29
Brain Drain and Brain Gain: Selected Country Experiences and Responses Manuel M. Dayrit MD, MSc Dean, Ateneo School of Medicine and Public Health Manila, Philippines [email protected]
Brain Drain and Brain Gain:
Selected Country Experiences and Responses
Manuel M. Dayrit MD, MSc
Dean, Ateneo School of Medicine and Public Health
Manila, Philippines
Australia, Canada, UK and US
together account for
72% of foreign-born nurses and69% of foreign-born doctors
working in the OECD.
Source: WHO EB132/23 14 December 2012,
The Philippines -- top source fornurses in the US, UK, Canada;third-largest source in Australia.
India -- top source for doctors in theUS, UK, Australia; recently secondplace in Canada.
Source: WHO EB 132/23, 14 December 2012
.
Source: OECD, 2007
4
i) Nurses: Top 10 countries of origin ii) Doctors: Top 10 countries of origin
International Migration of Health Personneltowards and between OECD countries
0 10,000 20,000 30,000 40,000 50,000 60,000
Iran
Canada
Pakistan
Algeria
Former USSR
China
Philippines
United Kingdom
Germany
India
0 20,000 40,000 60,000 80,000 100,000 120,000
Former Yug.
Haiti
Nigeria
Ireland
India
Canada
Jamaica
Germany
United Kingdom
Philippines
Philippines is top exporter ofnurses to OECD
2000 2009
Nurses migrating 7683 13,014
US Philippines
Salary (US$/month) 5000 58 - 115
2000: 163,756 nurses working abroad110,774 (67%) in OECD
Source: Kanchanachitra C. et al. Human resources for health in southeast Asia: shortages,distributional challenges, and international trade in health services. The Lancet 2011:377:769-81
Manila taxi: www.workabroad.phfor all types of jobs
The Philippines is trying toaddress its nursing imbalances
• NARS Nurses Assigned to Rural Serviceprogramme; 11 085 unemployed nurses sent;
• Project EntrepreNurse Nurses asindependent primary care providers in nurse-managed cooperatives; Pilot project
• The Nurse Roadmap Strengthen professionalnorms and organization within nursing sector.
Source: Dimaya RM, McEwen MK, Curry LA et al. 2012
Source: OECD, 2007
8
i) Expatriation rates for nurses inOECD countries, circa 2000
ii) Expatriation rates for doctors in OECDcountries, circa 2000
Poor countries lose large percentages of theirdoctors and nurses to OECD countries
0% 20% 40% 60% 80% 100%
Haiti
Jamaica
Grenada
Belize
Saint Vincent and the Grenadines
Guyana
Barbados
Saint-Kitts and Nevis
Antigua and Barbuda
Trinidad and Tobago
Liberia
0% 20% 40% 60% 80% 100%
Antigua and Barbuda
Grenada
Guyana
Mozambique
Angola
Fiji
Sierra Leone
Tanzania
Trinidad and Tobago
Saint-Vincent and the Grenadines
Haiti
Health worker shortages in countriesCritical threshold: 2.3 workers per 1,000 population
Source: WHO (2006). The World Health Report 2006 – Working Together for Health. Geneva, World Health Organization
Countries Latest year All HRH density
Afghanistan 2009 0.71
Bangladesh 2007 0.57
Bhutan 2007 0.34
Cambodia 2008 1.02
India 2008 1.65
Indonesia 2007 2.33
Myanmar 2008 1.26
Pakistan 2009 1.37
PDR Laos 2005 1.24
PNG 2008 0.51
Global Health Workforce Statistics, World Health Organizationhttp://www.who.int/hrh/statistics/hwfstats/).
Physician, nurse, midwife density in Asia
Countries Latestyear
Physician density
Afghanistan 2009 0.21
Bangladesh 2007 0.30
Bhutan 2007 0.02
Cambodia 2008 0.23
India 2009 0.65
Indonesia 2007 0.29
Myanmar 2008 0.46
Pakistan 2009 0.81
PDR Laos 2005 0.27
PNG 2008 0.05
Global Health Workforce Statistics, WHO
Physician density in Asian countries
Countries
Latestyear Nurses and Midwives density
Afghanistan 2009 0.50
Bangladesh 2007 0.27
Bhutan 2007 0.32
Cambodia 2008 0.79
India 2008 1.00
Indonesia 2007 2.04
Myanmar 2008 0.80
Pakistan 2009 0.56
PDR Laos 2005 0.97
PNG 2008 0.46
Global Health Workforce Statistics ,WHO
Nurse & Midwife density in Asian countries
Nursing migration to the United Kingdom
• Significant variations over time among major source countries
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
1998/99 1999/00 2000/01 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07
India Philippines Australia Nigeria Pakistan
Nepal Zimbabwe China New Zealand Ghana
Zambia South Africa Kenya Canada
UK increased nurse production,now trend has reversed
• From 1995 to 2005, progressive increaseof annual production of nurses from11,000 to 23,000; midwives from 600 to1,600.
• Since 2010, declining level of fundedtraining places, much lower than the
number of applications to nursing schools
Source: Department of Health, UK, Buchan and Seccombe 2012
Forecasts of shortagesin recent nursing workforce studies
Country Source Estimated shortage /gap
AustraliaHealth WorkforceAustralia 2012. (Federalgovernment agency)
2025: Do nothing scenario showsshortfall of 90,000 to 109,500.
CanadaAcademic researchers(Tomblin-Murphyet al., 2012)
2022: 259000 required FTE / 199,000FTE available
= 60,000 shortage
USAUS Department ofLabor, 2012
2020 Projected growth of 711,000 jobs(+26% in demand)
USAAcademic researchAuerbach, 2012
2015: Forecast 94% growth in NP jobs
UKAcademic researchBuchan andSeccombe, 2011
2021/22: ‘Steady state’ scenario shows309,297.
Reduction of 42,807 over 2010 baseline(12.2% reduction)
Source: Buchan and Seccombe, 2012
Japan is recruiting nurses
2008: Bilateral agreements with Indonesiaand the Philippines
2011: 200 nurses and 300 careworkers wereallowed from each country
19/650 (3%) passed exams to stay in Japan
Source:OECD, International Migration Outlook 2012
Will US recruitment of foreignmedical graduates rise in next
decade?
‘‘… the inflow of doctors into the UnitedStates has remained stable since themid-2000s, whereas it has increased inAustralia and Canada. ’’
WHO EB 132/23, 14 December 2012
Australia is increasingrecruitment of physicians
Professional registration requirementsfor international medical graduateshave been liberalized for those whohave been licensed to practise by“trusted” authorities in English-speakingcountries.
WHO EB132/23, 14 December 2012
Percentage of births attended by skilled health personnelby level of total health spending
Source: World Health Statistics, 2010. WHO 2010.
Nepal
Mauritania
Malawi
Peru
Ethiopia
Philippines
ThailandBrazil
Mali
SudanTanzania
Guinea
0
10
20
30
40
50
60
70
80
90
100P
erc
enta
geofbirth
sattended
by
Skill
ed
Birth
Pers
onnel
5 10 15 2 0 30 40 60 100 150 2 00 3 00
Total health expenditure per capita in (US$) (log-scale)
Source: World Health Report 2 01 0
Low-and middle-income countries, latest available year
Malawi 2005-2010
US$ 95.6M direct investment
2004 2009 %
Physicians 43 265 516%
Nurses 3456 4812 39%
HW density 0.87 1.44 83%
Safe deliveries: 15% increase
Outpatient services: 49% increase
13,187 lives saved
http://www.msh.org/news-bureau/upload/Evaluation-of-Malawi-s-Emergency-Human-Resources-Programme.pdf
Promoting multiple strategies to improveretention in Thailand
Bangkok vs. Rural Northeast(Doctor to Population Ratio)
• Regulatory: compulsory contract of 3years of public work after graduation
• Economic: rural development project andfinancial incentives
• Education: rural recruitment and trainingin rural health facilities; development ofcommunity medicine
• Managerial: personnel management
• Social: movement for rural development
Source: Wibulpolprasert S, 2003
Strategies that worked:
Developments after WHO Codewas adopted in 2010
• 48/193 (25%) Members States havereported to WHO Secretariat
• 32/48 (67%) maintain statistical records onmigrant health personnel
• 22/48 (46%) undertake research onmigration
• 9/48 (19%) maintain records of authorizedrecruiters
Source: WHO EB 132/23, 14 December 2012
Concluding Remarks
• Overall, international recruitment by OECDcountries likely to increase in the nextdecade
• Key research, policies and investments incountries are essential to address HRHshortages and imbalances
• Ongoing health workforce planning is keyto address labor market conditions anddefine policy responses
ANNEX
The slides that follow are not forpresentation but may be used in
the open forum
CountriesAve. Annual Rate of
Population change (%)Earliest
yearAll HRHdensity
Latest yearAll HRHdensity
2000-05 2005-10
Afghanistan 3.8 2.6 2001 0.41 2009 0.71
Bangladesh 1.6 1.1 2003 0.48 2007 0.57
Bhutan 2.9 1.9 2004 0.27 2007 0.34
Cambodia 2.2 1.1 1996 1.09 2008 1.02
India 1.6 1.4 2000 1.76 2008 1.65
Indonesia 1.6 1.1 1992 0.69 2007 2.33
Myanmar 0.6 0.7 2004 1.34 2008 1.26
Pakistan 2.6 1.8 1992 0.84 2009 1.37
PDR Laos 2.1 1.5 1995 1.65 2005 1.24
PNG 2.5 2.4 2000 0.58 2008 0.51
WHO Global HRH Atlas 2013
Physician, nurse, midwife density in Asia
CountriesAve. Annual Rate of
Population change (%) Earliestyear
Physiciandensity
Latestyear
Physiciandensity
2000-05 2005-10
Afghanistan 3.8 2.6 2001 0.19 2009 0.21
Bangladesh 1.6 1.1 2001 0.23 2007 0.30
Bhutan 2.9 1.9 2004 0.05 2007 0.02
Cambodia 2.2 1.1 1996 0.11 2008 0.23
India 1.6 1.4 2000 0.55 2009 0.65
Indonesia 1.6 1.1 1993 0.06 2007 0.29
Myanmar 0.6 0.7 2004 0.36 2008 0.46
Pakistan 2.6 1.8 1992 0.52 2009 0.81
PDR Laos 2.1 1.5 1995 0.35 2005 0.27
PNG 2.5 2.4 2000 0.05 2008 0.05WHO Global HRH Atlas 2013
Physician density in Asian countries
CountriesAve. Annual Rate of
Population change (%) Earliest year
Nurses andMidwives
densityLatest year
Nurses andMidwives
density
2000-05 2005-10
Afghanistan 3.8 2.6 2001 0.22 2009 0.50
Bangladesh 1.6 1.1 2003 0.25 2007 0.27
Bhutan 2.9 1.9 2004 0.22 2007 0.32
Cambodia 2.2 1.1 1996 0.98 2008 0.79
India 1.6 1.4 2000 1.21 2008 1.00
Indonesia 1.6 1.1 1992 0.63 2007 2.04
Myanmar 0.6 0.7 2004 0.98 2008 0.80
Pakistan 2.6 1.8 1992 0.32 2009 0.56
PDR Laos 2.1 1.5 1995 1.30 2005 0.97
PNG 2.5 2.4 2000 0.53 2008 0.46
WHO Global HRH Atlas 2013
Nurse & Midwife density in Asian countries
Nursing migration to the United Kingdom
• Significant variations over time among major source countries
Source: NMC, 2012
U.S. Supply of Active Physicians and Ratio to PopulationActual 1950-2000 and Projected 2010-2020
Source: Fitzhugh Mullan, GWU, February 2008
219'897259'443
323'799
453'165
601'237
776'301
906'278 988'100
299.2297.4277.4
236.9
195.9
155.6
141.6142.2
0
200'000
400'000
600'000
800'000
1'000'000
1950 1960 1970 1980 1990 2000 2010 2020
Su
pp
ly(T
ho
usa
nd
s)
Physicians Per 100,000Population
Population is U.S. civilianpopulation including
possessions
Source: Bureau of Health Professions/HHS
