Research Assistant and Project Coordinator
In March 2012, the Peace Corps, the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), and the Global Health Service Corps launched the public-private Global Health Service Partnership (GHSP), a promising initiative that could improve the health sector in a number of developing countries. The CSIS Global Health Policy Center was fortunate to have the opportunity to play a modest role during the planning stages of this innovative enterprise. As the Partnership moves forward, a number of potential concerns will require careful attention.
In July 2013, the Global Health Service Partnership will temporarily assign health professionals to medical and nursing schools in three African countries – Tanzania, Malawi, and Uganda – that have each reported health personnel shortages. The GHSP aims to alleviate these shortages by improving their medical education programs. The need is acute: personnel “shortages limit the ability of developing countries to deliver even basic health care let alone respond to new, unforeseen epidemics,” according to Dr. Vanessa Kerry, CEO of the Global Health Service Corps. Furthermore, a 2004 article in The Lancet maintained that improving human resources for health in developing countries is “far more important” than providing more money and/or pharmaceuticals to lower-income nations.
Medical out-migration – or “medical brain drain” – is one factor responsible for personnel shortages. By providing advanced educational opportunities for health professionals, the GHSP aims to reduce medical out-migration. Citing a WHO report, Dr. Kerry and her co-authors noted that: “In Cameroon, lack of opportunities or promotion, and desire to gain advanced training, ranked above poor wages as reasons why health care professionals chose to migrate.” If the factors motivating out-migration in Cameroon are the same factors causing out-migration in Tanzania, Malawi, and Uganda, one can expect the GHSP to reduce health personnel shortages.
However, there is a need for tempered optimism: improving training may be insufficient for alleviating health worker shortages because some individuals may migrate for other reasons. In addition to lack of training opportunities, medical out-migration is also driven by: market forces (including the prospect of better jobs and higher salaries in higher-income countries); sub-standard working conditions; and the possibility of a higher quality of life for oneself and one’s family. For some individuals, these other factors are more important than opportunities to gain advanced training in their decision calculus to migrate.
Although this may be counter-intuitive, some argue that improving health worker training opportunities ceteris paribus may exacerbate health worker shortages: better trained health professionals may subsequently seek work in more affluent countries. Arah et. al. found that physicians in “relatively rich” developing countries with “higher training capacities” than poorer countries are more likely to emigrate to high-income countries. The Committee on the U.S. Commitment to Global Health – convened by the Institute of Medicine – cited this finding and consequently emphasized that international medical partnerships should promote health worker training and retention. Arah et. al. succinctly and urgently outline the stakes: “Ultimately, developing nations will have to ‘train, retain, and sustain’ their physicians and other health workers if they are to save their health systems from complete implosion.”
Others argue that medical training programs contribute to alleviating human resource shortages in the health sector by increasing the overall number of qualified health workers – even if some emigrate after receiving training. Thus as long as an equal or lower proportion of workers decide to stay as compared with pre-GHSP levels, the Partnership will have made a positive impact.
Based on these seemingly contradictory findings, one cannot conclusively predict whether the training opportunities provided by the GHSP will increase, reduce, or have no effect on medical out-migration. In light of the risk of encouraging greater emigration by providing advanced training opportunities, the GHSP should also emphasize health worker retention. Numerous strategies for improving retention have been proposed, including: increasing health worker remuneration and improving working conditions by developing better health sector management capacity and ameliorating medical supply shortages. To this end, the GHSP could supplement its curriculum with a focus on health sector management. The GHSP may also collaborate with focal country governments to improve working conditions and remuneration for health professionals. By broadening its portfolio to emphasize training and retention, the Partnership can maximize its positive impact on the Tanzanian, Malawian, and Ugandan health sectors. However, the ultimate effectiveness of this strategy remains to be seen.