Medical Brain Drain in Developing Countries

Medical Brain Drain in Developing Countries CHAPTER ONE BACKGROUND The loss of human capital from developing countries to developed countries is not a new phenomenon. It is commonly refer to as brain drain which broadly represents the migration of highly skilled professionals from one country or part of a country to another in search of a better prospect (Sako, 2002). The loss of highly skilled professional attributed to brain drain has been of interest internationally for over four decades (Giannoccolo, 2004). Concern over the international migration of health workers first came to limelight at the Edinburgh Commonwealth Medical Conference in 1965. This situation prompted the World Health Organisation (WHO) in 1970 to examine the global process and flows of doctors and nurses (Mejia, 1978). The report however made little impacts on migration of health workers which has continually been on the increase over the years (Levy, 2003, Pang et al. 2002) The concept of the medical brain drain, that is the migration of doctors and other health professionals from developing economies to developed countries has been the subject of interest and research across a variety of fields including labour economics, human resource studies and human geography (Diallo, 2004, Buchan, 2004 and Stilwell et al., 2004) The migration of medical personnel has been identified by WHO as the most critical problem facing the delivery of health service in developing countries (WHO, 2007), besides the emigration of doctors in particular to other countries have received a more considerable attention (Beecham, 2002) The extent to which health professionals migrate to developed countries has continue to be on the increase in recent years and this has been attributed to an apparent response to demand from the developed countries where medical professional are in short supply to cater for demands due to demographic changes, aging population, growing income, feminisation of workforce amongst others (Pond and McPake, 2006). Foreign-trained medical and nursing workforces are estimated to account for more than a quarter of health professionals of the Australia, Canada, the US, and the UK (OECD, 2002).The quest for highly skilled professionals has been on the increase in many developed countries. According to statistic report from the Global Atlas of Workforce cited in Pond and McPake, (2006), the United Kingdom (UK) was ranked among the least staffed of high income countries with 166 doctors and 497 nurses per 100,000 populations the second lowest doctors density and the fourth nurses lowest density among the Organisation for Economic Cooperation and Development (OECD) countries. Moreover, as at the year 2000, the UK health system currently require about 10,000 physicians and 20,000 more nurses to meet the demand of the NHS plan (Department of Health, 2000). Between the year 1999 and 2004 when the targets was achieved earlier than expected, a new target was set to increase the number of nurses by 35000 ( 10%) and physicians by 15000 (25%) between 2001 and 2008. In order to achieve the new target, several methods were adopted to recruit doctors and nurses from other country to fill the shortage within the NHS. However, the approach created a surge in the international recruitment of health worker (Department of Health, 2004). Conversely, the poor economy condition in the developing countries coupled with poor remunerations, lack of infrastructural facilities, and low morale, emigrating to developed countries by doctors is seen as an opportunity for a better prospect. Furthermore, the continuous rise in disease prevalence, emigration, productivity losses, and shortage of doctors in Sub-Saharan Africa, has resulted in health resource crisis (Aluwihare, 2005). Insufficiency in human capacity for health care delivery in developing countries have been identified as a significant factor that is responsible for the inability to achieve the target set by WHO for the treatment of 3 million HIV infected people by year 2005. (This initiative was tagged 3by5) (WHO, 2005). This has also been identified as a major constraint limiting the progress of Millennium Development Goals (MDGs) Initiatives (IOM, 2005). In response to the migration of health professionals to developed countries and the undermine effect to the economy, social and health status of exporting countries, the Commonwealth Ministers of Health agreed to uphold and keep the Commonwealth values of cooperation, sharing and supporting one another, thus a consensus approach to deal with the problem of international recruitment of health workers was adopted. The Code of Practice for the International Recruitment of Health Workers is intended to provide a framework to governments within which international recruitment should be carried out (Commonwealth Code of Practise, 2003). Similarly, Department of Health (2004), presented a revised policy on code of practise for international recruitment of health care professionals this demonstrated the concerned of the UK government in protecting the health care system of developing countries. The revised code of practise for recruitment addresses role of private employer and agencies in the international recruitment of health professionals from developing countries (Eastwood et al., 2005). Nevertheless, developing countries have made some effort in preventing the emigration of physician to developed countries. In spite of this, addressing factors that encourage emigration, such as large disparity in remunerations, standards of living, opportunities for career development amongst host other benefits are usually difficult to come by. At the 1998 UN Conference on Trade and Development, WHO study indicated that 56% of doctors from developing countries migrate to developed nations, while only 11% migrate in the opposite direction; the imbalance is even greater for nurses. (Chanda, 2002). As a result, further effort is being deployed by developing countries to search for means to manage the migration of the health workforce to developed countries (Hussey, 2007). Despite measures, it may be difficult to totally prevent health professionals from migrating. As the large scale of medical brain drain from developing countries is now having a negative impact on the development process of the health system of those countries, it is however imperative for stakeholders to develop a consequential means to curtail the continual movements of health professionals. Nigeria Health Services Historical Background Nigeria, the most populous black nation in the world with a total population of 140 million people (2006 census). As a country with mono-cultural economy, the major source of foreign earnings is from crude oil. The poor level of resources allocated to the health care sector is one of the main factors responsible for the deplorable health condition in the country (Campbell, 2007). The public health service in Nigeria started in 1946 with a 10-year colonial administration plan; the development came about when treatment was required for soldiers of the West African Frontier Force and the colonial administration staff. In 1975 attempt was made to adopt primary health care under the Basic Health Service Scheme (BHSS). The BHSS aimed to improve the accessibility to heath care in terms location, affordability, increase access to disease prevention and distribution of services, and provision of adaptable health services based on local need and socially acceptable method of technology (Hodges 2001). The Current Health Care System in Nigeria Over the last two decades, the health care system in Nigerias has deteriorated a fact ascribed to the countrys poor governance and leadership which was more pronounced during the military era. This was reflected in budget allocations and the fiscal requirements of the Structural Adjustment Programmes. The deficient of reliable data makes it difficult to provide a detailed assessment of the degree of financial commitment to the health sector (Ali-Akpjiak and Pyke, 2003). According to World Bank source, Nigeria public spending per capita for the health sector is less than $5 USD and is as low as $2 USD in some parts of the country. This is far below the $34 USD recommended by WHO for developing countries within the Macroeconomics Commission Report. Nevertheless the Federal Government recurrent budget on health showed an increasing trend from 1996 to 1998, a decline in 1999 and started to rise again in 2000, available evidence shows that most of the recurrent expenditure is spent on personnel. The Federal Government recurrent expenditure on health as a share of the total Federal Government recurrent expenditure which stood at 2.55% in 1996, 2.96% in 1997, and 2.99% in 1998, declined to 1.95% in 1999 and 2.5% rose in 2000. Beyond budgetary allocations, there is a wide gap in the available between the budgetary figures and the actual amount of funds released from the treasury for health activities (WHO 2009a). The decline in the Nigeria health sector was accompanied by collapse of institutional capacities, poor remuneration and lack of conducive environment, dilapidated equipment and infrastructure have over the years, job dissatisfaction and low motivation, have led to increase migration of health professionals to seek employment in overseas countries. In a bid to curtail the impasse, Nigeria has subscribed to the Commonwealth Code of Practice for the International Recruitment of Health Workers for which a framework of responsibilities is presently being developed (WHO 2009b). Demographic and Health Indicators The demographic data in Nigeria are not very reliable. Data gathered from various exercises such as census, vital registrations and surveys are often inconsistence and sometimes contradictory. Nonetheless, there is evidence that the key indicators have either remained constant or worsened (WHO 2005). Life expectancy declined from 52.6 years for male and 58.8 years for female in 1991 to 45 years and 46 years for both Male and Female respectively in 2004. The infant mortality rate (IMR) in 2004 is 103 per 1000 live births when compared to 87.2 per 1000 live births in 1999. Fifty percent of deaths under 5 years of age have been attributed to malnutrition. The maternal mortality rate (MMR) of 800 per 100,000 births is the second highest in the world after India. This has been attributed partly to shortage of skilled medical personnel. For instance only 41.9 % of primary health facilities is provides antenatal and delivery services. Moreover 57.3% of such health facilities operate without a doctor, midwives or senior community extension worker. The Nigeria health system is one of the worst in sub-Saharan African with a disability life adjusted expectancy of 38.3 years and ranked 187 in the world (WHO 2005) Health Workforce in Nigeria Among the several challenges facing the health system in Nigeria is the lack of competent health care professionals. This has been attributed to inadequate infrastructures and poor remunerations packages, making a sizeable numbers of doctors, nurses and other medical professionals vulnerable to be lured away to developed countries in search of a fulfilling and lucrative employments (Stilwell and Awofeso, 2004, Raufu, A., 2002) There are 52, 408 Nigerian Doctors registered with the Nigeria Medical Council as at December 2007, There are 128,918 nurses and 90,489 midwives on the register, although only a fraction of these pay the required practicing licensing fee. There are 13,199 pharmacists, 840 radiographers, 1,473 physiotherapists, 12,703 medical laboratory scientists, and 19,268 Community Health Officers. All these health workers are required to pay annual practicing licensing fees; however the lists have not been pruned for those have migrated out to foreign countries, deaths, retirements or those that have left the profession for another career entirely. Health workers are poorly distributed and most are in favour of urban areas, southern, tertiary health care services delivery, and curative care. For some cadres of health workers such as doctors and nurses, more than 50% have their place of work in the South Western part of the country with vast majority residing in the commercial city of Lagos (Labiran et. al, 2008). Medical Brain Drain in Nigeria Among the countries in sub-Saharan African, Nigeria is a major export of health professionals. An estimated number of 20, 000 health professionals emigrate from Africa annually. A trend that poses threat to sustainable health care delivery in Nigeria. Statistical data on Nigerian doctors who are legally migrating overseas are scarce and unreliable, this is largely due to the fact that most wealthy nations like Australia currently makes it very difficult for overseas trained doctors to practise in their country primarily on the basis of medical skills. However, hundreds of doctors trained in Nigeria continue to emigrate to developed countries annually (Stilwell and Awofeso, 2004). Better remunerations and medical facilities among other factors are cited as one of the major reason for flight of Nigerian doctors (Raufu, 2002) and also there are limited incentives and encouragement for overseas based Nigerian doctors that is willing to relocate back to the country (Stilwell et al., 2004) . Purpose of the study In sub-Saharan African, there is has been a significant rise in disease burden, loss of productivity and the emigration of medical doctors to developed counties have resulted in the in dearth of the most required health resource (Aluwihare, 2005). Most studies on medical brain drain have examined the subject from the perspective of recipient developed countries and little attention has been paid to the donor developing countries. Thus, scarcity of data from developing country makes it difficult to fully describe the impact of migration on countries of origin (Hagopian et al., 2004). Most studies on doctors migration from Sub-Saharan African have tended to focus on numbers, without exploring the underlying reason for migration, assessing the potential negative impact of migration on the health care systems, or considering means to alleviate the problem. In actual fact, information regarding the extent of migration is usually obtained through data from countries of destination (Stilwel l et al 2003). The migration of medical doctors from Nigeria and other countries in sub-Saharan African generates three areas of major concern. The first is a loss of the basic health services available to the citizen. for instance, Ghana, faced with a ratio of nine doctors to every 100 000 patients and no more than 22 paediatrician are licensed to practise in country and no more than 10 specialists of any kind practising in the remote area. Similarly, Nigeria lack adequate doctors to care for the sick especially patients residing in the rural communities The second effect doctor migration from Nigeria is that it prevent the health sectors the ability to organize and expand. Public health institutions heavily depend on doctors to lead, develop and promote them as they work to advance health care delivery. As obtained in US, doctors are well positioned to serve their organisation by actively involved in managing resources and articulating priorities. It is therefore speculated that as the numbers of available medical doctors in developing countries reduces. The third challenges are that doctors migration depletes a significant element of the middle class in developing countries. As in the developed countries, medical doctors in African comprise of an important segment of the social and economic make up of the middle class. They are generally accorded a lot of respect in the society, as being above corruption, they advocate for improvement in quality of education of public schools and they play a vital role in political (Hagopian et al., 2005). In Nigeria, over 70.2% of the population lives on $1 per day (WHO, 2006) Research aim and objectives The aim of this study is to analyse the causes of medical brain drain from developing countries, benefits and burdens associated with brain drain based largely on the views of Nigerian doctors practising in UK. The objectives are: To identify the factors that influence the decision of medical doctors to migrate to developed countries migration To identify the impacts of migration on healthcare in developing countries CHAPTER TWO LITERATURE REVIEW Concept of Brian Drain Brain drain has been defined by many analysts in different ways. It is not surprising the social phenomenon has been examined and analysed from different perspective, based on their general orientation and or awareness of the subject. Brain drain will be conceived in this study as the loss of medical professionals or significant number of human capital within the health care system to other sector of the economy or country. Migration of skilled professionals differs from one country to another and from time to time it is however misleading to generalise the possible impacts of migration in developing countries. Moreover, it can be argued that various studies have attempted to measure the phenomenon from different perspective. Single analytic measurement cannot be used to justify all migration although migration of highly skilled professionals from developing countries has been attributed to various factors which political, social and economical factors account for a significant reasons behind the phenomenon (AUN report, 2002). The migration of highly skilled workers can justify the use of the term brain drain however the expression should be used cautiously. Replacing drain by a more common and value expression such as migration may generate alternate meaning. The difference in the word may be heightened by saying while all brain drains constitute brain migration notwithstanding, brain migration may not necessarily refer to brain drain. Brain drain denote the de-facto transfer of resources spent on impacting education and developing both technical and professional skills of the drained brain in question by the parent (donor) country to the (recipient) country of transfer. The developed countries thus save financial resources on education and professional training and invariably obtain the service of professionals such as doctors, nurses, engineers, scientists who earn more than their colleague in developing countries with a better comfortable living environment (Glaser and Habers, 1978). Several efforts have been made to define the concept of brain drain, most especially by international organisation. According to United Nations Educational, Scientific and Cultural Organisation (UNESCO report, 1969), the brain drain could be defined as an abnormal form of scientific exchange between countries, characterized by a one- way flow in favour of the most highly developed countries. Approximately four decades later, the definition of brain drain has undergone no significant change with a lot of highly skilled workers still leaving the shores of developing countries in pursuit of greener pastures in the developed nations. Medical doctors, engineers and scientists usually tend to predominate or account for a larger proportion among the migrants. Their higher the level of skills or professional qualification, make them more susceptible to migration. Gillis, et al. (1987) suggested two main reasons why brain drain is detestable to most developing countries. The first is that the calibres of people that migrate represent one of the scarce human resources in these developing countries and secondly the amount of resources, financial cost and time involve in educating these group of people is expensive and heavily subsidise by the government. Such migration to foreign country therefore becomes expensive and costly to the donor countries. In most cases the developing countries completely loose these highly skill professionals to the developed countries (Edokat, 2000). This phenomenon has generated a lot of arguments that have been advanced for or against brain drain; however this is not a concern for this study. All that can be concluded is that migration of highly skilled workers from developing countries to develop countries creates a vacuum in the former countries (Edokat, 2000). Types of brain drain Primary external brain drain occurs when trained professional or skilled human resources emigrate from their country of origin to work in developed countries such as America, Europe and Australia. Secondary external brain drain occurs when a trained professional or skilled human resources leave their country or any other less developed country to work in a another developing country such as Botswana, South Africa, Zimbabwe and Namibia. Internal brain drain occurs when a trained professional or skilled or skilled human resources seek for employment in a field not related to his to his/her expertise or when such individual migrate from the public sector to private sector or to another sector within a particular country. While this may pose a problem for a country, it is however not a loss of human resource to the country or the continent. Brain Drain Theories These theories are based on general migration approaches. In brain drain discussion, these approaches have been referred to briefly or summarized. Occasionally specific remarks will be made to provide more clarity regarding the theories. It is however important to state that nearly the theoretical outlook consists of specific mix of different theories or based on the nature of the dominating factors. On the other hand, the scientific approach in which the theories were founded. Another approach in the use of division based on the level Micro, Meso or Macro. These groups cover greater number of theoretical approaches (Oderth, 2002). This level has been defined as: Micro level the decision making of individual is affected by his or her motives, circumstances and access to information. Meso level an aspect of social ties that affects migration such as the effect of network of friends and relatives on migration Macro level opportunities and constraints available at societal level which include political, socio-cultural and economical factors There is no Grand theory linked with research on brain drain although attempts have been made to integrate the subject with economic and social theory, spatial analysis and social science (Kangasniemi et. al., 2004). The study of brain drain and other behaviour by demographers was able to draw insights from other disciplines such as statistics, history, economy, medicine and anthropology (Oderth 2001). A common example is the push and pull model of labour mobility. The model states that individual migration decision is a combination of family, economic, social and political factors. Categories of factors identified to be affecting migration include: 1) Factors at the point of origin, 2) Factors at point of destination, 3) Intervening obstacles and 4) personal circumstances. The push and pull model has been widely used by scholars in studies. Economic factors of employment and material benefits are regarded to have the strongest influence on migration decision (Oderth 2002) Despite the frequent use of the push and pull model approach in migration literature, the approach has been seen as too mechanical and rational choice based and with less consideration for intervening obstacles or institutional and structural constraints (Massey et al, 1993). Most migration tends to be unidirectional from poor to rich nations. The rate of emigration also differs vary considerately between countries and regions on similar economic level and the poorest or the less educated people hardly ever move. A major challenge for the migration is lack of insights in the interconnectedness of all the processes (Kangasniemi et. al., 2004) Another model is the migration system approach it involves formation of a link that encourages migration between a sender and receivers which are strengthened over a period of time. Such links include economic, political and cultural interaction often based on historical activities. Once a link has been created between the migrant places subsequent migration is facilitated through the links. The migration system approach emphasis that social network of the migration provides the intending migrants with information and assistance to ease migration. An important feature of such system is that immigration to a country is directed to specific regions. Such migration is partly dependent on specific areas (Gillis, et al. (1987)). The scope of medical brain drain The World Health Report (2006) estimated that an approximately 817,992 (138%) health workers would be required In Africa to achieve the coverage of basic health interventions. The rate at which doctors and other health professional migrate differs from country to country. Nevertheless, the pattern of migration shares certain similarities. The severe shortage of doctors particularly in rural health facilities has critical negative effects on accessibility and equitable distribution of health care in sub-Saharan African (Ovberedjo, 2007). Studying a specific group of employments from a pool of migration statistics revealed a substantial net loss of human capital among certain key profession in sub-Saharan African. An obvious and highly skilled professional to emerge from such analysis are medical doctors (SOPEMI, 2008). This particular phenomenon can be described as Medical Brain Drain. However, to what extent doctors migrated from sub Saharan African to developed countries? This section will review the scope of migration among doctors in sub Saharan African. Medical brain drain is important and deserves consideration because it is obvious that any decrease in the labour supply among doctors in any country is bound to generate a significant negative impact on the health system of that particular country. In year 2000, statistical data revealed an average of 18.2% of employed doctors working in OECD countries were foreigners. The United States has the largest number of doctors (about 200,000) born and trained in foreign countries followed by the United Kingdom which account for almost 50,000 and France about 34,000. Health worker in India and Philippine formed a greater percentage of the immigrant health workforce OECD countries. In addition, doctors from India account for 56,000 of foreign born doctors practising in OECD countries while nurses of Philippine origin account for about 110, 000. These represent about 15% each of the total (SOPEMI, 2008). The French and the Portuguese African speaking countries contribute some of the highest emigration rate to OECD countries for medical doctors some of other African countries such as Guinea Bissau, Sao Tome and Principe, Senegal, Carpe Verde, Congo, Benin and Togo rank between 17th and 23rd places with emigration rate of 40%, while the English speaking countries in African such as Malawi, Kenya and Ghana have lower emigration rate ranked 25th, 28th and 38th respectively. South African and Nigeria were the only two countries in sub-Saharan African among the top 25 countries with foreign doctors and nurses practising in the OECD countries. This was due to the fact that most African countries have smaller population of workforce (SOPEMI, 2007). Statistical data from the American Medical Association (AMA) Physician Master file shows that 5, 334 non-federal trained doctors trained in Africa medical schools were licensed to practise medicine in the United States in 2002. Nigeria account for 2,158, while South Africa 1,943 doctors. Another 478 doctors are from Ghana medical schools. Other countries contributing to the list in sub-Saharan African include Ethiopia 257 physician, Uganda 153 doctors, and Kenya 93 doctors. The total number of 5,334 represents 6% of the total number African doctors (Hagopian et al. 2004). After United States, the United Kingdom and Canada are the most common destinations in developed countries for African Physicians, with a total of 3,451 and 2, 151 African trained doctors are recorded to be practising in United Kingdom and Canada respectively. Moreover figures in the UK include only doctors who arrived after 1992 thus the number may probably be higher, other destinations for African-trained doctors include Australia, New Zealand and the Gulf States (Hagopian et al. 2003) Migration of doctors also occurs between countries within African continent. For instance, countries such as South Africa, Senegal and Botswana export doctors to developed countries and likewise import doctors from other African countries to cater for shortfall in medical personnel (EQUINET, 2003). Causes of Brain Drain The factors guiding individual choice of migration is in essence personal and thus susceptible to the prevailing personal circumstances. Nonetheless, the economic and social context of such decision deserves an important consideration. Moreover, the disparity between the economic and social development status of different sectors within a particular country and of different countries within African has countries has broaden over the year (Stilwell, 2004). Brain drain of doctors and other highly skilled professional from Africa has been blame on unfulfilled dream at country of origin caused by strife, corruption and misuse that mark Africas post-colonial history (Bridgewater, 2003 cited in Mbanefoh, 2007). Also according to Dovlo (2003), causes can be linked using six gradients which include job satisfaction, salary, career opportunity, governance, social security and benefit, protection and risk. Furthermore the dualistic nature of the world economy has been found to be a major contributing factor to brain drain, as highly skilled medical professionals particularly doctors try to escape the endemic poverty by migrating to wealthy, developed and technologically advanced countries of the world (Mbanefoh, 2007). Factors guiding individual decision to emigrate are a result of the interplay of economic, cultural, social, political and legal forces. Others factors encouraging cross-border migration are usually considered under two main categories: Push factors (Supply) and Pull factors (Demand) (Kline, 2003). Over time the pattern of migration is facilitated through networks that provide prospective migrants with information about job opportunities in countries of destination as well as offer various support to help adjustment after migration (Matin, 2003). Push factors (Supply) these are conditions that make a doctor to be dissatisfied with work and professional careers in their country of origin. The factors may be evident both in the developed and developing countries facilitating the migration of health care professionals from one country to another which is perceive to offer better opportunities in some way. However, these factors are more prominent in developing countries, and they greatly influence the decision of doctors to emigrate in these countries. Pull factors (Demand) these are conditions in countries of destination that motivate workers to migrate. In the same manner as push factors, pull factors can also influence the migration of doctors from one developed country to another developed country. However, the pull factors has a more pronounced influence on individuals in developing countries for instance, there is surge in migration of nurses to Canada after the review of cost of Medical Brain Drain in Developing Countries Medical Brain Drain in Developing Countries CHAPTER ONE BACKGROUND The loss of human capital from developing countries to developed countries is not a new phenomenon. It is commonly refer to as brain drain which broadly represents the migration of highly skilled professionals from one country or part of a country to another in search of a better prospect (Sako, 2002). The loss of highly skilled professional attributed to brain drain has been of interest internationally for over four decades (Giannoccolo, 2004). Concern over the international migration of health workers first came to limelight at the Edinburgh Commonwealth Medical Conference in 1965. This situation prompted the World Health Organisation (WHO) in 1970 to examine the global process and flows of doctors and nurses (Mejia, 1978). The report however made little impacts on migration of health workers which has continually been on the increase over the years (Levy, 2003, Pang et al. 2002) The concept of the medical brain drain, that is the migration of doctors and other health professionals from developing economies to developed countries has been the subject of interest and research across a variety of fields including labour economics, human resource studies and human geography (Diallo, 2004, Buchan, 2004 and Stilwell et al., 2004) The migration of medical personnel has been identified by WHO as the most critical problem facing the delivery of health service in developing countries (WHO, 2007), besides the emigration of doctors in particular to other countries have received a more considerable attention (Beecham, 2002) The extent to which health professionals migrate to developed countries has continue to be on the increase in recent years and this has been attributed to an apparent response to demand from the developed countries where medical professional are in short supply to cater for demands due to demographic changes, aging population, growing income, feminisation of workforce amongst others (Pond and McPake, 2006). Foreign-trained medical and nursing workforces are estimated to account for more than a quarter of health professionals of the Australia, Canada, the US, and the UK (OECD, 2002).The quest for highly skilled professionals has been on the increase in many developed countries. According to statistic report from the Global Atlas of Workforce cited in Pond and McPake, (2006), the United Kingdom (UK) was ranked among the least staffed of high income countries with 166 doctors and 497 nurses per 100,000 populations the second lowest doctors density and the fourth nurses lowest density among the Organisation for Economic Cooperation and Development (OECD) countries. Moreover, as at the year 2000, the UK health system currently require about 10,000 physicians and 20,000 more nurses to meet the demand of the NHS plan (Department of Health, 2000). Between the year 1999 and 2004 when the targets was achieved earlier than expected, a new target was set to increase the number of nurses by 35000 ( 10%) and physicians by 15000 (25%) between 2001 and 2008. In order to achieve the new target, several methods were adopted to recruit doctors and nurses from other country to fill the shortage within the NHS. However, the approach created a surge in the international recruitment of health worker (Department of Health, 2004). Conversely, the poor economy condition in the developing countries coupled with poor remunerations, lack of infrastructural facilities, and low morale, emigrating to developed countries by doctors is seen as an opportunity for a better prospect. Furthermore, the continuous rise in disease prevalence, emigration, productivity losses, and shortage of doctors in Sub-Saharan Africa, has resulted in health resource crisis (Aluwihare, 2005). Insufficiency in human capacity for health care delivery in developing countries have been identified as a significant factor that is responsible for the inability to achieve the target set by WHO for the treatment of 3 million HIV infected people by year 2005. (This initiative was tagged 3by5) (WHO, 2005). This has also been identified as a major constraint limiting the progress of Millennium Development Goals (MDGs) Initiatives (IOM, 2005). In response to the migration of health professionals to developed countries and the undermine effect to the economy, social and health status of exporting countries, the Commonwealth Ministers of Health agreed to uphold and keep the Commonwealth values of cooperation, sharing and supporting one another, thus a consensus approach to deal with the problem of international recruitment of health workers was adopted. The Code of Practice for the International Recruitment of Health Workers is intended to provide a framework to governments within which international recruitment should be carried out (Commonwealth Code of Practise, 2003). Similarly, Department of Health (2004), presented a revised policy on code of practise for international recruitment of health care professionals this demonstrated the concerned of the UK government in protecting the health care system of developing countries. The revised code of practise for recruitment addresses role of private employer and agencies in the international recruitment of health professionals from developing countries (Eastwood et al., 2005). Nevertheless, developing countries have made some effort in preventing the emigration of physician to developed countries. In spite of this, addressing factors that encourage emigration, such as large disparity in remunerations, standards of living, opportunities for career development amongst host other benefits are usually difficult to come by. At the 1998 UN Conference on Trade and Development, WHO study indicated that 56% of doctors from developing countries migrate to developed nations, while only 11% migrate in the opposite direction; the imbalance is even greater for nurses. (Chanda, 2002). As a result, further effort is being deployed by developing countries to search for means to manage the migration of the health workforce to developed countries (Hussey, 2007). Despite measures, it may be difficult to totally prevent health professionals from migrating. As the large scale of medical brain drain from developing countries is now having a negative impact on the development process of the health system of those countries, it is however imperative for stakeholders to develop a consequential means to curtail the continual movements of health professionals. Nigeria Health Services Historical Background Nigeria, the most populous black nation in the world with a total population of 140 million people (2006 census). As a country with mono-cultural economy, the major source of foreign earnings is from crude oil. The poor level of resources allocated to the health care sector is one of the main factors responsible for the deplorable health condition in the country (Campbell, 2007). The public health service in Nigeria started in 1946 with a 10-year colonial administration plan; the development came about when treatment was required for soldiers of the West African Frontier Force and the colonial administration staff. In 1975 attempt was made to adopt primary health care under the Basic Health Service Scheme (BHSS). The BHSS aimed to improve the accessibility to heath care in terms location, affordability, increase access to disease prevention and distribution of services, and provision of adaptable health services based on local need and socially acceptable method of technology (Hodges 2001). The Current Health Care System in Nigeria Over the last two decades, the health care system in Nigerias has deteriorated a fact ascribed to the countrys poor governance and leadership which was more pronounced during the military era. This was reflected in budget allocations and the fiscal requirements of the Structural Adjustment Programmes. The deficient of reliable data makes it difficult to provide a detailed assessment of the degree of financial commitment to the health sector (Ali-Akpjiak and Pyke, 2003). According to World Bank source, Nigeria public spending per capita for the health sector is less than $5 USD and is as low as $2 USD in some parts of the country. This is far below the $34 USD recommended by WHO for developing countries within the Macroeconomics Commission Report. Nevertheless the Federal Government recurrent budget on health showed an increasing trend from 1996 to 1998, a decline in 1999 and started to rise again in 2000, available evidence shows that most of the recurrent expenditure is spent on personnel. The Federal Government recurrent expenditure on health as a share of the total Federal Government recurrent expenditure which stood at 2.55% in 1996, 2.96% in 1997, and 2.99% in 1998, declined to 1.95% in 1999 and 2.5% rose in 2000. Beyond budgetary allocations, there is a wide gap in the available between the budgetary figures and the actual amount of funds released from the treasury for health activities (WHO 2009a). The decline in the Nigeria health sector was accompanied by collapse of institutional capacities, poor remuneration and lack of conducive environment, dilapidated equipment and infrastructure have over the years, job dissatisfaction and low motivation, have led to increase migration of health professionals to seek employment in overseas countries. In a bid to curtail the impasse, Nigeria has subscribed to the Commonwealth Code of Practice for the International Recruitment of Health Workers for which a framework of responsibilities is presently being developed (WHO 2009b). Demographic and Health Indicators The demographic data in Nigeria are not very reliable. Data gathered from various exercises such as census, vital registrations and surveys are often inconsistence and sometimes contradictory. Nonetheless, there is evidence that the key indicators have either remained constant or worsened (WHO 2005). Life expectancy declined from 52.6 years for male and 58.8 years for female in 1991 to 45 years and 46 years for both Male and Female respectively in 2004. The infant mortality rate (IMR) in 2004 is 103 per 1000 live births when compared to 87.2 per 1000 live births in 1999. Fifty percent of deaths under 5 years of age have been attributed to malnutrition. The maternal mortality rate (MMR) of 800 per 100,000 births is the second highest in the world after India. This has been attributed partly to shortage of skilled medical personnel. For instance only 41.9 % of primary health facilities is provides antenatal and delivery services. Moreover 57.3% of such health facilities operate without a doctor, midwives or senior community extension worker. The Nigeria health system is one of the worst in sub-Saharan African with a disability life adjusted expectancy of 38.3 years and ranked 187 in the world (WHO 2005) Health Workforce in Nigeria Among the several challenges facing the health system in Nigeria is the lack of competent health care professionals. This has been attributed to inadequate infrastructures and poor remunerations packages, making a sizeable numbers of doctors, nurses and other medical professionals vulnerable to be lured away to developed countries in search of a fulfilling and lucrative employments (Stilwell and Awofeso, 2004, Raufu, A., 2002) There are 52, 408 Nigerian Doctors registered with the Nigeria Medical Council as at December 2007, There are 128,918 nurses and 90,489 midwives on the register, although only a fraction of these pay the required practicing licensing fee. There are 13,199 pharmacists, 840 radiographers, 1,473 physiotherapists, 12,703 medical laboratory scientists, and 19,268 Community Health Officers. All these health workers are required to pay annual practicing licensing fees; however the lists have not been pruned for those have migrated out to foreign countries, deaths, retirements or those that have left the profession for another career entirely. Health workers are poorly distributed and most are in favour of urban areas, southern, tertiary health care services delivery, and curative care. For some cadres of health workers such as doctors and nurses, more than 50% have their place of work in the South Western part of the country with vast majority residing in the commercial city of Lagos (Labiran et. al, 2008). Medical Brain Drain in Nigeria Among the countries in sub-Saharan African, Nigeria is a major export of health professionals. An estimated number of 20, 000 health professionals emigrate from Africa annually. A trend that poses threat to sustainable health care delivery in Nigeria. Statistical data on Nigerian doctors who are legally migrating overseas are scarce and unreliable, this is largely due to the fact that most wealthy nations like Australia currently makes it very difficult for overseas trained doctors to practise in their country primarily on the basis of medical skills. However, hundreds of doctors trained in Nigeria continue to emigrate to developed countries annually (Stilwell and Awofeso, 2004). Better remunerations and medical facilities among other factors are cited as one of the major reason for flight of Nigerian doctors (Raufu, 2002) and also there are limited incentives and encouragement for overseas based Nigerian doctors that is willing to relocate back to the country (Stilwell et al., 2004) . Purpose of the study In sub-Saharan African, there is has been a significant rise in disease burden, loss of productivity and the emigration of medical doctors to developed counties have resulted in the in dearth of the most required health resource (Aluwihare, 2005). Most studies on medical brain drain have examined the subject from the perspective of recipient developed countries and little attention has been paid to the donor developing countries. Thus, scarcity of data from developing country makes it difficult to fully describe the impact of migration on countries of origin (Hagopian et al., 2004). Most studies on doctors migration from Sub-Saharan African have tended to focus on numbers, without exploring the underlying reason for migration, assessing the potential negative impact of migration on the health care systems, or considering means to alleviate the problem. In actual fact, information regarding the extent of migration is usually obtained through data from countries of destination (Stilwel l et al 2003). The migration of medical doctors from Nigeria and other countries in sub-Saharan African generates three areas of major concern. The first is a loss of the basic health services available to the citizen. for instance, Ghana, faced with a ratio of nine doctors to every 100 000 patients and no more than 22 paediatrician are licensed to practise in country and no more than 10 specialists of any kind practising in the remote area. Similarly, Nigeria lack adequate doctors to care for the sick especially patients residing in the rural communities The second effect doctor migration from Nigeria is that it prevent the health sectors the ability to organize and expand. Public health institutions heavily depend on doctors to lead, develop and promote them as they work to advance health care delivery. As obtained in US, doctors are well positioned to serve their organisation by actively involved in managing resources and articulating priorities. It is therefore speculated that as the numbers of available medical doctors in developing countries reduces. The third challenges are that doctors migration depletes a significant element of the middle class in developing countries. As in the developed countries, medical doctors in African comprise of an important segment of the social and economic make up of the middle class. They are generally accorded a lot of respect in the society, as being above corruption, they advocate for improvement in quality of education of public schools and they play a vital role in political (Hagopian et al., 2005). In Nigeria, over 70.2% of the population lives on $1 per day (WHO, 2006) Research aim and objectives The aim of this study is to analyse the causes of medical brain drain from developing countries, benefits and burdens associated with brain drain based largely on the views of Nigerian doctors practising in UK. The objectives are: To identify the factors that influence the decision of medical doctors to migrate to developed countries migration To identify the impacts of migration on healthcare in developing countries CHAPTER TWO LITERATURE REVIEW Concept of Brian Drain Brain drain has been defined by many analysts in different ways. It is not surprising the social phenomenon has been examined and analysed from different perspective, based on their general orientation and or awareness of the subject. Brain drain will be conceived in this study as the loss of medical professionals or significant number of human capital within the health care system to other sector of the economy or country. Migration of skilled professionals differs from one country to another and from time to time it is however misleading to generalise the possible impacts of migration in developing countries. Moreover, it can be argued that various studies have attempted to measure the phenomenon from different perspective. Single analytic measurement cannot be used to justify all migration although migration of highly skilled professionals from developing countries has been attributed to various factors which political, social and economical factors account for a significant reasons behind the phenomenon (AUN report, 2002). The migration of highly skilled workers can justify the use of the term brain drain however the expression should be used cautiously. Replacing drain by a more common and value expression such as migration may generate alternate meaning. The difference in the word may be heightened by saying while all brain drains constitute brain migration notwithstanding, brain migration may not necessarily refer to brain drain. Brain drain denote the de-facto transfer of resources spent on impacting education and developing both technical and professional skills of the drained brain in question by the parent (donor) country to the (recipient) country of transfer. The developed countries thus save financial resources on education and professional training and invariably obtain the service of professionals such as doctors, nurses, engineers, scientists who earn more than their colleague in developing countries with a better comfortable living environment (Glaser and Habers, 1978). Several efforts have been made to define the concept of brain drain, most especially by international organisation. According to United Nations Educational, Scientific and Cultural Organisation (UNESCO report, 1969), the brain drain could be defined as an abnormal form of scientific exchange between countries, characterized by a one- way flow in favour of the most highly developed countries. Approximately four decades later, the definition of brain drain has undergone no significant change with a lot of highly skilled workers still leaving the shores of developing countries in pursuit of greener pastures in the developed nations. Medical doctors, engineers and scientists usually tend to predominate or account for a larger proportion among the migrants. Their higher the level of skills or professional qualification, make them more susceptible to migration. Gillis, et al. (1987) suggested two main reasons why brain drain is detestable to most developing countries. The first is that the calibres of people that migrate represent one of the scarce human resources in these developing countries and secondly the amount of resources, financial cost and time involve in educating these group of people is expensive and heavily subsidise by the government. Such migration to foreign country therefore becomes expensive and costly to the donor countries. In most cases the developing countries completely loose these highly skill professionals to the developed countries (Edokat, 2000). This phenomenon has generated a lot of arguments that have been advanced for or against brain drain; however this is not a concern for this study. All that can be concluded is that migration of highly skilled workers from developing countries to develop countries creates a vacuum in the former countries (Edokat, 2000). Types of brain drain Primary external brain drain occurs when trained professional or skilled human resources emigrate from their country of origin to work in developed countries such as America, Europe and Australia. Secondary external brain drain occurs when a trained professional or skilled human resources leave their country or any other less developed country to work in a another developing country such as Botswana, South Africa, Zimbabwe and Namibia. Internal brain drain occurs when a trained professional or skilled or skilled human resources seek for employment in a field not related to his to his/her expertise or when such individual migrate from the public sector to private sector or to another sector within a particular country. While this may pose a problem for a country, it is however not a loss of human resource to the country or the continent. Brain Drain Theories These theories are based on general migration approaches. In brain drain discussion, these approaches have been referred to briefly or summarized. Occasionally specific remarks will be made to provide more clarity regarding the theories. It is however important to state that nearly the theoretical outlook consists of specific mix of different theories or based on the nature of the dominating factors. On the other hand, the scientific approach in which the theories were founded. Another approach in the use of division based on the level Micro, Meso or Macro. These groups cover greater number of theoretical approaches (Oderth, 2002). This level has been defined as: Micro level the decision making of individual is affected by his or her motives, circumstances and access to information. Meso level an aspect of social ties that affects migration such as the effect of network of friends and relatives on migration Macro level opportunities and constraints available at societal level which include political, socio-cultural and economical factors There is no Grand theory linked with research on brain drain although attempts have been made to integrate the subject with economic and social theory, spatial analysis and social science (Kangasniemi et. al., 2004). The study of brain drain and other behaviour by demographers was able to draw insights from other disciplines such as statistics, history, economy, medicine and anthropology (Oderth 2001). A common example is the push and pull model of labour mobility. The model states that individual migration decision is a combination of family, economic, social and political factors. Categories of factors identified to be affecting migration include: 1) Factors at the point of origin, 2) Factors at point of destination, 3) Intervening obstacles and 4) personal circumstances. The push and pull model has been widely used by scholars in studies. Economic factors of employment and material benefits are regarded to have the strongest influence on migration decision (Oderth 2002) Despite the frequent use of the push and pull model approach in migration literature, the approach has been seen as too mechanical and rational choice based and with less consideration for intervening obstacles or institutional and structural constraints (Massey et al, 1993). Most migration tends to be unidirectional from poor to rich nations. The rate of emigration also differs vary considerately between countries and regions on similar economic level and the poorest or the less educated people hardly ever move. A major challenge for the migration is lack of insights in the interconnectedness of all the processes (Kangasniemi et. al., 2004) Another model is the migration system approach it involves formation of a link that encourages migration between a sender and receivers which are strengthened over a period of time. Such links include economic, political and cultural interaction often based on historical activities. Once a link has been created between the migrant places subsequent migration is facilitated through the links. The migration system approach emphasis that social network of the migration provides the intending migrants with information and assistance to ease migration. An important feature of such system is that immigration to a country is directed to specific regions. Such migration is partly dependent on specific areas (Gillis, et al. (1987)). The scope of medical brain drain The World Health Report (2006) estimated that an approximately 817,992 (138%) health workers would be required In Africa to achieve the coverage of basic health interventions. The rate at which doctors and other health professional migrate differs from country to country. Nevertheless, the pattern of migration shares certain similarities. The severe shortage of doctors particularly in rural health facilities has critical negative effects on accessibility and equitable distribution of health care in sub-Saharan African (Ovberedjo, 2007). Studying a specific group of employments from a pool of migration statistics revealed a substantial net loss of human capital among certain key profession in sub-Saharan African. An obvious and highly skilled professional to emerge from such analysis are medical doctors (SOPEMI, 2008). This particular phenomenon can be described as Medical Brain Drain. However, to what extent doctors migrated from sub Saharan African to developed countries? This section will review the scope of migration among doctors in sub Saharan African. Medical brain drain is important and deserves consideration because it is obvious that any decrease in the labour supply among doctors in any country is bound to generate a significant negative impact on the health system of that particular country. In year 2000, statistical data revealed an average of 18.2% of employed doctors working in OECD countries were foreigners. The United States has the largest number of doctors (about 200,000) born and trained in foreign countries followed by the United Kingdom which account for almost 50,000 and France about 34,000. Health worker in India and Philippine formed a greater percentage of the immigrant health workforce OECD countries. In addition, doctors from India account for 56,000 of foreign born doctors practising in OECD countries while nurses of Philippine origin account for about 110, 000. These represent about 15% each of the total (SOPEMI, 2008). The French and the Portuguese African speaking countries contribute some of the highest emigration rate to OECD countries for medical doctors some of other African countries such as Guinea Bissau, Sao Tome and Principe, Senegal, Carpe Verde, Congo, Benin and Togo rank between 17th and 23rd places with emigration rate of 40%, while the English speaking countries in African such as Malawi, Kenya and Ghana have lower emigration rate ranked 25th, 28th and 38th respectively. South African and Nigeria were the only two countries in sub-Saharan African among the top 25 countries with foreign doctors and nurses practising in the OECD countries. This was due to the fact that most African countries have smaller population of workforce (SOPEMI, 2007). Statistical data from the American Medical Association (AMA) Physician Master file shows that 5, 334 non-federal trained doctors trained in Africa medical schools were licensed to practise medicine in the United States in 2002. Nigeria account for 2,158, while South Africa 1,943 doctors. Another 478 doctors are from Ghana medical schools. Other countries contributing to the list in sub-Saharan African include Ethiopia 257 physician, Uganda 153 doctors, and Kenya 93 doctors. The total number of 5,334 represents 6% of the total number African doctors (Hagopian et al. 2004). After United States, the United Kingdom and Canada are the most common destinations in developed countries for African Physicians, with a total of 3,451 and 2, 151 African trained doctors are recorded to be practising in United Kingdom and Canada respectively. Moreover figures in the UK include only doctors who arrived after 1992 thus the number may probably be higher, other destinations for African-trained doctors include Australia, New Zealand and the Gulf States (Hagopian et al. 2003) Migration of doctors also occurs between countries within African continent. For instance, countries such as South Africa, Senegal and Botswana export doctors to developed countries and likewise import doctors from other African countries to cater for shortfall in medical personnel (EQUINET, 2003). Causes of Brain Drain The factors guiding individual choice of migration is in essence personal and thus susceptible to the prevailing personal circumstances. Nonetheless, the economic and social context of such decision deserves an important consideration. Moreover, the disparity between the economic and social development status of different sectors within a particular country and of different countries within African has countries has broaden over the year (Stilwell, 2004). Brain drain of doctors and other highly skilled professional from Africa has been blame on unfulfilled dream at country of origin caused by strife, corruption and misuse that mark Africas post-colonial history (Bridgewater, 2003 cited in Mbanefoh, 2007). Also according to Dovlo (2003), causes can be linked using six gradients which include job satisfaction, salary, career opportunity, governance, social security and benefit, protection and risk. Furthermore the dualistic nature of the world economy has been found to be a major contributing factor to brain drain, as highly skilled medical professionals particularly doctors try to escape the endemic poverty by migrating to wealthy, developed and technologically advanced countries of the world (Mbanefoh, 2007). Factors guiding individual decision to emigrate are a result of the interplay of economic, cultural, social, political and legal forces. Others factors encouraging cross-border migration are usually considered under two main categories: Push factors (Supply) and Pull factors (Demand) (Kline, 2003). Over time the pattern of migration is facilitated through networks that provide prospective migrants with information about job opportunities in countries of destination as well as offer various support to help adjustment after migration (Matin, 2003). Push factors (Supply) these are conditions that make a doctor to be dissatisfied with work and professional careers in their country of origin. The factors may be evident both in the developed and developing countries facilitating the migration of health care professionals from one country to another which is perceive to offer better opportunities in some way. However, these factors are more prominent in developing countries, and they greatly influence the decision of doctors to emigrate in these countries. Pull factors (Demand) these are conditions in countries of destination that motivate workers to migrate. In the same manner as push factors, pull factors can also influence the migration of doctors from one developed country to another developed country. However, the pull factors has a more pronounced influence on individuals in developing countries for instance, there is surge in migration of nurses to Canada after the review of cost of