After Covid-19, the recruitment of healthcare personnel by rich countries to poor ones has increased. A hidden face of migration, which is causing a real emergency. But in their places of origin
The Covid-19 pandemic has left consequences that have gone well beyond the long emergency that involved and shocked the whole world, accentuating critical issues that were already evident before. One of these is the increasingly serious shortage of healthcare personnel in our hospitals and elderly homes, as well as in those of many other so-called “developed” countries. Countries that are trying to fill these gaps by “importing” personnel from poor and developing nations. Consequently, making them even poorer and more vulnerable also from the point of view of access to health care and seriously undermining the right to health.
The alarm – which went somewhat unnoticed – was launched last March by the director general of the World Health Organization (WHO), Tedros Ghebreyesus, who presented a red list of 55 countries particularly at risk for the loss of healthcare personnel due to international migration. Of these, 40 are located in Africa, while others concern the Western Pacific and South-East Asia region to which must be added Afghanistan, Pakistan, Yemen and Haiti.
«Health workers – declared Ghebreyesus – are the backbone of every health system, yet these countries with some of the most fragile systems in the world do not have enough of them and many are losing theirs due to international migration. WHO is working to support them, strengthening their health personnel and asking all countries to respect the provisions set out in the Organization’s list of guarantees.” Among these provisions – which are not binding – some ask that “the international movement of health workers be managed in an ethical manner, that the rights and well-being of migrant health workers and the objectives of providing health services be guaranteed”. But also that all necessary measures are adopted to guarantee an adequate presence of operators in all countries and that protections are also extended to medium and low income countries.
In reality, what has happened in recent years is exactly the opposite: there has in fact been an increasingly massive exodus of doctors and nurses from poorer countries to richer and older ones. The World Bank – very pragmatically, but also very cynically – underlines in its report “World Development Report 2023: Migrants, Refugees, and Societies” the fact that demographic divergences will make «migration increasingly necessary in the coming decades». For this reason, he suggests that «governments of countries of origin should make labor migration an explicit part of their development strategy, while those of destination should use migration to meet their labor needs». A mercantile logic which inevitably benefits those who already have a lot and impoverishes, in every sense, those who have little or nothing. Also in terms of qualified human resources.
This logic has led to a real hemorrhage of doctors and nurses from many poor countries, which have invested resources to train them, but which have health systems that are too fragile and often disorganized to be able to retain them. Countries that are unable to compete with the job and salary offers that come from rich nations.
An emblematic case for the breadth of the phenomenon concerns Great Britain. After Brexit – which resulted in the departure of thousands of European Union doctors – and after the Coronavirus pandemic which further stressed the system, the country found itself with a serious shortage of healthcare workers. And he went to get it especially in the former colonies. Today, for example, in the United Kingdom there are more than 11 thousand doctors trained in Nigeria, the third nationality after Indians and Pakistanis, according to the UK General Medical Council. For its part, the Nigerian Association of Resident Doctors (Nard) estimates that in Nigeria there are only 24 thousand doctors for 220 million inhabitants, while according to the WHO at least 363 thousand would be needed. But the flow is unstoppable: in 2022 alone, the United Kingdom issued 1,609 visas to Nigerian medical staff and thousands of other workers left for the United States and Canada.
The issue has sparked a great debate and much controversy in Nigeria, where among other things the counterfeit medicine industry proliferates and the practices of pseudo healers-quacks are rampant, often contributing to worsening an already very precarious health condition. The situation is, in some ways, even more serious in countries like Zimbabwe, where very controversial and contested presidential elections were held last August. In a context of instability and widespread poverty, despite the significant progress made especially in the education and university sectors, migration still represents a way out and success for many today. And there are those who take advantage of it. In 2022 alone, the number of visas granted by Great Britain to Zimbabweans increased by as much as 1,576%. Many of those who have obtained it are doctors, nurses and social and healthcare workers. Already the previous year, in 2021, as many as 2,200 healthcare workers, including 900 nurses, had left the country. According to the Zimbabwe Medical Association, there are only 3,500 doctors in a country of 15 million people, who continue to be attracted by better salaries and better living conditions for themselves and their families abroad. But the exodus does not only concern healthcare personnel. In February 2023, the United Kingdom also drew up a list of countries and territories whose teachers can obtain qualified teacher status, which allows them to work long-term. Among these there are, indeed, Zimbabwe, but also Nigeria, Ghana and South Africa as far as Africa is concerned. This is another disturbing sign if we consider that to imagine sustainable development in these countries the first level to be strengthened is precisely that of education which – together with healthcare and the economy – is the basis for guaranteeing a future for the new generations . Yet even today most African countries have a very low universal health coverage index and a staff density rate much lower than the world average which is 49 doctors, nurses and midwives per 10 thousand inhabitants. “These countries – says the WHO – require priority support for workforce development and health system strengthening, together with further safeguards that limit active international recruitment.”
This support, however, is not yet visible or effectively implemented, neither by the WHO itself nor by local governments, who continue to neglect their own health systems; the consequence is that they are often without structures, infrastructures, instruments and medicines and the staff is paid very little or even irregularly. As for the governments of the rich world – and not just the Anglo-Saxon ones – it seems that they do not have too many scruples in pursuing policies of “importing” qualified personnel.
It is another side of the migration phenomenon, less mediatized and less talked about, but which is very present in the flows and which is often encouraged by those same countries which then place walls and barriers on the arrival of migrants. Still sticking to Great Britain – just to give an example – the London government has tried in every way to implement a project to “outsource” the reception of asylum seekers even in Rwanda, 6,500 kilometers away. After various legal disputes and accusations of human rights violations, London seems to have given up on this unfortunate hypothesis, which envisaged – for example – a one-way trip to Kigali, where the refugees (many of them Afghan or Iranian) could have obtained refugee status to remain in Rwanda or seek asylum in another “safe third country”. The government of Rishi Sunak and his Home Minister Suella Braverman – both of whose parents were of Indian origin who immigrated to England from Africa – had stated that “anyone who entered the United Kingdom illegally after 1 January 2022 could have been sent to Rwanda, without limits on numbers.” Now that the project seems to be blocked, the British government has seen fit to confine up to 500 asylum seekers on a prison ship off the coast of Portland. It is certainly not the same treatment that is reserved for specialized personnel, even in other countries with very selective migration policies – such as the United States, Canada, Australia or, to remain in Europe, France – which favour, or rather incentivise, the entry of qualified professional figures in the medical-health field.
Even on the African front, however, the serious shortcomings and lack of vision must be noted. Governments, often fragile and ineffective, struggle to take measures to try to stem these migratory flows. In Zimbabwe, former vice president and health minister Constantine Chiwenga had threatened to make the recruitment of health workers illegal and compared it to a “crime against humanity”. «If people die in hospitals because there are no nurses and doctors it is because someone was so irresponsible as not to train their own citizens, but took advantage of those trained in poor countries. This is a crime and must be taken seriously.” It’s a shame that, in many cases, these same governments willingly accept funds or “compensation” theoretically intended to improve their healthcare systems but often diverted into the depths of inefficiency or, worse, corruption. And so, in addition to the proclamations, there is very little left to make the exercise of a profession as indispensable for the well-being of all as the medical profession more dignified.