Brain Drain and Brain Gain: Selected Country Experiences and Responses

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 manuel_m_dayrit@yahoo.com

Australia, Canada, UK and US together account for 72% of foreign-born nurses and 69% of foreign-born doctors working in the OECD. Source: WHO EB132/23 14 December 2012,

The Philippines -- top source for nurses in the US, UK, Canada; third-largest source in Australia. India -- top source for doctors in the US, UK, Australia; recently second place in Canada. Source: WHO EB 132/23, 14 December 2012.

International Migration of Health Personnel towards and between OECD countries i) Nurses: Top 10 countries of origin ii) Doctors: Top 10 countries of origin Philippines United Kingdom Germany Jamaica Canada India Ireland Nigeria Haiti Former Yug. 0 20,000 40,000 60,000 80,000 100,000 120,000 India Germany United Kingdom Philippines China Former USSR Algeria Pakistan Canada Iran 0 10,000 20,000 30,000 40,000 50,000 60,000 Source: OECD, 2007 4

Philippines is top exporter of 2000: 163,756 nurses working abroad 110,774 (67%) in OECD nurses to OECD 2000 2009 Nurses migrating 7683 13,014 US Philippines Salary (US$/month) 5000 58-115 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

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The Philippines is trying to address its nursing imbalances NARS Nurses Assigned to Rural Service programme; 11 085 unemployed nurses sent; Project EntrepreNurse Nurses as independent primary care providers in nursemanaged cooperatives; Pilot project The Nurse Roadmap Strengthen professional norms and organization within nursing sector. Source: Dimaya RM, McEwen MK, Curry LA et al. 2012

Poor countries lose large percentages of their doctors and nurses to OECD countries i) Expatriation rates for nurses in OECD countries, circa 2000 ii) Expatriation rates for doctors in OECD countries, circa 2000 Liberia Trinidad and Tobago Antigua and Barbuda Saint-Kitts and Nevis Barbados Guyana Saint Vincent and the Grenadines Belize Grenada Jamaica Haiti 0% 20% 40% 60% 80% 100% Haiti Saint-Vincent and the Grenadines Trinidad and Tobago Tanzania Sierra Leone Fiji Angola Mozambique Guyana Grenada Antigua and Barbuda 0% 20% 40% 60% 80% 100% Source: OECD, 2007 8

Health worker shortages in countries Critical threshold: 2.3 workers per 1,000 population Source: WHO (2006). The World Health Report 2006 Working Together for Health. Geneva, World Health Organization

Physician, nurse, midwife density in Asia 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 Organization http://www.who.int/hrh/statistics/hwfstats/).

Physician density in Asian countries Countries Latest year 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

Nurse & Midwife density in Asian countries Countries Latest year 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

Nursing migration to the United Kingdom Significant variations over time among major source countries 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0 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 increase of annual production of nurses from 11,000 to 23,000; midwives from 600 to 1,600. Since 2010, declining level of funded training places, much lower than the number of applications to nursing schools Source: Department of Health, UK, Buchan and Seccombe 2012

Forecasts of shortages in recent nursing workforce studies Country Source Estimated shortage /gap Australia Canada USA Health Workforce Australia 2012. (Federal government agency) Academic researchers (Tomblin-Murphy et al., 2012) US Department of Labor, 2012 2025: Do nothing scenario shows shortfall of 90,000 to 109,500. 2022: 259000 required FTE / 199,000 FTE available = 60,000 shortage 2020 Projected growth of 711,000 jobs (+26% in demand) USA UK Academic research Auerbach, 2012 Academic research Buchan and Seccombe, 2011 2015: Forecast 94% growth in NP jobs 2021/22: Steady state scenario shows 309,297. Reduction of 42,807 over 2010 baseline (12.2% reduction) Source: Buchan and Seccombe, 2012

Japan is recruiting nurses 2008: Bilateral agreements with Indonesia and the Philippines 2011: 200 nurses and 300 careworkers were allowed from each country 19/650 (3%) passed exams to stay in Japan Source:OECD, International Migration Outlook 2012

Will US recruitment of foreign medical graduates rise in next decade? the inflow of doctors into the United States has remained stable since the mid-2000s, whereas it has increased in Australia and Canada. WHO EB 132/23, 14 December 2012

Australia is increasing recruitment of physicians Professional registration requirements for international medical graduates have been liberalized for those who have been licensed to practise by trusted authorities in English-speaking countries. WHO EB132/23, 14 December 2012

Percentage of births attended by skilled health personnel by level of total health spending Low-and middle-income countries, latest available year 100 Thailand Brazil 90 80 70 Peru Percentage of births attended by Skilled Birth Personnel 60 50 40 Mauritania Malawi Tanzania Guinea Sudan Philippines Mali 30 20 Nepal 10 Ethiopia 0 5 10 15 2 0 30 40 60 100 150 2 00 3 00 Source: World Health Statistics, 2010. WHOTotal 2010. health expenditure per capita in (US$) (log-scale) Source: World Health Report2010

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: Outpatient services: 15% increase 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 improve retention in Thailand Bangkok vs. Rural Northeast (Doctor to Population Ratio) Strategies that worked: Regulatory: compulsory contract of 3 years of public work after graduation Economic: rural development project and financial incentives Education: rural recruitment and training in rural health facilities; development of community medicine Managerial: personnel management Social: movement for rural development Source: Wibulpolprasert S, 2003

Developments after WHO Code was adopted in 2010 48/193 (25%) Members States have reported to WHO Secretariat 32/48 (67%) maintain statistical records on migrant health personnel 22/48 (46%) undertake research on migration 9/48 (19%) maintain records of authorized recruiters Source: WHO EB 132/23, 14 December 2012

Concluding Remarks Overall, international recruitment by OECD countries likely to increase in the next decade Key research, policies and investments in countries are essential to address HRH shortages and imbalances Ongoing health workforce planning is key to address labor market conditions and define policy responses

ANNEX The slides that follow are not for presentation but may be used in the open forum

Physician, nurse, midwife density in Asia Countries Ave. Annual Rate of Population change (%) Earliest year All HRH density Latest year All HRH density 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 density in Asian countries Countries Ave. Annual Rate of Population change (%) Earliest year Physician density Latest year Physician density 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 0.05 WHO Global HRH Atlas 2013

Nurse & Midwife density in Asian countries Countries Ave. Annual Rate of Population change (%) Earliest year Nurses and Midwives density Latest year Nurses and Midwives 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

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 Population Actual 1950-2000 and Projected 2010-2020 Source: Fitzhugh Mullan, GWU, February 2008 Physicians Per 100,000 Population 1'000'000 Population is U.S. civilian population including possessions 800'000 Supply (Thousands) 277.4 297.4 299.2 906'278 988'100 2010 2020 236.9 776'301 195.9 601'237 155.6 600'000 141.6 142.2 400'000 453'165 323'799 219'897 259'443 200'000 0 1950 1960 Source: Bureau of Health Professions/HHS 1970 1980 1990 2000