Retain healthcare workers in Uganda - Export is less viable

One of the biggest challenges faced in the health sector is the difficulty experienced in managing Human Resources for Health (HRH), amidst undersupply of healthcare workers. The scarcity of healthcare professionals especially in developing countries is primarily due to underinvestment in human capital for health, among other reasons - for example Uganda’s investment in health has relentlessly stayed below the promise of commitment in the Abuja Declaration.

Whilst the government has registered progress in approving and filling posts for the required health facility staffing, undersupply of healthcare workers is prevalent and remains a critical challenge for Uganda. The staffing rate (percent of filled posts) has persistently remained below national target in the Health Sector Strategic and Investment Plan (HSSIP). Out of the 57,050 total approved posts in public health facilities, only 35,903 are filled, representing a staffing gap of about 37 percent. This kind of gap is widening with exodus of health workers. The state of affairs is likely to be worsened by recent government proposal to export healthcare workers. Before diagnosing the viability of such an export scheme, it is important to first understand what triggers health worker exodus or mobility.

Mobility of health professionals is explained by both local and global forces that set in time and again, driving health workers to migrate. The migration can take place locally through inter-sectoral mobility (e.g. from the public sector to well-resourced private sector health facilities), rural-urban movement, and international mobility or export. The International Organization for Migration (IOM) contends that due to healthcare globalization, international mobility of healthcare workers is here to stay and is an indispensable part of the contemporary world, a global phenomenon requiring cognizance of policy makers, for better management of HRH. 

Research has shown that international migration of health workers is mainly catalyzed by “push and pull forces”. Healthcare workers are pushed out by appalling conditions in their own countries. The conditions affect their wellbeing, and also debilitate their efforts towards delivering sufficient and quality healthcare services. Such push socio-economic and health related factors include: inadequacy of jobs or underemployment, deteriorating work environment, lack of promotions, inadequate medicine and equipment, healthcare worker burnout, inflated patient-health care provider ratios, low salaries, inability to accrue savings, non-payment of salaries, poor accommodation, and lack of transport to go for work. On the other hand, health workers are pulled into the importing countries by captivating factors such as: availability of gainful jobs, fairness in granting promotions, reasonable workload and conditions of work, higher pay and ability to save, absence of corruption, safe working environment and appropriate medical equipment.

Recent demographic trends in many industrialized nations, characterized by ageing population and low fertility rates among others, are increasingly exacerbating the exodus of healthcare personnel from developing nations. Such trends are widening healthcare labour market supply-demand gap in developed nations (demand is skyrocketing, with a struggling supply side), exerting immense pressure on a developing country like Uganda, further pulling health workers to migrate to the developed nations.

Recently in Uganda, there has been a proposal by the Ministry of Foreign Affairs to export about 283 well-skilled health workers to Trinidad and Tobago, a move which will further accelerate international migration of healthcare workers. This requires careful decisions to be made with evidence concerning the costs and benefits of such a proposal to the economy. The move has nonetheless attracted serious criticisms, both from nationals, and development partners such as the European Union. The plausible reason advanced is that it poses a serious threat to the delivery of essential health services, and may undermine efforts towards the renewed focus on Universal Health Coverage (UHC), including quality of health care.

Some positive aspects associated with exporting health workers do exist as well, although marginal. The key macroeconomic benefit is financial transfers to the country of origin through remittances, which is a source of foreign exchange expected to contribute in propelling economic development. Other probable benefits are non-financial, for example transfer of knowledge, skills, and technology back into the country. Conversely, loss of human capital due to brain drain retards development in the country of origin. Uganda in particular encounters hefty illness burdens (for instance due to malaria and HIV/AIDS) and exporting health care workers can worsen the health care system, with adverse ramifications on the availability, cost, and quality of care. Economic losses present in the form of foregone tax contribution of exported health workers, and this can slow down economic growth. Additionally in the long run, the exporting country loses its initial capital investments used for educating and training the exported health workers. Some studies have also demonstrated that exported healthcare workers tend to have better labour market outcomes (mean hours of work) in the destination countries, an opportunity foregone by the country of origin.

Countries that have supported the idea of outflow of their workers (e.g. Philippines and India) do so with the aim of reaping big from foreign capital via remittances. Nevertheless, it has been observed by IOM that the value of remittances hardly counterbalances the lost talent and skills, particularly if exported workers don’t return home. From a cost-benefit analysis perspective, health worker export seems not to be a viable scheme, given that the ultimate economic impact is a net capital outflow for the exporting country. For instance empirical evidence has shown that annual inward remittances for both nurses and doctors are less than annual government investment in training doctors alone (excluding nurse’s training costs), which yields a benefit-cost ratio of less than unity. Likewise, the source country’s health system does not benefit from remittances, hence failure of remittances to compensate for the losses or gaps created in the health system due to health worker migration.

Others have argued that developed importing countries reap more gains than poor exporting countries, through the “perversive subsidy” mechanism. This is a scenario where the latter countries actually provide aid to the former, unnoticed. In this circumstance, the amount of money saved by the destination (importing) country as a result of employing imported health workers exceeds the amount of development assistance channeled for health to the exporting country.

Uganda should, therefore, consider balancing its national interest by taking into account national health requirements, and the economic implications of exporting health workers, prior to embarking on the healthcare personnel export scheme. Alternately, there is need for instituting strong mechanisms for replenishing outflow of health professionals to avoid some of the dangers associated with aspects of health worker migration that may be difficult to control.

It is incumbent on policy or decision makers to rethink the export scheme, and focus should instead be put on resolving the “push and pull forces”, in order to retain healthcare professionals in the country and avoid the prodigious negative socio-economic impact of healthcare worker expatriation. Overall, healthcare workforce attrition or international migration can be contained by meaningfully investing in the healthcare system, and particular attention should be paid to establishment of a comprehensive incentive-based strategy for development of Human Resources for Health.