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.
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.