PHA-Exchange> Fw: Exporting health

[Maria Hamlin Zuniga]

María Hamlin Zúniga
International People´s Health Council - IPHC
Apartado · 3267
Managua, Nicaragua

Telefax:  505-2662225
iphc at cablenet.com.ni
iphc at cisas.org.ni
----- Original Message -----
From: "Le Monde diplomatique" <english at monde-diplomatique.fr>
To: "Le Monde diplomatique" <english at monde-diplomatique.fr>
Sent: Wednesday, May 15, 2002 4:09 PM
Subject: Exporting health


>
>    Le Monde diplomatique
>
>    -----------------------------------------------------
>
>    May 2002
>
>                  GLOBAL MARKET IN MEDICAL WORKERS
>
>                          Exporting health
>      _______________________________________________________
>
>     There is now an international trade in doctors and nurses,
>     and every year poor countries lose both the $500m that it
>       has cost them to train health workers recruited by the
>       developed world, and the health workers, who could be
>      crucial to a permanent improvement in conditions in the
>                               South.
>
>                                          by DOMINIQUE FROMMEL *
>      _______________________________________________________
>
>      The United Kingdom began to recruit doctors from abroad
>      in December 2001; it had realised that, for the National
>      Health Service to work properly, it would need 8-10,000
>      more doctors by 2004. Earlier in the year South Africa
>      had asked Canada to stop recruiting South African doctors
>      to make up for a shortfall of general practitioners in
>      rural Canadian areas; South Africa had recruited 350
>      Cuban doctors (1) to cover for the exodus of locally
>      trained staff. Ireland hired 55 anaesthetists from India
>      and Pakistan in 2000.
>
>      Even Sweden, with its welfare system, has had to recruit
>      30 Polish doctors. In the United States 23% of doctors
>      qualified abroad; in the UK about 20% of doctors are
>      Asian in origin; in France 8,000 doctors trained abroad,
>      4,400 outside Europe. Many of these are on night call in
>      children's and maternity wards, and X-ray departments of
>      state-run hospitals. But they do not qualify for the same
>      conditions or salaries as do their French colleagues.
>
>      The Gulf states employ 20,000 doctors, mostly from the
>      Indian subcontinent, though such South-South migration is
>      usually temporary (2). This talent drain has serious
>      consequences. By 2000 only 360 of 1,200 doctors who had
>      been trained in Zimbabwe in the 1990s were still working
>      there. Half of the doctors who qualified in Ethiopia,
>      Ghana and Zambia have left home, and many of them no
>      longer work in medicine in their host country. The
>      available statistics about voluntary immigrants and
>      refugees, and nationals born abroad, are not detailed
>      enough to get an accurate picture of migratory movements
>      (3).
>
>      The shortage of nurses is even more acute. In 2000 the UK
>      hired more than 8,000 nurses and midwives from outside
>      the European Union, to join 30,000 overseas nurses
>      already working in state and private hospitals. Forecasts
>      for the US, France and the UK predict a shortfall of tens
>      of thousands of qualified staff by 2010.
>
>      Science has always gained from the circulation of people
>      and ideas, and medicine is no exception. In the Middle
>      Ages, doctors travelled to study in the famous schools of
>      Alexandria, Cordoba, Bologna or Montpellier. Later they
>      sailed with explorers. After Louis Pasteur's medical
>      discoveries, they travelled all over the world and
>      founded tropical medicine. Now only a few doctors still
>      work in Christian missions and Western experts have not
>      replaced them. Nor have NGOs. The flow of doctors and
>      nurses has changed direction since former colonies gained
>      independence. Increased demand in industrialised
>      countries partly accounts for this. The structural
>      adjustment plans imposed by international funding
>      agencies at the beginning of the 1980s, and their
>      disastrous effect on health budgets, are also
>      responsible.
>
>      People do not emigrate just because they are poor and
>      need to earn, or because behaviour patterns change. They
>      mainly leave because they think countries in the North
>      offer qualified professionals a life and career
>      opportunities on a par with their education. Many factors
>      are more important than material benefits (4) political
>      instability, ethnic discrimination, professional
>      dissatisfaction (with bureaucracy, salary arrears,
>      autocratic management, isolation), the gap between
>      learning and achievement, family life.
>
>      The reasons why doctors lose interest in their work are
>      complex. One, which affects both rich and poor countries
>      and is often glossed over, is a crisis in medical
>      thought. Consciously or not, doctors believe that
>      medicine is the solution to human problems. This mirage,
>      which is often given as the reason for entering the
>      profession, soon disappears when material resources run
>      short, and leads to frustration and anger. For most
>      doctors in developing countries, there is no scope for
>      laboratory tests to confirm a diagnosis. The right
>      pharmaceuticals are not available. Minimum standards of
>      hygiene are not possible. Those who are lucky enough to
>      consider emigrating must resolve a dilemma between
>      loyalty to their country, and their duty to care for the
>      sick.
>
>                             Vain hopes
>
>      In its Health for All by the Year 2000 initiative (5),
>      the World Health Organisation (WHO) set targets for
>      developing countries. It aimed to provide a doctor for
>      every 5,000 people and a qualified nurse for every 1,000
>      people, with improved access to treatment, particularly
>      in rural areas. But market forces, unrealistic funding
>      agencies and negligent governments have shattered these
>      hopes. The world average now is one doctor for 4,000
>      people: but that is one for 500 in Western countries, one
>      for 2,500 in India and one for 25,000 in the 25 poorest
>      countries. Free circulation of doctors, nurses and
>      paramedics has created a health gap in developing
>      countries.
>
>      The international bodies responsible for deciding policy
>      on health and fighting social inequality have little to
>      say about this. Since 1979 neither the WHO nor the United
>      Nations Development Programme (UNDP) have published
>      reports on the consequences of this trend for deprived
>      populations (6). The World Bank has produced many studies
>      celebrating the benefits of free markets, but it has not
>      assessed the flow of funds resulting from exchanges of
>      human capital. It no doubt prefers to disregard UN
>      resolution 2417 on the "outflow of trained professional
>      and technical personnel from the developing countries",
>      which bans poaching of specialist professions (7). A
>      country's health service does not contribute directly to
>      its gross domestic product.
>
>      A WHO document, Health for All in the 21st Century,
>      published in 1995, focuses on resources required for a
>      global health policy. But it makes no attempt to control
>      the movement of medical skills (8). And the WHO does not
>      take account of missing doctors and nurses when
>      calculating average lost years of good health an index
>      that factors in premature death and disability. Nor does
>      the UNDP take the brain drain into account in its human
>      development index for each country. It may be impossible
>      to quantify the suffering of people deprived of
>      healthcare, but it is very clear just why infant and
>      maternal mortality has stopped declining.
>
>      Now that public opinion is critical of the global market,
>      the WHO director general has set up a commission on
>      macroeconomics and health to propose a new approach to
>      investment (9). In its report the commission challenges
>      the usual argument that health inevitably improves with
>      economic growth, stressing rather that improved health is
>      essential to development and social progress in
>      low-income countries. It calls for a new pact for health
>      to redefine relations between donor and beneficiary
>      countries. But it scarcely mentions the medical staff
>      required to put proposals into practice. To achieve its
>      objectives, the global fund to fight Aids, tuberculosis,
>      and malaria will need teams of doctors and social
>      workers, in particular to be responsible for monitoring
>      patients treated with antiretroviral drugs.
>
>      It is never easy to evaluate the cost of training
>      doctors, which varies in different parts of the world. It
>      is equally difficult to assess the impact on health
>      services and development. But we can assume that it costs
>      about $60,000 to train a general practitioner in the
>      South and $12,000 for a paramedic. On this basis,
>      developing countries are subsidising North America,
>      Western Europe and Australasia at about $500m a year
>      (10). The World Trade Organisation (WTO), always quick to
>      defend the prerogatives of multinational pharmaceutical
>      groups, seems incapable of understanding how important
>      doctors are to prescribing drugs. Is the WTO counting on
>      street market traders to boost prescription drug sales
>      (11)?
>
>                          Two way benefits
>
>      Is there an inexpensive way of discouraging rich
>      countries from poaching scientists from poorer countries
>      (12)? Several solutions are possible. The first, far from
>      new, has recently attracted attention (13): host
>      countries should compensate those countries that
>      originally trained their doctors and nurses. But it would
>      be hard to apply such a measure without strict
>      international rules. Poor countries could obstruct
>      emigration, or delay it, introducing compulsory community
>      service before qualification. Host countries could demand
>      higher qualifications. But banning emigration will not
>      prevent the deterioration of treatment and government
>      decisions have little real effect on migration.
>
>      The second solution, more far-reaching, would be to
>      bolster the medical profession's image in developing
>      countries. At present doctors cannot effectively deal
>      with the needs of patients because their training is
>      based on a universal concept of curative, scientific
>      medicine that gives marginal importance to public health
>      education. Before doctors can acquire the intellectual
>      and practical tools they need to identify with the
>      development of their countries, they must break with the
>      ideology behind the training founded by former colonial
>      powers (14).
>
>      The new perspective would give priority to preserving
>      health rather than treating disease. It would focus more
>      on the community, less on individuals. It would demand
>      teamwork between different disciplines to reconcile cure
>      and prevention. Hospitals, which only benefit a minority,
>      would have to stop being the only places where quality
>      treatment can be dispensed. This change would oblige
>      management and practitioners to justify their acts to
>      society rather than just to international funding
>      agencies.
>
>      But the switch from a universal approach to an integrated
>      one, based on recognising regional differences and
>      optimising local resources, would be likely to endorse
>      the principle of two-tiered healthcare, one for rich
>      countries, and another for poor ones. And though the West
>      might stop recognising Southern professional
>      qualifications, making it more difficult for health
>      professionals to emigrate, the brightest students would
>      leave anyway. Some 75% of graduates from the All India
>      Institute of Medical Sciences continue their studies in
>      the West (15). It seems likely that, with the
>      international community disregarding their scientific
>      work, the status of doctors who opt to stay at home would
>      decline.
>
>      There is no single answer to the problem. The countries
>      of the South are not all the same, and co-operation must
>      take account of their diversity and what is at stake
>      short and medium term. Some countries (Cuba, Egypt,
>      Spain, Italy, Israel and the Philippines) train more
>      doctors than they can employ. Others (US, Canada and the
>      UK), train too few to keep doctor-patient ratios at a set
>      level. Limiting individual mobility will not prevent
>      emigration by health workers.
>
>      Another solution seems more promising: finding ways to
>      encourage qualified staff to stay put or even return
>      home. This gives everyone equal access to healthcare and
>      encourages investment in education and health. Increasing
>      availability of information and communications technology
>      provides scope for new methods, such as distance learning
>      workshops and interactive networks.
>
>      The workshops act as virtual medical schools, backed by a
>      university in the South and a teaching hospital in Europe
>      or North America. The hospital is responsible for keeping
>      course content up to date and giving students access to
>      specialist libraries. Interactive networks connect
>      expatriate doctors to colleagues at home. Such networks
>      give a new shape to an intellectual and scientific
>      diaspora, fostering North-South collaboration, promoting
>      abroad the work of those who stay at home, and finding
>      ways for emigrants to return temporarily or permanently.
>
>      There are already more than 40 networks, operating in 30
>      countries. Their membership ranges from dozens to
>      hundreds (16). By restoring links with home, while
>      remaining abroad, expatriates can contribute to their
>      countries' development. The UNDP and the International
>      Organisation for Migration are funding the Tokten
>      (transfer of knowledge through expatriate nationals)
>      programme to encourage return. But so far it has had only
>      a limited effect on health services.
>
>      It is difficult to predict population and economic
>      growth, and harder to forecast human resources
>      requirements; and the brain drain is not the uniform
>      result of a single policy affecting the world. Human,
>      cultural and social differences in developing and
>      developed countries have to be considered. The fate of
>      doctors and nurses should be decided neither by
>      directives on world trade by rich countries and the WTO,
>      nor by uncoordinated laws passed by poor countries.
>
>      It is time for the WHO to honour its mandate and define a
>      healthy world based on solidarity and ethical values. The
>      WHO could prompt a debate on the future of trading in
>      public services, involving all UN agencies, economic
>      development and funding agencies, and experts in
>      international law. The objective would be to draw up a
>      convention on international recruitment. It would
>      stipulate the conditions under which developed countries
>      may recruit health workers in countries that are
>      short-staffed (17). This would complement international
>      agreements on qualifications and consolidate the right to
>      good health recognised by the Declaration of Human
>      Rights.
>        ____________________________________________________
>
>      * Doctor, former lecturer at the universities of
>      Minnesota, Paris, Addis Ababa and Calcutta
>
>      (1) Cuba trains more doctors than it needs. It has
>      agreements with several African countries, some of which
>      include financial compensation.
>
>      (2) On changes in migration policy, see Joaquín Arango,
>      "Expliquer les migrations: un regard critique", Revue
>      internationale des Sciences Sociales, Unesco, Paris,
>      September 2000.
>
>      (3) See Sabine Cessou, "Fuite des cerveaux: L'Afrique
>      part en croisade", Marchés tropicaux, Paris, 23 February
>      2001, no 2889. Stephen S Mick, Shoou-Yih D Lee, Walter P
>      Wodchis, "Variations in geographical distribution of
>      foreign and domestically trained physicians in the United
>      States: 'safety net' or 'surplus exacerbation'", Social
>      Science and Medicine, Blackwell, Oxford, vol 50, January
>      2000.
>
>      (4) See Marc-Eric Gruénais and Roland Pourtier (ed), "La
>      santé en Afrique", Afrique Contemporaine, Paris, n° 195,
>      July-September 2000, in particular Marie Badaka,
>      "Profession: médecin".
>
>      (5) Health for All was adopted in 1977 and launched at
>      the Alma Ata conference in 1978.
>
>      (6) Alfonso Mejìa, Helena Pizurki, Erica Royston,
>      "Physician and Nurse Migration: Analysis and Policy
>      Implications", WHO, Geneva, 1979.
>
>      (7) General Assembly, 23rd session, Resolution 2417
>      (XXIII) "Outflow of trained professional and technical
>      personnel at all levels from the developing to the
>      developed countries, its causes, its consequences and
>      practical remedies for the problems resulting from it",
>      1745th plenary session, 17 December 1968.
>
>      (8) WHO, Regional Office for Europe, Health 21 - "Health
>      for all in the 21st century", WHO, Copenhagen, 1999.
>
>      (9) Report of the Commission on Macroeconomics and Health
>      (led by Jeffrey S Sachs) Investing in health for economic
>      development, WHO,Geneva, 20 December 2001. See also
>      Amartya Sen, "Health in Development", WHO Bulletin,
>      volume 77, September 1999.
>
>      (10) Sophie Boukhari in "Diplômés aux enchères", Courrier
>      de l'Unesco, Paris, September 1998, estimates the annual
>      cost of the brain drain as a whole as $10bn.
>
>      (11) See Jeanne Maritoux, Carinne Bruneton, Philippe
>      Bouscharin, "Le secteur pharmaceutique dans les États
>      africains francophones", Afrique Contemporaine,
>      July-September 2000, n° 195. In West Africa 25% to 40% of
>      drugs are peddled on markets.
>
>      (12) The US Bureau of Labour Statistics forecasts that
>      growth in healthcare services will increase by 30%
>      between 1996 and 2006, accounting for 3.1m jobs,
>      numerically the largest increase in all sectors in the US
>      ("Occupational statistics outlook", Statistics Handbook
>      1998-1999). In France, 35,000 to 80,000 new hospital jobs
>      are due to be created by 2004.
>
>      (13) Peter E Bundred, Cheryl Levitt, "Medical Migration:
>      Who are the real losers?", The Lancet, London, vol 356,
>      15 July 2000.
>
>      (14) In industrialised countries, the content and funding
>      of medical training have also drawn criticism. See, in
>      particular, Arnold S Relman, "The crisis of medical
>      training in America. Why Johnny can't operate", The New
>      Republic, Washington DC, 10 February 2000.
>
>      (15) Sanjoy Kumar Nayak, "International migration of
>      physicians: Need for new policy directions. (Interpreting
>      new evidence with reference to India)" European
>      Association of Development, Research and Training
>      Institutes (EADI), 8th General Conference, Vienna, 11-14
>      September 1996.
>
>      (16) Jacques Gaillard, Anne Marie Gaillard, "Fuite des
>      cerveaux, retours et diasporas" , Futuribles, Paris, n°
>      228, February 1998. Jean-Baptiste Meyer, "Expatriation
>      des compétences africaines: l'option diaspora de
>      l'Afrique du Sud", Afrique contemporaine, n° 190, 2nd
>      quarter, 1999.
>
>      (17) Tikki Pang, Mary Ann Lansang and Andy Haines make a
>      similar proposal in "Brain drain and health
>      professionals" British Medical Journal, London, vol 324,
>      2 March 2002.
>
>
>
>                                    Translated by Harry Forster
>
>
>        ____________________________________________________
>
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>
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