Happy New Year to you all.
Joe
How Africa subsidizes U.S. health care
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Washington Post
Published Date: November 29 2004
By Sebastian Mallaby, Email: [log in to unmask]
This Wednesday is World AIDS Day: It will be marked by concerts
and candlelit vigils from Armenia to Zambia. The speeches and
statistics will have a horrific familiarity: Two decades after
the first diagnoses, AIDS shows no signs of letting up. And yet
the debate about AIDS is changing subtly. In Africa, the epicen-
ter of the crisis, the shortage of cash and affordable medicines
is no longer the prime issue. Attention is turning to the short-
age of health workers, and hence to a dark aspect of globaliza-
tion.
It isn't a surprise that Africa is short of doctors and nurses:
The continent has 1.4 health workers
per 1,000 people, compared
with 9.9 per 1,000 in North America. What's shocking is that
this shortage is partly created by rich countries. Poor nations
such as Malawi and Zambia are paying to train medics who emi-
grate to staff the hospitals of the United States and Europe. We
should be helping Africa. Instead, Africa is subsidizing us.
Not just slightly, either. Ghana trains 150 doctors annually;
five years after graduation, 80 percent have left, according to
Ghanaian data reported by the World Bank. For pharmacists, the
proportion is about 40 percent; for nurses and midwives, it's
about 75 percent - which is why half the nursing posts in Ghana
are vacant. Meanwhile, South African doctors emigrate at a rate
of about 1,000 annually. In 2001, Zimbabwe graduated 737 nurses;
437 left for one country, Britain.
Medical migration is not a new
phenomenon. Sabina Alkire and
Lincoln Chen of Harvard cite the (non-African) example of the
Philippines: In 1970 more Filipino nurses were registered in the
United States and Canada than in their home country. But the mi-
gration is accelerating. In 2001, the number of emigrating Fili-
pino nurses was three times higher than in 1996. Likewise, the
number of non-European Union nurses and midwives in Britain has
jumped more than tenfold in a decade.
This isn't a scandal; it's more complex than that. Development
economists have traditionally celebrated migration as a route
out of poverty: If a cab driver moves from Lima, Peru, to Los
Angeles, his income whizzes up even though his skills remain the
same. Moreover, the immigrant cab driver may send money home to
relatives; such remittances to poor countries are twice the size
of official
development assistance.
Harvard's Dani Rodrik calculates that further liberalization of
visa rules could benefit the citizens of poor countries more
than liberalized access to the rich world's outrageously pro-
tected markets for farm goods.
That's the upside of the global labor market. But the downside
is equally powerful, and it deserves special consideration given
the evolution in our understanding of what it takes for poor
countries to grow. The central finding of development economics
in the past decade is that institutions matter: You need effi-
cient, uncorrupt government departments and public services to
create a foundation for private-sector growth. But how do you
create competent institutions if global price signals are suck-
ing your best people out of the country? The medical brain drain
is just one example of this problem,
which is the central chal-
lenge of development in a globalized world.
It's a particularly vivid one, however. After a century of the
most spectacular health advances in human history, life expec-
tancy in many poor countries is actually falling. Donors have
battled this reversal by making money and medicines available:
In Botswana, for example, the pharmaceutical giant Merck has
teamed up with the Bill and Melinda Gates Foundation to bring
overwhelming resources to bear in the battle against AIDS. But
Botswana has made only gradual progress, and a main obstacle has
been the shortage of competent administrators and health work-
ers.
It's hard to weigh the issues here: the right of individuals to
seek a better life by emigrating and the poverty trap that they
entrench by doing so. But it's clear that, in the absence of
some kind of
intervention, this poverty trap may deepen. The
citizens of the rich world are aging; their willingness to care
for infirm relatives is waning; medical breakthroughs constantly
expand the demand for medical personnel. All these factors rein-
force the rich world's temptation to poach the poor world's
health workers.
There is no one-shot fix for this problem, but several policies
could help. Rich countries should compensate poor ones for the
cost of training medics who emigrate; that money, supplemented
by other aid flows, should be used to boost medical salaries in
the poor world. Poaching countries should issue fewer permanent
visas and more temporary ones. Temporary visas spread the oppor-
tunity to migrate more broadly, and returnees go home with ex-
perience and savings that fuel development.
And then there is another reform that
applies specifically to
one country. The United States must end its nutty overpayment
for health care, which not only wastes billions but also sends
price signals that depopulate hospitals in the poor world. Elli-
ott Fisher of Dartmouth Medical School has demonstrated that re-
gions of the United States with a high concentration of medics
spend extra on health care without becoming healthier: This
country actually has too many health workers.
Meanwhile in Africa a single nurse can be responsible for 50 pa-
tients. Because of America's dysfunctional system, the global
labor market is siphoning doctors from places where they are
needed into places where they accomplish nothing measurable at
all.
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