Preventing Brain Drain

by Alanna Shaikh

Published January 06, 2009 @ 09:00PM PT

(image credit: Spierzchala)

In the comments on my last post, Rani P. asked about health care provider training. "I wonder if you had any thoughts about the challenge of retention.  I remember reading that due to the shortage of health care workers globally, workers were often hired away after they had completed more advanced training."

She's got an excellent point. The heart of building the capacity of a health care system is its providers. Doctors, nurses, radiologists, medical techs...these people are the core of your system. Building its capacity mostly means training them. But one you've trained them, they never stay where they are. It's all well and good to build up a rural clinic by training its doctors, but what do you do when they use that training to get better paying jobs in the capital? Or you spend a year training a nurse-midwife in perinatal care, after which she gets married, gets pregnant and promptly leaves the workforce. And then, of course, there is brain drain, in which qualified medical professionals leave their home countries in the developing world for high-paying jobs in wealthy countries. It is a much-reported phenomenon.

Any time you trade health care providers, you've got to take turnover into account. Your impact will erode very, very fast if you don't. Your training gives people a valuable new skill. You'd like them to use it for the public good; very often they want to use it for their own good. (and who can blame them?)

In my experience, there are four ways you can deal with provider turnover after training:

Incentives - you can find ways to keep the health care worker in their job after training. The most obvious way to do it is to increase salaries for trained workers. This makes their income more competitive with whatever is luring them away. The downside is that it (obviously) costs money in a long-term way, and often you can't afford to pay enough to be really competitive with the private sector or the glitz of the capital.

There are other incentives besides money. If you can build a culture of respect for health care providers, they may feel loyalty which keeps them from leaving despite salary disparities. Additional responsibility and a more senior title may also encourage people to stay. Even little things like employer-provided uniforms, t-shirts, or knapsacks can have a surprising effect on staff loyalty.

Coercion - you can force people to stay. This is more common than you'd think. Ministries of health often require people to sign multi-year contracts before they are eligible for training. NGOs use voluntary commitment documents, where people promise to stay in their jobs, or at one location, for a specified amount of time after education. These are non-binding, but people tend to take them seriously.

Extremely selective process when choosing trainees and training subjects- this may mean choosing your individuals with great care, or training only certain kinds of health workers. If you train village health nurses, for example, they are unlikely to leave for other jobs. Even a well-trained village health nurse is unlikely to have skills for anything but village health programs. There are a number of basic primary health care jobs that fit that criteria - vaccination personnel, clinic helpers, and so on. Training these people will improve health care almost as much as training physicians, with less risk of brain drain.

And even higher level personnel, such as doctors, are going to find some kinds of training more marketable than others. Train a physician in the diagnosis and treatment of sexually transmitted infections, or tuberculosis, and she'll be off to a high-paying private sector job in the blink of an eye. Train a doctor in the integrated management of childhood illness, though, and it's not going to net them anywhere near as much money.

You can also choose individual trainees to try to limit turnover. If there is an application process for the training, you can screen out people who seem likely to leave. This can be very effective, but it can also turn into discrimination. One program I read about didn't take any unmarried women for training, because they assumed women would leave the profession once they were married. That's not exactly good for gender equity.

Let it happen, and work around it. This may mean allowing providers to work nights for private pay at the same public clinic they staff during the day. Or it could involve letting them charge an extra fee for each patient that goes directly to the provider. This is a very tricky option; it's highly effective but it can easily lead to patient exploitation.