Sharing knowhow and joining forces towards Health for All
Contribution to the Annual Report 2014 of the MMI Network

Aid in reverse - compensation for health worker migration

Health worker in Cambodia
Health worker in Cambodia

Exploring the phenomena whereby rich countries have actively recruited health workers from the Global South, causing a catastrophic shortage of health workers in those countries, Health Poverty Action called upon the UK government to recognise how it has unfairly benefited from this situation and to do something about it. The latest report released by the International Development Committee, a parliamentary committee that scrutinises the UK’s development work, picked up on our recommendation for compensation

The global distribution of health workers is an emblem for global health inequalities. 70% of the countries with a critical shortage of heath workers are in Africa. In the UK we have 279 doctors for every 100,000 people. Sierra Leone has two. Tanzania and Liberia have one. These critical shortages impact on health outcomes. A child in Sierra Leone is 90 times more likely to die before his or her fifth birthday than a child in Luxembourg.

Many health workers from low and middle income countries are working in high income countries. In 2006, it was estimated that 25% of all doctors and 5% of nurses that were trained in sub-Saharan Africa were working in countries of the OECD. Five African countries (Sierra Leone, Tanzania, Mozambique, Angola and Liberia) have emigration rates of over 50%, meaning that more than half the doctors trained in these countries have migrated to the OECD.

At Health Poverty Action, we do not question the right of individuals to migrate, nor claim that migration is bad for development; but we do question the congratulatory focus of donor countries on the aid they provide, when in some cases the financial subsidy provided back to them – in the cost savings of training health workers – is actually a greater sum. Through this ‘perverse subsidy’ or ‘reverse aid,’ some of the poorest countries with the lowest numbers of health workers are in fact subsidising some of the richest. This is why we are part of the “Health Workers for All” project, funded by the European Union.

Of all the countries in Europe, the UK has received the most internationally-trained doctors and nurses, and is therefore a key beneficiary of this ‘reverse aid’. 26% of all doctors and 10% of all nurses in the UK were trained outside of Europe. Whilst health worker migration to the UK today is much lower than in the past – a result of the UK’s Code of Practice, changes to registration criteria and increasingly restrictive immigration polices – we still have much to do to compensate for the subsidies we have received.

Take the example of Sierra Leone, currently battling the Ebola crisis. In 2010, the country had 136 doctors and 1,017 nurses. That’s one doctor for approximately every 45,000 people. In contrast, the UK has 1 doctor for every 357 people. In 2000, Sierra Leone’s health system was declared the weakest in the world, whilst the NHS was recently voted the strongest. Yet 27 doctors and 103 nurses who trained in Sierra Leone are currently in the UK. Whist it is not possible to quantify the losses to Sierra Leone in terms of the value of their care or the lives that could have been saved, it is possible to attempt to calculate the financial subsidy Sierra Leone is providing to the UK. We do not know at what level or where they are working (NHS or private), but if we assume the 27 doctors are junior doctors, based on the savings generated (It costs the NHS GBP 269,527 to train a junior Doctor and GBP 70,000 to train a nurse) Sierra Leone’s doctors and nurses are providing a saving of GBP 14.5 million to UK health services (EUR 19.8 million). If those doctors are consultants, the total subsidy Sierra Leone is providing to UK health services (NHS and private) could be up to GBP 22.4 million (EUR 30.4 million).

Thankfully, the UK’s role in creating and sustaining global health inequalities is finally beginning to be recognised. In October 2013 Health Poverty Action produced a report and briefing, Aid in Reverse, focusing on the global health worker crisis and the UK’s role in perpetuating it. Hundreds of our supporters wrote to UK Government ministers calling for compensation for countries that are providing a subsidy to UK health services.

In July 2014, along with 13 other UK and African NGOs we launched our Honest Accounts report looking at the resource flows – including health workers – from sub-Saharan Africa and calling for a more honest account of the UK’s relationship with the continent. Along with other UK NGOs we have lobbied the UK’s International Development Committee to undertake an inquiry into the UK’s work on health systems strengthening. Their inquiry picked up on our concerns and in September 2014 they included in their recommendations a call for the Department for International Development (DFID) to “consider options for compensating source country systems”.

DFID has now committed to produce a new framework on health systems strengthening and, following further questioning in December, the Minister agreed that the UK would review international recruitment into the NHS. The outcomes of this remain to be seen, but recognising that the UK contribution to health systems goes beyond aid, and requires action on our policies and practices, is an important – if belated – start.

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Contribution by Health Poverty Action to the Annual Report 2014 of the MMI Network

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