Abstract
IntroductionTrained human resources are fundamental for well-functioning health systems, and the lack of health workers undermines public sector capacity to meet population health needs. While external brain drain from low and middle-income countries is well described, there is little understanding of the degree of internal brain drain, and how increases in health sector funding through global health initiatives may contribute to the outflow of health workers from the public sector to donor agencies, non-governmental organisations (NGOs), and the private sector.MethodsAn observational study was conducted to estimate the degree of internal and external brain drain among Mozambican nationals qualifying from domestic and foreign medical schools between 1980–2006. Data were collected 26-months apart in 2008 and 2010, and included current employment status, employer, geographic location of employment, and main work duties.ResultsOf 723 qualifying physicians between 1980–2006, 95.9% (693) were working full-time, including 71.1% (493) as clinicians, 20.5% (142) as health system managers, and 6.9% (48) as researchers/professors. 25.5% (181) of the sample had left the public sector, of which 62.4% (113) continued working in-country and 37.6% (68) emigrated from Mozambique. Of those cases of internal migration, 66.4% (75) worked for NGOs, 21.2% (24) for donor agencies, and 12.4% (14) in the private sector. Annual incidence of physician migration was estimated to be 3.7%, predominately to work in the growing NGO sector. An estimated 36.3% (41/113) of internal migration cases had previously held senior-level management positions in the public sector.DiscussionInternal migration is an important contributor to capital flight from the public sector, accounting for more cases of physician loss than external migration in Mozambique. Given the urgent need to strengthen public sector health systems, frank reflection by donors and NGOs is needed to assess how hiring practices may undermine the very systems they seek to strengthen.
Highlights
Trained human resources are fundamental for well-functioning health systems, and the lack of health workers undermines public sector capacity to meet population health needs
Internal migration, or the movement of health workers from the public sector to work for other entities within the same country including non-governmental organizations (NGOs), the private sector, and multi-lateral and bilateral donor agencies, has received less attention though it has an important impact on public sector capacity [7]
Data collection initiated with physicians qualifying in 1980 to capture career decisions most directly linked to public sector health system capacity; pre-1980 graduates were excluded as they initiated medical school before the creation of the National Health Service (NHS), and arguably had different professional objectives than those initiating medical school post-independence
Summary
Trained human resources are fundamental for well-functioning health systems, and the lack of health workers undermines public sector capacity to meet population health needs. Over the last two decades international NGOs have played an increasingly important role in supporting public sector health systems in low and middle-income countries, fuelled largely by shifts in funding away from support for state health systems to NGOs as well as other private sector providers [8,9,10,11]. Reports suggest that these actors compete with public sector health systems for local qualified staff [12,13]. The substantial increase in funding for health activities outside the public sector through vertical initiatives, such as PEPFAR and the Global Fund to Fight HIV, TB, and Malaria, has led to a rapid rise in NGO-directed funding, which has created conditions leading to accelerated internal migration
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