2. LITERATURE REVIEW
2.5 The case of health professional migration
2.5.3 International migration data on health professionals
A brief glance over local newspaper headlines within recent years reveals troubling trends in health care, health care systems and occupational conditions among health care professionals in South Africa. Some headlines include: “State doctors want to get paid” (Sapa, 2011),
“Shortage of rural doctors critical” (McLea, 2010) and “High price to nurse staff shortage at hospitals” (Mokgata, 2007). A trend which has highlighted the crisis within the health sector has been the series of, at times violent and dramatic, health professional strikes, as is seen in headlines such as: “KZN braces for doctors‟ strike” (Oellermann, 2009) and “Better not get sick today: striking KwaZulu-Natal and Eastern Cape medics say they will not treat patients”
(Lekotjolo & Nair, 2009).
While strikes have been used by many health professionals as a form of mass action, another phenomenon which has occurred relates to health professionals „voting with their feet‟ as they migrate to countries such as the U.S.A., the U.K., Australia and New Zealand in order to seek better working conditions, pay and general security. This phenomenon has been
reflected in headlines such as “Billions lost as doctors flee SA” (Keeton, 2004) and “SA‟s doctor brain-drain” (Huisman & Masondo, 2009). One could argue that such media
headlines are often sensationalized and may not necessarily reflect the reality presently facing the health sector in South Africa and other similar nations. Agenda-setting research has shown that the media is strongly driven to increase ratings through sensationalised stories ("High cost of sensationalism," 2004). There are also strong links between media salience and public opinion (Kiousis & McCombs, 2004). However, there are journalists such as Kristof and WuDunn (2009) who call for greater accuracy in both the media and academia so as to present a more accurate view of real world indicators to the public. Because of a
possible mismatch between the media agenda and real world indicators, it can be dangerous using such headlines as a gauge of the current state and attitudes of health professionals in South Africa and the South in general.
However, one must also recognize that, while such coverage may be sensationalized, health professionals in much of the South are facing a range of critical professional challenges, such
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as human resource crises in the health sector and a high burden of infectious diseases, such as HIV/AIDS (McCoy, et al., 2008), as well as non-professional difficulties which are
common in the South, such as personal safety, political and economic stability and the lack of possibilities for prosperity for one‟s family (Stilwell, et al., 2004). There is an urgent need to collect reliable, valid and relevant data in order to appropriately assess, plan for and address the migration of health professionals from nations such as South Africa. This data must also be responsibly disseminated to the public in order to inform society regarding the reality of health professional migration.
There has been a long-standing interest in the migration of health professionals, both from rural to urban settings within a nation and also at a global level from the South to the North (Buchan & Sochalski, 2004, p. 57). One of the earliest pieces of research addressing the issue was conducted by Mejía (1978), which is noted by Bach (2004, p. 624) to be a
“landmark study of physician and nurse migration”, which focused primarily on push and pull factors in health migration.
Despite attempts by early studies to achieve rigorous standards, the reliability of this type of research is difficult to establish (Stilwell, et al., 2004). This problem is common among migration studies because there is no standard for keeping records on migration between countries (Brown, et al., 2002; Diallo, 2004). In addition, much of the research into this area focuses on issues of professional conditions and factors, such as low income, unpleasant and unhygienic working conditions, poor leadership within the health sector and lack of
professional opportunities for advancement and additional training (Dolvo, 2005b; Saravia &
Miranda, 2004). However, personal factors such as well-being or quality of life, chances for prosperity and issues related to personal safety and national stability seem to be either stated implicitly or are simply neglected. There is a need to investigate the effects of personal factors within migration decisions of health professionals in order to more holistically understand this phenomenon.
Although there is a paucity of rigorous data around this topic, there are some concerning statistics that have been published which give some indication of the magnitude of South to North health professional migration, although the exact extent is difficult to determine precisely. There are some statistics which are frequently cited in recent literature, which highlight the gravity of the extent of health professional migration. Although some of these
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cases seem extreme, they are often used to show how devastating this phenomenon can be for the countries of the South which are particularly constrained in terms of economic and human resources. According to Dolvo and Nyonator (1999, in Dolvo, 2005b), an estimated 61% of doctors trained and qualified from one medical school in Ghana emigrated between 1986 and 1995. Martineau, Decker and Bundred (2002, as cited in Buchan & Sochalski, 2004) state that between 1999 and 2001, over 60% (114 nurses) of registered nursing staff at a single medical institution in Malawi emigrated.
Mullan (2005) reports that six of the twenty countries with the highest emigration factors with regards to health professionals are in sub-Saharan Africa, with South Africa being one of them. In terms of South African medical emigrants, Mullan also states that there are at least 6993 South African physicians located in the recipient countries of the U.S.A., the U.K., Canada and Australia, while there are 30740 physicians still located in South Africa. This indicates that 18.5% of locally trained nationals are practicing outside of South Africa. Based on data analyzed by Clemens and Petterson (2008), it is estimated that 21% (7363 physicians) of South Africa‟s physicians and 5% (4844 nurses) of its nurses are living and practicing abroad, based in nine receiving countries. Based on this same data, Clemens and Petterson state that 11% of the nurses and 28% of the physicians born in Sub-Saharan Africa had migrated to nine receiving countries by 2000. These figures represent a great deal of lost investment in human capital, along with a great deal of important skills which the source countries are not benefiting from.
In terms of understanding the notion of the migration of health professionals, it is often not absolute numbers which are critical, but instead the proportion of trained professionals which is significant (Stalker, 2001). Martineau et al. (2004) argue that the loss of just a small number of health professionals can have a significant impact on a country‟s health system.
Martineau et al. (2004, p. 4) recount the following instance:
The Centre for Spinal Injuries in Boksburg, near Johannesburg, South Africa was the referral centre for the whole region. On the same day in 2000 the two anaesthetists were recruited by a Canadian institution opening a new Spinal Injuries Unit. A consequence of the loss of these two key staff was the temporary closure of the Centre.
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Despite some of the anecdotal and statistical evidence presented above, it is widely accepted that data regarding health systems and the health workforce within African countries is generally poor, thereby making it difficult to assess the impact of health professional migration, on both the source and destination countries (Hagopian, et al., 2004; Stilwell, et al., 2003). Data from the North is generally viewed as more accurate than that of the South and there is often a significant disparity between these two sources of data, making any accurate assessment of international migration difficult (Brown, et al., 2002). For example, research conducted by the Southern African Migration Project (SAMP) suggests that it is possible that official South African emigration statistics are potentially undercounting the loss of skilled professionals by around two-thirds (Brown, et al., 2002). While South African emigration records show that 10140 professionals left the country between 1987 and 1997, destination country statistics (Australia, Canada, New Zealand, the U.K. and the U.S.A.
combined) show 32296 professional immigrants arriving from South Africa during those same years (Brown, et al., 2002). There is an urgent need for high-quality data in order to accurately assess, plan for and appropriately intervene in the case of health professional shortages in the South.