Health economist Professor Gavin Mooney has had a longstanding concern about the flow of health professionals from poor to wealthy countries.
In the article below, he proposes a plan for how Australia might address its responsibilities to countries like South Africa. Instead of the “unethical” practice of draining poor countries of health professionals, we should be exporting our own, he says.
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A plan for a fairer deal for South Africa
Gavin Mooney writes:
I have recently returned from South Africa where I had been invited to talk at a conference on the future of that country’s proposed National Health Insurance. That has got me thinking again about the ‘stealing’ by Australia of health workforce personnel from sub-Saharan Africa and what might be done about it.
In South Africa, for example, there is a chronic shortage of doctors, especially in the public sector. There is also a major health crisis and a major health care crisis. Poverty and inequality remain massive killers; sadly, and so disappointingly, South Africa is now one of the most unequal societies on the planet and more unequal today than it was in the apartheid years.
The health care crisis is not just one of underfunding per se but quite incredible inequity between public and private sectors – read between poor and rich and again read in essence black and white.
Thus the government’s Green Paper states:
“The 8.3% of GDP spent on health is split as 4.1% in the private sector and 4.2 % in the public sector. The 4.1% spend covers 16.2 % of the population … largely on medical [private] schemes. The remaining 4.2% is spent on 84% of the population … in … the public healthcare sector.”
Yet Australia (and other rich and healthy countries) continues to steal South African doctors and nurses.
While in South Africa, I spoke with Ms MP Matsoso, the Director General of Health. I promised her that on my return home I would raise the issue of the flow of doctors and nurses from South Africa to Australia.
The current situation is unethical and unconscionable. We in Australia have a shortages of skilled health workforce but such shortages pale into insignificance alongside those of sub Saharan Africa.
The ‘opportunity cost’ – the benefit foregone – in an HIV/AIDS-torn, desperately poor South Africa – of every doctor pinched by us is to be measured in far greater human terms of sickness and death than any health gain we may have. (And, in any case, if a poor country like Cuba can export doctors, why can’t we?)
Further, in South Africa, as this BMJ article notes:
“The estimated government subsidised cost of a doctor’s education [is] $58 700… The overall estimated loss [to South Africa] of returns from investment for all doctors [trained in South Africa] currently working in [Australia, Canada, the US and the UK] was … $1.41bn.”
At the International Federation of Medical Students’ Association (IFMSA) Congress in Mandurah in 2007 which was attended by a great bunch of socially-conscious medical students, many from poor countries, I cringed as Tony Abbott, the then Health Minister, appealed to these starry eyed, future doctors to come and work in Australia. His message was clear. Never mind the sick and lame and dying back in your own home countries. Move here where you can earn much more. (Fortunately the students resoundingly rejected his sordid appeal.)
More recently, however, there has been a very different appeal from a very senior voice in Australian health policy.
Dr Andrew Pesce, towards the end of his tenure as President of the AMA, in a speech at the World Medical Association Symposium in Sydney in April last year asked:
“What right do … wealthier countries have to address their own health workforce shortages with recruitment policies that worsen workforce and skills shortages in developing countries?”
And he went on: “Unfortunately, our health planners have hidden their own workforce planning failures by importing trained doctors and nurses. Inevitably developing countries are most at risk of a net workforce loss.”
Well said, Andrew, and now that we have a new Health Minister who does seem to have a concern for social justice, perhaps we can hope for change in Australian Government thinking on this front.
What is needed?
Well I suggest a four-point plan.
1. That to curb health workforce stealing, Australia enter into an agreement with South Africa similar to that which was negotiated between the UK and South Africa in 2003.
2. That for each doctor we do steal (or have already stolen?) we pay South Africa the estimated cost to that country of the training costs and the opportunity cost to them of each exported doctor.
3. That such payment be made by providing the South African public health care system with support in kind to build a better management system and train good managers (which are crucial if the proposed NHI is to work).
4. That we look at adopting a medical and nursing workforce plan that results in our not stealing from poor countries but exporting to poor countries.
When I was at the South Africa conference, I spoke of how a national health insurance scheme there would not only help to bring about a healthier population but also be a social institution that would assist in building a less divided, more united country – a more decent society.
At the start of this New Year, following one where there have been many signs of hope for a better, more decent world globally yet a pettiness and narrow mindedness here at home, how better to kick off Australian health policy in 2012 than for our new health minister to adopt the four-point plan above?
Now wouldn’t that be the act of a decent society!
I don’t think “decent country” and Australia belong in the same sentence.
Excellent piece Mr Mooney!
Sadly one of the great exports of many “developing” nations is their educated young people. India and Egypt spring to mind. Not just doctors – engineers, lawyers, potential political leaders and reformers… even economists. The country in question might be getting the better part of the deal with the latter actually.
The point is that it is the entire social structure of the source country that is undermined and eroded by the loss of its young and educated children. We are pinching their future.
It means the education system leaks like a sieve. It means that this absolutely critical investment in a country and building its future is essentially nobbled. And the beneficiaries are us. Bit like intellectual strip mining.
I’d like to suggest a coupe of extra points to your four point plan I could.
Bonds for students to perform work in the training country for a certain period in return for the education and support they receive. Used to work here with teachers as I recall. Painfully.
A fund – for education in source countries – paid for by the beneficiaries of the training. UNESCO could do this I’d reckon.
And lastly, it would be decent of the universities – who also benefit from poached talent perhaps more than any other single sector – would establish programs designed to encourage the transfer of skills and graduates with the source country. You know so that part of your engineering degree might involve spending 6 months building a solar thermal plant in Nigeria or Kenya for example.
One point that is worth mentioning is the distinctly self-serving process employed by the local professional bodies in vetting and essentially licensing operators from overseas. Not sure what it’s like now but 30 years ago I had some dealings in this area and encountered a barrage of rather contrived hurdles and obstacles designed purely to protect local vested interests. Those trained in English-speaking countries seemed to get the rails run.
Meanwhile, our front-line health care system – particularly in rural Australia where I live – is increasingly reliant on the universities of Cairo and Mumbai. Thanks folks.
Great piece, Gavin – useful coverage of an often-overlooked issue.
Although on the surface enticing overseas health workers to come here may look like a good deal for Australia, there’s another flow-on effect in the source countries that ultimately comes back to bite us (and other nations which do similarly): many of the countries from which we take health workers are also recipients of Australian (and other nations’) development assistance. How much more are we ‘costing’ ourselves in this kind of investment when we’ve assisted in removing some of the very personnel who will deliver health interventions on the ground?
I hope your four-point plan (or something similar) is taken on – and I hope it works: anecdotal evidence I have from some of the English-speaking southern African countries is that the UK’s 2003 agreement that you mention is more honoured in the breach than in the observance…
Strange, I thought that we were supposed to be a welcoming country, the demands being that we be a country that is welcoming to people and allows them to move here with ease. Now we are heartless for letting in people who seek to come here in search of a better life.
People like Marilyn decry Australia for attempting to disuade people from coming here by boat, most of whom are ‘economic refugees’, seeking to come to Australia for a better life and lifestyle than they would have at home.
Other people come here through appropriate channels, seeking to turn their skills to use in a new country, as immigrants have from time immemorial, and it’s somehow Australia’s fault?
If it is OK for a school teacher or a lawyer from Afghanistan to come here seeking a better life for their family, at the cost of leaving their original country poorer for their loss, why then is it wrong for a doctor or nurse from South Arfica to come here for exactly the same reason?
Can we at least ask for some consistency here people.
Very good piece Mr Mooney. This is scandalous!! The Australian Nursing Federation has called for a end to this practice of stealing doctors and nurses from countries that need them , but who listens to unions these days?
(Note from Croakey: this comment has been edited to delete expletives and invectives – a reminder to readers to please keep comments civil) Michael James, there is no such thing anywhere in the world as an economic refugee. A refugee is a person by definition with a well founded fear of persecution and money or wealth or lack of has zero to do with anything.
As for coming by boat, they are allowed to. This is an island, boats are the second most popular method of arrival and until the advent of planes the only method of arrival.
So – poaching doctors from poor countries so rich white folks can set them up as terrorists while the poor of their own country die due to lack of medical care has zero to do with refugees.
I praise Mr Mooney for the concern he shows for a country that is, unfortunately, renowned for disease and poverty. I am however insulted and concerned by his grossly oversimplistic misrepresentation of such a complex issue as this.
No country in the world does or can in fact ‘steal’ health workers (or engineers or teachers or businessmen, for that matter). Mr Mooney’s implication that these people are nothing more than the playthings of global geopolitics is an insult to their intelligence, and to their dignity as autonomous free-thinking individuals. These migrants decide for their own reasons, not because of the fumbling machinations of nation-states, that the country of their birth, was not a place worth staying in.
Moreover, it is rare for migrants to completely cut themselves off from their homelands. Study after study have shown that migrants maintain ties with their places of birth in a multitude of ways. They transfer hundreds of billions of dollars in remittances from the rich world every year. Their backgrounds often give them leading roles in foreign investment drives from their adopted countries. They flourish in the ivory towers of the West and bring back ideas that they could not have learned back home. These connections and practices often survive for generations.
The possible reasons to migrate are, of course, as infinite as the human experience. For countries such as South Africa, economic reasons are more common. That however, is not the whole story.
Crucially if sadly, South Africa’s poverty, is not the only reason that propels free men and women to leave the place of their birth, of their families, of their culture. South Africa’s problems are manifold and its people suffer from alarming rates of crime, a crony-capitalism that favours sycophants of the ruling party, casual corruption, appalling public education, and yes, a horrid health sector that has left Africa’s richest nation with the dubious honour of having the world’s largest number of infected in the world.
And yet. To blame only the problems above (and a legion more unlisted) is only to blame the symptoms. The reason why these continue to blight South Africa is misgovernment. One obvious example springs to mind. Thabo Mbeki, the country’s previous president, was loth to admit a connection between HIV and AIDS; Manto Tshabalala-Msimang, Mr Mbeki’s health minister, recommended treating the disease with beetroot and garlic. It would not be impossible to argue that Mr Mbeki’s decade of denialism caused more harm to South Africans’ health than any imaginary theft of health workers ever has.
The fact that the current president ended this insanity and reinfused government policy with sensible ideas should be celebrated. The country’s struggle to overcome its plethora of challenges requires the continued help and friendship of the West but the onus for action lies with its government and its people. If the rulers and friends (such as Mr Mooney) of South Africa wants its young, its educated, its hard-working, to stay home and continue building Mandela and Tutu’s Rainbow Nation, they should stop blaming others for problems which only South Africa itself can solve.
It’s not just Africa of course. In recent years we have also been plundering the elite of south Asia too, even taking doctors and nurses from Afghanistan to meet our own selfish needs. Once upon a time we had something called the Colombo Plan, where we trained professionals who returned to developing nations to help alleviate poverty Now we charge the same people to come here! It will not win us any friends. Dick Smith made this very point in his ABC documentary on Australia’s ridiculous population growth- and was derided by many. Let’s face it- we have turned into an incredibly selfish society living in a moral vacuum, willing to exploit the poorest nations.
That comment is offensive and should be withdrawn
I came from the UK. Is that OK?
I mean I’m a doctor and I came from the UK.
I agree with the concern expressed by Prof Moody about the serious impact on the ability of some poorer countries to develop and maintain an adequately sized medical and nursing workforce as a consequence of many health professionals going to work in wealthier countries.
But I don’t think it is helpful or accurate to label the activity of medical professionals moving from poorer countries to wealthier countries to work as ‘stealing’ those workers. Using this term just encourages an inaccurately narrow impression of the various factors which lead to the flow of skilled workers from poorer countries to richer ones.
Whilst one factor is the desire of wealthier countries to cover our workforce gaps, another obvious factor is that skilled people in poorer countries decide to take up employment opportunities in wealthier countries because they can earn more – and often just as importantly, access far better professional development opportunities and long-term career prospects.
It should also be noted that some of these workers subsequently use the extra skills and wealth they’ve gained to assist their country of origin in various ways. This doesn’t negate the impact on that country of losing them from their workforce, but it is none the less part of the wider picture which should be taken into account.
Seeking better employment and life opportunities is the major factor which has driven, and continues to drive, migration for centuries, and I don’t think it is helpful to portray this simply as the receiving country ‘stealing’ them.
It would be a perverse outcome if we were to adopt a policy approach which has the effect of denying people from poorer countries the opportunity to improve their life opportunities while still leaving that option open for those from rich countries – (something Australia is also benefitting from at present via the significant flow of medical and other skilled workers moving here from Ireland, the UK and elsewhere).
I am not suggesting this is the outcome which Prof Moody is advocating – in fact I am broadly supportive of the thrust of most of his ‘4 point plan’. But using an over-simplistic and not-terribly-accurate term like ‘stealing’ to describe a process which involves people from poorer countries deciding to improve their life opportunities by moving somewhere else (sometimes only temporarily) increases the likelihood of over-simplistic and potentially quite unjust policies being advocated in response.
While I agree with Mooney that Australia shouldn’t rely on other countries and particularly developing countries for its skilled people, he misses the most important point: increase Australia’s training of doctors so that she doesn’t need to import doctors from overseas. That is precisely what Australia has done over the last decade, and the increases in medical graduates are just starting to join the workforce now.
The Australian Government’s cuts in medical school intakes announced in the 1995 budget and the freeze on intakes thereafter were introduced at the insistence of the Australian medical workforce advisory committee, so I suggest that Mooney’s 4th point proposing a health workforce plan is precisely the last thing that Australia should have.
I work in recruitment! I am an evil headhunter who has bewitched overseas professionals and relocated them to Australia!! Or something.
I get the point of the argument, and the brain drain from Africa in particular is awful. I’ve spoken with South Africans who’ve almost been in tears about the decline of various industries due to the qualified leaving the country. However they did not blame Australia, uniformally they blamed either the local African government, or the tyranny of a violent and racist history.
In my headhunting activities, whether I’ve approached individuals or they’ve approached me, the ones who’ve elected to make the huge move to Australia have done so because of the worsening standard of living at home and the diminishing opportunities for their children. A number of Mining Engineers I’ve spoken with said they were happy in their home country until they got married and had kids and suddenly the crime, murders, and lack of economic stability seemed less like an adventure and more like a serious impediment to the future happiness of their offspring. Thus with heavy hearts they decided to move to Australia. The idea that they were stolen is false. As a headhunter I know you can never move someone who does not want to be moved.
Of course Australia should welcome these migrants – it would be wrong not to welcome individuals from overseas who are seeking the high standard of living we have to offer.
Stealing? If one takes without giving adequate compensation might that not be called stealing? Yes, I accept (and in no way did I imply that it was not the case) that the reasons for doctors and others moving from one country to another are complex. At no point did I suggest that they should not move. What I was suggesting was that when they did move from for example South Africa to Australia then the Australian government should compensate the South African government. That society paid large sums to train them which we then benefit from. Is that just? Without compensation being paid I think that to call this ‘theft’ or ‘stealing’ is justified even if emotive.
I note Jenny Haines’ point that the ANF cares about this stealing! Good on ‘em, Jenny! What about the AMA post-Pesce? In its recent submission to the Senate Inquiry on rural workforce (as far as I can see) the AMA makes no reference to the cost in health terms to developing countries of doctors moving from these poor countries to fill places in rural Australia (http://ama.com.au/node/7450). The submission states: “it is estimated that about 50 per cent of the rural medical workforce have been recruited from other countries. These practitioners have provided an essential and appreciated contribution to the health needs of rural communities but it is not a sustainable situation in the long run.” Agreed but I can see no concern being expressed by the AMA for the impact on the health of the people in the countries these doctors have left.
And things may be getting better in training more doctors here (as Gavin Moodie suggests) but the AMA at least agrees with me that there remains “an undersupply of medical practitioners … in many parts of Australia and no where more so than in rural and remote areas.”
Calling this “stealing” may get up some people’s noses. I make no apology for that if by doing so it might get the AMA and the Australian government to think about what they are doing to the health of the people of countries like South Africa by ‘taking’ their doctors – and change tack.
Clearly there are responses agreeing with my viewpoint – but how do we get change and recognition that there is something rotten in this ‘free trade’ in doctors and nurses? Can anyone really justify not compensating these poor countries who have trained doctors and nurses who then help to make us a healthier nation?
Whether or not you agree with the use of the term ‘stealing’, surely the ones who are committing the theft are the doctors themselves, not the country of Australia.
Once again it seems that the AMA is being partly blamed for this type of problem. …. very unfair!! The AMA is a voluntary membership representative organisation. Despite taking its role as the peak lobby group in the country for the medical profession very seriously, its input into actually making change is minimal. In fact, the AMA’s opinions, stance, recommendations, submissions are almost always “welcomed” then totally ignored by just about everybody but particularly government. As a 30 plus year member of the AMA, I can assure you that being dismissively denigrated with patronising tokenism is wearing thin.
Yes, we would love to train more medicos. Yes we would love to address the workforce maldistribution issues. Yes, we would love to train overseas people to return to their countries and provide better medical services but there are a couple of really big problems that the AMA has no control over:-
1] A really big part of the “training” of medical practitioners has no value accorded to it – i.e. trainers do not get paid at all for their educational input.
2] Training takes time and ay all times those of us who are working, experienced and interested in training are under huge and steadily increasing time pressures to be ‘more efficient’, spend more time properly documenting, being enslaved by health fund, compensation & legal process, being COPD’ed and maintaining registration, accreditation etc..
These issues are out of the control of the AMA. These issues discourage our own home grown young people from entering medicine, even if the places were available and are contributing to an amazing dropout % of our own people out of medicine.
Nice article and point of view Gavin but you are showing your deeply inexperienced understanding of the real health service issues in Australia. Remember, the AMA has been trying hard to gain traction and recognition for the best part of the 30 years that I have been a member and involved at State & Federal levels and to date , failure to be listened to is the only real consistent outcome that we have achieved.