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Reversing Africa’s Medical Brain Drain

OXFORD – There is understandable consternation over Uganda’s plan to send almost 300 health workers to Trinidad and Tobago. The plan reportedly includes four of Uganda’s 11 registered psychiatrists, 20 of its 28 radiologists, and 15 of its 92 pediatricians. In return, the Caribbean country (which has a doctor-to-patient ratio 12 times higher than Uganda’s) will help Uganda exploit its recently discovered oil fields.

Uganda’s foreign ministry says the agreement is part of its mandate to promote the country’s interests abroad through the transfer of skills and technology, as well as an opportunity to earn foreign exchange by sourcing employment for its citizens. But Uganda’s international donors are not convinced; the United States has voiced strong concern, and Belgium has suspended development aid to Uganda’s health-care sector.

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Two of my friends, a gynecologist and a pediatrician, have applied to go. Had I still been working with them in Uganda, I might have been tempted to join the exodus. Uganda’s health-care professionals are talented and highly qualified. But they often work in appalling conditions at great personal sacrifice. So it is not surprising that they become disheartened and seek professional opportunities elsewhere. They know that the status quo is failing, and that something has to change.

I knew it, too. In 2009, I was on track to become only the sixth neurosurgeon in Uganda, working at Mulago National Referral Hospital, the country’s main tertiary institution. We sometimes had to cancel major operations when the malfunctioning sewage system in our theatre regurgitated waste into what was supposed to be a sterile environment. We were severely understaffed. Once, during a string of consecutive night shifts, I was so tired that I accidentally pricked myself with a needle while drawing blood from an HIV-positive patient. I was given an antiretroviral treatment called Post-Exposure (PEP) for a month and had to take time off work because of the drug’s side effects. Meanwhile, adding to my anguish, the government delayed payment of our salaries – and not for the first time.

The deal between Uganda and Trinidad and Tobago violates the World Health Organization’s global code on the International Recruitment of Health Personnel, which is aimed at discouraging the recruitment of personnel from countries that have a critical shortage of health-care workers. A Ugandan think tank, the Institute of Public Policy Research, has called the plan a “state-sanctioned brain drain.” It has taken the government to court in an effort to force it to reverse its decision.

But the truth is that Uganda may have inadvertently stumbled upon an innovative policy. If the plan is executed properly, it could benefit both the health-care sector and the country, by raising additional funds, strengthening medical workers’ skills and motivation, and creating a model for engaging with the diaspora. Other developing countries facing similar challenges with retaining health-care workers could learn from Uganda’s experience.

Of course, this type of mass recruitment could have a major adverse impact on developing countries’ health-care systems. But it also should be recognized that it is not sensible to chain health-care workers to a failing system. There has to be a way to encourage doctors to contribute to their country’s health-care system, while offering them an opportunity to achieve their personal and professional goals.

In order to make it work, the recipient country would have to agree to recruit health-care professionals solely through the government. The country could then tax the foreign income of its workers and use the revenues to develop its health-care system.

Moreover, any agreement should explicitly require the provision of education and professional-development opportunities for recruited health-care workers. The recipient country might open their medical schools and health-care training to new recruits, or help pay for health-care education and a scholarship fund back home. That way, developing countries like Uganda could not only train more health-care professionals, but also have funds to send workers abroad for training.

The impact of such programs could be far-reaching, because the deficit of medical professionals is not limited to Sub-Saharan Africa. With so many qualified doctors emigrating to the United Kingdom and the US, the rest of the world, including developed countries, is also experiencing a tremendous medical brain drain. Roughly 35,000 Greek doctors have emigrated to Germany, while Bulgaria is “bleeding doctors,” losing up to 600 every year (equal to the country’s annual number of medical-school graduates).

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But developing countries face the biggest challenge. Eighty percent of countries where the density of skilled health workers is less than 22.8 per 10,000 people are in Africa, and another 13% are in Southeast Asia. The effects of such shortages were made clear during the recent Ebola crisis in West Africa.

The trouble is that the so-called brain drain in Uganda and elsewhere is not the cause of this dearth of health-care workers. It is only a symptom of health-care systems that are already in crisis. The ultimate solution is not to discourage professionals from working abroad; it is to ensure better training and more amenable working conditions. That way, we health-care professionals can focus on the task at hand: providing health care to our people.