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Lloyd Matowe is an assistant professor at the Faculty of Pharmacy Practice, Kuwait University
Mahama Duwiejua is an associate
professor at the Faculty of Pharmacy, Kwame Nkrumah University of Science and Technology, Ghana
Pauline Norris is a senior lecturer at the School of Pharmacy, University of Otago, New Zealand
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The emigration of doctors and nurses from poor countries leaves easily
noticeable gaps in health systems The loss of pharmacists could be equally
detrimental. Health systems in developing countries are characterised
by heavy reliance on charging users at the point of access, with less
use of prepayment systems (such as tax or insurance funding). User fees
constitute a significant barrier to access to medical services in developing
countries. This, coupled with inadequate numbers of medical personnel,
makes pharmacy more attractive because pharmacy consultations are free.
Thus any emigration of pharmacists from poor to rich countries greatly
hinders access to essential medicines in developing countries.
The shortage of pharmacists at points of drug usage deprives the population
of vital expertise in the management of drug-related problems in both
the community and hospital setting. In the community, pharmacists serve
as gatekeepers by managing simple diseases and referring clients to doctors
or hospitals. When there are inadequate numbers of pharmacists in the
community, clients are under-served by over-worked pharmacists or by
less qualified pharmacy assistants. Patients with chronic diseases, eg,
hypertension or diabetes, who would have otherwise benefited from the
seamless care offered by community pharmacists, are deprived of this
and have to make costly visits to hospitals staffed by over-stretched
nurses and doctors.
The brain drain also compromises pharmacists’ key role in the development
and implementation of national medicines policies.
Reasons
There are several reasons for the increasing demand of foreign-trained
health professionals in developed countries. These include problems
with attraction, retention and motivation of health professionals in
the developed countries themselves. Owing to increased globalisation,
the labour market of professionals, including those outside health,
appears to have become more international, and this is facilitated
by an increasing move towards standardising education systems worldwide.
In many developing countries, curricula are often adopted from those
in the US, the UK or other developed countries, and so it can be relatively
easy for young professionals to move into foreign labour markets after
graduation.
In developing countries, essential working conditions are not met.
Social or personal development opportunities are limited making it
difficult
for health professionals to remain satisfied. In a recent article in
the BMJ,1 Laurence Levy, from the University of Zimbabwe wrote: “While
the home situation remains unattractive compared with elsewhere, the
void that is the northern hemisphere will continue to suck in qualified
people from the third world in increasing numbers, and the third world
will continue to finance it”. Professor Levy further argues that
third world professionals are over-trained for their home countries.
This describes the situation in pharmacy well, where practice only remotely
resembles what students are taught, making students frustrated and disgruntled
on qualification. It is thus not surprising that young pharmacists seek
better career opportunities abroad where, apart from better remuneration,
they can also use their skills more fully. The situation could be alleviated
by designing home-based curricula that familiarise students with the
reality of the work environment. Pharmacy graduates from developing countries
who train abroad face similar frustrations when they return.
As a result most simply choose to stay and practise where they trained.
Developed countries could help by giving elective courses
relevant to specific foreign students to facilitate their return on completion
of their courses. Curricula divorced from practice
As pointed out earlier, curricula in developing countries are often
divorced from practice because of the compulsion to produce graduates
of international
standards.
Professor Levy writes: “We in the Third World are rarely willing
to admit to our ‘third worldliness’. We aspire to First World
standards, and the things we want more than anything else are a well-reputed
university, and, in particular, good medical schools. We are greatly
gratified by the recognition of our graduates as being of international
standard [but] there are difficulties with this. As soon as a country
produces graduates of an acceptable international standard then it is
fishing in the same pond as First World countries for their services.
It is inevitable that doctors and nurses will be attracted to countries
where salaries or working conditions are seen as better. In our anxiety
to be part of and recognised as first world we in the third world have
produced professionals whose expectations we cannot meet.”
We disagree with Professor Levy’s argument that training “substandard” professionals
is a solution to the brain drain. Such a system is unsustainable. Under
such a system, policy makers and the elite are prompted to seek alternative
treatment elsewhere. This already happens in many developing countries,
particularly in Africa. The worry is that little resources would be channelled
into mainstream health care if politicians and policy makers always had
to seek alternative treatment from outside. Upheaval and meltdown
The political upheaval and economic meltdown in some developing countries
play an important role in driving professionals out. Zimbabwe, for
example, ridden with political unrest and economic failure, appears
to have infected the rest of the Southern African region, leading to
a slump in investment and economic activities and prompting professionals
to leave. In 2001 alone, 600 pharmacists registered in South Africa
emigrated to take up employment elsewhere. Between 1990 and 2003 New
Zealand registered 99 pharmacists trained in South Africa. In Zimbabwe,
only 20 per cent of Zimbabwean pharmacists were reportedly still in
the country at the end of 2003.
Figures from the Pharmacy Council of Ghana paint an equally gloomy
picture. The following figures, in parentheses, are the numbers of
pharmacists
who have requested letters from the council to support their applications
to practise in North America or Europe: 1997 (4), 1998 (8), 1999 (10),
2000 (24), 2001 (58) and 2002 (84). For a country that has around 100
pharmacy graduates a year, the trend is disturbing and could cripple
pharmacy if it continues unchecked. In Uganda, out of a paltry 180 pharmacists
registered in the country, about a third are living and working outside
the country.
The figures above and those from the Pharmaceutical Society of New Zealand
appear to show that movement of pharmacists from developing countries
has accelerated over the past few years. Between 1980 and 1989 New Zealand
registered eight pharmacists trained in Africa, the Middle East or Asia.
This number increased to 113 between 1990 and 1999. From the year 2000
up to the time of obtaining these data in November 2003, already 51 pharmacists
from these regions had been registered to practise pharmacy in New Zealand.
Considering that New Zealand is much smaller than other recipient countries
such as the US, Canada and Australia, the New Zealand figures could be
only the tip of the iceberg.
Most developing countries have invested scarce resources in training
health personnel and the ethics of luring such professionals from developing
countries should be questioned. In the UK, the code of practice for international
recruitment states that “there should be no NHS advertising in
developing countries unless that country has specifically invited the
UK to undertake a recruitment programme” and that recruitment “should
only be undertaken as part of an inter-governmental co-operation agreement”.
However, private recruitment agencies and private pharmacies from the
UK advertise in a number of
developing countries for various posts in the UK. Possible solutions
Although we do not advocate the creation of new barriers to the movement
of people between countries, steps should be taken to redress the situation.
We would like to offer some possible solutions For a start, long-term
partnerships, including funding and training to strengthen research,
clinical and teaching infrastructure of institutions in developing
countries should be fostered with the developed world. This would ensure
the survival
of academic and teaching institutions in developing countries. Grants
could also be made available to attract professionals to return to
their home countries, and developed countries could be encouraged to
set up
distance education programmes for professionals from developing countries
to reduce professional isolation.
Pharmacy curricula in both developing and developed countries could
include some aspects of health care and the role of pharmacists in
developing
countries. Governments in developing countries could do more to retain
and facilitate the return of professionals by creating favourable working
and political environments. Pharmacy students from developed countries
could be encouraged to participate more in electives in developing
countries. Acknowledgments We thank the Pharmaceutical Society of New Zealand,
Robert Puni from the Pharmacy Council of Ghana and Patrick Mubangizi
from Uganda for providing information.
References
1. Levy LF. The first world’s role in the third world brain drain.
BMJ 2003;327:170 |
The
Pharmaceutical Journal