Department of Global Health Lecture Series Amy Hagopian October 7, 2008 'HELP WANTED! Problems in Health Workforce Globalization.'

1. HELP WANTED : Problems in Health Workforce Globalization Amy Hagopian U.W. Department of Global Health October 7, 2008

3. Caveats about this talk: Focus on physicians Focus on Africa

6. An example from Mozambique A computer model using interlocking spreadsheets to predict health workforce needs based on treatment guidelines. Hagopian & Micek, HRH 2008.

8. New Graduates, 1985 to 2005 Slide from Pascal Zurn New grads per capita, OECD avg.

9. WHO: Africa has 24% of the world’s disease burden, but only 2% of the world’s health care workers. (Scheffler, 2008)

10. Physician Density per 100,000 Population Source: World Health Organization (2006) Working Together for Health. The World Health Report 2006: WHO Press.

11. Countries with a critical shortage of health service providers and respective emigration factors 13.9 13.9 10.7 8.4 1.3 1.7 5.2 1.6 1.4 Source: Mullan, F. (2005). The Metrics of the Physician Brain Drain. NEJM: 353:1810-1818. Source: World Health Organization (2006) Working Together for Health. The World Health Report 2006: WHO Press.

12. African docs in the U.S.= 6127 10 medical schools in 5 countries produce 75% of African migrants to the U.S. http://www.human-resources-health.com/content/2/1/17 Source: AMA masterfile School Country U.S. Physicians Nigeria 2636 South Africa 1901 Ghana 561 Ethiopia 359 Sudan 268 Others 546

13. Characteristics of Physician Workforces of US, UK, Canada, & Australia Source: Mullan, F. (2005). The Metrics of the Physician Brain Drain. NEJM: 353:1810-1818. Geez. Country Physicians per 100,000 population % IMGs in MD workforce (total IMGs) % IMGs from lower income countries % IMGs from other three countries U.S. 293 25.0 (208,733) 60.2 6.5 U.K. 231 28.3 (39,266) 75.2 2.5 Canada 220 23.1 (15,701) 43.4 22.3 Australia 271 26.5 (14,346) 40.0 33.5

14. Foreign-trained proportion of new doctors in rich countries is growing over time As a result of the growth in the demand for health professionals, combined with reduced domestic training rates, foreign trained doctors have made a progressively greater contribution to the health workforce in many OECD countries.

15. Source: OECD population censuses and population registers, circa 2000. Authors’ calculations Foreign-born doctors and nurses in OECD countries, by birthplace 50,000 20,000

16. Nurses Applying for External Licensing by Qualification, Uganda 2000-2005 (n=586) Over 75% of the nursing workforce applying for out-migration are Registered Nurses or Midwives. … Using routine licensure data (newly computerized)

17. New York Times June 24, 2007, graphic by Farhana Hossain from UN Population Division data http://www.nytimes.com/ref/world/20070622_CAPEVERDE_GRAPHIC.html Global Migration Snapshot

21. Migration theory Equinet diagram: Padarath

30. Money Source: Lancet, Vol 371 February 23, 2008, p. 675-681 - McCoy, Bennett, et al. Zambian doctor makes $1400/month Ghanaian doctor makes $1200/month after moonlighting American doctor makes $160,000 per year. Any questions?

35. August 2003 headline, Accra

37. Stakeholder: foreign medical schools

43. Stakeholders: Certain key U.S. states NY CA TX MD IL GA PA NJ FL OH MA

45. Seattle’s immigrant rights march May 1, 2006

48. At 2.5 workers per 1,000, health service coverage tends to level off 1yr olds fully Immunized against measles Births attended by skilled health personnel JLI report Fig. 1.3 Liberia, CAR, Chad, Mali, Eritrea, Ethiopia, the Gambia, Rwanda and Somalia have <.25 workers per 1,000 2.5 workers per 1000 population is minimum standard to achieve basic health goals

50. Doctors leave with other professionals Source: OECD International Migration Outlook, 2007, p. 177-Slide thanks to Pascal Zurn High rates of emigration of doctors is also generally associated with high rates of emigration of tertiary trained people in general . Highly skilled Doctors R=.6723

55. Focus on the public sector

56. Appeal to rich countries “ T he obvious solution is for wealthier countries to reimburse Africa's health and educational systems for the cost of poaching their professionals .” August 13, 2004 Africa's Health-Care Brain Drain s Africa tries to fight AIDS, the single most serious obstacle is a desperate shortage of health workers. Yet at the same time, doctors, nurses and pharmacists in English-speaking African countries are emigrating in droves to Britain, the United States, Canada and Australia. In Ghana and Zimbabwe, three-quarters of all doctors emigrate within a few years of completing medical school. Randall Tobias, President Bush's global AIDS coordinator, said in a recent speech that there were more Ethiopian-trained doctors practicing in Chicago than in Ethiopia. The problem isn't new, particularly when it comes to African doctors, but as Celia Dugger wrote recently in The Times, the flight of nurses is a growing phenomenon, fueled principally by the nursing shortages in wealthy nations. Instead of paying salaries that would attract homegrown nurses, American hospitals recruit in the Caribbean, the Philippines, India and Africa. The same is true in Britain. From 1994 to 2001, the number of nurses registering to work in Britain who came from outside Europe grew to 15,000 from 2,000. The group Physicians for Human Rights recently published a detailed report about this problem and its consequences. One is that the world's poorest countries are providing enormous quantities of medical aid to the richest. The United Nations estimates that every time Malawi educates a doctor who practices in Britain, it saves Britain $184,000. It's understandable why overseas work is attractive. AIDS and tuberculosis have stretched African health services to the breaking point, placing impossible demands on nurses in particular. They do their jobs without adequate equipment or drugs. Their paychecks sometimes arrive months late. They risk infection - in some places, even gloves are scarce. While rich countries average 222 doctors per 100,000 people, Uganda has fewer than 6. Malawi has 17 nurses for every 100,000 citizens; many rich countries have more than 1,000. This is a problem with no easy solutions. One of the worst ideas would be any sort of restrictions on emigration, which would not only be discriminatory, but also counterproductive. Africans would be even less likely to choose careers in medicine. Nevertheless, it's unseemly for wealthy countries, which could afford to pay nurses enough to create an ample homegrown supply, to run ads instead to recruit skilled staff in places like South Africa. In 2001, the British National Health Service swore off recruiting nurses from countries without their governments' agreement, but private hospitals and nursing homes still do it. African doctors and nurses understand how much they are needed at home, and many would resist relocation if the conditions under which they work were more bearable. The obvious long-term solution to the medical brain drain is for wealthier countries to reimburse Africa's health and educational systems for the cost of poaching their professionals, and to greatly increase the financing and technical help for Africa's health systems - in their entirety, not just the clinics that deal with AIDS. The concern over AIDS, paradoxically, has created an opportunity by focusing world attention on Africa's miserable health care. Improving it would cost very little money, relatively speaking, and end the exodus of doctors and nurses that is exacerbating the epidemic's devastation. Copyright 2004 The New York Times Company | Home | Privacy Policy | Search | Corrections | RSS | Help | Back to Top

57. Norwegian Principles

67. END END.