In his article "How The Brain Drain To The West Worsens Africa's Public Health Crisis" Rotimi Sankore documents very well the devastating effect of the "brain drain" on Africa's health services, and the appalling cost to the continent of subsidising health services in rich countries. However, there is one measure which would address this problem very effectively, but which is rarely proposed, even though it is the key to Cuba's success in maintaining its high standards of health and doctor-population ratio of 1 to 165. This is for African countries to stop aiming for "equivalence" with the West in the training of health professionals.

At the moment most countries strive hard to maintain professional qualifications that are recognised in rich countries or provide a relatively easy stepping-stone to achieving registration there. Though there is much waffle about "maintaining standards", the real reason is so that the professionals who determine these qualifications (or their children) can readily leave Africa to work in rich countries. The training of doctors, nurses, dentists, pharmacists and other health workers should instead be focusing on African health needs, which differ greatly from those of rich countries. If African health qualifications didn't make it easy to get registered in the UK, Canada or the US, then much of the brain drain would stop.

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In its 2006 annual report, the WHO reports that out of 57 countries, 36 countries in sub-Saharan Africa suffer from a severe shortage of health workers, such as doctors, nurses, pharmacists, lab technologists, radiographers and other frontline or support staff. Rotimi Sankore argues that the ‘brain drain’ is slowly and indirectly killing the continent.

In times of crisis and epidemics, diplomacy is a luxury the dying cannot afford, especially when millions of Africans know that an over emphasis on niceties will almost surely lead to millions more deaths.

Conventional wisdom has it that Africa is suffering from an AIDS crisis. In reality, Africa is suffering from a public health crisis, and the AIDS pandemic is the most significant symptom of that crisis, which has been worsened by the drain on Africa’s healthcare workforce to the ‘West’. The amazingly wrong political diagnosis of the challenging healthcare problems facing Africa and indeed the planet, has blunted the obvious fact that tuberculosis, malaria, a host of other preventable diseases and malnutrition still claim more African lives than the 2 million deaths attributed to HIV/AIDS annually. Combined with HIV and AIDS, these diseases are rapidly turning Africa into a continental graveyard. Yet the emphasis remains mainly on AIDS, which has been crowned the most sexy villain.

The countries with little or no health worker shortages and better health infrastructure have managed to cope better with HIV/AIDS because they are better able with preventable diseases like TB, sexually transmitted infections, sexual and reproductive rights education and malnutrition. AIDS is a problem on its own, but it is also being fed by other unresolved health problems and the lack of political will and courage. Resolving Africa’s public healthcare crisis will resolve most of the other issues and be a step towards isolating AIDS which can then be tackled more easily. The first step must be resolving the health worker shortages, which includes dealing with the “brain drain”.

2006 has been a landmark year for HIV/AIDS in terms of the number of huge international meetings and conferences organised. These include the Abuja African Union Special Summit on HIV/AIDS, Tuberculosis and Malaria in June; the UN General Assembly Special Session on HIV/AIDS (UNGASS); and the 16th International AIDS Conference in Toronto in August.

These events reflect the huge progress that has been made in tackling HIV/AIDS. With the exception of the most backward governments and institutions, it is clearly understood by the majority that inequality in gender relations is one of the most significant factors behind heterosexual transmission.

On the other hand, these events underscore the huge failures and missed opportunities in the struggle against HIV/AIDS, the biggest yet being the comprehensive failure to resolve the human resource and health infrastructure crisis in Africa.

The problem seems to be that acknowledging, prioritising and acting on the “brain drain” problem means that governments of countries that have benefited from the “brain drain” have to take responsibility, and cease their recruitment of healthcare workers from Africa. Likewise, many African governments will also have to address their governance problems and the working conditions for healthcare workers as means to counter the “brain drain”.

United Nations population researchers conclude that unless the spread of HIV is halted or reversed, Africa will top the global AIDS death league with about 100 million deaths by 2025. This is more than double the projections for India and China of 31 million and 18 million respectively, both of which have larger populations than Africa. People aged between 16 and 45 years of age will be most affected.

It is remarkable that institutions and social movements alike focus not on the continent’s health care crises, but on anti-retroviral drugs only. Anti-retroviral drugs are useful but when there are no healthcare workers to administer them to patients, they become useless

To drive the point home, let me put it like this, no war can be fought successfully without soldiers.

In April 2006, the World Health Organisation (WHO) officially acknowledged what African intellectuals have been saying for the last three decades, that the “brain drain” from all sectors of African society, but especially from the health sector, is slowly and indirectly killing the continent.

In its 2006 annual report, the WHO reports that out of 57 countries, 36 countries in sub-Saharan Africa suffer from a severe shortage of health workers, such as doctors, nurses, pharmacists, lab technologists, radiographers and other frontline or support staff. The report noted that the richest countries are filling their shortages by draining away doctors, nurses and others from less developed countries. As a result, one in four doctors and one in twenty nurses trained in Africa, is now working in the 30 most industrialised countries. Consequently, Africa is the only continent where the absolute number of shortage of health workers (817,992) far outstrips the current stock of 590,198.

Other studies have shown that “the majority of the countries in sub-Saharan Africa also do not meet the WHO’s recommended ratio of 1 to 1,000 [doctors]. Indeed, there are fewer than 10 doctors for every 100,000 people in 24 of the 44 Sub-Saharan African countries for which the statistics are available.” (Orji, Utsimi & Uwaje in paper presented to the International eHealth Association in 2005).

In contrast, Cuba has a doctor-population ratio of 1 to 165, South Korea 1 to 337, the UK 1 to 610, the USA 1 to 358, and Italy 1 to 165 (UNDP/Human Development Report, 2004). Figures from the International Development Research Centre (IDRC) state that on average, “The doctor-patient ratio is currently one per 500 in wealthy countries, and only one per 25 000 in the 25 poorest countries.”

The main factor that contributes to the low doctor-patient ratio in Africa is the “brain drain”. Quoting WHO and OECD figures amongst others, the IDRC illustrates the problem in Nigeria and South Africa. “One-third to a half of all graduating doctors in South Africa migrate to the US, UK and Canada, at a huge annual cost to South Africa (lost investment in education/training). Including all health personnel, the losses for South Africa reach US$37 million annually. This exceeds the combined (multilateral and bilateral) estimated education assistance for all purposes, not just health professional training, received by South Africa in 2000.” Alongside this, “over 21 000 Nigerian doctors are practising in the US, while there is an acute shortage of physicians in Nigeria.”

Not surprisingly, the IDRC concludes that “another reason for the deterioration of health-care systems in developing countries is the ‘brain drain’ of health professionals… which primarily benefits wealthier nations, such as the UK, the US and Canada, [and] calls into question G8 commitments to support developing countries in reaching health targets of the International and Millennium Development Goals”.

IDRC findings also reveal that “developing countries invest about US$500 million each year in training health-care professionals, who are then recruited by or otherwise move to developed countries… Meanwhile the United States, with its 130, 000 foreign physicians, saved an estimated US$26 billion in training costs for nationals… while estimates suggest that Africa spends approximately US$4 billion annually on salaries of 100 000 foreign experts (all sectors, not only health) to ‘build capacity’ and/or provide technical assistance, and incurs a loss of US$184 000 per migrating African professional”.

Dr Peter Ngatia of AMREF puts it more sharply: “Africa literally subsidises the West. It is a reverse subsidy from the poor to the rich… History is replete with instances of outflows of human resources from Africa to the rest of the world. The disgraceful and shameful slave trade epitomises this outflow, which robbed parts of the African continent of its young and strong-bodied men and women. This was followed by the colonial exploitation of the same in-fighting imperial wars that had nothing to do with Africa. The recent migration of workers, in the opinion of many, is nothing new. It is a perpetuation and perfection of what started centuries ago and has continued unabated.”

He expands by saying “According to the International Organisation for Migration (IOM), Africa has already lost one third of its human capital and is continuing to lose its skilled personnel at an increasing rate, with an estimated 20,000 doctors, university lecturers, engineers and other professionals leaving the continent annually since 1990. This same source estimates that there are currently 300,000 highly qualified Africans in the diaspora, 30,000 of whom have PhDs.”

Taking these factors into account, a coalition led by the US based Physicians for Human Rights, HIV Medicine Association and Association of Nurses in AIDS Care issued a 15 point plan at the July 2006 G8 summit aimed at ending Africa’s healthcare worker shortage. The statement emphasised that “G8 countries, particularly the US and UK, should reduce their reliance on health workers from abroad and seek to become self-sufficient in meeting their own health worker needs. For example, they should increase the domestic training of nurses, doctors, and other health workers. The United States should also develop a code of practice on international recruitment of health professionals, which includes not actively recruiting health workers from developing countries except in the context of an agreement with those countries that respects the right to health in those countries and is mutually beneficial.”

The British Medical Association has also cautioned that severe shortage of healthcare workers in sub-Saharan Africa because of migration to developed countries is a significant component of Africa’s AIDS crisis, and that countries like the UK must end their reliance on overseas doctors and nurses.

It is crucial to continue to stress the role of the “brain drain” in undermining African development in order to fight the myth that millions of Africans are dying of AIDS because Africa is a useless continent incapable of saving itself from anything. But stressing this is not enough. Africans must also lead from the front, or complain all the way to their graves, where only the silence of the tombstones will speak for them.

There is no doubt that Africa can rebuild its healthcare workforce both by further training and attracting some of those in the diaspora back home. The fact that a small country like Cuba, despite political and economic constraints, has a better doctor to patient ratio than most of the world’s developed countries also shows that it can be done by any country with the right healthcare priorities.

There is no human right more significant than the right to quality public health care. The infected and the deceased need first to live in order that all other rights to be significant.

This is why, as a contribution towards upholding the right to a healthy life in Africa and resolving Africa’s health care crisis, the AIDS and Public Health Program of CREDO-Africa, together with partners in Africa and around the world, are launching a campaign towards:

- That African governments make resolving the health worker shortage their number one public health care priority.
- That governments of countries that have benefited most from the “brain drain” cease such policies and examine ways to compensate Africa’s health care system for the damage their recruitment policies have done. - That the theme of the next International Aids Conference is focussed on scaling up human resources and health care infrastructure, especially in Africa.
- That all intergovernmental organisations such as UNAIDS and its key agencies focus on and act rapidly towards resolving the human resource and infrastructure shortages in Africa and the infrastructure in the next eight to 10 years.

*Sankore is Coordinator of Centre for Research Education & Development of Rights in Africa [CREDO-Africa]. He can be contacted at: [email][email protected]

*Please send comments to [email protected] or comment online at www.pambazuka.org