An economic perspective on Malawi's medical "brain drain"

Globalization and Health BioMed Central Open Access Debate An economic perspective on Malawi's medical "brain drain" Richard Record*1 and Abdu Mohiddin2 Address: 1Trade and Private Sector Development, Ministry of Industry, PO Box 30366, Capital City, Lilongwe 3, Malawi and 2Division of Health and Social Care Research, Guy's, King's and St Thomas' School of Medicine, Kings College London, London SE1 3QD, UK Email: Richard Record* - ; Abdu Mohiddin - * Corresponding author Published: 18 December 2006 Globalization and Health 2006, 2:12 doi:10.1186/1744-8603-2-12 Received: 09 August 2006 Accepted: 18 December 2006 This article is available from: http://www.globalizationandhealth.com/content/2/1/12 © 2006 Record and Mohiddin; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Background: The medical "brain drain" has been described as rich countries "looting" doctors and nurses from developing countries undermining their health systems and public health. However this "brain-drain" might also be seen as a success in the training and "export" of health professionals and the benefits this provides. This paper illustrates the arguments and possible policy options by focusing on the situation in one of the poorest countries in the world, Malawi. Discussion: Many see this "brain drain" of medical staff as wrong with developed countries exploiting poorer ones. The effects are considerable with Malawi facing high vacancy rates in its public health system, and with migration threatening to outstrip training despite efforts to improve pay and conditions. This shortage of staff has made it more challenging for Malawi to deliver on its Essential Health Package and to absorb new international health funding. Yet, without any policy effort Malawi has been able to demonstrate its global competitiveness in the training ("production") of skilled health professionals. Remittances from migration are a large and growing source of foreign exchange for poor countries and tend to go directly to households. Whilst the data for Malawi is limited, studies from other poor countries demonstrate the power of remittances in significantly reducing poverty. Malawi can benefit from the export of health professionals provided there is a resolution of the situation whereby the state pays for training and the benefits are gained by the individual professional working abroad. Solutions include migrating staff paying back training costs, or rich host governments remitting part of a tax (e.g. income or national insurance) to the Malawi government. These schemes would allow Malawi to scale up training of health professionals for local needs and to work abroad. Summary: There is concern about the negative impacts of the medical "brain-drain". However a closer look at the evidence for and against the medical "brain-drain" in Malawi suggests that there are potential gains in managing medical migration to produce outcomes that are beneficial to individuals, households and the country. Finally we present several policy options. Page 1 of 8 (page number not for citation purposes) Globalization and Health 2006, 2:12 http://www.globalizationandhealth.com/content/2/1/12 Background With a GDP per capita of just USD 167 in 2004, Malawi remains one of the poorest countries in the world. Economic growth rates during the last 10–15 years have consistently fallen below that required to make an impact on poverty, and on most socio-economic indicators Malawi compares unfavourably with her regional neighbours. Malawi's exports are dominated by commodities (like tobacco) where the terms of trade are turning against the country. A number of efforts have been made by the Government of Malawi to move into new export sectors however the poor economic climate (high interest rates and inflation), the poor state of utilities and very high transport costs have hampered them. Yet, in recent years Malawi has achieved notable success in the export of services – the export of skilled medical personnel – without any policy effort. Trade in services is increasingly being given more attention as a potential source of foreign exchange for land-locked countries such as Malawi that are struggling to compete in the world trading system and appear to have no comparative advantage in any product sector. But this "brain drain" has been described as rich countries "looting" doctors and nurses from developing countries [1]. The Malawi press has also described how the "nurses brain drain" is resulting in significantly reduced quality of care in public hospitals in the country [2,3]. The costs of the "brain-drain" are perceived as being much greater than the gains and include loss of public educational investment, intellectual capital, fewer and poorer health services, and understaffing of services [4-7]. Some recent research, however, has suggested that health sector migration might be a "win-win" for both developing and developed countries, if properly managed [8]. The purpose of this paper is to explore the costs and benefits of this migration to Malawi, and to determine what policy measures are required. Discussion The scale of the brain drain in Malawi and mitigation attempts Many commentators in both the developed and developing world see this "brain drain" of essential medical staff from poor and HIV/AIDS afflicted countries such as Malawi as something which is fundamentally wrong. At first glance these arguments are compelling and draw upon the idea that developed countries are exploiting the developing world by taking the few trained medical staff away from essential work. In a recent and full analysis, the Ministry of Health in Malawi has described the human resource situation as "critical" [9]. As can be seen in Table 1, the level of vacancies across the entire public health system is acute with an overall vacancy rate of 33 percent. However, this figure masks the severe shortage of nurses where 64 percent of established posts are unfilled. For surgeons and various types of doctor, the vacancy ratio reaches close to 100 percent. Of Malawi's 156 public sector doctors, 81 are working in central hospitals meaning that some districts do not have any doctor at all. Clinical Officer posts are much better filled (73%). The MoH document continues to state that the average number of nurses in health centres is approximately 1.9, an indication that many are run with one or none at all and indeed, some health centres are now manned as health posts by Health Surveillance Assistants with as little as ten weeks of training. In its national development plans, the Government of Malawi provides for the implementation of an Essential Table 1: Established posts and vacancies in Malawi's pu (...truncated)