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Contextualization of the Global Medical Brain Drain in Sub-Saharan African Countries

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by Christiana Oshotse

Introduction

The ‘medical brain drain’ refers to the mass movement of health care workers from low and middle-income countries (LMICs) to high-income countries (1). Driving forces such as poverty and political instability intensify the mass emigration of health care workers from LMICs, resulting in critical shortages of remaining workers to meet the basic health needs of citizens in these countries. Widespread agreement exists that the medical brain drain severely undermines the capacity of LMICs to develop competent healthcare systems (2-4). Despite efforts at the national and international levels to impose policies encouraging against the medical brain drain, these policies have lacked implementation and have remained largely ignored (2). As LMICs increasingly suffer the harmful effects of the medical brain drain, a debate continues over the morality and legality of international health care workers migration and of the policies appropriate to address this phenomenon. 

The medical brain drain is a pressing issue that requires complex analysis of the ethical components characterizing the factors exacerbating this phenomenon. Such consideration of the brain drain is necessary in order to disentangle the relationships and circumstances requiring interventions to reverse existing shortages and develop international health care systems. This article focuses specifically on the context of medical workers emigrating from LMICs experiencing critical shortages of health care workers. Nigeria and Malawi are provided as case studies to effectively contextualize the causes, effects, and attempts to mitigate the health care worker shortage amidst the often-burgeoning attempts of these countries to remain relevant and powerful in the global economy as post-colonial nations. This paper does not examine all countries affected by the medical brain drain. LMICs are in dire need of solutions, and this paper delves into several policy recommendations. The need for viable policy recommendations is critical due to challenges in creating policy that mitigates the conflict between individual rights to migrate and LMICs need for these medical workers to stay. 

Global Context

The migration of medical workers is part of the current global health workforce crisis characterized by the severe shortage of health care workers in countries suffering from high burdens of disease (5). Attempts to accurately quantify the migration of health care workers is difficult in part because of challenges such as missing emigrant/immigrant registration data from source and destination countries and inconsistent use of proper definitions of migration statuses for emigrating medical workers (1). Existing data on health care workforce migration patterns is not entirely reliable, but the legitimacy of this issue is evident and efforts to research the extents of the medical brain drain have continued. 

The World Health Organization (WHO) estimates that over 4.3 million additional health care workers are needed to reach the Millennium Development Goals, objectives set by the United Nations to combat HIV/AIDs and other diseases, reduce child mortality and improve maternal health (3, 6-7). Though this figure appears high, the WHO’s estimate only accounts for shortages of health care workers in 57 countries experiencing “critical shortages,” and does not account for countries experiencing shortages in the capacity to provide basic health services (see Figure 1) (5-6, 8).  Thirty-six of the 57 countries are in Africa, a continent experiencing 25% of the global burden of disease yet possessing far less of a capacity to provide care to its inhabitants compared to the demand of its inhabitants for access to care (see Table 1) (6).  In LMICs such as Ghana, 29% of doctors work abroad, and in Mozambique, there are 3 doctors for every 100,000 people (3). 

It is necessary to identify the factors engendering the emigration of medical workers in order to appropriately contextualize the experiences of these workers and to identify necessary solutions to the problems posed. Medicals workers may emigrate for better employment opportunities, to earn higher wages, and to secure the future of their families (3, 6). Other factors include a desire of safer working conditions with greater resources (6). This is relevant especially in Sub-Saharan African countries whose immense burden of HIV/AIDs and resource limited settings overburden medical staff, who work long hours in conditions often lacking proper protective medical equipment (3, 7, 9). Paradoxically, the emigration of these medical workers further exacerbates the problems that served as the initial driving forces for their migration. Political instability and war are other significant factors that spark high migration rates from medical workers.

The health care workers who emigrate tend to be among the most skilled and educated in the source country; therefore, the migration of these workers represents a financial loss to the source country that has invested heavily in their education and training. It has been estimated that LMICs spend up to $500 million annually to educate medical workers who emigrate (6). A recent study calculated the cost of training medical professionals in Kenya and estimated that the country loses $517,931 for every doctor and $338,868 for every nurse who emigrates (9). These losses represent immense benefits to the destination countries that receive highly trained health professionals for free. The magnitude of this loss of human capital stunts the capability of LMICs to achieve long-term economic development. 

The migration of medical workers from LMICs disproportionately concentrates medical workers in high-income countries. Hospitals and clinics in LMICs are left understaffed and overflowing with individuals seeking healthcare. Existing staff is overburdened by the massive amounts of patients seeking care, which decreases the overall standard of care that each patient receives. These countries typically have high rates of HIV/AIDs, tuberculosis (TB), malaria, and other communicable diseases (3, 5).Furthermore, the limited staff tending to these populations are often more susceptible to burnout and stressful conditions which may contribute to medical errors and to safety mistakes that cause staff to accidentally contract the disease from their patients (3). 

The critical shortage of medical workers challenges the ability of source countries to effectively implement health interventions aimed at addressing the high rates of HIV/AIDs, TB, and maternal and child mortality rates. For instance, the Zimbabwean government has faced challenges in administering antiretroviral therapy (ART) to its HIV/AIDs patients in part because of the medical brain drain (10). The health system lacks the workers necessary to provide the sustainable care crucial to help HIV/AIDs patients achieve the proper adherence required to suppress the virus. 

In response to these issues, countries such as the Philippines, Thailand, and Vietnam have enforced mandatory national service periods for recently matriculated health care workers as measures to slow the brain drain (11). Additionally, the WHO collaborated with partners such as the Global Health Workforce Alliance (GHWA) and the Health Worker Migration Policy Initiative (HWMPI), to develop the Global Code of Practice on the International Recruitment of Health Personnel (12). This code is an ethical framework developed to govern the recruitment and migration of health care workers from shortage countries. When asked about the impact of the code, a Sudanese official remarked that, “as far as the WHO Code is voluntary and as far as beneficiary countries in the region do not have media or civil groups pressures, they will not be part of this code, I do not think there is hope!” Implementation of the code is left to the WHO Member States, which has allowed the migration of health care workers into high-income nations to continue (2).

The migration of medical workers is part of the current global health workforce crisis characterized by the severe shortage of health care workers in countries suffering from high burdens of disease (5). Attempts to accurately quantify the migration of health care workers is difficult in part because of challenges such as missing emigrant/immigrant registration data from source and destination countries and inconsistent use of proper definitions of migration statuses for emigrating medical workers (1). Existing data on health care workforce migration patterns is not entirely reliable, but the legitimacy of this issue is evident and efforts to research the extents of the medical brain drain have continued. 

The World Health Organization (WHO) estimates that over 4.3 million additional health care workers are needed to reach the Millennium Development Goals, objectives set by the United Nations to combat HIV/AIDs and other diseases, reduce child mortality and improve maternal health (3, 6-7). Though this figure appears high, the WHO’s estimate only accounts for shortages of health care workers in 57 countries experiencing “critical shortages,” and does not account for countries experiencing shortages in the capacity to provide basic health services (see Figure 1) (5-6, 8).  Thirty-six of the 57 countries are in Africa, a continent experiencing 25% of the global burden of disease yet possessing far less of a capacity to provide care to its inhabitants compared to the demand of its inhabitants for access to care (see Table 1) (6).  In LMICs such as Ghana, 29% of doctors work abroad, and in Mozambique, there are 3 doctors for every 100,000 people (3). 

It is necessary to identify the factors engendering the emigration of medical workers in order to appropriately contextualize the experiences of these workers and to identify necessary solutions to the problems posed. Medicals workers may emigrate for better employment opportunities, to earn higher wages, and to secure the future of their families (3, 6). Other factors include a desire of safer working conditions with greater resources (6). This is relevant especially in Sub-Saharan African countries whose immense burden of HIV/AIDs and resource limited settings overburden medical staff, who work long hours in conditions often lacking proper protective medical equipment (3, 7, 9). Paradoxically, the emigration of these medical workers further exacerbates the problems that served as the initial driving forces for their migration. Political instability and war are other significant factors that spark high migration rates from medical workers.

The health care workers who emigrate tend to be among the most skilled and educated in the source country; therefore, the migration of these workers represents a financial loss to the source country that has invested heavily in their education and training. It has been estimated that LMICs spend up to $500 million annually to educate medical workers who emigrate (6). A recent study calculated the cost of training medical professionals in Kenya and estimated that the country loses $517,931 for every doctor and $338,868 for every nurse who emigrates (9). These losses represent immense benefits to the destination countries that receive highly trained health professionals for free. The magnitude of this loss of human capital stunts the capability of LMICs to achieve long-term economic development. 

The migration of medical workers from LMICs disproportionately concentrates medical workers in high-income countries. Hospitals and clinics in LMICs are left understaffed and overflowing with individuals seeking healthcare. Existing staff is overburdened by the massive amounts of patients seeking care, which decreases the overall standard of care that each patient receives. These countries typically have high rates of HIV/AIDs, tuberculosis (TB), malaria, and other communicable diseases (3, 5).Furthermore, the limited staff tending to these populations are often more susceptible to burnout and stressful conditions which may contribute to medical errors and to safety mistakes that cause staff to accidentally contract the disease from their patients (3). 

The critical shortage of medical workers challenges the ability of source countries to effectively implement health interventions aimed at addressing the high rates of HIV/AIDs, TB, and maternal and child mortality rates. For instance, the Zimbabwean government has faced challenges in administering antiretroviral therapy (ART) to its HIV/AIDs patients in part because of the medical brain drain (10). The health system lacks the workers necessary to provide the sustainable care crucial to help HIV/AIDs patients achieve the proper adherence required to suppress the virus. 

In response to these issues, countries such as the Philippines, Thailand, and Vietnam have enforced mandatory national service periods for recently matriculated health care workers as measures to slow the brain drain (11). Additionally, the WHO collaborated with partners such as the Global Health Workforce Alliance (GHWA) and the Health Worker Migration Policy Initiative (HWMPI), to develop the Global Code of Practice on the International Recruitment of Health Personnel (12). This code is an ethical framework developed to govern the recruitment and migration of health care workers from shortage countries. When asked about the impact of the code, a Sudanese official remarked that, “as far as the WHO Code is voluntary and as far as beneficiary countries in the region do not have media or civil groups pressures, they will not be part of this code, I do not think there is hope!” Implementation of the code is left to the WHO Member States, which has allowed the migration of health care workers into high-income nations to continue (2).

Case 1: Nigeria’s Shortage of Health Care Workers

Lagos is a major city, but in the midst of the daily movement of its approximately 21 million inhabitants, no reliable network of emergency care exists (4). Consequently, fatalities from car accidents and other medical emergencies are frequent. When individuals with chronic or communicable diseases are able to reach one of the few major public hospitals, they confront long lines to receive care. Current statistics show that there are 1.95 medical workers per 1,000 individuals in Nigeria (4). This shortage is worsened further by the inequitable distribution of workers within the nation. There are no policies regulating the distribution of workers, so public agencies deploy workers at their own discretion, which complicates the situation because these agencies often have conflicting interests in where to assign workers (4).  

Historical Background

Nigeria has one of the largest economies in Africa, developing its economy on trading crude oil with foreign nations (29).  With a population of 190 million individuals, there is a lack of prioritization of the health care needs of citizens despite the resources available from the country’s sizable GDP (28).Yet decades of poor economic management, military rule, and corruption have left the country with high levels of poverty and poor infrastructure to meet its needs (29). 

Plans to expand the health care infrastructure and develop the strength of curative medicine in Nigeria led to the implementation of primary health care (PHC) in the 1960s (30, 31). In 1975, strides towards a primary health care system were made with the development of the National Basic Health Services Scheme (NBHSS) (30). The NBHSS intended to improve access to health care through addressing issues of accessibility and affordability of care, prevention and cure of diseases, and provision of health care to the needy. However, the NBHSS never reached its final stage of implementation, leaving many without access to PHC. 

Under the leadership of Professor Olikoye Ransome-Kuti, Nigeria’s first national health policy implementing PHC took place in 1988. Professor Ransome-Kuti expanded PHC responsibility to all local governments and attained an 80% immunization rate for all Nigerian children (32) as an attempt to implement the tenets of the Alma Alta Declaration of 1978, which identified primary health care as a key to addressing health-related inequalities. Between 1958 and 1992, Ransome-Kuti introduced comprehensive health policies that provided preventative medicines and health care services, breast-feeding practices, free immunization, and compulsory vaccination to all Nigerians (32). Under his leadership, an effective HIV/AIDS campaign was implemented in the early 1990s, and in 1992 the National Primary Health Care Development Agency (NPHCDA) was created to continue the implementation of PHC related policies (30, 32). 

Current Health Care in Nigeria 

The Nigerian government experienced a military takeover in 1993, which brought the progress made by Ransome-Kuti and others to a screeching halt. It has been 25 years since progress such as Ransome-Kuti’s has been pursued in order to transform Nigeria’s desperate health care system into one able to meet the needs of its inhabitants. Currently, Nigeria’s health care system only operates with 20% of the 30,000 PHC facilities available due to lack of infrastructure to provide quality and effective care to its patients (33). Nigeria spends less than $5 USD per capita on health care, which pales in comparison to the WHO recommendation of $34 USD per capita on health care for developing countries (30).Analysis of the allocations of the Federal Government budget allocations show allocations on health care rose from 2.55% in 1996 to 2.99% in 1998 under the leadership of Ransome-Kuti (30, 34). In 1999, health care’s share of the budget declined to 1.95% and rose to 2.5% in 2000 (30, 34). 

Despite Nigeria’s menial expenditure on health care, there are ample funds in the federal budget for Nigeria to invest in its health care sector. Without such funding, issues of poor infrastructure, inadequate equipment and inefficient health care services were prevalent. Nigerian health care workers, who sought to serve their country, experienced immense job dissatisfaction and low motivation while attempting to provide adequate care to individuals—lack of resources doomed these health care workers from the start (30, 35). 

The Nigerian government implemented the Commonwealth Code of Practice for the International Recruitment of Health Workers in an effort to stem the flow of health care workers out of Nigeria (30). Meanwhile, tenets of the Abuja Declaration of 2001—including allocation of at least 15% of a country’s annual budget to the healthcare sector—remain unfulfilled in Nigeria. (36). Implementing the Abuja Declaration would increase resources for the development of PHC services for all Nigerians, but it is unclear now whether fulfilling this policy is a priority on the agenda of the Nigerian government.

Case 2: Malawi’s Efforts to Address Capacity Issues Due to the Medical Brain Drain

Malawi a landlocked country of approximately 19 million individuals in southeast Africa (37), is another one of the sub-Saharan countries severely affected by the medical brain drain. Malawi, where 85% of the population survives on less than $2 per person per day, relies largely on its agricultural productions to stimulate the economy, though the country’s food supply has suffered due to precarious climate events (38). While Malawi’s health care worker shortage situation mirrors those of its geographic neighbors, this country has taken unique aims to address its health care capacity issues. 

Migration of Health Workers

The migration of health workers out of Malawi began in the early 1990s (39). Previously, Malawian health care workers who emigrated from the country remained in OECD countries after obtaining their medical training. In the 1990s, the country experienced severe economic turmoil as the government attempted to expand its medical training and health care services capacity with the creation of nursing and medical schools (39). During this time, Malawi’s usually strict control of movement of its citizens and civil servants devolved. Before 1993, individuals needed government clearance to go abroad, but as the country experienced political and economic turmoil, these conditions relaxed (39). The lasting effects of this were newly trained health care workers without the health care facilities to perform their duties. Many opted to emigrate abroad.  

Malawi has an overall vacancy of health care workers of 33% (40). For surgeons, among other specialties needed, the vacancy reaches up to 100%. In 2004, the country lacked 64% of the nurses it needed to fill the 6,084 posts it had established around the country to serve its citizens (41). These shortages have since grown to a 75% vacancy for nurses. Malawi also lacks the capacity to provide quality obstetric care, as it lacks 115 of the 126 positions for Obstetricians/Gynecologists it has established (42, 44).Midwives and clinical officers who typically step in to fill the gap in obstetrics care are also in severe shortage. This has left the country with a high maternal and child mortality rate, with 16 women dying every day in Malawi from childbirth-related complications. 

Mitigation Attempts

The Malawian government implemented a six-year Emergency Human Resources Program (EHRP) in 2005 in an attempt to address its shortage of health care workers (40). The program implemented financial and structural incentives to train health workers through a 52% salary increase for health professionals and heavily recruited volunteer doctors and nurses as short-term fillers (49). The country created the Kamuzu College of Nursing and the School of Medicine to increase production of nurses and doctors (39). These efforts were made to tackle the glaring vacancies of health care workers and disparities in existing health care workers between the urban and rural areas of the country. From 2004 to 2009, the country has approximately doubled its output of physician graduates and clinical officers and quintupled its output of laboratory technicians while also decreasing the migration of nurses (43). Despite these necessary gains, the country still requires massive additions to its capacity deficits. The EHRP is an example that more targeted interventions to increase the capacity of health care services are necessary to alleviate one of the main push factors of health care workers who emigrate—lack of resources and capacity to provide the care they desire to administer in their country. 

Ethics and the Misdistribution of Burdens and Benefits 

Human Rights and the Ethicality of the Global Medical Brain Drain

Individuals in source countries have a right to healthcare that cannot be fulfilled by the individual alone (16). The fulfillment of this human right requires an extensive organization of government systems, institutions, and medical personnel to coordinate an adequate level of accessible care (17). The duty of care for these individuals falls primarily on the source country’s government who must maintain an adequate supply of medical workers who can provide care to individuals (18). Medical workers are crucial to healthcare systems; therefore they are the secondary duty-bearers of individuals’ rights to healthcare (16, 18). Medical workers are duty-bound to contribute to the government’s ability to uphold access to health care as a human right. When the medical brain drain depletes the availability of medical staff in a country to a critical level, emigration becomes unethical because it leaves citizens of the source country without access to an adequate standard of medical care. A sufficient standard of care is not reached when a critical shortage of medical workers robs inhabitants of access to the most basic of healthcare, such as primary care (5-6). 

The primary causes inducing the migration of workers—poverty, poor working conditions, low pay, etc.—are engendered by inequalities partly rooted in larger macroeconomic trends of economic development and international trade, which subsequently makes the medical brain drain itself unjust The migration of these medical workers is a symptomof fundamental structural inequalities between LMIC and high-income countries (5). The extreme poverty and deprivation of human capabilities evident in LMICs must be addressed on the grounds that the condition of individuals in LMICs are not being made better in existing inequalities (14, 19). Taking into account the broader causes and effects of global inequality (of which this paper does not have the space to detail) allows us to understand the medical brain drain as an outcome of existing global injustices. High-income countries and LMICs must work together towards more global justice. As LMICs make efforts to address the vulnerabilities in their health systems, high-income countries have responsibility to address the medical brain drain, as it is a symptom of global injustice (5).

Misdistribution of Burdens and Benefits 

The benefits and burdens of this migration flow are differentially accrued: the source country and its inhabitants largely receive burdens and minimal benefits, and the destination country and the migrants’ primarily receive benefits (see Table 2) (15). This inequitable distribution of benefits and burdens causes significant harm to the source countries.  

Healthcare workers from countries experiencing critical shortages accomplish the greatest good in terms of lives saved and economic return on investment to the home country when they remain in their home country to work (5). These individuals have important medical skills, which when combined with their local knowledge, make them uniquely capable to provide care in their home country (5, 15). The utility of health care workers remaining in their home country can be extended to entire regions around the world. The millions of lives suffering, billions of dollars lost to the source country in emigrated workers, and immense burden of disease represent a gross imbalance representation of the burdens accrued to source countries who lose healthcare workers. 

Source and destination countries disproportionately experience the distributions of benefits and burdens of the medical brain drain. The former part of this paper details some of the detrimental effects source countries endure due to the medical brain drain. On the other hand, destination countries experience numerous benefits of added medical workers to strengthen their health systems without undergoing the cost of training these professionals. These benefits include: less need to meet the growing demand of health care workforce, added stability of health systems, and less need to invest in national medical education (9). 

Policy Recommendations 

The following policy recommendations are proposed to rectify the harms endured by source countries and to introduce sentiments of justice into the emigration of health care workers to destination countries. The international community has taken an important step in adopting the WHO Global Code to tackle shortages in LMICs by acknowledging that ethical norms must be used to guide cooperation on the issue of the migration of health care workers. However, the code has been ineffective because of its non-binding nature and lack of incentives to guide destination countries to adopt national policy changes consistent with the code (12). The WHO should employ pressure through the media to mobilize national civil groups as a tactic to prompt destination countries to employ policy changes that address these countries’ roles as passive recruiters of foreign health care workers (2).        

A mechanism of reimbursement should be developed to address the issues of “reverse aid” in which poor source countries provide ready-trained medical professionals to wealthy destination countries (5, 6). Source countries also have some obligation to address the medical brain drain by improving the education and training of medical professionals and by increasing their quality of health care systems (6). Poor working conditions and low wages are issues that source countries must rectify. Ghana is recent example that increasing wages is effective in incentivizing medical workers to remain in source countries (24). Malawi’s implementation of the EHRP program included a 52% increase in salary for health professionals that partially contributed to the country’s ability to retain its health workers. In 2003, Kenya’s health minister, Charity Ngilu, worked to increase its salaries for starting physicians from $250 to $500, and reported that the salaries drew some physicians from the private sector back to the public sector and partly contributed to the country’s ability to retain the increased numbers of physicians it had recently graduated (52). These countries serve as evidence that any country’s attempt to address its lack of health workers should consider wage increase as part of its policy solution. 

Countries experiencing a shortage of health workers are often resource-poor countries experiencing declining public health budgets and increasing debt. Efforts to implement health systems strengthening-focused policies must take this reality into account. This may necessitate destination countries and international NGOs to collaborate with source countries to provide the funding and support necessary for source countries to successfully implement sustained policies to address the deficiencies of its health sectors. Development of a global health resource fund is a policy proposal that is slowly gaining traction among researchers and policy analysts (53). This fund would be coordinated by the WHO and the World Bank to implement cost-sharing and reimbursement mechanisms for source countries to fund programs targeting health systems strengthening and other policies to address the brain drain. This fund would be financed by a global fee structure against destination countries and private sectors that benefit from the migration of health workers from source countries (53). This policy proposal devises a sustainable mechanism of supporting the development of health systems in source countries. 

An increase in salaries to satisfactory levels may have no significant effect in retaining workers if dangerous working conditions persist. It is crucial for countries to prioritize the safety and wellbeing of its health workers. Improved health infrastructure and efficient health systems management are necessary to increase the ability of health workers to provide services in a risk-free environment. This can be accomplished through source-destination country collaborations to repair and upgrade existing health facilities to have up-to-date physical infrastructures, technology, drugs, and supplies/equipment (52).Destination countries should assist source countries with the development of efficient and sustainable health system management approaches that train source countries to develop country appropriate methods of drug distribution systems, emergency medical services, and health information management systems (52).

Other tactics such as task shifting to less specialized health care workers should be employed to expand the coverage of the health systems (25). The WHO recently launched the WHO/OGAC Task Shifting Project as a measure to expand the capacity of existing health care workers in African countries especially experiencing the burden of HIV/AIDS (45). Under this program, tiered level of workers are recruited to serve as field officers, community antiretroviral therapy supporters, antiretroviral therapy aides, and community health workers and trained to provide education on HIV prevention, treatment, and adherence, to provide assistance to nurses, and to follow-up with individuals receiving antiretroviral therapy. Seven countries—Ethiopia, Haiti, Malawi, Namibia, Rwanda, Uganda, and Zambia—have begun to implement task-shifting approaches. In Uganda in particular, there is only one doctor for every 22,000 patients, so Uganda’s nurses are now trained to fulfill the tasks that were formerly accomplished by doctors in order to expand its human resources capacity to deliver HIV/AIDs treatments to its population (45).  

Source countries should consider imposing a compulsory service requirement, which makes access to education contingent upon health care workers temporarily agreeing to remain in the source country for two years (26). Countries such as Nigeria have employed this tactic in order to reduce the flow of health care workers (27). Of the countries who measure the impact of a compulsory service requirement on the level of health workers in the country are Puerto Rico, Indonesia, Turkey, and South Africa, which report positive impacts of the program (46).  Before implementing a service requirement, 16 out of 78 municipalities in Puerto Rico lacked a physician (47). After the requirement, every municipality had at least one physician. Some countries, such as Indonesia, may requirement incentivized-based requirement programs in order to retain health workers. In Indonesia’s case, incentivizing the compulsory requirement increased the amount of new doctors inclined to work in rural areas experiencing shortages (48).Often times, compulsory service requirement programs are challenged by many health professionals due to the poor execution of the program leading to high costs, low utility of the programs, and high turn-over rates after required service period has ended. But it is necessary to implement quality management teams, be transparent and clear about the intent of the program, and to provide proper support for participating health workers in order to increase the efficacy of the program (48).  

Conclusion  

There is no quick fix to address the push and pull factors contributing to the global medical brain drain. This complex phenomenon has drawn on-going debates about ethicality of its persistence and of the most sustainable methods to curtail the brain drain. Nigeria and Malawi are among the many African nations experiencing the most severe brunt of the shortage of health care workers. These countries, among others experiencing gross shortages of health care workers, are often plagued with extensive economic inequalities rooted in their history as post-colonial countries. 

A rightful response to the global medical brain drain is not to turn an eye from the suffering of these countries but to prioritize the development and implementation of ethical policies aimed at rectifying the harms experienced by source countries and the greater social and economic injustice these countries endure. Source countries and destination countries must continue to work together to rebuild the foundations of structural inequality in source countries that make it vulnerable to these critical shortages. Efforts such as task shifting, the WHO Global Code, and funding for health systems strengthening of source countries fall short if not supported by sustainable international efforts. Intermittent funding of health programs and short-lived policies will not address the complex phenomenon of the global medical brain drain. It is necessary that countries remain committed and hold one another accountable in rectifying the damages caused by the brain drain.  

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