Trouble in Paradise
Life (series 5)
For tourists, the Maldives are a paradise on earth. But in December 2004 the Tsunami unleashed devastation on this small island nation in the Indian Ocean.
Investigates why health care professionals leave developing countries to work abroad, and the impact on health services on both sides.
For over forty years there’s been a trickle of Ghanaian nurses to the English-speaking developed world. One widely quoted source says almost two thousand nurses left the country between 1995 and 2002. And the exodus is set to continue as nurses opt to leave a crumbling health system to earn more abroad. In the UK, some nurses can earn more in a day than they could in a month back home.
Director-General of the Ghana Health Service, Professor Akosa, says: “Nurses we have in the order of 8000 and this includes professional and non-professional nurses, so we are not doing well at all, and it’s all because we train our resource, our human resource to a very high standard, and why not? And because the systems in country are not attractive enough, the health workers leave this country for pastures new. And that is a problem, and it’s a very, very big problem.”
James Johnson, Head of the British Medical Association (BMA), says that it's the major medical problem facing the world today.
"It costs £12,500 to produce a nurse in the UK. We can afford it, even though it’s expensive, they can’t afford it, and to expect developing countries to spend part of their tiny amount of money to produce doctors and nurses to work in our health service, and America’s health service, is quite immoral."
Lydia Kwashie left Ghana 16 months ago to come to work as a carer in a nursing home in Sheffield. “Back home you can work for a whole lot of years, 20 years, 25 years, and you go home with nothing, no house, nothing, not even a bicycle. I’m just here 1 year 4 months, I have my own accommodation, I’m working, I have a car – back home I couldn’t, I couldn’t even go near a car tyre, and ask how much is this tyre.”
Lydia goes back on a visit to Accra, Ghana’s capital city, and to Korle-Bu, the premier teaching hospital, where she trained. Despite being one of the best hospitals in the country, Korle-Bu hospital has a serious staff shortage. The accident department is operating on less than fifty per cent of its recommended medical staff.
Spending on health in Ghana has gone up but its value has declined. In 1990 it was $4.5 dollars per person per year. In 2004 the figure was $13.4 dollars. However inflation means that Ghana is spending less in real terms per person. Most of that money goes on wages. For almost everything else, patients have to pay, because the health service operates on a ‘user pays’ principle, the so-called “Cash and Carry” system. The stresses of this system is one reason health workers leave.
Major Courage Quashigah, the Health Minister, blames rich countries for the exodus. He points out that they give development aid to help poor countries out of poverty. “We use the money to train doctors and nurses and other professionals and then they come to your country and you happily welcome them. Where is the morality in that?”
He adds that that nurses should consider their job a vocation and they should show some loyalty to the country that trained them. “If you are patriotic you would not leave, because nursing is a calling, it’s not just a profession; it’s a special calling to serve humanity. And if your country has spent a lot of money training you, there is a need for you to offer your services.”
And Dr Fred Sai, Senior Adviser to the President on Health, agrees: "If you give a person a university education, it is a value added, and a country has to pay for that education in the sense that the education will be put to use for the country's development. So if it is not being put to use and the individual wants to apply their skills elsewhere, make it more difficult to a) get the education, and b) feel comfortable leaving who paid for it and go away somewhere else."
But Professor Okosa, Director-General of the Health Service, takes a more pragmatic view. He believes that Ghana must take steps to reduce the number of nurses leaving – beginning with providing priority housing and transport. "I dare say that if we don’t improve it, people will go. And improving it means introducing systems by which people can get mortgages and acquire a house, for people to be paid properly. People should have facilities, if they want to own a car by all means let them own a car, and they should be able to look after their spouses and their children."
The reality is shown by the case of four-year-old Vincentia brought in to Korle-Bu Accident Department with first-degree burns. The mother was asked to buy a mattress because there wasn’t one in the ward, and painkillers which aren’t provided free. But she has no money.
After a wait of nearly four days, Vincentia finally gets a bed in the Plastic Surgery ward, a department that is also losing nurses to the UK and US.
UK Prime Minister Tony Blair says the British government’s policy is clear. “There is no policy to steal doctors and nurses from developing countries. There is a code of practice to which we adhere, that ensures we do not do such a thing. If many of the people who come to this country were not coming here, I am afraid that they would not be staying in their own countries. That is the problem because they would simply be going elsewhere.”
But James Johnson of the BMA points out that that doesn’t stop private companies from doing the recruiting. And he adds: It’s been estimated that Sub-Saharan Africa will need an extra million healthcare workers in exactly, incidentally, the same time-scale that the United States are hoping to recruit another million doctors and nurses from the rest of the world. It’s pretty obvious which of those two opposing ideas is going to be the successful one."
Lydia and Ghanaian nurses like her are unlikely to return to their homeland unless the ‘push’ factors are removed by improving salaries and conditions. But if they were… "Yes, yes I will come and serve my nation country, yes. I will come and serve Ghana. If it is really implemented, I’ll come back," says Lydia.
The Royal College of Nursing urged the July G8 meeting to urgently tackle the exodus of health care workers from developing countries if they are to defeat global poverty. And the British Medical Association organised a conference on the health care skills brain drain in April 2005.
Read an article on the migration of health-care workers from developing countries in the World Health Organisation's Bulletin.