Should active recruitment of health workers from sub-Saharan Africa be viewed as a crime?

Shortages of health-care staff are endemic in sub-Saharan Africa (table). Overall, there is one physician for every 8000 people in the region. In the worst aff ected countries, such as Malawi, the physician-to-population ratio is just 0·02 for every 1000 (one per 50 000). There are also huge disparities between rural and urban areas: rural parts of South Africa have 14 times fewer doctors than the national average. These numbers are very diff erent to those in developed countries: the UK, for example, has over 100 times more physicians per population than Malawi. Furthermore, almost one in ten doctors working in the UK are from Africa. The insuffi ciency of health staff to provide even basic services is one of the most pressing impediments to health-care delivery in resource-poor settings. The consequences are clearly shown by the inverse relation that exists between health-care worker density and mortality. High-income countries, such as Australia, Canada, Saudi Arabia, the USA, the United Arab Emirates, and the UK have sustained their relatively high physician-to-population ratio by recruiting medical graduates from developing regions, including countries in sub-Saharan Africa. In contrast, over half of the countries in sub-Saharan Africa do not meet the minimum acceptable physician to population ratio of one per 5000—WHO’s Health for All standard. Nurses, pharmacists, and other health workers are systematically recruited from a region struggling with the greatest burden of infectious and chronic illness and the specifi c challenge of HIV/AIDS. Several recent reviews of health workers employed in Australia, Canada, the UK, and the USA have shown the extent of the brain drain. An estimated 13 272 physicians trained in sub-Saharan Africa are practising in Australia, Canada, the UK, and the USA. Around a third of medical graduates from Nigerian state medical schools migrate within 10 years of graduation to Canada, the UK, and the USA. In sub-Saharan Africa, nurses commonly bear the brunt of health-care delivery, but their numbers have declined substantially in recent years because of migration. In Malawi, for example, there has been a 12% reduction in available nurses due to migration. In 2000, roughly 500 nurses left Ghana, double the total number of nursing graduates for that same year. The recent upsurge in migration has aff ected the ability of nurse training programmes to continue because of poor staffi ng levels. Death caused by infectious and chronic diseases is also a major contributor to nurse attrition in the region. The number of pharmacists living in sub-Saharan Africa is also very low in comparison with that in many other regions of the world. Liberia has a pharmacist-topopulation ratio of only one to 85 000, 77 times lower than that in the USA. In 2001, more pharmacists emigrated from South Africa (600) and Zimbabwe (60) than graduated (500 and 40). Many pharmacy outlets have closed because of a scarcity of trained pharmacists and pharmacy technicians. Recruitment from sub-Saharan Africa occurs despite pleas to discontinue such eff orts from local and international ministries of health. Western recruitment agencies, such as O’Grady Peyton International (USA and UK) and Allied Health (Australia), have established offi ces in South Africa to facilitate recruitment, while corporations such as Shoppers Drug Mart (Canada) and Rite Aid actively recruit from South Africa using touring recruitment workshops. Recruitment strategies involve advertising in national newspapers and journals, text-messaging to health workers, personal emails and internet sites, and recruitment workshops. Off ers of employment are accompanied by legal assistance with immigration, guaranteed earnings, and moving expenses. Lancet 2008; 371: 685–88