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

1. BRAIN DRAIN IN THE HEALTH SECTOR IN AFRICA:EXAMPLES FROM THE UNIVERSITY COLLEGE HOSPITAL (UCH) IBADAN, NIGERIA.

2. I. INTRODUCTION Africa in Perspective Africa is home to nearly 800 million inhabits 300 million of the world�s poorest ranks very low in health status compared to other continents of the world more than 10 African countries have doctor population ratio of 1:30,000 or more WHO recommends 1:5000 people

3. 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-1980�s, the loss had become massive with migrants recruiting colleagues for host establishments. destinations - Europe, North America and the oil rich Middle East

4. 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.

5. 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

6. forced ejection of doctors from government quarters in 1985 for failure to call off strike action on government�s 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.

7. 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

8. 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.

9. II. DIMENSIONS OF THE BRAIN DRAIN Dimensions include: types, magnitude, causes, and consequences.

10. 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.

11. 2.1 Types of the Brain Drain External Brain Drain In this study, external brain drain means loss of Africa�s 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 migrant�s absence becomes unusually prolonged, naturalizes in host country characteristic of migrants to Europe and North America

12. 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�.

13. 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.

14. 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

15. 2.4 Consequences of the Brain Drain health of the nation direct financial costs indirect costs

16. 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. 2.4 Consequences of the Brain Drain

17. 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). 2.4 Consequences of the Brain Drain

18. 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 2.4 Consequences of the Brain Drain

19. 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

20. 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 IIl. MEASURES TO STEM/REVERSE THE BRAIN DRAIN

21. 3.4 The Diaspora Option The Diaspora programme Has been on for decades with modest impact described as: sporadic exceptional limited in scope.

22. Collaborative Efforts towards maximization of gains AfricaRecruit has since 2002 joined hands with the New Partnership for Africa�s 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). 3.4 The Diaspora Option

23. 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.

24. 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. IV. ROLES OF GOVERNMENTS AND UNIVERSITIES

25. 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

26. 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 4.2 Role of Universities

27. 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 4.2 Role of Universities

28. 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. 4.2 Role of Universities

29. 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.

30. 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.

31. 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.

32. 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 Recommendations on the way forward

33. 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. Recommendations on the way forward

34. 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. Recommendations on the way forward

35. 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. Recommendations on the way forward

36. Thank You for Listening