31 March 2006
Nurses and doctors from developing countries can no longer be poached by the NHS, but other richer nations do not have the same restrictions. Ministers Rosie Winterton and Gareth Thomas call for a campaign of 'ethical recruitment' from the international community
The story goes that there are more Malawian doctors in Birmingham than there are in Malawi. It is often retold when the subject of Africa's health sector crisis is raised. Whether the story is true or not, it underlines the terrible truth that many developing African countries have an acute shortage of health sector workers.
The facts speak for themselves. Compare Europe, where there is one health worker for every 100 people, to Malawi, where there is only one health worker for every 1,250, where over half of nursing posts remain unfilled and there are 90% vacancy rates in many clinical specialities.
Blame for the 'skills drain' problem is ascribed to richer countries that actively recruit from developing countries. But the problem is much more complex. We often break it down rather simplistically into 'push' and 'pull' factors: the push of poor conditions of service and the pull of greener pastures overseas.
The UK is doing much to address the 'pull' factors. We are the only developed country to make it government policy that we should not actively recruit health professionals from developing countries into the NHS. This is laid down in the Department of Health's code of practice, which specifies countries in sub-Saharan Africa and the Caribbean.
The code was strengthened in December 2004 to include locum as well as permanent staff, and is starting to deliver results, with a marked drop in recruitment of overseas nurses year on year.
But, even though the NHS leads the way in ethical recruitment and our approach is recommended by the World Health Organisation, other richer nations need to follow suit if there is to be any real impact on the 'brain drain'.
The UK's independent health care sector is playing its part by agreeing to abide by the code, as have more than 200 recruitment agencies.
Some have said that we should ban health sector professionals in developing countries from getting jobs in Britain. But we believe that is morally wrong. People, whatever their profession, should be able to go where they choose and apply for jobs they want in a global economy.
Many who choose to work away from home send small sums of money, anything from £50 to £500, to support their families. More than £40bn a year is sent in this way to developing countries. In fact, such remittances are the second largest global financial inflow to developing countries after foreign direct investment, exceeding international aid. An estimated £3bn is sent to developing countries from the UK in the form of remittances every year, so at face value there is an economic benefit.
And, of course, there are very positive training benefits for health care professionals coming to this country. Obviously, these can only be felt if those workers are then attracted to return home to work. And that is where the 'push' factors need to be addressed.
Recently, we visited Malawi and Zambia to evaluate the situation for ourselves and see what more the UK could do to help. The visit had a profound effect on both of us and highlighted the complexity of the problem.
The root cause is poverty. Malawi is the tenth poorest country in the world, with two-thirds of the population living on less than 64 pence a day. The nation's health budget is based on £6 per person a year, compared with around £1,500 for every person in Britain. The health status of Malawians reflects the high levels of poverty there, and has been made worse by HIV/Aids. More than 14% of adults are infected, making Malawi among the worst hit of any country in the world.
The consequences of long-term underinvestment in the health sector and training are clear. We listened to the concerns of doctors and nurses, some still in training, which are echoed in many countries across sub-Saharan Africa. Low wages, poor working conditions and a lack of basic medicines and equipment prevent staff from doing the job they are trained to do.
For those who are attracted into training, there are few opportunities for career progression. And there is every chance that those posted to rural areas will be working in very poor conditions and inadequate housing. Of Malawi's 400 health centres, well over half don't have electricity, running water or a simple means of communication such as a telephone or radio.
The nurses sent to work in more remote areas often won't have any means of transport either, so they can't do basic things such as go shopping or visit their friends and families. Once established in post, and 'plugging the gap' in service provision, they are often forgotten about by the health authorities, who are focused on simply filling vacancies to avert crises.
Aids is tipping the balance, with workloads increasing and becoming more stressful, and many health workers becoming terminal carers, not healers.
The result is that many vote with their feet. They either leave the public health service for Malawi's private sector – so serving only the few that can afford to pay for private health care – they quit nursing altogether, or they take their skills abroad.
We met a district nurse who recently studied for a degree in nursing education. Her story illustrated the national crisis: of the 24 nurses in her class, only four remain in the country. 'I enjoy nursing here but there are few incentives and much more needs to be done to increase job satisfaction,' she told us. 'Yes, I have been attracted abroad but have chosen not to go because I have family commitments here. But let's be realistic, we are open to the rest of the world, one only has to look on the Internet for job opportunities abroad.'
The UK is doing its bit to try to reduce the push factors that drive registered nurses to other countries, but clearly there is a lot more that the international community must do to help.
The Department for International Development is providing £100m to the Malawi government to help bolster its health provision, of which £55m is earmarked to support the human resources crisis.
The funding is going some way to increase incentives for recruitment and retention of health workers by topping up salaries. It is also helping to triple the number of doctors and double the number of nurses in training, as well as paying for volunteer doctors and nurse tutors to cover vacancies while Malawian doctors and nurses are trained to fill them.
Our commitment to long-term, predictable funding is helping to give the health sector confidence to spend money on sustainable health projects as well as increase wages. It's a start, but more needs to be done.
We visited Nkhata Bay District Hospital on the shores of Lake Malawi. This 137-bed hospital, which serves 20,000 people, is staffed by only one doctor, ten clinical officers and 15 nurses. At night, there are only two nurses on duty for the whole hospital, while the labour ward, with only four beds, has up to 50 expectant mothers waiting to deliver at any one time.
There we witnessed the operation of the recently opened Aids clinic which, despite the scale of the Aids problem, has raised staff morale as they now feel that they can 'do something' to help sufferers.
The predictable funding is also bringing dividends: the salary top-ups have slowed down the exodus of qualified nurses, almost 600 new health staff have been recruited in the past six months and more than 60 expatriate doctors and nurse tutors have arrived to fill critical positions. Infrastructural expansion and upgrading of training schools has begun.
Meanwhile, Mchinji District Hospital is bursting at the seams with patients, with its 30-bed paediatric ward regularly accommodating 130 children. The labour ward has one nurse/midwife at night, who also covers the antenatal and postnatal wards and obstetric emergencies. The hospital is supported by a rural hospital and nine health centres with outreach services. Staffing at the latter has improved and all the centres now have at least one medical assistant and one or two nurses. Salary top-ups have been welcomed by staff and resignations have declined.
These are the sort of comprehensive, innovative responses that we should be supporting. If we can help put in place a working health service in developing countries that provides health staff with a decent living and job satisfaction, then we are likely to reduce the 'pull' of greener pastures, both within their own countries and overseas.
Many individuals are also taking the initiative and setting up local schemes. Much good work is already going on and there are a number of existing links between Malawian hospitals and NHS trusts. For example, Lilongwe Central Hospital has a link with South Tees covering a wide range of expertise; Zonga Hospital is linked with Harrogate on mental health issues; and Blantyre Hospital is linked with North Cumbria on orthopaedics.
We want to do more to build on the NHS Links programme so that these positive experiences – which benefit the NHS staff who participate in them as well as the health care professionals from developing countries – can be spread more widely.
But the UK alone cannot hope to solve the health care crisis. The initiative needs to come from developing countries first, through the development of long-term health plans that are fully tailored to each country's context and needs and can then be backed and supported by donors.
Malawi and other countries such as Ghana, Uganda and Zambia are using a range of approaches to retain and motivate staff: salary increases, financial incentives to encourage work in underserved areas, car and housing loans, and opportunities for career development. Over time, this should generate a body of good practices that will help other countries in similar circumstances.
Of course, richer donor countries also need to do more. There are signs of progress, but there is still a long way to go. We are determined to continue to work together across government to ensure that our development, health and migration policies are mutually reinforcing, so that we can have a real impact on the complex problems we have witnessed at first hand.
Gareth Thomas is international development minister and Rosie Winterton is health minister
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