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June 15, 2010

The Brain Drain: The Gauze or The Tie? 10th Day at the 7th GHC

Today's theme was practically about emergencies and unintentional injuries and their global impact. However, I wanted to deal more on the last lecture for the day which was originally scheduled for last week. It was about the issue of immigration of health professionals in the global stage. Basically the lecture was about how the imbalance distribution of health professionals are affecting the delivery of health care services. The movement of health professionals from one side of the world to the other is one of those contributing to this inequitable distribution of health care providers. This phenomenon is very much predominant in the Philippine setting although not exclusive. African countries and other South Asian countries are also experiencing the phenomenon of what is called "Brain Drain". For some of these source-countries, it is more than just brain drain. It is already a Hemorrhaging Brain. The concept therefore of addressing the issue lies on the level of recognition of the severity of this global reality.

There are basically many measures, considering the "push" and "pull" factors that complicate the situation. What are the reasons why many doctors and nurses and midwives leave their respective countries? What are the reasons why many doctors and nurses and midwives are attracted to migrate to certain countries? The most obvious and major reason is always economics.

Poorly paid doctors especially those who are in the field of public health are forced to seek other sources of livelihood in other countries. The reason for being poorly paid is complex but for the Philippine setting, it is nevertheless political. In a devolved health system, with standardized salaries for health professionals among other government employees, the ability of a local government to hire and pay for the benefits on top of the basic salaries of its health care workers depends largely on the availability of financial resources and the presence or absence of limitations as prescribed by the legal and political system.

In a devolved system, the local chief executive, which is either the mayor or the governor, is technically the health manager of the locality. The LCE, through policies, dictate the direction to which he would want his health programs to run. It is a given therefore that the LCE must be prioritizing health in the first place in order to proclaim such policies, but this is not always and most often the case.

The prioritization of health as a political agenda is nothing more than just lip service for some or many of our political leaders. A classic example of a clear disregard for its health care workers is the non-implementation of the Magna Carta for Public Health Workers.

Majority of the municipalities and cities in the Philippines have yet to implement in full this national law which carries with it penalties for those who cannot implement such law. Thus, it is no surprise that there are cases when health care workers sue their Local Government Units for these unpaid benefits or mass exodus from the public health sector to the private sector or worse, out of the country.

One proposed remedy is the innovation of our medical education. There are cases in African countries where exodus of health care workers would leave empty hospitals and clinics. To address this, they would train their nurses for example to perform major surgeries such as Cesarean sections. There are midwives also trained to perform such major procedure. Present studies indicate that there is no significant difference in the outcome of the patient between an OB-GYNE specialist or a nurse trained as a Clinical Assistant performing Cesarean sections.

The proposal therefore is that maybe the Philippines must also start looking at doing such a thing. Training its nurses and midwives to perform major, if not minor surgeries. In fact, there are trainings already conducted among midwives wherein they are taught to perform episiotomy and episiorrhaphy. The Philippine government in the 1990's did do practically the same thing, training traditional birth attendants to perform safe deliveries to address the high maternal mortality rates due to lack of skilled birth attendants.

Unfortunately though, despite the presence of trained birth attendants, the maternal mortality ratio in the Philippines was still relatively high.

However, with regards to preventing the Brain Drain phenomenon, I feel that such a proposal is more of a band-aid procedure, what I would call The Gauze approach. Basically, we stop the bleeding by pressing on the bleeding site. It temporarily stops the bleeding since the number of professionals leaving the country are offset by the number of newly trained "mid-level medical care" professionals. Unfortunately it does not resolve the root cause of the exodus of these health care professionals.

Since the root cause of the problem is basically economics, the solution must also be economics. To tie the bleeding artery is the more productive solution to the problem. We must allow our health care professionals to be well compensated and to grow professionally. It is not a simple task and the mechanism may be complex but the rationale is clear. Every time we propose stop gap measures, we will end up with a bleeding wound wrapped in thick gauze with no guarantee even if the bleeding will stop. And that usually happens in the Philippines. We have so many programs and measures that eventually aim to regulate the exodus of health care professionals but basically there are still health care professionals leaving. Perhaps the reason is that we have not directed our collective efforts to solving the causes of this mass exodus.

The Brain Drain phenomenon in The Philippines might stay for long however, especially since we have a government who adopts a policy of exporting its own people in exchange for remittances. I do hope that we will have a government and a nation that will somehow reverse this tragic situation, where more doctors and nurses opt to remain rather than abandon post.

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