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health workforce

Jan 11, 2012

A call for Australia to stop "stealing" health professionals from South Africa

Health economist Professor Gavin Mooney has had

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Health economist Professor Gavin Mooney has had a longstanding concern about the flow of health professionals from poor to wealthy countries.

In the article below, he proposes a plan for how Australia might address its responsibilities to countries like South Africa. Instead of the “unethical” practice of draining poor countries of health professionals, we should be exporting our own, he says.


A plan for a fairer deal for South Africa

Gavin Mooney writes:

I have recently returned from South Africa where I had been invited to talk at a conference on the future of that country’s proposed National Health Insurance. That has got me thinking again about the ‘stealing’ by Australia of health workforce personnel from sub-Saharan Africa and what might be done about it.

In South Africa, for example, there is a chronic shortage of doctors, especially in the public sector. There is also a major health crisis and a major health care crisis.  Poverty and inequality remain massive killers; sadly, and so disappointingly, South Africa is now one of the most unequal societies on the planet and more unequal today than it was in the apartheid years.

The health care crisis is not just one of underfunding per se but quite incredible inequity between public and private sectors – read between poor and rich and again read in essence black and white.

Thus the government’s Green Paper states:

“The 8.3% of GDP spent on health is split as 4.1% in the private sector and 4.2 % in the public sector. The 4.1% spend covers 16.2 % of the population … largely on medical [private] schemes. The remaining 4.2% is spent on 84% of the population  … in … the public healthcare sector.”

Yet Australia (and other rich and healthy countries) continues to steal South African doctors and nurses.

While in South Africa, I spoke with Ms MP Matsoso, the Director General of Health. I promised her that on my return home I would raise the issue of the flow of doctors and nurses from South Africa to Australia.

The current situation is unethical and unconscionable. We in Australia have a shortages of skilled health workforce but such shortages pale into insignificance alongside those of sub Saharan Africa.

The ‘opportunity cost’ –  the benefit foregone – in an HIV/AIDS-torn, desperately poor South Africa – of every doctor pinched by us is to be measured in far greater human terms of sickness and death than any health gain we may have. (And, in any case, if a poor country like Cuba can export doctors, why can’t we?)

Further, in South Africa, as this BMJ article notes:

“The estimated government subsidised cost of a doctor’s education [is] $58 700… The overall estimated loss [to South Africa] of returns from investment for all doctors [trained in South Africa] currently working in [Australia, Canada, the US and the UK] was … $1.41bn.”

At the International Federation of Medical Students’ Association (IFMSA) Congress in Mandurah in 2007 which was attended by a great bunch of socially-conscious medical students, many from poor countries, I cringed as Tony Abbott, the then Health Minister, appealed to these starry eyed, future doctors to come and work in Australia. His message was clear. Never mind the sick and lame and dying back in your own home countries. Move here where you can earn much more. (Fortunately the students resoundingly rejected his sordid appeal.)

More recently, however, there has been a very different appeal from a very senior voice in Australian health policy.

Dr Andrew Pesce, towards the end of his tenure as President of the AMA, in a speech at the World Medical Association Symposium in Sydney in April last year asked:

“What right do … wealthier countries have to address their own health workforce shortages with recruitment policies that worsen workforce and skills shortages in developing countries?”

And he went on: “Unfortunately, our health planners have hidden their own workforce planning failures by importing trained doctors and nurses. Inevitably developing countries are most at risk of a net workforce loss.”

Well said, Andrew, and now that we have a new Health Minister who does seem to have a concern for social justice, perhaps we can hope for change in Australian Government thinking on this front.

What is needed?

Well I suggest a four-point plan.

1. That to curb health workforce stealing, Australia enter into an agreement with South Africa similar to that which was negotiated between the UK and South Africa in 2003.

2. That for each doctor we do steal (or have already stolen?) we pay South Africa the estimated cost to that country of the training costs and the opportunity cost to them of each exported doctor.

3. That such payment be made by providing the South African public health care system with support in kind to build a better management system and train good managers (which are crucial if the proposed NHI is to work).

4. That we look at adopting a medical and nursing workforce plan that results in our not stealing from poor countries but exporting to poor countries.

When I was at the South Africa conference, I spoke of how a national health insurance scheme there would not only help to bring about a healthier population but also be a social institution that would assist in building a less divided, more united country – a more decent society.

At the start of this New Year, following one where there have been many signs of hope for a better, more decent world globally yet a pettiness and narrow mindedness here at home, how better to kick off Australian health policy in 2012 than for our new health minister to adopt the four-point plan above?

Now wouldn’t that be the act of a decent society!



Melissa Sweet —

Melissa Sweet

Health journalist and Croakey co-ordinator

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17 thoughts on “A call for Australia to stop “stealing” health professionals from South Africa

  1. Peter Ormonde

    Excellent piece Mr Mooney!

    Sadly one of the great exports of many “developing” nations is their educated young people. India and Egypt spring to mind. Not just doctors – engineers, lawyers, potential political leaders and reformers… even economists. The country in question might be getting the better part of the deal with the latter actually.

    The point is that it is the entire social structure of the source country that is undermined and eroded by the loss of its young and educated children. We are pinching their future.

    It means the education system leaks like a sieve. It means that this absolutely critical investment in a country and building its future is essentially nobbled. And the beneficiaries are us. Bit like intellectual strip mining.

    I’d like to suggest a coupe of extra points to your four point plan I could.

    Bonds for students to perform work in the training country for a certain period in return for the education and support they receive. Used to work here with teachers as I recall. Painfully.

    A fund – for education in source countries – paid for by the beneficiaries of the training. UNESCO could do this I’d reckon.

    And lastly, it would be decent of the universities – who also benefit from poached talent perhaps more than any other single sector – would establish programs designed to encourage the transfer of skills and graduates with the source country. You know so that part of your engineering degree might involve spending 6 months building a solar thermal plant in Nigeria or Kenya for example.

    One point that is worth mentioning is the distinctly self-serving process employed by the local professional bodies in vetting and essentially licensing operators from overseas. Not sure what it’s like now but 30 years ago I had some dealings in this area and encountered a barrage of rather contrived hurdles and obstacles designed purely to protect local vested interests. Those trained in English-speaking countries seemed to get the rails run.

    Meanwhile, our front-line health care system – particularly in rural Australia where I live – is increasingly reliant on the universities of Cairo and Mumbai. Thanks folks.

  2. Jung Zd

    I praise Mr Mooney for the concern he shows for a country that is, unfortunately, renowned for disease and poverty. I am however insulted and concerned by his grossly oversimplistic misrepresentation of such a complex issue as this.

    No country in the world does or can in fact ‘steal’ health workers (or engineers or teachers or businessmen, for that matter). Mr Mooney’s implication that these people are nothing more than the playthings of global geopolitics is an insult to their intelligence, and to their dignity as autonomous free-thinking individuals. These migrants decide for their own reasons, not because of the fumbling machinations of nation-states, that the country of their birth, was not a place worth staying in.

    Moreover, it is rare for migrants to completely cut themselves off from their homelands. Study after study have shown that migrants maintain ties with their places of birth in a multitude of ways. They transfer hundreds of billions of dollars in remittances from the rich world every year. Their backgrounds often give them leading roles in foreign investment drives from their adopted countries. They flourish in the ivory towers of the West and bring back ideas that they could not have learned back home. These connections and practices often survive for generations.

    The possible reasons to migrate are, of course, as infinite as the human experience. For countries such as South Africa, economic reasons are more common. That however, is not the whole story.

    Crucially if sadly, South Africa’s poverty, is not the only reason that propels free men and women to leave the place of their birth, of their families, of their culture. South Africa’s problems are manifold and its people suffer from alarming rates of crime, a crony-capitalism that favours sycophants of the ruling party, casual corruption, appalling public education, and yes, a horrid health sector that has left Africa’s richest nation with the dubious honour of having the world’s largest number of infected in the world.

    And yet. To blame only the problems above (and a legion more unlisted) is only to blame the symptoms. The reason why these continue to blight South Africa is misgovernment. One obvious example springs to mind. Thabo Mbeki, the country’s previous president, was loth to admit a connection between HIV and AIDS; Manto Tshabalala-Msimang, Mr Mbeki’s health minister, recommended treating the disease with beetroot and garlic. It would not be impossible to argue that Mr Mbeki’s decade of denialism caused more harm to South Africans’ health than any imaginary theft of health workers ever has.

    The fact that the current president ended this insanity and reinfused government policy with sensible ideas should be celebrated. The country’s struggle to overcome its plethora of challenges requires the continued help and friendship of the West but the onus for action lies with its government and its people. If the rulers and friends (such as Mr Mooney) of South Africa wants its young, its educated, its hard-working, to stay home and continue building Mandela and Tutu’s Rainbow Nation, they should stop blaming others for problems which only South Africa itself can solve.

  3. Andrew Bartlett

    I agree with the concern expressed by Prof Moody about the serious impact on the ability of some poorer countries to develop and maintain an adequately sized medical and nursing workforce as a consequence of many health professionals going to work in wealthier countries.

    But I don’t think it is helpful or accurate to label the activity of medical professionals moving from poorer countries to wealthier countries to work as ‘stealing’ those workers. Using this term just encourages an inaccurately narrow impression of the various factors which lead to the flow of skilled workers from poorer countries to richer ones.

    Whilst one factor is the desire of wealthier countries to cover our workforce gaps, another obvious factor is that skilled people in poorer countries decide to take up employment opportunities in wealthier countries because they can earn more – and often just as importantly, access far better professional development opportunities and long-term career prospects.

    It should also be noted that some of these workers subsequently use the extra skills and wealth they’ve gained to assist their country of origin in various ways. This doesn’t negate the impact on that country of losing them from their workforce, but it is none the less part of the wider picture which should be taken into account.

    Seeking better employment and life opportunities is the major factor which has driven, and continues to drive, migration for centuries, and I don’t think it is helpful to portray this simply as the receiving country ‘stealing’ them.

    It would be a perverse outcome if we were to adopt a policy approach which has the effect of denying people from poorer countries the opportunity to improve their life opportunities while still leaving that option open for those from rich countries – (something Australia is also benefitting from at present via the significant flow of medical and other skilled workers moving here from Ireland, the UK and elsewhere).

    I am not suggesting this is the outcome which Prof Moody is advocating – in fact I am broadly supportive of the thrust of most of his ‘4 point plan’. But using an over-simplistic and not-terribly-accurate term like ‘stealing’ to describe a process which involves people from poorer countries deciding to improve their life opportunities by moving somewhere else (sometimes only temporarily) increases the likelihood of over-simplistic and potentially quite unjust policies being advocated in response.

  4. Gavin Mooney

    Stealing? If one takes without giving adequate compensation might that not be called stealing? Yes, I accept (and in no way did I imply that it was not the case) that the reasons for doctors and others moving from one country to another are complex. At no point did I suggest that they should not move. What I was suggesting was that when they did move from for example South Africa to Australia then the Australian government should compensate the South African government. That society paid large sums to train them which we then benefit from. Is that just? Without compensation being paid I think that to call this ‘theft’ or ‘stealing’ is justified even if emotive.

    I note Jenny Haines’ point that the ANF cares about this stealing! Good on ‘em, Jenny! What about the AMA post-Pesce? In its recent submission to the Senate Inquiry on rural workforce (as far as I can see) the AMA makes no reference to the cost in health terms to developing countries of doctors moving from these poor countries to fill places in rural Australia (http://ama.com.au/node/7450). The submission states: “it is estimated that about 50 per cent of the rural medical workforce have been recruited from other countries. These practitioners have provided an essential and appreciated contribution to the health needs of rural communities but it is not a sustainable situation in the long run.” Agreed but I can see no concern being expressed by the AMA for the impact on the health of the people in the countries these doctors have left.

    And things may be getting better in training more doctors here (as Gavin Moodie suggests) but the AMA at least agrees with me that there remains “an undersupply of medical practitioners … in many parts of Australia and no where more so than in rural and remote areas.”

    Calling this “stealing” may get up some people’s noses. I make no apology for that if by doing so it might get the AMA and the Australian government to think about what they are doing to the health of the people of countries like South Africa by ‘taking’ their doctors – and change tack.

    Clearly there are responses agreeing with my viewpoint – but how do we get change and recognition that there is something rotten in this ‘free trade’ in doctors and nurses? Can anyone really justify not compensating these poor countries who have trained doctors and nurses who then help to make us a healthier nation?

  5. Kim Bulwinkel

    Once again it seems that the AMA is being partly blamed for this type of problem. …. very unfair!! The AMA is a voluntary membership representative organisation. Despite taking its role as the peak lobby group in the country for the medical profession very seriously, its input into actually making change is minimal. In fact, the AMA’s opinions, stance, recommendations, submissions are almost always “welcomed” then totally ignored by just about everybody but particularly government. As a 30 plus year member of the AMA, I can assure you that being dismissively denigrated with patronising tokenism is wearing thin.

    Yes, we would love to train more medicos. Yes we would love to address the workforce maldistribution issues. Yes, we would love to train overseas people to return to their countries and provide better medical services but there are a couple of really big problems that the AMA has no control over:-

    1] A really big part of the “training” of medical practitioners has no value accorded to it – i.e. trainers do not get paid at all for their educational input.
    2] Training takes time and ay all times those of us who are working, experienced and interested in training are under huge and steadily increasing time pressures to be ‘more efficient’, spend more time properly documenting, being enslaved by health fund, compensation & legal process, being COPD’ed and maintaining registration, accreditation etc..

    These issues are out of the control of the AMA. These issues discourage our own home grown young people from entering medicine, even if the places were available and are contributing to an amazing dropout % of our own people out of medicine.

    Nice article and point of view Gavin but you are showing your deeply inexperienced understanding of the real health service issues in Australia. Remember, the AMA has been trying hard to gain traction and recognition for the best part of the 30 years that I have been a member and involved at State & Federal levels and to date , failure to be listened to is the only real consistent outcome that we have achieved.

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