NGOs and the health braindrain – help me resolve this dilemma
Monday 16 August 2010
In this week’s Lancet, there is a very thought-provoking article about the way that research institutions, UN agencies and NGOs (non-governmental organisations) contribute to the “braindrain” by drawing health staff away from government employment.
This has long been a major worry of mine but there is not a simple answer to the question: who should NGOs employ?
We do employ what we call “ex-pats” (i.e. people from other countries) who bring many skills to working in a developing country programme, including global experience.
However they do not come from the same culture, stay shorter periods, rarely speak the local languages and their interest in the country’s development must be different from someone who grew up there.
Some NGOs, such as ActionAid and Acord, now mostly avoid using ex-pat staff from Europe and North America, although they still use plenty of ex-pats from other low-income countries.
Those who are not “ex-pats” are sometimes referred to as “national staff” (i.e. citizens of that country). I usually ask these colleagues what they did before working for NGOs. Many of them were employed by the government, health staff often as doctors and nurses.
They are always extremely committed to NGO ways of working with communities. However, as much as I admire them and benefit from working with them, a part of me regrets that they are not in the national health service or the Ministry where their training, knowledge and abilities could be leading major changes in their country.
In the UK, after working for a charity, a voluntary group or an NGO, one might aspire to go to work for national or local government. The skills that one has developed in a more informal setting or in a smaller geographic area should then be used to achieve benefits for a whole population or region.
In many low-income countries, especially African countries, it is the other way round. Staff leave jobs working for the government and go to work for NGOs because, in many cases, the salary and the working conditions are better in a big NGO with fewer limitations and frustrations than working for the government.
This braindrain (which UN organisations, health services in rich countries and the private sector also contribute to) is a major impediment to developing strong and effective government that can provide universal access to good quality services.
We clearly have to look critically at our own recruitment but this will only really change when governments have the money to pay better salaries than NGOs.
Hence why we call for more aid to support government budgets and fewer restrictions on salaries from influential bodies such as the International Monetary Fund.
This would then push NGOs to look towards talented and committed community activists and volunteers as possible employees. This would mean changing our recruitment criteria, prioritising local knowledge, connections and skills above qualification.
It would mean building different working cultures and different success criteria from the traditional donor-driven measures. As I said, this is a big, big question and I am not sure I have the right answers. What do you think?
Tags: braindrain, health workers, IMF, International Monetary Fund, NGOs
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August 16th, 2010 at 6:02 PM
Simon – you are dead right on this issue. Allow me to relate some personal perspective which captures the dilemma of many health workers within developing countries faced with few training opportunities and poor remuneration. I am a Kenyan doctor who trained as a clinical epidemiologist in the UK. After my return home in 2004, the government, having allowed me leave to go and study, was unsure what the role of a clinical epidemiologist was and would not figure out what it could do with me. Combined with corrupt systems at the time, i lost my job in the public service, which i was very keen to get back into so that i could contribute meaningfully in the delivery of health care by helping build a more responsive service system. I am a keen believer that one cannot isolate research and service in the settings of developing countries like Kenya. Anyway, I was without work for several months despite my qualifications. I got employed with a UK funded research programme in Kenya and liked it because it dealt a lot with clinical service and research. However, this institution was to morph under the pressure of its funders to concentrate more on research, thus slashing a reasonable amount of its funding on clinical training and service to concentrate on broad research issues. Needless to take the story further, a lot of health staff who hoped to gain on training in clinical research and service were forced to abandon their pursuit of clinical excellence and follow the route of research, policy and PhD with minimal hope of integration back into the country’s health system. I struggled individually to advance my clinical training but had no funds and was forced to opt for a career in research and a PhD. This sounds rosy, but i know too well that all this is outside the public health system of the country and my hope of ever getting back in is extremely trim. Truth be told, majority of these PhDs are not in a position to win research grants that are normally open to nationals of funding countries and end up being educated job seekers looking for one better opportunity after another after their training. A lot of other health workers are getting into this trap – leave governement jobs and join NGOs where salaries are a lot better but then keep moving from one NGO to the next in search of better paying and secure employment.
I decry the existence of parallel systems taking care of for example HIV patients and ran from distant NGO offices within the same hospitals. You will find that even the skilled clinicians end up being lured into working for such programs and ignoring the larger problems affecting the population. I think time is ripe to address this issue comprehensively for there are extremely few qualified health workers working within the public health systems in developing countries – they are in NGOs, research institutions and other such AID enterprises. Take a simple survey on the health workers many will tell their desires to work in NGO and international reasearch settings.
This needs to be heard as it may become the single largest failure of well-intended AID directed towards health. My views have not found a lot of favour with those that i work with because sometimes it sounds like an indictment to their work, and the natural perception that a person of my stature should not subscribe to such a minority view!
August 17th, 2010 at 11:05 AM
So what’s to be done?
Does anyone know who has taken this seriously and done some policy work on it?
Some ideas off the top of my head:
NGO/UN recruitment policy restricting employment of public health system workers or NGO/UN help and training for employees wishing to go into/back into the puclic service.
Integrated healthcare delivery involving UN/NGOs and Government in coordination and collegiate atmosphere of hiring between all three.
The only thing that worries me is that it’s quite complicated by the huge numbers of roles that both public health workers and NGO health workers perform – yes they are sometimes overlapping or taking from the most deprived areas, but sometimes they work in accord and are the best partnerships serving the most deprived areas. Will stopping recruiting ‘nationals’ hinder the programs that can really make a big difference like child immunization and school based programs of NTD treatments etc.?
Just throwing things out there…
August 17th, 2010 at 6:54 PM
I am a Tanzanian Paediatrician, completed my Mmed in Pediatric and Child Health in 2007. I am one of those health workers left the Government and I work with an International organization.
There are many reasons for the movement from Government to International organization/NGO’s.
Low salaries in the government, No appreciation/incertives of the hard work we are performing, I mean, there is a gap between the seniors and juniors, leaders and normal workers, when you work hard someone should at least appreciate, but NONE.
In the other side they know how to appreciate and the package is good, at least you can pay for childrens school fees for a good school. It is disappointing when you have gone to school for more than 8 years only to get frustrations. Unfortunately nobody seem to understand that people are frustrated.
Others now they are running to politics, this is because it pays them.
My suggestion is that the government should be creative enough not necessarily to give us money but at least buid good houses and let us pay slowly, give us cars and things like that, I know they can do that, if they are doing it for Big potatoes “Parliament members” why not us?
Thanks for now
August 18th, 2010 at 2:14 PM
“We clearly have to look critically at our own recruitment but this will only really change when governments have the money to pay better salaries than NGOs.”
A cheaper alternative would be that NGOs should pay less their staff so the gap isn’t has important.
Less money to rise for NGO, no increase of the budget of government. Everyone wins, and you lefties still stubbornly refuse better solutions
More seriously, you start saying that gov delivers a larger scale than NGOs, and seems to deduce that the individual result of on person working on an NGO would be greater if she was working for the gov.
August 23rd, 2010 at 12:45 PM
Global health is the health of populations in a global context and transcends the perspectives and concerns of individual nations.Health problems that transcend national borders or have a global political and economic impact, are often emphasized. It has been defined as ‘the area of study, research and practice that places a priority on improving health and achieving equity in health for all people worldwide’.Thus, global health is about worldwide improvement of health, reduction of disparities, and protection against global threats that disregard national borders. The application of these principles to the domain of mental health is called Global Mental Health.
August 24th, 2010 at 11:07 AM
I think VSO has done some research on this subject, well brain drain, at least. I recall reading a finding that there are more Malawaian doctors in Manchester than in Malawi! So many of the nurses trained in Africa with donor funds ended up in Europe. Some go back, with more experience, skills and welcome remittances.
It seems to me that this is primarily an issue of market forces which favour wealthier nations (& organisations that are funded by them). Whoever pays most gets to employ the brightest and the best – apart from the few whose value-set puts service above personal gain. There appears to be a food chain, with skilled people moving from local govt > national govt > local NGO > INGO > multi-lateral. My wife used to be a Director of Health in an Asian Ministry, but now works in the UN. At least she served a 4-yr ‘bond’ of serrvice in her country after qualification.
If responsible agencies clarfiied their role as sector-strengthening, then Simon’s proposal to recruit less-qualified staff and invest in them makes sense. The business model for NGOs would be quite different. I can imagine a systems approach to this issue could define more distinct roles for each agency and perhaps result in different target populations for recruitment.
January 29th, 2012 at 10:16 PM
Abolutely spot on Simon – great article.