ranged from Australia's 40 per cent to a high of 75.2 per cent in the United Kingdom.
The research process was complex, and some of the calculations had to be based on extrapolations and estimates. For example, the United Kingdom records statistics of doctors trained abroad who practice for the National Health Service in England, but no comparable figures exist for Scotland, Wales and Northern Ireland, nor are there records of physicians in private practice or serving the military.
Statistics on the number of doctors in lower-income countries are drawn from the World Health Organization's Global Atlas of the Health Workforce. Only countries with over 1000 physicians were included in Mullan's study, suggesting that the actual social cost of emigration is likely to be even higher.
Other reports have indicated that Africa's smallest, poorest countries are targets of medical recruiters from wealthy nations - and doctors where living and working conditions are most difficult have a heightened incentive to leave. Mullan's calculations for four other African countries, outside the scope of the published study, tend to support that heightened drain. He found that percentages of doctors from four other African countries who are practicing in North America, Canada or Australia range from 20.2 for Zambia to 58.6 for Liberia.
Nor is that the entire story, although those four recipients account for the bulk of immigrants from lower-income countries. While the number of doctors from Africa in France or Portugal may be small in relative terms, their loss could nevertheless represent a significant percentage of skilled physicians in their respective countries.
The shortage of African health care providers has increasingly figured in discussions about Africa's future. Members of the UN Commission on HIV/Aids and Governance in Africa, whose report on its three-year assessment is expected in February, say the issue loomed larger in their deliberations as the severity of the crisis became apparent. Last January, the Global Coalition for Africa, meeting in Addis Ababa, Ethiopia, made the issue the topic of its deliberations among heads of state and other high-level officials. A September report by the United Nations Population Fund and a meeting this month organized by the World Health Organization (WHO) and the World Bank also focused on the health professional brain drain. WHO plans to publish a strategic action plan to secure human resources for health care.
The rising prevalence of HIV/Aids in Africa has further strained already inadequate health systems and pushed life expectancy into a dramatic downward spiral, particularly in southern Africa. With some 600,000 doctors, nurses and birthing professionals for 600 million people, sub-Saharan Africa needs at least a million additional skilled health workers to offer basic services, an editorial accompanying Mullan's article in the New England Journal says.
Health policy analysts say any solution to the problem will need to address both the 'push' factors that drive emigration and the 'pull' factors that create a market in wealthy countries. The New England Journal editorial points to "dire predictions of massive shortages of 200,000 physicians and 800,000 nurses in the United States by 2020."
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Mullan, a physician and professor of health policy at George Washington University in Washington DC, says that expanding medical education in the United States is an important step towards a long-term solution. "Demand is there," he argues, noting the number of U.S. students who study at medical schools outside the United States and return home to practice.
Potential shorter-term measures include dramatically increasing the number of health professionals who spend as long as a year at a time in acutely affected countries. Mullan is the lead author of an April report by the Institute of Medicine in the United States, which proposes the creation of a global health service, funded by the U.S. government, to mobilize full-time medical professionals to combat HIV/Aids in the worst-hit regions. The estimated cost of the service would be $100 million annually.
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