Jairos N Hiliza — Perspectives on Brain Drain from a Tanzanian MD Student

I am a Tanzanian born to a poor family in a western part of Tanzania, Kigoma region, where everything signifying poor development is vividly seen; such as muddy seasonal roads, poor health facilities and absence of electricity.

Upon completion of my advanced secondary education I was enrolled at Weill Bugando University as a medical student. I have reached this point despite many difficulties. I recently sat down to figure out the education system in Tanzania, especially with regard to health worker training and realized that “brain drain” cannot be stopped unless the system is changed. I write this to let the know how the Tanzanian society is stratified (classified) and, hence, favors brain drain.

As I see it, there are three strata when it comes to the possession of wealth in Tanzania.

The first stratum covers those with high ranks in government leadership such as the ministers, members of parliaments and various managers and general secretaries of public and private offices. International businessmen are included in this class. Regarding health care, when they become sick the take a flight to developed countries such as the USA and UK for treatment. Also their sons and daughters do not study in Tanzanian schools or universities, so when they graduate, they are not willing to work in poor working conditions as I described above, because they do not know the problems facing Tanzania and are not used to this environment. They opt to work in wealthier countries that agree with their class and standard of living.

The second stratum comprises those who are private and government employees and live in the cities and towns. Since they earn a monthly salary, they are able to take their sons and daughters to mostly privately-owned secondary schools with all the teaching facilities and plenty of well-qualified teachers and expensive school fees. These pupils are the ones to score best. The Tanzanian government enrolls students in universities and gives them loans to meet university costs based on the grades they receive. So this group, who is raised in towns and cities like their parents had been, are the ones to get university level education. When graduated they want to work in towns but there are no vacancies and telling to go work in remote villages and poor towns where real problems exist is like telling them to go to hell, so they opt to move to well developed countries to find work.

The third class comprises the laborers, nomadic persons and local farmers (hand and hoe farmers) who are living under less than one US dollar and send their sons and daughters to local secondary schools, nick-named “Saint Kayumba”. These secondary schools are built by politicians in order to win votes from this class of uneducated people, so these schools are called “political secondary schools” and are, in actuality, only buildings that do not fulfill the purpose of a school. You find two teachers with thousands of pupils, no teaching materials and poor working conditions so that education is very poor. These pupils end up doing poorly in school so the idea of becoming a university student will remain an unfulfilled dream. And these people are the ones who know the situations of ordinary Tanzanians especially when it comes to the health sector because they and their relatives are facing these problems. Sadly, they do not have a say with the government or any other vehicles to enable them to get the know how to save themselves and their people.

Weill Bugando University realized that too many students in the third class I described were not given any opportunities because they have low grades due to the poor education system in their home secondary schools. This university, along with the Catholic Church and Governing Board, sat down and decided to target these students especially.  Funnily enough, amongst Tanzanians and according to the Tanzanian Commission of Universities (TCU), Weill Bugando University has first rank academic performance compared to other public and private medical universities. I am sure graduates including myself are going to help and heal Tanzanians because we know the inner core of Tanzania’s health problems, and the sufferers in poor towns and villages to which we belong.

Whomever helps this third class of Tanzanian people not only will be healing the whole Tanzanian population but, also, will be helping Tanzania to minimize if not to eliminate the brain drain problem. Thanks to Touch Foundation for linking us to heart-felt people around the world to make sure that their support reaches us quickly and unchanged.

I belong to the villages so after my graduation I MUST return to save and heal my people. I am ready to cooperate with anybody who is assisting Tanzania in the health sector to save the majority of Tanzania’s population.

Jairos N Hiliza is a third-year MD student at Weill Bugando University in Mwanza, Tanzania.

Eric Williams — Push and Pull Factors Affecting Attrition of Health Workers

The global shortage of health workers poses one of the greatest challenges to health and development for developing nations. The World Health Organization estimates that 57 countries – 39 of which are African nations – have severe shortages and require some 4.3 million health workers to fill immediate and critical gaps in fragile health systems.

For better perspective, consider the following excerpt from a statement by an international coalition of organizations and individuals concerned with how certain proposals to address the U.S. domestic health worker shortage have  “significant potential to worsen international health outcomes,” particularly with respect to the global supply of health workers:

“While the United States enjoys workforce ratios of 8 nurses and 3 doctors for every 1,000 Americans, in Ghana more than 10,000 people have to share a single doctor, and India has less than one nurse for every 1,000 people. Washington, DC, with a population of fewer than 600,000 people, has about twice as many physicians as do the more than 80 million residents of Ethiopia.”

Health worker safety, salaries, benefits and a host of other issues are “push” factors driving health workers to leave the health sector or forcing them to migrate to other regions and countries for better pay and safer work conditions. Additionally, “pull” factors fuel a brain drain to richer nations where higher salaries, stable governments, and better schools are available for health workers and their families.

There have been large increases in development aid over the last decade – though still inadequate – for developing nations, rich nations are part of the problem. Rich nations recruit health workers from lesser developed countries to meet their own growing health demands. It is estimated that 25%, or 200,000, of U.S. physicians were trained overseas and that 60% of those physicians were trained in low to lower-middle income countries. And among nurses, the U.S. nurse workforce now includes 400,000 foreign trained nurses – 16% of the entire nursing workforce. Such drains on developing nation health workforce only further exacerbate widespread shortages and makes it all the more difficult to address endemic and epidemic challenges such as HIV/AIDS, TB, malaria, reproductive and maternal child health issues, neglected tropical diseases and so on.

There is much that donor and developing country governments must do to address the health worker crisis and to strengthen health systems, including:

• Supporting robust health workforce plans and providing needed funding
• Funding commitments
• Code on international recruitment of health personnel
• Increasing number of domestically-educated health professionals
• Other relevant activities or developments

The full list of recommendations developed by the Health Workforce Advocacy Initiative can be found here.

The U.S. government officials announced in May 2009 a new comprehensive strategy under development that is to be an “integrated approach to fighting diseases, improving health, and strengthening health systems.” In a report released in late October 2009, a broad coalition of advocates and implementers called for a doubling U.S. aid for health and establishing U.S. targets for improved health outcomes. Health workforce plays a prominent and central role in the report.

Eric Williams is a Policy Associate at Physicians for Human Rights (PHR), a nonprofit that “mobilizes health professionals to advance health, dignity and justice, and promotes the right to health for all. Harnessing the specialized skills, rigor, and passion of doctors, nurses, public health specialists and scientists, PHR investigates human rights abuses and works to stop them.” Eric is based in PHR’s policy office located in Washington, D.C., but the nonprofit’s primary office is in Cambridge, MA.

PHR chairs the Health Workforce Advocacy Initiative (HWAI), which is an international civil society-led coalition affiliated with the Global Health Workforce Alliance. HWAI prioritizes human resources for health and health systems strengthening, and seeks to ensure that people everywhere have access to skilled, motivated and supported health workers within well-functioning health systems.

Emily Bell — Is “brain drain” responsible for the shortage of health workers?

The Who Cares? Campaign Blog is exploring the issues of “brain drain” and attrition for the month of November.

Tanzania faces one of the worst health worker shortages in the world. The country has only 822 doctors and 13,292 nurses who deliver healthcare for almost 40 million people. This means doctor and nurse to patient ratios are 100 and 25 times lower, respectively, than they ought to be to meet basic healthcare needs.

To what extent is this shortage of health workers in Tanzania due to “brain drain” – the phenomenon whereby skilled workers migrate to other places in search of better paying or more satisfying work conditions?

Interestingly, the Touch Foundation report, Catalyzing Change: Molecular Strengthening of the Health System in the Tanzanian Lake Zone, found that external migration of doctors, nurses and other health workers is not as significant a challenge in Tanzania as in other sub-Saharan African countries: “Only 6-15 percent of doctors and less than five percent of nurses in Tanzania emigrate, compared with 37 percent of doctors and 34 percent of nurses in some countries. The low rate of external migration can be attributed to structural factors – political stability, economic growth, and large numbers of ‘paraprofessional’ health workers such as Assistant Medical Officers (AMOs) and Clinical Officers (COs) whose qualifications are not easily transferrable outside Tanzania.”

Despite relatively low rates of external migration, Tanzania faces other challenges with respect to the shortage of health workers. The low production of health workers is a major cause of the shortage. In the Touch Foundation report, Action Now on the Tanzanian Health Workforce Crisis: Expanding Health Worker Training – The Twiga Initiative, we determined there are six major reasons for low production, including a shortage of qualified students and financial support, shortage of clinical faculty, limited non-clinical faculty, fragile clinical and non-clinical (basic science) infrastructure, and overall financial resources.

The small number of new health workers who graduate each year do not always stay in the healthcare profession.   Twenty percent of graduates will not enter the workforce at all and many switch careers within the first year of being deployed. Attrition stems from a variety of causes. Those who choose to become health professionals often experience challenging conditions, including low pay, lack of supplies, and poor management. These challenges ultimately lead to low job satisfaction.

The Touch Foundation is planning to address attrition and other challenges facing health workers in the Lake Zone region of 15 million people by creating a regionalized training network to increase capacity and healthcare access in the region. Our work will draw on our in-depth analytical studies on health worker production and health systems challenges as well as our practical experience in supporting Weill Bugando’s medical school and hospital.

Emily Bell is Head of Advocacy and Communications at the Touch Foundation.