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New Cannibal Markets

Jean-Daniel Rainhorn
Samira El Boudamoussi

Part 3. Brain Theft

An Unfair Trade? Mobility of Africa’s Health Professionals

Delanyo Dovlo et Sheila Mburu

Texte intégral

1Africa has the lowest density of health professionals per population and yet has lost and continues to lose a significant portion of its health-workers to wealthier countries. It has 24% of the global disease burden but only 3% of global health workforce, compared to the Americas with 37% of health-workers and 10% of the disease burden, and Europe with 35% and 10% respectively (WHO 2006). The supply in sub-Saharan African countries is not improving, and these countries have only 7.5% of the global supply of medical schools and an annual production of 10,000 graduates, which is extremely low given the disease burden (Kasper and Bajunirwe 2012). Of the 49 countries identified by the World Bank as being low-income countries, 36 are in sub-Saharan Africa and only five meet the health-worker threshold required to achieve minimum health-care (WHO 2010).

2For many of the high-income destinations attracting health professionals from low-income countries (LIC), the influx of LIC health professionals probably constitutes a relatively small percentage of their workforce. However, for the source countries, it can be a devastating loss.

3In this context, can health “labor” or skills be considered a commodity? More specifically, are trained health professionals simply selling a service and therefore not a commodity? We suggest that since the skills that provide the service are indivisible from the person/body, health professionals, having been trained along internationally defined standards and norms, by definition can be considered a global commodity subject to trade practices. However, the brain drain or trade in health professionals from sub-Saharan Africa is not a simple labor market issue, but has many ethical, moral, and socio-economic aspects that have a negative impact on the source countries.

4This paper reviews the status and trends in migration of health professionals from sub-Saharan African countries, along with the health, social, and economic impacts these migrations may cause and the ethical and moral issues resulting from entrenched trade and economic inequalities and power relations between source and destination countries.

5Our view is that this is a trade that has clear winners and losers, and any gains for source countries such as remittances and return with improved skills may not adequately match the full extent of the losses.

6Advocacy for free trade often includes arguments for free labor mobility and health professionals’ rights to choose where to live and work. Such rights-based arguments are undermined by destination countries selectively and unevenly applying these rights to less well educated/lower-skilled migrants. Sub-Saharan African countries may therefore be denuded (or looted) of health professionals, while barriers are created to bar their likely patients who seek to exercise these same rights. A 2013 joint report by the United Nations Department of Economic and Social Affairs (UN-DESA) and the Organisation for Economic Co-operation and Development (OECD) estimated that one in nine African graduates live in an OECD country. In many sub-Saharan African (SSA) countries, the skilled-worker emigration rate was much higher than for the population as a whole.

7However, it must be noted that the issues of ethics and morality in transforming health professionals into commodities are important to both destination and source countries. This is because major push factors include not only income and economics, but leadership, governance, and accountability challenges in poor countries.

8In destination countries, the European Commission found that the domestic physician workforce is comprised of 23% to 28% international medical graduates (IMGs), and 40% to 75% of these IMGs are from low-income countries (European Commission 2012).

9Overall, the problem is likely to continue given the global shortage of health professionals. In 2000, the global health-worker shortage was estimated at 9 million doctors and 15 million nurses and midwives (Joint Learning Initiative 2004).

10The basic dynamics of health-worker flows depend on both inflow and outflow (see Figure 1). Clearly, the production of health professionals is low in sub-Saharan African countries, and the stock of health-workers is generally lower than the numbers expected to provide minimum services to their populations. This is further exacerbated by both active and passive losses to migration, for which the recompense is unclear. At a glance, these significant outflows can only deplete this resource, which is both an inert commodity and one that does contribute to the development of good health services and better living standards while the health-worker is still a resident in the source country.

Figure 1. Dynamics of health-worker flows. (Adapted from Human Resources for Health: Overcoming the crisis. Joint Learning Initiative, 2004.)

Figure 1. Dynamics of health-worker flows. (Adapted from Human Resources for Health: Overcoming the crisis. Joint Learning Initiative, 2004.)

The labor market for sub-Saharan African health professionals

11Conventional wisdom dictates that the loss of health professionals from some of the least developed countries is devastating for their health and development efforts, and while there is a demand and supply situation underlying any analysis of this market, we argue that if we aim to find comprehensive and coherent solutions, a discussion of ethics and morality must also be part of the analysis, as is the case with tissue and organ movements.

12The demand for health professionals is high worldwide as the ageing population expands in developed countries—this phenomenon is nascent in LICs as well—and health patterns change, resulting in increasing need for care of chronic non-communicable diseases over an ever-increasing life expectancy. The number of elderly persons aged 65 and over in the European Union (EU) is projected to almost double over the next 50 years, from 87 million in 2010 to 152.7 million in 2060 (European Commission 2012). This also affects health professionals and, in 2009, it was estimated that some 30% of doctors in the EU were over 55 years old and that by 2020, 60,000 doctors would retire annually (Mills et al. 2008). The average age of nurses currently employed in the EU is 45 to 50 years old! Despite these well-documented shortfalls in the rich countries, supply/production of health professionals has not been adequately increased, leaving room for recruitment from poorer countries to fill a significant part of that demand.

13The migration phenomenon is perhaps greatest in countries that share a colonial history and therefore some level of linguistic and professional compatibility and where often qualifications can be accepted with moderate retraining or orientation.

14In this paper, we consider health professionals to be a commodity because the definition of the main frameworks that apply to doctors, nurses, and midwives are nearly universal. There are global standards and generic core functions that can arguably be similarly utilized anywhere. An example of a commodity-driven approach to health-care professionals is that of Cuba “trading” health-worker services for oil with Venezuela. Cuban medical brigades in SSA countries are also sources of official foreign exchange, traded for goods needed in Cuba.

15Indeed some countries in Asia, such as the Philippines and India, have followed an “export” model, producing excess health-workers and encouraging migration to gain from their remittances (Dimaya et al. 2012). But is this fair trade when the trade is an unwilling exchange, yields negative consequences for the vendor, and the market is overwhelmingly unbalanced in favor of the economically powerful?

16The supply situation of health professionals is dire in sub-Saharan Africa and many low-income countries but is also inadequate in countries that could afford to increase supply comfortably. For example, the annual supply of doctors is still significantly higher in Europe and the Americas (see Figure 2), but as demand remains higher and is increasing in these countries, the supply remains significantly inadequate to begin to satisfy needs.

Figure 2. Health-worker Inflow per World Health Organization (WHO) region. Yearly production of medical graduates (Adapted from Human Resources for Health: Overcoming the crisis. Joint Learning Initiative, 2004).

Figure 2. Health-worker Inflow per World Health Organization (WHO) region. Yearly production of medical graduates (Adapted from Human Resources for Health: Overcoming the crisis. Joint Learning Initiative, 2004).

17The European Commission estimates a potential shortfall of around one million health-care workers by 2020 (Table 1), rising up to two million if long-term care and ancillary professions are taken into account. This means around 15% of total care will not be covered.

Table 1. Health-worker shortage in the European Union by 2020 (European Commission 2012).


Estimated shortage

Estimated% of care not covered




Dentists, pharmacists and physiotherapists









Health-worker shortage estimates from selected EU countries (European Commission 2012)
Italy—13,500 nurses were due to retire in 2010, but only 8,500 were trained in 2008–2009. Competition for graduates is high, and many end up in different higher paid sectors
Finland—Shortages specifically in rural areas, and health-worker shortage predicted to reach over 200,000 by 2020.
Germany—There was a shortage of 17,000 doctors in 2010. This is projected to rise to 45,000 doctors in 2020 and 135,000 in 2030. Also shortage of elderly-care nurses.
Hungary—19% of public health physician positions were vacant and 13% of physicians in 2008.
Spain—Forecasted shortfall by 25% of health workforce by 2025. Persistent shortages of specialists.
United Kingdom—Severe shortages of 35 specific health-related professions. Unless training posts are revised, the shortage of general practitioners and medical specialists could be greater than 6,000.

18Global demand outstrips the global supply, but clearly the trade advantage in health professionals shall continue to rest with the richer countries on account of the strong pull factors of better income and living standards and the obverse push factors in source countries.

19In effect, Sub-Saharan African countries participate in a “perverse subsidy” by investing their scarce resources to train health professionals that are then used by rich countries not ready or willing to make their own such investments. The loss of the investment in health professionals training in sub-Saharan Africa is estimated to be $2.1 billion and the gain to destination countries from avoiding training and other investments at $4.54 billion (Mills et al. 2012). Table 2 presents the estimated loss of investment in some sub-Saharan African countries and the estimated gains in training and investment costs in destination countries.

Table 2. Estimated loss of investment in some sub-Saharan African countries and the estimated gains in training and investment costs in destination countries (Mills et al. 2012).

Table 2. Estimated loss of investment in some sub-Saharan African countries and the estimated gains in training and investment costs in destination countries (Mills et al. 2012).

20While individual health-workers and their families may gain substantially from migration, the lost cost to society comes from investments made in their training and the loss of their likely contribution to the economy.

21A 2008 World Bank study found that higher-skilled health-workers tend to remit a smaller proportion of their wages compared to less-educated migrants (Niimi et al. 2008). The generic numbers also hide a number of negative externalities. Often a higher proportion of educators and specialists are lost, and this further undermines the source countries’ ability to sustain or even begin to increase the supply of new health-workers and to replace losses. The loss of well-trained health professionals and health service may undermine the establishment of a middle class and/or reduce the attractiveness of the source country as a destination for investment and development growth. Furthermore, a recent study of the United States job market showed that immigrants with a bachelor’s degree from 7 out of 15 African countries surveyed had less than 40% chance of ending up in a skilled job (Ratha et al. 2011).

22It is also documented that at times qualified physicians from LICs may have to retrain as nurses or take on lower jobs inconsistent with their qualifications or specialties in order to remain employed (Runnels et al. 2011).

23The rights of movement of natural persons and services is well documented under the General Agreement on Trade in Services (GATS), Mode 4 (WTO 1995). However the rights of poor countries, populations, and communities to expect dividends from their investments remain unclear and under-debated. Would it be ethical to remove two kidneys from a poor donor who needs the money? Is it fair for already struggling countries to be undermined further? What will be a good and fair recompense for a kidney or for a health professional? Is it trafficking when a human “commodity” is moved between countries without firm rules and agreements; especially when third parties and agents are often involved (sometimes to shield the direct involvement of government agencies)?

24Notwithstanding the foregoing discussions, there are indeed gains for source countries, but do these gains offset the core costs of brain drain?

25Remittances were found to be the highest source of foreign income in many African countries equaling some $60 billion in 2012, which is much more than obtained from aid or foreign direct investment (World Bank 2013). For example, in Lesotho, Senegal, and Togo, remittances accounted for 30.2%, 10.8%, and 10.2% of their GDP respectively, measured between 2008 and 2011 (Ncube and Brixiova 2013).

26Whether such remittances adequately cover the loss source countries suffer is arguable for a number of reasons. Remittances are interpersonal transfers that are relatively unstable and difficult for source countries to document effectively. The irregular flow of remittances makes it an ineffective source of resources that, for example, countries could mobilize for securitization of bonds or for long term investment planning. Individuals often use remittances for simple basic consumption, medication, or building private homes, and rarely as an investment in core human capital. Taxes on remittances are estimated to be highest on flows to Sub-Saharan Africa at 12% compared to a global average of 8% to 9% (AIR and World Bank 2013), therefore earnings by migrants are perhaps taxed twice by destination countries. Again, World Bank studies in 2008 (Niimi et al. 2008) indicate that on average highly skilled migrants (such as health professionals) remit less than lower-qualified migrants, who perhaps did not benefit as much from national investments in training. Skilled and wealthier migrants tended to migrate with the entire family and often come from the richer families in source countries, that do not require as much support to be remitted home.

27The financial gains for destination countries estimated by Mills et al. (2012) illustrate the so-called “perverse subsidy” of developed country health-care costs by very poor countries. In addition to the financial loss of training costs, the loss of key professionals impacts on their roles as local employers and users of local commerce and services, but even more important is the loss of specialists and trainers that are required to produce the next generation it represents. For example, in Ghana, the average age of medical school lecturers was said to have risen from 36 to 55 over a decade, likely due to the migration of younger lecturers (Martineau et al. 2002).

28However, other researchers talk of a “brain circulation” as a gain, with returning migrants offering their homelands improved knowledge, skills, and technology.

29In general, the global labor market in health professionals can be argued to be an unfair one, made up of an unwilling trade by poor countries of a commodity or persons that are vital to their populations’ well-being, much in the same way as the loss of a kidney may not be adequately compensated for and may eventually be detrimental to the “donor.”

Ethics and morality, and the motivation to behave well

30The issues of ethics and morality and commodification do cut both ways, requiring leaders in both poor and rich countries—sources and destinations—to modify economics and markets with common sense morality. Much migration of health professionals is motivated by significant “push” factors in the source countries as well as the pulls from the destinations.

31Since the early to mid-2000 a variety of efforts have been made to create an ethical dimension to the management of health professionals’ migration and brain drain. The latest was the voluntary code developed by the World Health Organization and endorsed by the World Health Assembly in 2011 (WHO 2010). A variety of international professional groups have also developed sets of guidelines on “ethical recruitment” from countries with limited human resources. The more common codes are described in Table 3. South Africa has since implemented a policy of non-recruitment of health professionals from neighboring countries as a principle (South African Department of Health 2002) and in cognizance of the effects that such recruitment has on populations in the source countries. It also tightened post-graduate training arrangements in order to restrict retention of foreign graduates.

32With the economic crises in many developed (and developing) countries, the increasing demands for more care and the shortage of health-workers, the ethical suasion measures have been restricted to voluntary “guidance” that clearly has not made much impact to date. These guidelines perhaps provide a moral cover without giving stronger incentives for effective implementation. Many appear to have been weakened as part of the negotiations in order to get the buy-in of powerful destination countries.

33The example of South Africa’s bilateral agreement and the law barring recruitment from SSA appears to be the sole successful mechanism, reducing South African health-worker registration in the United Kingdom from 3,206 in 2003 to 4 in 2004 (Blacklock et al. 2012).

34Similar issues of need and demand found in the case of tissue and organ reception from less-resourced persons provide perhaps a more dramatic sense of morality as well as a clearer definition of trafficking. However, in both cases—migrants and organ donors—the source is willing due to poverty and the information gap rather than free choice.

Table 3. Ethical recruitment guidelines and codes.

WHO code for international recruitment of health-workers (WHO 2010)

The rights and obligations of source countries, destination countries, and health-workers themselves. Implemented by very few countries. Its voluntary nature gave little incentive for implementation.

National Health Service code (UK Dept. of Health 2000)

Provided a list of 151 countries that recruiters are prohibited from recruiting from. Initially only targeted National Health Service and the private sector could still recruit. In 2003, recruited African health-workers rose by 174% to 4,626.

World Organization of Family Doctors (WONCA 2002)

Focus is on sufficient training of domestic health-workers to prevent international recruitment.

International Council of Nurses–Ethical Nurse Recruitment (ICN 2007)

Code focuses on the treatment of nurses during the recruitment process, whilst in destination countries, and their individual rights as migrant workers.

Commonwealth Code (Commonwealth Health Ministers 2003)

Commonwealth ministers of health agreed that a consensus would be reached regarding the problem of international recruitment of health-workers from resource poor countries. Some countries (including the United Kingdom—one of the largest health-worker recruiters) refused to sign due to the compensation clause.

South African Recruitment Policy (South African Dept. of Health 2002)

South Africa successfully implemented a law to stop recruitment of health-workers from neighboring resource-poor countries. An unrelated bilateral agreement between the United Kingdom and South Africa reduced health-worker migration from South Africa drastically (from 3,206 registered in 2003 to 4 in 2004).

Summary and conclusions

35Migration of health-workers remains an important issue for sub-Saharan Africa where 36 of 57 “human resources for health (HRH) crisis” countries are located (WHO 2006). A number of initiatives have been launched to improve medical and nursing education and output, such as the US President’s Emergency Plan for AIDS Relief (PEPFAR) and supported Medical and Nursing Education Partnership Initiatives (Mullan et al. 2012). However, the key issue is to ensure that the cosmopolitan/standard graduates graduating from such initiatives do not become even more attractive to destination labor markets.

36The discussion around compensation has been a muted and difficult one, as destination countries are reluctant to consider it and in many cases, it is unclear how this would be computed in terms of who should be compensated, exactly what they should be compensated for, and how source governments could be obligated to utilize such funds effectively and transparently. The increasing number of private and fee-paying health training schools also undermine the rationale for compensation to governments.

37In the calculation as it stands, countries of the sub-Saharan Africa are losers in this trade, and the destination European countries (especially those with colonial and linguistic links to source countries) and the United States appear to be the big winners in what can only be a very lopsided market.

38The movement of health-workers can indeed be likened to that of a commodity, which has similar global “specifications” and is used around the world. Global health organizations continue to promote the core designations and typologies that can readily be moved between countries, through standardized curricula and education approaches and cross-border professional associations that may encourage global equivalences for health work.

39Not much donor investment nor many education initiatives appear to have gone into the development and expansions of more locally relevant and non-internationally reciprocated cadres such as medical assistants and clinical officers in SSA countries, who tend to migrate much less. Furthermore, there is no indication that OECD countries are likely to rapidly and significantly increase health-worker training to address the serious shortages in EU countries.

40There are of course great benefits to individual health-professional migrants and their families, and even perhaps indirectly to their countries, but the summation of effects is likely to continue to be to the detriment of vulnerable and poor populations in source countries.

41International professional organizations such as the International Council of Nurses (ICN) and the World Organization of Family Doctors (WONCA) have pushed for ethics and fairness in the working conditions of migrant professionals, but no group seems to speak for the communities and populations forced to continually find dwindling resources to invest in yet another health-worker in order to meet critical health needs.



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Table des illustrations

Titre Figure 1. Dynamics of health-worker flows. (Adapted from Human Resources for Health: Overcoming the crisis. Joint Learning Initiative, 2004.)
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Titre Figure 2. Health-worker Inflow per World Health Organization (WHO) region. Yearly production of medical graduates (Adapted from Human Resources for Health: Overcoming the crisis. Joint Learning Initiative, 2004).
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Titre Table 2. Estimated loss of investment in some sub-Saharan African countries and the estimated gains in training and investment costs in destination countries (Mills et al. 2012).
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The WHO Representative to Rwanda until July 2014. Prior to this, he was Health Systems Adviser at WHO-HQ in Geneva. He trained as a general practice physician and public health specialist in Ghana, UK and USA, and has had over thirty years clinical and public health practice experience and is an expert in Human Resources for Health issues. He was a former director of Human Resources for the Ministry of Health of Ghana and has consulted widely on this subject and on health-sector reforms. In July 2014, he was appointed to his current position as director of the Health Systems and Services Cluster, at the WHO Regional Office for Africa in Brazzaville, Congo.

Currently an MSc candidate at the London School of Hygiene and Tropical Medicine. Prior to this, Sheila worked as a consultant in the WHO Rwanda Country Office. During this time she co-wrote and edited WHO’s biennial report, supported national nutrition programs, managed WHO’s online communications and participated in implementation of the UN Communications Strategy. Sheila graduated from the University of Nottingham, with an MSci degree in biochemistry and genetics.

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