pH7 Magazine - Out of Africa

Africa’s foreign assistance to the developed world often appears to be doctors, nurses and teachers. This brain drain, or the export of skilled labour from developing to developed countries, can be quite dramatic: almost 70 per cent of Ghana’s health professionals have emigrated to the richer world.

However, it is clearly unfair, inefficient and inconsistent for developed countries to provide aid to help developing countries make progress towards the UN’s Millennium Development Goals (MDGs) on health and education, whilst helping themselves to the nurses, doctors and teachers who have been trained in, and at the expense of, these countries.

Highly-skilled labour migration to more developed countries poses problems for many developing countries. One response would be to attempt to stop such migration. However, this would be neither desirable nor practical. As well as curtailing the rights of individuals to pursue opportunities and to make the most of their skills, it simply would not work. People would still move, but in the absence of legal channels for migration, they would be pushed into the arms of traffickers and smugglers. A second response would be to compensate developing countries for the loss of skilled personnel. At first glance, this seems sensible, but as the government rightly states, compensation is not the most appropriate response because it would be very difficult – that is, too expensive – to level up wage rates globally.

So what alternatives exist? To its considerable credit, the government highlighted the tension between the UK’s need to recruit staff to fill skills gaps in the National Health Service and the needs of developing countries’ health systems in its second white paper on international development. The Department for International Development (DfID), in particular, is fully aware of the development implications of highly skilled migration and specifically international recruitment. The government’s response to this tension has been to develop a code of practice for NHS employers involved in the international recruitment of healthcare professionals.

The code asks employers not to recruit actively from countries which would suffer as a result of losing staff. The Department of Health (DoH) has worked with DfID to produce a list of countries from which there should be no active recruitment, based on the OECD Development Assistance Committee’s list of aid recipients. Exceptional agreements have been reached with the Philippines and with India. These two countries have decided that they are content for the UK to recruit from them. The DoH also publishes a list of recruitment agencies which operate in line with the code and strongly advises employers to consult this list.

Welcome as the code of practice is, there are serious questions about its effectiveness. The content is fine, but the coverage is partial and the level of compliance is unclear. There are several loopholes in the code. Firstly, it is a voluntary code with no enforcement powers. Secondly, whilst it discourages active recruitment, it does not discourage employers from responding to enquiries from individuals in developing countries. Thirdly, it applies to England, but not to Scotland, Wales or Northern Ireland; and, lastly, it does not apply to private sector recruitment agencies.

This means that employers can get round the code through the use of private sector recruitment agencies. They can also circumvent the code by recruiting migrants who enter the UK for other reasons, but are subsequently employed by the NHS. Several issues need clarifying. How effective has the NHS code of practice been? What will the government do to enforce the code or to encourage NHS employers to adhere to it? Where does passive recruitment end and active recruitment begin? Why is there no code of practice for Northern Ireland, Scotland and Wales?

If the NHS is to depend on overseas workers, then the government is considering designing schemes to train nurses in developing countries for temporary employment in the NHS for a specified number of years, with the understanding that they would then return to their home country. Such schemes should be designed with the input of developing countries, migrants’ organisations and employers.

The nurses would have an opportunity to earn more and to acquire skills. Their home countries would see an increase in their skills base, and the UK would receive a temporary influx of staff for its health service. Such a scheme would need careful design, not least to ensure that migrants did return to their home countries, but the potential development benefits, and the fact that this would be a more cost-effective way of training nurses, no matter where they ended up working, make it worthy of serious consideration. The costs of training nurses should not be borne by countries which do not benefit from their training.

Whilst “just training yet more nurses”, as international development secretary Hilary Benn put it, will not reduce the brain drain in itself, it may help to address what appears to be a global shortage of nurses. However, in combination with efforts to address the push factors, such an approach has considerable potential to make migration work in a fairer and more cost-effective way to ensure development and reduce poverty.