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Rapid Responses: Rapid Responses published:
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Human Resource Management in Africa
- Andrew C Don-Wauchope (4 November 2005)
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Human resources for health in Africa: Is it national or international policies causing the brain drain?
- Felix I D Konotey-Ahulu (7 November 2005)
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There is more to the Africa human resources crisis.
- Albert M. E. Coleman (7 November 2005)
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Starving in the midst of plenty!!
- Fatai Salawu (7 November 2005)
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Human Resources for Health in Africa - An Economic Problem
- Frank O Olaleye (10 November 2005)
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Human Resources for Health in Africa – an incomplete picture.
- Timothy J Hughes, Libby Hughes (11 November 2005)
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Re: Human Resources for Health in Africa – an incomplete picture.
- Frank O Olaleye (12 November 2005)
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There is still hope for Africa!
- Ezechi. C Nwosu (6 December 2005)
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Trying to reverse the brain drain:a Ugandan solution
- Julia F Dancy, Emma C Wall (14 December 2005)
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Andrew C Don-Wauchope, Lecturer in Clinical Medicine Trinity College, Dublin 8
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Dr Lucas's editorial once again raises the important issue of migration of health care professionals from Africa to the west. It should be noted that this is a general issue faced by all developing nations. It should also include internal migration in Africa from poorer to wealthier African countries. The points he has laid out in the table are commendable. Particularly the human resource management points, 5 and 6. As indicated in the editorial and other papers on the matter there are numerous reasons why health care professionals migrate. It would seem impossible to stop migration but by improving working conditions in the home country health professionals will think harder about leaving. This requires a concerted effort to make the personnel departments more proactive, to encourage decent working conditions and to provide adequate support for developing a career. There is possibly another aspect that requires some investigation and that is the way in which health care professionals returning to their home country from a period of working or training abroad are received. They are often welcomed back and the experience gained abroad will be shared with colleagues. However, there may occasionally be animosity from those who have not gained international experience to those that have. The returning health care professional may find it difficult to adjust to working in a developing nation with restriction on facilities, investigations and medications. The impact on this on their personal job satisfaction is not determined. Further, the international experience gained will include experience of personnel departments and conditions of service that value the health care professional. In my experience the value placed on public sector health care professionals in the developing world is minimal and this can be very frustrating. It would be fantastic if the wealth of health care professionals from Africa could be harnessed for the benefit of Africa and the points in the editorial should encourage better retention and recruitment of health care professionals to Africa. The migration of physicians from sub-Saharan Africa to the United States of America: measures of the African brain drain Amy Hagopian, Matthew J Thompson, Meredith Fordyce, Karin E Johnson and L Gary Hart. Human Resources for Health 2004, 2:17 doi:10.1186/1478-4491-2-17 Loss of health professionals from sub-Saharan Africa: the pivotal role of the UK, J B Eastwood, R E Conroy, S Naicker, P A West, R C Tutt, J Plange-Rhule. Lancet 2005; 365: 1893–900 Where have all the doctors gone? Career choices of Wits medical graduates, Max Price, Renay Weiner. S Afr Med J 2005; 95: 414-419. Employment contracts for South African doctors, Andrew C Don-Wauchope. S Afr Med J 2005; 95: 542. Competing interests: None declared |
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Felix I D Konotey-Ahulu, Kwegyir Aggrey Distinguished Professor of Human Genetics, University of Cape Coast, Ghana Consultant Physician, Ten Harley Street, London W1N 1AA, UK
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Human resources for health in Africa: Is it national or international policies causing the brain drain? EDITOR--- Professor Adetokunbo Lucas [1] has hit the nail on the head when he concluded that some development partners in Africa’s health programmes “have followed only their own globally focussed agenda in the past” and must now “show that they respect the national goals and priorities of African countries” [1] Adetokunbo knows what he is talking about, because he has an unrivalled rear epidemiological vision spanning nearly five decades in as varied geographical locations as Africa, the UK, WHO in Geneva, and now the USA. Many of the expatriate partners on the African health scene appear to blame the continent’s brain drain predominantly on national policies, but as I have recently pointed out [2], the questions that they need to answer to help direct attention to the role of international (rather than national) policies in Africa’s predicament, are the following: 1. Why continue dictating the price of our raw materials? 2. Why slap tariffs on our produce, preventing us to sell to Europe? 3. Why subsidize your farmers in order to dump rice and sugar on our markets? 4. Why do you allow your banks to accept billions from our corrupt dictators, and then keep all the money when they die? [2] 5. Why do you always advise devaluation of our currency? [2] However excellent our policies in Ghana are to make us maintain our place as the best producers of cocoa and gold in the world, what use are those policies to us when the world prices are determined in London and New York? Then when the prices soar, and we stand to benefit, some economic expert arrives in the country to advise devaluation so that more of our produce is taken out for less foreign exchange. By including Inwani Malweyi’s Personal View [3] among the excellent articles assembled for the October 1 2005 issue of the BMJ devoted to “Health in Africa”, you have drawn attention to this aspect of the diagnosis of Africa’s woes. But diagnosis alone is not enough. How do we begin to address the problem arising from brain drain, or talent export as I prefer to call it? I have a few suggestions. First of all, to think Africa’s problems can be solved by Africans alone is an illusion. I am in complete agreement with 'Aggrey of Africa' who believed in co-operation between white and black people. Such co- operation, Aggrey said, “means that each side has something to contribute – something more than brawn on one side, brain on the other – to the well being of both” [4], hence Kwegyir Aggrey’s famous piano keys illustration on the badge of my Alma Mater, Achimota School (Prince of Wales College), which he co-founded and opened in 1927 with Rev A G Fraser and the then Colonial Governor Sir Gordon Guggisberg: “You can play a tune of sorts on the black keys only, and you can play a tune of sorts on the white keys only, but for perfect harmony you must use both the black and the white keys” [4] But another illusion is to think that all “white keys” are the same. While some foreign experts representing development partner countries undoubtedly “followed only their own globally focussed agendas” [1], others genuinely had the African’s welfare at heart. It is the African’s duty to identify these latter “white keys”, some of whom have paid dearly for their pro-African stance [5], and urge them not to give up. When, in the context of the present huge African health problem, I said “I appeal to any godly person reading this communication” [5], it was these genuine “white keys” I had in mind. Finally, Africa’s talent export can be made to assist national health projects. Although Ghana’s President Kufuor revealed that in the year 2004 “remittances from abroad reached a record 2 Billion US Dollars, exceeding earnings from cocoa, the highest earner by 100%” [6], there is no indication of how much this foreign exchange earning benefited the health sector. Writing in today’s Ghanaian Times, I had this to say: “One Ghanaian footballer had such pedal talent as fetched Twenty Four Million Pounds. Equivalent to Thirty-six Billion Cedis! Just a tiny fraction of this money could build hundreds of modern latrines (Tafracher) in his town, and reduce the incidence of Hepatitis and Typhoid drastically. Let us organise contacts with Ghanaians abroad, to drain some of the money into Ghana specifically for health purposes” [7]. I went on: “I know that Ghanaians in the Diaspora did send some 2 Billion US Dollars in the year 2004, but effort should be made to supplement what government is doing with Ghanaian help from abroad”. [7] Felix I D Konotey-Ahulu MD(Lond) FRCP(Lond) DTMH(L’pool)
1 Lucas AO. Human resources for health in Africa. Better training and firm national policies might manage the brain drain. BMJ 2005; 331:1037-8 (5 November) 2 Konotey-Ahulu FID. Controlling the three “P”s in Africa. Lancet 2005; 366: 634. 3 Malweyi I. Africa does not need aid, but the opportunity for fair trade. BMJ 2005; 331: 784. 4 Konotey-Ahulu FID. Dr JE Kwegyir Aggrey – A 20th Century phenomenon “Only the best is good enough for Africa”. New African 2004; No; 433 October, pp 50-51. 5 Konotey-Ahulu FID. AIDS in South Africa: wake up call and need for paradigm shift. http://bmjjournals.com/cgi/letters/326/7387/495#30917 (accessed November 5 2005). 6 Kufuor JA. Ghanaians abroad top list of Ghana’s income. Ghanaweb 5 January 2005. http://www.ghanaweb.com/GhanaHomePage/diaspora/artikel.php?ID=72826 (accessed 5 November 2005). 7 Konotey-Ahulu FID. The need for private/government partnership in health care delivery. Anniversary Lectures (3). Ghanaian Times 5 November 2005, p 6. Competing interests: None declared |
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Albert M. E. Coleman, Associate specialist psychiatrist. Greenarces CMHT, WSHSC NHS Care trust, Homefield road. Worthing, BN11 2DH. W. Sussex.
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EDITOR, - Lucas’s comments and suggested guidelines for managing the human resources crisis in African health systems made interesting reading (1). The suggestions however cannot in my view be dissociated from all the other components that have led to the poor state of health systems and human resource crisis in Africa. Some African health professionals attribute some of the mitigating factors contributing to the African health crisis to bad government policies (2). As I have mentioned in a previous contribution, the factors are known are well recognised and African health systems should acknowledge the problems, the solutions and get back to basics to tackle and begin to resolve them (3). This sooner than later. On the particular issue of human resources crisis addressed by Lucas (1), this raises a red flag of concern. For some time there has been a notion that instituting local incentives ---viz local postgraduate training, subsidized housing, subsidised means of transportation etc might help stem the trend of mass migration of personal. Ghana was mentioned as an example of a country that has been relatively successful in that light per Lucas. As a Ghanaian, having worked in Ghana and international health, as well as mingling with various migrant African professionals overseas, I find the suggestions and solutions too simplistic. Despite all the effort successive governments have tried to retain professionals especially health professionals, a recent World bank publication, and a follow-up Ghanaian news commentary on the publication indicated that on the average 45 % plus of qualified Ghanaian tertiary level graduates have left the country, and continue to do so (4-5). A good number were educated with state funds! My worry about the human resource crisis in African health systems goes back to how a good number of educated indigenous Africans contribute to the crisis. The politicians might contribute their share through bad governance and policies at the expense of providing good and adequate healthcare to the African population (2)(6). But then who are these politicians? A good number are tertiary level educated, who see entry into politics as a part to quick enrichment. Just as their counterpart health professionals who chose to leave, patriotism, integrity, and accountability, gets thrown overboard, enter the fray of free for all corrupt practices and national abandonment. As Deming postulated and demonstrated, that achieving a robust self driven national economy entails management reform, incorporating quality assurance in every step of production/management (7), Africa, and African health systems have a lot to learn from this. Unless and until, we incorporate in our national education systems a strong curriculum of accountability, integrity, good governance and delayed gratification the rotten situation will continue and prevail. Our governments, population and academics need to understand that capacity building and retention is not only about money in people’s pocket’s, but additionally a strong national and individual ethics of integrity, accountability and respect for the law. 1)Lucas, AO. Human resources for health in Africa. BMJ 2005; 33:11037 -38. (5 November). 2)Sangosanya, GO. Medical brain drain is a consequence of bad policy. BMJ20005; 331:905. (15 October) 3)Coleman, AME. Africa’s health crisis--and get back to basics. BMJ 2005; 331:905. (15 October). 4)World Bank. International Migration, Remittances, and the Brain Drain. Schiff, M Ozden, C (eds). Palgrave Macmillan. October 2005. 5)www.ghanaweb.com. Ghana bleeding from brain drain. www.ghanaweb.com/GhanaHomePage/NewsArchive. General news of Monday, 31 October 2005. Accessed 31 October 2005 and 6 November 2005. 6)www.ghanaweb.com. Hotel bills for MPs over C10 billion. www.ghanaweb.com/GhanaHomePage/NewsArchive. General news of Wednesday, 2 November 2005. Accessed 2 November 2005 and 6 November 2005. 7)Deming WE. The New Economics: For Industry, Government, Education. 2nd edition. The MIT press. October 2005. Competing interests: I am from Ghana, Africa, and I have contributed on a related issue in the BMJ. |
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Fatai Salawu, Clinical neurologist Specialist Hospital,Maiduguri.Nigeria
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I read with great interest the article of Prof Lucas.What is happening in the health sector in the developing countries is really unfortunate.There are numerous qualified specialists in Nigeria for example who are not gainfully employed for reasons that would not be disclosed by relevant employers.But I would like to allude to religious and socio-ethnic reasons amongst others.Would Prof Lucas now blame such individuals for relocating to the States and Europe or the relevant authorities? Competing interests: It's really hard to believe that we are starving in the midst of plenty!! |
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Frank O Olaleye, Clinical Fellow in O&G Darent Valley Hospital Dartford Kent DA2 8DA
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Dear Prof Adetokunbo Lucas, I have just read you article in the BMJ with rapt attention. I thought it was a brilliantly written piece. I am particularly interested in the topic because I have over the past 3 years or so being running a self-funded project looking at developing innovative healthcare investment strategies aimed at empowering locally trained healthcare professionals in Africa. One of the longer term aims of this project is to discourage the ‘brain-drain’ phenomenon. A phenomenon that has resulted from the poor economic climate that is prevalent in most African countries. What is the point of training doctors, pharmacists and nurses if they cannot use their training to sustain themselves economically? The economic situation in most African countries is so bad that those professionals that have not left the continent are either practising quackery or have abandoned their professional training to work in banks, engage in buying and selling or simply come abroad and having got here and failed to get into the ever increasingly difficult systems (after contending with multi-stage exams and fruitless job searches), give up medicine altogether to become IT consultants etc. Either way, a great loss of much-needed professional hands back in Africa is occurring through these means almost on a daily basis. The WISH For Africa project in addition to establishing a network of healthcare outlets in poor communities of Africa also looks at encouraging members of the Diaspora to transfer back the skills they have acquired abroad back to their local communities in Africa through our medical overseas volunteering programme. The aim of this is to turn the ‘brain drain’ into ‘brain gain’ as it is economically suicidal to expect a generation of practitioners that had left Africa to pack up and go back. I personally believe that through the projects that we have established in Nigeria, we can make these ‘gains’ percolate back to our respective communities. I was at the recent conference of the Medical Association of Nigerian Specialists and General Practitioners (MANSAG) in Norwich where I was asked to deliver a lecture ‘The role of the Diaspora in fostering healthcare delivery in Nigeria – WISH for Africa as a case study’. I made a case for Associations like MANSAG and ANPA to invest more in medical missions back to Nigeria. I am pleased to say that the message was well- received and the present executive committee and members of MANSAG are working assiduously to make things happen along this line. I am hopeful that your article, by bringing these issues on to the front burners of international discourse, will encourage other African healthcare professionals in the Diaspora to become alive to their responsibilities. Thank you. Competing interests: None declared |
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Timothy J Hughes, Consultant Anaesthetist Doncaster Royal Infirmary DN4 6AD, Libby Hughes
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This editorial highlights an important issue which seems to have been aired frequently over recent months in both the professional and popular press (1-3). While we applaud the continuing debate, our personal experience of working in Africa suggests that most reviews on health professional provision in that continent are incomplete. We have just returned from a two year placement as general doctors at a District Hospital in Kenya where medical staffing has relied on successive placements of Western “volunteers” like us. Such gap filling donations are clearly of limited sustainable value, but at least a clearer view of realistic future staffing options can be gained from such opportunities. While there will always be a demand for well trained specialist medical leadership, why is there not more emphasis on the place of the “doctor” who is trained for local requirements but who does not have easily marketable credentials? St Mary’s Hospital in Mumias has an attached “Clinical Officer” (C.O.) training school for which we had teaching responsibilities, and we worked closely with qualified and indeed specialised individuals who had graduated from this establishment. We have been deeply impressed not only by their clinical knowledge and expertise, but also by their professional commitment to local health services, poorly resourced as they are. The “Clinical Officer / Assistant Medical Officer” grade is a well established role in many African countries for both community and hospital services. Their initial intensive three year training starts after completion of secondary education and is modelled on the traditional five year university medical course. When qualified they usually have a compulsory 12 month internship prior to full registration and then carry much the same clinical responsibilities that a “Medical Officer” (doctor) would if available. They significantly out number doctors in many places and, with further postgraduate training, can specialise in areas such as obstetrics and anaesthetics (4). Why is such scant regard given to this health professional? African medicine would probably collapse without them but it is not surprising that their existence and potential is seldom acknowledged by those who have not worked with them. In their recent review, Eastwood et al (3) gloss over what they refer to as the “half-trained doctor” as an unrealistic option, and seem to be oblivious of the fact that they already exist! Is there just ignorance of the potential of the C.O. grade amongst the interested medical community in the UK, or are we perhaps allowing our own tendency to be suspicious of other health professionals taking on duties traditionally carried out by doctors to influence solutions for a problem that for millions of Africans is a desperate situation? It might seem patronising to suggest that Africa be encouraged to adopt a “second best” approach but the size of the problem, its urgency and the lack of resource dictate the need for realistic approaches. We have no doubt that interested bodies in the UK and other developed countries should look more closely at the value of the C.O. Maybe we could more appropriately repay our “medical debt” to Africa by, not only sponsoring in-country specialist training of doctors, but also by enhancing the rapid development and expansion of this “half-doctor”. Why not help gain full advantage from a role which costs less both time and money to train and which, at the moment, the West cannot “poach” because their qualifications, unlike doctors and nurses, are only recognised within the African countries that most need them? Tim Hughes Libby Hughes 1. Medical Staff quit for the West; The Independent; 27th May 2005. 2. Johnson J; Stopping Africa’s medical brain drain; BMJ 2005331:2-3. 3. Eastwood J. et al; Loss of health professionals from sub-Saharan Africa: the pivotal role of the UK; Lancet 2005;365: 1893-1900. 4. Fenton P.M. et al; Caesarian Section in Malawi: prospective study of early maternal and perinatal mortality; BMJ 2003; 327:587-590 Competing interests: None declared |
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Frank O Olaleye, Clinical Fellow in O&G Darent Valley Hospital Dartford Kent DA2 8DA
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I have just read your response to Prof Lucas’ article in the BMJ. I quite agree with your contribution about recognising the efforts of the locally trained healthcare professionals. I would also like to say thank you (and to Libby, I presume) on behalf of all Africans for volunteering your much-appreciated medical skills to the community you were placed in Africa. More thought-provoking however is your comment ‘ While there will always be a demand for well trained specialist medical leadership, why is there not more emphasis on the place of the “doctor” who is trained for local requirements but who does not have easily marketable credentials?’ I found it reassuring that people are now asking such questions. It is the first step in the long journey needed to reverse the trend of ‘brain-drain’ and all the horrible sequelae of the phenomenon. Due to complicity of multiple factors, but mostly economic, the quality and standards of medical training in most African countries have dipped so badly that the ‘qualified’ medical graduates of these days are not any better anyway than the ‘half-doctors’ you referred to in your article. I have always argued that the focus therefore should be to acknowledge the contributions of these ‘professionals on the ground’ and empower them by creating economically viable healthcare infrastructures for them, re-train them through a CPD-type programme and then review, audit and reward their performances. The big ‘gainers’ are their immediate communities who benefit from the improved quality of care that ensues. We cannot keep postulating and writing endless articles that really do not impact on the lives of the common man in Africa. Something tangible needs to be done. I run a project in Africa (Nigeria at the moment) that has built in sustainability and viability from the start - and the project is aimed at doing just what I have described above. It is tough going but the message is gradually getting through to the people that matter in shaping policy and planning for healthcare development in Africa. I would like to encourage you and recognise your efforts in these thankless days. I hope you have been personally enriched by your experiences in Africa. Best wishes Dr Frank Olufemi Olaleye MB.ChB (Ife) MBA DIC (Imperial College)
Competing interests: Founder of WISH For Africa - A UK Charity dedicated to making healthcare affordable and accesible to poor communities in Africa |
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Ezechi. C Nwosu, Consultant O & G / Clin Director Whiston Hospital, Prescot, L35 5DR
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I wish to congratulate Professor Lucas firstly for an excellent editorial on the Human Resources in Africa and secondly for bringing this problem to the attention of the world for comment. The issues raised are constantly discussed and regularly debated at the (bi-annual) meetings of the Medical Association of Nigerian Specialists in the British Isles (MANSAG). I am sure this no doubt is a debating point for all Medical Doctors in Diaspora. We acknowledge that the problems facing Africa is huge. Nevertheless, although the situation looks bad on the surface, there are signs that we can improve. The current situations in Ghana, Kenya and South Africa are such indicators of hope that given good leadership (instead of firm leaders!) and a little help/co-operation from developed countries Africa can look after herself. If developed countries can open up a small fraction of the international market, there could possibly be some free flow of valuable drugs and personnel. If this happens then there may be no need to worry about personnel haemorrhage from Africa in the long term. Because stability is very important to such progress developed countries should stop supporting wars, selling ammunition to Africa and banking embezzled African funds and more especially protecting the embezzlers. There are many good Africans who can get things right for the continent. Their problems are that these bad guys in the continent are supported by very powerful allies. Things can, and will only get better if this situation is reversed and the good people are supported instead by the powerful. The situation in Ghana, Kenya and South Africa gives us hope. Competing interests: None declared |
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Julia F Dancy, Lecturer in medicine Mbarara University of Science and Technology, Uganda, Emma C Wall
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Editor- Lucas1 describes the well recognised phenomenon of ‘brain drain’ in Africa and possible strategies to combat it. One leading incentive for migration is higher education and training2. We have personal experience of an effective and sustainable partnership providing good quality postgraduate training in Uganda. THET (The Tropical Health Education Trust3,4), with the Royal College of Physicians UK, has been supporting the postgraduate Master of Medicine in Internal Medicine (Ugandan MRCP equivalent) in Uganda, for 5 years. Through THET, we are working as university lecturers, providing teaching and organisational support. The positive impact this collaboration has had on the Department of Medicine is impressive. None of the six graduates of this programme have migrated overseas and all have taken on senior roles in the department. Initially largely organised and taught by British registrar lecturers, the course will soon be entirely run by Ugandan doctors with financial support through THET. The curriculum is adapted from a traditional British model, to one relevant to local disease patterns and resources. British consultants visit Mbarara throughout the academic year to give specialist lectures to supplement local clinical teaching. Students each spend 6 weeks learning a new skill e.g. echocardiography. This is specifically chosen to meet the hospital’s needs and can be undertaken in the UK or in recognised African centres. Good quality research skills are emphasised. Each student must produce a research thesis and undertake clinical audit during the course. Several of the current graduates now play key roles in local and national research projects. Ugandan graduates whom have attained a respected post-graduate qualification from this collaboration are now teaching undergraduates, providing excellent role models. As a result the course is becoming increasingly popular and with continued funding should thrive, proving that good quality postgraduate education may help to reverse the ‘brain drain’. Dr Julia Dancy and Dr Emma Wall 1.Lucas AO. Human resources for health in Africa. BMJ 2005; 331:1037- 8.(5th November.) 2.Stilwell B, Diallo K, Zurn P, Vujicic M, Adams O, Poz M. Migration of healthcare workers from developing countries; strategic approaches to its management. Bull World Health Organ. 2004;82:595-600. 3.Eastwood JB, Conroy RE, Naicker S, West PA, Tutt RC, Plange-Rhule J. Loss of health professionals from sub Saharan Africa; the pivotal role of the UK. Lancet 2005;365:1893-900. 4.Adams S. Achieving the Millennium Development Goals. Lancet 2005;365:1030. Competing interests: JD and EW were recruited through THET to work in Mbarara |
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