Module 2: Human Resource Shortage

In the Doctors Without Borders documentary Living in Emergency, the filmmakers depict expatriate physicians working in virtual isolation with many patients at once, hitherto neglected by their local health system. Tempers are short, stress is high, and tragedy seems ubiquitous. Having expatriate physicians provide care is at best a temporary band-aid solution, and one that fails to address the structural issues that have caused physician shortages to begin with.

A major cause of healthcare shortages is the brain drain. The brain drain can be attributed to disparities in compensation and opportunity in another country that compel locally-trained doctors to leave. Any solution to this complex problem must transcend simply increasing foreign aid or forgiving debt; given the history of corruption in countries such as Malawi, much of the money would never even reach its intended target. Worse still, injecting money blindly into a country ignores the root causes of the problem. (1) Instead, the solutions must involve empowering local communities to solve their own problems. For a more detailed discussion of the causes and potential solutions of the brain drain phenomenon, click here.

Chronic health personnel absenteeism is another major resource limitation in resource-poor settings. A survey of 6 developing countries concluded that absenteeism averaged 35 %, a rate several times that of developed countries.(2)  Some of the causes include extremely high job security and fixed salaries rather than fee-for-service.  Because this problem is especially pronounced in rural areas, it has been suggested that remote areas could shift their focus to primary care health policies that do not require specialized health personnel such as physicians. These physicians could then be concentrated in urban hospitals, where increased monitoring limits absenteeism.(3) On the other hand, such a strategy could further increase healthcare disparities between urban and rural populations. Paying workers by service rather than by salary is another option, although this would require consistent and reliable monitoring, and would link healthcare expenditures to demand, making the total cost unpredictable.   

A Case Study: Sierra Leone

Located on the west coast of Africa, Sierra Leone is one of the least developed countries in the world.(4) In 2007, Sierra Leone had 67 medical officers and 225 nurses, even though the World Health Organization recommended a minimum of 300 medical officers and 600 nurses.(5) This disparity is in part due to brain drain.

One primary factor causing the exodus of healthcare professionals from Sierra Leone is salaries. Medical specialists are only paid $110 USD a month; the Sierra Leone Medical and Dental Association is currently lobbying for an increase to $1,000 monthly. Although salary increases have yet to be realized, there are several factors that are promising for change. First, the government re-launched its system of taxation under a new revenue authority, which should improve collection of taxes. Second, infrastructure investments currently use up approximately 70 % of healthcare expenditures because of the repairs and reconstruction of hospitals torn apart by the Civil War of 1991-2002. As the hospitals finish reconstruction, a greater fraction of healthcare expenses can be devoted to salaries.(6)

Furthermore, the recent import of a donated computed tomography machine should pave the way for the first internal residency program, which should address another brain drain factor—the lack of opportunities for specialization. The bureaucracy surrounding postgraduate training is also currently being reduced by decentralizing the recruitment process.(7)

These are practical ways in which governments can act to reduce brain drain, ultimately allowing nonprofits and NGOs to help support existing healthcare networks rather than replace them, paving the way for a more sustainable health system.

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(1) Theroux, P. “Misguided Aid for Africa.” The New York Times. 19 Dec 2005. Accessed on June 3, 2010.

(2) Chadhury, S., Hammer, J., Kremer, M., Muralidharan, K. and Rogers, F.H. “Missing in Action: Teacher and Health Worker Absence in Developing Countries.” The Journal of Economic Perspectives. 20.1 (2006): 91-116. Accessed on June 2, 2010.

(3) Ibid.

(4) United Nations Human Development Report 2009. “Statistics of the Human Development Report.” United Nations. 2009. Accessed June 22, 2010.

(5) Kelly, J.D. and Barrie, M.B. “Global Health: Will Positive Changes for Sierra Leone’s Health Professionals Mean the End of its Brain Drain?” Journal of Public Health Policy. 31 (2010): 112-114. Accessed June 22, 2010.

(6) Ibid.

(7) Ibid.