Adam Briggs, final year medical student, University of Oxford.

Human resources for health are in crisis. The migration, or brain drain, of healthcare professionals from developing to developed countries is legitimised by the World Trade Organisation’s General Agreement in Trade Services and fuelled by significant push and pull factors. Push factors such as inadequate salaries, poor working conditions, and conflict all affect an employee’s decision when promised better training, higher socio-economic status, and political stability in another country.¹ Internal migration of doctors and nurses to urban areas and the private sector also has devastating effects on many poor and rural populations. Box 1 helps to put the current situation into context.

• Africa carries 25% of the world’s disease burden yet has only 3% of the world’s health workers and 1% of the world’s economic resources.²
• Between 1998 and 2002, Ghana lost roughly £35 million of its training investment in health professionals and the UK saved £65 million by recruiting them.³
• About 20% of African-born physicians are working overseas in developed countries.⁴
• Conflict only exacerbates problems with human resources for health: in Liberia, 14 years of war have reduced the numbers of practicing doctors from 237 to less than 20.⁵

Box 1. Some of the problems in human resources for health

March 2008, saw the first Global Forum on Human Resources convened by the Global Health Workforce Alliance (GHWA) in Kampala, Uganda. The Global Forum launched the Agenda for Global Action: a plan to address human resources for health problems over the coming decade, set targets, and monitor progress and accountability. GHWA was formed in May 2006, and through many programmes and publications, such as the Human Resources for Health Action Framework, it is helping countries with their health-workforce problems.^6-8

The UK based charity, Merlin (medical relief, lasting health care), ‘responds worldwide with vital health care and medical relief for vulnerable people caught up in natural disasters, conflict, disease and health system collapse.’⁹ It is an example of a non-governmental organisation (NGO) that can help to fulfil GHWA’s Agenda for Global Action. Established in 1993, Merlin has organised missions to countries as diverse as Afghanistan, Rwanda, and Honduras. Merlin’s experience in helping restructure a health workforce in countries with significant endemic problems, known as fragile states, has shown that an appropriate living wage, workforce restructuring measures, and a meritocratic promotion system are crucial issues. Their Director of Health and Policy, Linda Doull, wrote a comment in Lancet about human resources for health in fragile states.¹⁰ In the article she stressed the need for a strategic approach to tackle human resources for health crises which encompass both short-term and long-term solutions. I spoke with her to find out more about Merlin and how they’re working to reduce inequality of human resources for health in such difficult environments.

Merlin’s mandate is to work in areas requiring acute relief, and to work with the country through to recovery; they recognise that solving health problems is a long-term issue. Merlin does this through working at the level of both the community and the government to rebuild the health system.

I asked Linda what her view was on the GHWA and whether it will be effective in solving the human resources for health crisis. She believes that putting human resources for health at the top of the global health agenda is a very positive step, which will hopefully act as a catalyst for coordinated action. She compared the GHWA to the millennium development goals - often touted as unachievable but acting as a focus for political initiative.

Linda explained that there are several stakeholders that need to act to solve the human resources crisis. Ultimately, it can be argued that the responsibility rests with the government; however, does that government have sufficient investment? Governments in fragile states are often unwilling or unable to provide basic services. “Take Liberia as an example: Merlin’s budget (in Liberia) is as big as the health budget for the ministry in Liberia. Why are those distortions there? Maybe international donors aren’t willing to invest. Maybe the ministry has money, but has chosen to invest elsewhere.” She argued that perhaps NGO funding needs to be done differently. For example, perhaps Merlin needs to engage more at a national level offering technical assistance to develop curricula. “There is no one single factor, there is a mix. (We must) recognise that that (mix) has to come together and has to come together earlier. Hopefully that’s what the global alliance will help to facilitate.”

It has been suggested that the recruitment policy of some NGOs perpetuates the drain of health care professionals away from areas of need in their local health service. Merlin protects against this by advertising vacancies and vetting those who apply rather than actively recruiting staff. If, for example, a senior health minister applied for a post then they would only consider offering the job if the ministry agreed to release the minister, rather than give that person the opportunity to leave crucial local employment. Merlin prefers to work within the existing health system, with the local health care professionals. Where there are gaps in the clinics Merlin works with the relevant country’s health ministry to identify and transfer a staff member to that hospital rather than recruit staff members themselves. However, limited resources mean that staff transfer is often not easy and staff may not want to move. As an interim solution, Merlin will often employ an international health worker.

So what can we, as students, do to help? Organisations such as Merlin need volunteers who are highly skilled at both a technical level and a managerial level; senior registrars and consultants are ideal. However, as students we can still have a role. We need to recognise global health needs and be advocates through organisations such as Medsin in order to keep the issue of human resources for health on the global political agenda. As Linda says “(Medical professionals in the developed world) are very, very lucky and every health worker should be allowed to have a level of investment that makes them a competent safe practitioner, so if nothing else remember that.”

Solving human resources for health problems is a difficult balancing act. NGOs want to employ local health care workers, but do not want to relocate them from areas of health need; overseas doctors rarely provide a permanent solution. Although acute care is essential in many situations, for lasting solutions I believe that change needs to take place at an administrative level and until this happens, the problems highlighted in box 1 will continue. Local doctors should not be blamed for wanting to leave war-torn and impoverished countries but as a medical community, from students to consultants, we should be pressurising governments through NGOs and our nominated unions for better working conditions for our international colleagues.

References

1. World Health Organisation. World health report 2006: working together for health. Geneva: World Health Organisation; 2006.
2. Robinson M, Clark P. Forging solutions to health worker migration. Lancet 2008;371:691-93
3. Martineau T, Decker K, Bundred P. “Brain drain” of health professionals: from rhetoric to responsible action. Health policy 2004;70:1-10
4. Clemens MA, Pettersson G. New data on African health professionals abroad. Human Resources for Health 2008;6:1
5. Interagency Health Evaluation, Liberia, 2005: final report. http://www.unhcr.org/research/RESEARCH/456ac0682.pdf (last accessed 12/03/08)
6. The Global Health Workforce Alliance. Strategic plan. 2006. http://www.who.int/workforcealliance/GHWA_STRATEGIC%20PLAN_ENGLISH_WEB.pdf (last accessed 12/03/08)
7. The Global Health Workforce Alliance. Working groups and task forces. http://www.who.int/workforcealliance/workingroups/en/index.html (last accessed 12/03/08)
8. HRH Action Framework. http://www.capacityproject.org/framework/ (last accessed 12/03/08)
9. Merlin. Medical relief, lasting health care. http://www.merlin.org.uk/ (last accessed 12/03/08)
10. Doull L, Campbell F. Human resources for health in fragile states. Lancet. 2008;371:626-27.

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