Health Systems and the "Brain Drain"

A significant and oft-invoked barrier to effective health care in resource-poor settings is the lack of medical personnel. In what is termed the brain drain, many physicians and nurses emigrate from their home countries to pursue opportunities abroad, leaving behind health systems that are understaffed and ill-equipped to deal with the epidemic diseases that ravage local populations. The WHO recommends a minimum of 20 physicians and 100 nurses per 100,000 persons, but recent reports from that organization and others confirm that many countries, especially in sub-Saharan Africa, fall far short of those target numbers. More than half of these countries register fewer than 10 physicians per 100,000 population. In contrast, the United States and Cuba register 279 and 596 doctors per 100,000 population, respectively. Similarly, the majority of sub-Saharan African countries do not have even half of the WHO-recommended minimum number of nurses. In addition to these appalling national aggregates, further inequalities in health care staffing exist within countries. Rural-urban disparities in health care personnel mirror disparities of both wealth and health. In 1992, the poorest districts in southern Africa reported 5.5 doctors, 188.1 nurses, and 0.5 pharmacists per 100,000 population. The same survey found, in the richest districts, 35.6 doctors, 375.3 nurses, and 5.4 pharmacists per 100,000 population. Nearly 90% of Malawi's population is rural, but >95% of clinical officers were at urban facilities, and 47% of nurses were at tertiary care facilities. Even community health workers, trained to provide first-line services to rural populations, often transfer to urban districts. In 1989 in Kenya, for example, there were only 138 health workers per 100,000 persons in the rural North Eastern Province, whereas there were 688 per 100,000 in Nairobi.


In addition to inter- and intranational transfer of personnel, the AIDS epidemic contributes to personnel shortages across Africa. Although data on the prevalence of HIV infection among health professionals are scarce, the available numbers suggest substantial and adverse impacts on an already-overburdened health sector. In 1999, it was estimated that 17–32% of health care workers in Botswana had HIV disease, and this number is expected to increase in the coming years. A recent study that examined the fates of a small cohort of Ugandan physicians found that at least 22 of the 77 doctors who graduated from Makerere University Medical School in 1984 had died by 2004—most, presumably, of AIDS. Similar numbers have been registered in South Africa, where a small study by the Human Sciences Research Council found an HIV seroprevalence among health professionals similar to that among the general population—in this case, 15.7% of all health care workers surveyed. The shortage of medical personnel in the areas hardest hit by HIV has profound implications for prevention and treatment efforts in these regions. The cycle of health-sector impoverishment, brain drain, and lack of personnel to fill positions when they are available conspires against ambitious programs to bring ART to persons living with both AIDS and poverty. The president of Botswana recently declared that one of his country's main obstacles to rapid expansion of HIV/AIDS treatment is "a dearth of doctors, nurses, pharmacists, and other health workers."3 In South Africa, the departure of nearly 600 pharmacists in 2001, coupled with standing vacancies for 32,000 nurses, has put continued strain on that relatively affluent country's ability to respond to calls for expanded treatment programs. In Malawi, only 28% of established nursing posts are filled. Furthermore, the education of medical trainees is jeopardized as the ranks of the health and academic communities continue to shrink as a result of migration or disease. The long-term implications are sobering.

A proper biosocial analysis of the brain drain reminds us that the flight of health personnel—almost always, as most reviews suggest, from poor to less-poor regions—is not simply a question of desire for more equitable remuneration. Epidemiologic trends and access to the tools of the trade are also relevant, as are working conditions in general. In many settings now losing skilled health personnel, the advent of HIV has led to a sharp rise in TB incidence; in the eyes of health care providers, other opportunistic infections have also become insuperable challenges. Together, these forces have conspired to render the provision of proper care impossible, as the comments of a Kenyan medical resident suggest: "Regarding HIV/AIDS, it is impossible to go home and forget about it. Even the simplest opportunistic infections we have no drugs for. Even if we do, there is only enough for a short course. It is impossible to forget about it. . . . Just because of the numbers, I am afraid of going to the floors. It is a nightmare thinking of going to see the patients. You are afraid of the risk of infection, diarrhea, urine, vomit, blood. . . . It is frightening to think about returning."4 Another resident noted, "Before training we thought of doctors as supermen. . . . [Now] we are only mortuary attendants."5 Nurses and other providers are, of course, similarly affected.

Given the difficult conditions under which these health care personnel work, is it any surprise when the U.S. government's appointed Global AIDS Coordinator notes that there are more Ethiopian physicians practicing in Chicago than in all of Ethiopia? In Zambia, only 50 of the 600 doctors trained since the country's independence in 1964 remain in their home country. Nor is it surprising that a 1999 survey of medical students in Ghana in their final year of training revealed that 40 of 43 students planned to leave the country upon graduation. When providing care for the sick becomes a nightmare for those at the beginning of clinical training, physician burn-out soon follows among those who carry on in settings of impoverishment. In the public-sector institutions put in place to care for the poorest people, the confluence of epidemic disease, lack of resources with which to respond, and unrealistically high user fees has led to widespread burn-out among health workers. Patients and their families are those who pay most dearly for provider burn-out, just as they bear the burden of disease and—with the introduction of user fees—much of the cost of responding, however inadequately, to new epidemics and persistent plagues.

3Dugger C: Botswana's brain drain cripples war on AIDS. New York Times A10 (13 November 2003).

4Raviola G et al: HIV, disease plague, demoralization, and "burnout": Resident experience of the medical profession in Nairobi, Kenya. Cult Med Psychiatry 26:55, 2002.

5Ibid.