Managing brain drain in Zimbabwe’s health care sector.


BRAIN drain has become one of the major concerns bedeviling particularly the health services sector in most middle to low-income countries.

When we talk of brain drain, we refer to extensive emigration of individuals as a result of economic, political turmoil or the existence of more auspicious professional opportunities in other jurisdictions. Often, this has been prevalent in low-income countries exacerbated by the economic nature of these countries which basically involves low paychecks, benefits and incentives which in contrast, are relatively high in the developed countries.

Zimbabwe has been one such country to experience brain drain in the health sector and the professional have been leaving in droves over the years. But the World Health Organisation has noted that, while health workers are the backbone of every health system, ,55 countries with some of the world’s record delicate health systems have serious shortages and are losing their health workers to international migration.

Healthcare workers in low-income countries frequently face difficulties including insufficient opportunities for career advancement as well as lack of resources to effectively discharge their duties. While the pastures seem greener on the other end of the continuum, seeking to leave unfavorable conditions can be seamlessly reasonable although there are circumstances in which low-income countries can expect migrants to contribute in offsetting some of the harms experience by those left in their home countries.

The Zimbabwean experience


Over the years Zimbabwe has been battling with brain drain and the health services sector has been severely affected. The emergence of the global pandemic, Covid -19, in 2020 was a huge blow to the sector, not only for Zimbabwe but the world at large. Official statistics show that in excess of over 4 000 nurses and doctors left the country, the following year (2021) plunging the country into a deeper health crisis.

The country’s health sector has been thrown into a crisis as poor remuneration and working conditions drive qualified health professionals to migrate to other countries. This is despite the fact that the country on the other had has been bleeding when it comes to the costs in training these health professionals. According to the Zimbabwe Medical Association, the country only has 3 500 doctors to serve a population of 15 million

But even before this, Zimbabwe has been struggling to meet its 10 000 doctors requirement to enable it to effectively cater for its population as stipulated by WHO. While it is difficult for the Zimbabwean government to stop this exodus of professionals as doing so might breach citizens’ rights as vested in the country's constitution, the continued brain drain is increasingly becoming worrisome as it also stands in the way of growth for this sector.

British Home Office Data shows that Zimbabwe is now in the top-five skilled workers’ visa recipient countries with more that 8,300 medical professionals having been granted work visas by the United Kingdom between 2019 and September 2022. In its National Health Strategy for Zimbabwe 2016-2020, Zimbabwe admits that the working conditions for most of the health workers, as compared to regional conditions including salaries, have remained low creating low motivation resulting in brain drain and failure to re-attract those who left back into the country.


Tackling Brain Drain


Zimbabwe is one of the eight countries which were in March 2023 added to the WHO health workforce support and safeguards list 2023 since its original publication in 2020 according to TRT Africa. 37 of the countries added to the red list are in WHO region, eight in the western pacific, six in the Mediterranean region, three in the Americas, and the other three are in the eastern Mediterranean region. This implies how serious the problem is. However, experts believe there is a way to nip brain drain in the bud.


Policy Considerations.


There are a number of policy options that Zimbabwe can consider in an attempt to reduce brain drain. For example, Thailand, mandates that all public medical graduates work in the country for three years with a US$250 monthly incentive for private practioners. On the other hand, Vietnam and Mongolia all have compulsory rural service as a prerequisite for a post-graduate medical degree, and India is also considering the idea.Other countries like China have placed restrictions on employment of doctors by the growing private sector, as it tries to control internal brain drain. There are a variety of other policy options that Zimbabwe can consider;

a) Remuneration
In Zimbabwe, the vast exodus of health professionals has over the years been exacerbated by poor salaries and lack of attractive incentives. The country has not been able to tap into the benefits of remuneration as it has over decades been embroiled in economic meltdown episodes. However, studies have shown how an occupation-specific dispensation model can be used to remunerate health workers, for example, in South Africa. Making the remuneration of health workers a priority through crafting and implementing a policy that speaks to the issue may be key in reducing brain drain. However, there are other policy areas that Zimbabwe can look into, for example, compulsory service programmes.

b) Compulsory Service Programs.
Compulsory service programmes have been used globally as a way to position and preserve a professional health workforce within countries. These programs are all governed by some type of regulation, ranging from a parliamentary law to a policy within the ministry of health and doctors, nurses, midwives and all types of related health workers would be required to participate in the programme. To ensure compliance to such programmes, withholding full registration until obligations are adhered to, withholding degree and or salary, or imposing large fines would be noble examples. This may also include making it part of the degree or programme requirements and students may be required to comply on completion of the programme.

Another option would be a delay between the period one completes the programmes and the awarding of the certification, for example, the diploma or the degree. This ensures that while they wait for their certification they can be working in the country. However, doing this outside the law can be an abuse of human rights thus the need for policy intervention. Zimbabwe used to have a programme under which students who went to school funded by the government were be bonded for a certain period after which they were free to leave the country. In some countries, students are mandated to go for national service programmes to allow them to work in some jurisdictions. National service can also be necessary to gain a license to practice in the country. This implies that without national service one cannot attain the license.

c) Demanding compensation from receiving countries
Over time, there have been shocking numbers revealing how much African countries’ have lost due to brain drain. Annually, it is estimated that Africa loses around $2.0 billion through brain drain in the health sector alone. Considering the number of health professionals that Zimbabwe has lost to brain drain, it would be logical if recipient nations reimburse the country for the costs incurred in producing the health professionals. Sadly, Zimbabwe, like many other African countries have had no successful compensation programmes. In essence it has been noted that countries such as Canada, the United Kingdom, and Australia did not sign the Commonwealth Secretariat’s Code of Practice for International recruitment of health workers because of a clause related to the prospects of compensation. Zimbabwe not being a member of the common wealth, also becomes more compromised.

d) Taxation
The notion behind such taxation programmes would be that the professionals leaving the country can be required to pay some form of taxation. The professionals can be eligible to pay tax to the government for a certain period, say five years after leaving the country. The taxes can be used for the development of the health profession, for example, with the hordes of health professional that have left Zimbabwe, millions of dollars could be realised. At a time, the country’s system is in shambles, the taxation system can be viewed as a way of giving back to the profession thus coming in handy to the growth of the profession while also deterring people from leaving and work locally for the betterment of the country.

But some experts have argued that such measures can be permissible when they conform to certain requirements. A paper produced by Lancet notes that only legitimate governments that exercise power conscientiously can take this up. For example, the paper notes, governments that use public funds fairly and making good faith efforts to protect human rights – may make use of these measures. This will allow a government to typically plan on to meet residents’ desires and capitalize scarce resources in training sufficient skilled workers to meet those desires.

e) Recognising overseas qualifications
Regulatory instruments around recognising overseas qualifications can also come in as a solution to brain drain. As hoards leave for developed countries, there may be those that want to come and work in Africa. However, in the absence of a legislation that recognises their qualification, this can be difficult. Countries that have embraced this mechanism are South Africa and Kenya. In conclusion carefully constructed policy programmes are key to ensure growth in the health sector. These can help to curb brain drain as they can rationally poise the interests, freedoms and opportunities of all who are affected in various ways while taking considerations of the immigrants’ ambitions.


Definition of key terms

Brain Drain: Brain drain is a slang term that indicates a substantial emigration or migration of individuals.

Immigration: Immigration is the international movement of people to a destination country of which they are not natives or where they do not possess citizenship in order to settle as permanent residents or naturalized citizens

Compensation: Money that is paid to someone in exchange for something that has been lost or damaged or for some problem.

Taxation: Taxation refers to the act of levying or imposing a tax by a taxing authority

Compulsory: Something that must be done necessary by law or a rule.


References:


Frehywot S Et-al Compulsory service programmes for recruiting health workers in remote and rural areas: do they work? 2010 May;88(5):364-70. doi: 10.2471/BLT.09.071605.

Ibrahim foundation, Brain drain: a bane to Africa's potential, 2003

Gov.UK, Irregular migration to the UK, year ending September 2022-November 2022

Government of Zimbabwe, The national health strategy equity and quality in health: Leaving no one behind for Zimbabwe 2016-2020, Harrare, Zimbabwe

Kamarulzaman A et al Plugging the medical brain drain: October 29, 2022DOI: https://doi.org/10.1016/S0140-6736(22)02087-6

TRT Africa, Zimbabwe’s unique solutions to health sector brain drain, July 2023

WHO International News, WHO renews alert on safeguards for health worker recruitment; 2023 Geneva, Switzerland