GRF One Health Summit 2012, Davos: Presentation by Timothy Ken Mackey, California Western School of Law, University of California-San Diego - San Diego State University, United States of America

1. Stemming the Brain Drain: GRF 2012
Exploring Global Health Policy Solutions for Brain Drain Timothy Mackey
February 2012

2. Background:
The Healthcare Worker Brain Drain
• Brain Drain: Migration of professionals
from resource-poor to developed/high-
income countries
• Global Health: Major problem in global
health, global shortage of 4 million in
health workers worsened by brain drain
• Globalization: High emigration of 60
million health workers worldwide due to
liberalization of trade and travel
• Multi Sector: Challenge encompasses
public-private sectors, governance,
political, societal and economic factors

3. Background:
Negative Impacts of Brain Drain
• Brain drain involves physicians, nurses,
pharmacists, public and community health workers, Key Facts:
health care managers and administrators, and other -60 million health care
health care workers (“HCWs.”) workers globally
-4 million global shortage
• Financial and human resource loss and health
system weakening through maldistribution of
resources
• Inability to deliver life-saving health interventions for
HIV/AIDS, malaria, tuberculosis, and other infectious
diseases (PEPFAR, Global Fund, etc.)
• Failure in meeting health-related Millennium
Development Goals

4. Background:
Factors driving brain drain from both developed and
resource-poor
Aging Poor career
Population in advancement D C
A C developed and work E O
D O world environment
V U
V U
E N
A N
L T
N T
O R
C R High chronic Low
disease income/benef P I
E I prevalance its
I E
D E
N S
S
G
High tech Risk to
and resource personal
intense safety, health
healthcare and security

5. Global Imbalances North to South
Inequitable distribution
• The 57: World Health
Organization has
recognized 57 countries
with HCW critical
shortage, 36 in sub-
Saharan Africa
• Not Universal: Some
high-income countries,
such as France and
Japan, have less than
3% of workforce
originating from abroad
• Export: Countries such
as Philippines rely on
export economy of
health workers

6. Global Imbalances North to South
One way emigration out
OECD Countries
20% of physicians in OECD
1 countries originate from
abroad
Developed Country Dependence
USA, UK, Canada, and
2 Australia utilize 23-28% of all
int’l medical graduates
Lower Income Exodus
Figure: Share of foreign-trained doctors in
Lower-income countries selected OECD countries in 2008 (or latest
3 provide 40-75% of their int’l year for which data are available) (%)
medical graduates
Source: www.oecd.org/health/workforce

7. Imbalances in Political Economy
Templates
Global Economic Maldistribution
Loss of Health Investment Global Political Economy NGOs and State Subsidies
1 • Estimated $500 2 • Liberalization of 3 • NGOs aggressively
million in annual markets and opening recruit HCWs from
losses in educational of trade barriers resource-poor
expenditures for leads to easier countries with higher
HCWs (RPCs) migration wages
• Studies show 9 SS- • Macroeconomic • Becoming larger
African countries policies of IMF and players in global
have lost $2.17 billion World Bank create health governance
from physician brain barriers in health with decline of int’l
drain while USA and systems investment organizations
UK have gained 2.7b
and 846m • Structural adjustment • Domestic subsidies,
respectively policies imposed cut such as USA
public spending Medicare residency
• May result in higher programs, create
transaction costs due immigration demand
to recruitment
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8. Imbalances in Political Economy
Other Financial Implications and Waste
• Lost tax revenue
• Remittances not sufficient
to make up gap
• Brain waste: When HCWs
are underutilized in
destination countries
• HCW export may be good
for export economy but
fails to meet domestic
health needs

9. Responses to Brain Drain
Healthcare System Strengthening
• Task Shifting: Delegation of tasks to
less specialized health care workers
• Rebalancing Incentives: Address
microeconomic reasons by improving
incentives, resources, and providing
assistance
• Limitations: Requires substantial
investment/funding and coordinated
efforts which may not be available in
resource-poor or rural populations

10. Responses to Brain Drain
WHO Global Code of Practice
Global Code of Practice on the Int’l Recruitment of
Health Personnel (May 2010)
• Non-binding code (soft law) to
C maximize benefits and minimize
negative factors of health worker
migration, protect HCW rights, and
strengthen health systems
• Framework for bilateral and
multilateral agreements on equitable
HCW resource sharing especially for
NGOs
• Limitations: Voluntary by nature and
to be enforced by member states as
recommendations. Still relatively new
but implementation reports may help

11. Policy Solutions
Better Global Health Governance Systems
Would establish rules requiring healthcare facilities hiring
Health from shortage countries to allow HCWs to return to home
Exchange countries in event of emergency or require sharing of
Programs specialists for joint capacity building projects
Would eliminate certain barriers for re-entry in event of public
Brain emergencies, enhance capacity building programs, and
Mobility enhance knowledge sharing and equitable migration
pathways.
Accreditation: WHO and ILO could implement fee-based
credentialing program and provide technical assistance for
Global Health
adherence to HEP structure, labor and migration
Governance
standards, and WHO Code. They could also actively
engage in data collection.

12. Policy Solutions
Pros and Cons

13. The One Health Paradigm
Brain drain is not just HCWs
• Brain Drain is not just HCWs: Global
Health brain drain includes all
professionals, including veterinarians, a
multitude of researchers and scientists
(basic sciences, agricultural,
environmental) also internal migration.
• Impacts Everyone: Brain drain of
professionals has impact on disease
surveillance, vector control, biosecurity and
social determinants of health (economic
consequences of brain drain)
• Global Health Security: In an era of
globalization, diseases can be spread
around the world quickly, lack of adequate
infrastructure in parts of the world can
impact everyone.

14. Summary
Addressing Brain Drain
Brain Drain is Global Health Crisis
Brain drain is a global health crisis disproportionately affecting the health and well-
1 being of the resource-poor. Serious imbalances persist and must be addressed to
ensure global public health.
Current Responses Have Limitations
Current responses to brain drain require sustained investment in order to be
2 effective. This may be difficult in countries who already domestic financing or
depend on international aid/funding.
Global Health Governance Policy
Global health governance needs to be improved and coordinated to provide a
3 unified reform policy of more equitable resource sharing and international
agreement on HCW migration policies

15. THANK YOU!
Questions?