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The ‘Fatal Flow’ of Health Worker Migration

March 17, 2011 is Match Day, when tens of thousands of medical graduates learn their odds in a professional lottery that determines the rest of their careers—the day new physicians are matched with the residency programs that will train them as specialists. Every year, thousands of foreign-trained doctors who want to practice in the United States apply for and fill up to 20 percent of first-year residency positions, because US medical schools don't produce enough graduates to fill training programs at hospitals nationwide. Kate Tulenko is a physician herself and an expert on health workforce migration. She shares some of the implications and ethics of recruiting foreign physicians—starting with the country that has the highest attrition of doctors in the world…

This blog entry was also featured on InterAction's AID Buzz blog.

More than a year after its devastating earthquake, Haiti is still struggling to recover and rebuild its health system.  Yet one of the major barriers to providing even the most basic health services is the migration of health personnel out of the country. Over the past 20 years, most of Haiti’s physicians and a full 94% of its nurses have migrated out of the country to work—a rate higher than any country in the world. 

But the migration of health workers is not just a problem in unstable countries like Haiti. Countries like Malawi, which has never seen a war or major disaster, have more than half their physicians working outside the country while jobs sit empty and ten out of 100 children die before their fifth birthday. India, the second most populous country in the world, has a shortage of more than 450,000 health workers, while their physicians make up the largest group of foreign trained physicians in wealthy countries. In fact, 20 to 25% of health workers in wealthy countries are foreign-born and -trained.

Traditionally, we have viewed migration as a positive. Unskilled people left lives of unemployment and poverty to take jobs in wealthy countries that no one wanted. This is not the case with health workers. Most developing countries have large numbers of health worker vacancies, and health workers’ salaries, though small compared to those in developed countries, easily put them in the top 20% of wage earners in their country. Meanwhile in wealthy countries, many more qualified young people apply to nursing and medical school than there are seats.

The loss of these workers impairs the ability of their countries to fight against life- and economy-destroying diseases such as HIV/AIDS, malaria, and TB, and even common scourges such as diarrhea, pneumonia, and vaccine preventable diseases. Since the number of health workers per capita is directly related to the population’s health, migration has been branded as “Fatal Flows.” A recent study revealed that the number one cause of loss of professors from African medical schools was migration. So not only does migration cause the loss of labor, but it impairs countries’ ability to train more health workers. Since most health workers are trained using public funds, their importation to wealthy countries also represents a subsidy of developed country health systems.

Luckily, recent progress has been made. Last year the World Health Assembly, made up of ministers of health from around the world, approved the Global Code of Practice on the International Recruitment of Health Personnel. Although not binding, the code encourages wealthy countries to invest in their own young people and train enough health workers to meet their own needs. It also encourages wealthy countries to assist developing countries to train workers to replace those lost to migration and to help them improve their health systems so that there are fewer of the frustration factors that cause physicians and nurses to leave: poor management, lack of equipment and medications, and lack of access to career development.

The World Health Organization and the Global Health Workforce Alliance are taking further steps to address the issue. In January they convened the world’s experts on the global health worker shortage in Bangkok, Thailand at the Second Global Forum on Human Resources for Health and recommended several key changes and commitments that must be made to eventually ensure that everyone, everywhere, has access to a health worker and a robust health system. Readers can make a difference by encouraging their local nursing and medical schools to expand enrollment so that their community can be self-sufficient in the production of health workers and not need to import health workers from countries like Haiti, which can ill afford to lose them.