The Engagement of the Zimbabwean Medical Diaspora

The souThern african migraTion programme

The engagemenT of The Zimbabwean medical diaspora

migraTion policy series no. 55

The Engagement of the Zimbabwean Medical Diaspora

Abel Chikanda

Series Editor: Prof. Jonathan Crush

Southern African Migration Programme (SAMP) 2011 Acknowledgements I am grateful to the International Development Research Centre (IDRC) for funding the research and for permission to publish the results of my study here. I would like to thank Dr Belinda Dodson, my PhD super- visor, and Dr Jonathan Crush, for their editorial inputs and assistance. The views expressed in this paper are mine alone and do not necessarily represent those of SAMP and its funders.

Published by Idasa, 6 Spin Street, Church Square, Cape Town, 8001, and Southern African Research Centre, Queen's University, Canada.

Copyright Southern African Migration Project (SAMP) 2011 ISBN 978-1-920409-64-7 First published 2011 Design by Bronwen Müller

All rights reserved. No part of this publication may be reproduced or transmitted, in any form or by any means, without prior permission from the publishers. Bound and printed by Logo Print, Cape Town Contents Page

Executive Summary 1

Introduction 4

Overview of Physician Migration from Zimbabwe 5

The Study Sample 7 research Methodology 7 profile of Survey Respondents 8 profile of Interview Respondents 10

Migration Patterns and Channels 10 causes of Emigration 10 deteriorating Political Conditions 10 lack of Opportunities for Career Advancement 12 deteriorating Economic Conditions 14 unsatisfactory Working Conditions 14 inadequate Remuneration and Benefits 17 collapse of Public Healthcare 18 step Migration 19 recruiters and Networks 21

Informal Links with Zimbabwe 23 cash Remittances 23 remittances of Goods 30 value of Remittances 32 informal Services 33

Engaging the Diaspora 35 return Migration 35 medical Training and Capacity-Building 39 short-Term Visits 41 raising Funds and Sourcing Supplies 42 ‘Virtual Return’: Telemedicine 43 obstacles to Engagement 44

Conclusion: Brain Drain or Brain Gain? 46 Endnotes 47

Migration Policy Series 53

Tables Page

Table 1: location of Zimbabwean Medical Doctors Worldwide, 2000 6

Table 2: location of Survey Respondents 8

Table 3: demographic Profile of Survey Respondents 8

Table 4: employment History in Zimbabwe 9

Table 5: reasons for Leaving Zimbabwe 11

Table 6: Trends in Specialisation at Medical School in Zimbabwe 13

Table 7: resource Availability at Health Institutions 15

Table 8: sources of Information Used Prior to Migration 22

Table 9: distribution of Physician Remittances 26

Table 10: estimated Value of Cash Remittances 32

Table 11: estimated Value of Remitted Goods 33

Table 12: estimated Total Value of Remittances 33

Figures Page

Figure 1: number of Doctors in Zimbabwe, 1991-2004 7

Figure 2: adult (15-49) Prevalence Percent of HIV/AIDS in Zimbabwe 17

Figure 3: migration History of Zimbabwean Physicians 19

Figure 4: intermediate Destinations of Zimbabwean Physicians 20

Figure 5: frequency of Sending Remittances to Zimbabwe 24

Figure 6: annual Volume of Financial Remittances by Race 25

Figure 7: methods of Sending Money to Zimbabwe 28

Figure 8: use of Migrant Remittances Sent to Zimbabwe 29

Figure 9: proportion Remitting Goods Country of Residence 30

Figure 10: Type of Goods Remitted to Zimbabwe 31

Figure 11: Have Important Role to Play in the Future of Zimbabwe 35 MMIGRATIONigration PPOLICYolicy SERIESeries NOo. 4555

ExecuXECUTIVEtive SSummaryUMMARY

espiteealth theworkers well-documented are one of the negative categories impacts of skilled of the profession- ‘brain drain’als most of health affected professionals by globalization. from Africa, Over the there past is decade,an argu- mentthere that has theiremerged departure a substantial is not anbody absolute of research loss and that that tracks transnationally-orientedpatterns of international medical migration migrants of health (or diasporas)personnel, can DHact as development agents in their home countries. Financial remittanc- assesses causes and consequences, and debates policy responses at global es,and in national particular, scales. are saidWithin to have this significantliterature, thetransformative case of South development Africa is potential.attracting Africangrowing countries interest. areFor alsoalmost expected 15 years to Southbenefit Africa from knowledgehas been andthe targetskills transfer of a ‘global through raiding’ the ofreturn skilled of healthprofessionals professionals by several from devel- abroad. Otheroped countries. diaspora engagementHow to deal initiatives with the consequencesthat do not require of the permanent resultant out- returnflow of (such health as professionals short term work is a coreassignments, policy issue technological for the national transfer gov- to countryernment. of origin and ‘virtual’ participation of the diaspora involving the use Thisof communication paper aims to technologies)to examine policy are seen debates as another and issues positive concerning feed- backthe migration mechanism, of skilledmitigating health the professionals negative impact from of the out-migration. country and to furnishZimbabwe’s new insights economic on the and recruitment political crisis patterns has led of toskilled the emigration health per- ofsonnel. many Thephysicians objectives over of the the last paper twenty are yearstwofold: as the skills and experience• which To provide they possess an audit are valuedof the organizationin countries andin the patterns North ofas recruit-well as in Southment Africa. of skilledPrevious professionals studies have from focused South on Africa the magnitude in the health and damagingsector. impact The of paperthis exodus draws onupon the a Zimbabweandetailed analysis health of system.recruitment This is the firstadvertising study to focusappearing exclusively in the onSouth physicians African in Medical the diaspora. Journal The for study is thebased period on a 2000-2004global email and survey a series of physicians of interviews and conductedin-depth inter with- views withprivate Zimbabwean recruiting doctors enterprises. living and working in South Africa. The results• of Based the survey upon theand above interviews analysis provide and additionalnew insights interviews into the withnature of the Zimbabweankey stakeholders medical in thediaspora, South their African motivations health sector, for leaving the paper the county, theoffers links a series which of theyrecommendations maintain with forZimbabwe, addressing the the prospects problem of of them returningskilled health to Zimbabwe migration. and Thesetheir interest recommendations in making their are grounded skills, knowledgein bothand resourcesSouth African available experience to the country and an ininterrogation the future. of inter- The nationalconventional debates wisdom and ‘goodon the policy’ brain drainpractice is that for regulatingskilled profes recruit-- sionals movement. directly from a country of origin to a country of destination.The The paper impacts is organized of this movement into five sections.for both countriesSection Two are positionsthen assessed. However,debates about this failsthe migrationto capture ofthe skilled complexity health of professionals the migration within patterns a ofwider Zimbabwean literature physicians.that discusses Only the 42% international of those surveyed mobility had of talent.moved directlySection fromThree Zimbabwe reviews research to their currenton the globalcountry circulation of residence. of health Seventy pro- onefessionals, percent focusing of the Zimbabwean in particular doctorsupon debates in South relating Africa to came the experiencedirectly fromof countries Zimbabwe. in the The developing rest had first world. been Section to a variety Four movesof other the destinations focus from includinginternational the Unitedto South Kingdom, African Australia,issues and Asiaprovides and newelsewhere empirical in Africa. mate- Thisrial drawn suggests from that the there survey has of been recruitment “return migration” patterns and from key overseas, interviews but benefittingundertaken South with healthAfrica sectornot Zimbabwe. recruiters operating in South Africa. SectionA common Five addresses feature ofthe studies questions on the of causeschanging of skillspolicy migration interventions is to ask in respondentsSouth Africa to towards identify the discrete outflow “causes” of skilled of migration health professionals and then to and rank the them.recruitment In this of study, foreign respondents health professionals were presented to work with in a Southset of possibleAfrica. Therea- sons for leaving and then asked to rate the importance of each of them

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EXECUTIVE SUMMARY to the decision-making process on a five point scale from ‘strongly agree’ to ‘strongly disagree.’ The three factors with the highest levels of concur- ealth workers are one of the categories of skilled profession- rence were the bad political environment (74% in agreement), lack of als most affected by globalization. Over the past decade, opportunities for career advancement (73% agreed) and poor economic there has emerged a substantial body of research that tracks conditions in Zimbabwe (71% agreed). Other factors cited by the major- patterns of international migration of health personnel, ity of respondents were unsatisfactory working conditions, inadequate H remuneration and benefits, the collapse of the health care system and a assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is better future for their children. The relative importance of each of these attracting growing interest. For almost 15 years South Africa has been factors varied with race and the year when the physician left. the target of a ‘global raiding’ of skilled professionals by several devel- Another 30% of the respondents moved first from Zimbabwe to oped countries. How to deal with the consequences of the resultant out- South Africa and then joined the “brain drain” from South Africa and flow of health professionals is a core policy issue for the national gov- migrated onwards to a variety of overseas destinations. Less than half of ernment. the doctors who had migrated to the UK did so directly from Zimbabwe. This paper aims to to examine policy debates and issues concerning Only 5% of the Zimbabwean doctors in the USA, Australia, Canada and the migration of skilled health professionals from the country and to New Zealand came direct from Zimbabwe. South Africa and the UK are furnish new insights on the recruitment patterns of skilled health per- clearly the main transit countries for medical doctors from Zimbabwe. sonnel. The objectives of the paper are twofold: These two intermediary destinations seem to act as “stepping stones” • To provide an audit of the organization and patterns of recruit- to get to the ultimate destination. The intermediate point allows them ment of skilled professionals from South Africa in the health to specialise in their chosen field which then increases their chances sector. The paper draws upon a detailed analysis of recruitment of gaining entry to their ultimate destination. Furthermore, it enables advertising appearing in the South African Medical Journal for them to develop networks with similar professionals located elsewhere the period 2000-2004 and a series of interviews conducted with who can assist them in making an onward move. Eventually, a migration private recruiting enterprises. chain develops linking the emigrant Zimbabwean medical doctors in an • Based upon the above analysis and additional interviews with intermediate country to their counterparts located in a more attractive key stakeholders in the South African health sector, the paper destination. offers a series of recommendations for addressing the problem of Previous surveys have shown that migrant remittances play a major skilled health migration. These recommendations are grounded role in ensuring household survival in Zimbabwe. We do not know if in both South African experience and an interrogation of inter- physicians are distinctive in their remitting behaviour or whether they national debates and ‘good policy’ practice for regulating recruit- follow the general pattern. This study therefore focused on whether phy- ment. sicians, who are amongst the highest earning occupational category in The paper is organized into five sections. Section Two positions the Zimbabwean diaspora, display different remitting practices than other debates about the migration of skilled health professionals within a Zimbabweans. The survey found the following: wider literature that discusses the international mobility of talent. • 60% of the diaspora physicians send money to Zimbabwe while Section Three reviews research on the global circulation of health pro- 40% never do so. The propensity to remit was highest among fessionals, focusing in particular upon debates relating to the experience medical doctors working in South Africa, with 79% sending of countries in the developing world. Section Four moves the focus from money to Zimbabwe. Two thirds of doctors in the USA remit international to South African issues and provides new empirical mate- but only 42% in the UK and a third of those in Canada. To put rial drawn from the survey of recruitment patterns and key interviews these figures in context, various surveys of Zimbabweans in South undertaken with health sector recruiters operating in South Africa. Africa have found that 85-95% of migrants remit money home. Section Five addresses the questions of changing policy interventions in Another study of Zimbabweans in the UK found that 80% remit- South Africa towards the outflow of skilled health professionals and the ted funds to Zimbabwe. recruitment of foreign health professionals to work in South Africa. The • the propensity of physicians to remit varies with the year of emigration (with 95% of those who left after 2000 remitting) and

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EXECUTIVE SUMMARYrace (only a third of white doctors remit compared to 100% of black doctors.) • aroundealth 50% workers of those are whoone remitof the docategories so at least of onceskilled a month.profession- Amongstals most the affected general byZimbabwean globalization. migrant Over population the past decade, in the UK, aroundthere 41% has remit emerged at least a substantial once a month. body ofRemitting research frequencies that tracks frompatterns South Africa of international are higher; migration 60-75% at of least health once personnel, a month. HThere is thus nothing particularly unusual about the frequency assesses causes and consequences, and debates policy responses at global and nationalwith which scales. physicians Within this remit. literature, the case of South Africa is attracting• the growing vast majority interest. of ZimbabweanFor almost 15 migrants years South (over Africa 90%) hasuse beenvarious the targetinformal of a ‘global channels raiding’ when of remitting skilled professionals to Zimbabwe. by Highly-educated,several developed countries.middle-class How migrants to deal withsuch theas physicians consequences might of bethe expected resultant to outflow of makehealth more professionals use of formal is a coreremitting policy channels issue for suchthe national as banks gov- and ernment.money transfer companies. In fact, at the time of the survey This(2008), paper aims most to physicians to examine were policy also debatesusing informal and issues channels concerning and the migrationstayed awayof skilled from health the banks. professionals from the country and to furnish• thenew research insights onon Zimbabweanthe recruitment remittances patterns clearlyof skilled shows health that per- the sonnel. bulkThe ofobjectives it is spent of on the household paper are survivaltwofold: needs with very little •investment To provide ofan theaudit proceeds. of the organization The question and is whetherpatterns remittancesof recruit- fromment physicians of skilled professionalsare any different. from The South answer Africa is no.in the Over health 90% of thesector. respondents The paper who draws send upon cash a remittancesdetailed analysis do so ofto recruitment meet the day toadvertising day expenses appearing of family in themembers South in African Zimbabwe Medical including Journal food for purchase,the period rent 2000-2004 and the andcost a of series electricity of interviews and water. conducted with • theprivate only recruiting thing that enterprises. really distinguishes the physicians’ remit- •ting Based behaviour upon the is above the volume analysis sent and (which additional is well interviews above aver with- age).key stakeholders However, even in the if the South average African physician health remittance sector, the figure paper ofoffers US$2,616 a series p.a. of recommendationswas sustained over for a 30addressing year period, the problemthe total of remittancesskilled health from migration. one individual These recommendationswould still not compensate are grounded for theirin both training South costs African in the experience first place. and an interrogation of inter- Considerablenational internationaldebates and ‘good enthusiasm policy’ surroundspractice for the regulating idea of “return recruit- migration.”ment. In the case of Zimbabwean physicians outside the country, the Theprobability paper is of organized permanent into return five sections.migration Section is generally Two lowpositions but varies withdebates race, about age, theyear migration of emigration of skilled and location:health professionals within a wider• literature53% of black that discussesphysicians the said international they are likely mobility to return of talent. compared to Sectiononly Three 11% reviews of white research physicians. on the Conversely, global circulation 70% of theof health whites pro- said fessionals,they focusing would neverin particular return comparedupon debates to only relating 16% toof thethe experienceblacks. In of countriesother in words, the developing the potential world. for returnSection is Fourhigher moves amongst the blackfocus fromphy- internationalsicians to and South only Africana small minorityissues and (16%) provides definitely new empirical ruled out mate- the rial drawnpossibility. from the survey of recruitment patterns and key interviews undertaken• the possibility with health of returnsector recruitersis highest operatingamongst the in Southyounger Africa. doctors: Section78% Five in addresses the 31-40 the age questions group said of changingthey are likelypolicy to interventions return, com- in South Africapared totowards 23% in the the outflow 41-50 ofage skilled group, health 10% in professionals the 51-60 age and group the recruitmentand none of foreign over thehealth age professionalsof 60. to work in South Africa. The • the year of emigration is positively correlated with the possibility of return: 12% of those who left in the 1980s said they might 1 3 kkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkk MIGRATION POLICY SERIES NO. 45 The Engagement of the Zimbabwean Medical Diaspora

EXECUTIVE SUMMARY return compared to 30% of those who left in the 1990s and 79% of those who left after 2000. ealth workers are one of the categories of skilled profession- • possibility of return varies with a doctor’s current country of als most affected by globalization. Over the past decade, residence. Return was more likely among those located in South there has emerged a substantial body of research that tracks Africa (40%) than amongst those in the UK (21%) or in the patterns of international migration of health personnel, USA (13%). H Diaspora engagement has been increasingly advanced as a possible assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is solution to the skills problems facing developing countries. In Zimbabwe, attracting growing interest. For almost 15 years South Africa has been the diaspora option arguably offers the most sensible policy prescription the target of a ‘global raiding’ of skilled professionals by several devel- since it entails the use of the skills of the diaspora without requiring them oped countries. How to deal with the consequences of the resultant out- to return home permanently. Options proposed by the physicians and dis- flow of health professionals is a core policy issue for the national gov- cussed in this report include: medical training, short-term medical visits, ernment. raising funds, sourcing supplies and telemedicine. In each case the oppor- This paper aims to to examine policy debates and issues concerning tunities and obstacles to the particular form of engagement are discussed. the migration of skilled health professionals from the country and to furnish new insights on the recruitment patterns of skilled health per- Introduction sonnel. The objectives of the paper are twofold: • To provide an audit of the organization and patterns of recruit- he migration of medical doctors from Africa has been linked to ment of skilled professionals from South Africa in the health falling health standards and cited as a major impediment to the sector. The paper draws upon a detailed analysis of recruitment continent’s quest to attain the Millennium Development Goals. advertising appearing in the South African Medical Journal for The World Health Organisation (WHO) has even identified Tthe emigration of physicians as the most critical problem facing health the period 2000-2004 and a series of interviews conducted with private recruiting enterprises. systems in African countries today. 1 In 2000, an estimated 36,653 medi- • Based upon the above analysis and additional interviews with cal doctors (or 28% of the total trained in Sub-Saharan Africa) were key stakeholders in the South African health sector, the paper practising in nine major immigrant-destination countries.2 The “global offers a series of recommendations for addressing the problem of health care chain” has become one of the main mechanisms draining skilled health migration. These recommendations are grounded Africa of its physicians.3 African nations are unable to retain their medi- in both South African experience and an interrogation of inter- cal doctors and risk losing even more to developed countries which national debates and ‘good policy’ practice for regulating recruit- offer better conditions of service and remuneration. Pejoratives such as ment. ‘poaching,’ ‘looting,’ ‘stealing’ and the ‘new slave trade’ have entered the The paper is organized into five sections. Section Two positions discourse on health professional migration from Africa.4 debates about the migration of skilled health professionals within a Despite the losses which African countries suffer from the out-migra- wider literature that discusses the international mobility of talent. tion of skilled and experienced health professionals, there is an argument Section Three reviews research on the global circulation of health pro- that their departure is not an absolute loss and that transnationally- fessionals, focusing in particular upon debates relating to the experience oriented medical migrants (or diasporas) can act as development agents of countries in the developing world. Section Four moves the focus from for their home countries. Financial remittances, in particular, are said to international to South African issues and provides new empirical mate- have significant transformative development potential.5 African countries rial drawn from the survey of recruitment patterns and key interviews are also expected to benefit from knowledge and skills transfer through undertaken with health sector recruiters operating in South Africa. the return of health professionals from abroad.6 Other diaspora engage- Section Five addresses the questions of changing policy interventions in ment initiatives that do not require permanent return (such as short term South Africa towards the outflow of skilled health professionals and the work assignments, technological transfer to country of origin and ‘virtual’ recruitment of foreign health professionals to work in South Africa. The participation of the diaspora involving the use of communication technologies) are seen as another positive feedback mechanism, mitigating the negative impact of out-migration. 1 4 kkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkk MMIGRATIONigration PPOLICYolicy SERIESeries NOo. 4555

EXECUTIVEZimbabweSUMMARY is a potentially important site in which to test these com- peting visions of the effects of health professional migration. The country has lost manyealth of itsworkers medical are doctors one of andthe categoriesnurses over of the skilled past profession-two decades. The negativeals most impacts affected of by this globalization. brain drain Overhave beenthe past extensively decade, documented in thereprevious has studies.emerged7 Thisa substantial study set body out to of examineresearch whatthat trackskinds of linkages thesepatterns health of international professionals migrationmaintain withof health the country, personnel, whether Hthey mitigate the impact of the brain drain in any way and whether, and assesses causes and consequences, and debates policy responses at global underand national what conditions, scales. Within return this migration literature, is likely.the case Most of Southliterature Africa on theis brainattracting drain growing of health interest. professionals For almost focuses 15 onyears the South migration Africa of hashealth been professionalsthe target of froma ‘global Africa raiding’ to Europe of skilled and Northprofessionals America by (so-calledseveral devel- South- Northoped countries. migration). How Very to little deal attentionwith the consequenceshas been paid ofto thethe resultantmovement out- offlow physicians of health and professionals nurses within is a thecore South policy (South-South issue for the migration).national gov- Theernment. Zimbabwean case provides an opportunity to rectify this omission sinceThis Zimbabwean paper aims health to to examineprofessionals policy engage debates in South-Northand issues concerning and South-Souththe migration migration of skilled (and health in professionalssome cases both). from Zimbabweanthe country andhealth to professionalsfurnish new insightsare to be on found the recruitmentin various countries patterns inof Europeskilled healthand North per- Americasonnel. The but objectivesthey also migrate of the paperto other are countriestwofold: within Africa (primarily South• To Africa). provide For an instance,audit of thealmost organization 80 per cent and of patterns doctors ofemployed recruit- in Southment African of skilled rural hospitals professionals in 1999 from were South reportedly Africa innon-South the health Africans.sector.8 Most The were paper from draws Zimbabwe, upon aBotswana, detailed analysis Malawi, of and recruitment several other Africanadvertising countries. appearing9 This instudy the thereforeSouth African also set Medical out to Journalsystemati for- cally comparethe period the Zimbabwean2000-2004 and medical a series diaspora of interviews within Africaconducted with withthat outside theprivate continent recruiting to see enterprises. if there are any differences in their links with Zimbabwe• Based and upon their thereturn above and analysis diaspora and engagement additional potential. interviews with key stakeholders in the South African health sector, the paper Overview of offersPhysician a series ofM recommendationsigration from for Z addressingimbabwe the problem of skilled health migration. These recommendations are grounded inhe both exact South number African of physicians experience who and have an interrogationleft Zimbabwe of is inter- hard nationalto determine debates from and Zimbabwean ‘good policy’ sources. practice Zimbabwe’s for regulating Central recruitment.Statistics Office (CSO) used to publish data on the size of the The papermedical is organized workforce into but five stopped sections. in 2000. Section Data Two is available positions from Tthe Medical and Dental Practitioners Council of Zimbabwe (MDPCZ) debates about the migration of skilled health professionals within a butwider their literature numbers that are discusses completely the inconsistent international with mobility destination of talent. country data.Section10 For Three example, reviews the research MDPCZ on claims the global that the circulation number of medicalhealth pro- doctorsfessionals, in Zimbabwefocusing in has particular actually upon risen debatesby more relating than 50% to thesince experience 2000 to 2,783of countries in 2008. in Partthe developingof the explanation world. Sectionmay be thatFour doctorsmoves thewho focus leave from Zimbabweinternational often to maintainSouth African their professionalissues and provides registration new andempirical are counted mate- asrial being drawn in fromthe country the survey when of theyrecruitment are, in fact, patterns practising and key abroad. interviews undertakenDestination with country health data sector can recruiters be used tooperating shed light in Southon the Africa.volume ofSection emigration Five addressesof doctors. the Clemens questions and of Pettersson’s changing policy 2000 databaseinterventions on in theSouth global Africa distribution towards theof African-trained outflow of skilled physicians health professionalsuses information and the fromrecruitment various ofOECD foreign countries. health professionals11 By definition, to work the database in South excludes Africa. The Zimbabwean physicians in other African countries, a weakness that is

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EXECUTIVE SUMMARY partially addressed by the inclusion of South Africa. It also excludes New Zealand which is an important destination for doctors from Zimbabwe. ealth workers are one of the categories of skilled profession- Dumont and Zurn’s database also uses OECD data but includes New als most affected by globalization. Over the past decade, Zealand.12 It also excludes some of the other important African destina- there has emerged a substantial body of research that tracks tions for Zimbabwean doctors such as Botswana and Namibia. By com- patterns of international migration of health personnel, bining the two databases, it is possible to generate a picture of the global H distribution of Zimbabwean physicians in 2000 (Table 1). At that time, assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is South Africa was the most popular destination, accounting for 643 (or attracting growing interest. For almost 15 years South Africa has been 39%) of the 1,662 Zimbabwean doctors in the diaspora. The UK was the the target of a ‘global raiding’ of skilled professionals by several devel- second most popular destination with 553 (33%), while the USA had oped countries. How to deal with the consequences of the resultant out- 235 (14%), Australia 97 (6%), New Zealand 60 (4%) and Canada 55 flow of health professionals is a core policy issue for the national gov- (3%). ernment. Another study for the World Bank by Docquier and Bhargava docu- This paper aims to to examine policy debates and issues concerning ments the size of the domestic and foreign medical labour force in several the migration of skilled health professionals from the country and to countries, including Zimbabwe.13 This database shows that Zimbabwe furnish new insights on the recruitment patterns of skilled health per- lost 674 medical doctors between 1991 and 2004, with the number of sonnel. The objectives of the paper are twofold: registered medical doctors falling from 1,425 in 1991 to only 751 in 2004 • To provide an audit of the organization and patterns of recruit- (Figure 1). If the number of new medical doctors trained during this ment of skilled professionals from South Africa in the health period is factored in, it means that Zimbabwe lost nearly 1,800 medi- sector. The paper draws upon a detailed analysis of recruitment cal doctors through emigration (controlling for deaths and retirement). advertising appearing in the South African Medical Journal for Anecdotal evidence that emerged in this study suggests that it would be the period 2000-2004 and a series of interviews conducted with worth undertaking a tracer study using physician networks to see where private recruiting enterprises. graduating Zimbabwean physicians are currently located. Dr Walter • Based upon the above analysis and additional interviews with Choga, for example, who graduated in the early 1990s, noted that of the key stakeholders in the South African health sector, the paper 55 students in his class, only 3 remained in Zimbabwe. Thirty moved to offers a series of recommendations for addressing the problem of South Africa, 20 went either to the UK or US and 2 are in Australia.14 skilled health migration. These recommendations are grounded in both South African experience and an interrogation of inter- Table 1: Location of Zimbabwean Medical Doctors Worldwide, 2000 national debates and ‘good policy’ practice for regulating recruit- Country No. of doctors % emigrant Zimbabwean doctors ment. South Africa 643 38.7 The paper is organized into five sections. Section Two positions UK 553 33.3 debates about the migration of skilled health professionals within a USA 235 14.1 wider literature that discusses the international mobility of talent. Australia 97 5.8 Section Three reviews research on the global circulation of health pro- New Zealand 60 3.6 fessionals, focusing in particular upon debates relating to the experience Canada 55 3.3 of countries in the developing world. Section Four moves the focus from Portugal 12 0.7 international to South African issues and provides new empirical mate- Belgium 6 0.4 rial drawn from the survey of recruitment patterns and key interviews Spain 1 0.1 undertaken with health sector recruiters operating in South Africa. Section Five addresses the questions of changing policy interventions in Total abroad 1,662 100.0 South Africa towards the outflow of skilled health professionals and the Source: Clemens and Pettersson, 2006; Dumont and Zurn, 2007. recruitment of foreign health professionals to work in South Africa. The

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FigureEXECUTIVE 1: NumberS ofUMMARY Doctors in Zimbabwe, 1991-2004

3000 ealth workers are one of the categories of skilled professionals most affected by globalization. Over the past decade, 2500 there has emerged a substantial body of research that tracks patterns of international migration of health personnel, 2000H assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is 1500 attracting growing interest. For almost 15 years SouthTotal Africa expected has been the target of a ‘global raiding’ of skilled professionals Totalby several registered devel- Number of doctors 1000oped countries. How to deal with the consequences of the resultant outflow of health professionals is a core policy issue for the national gov- 500ernment. This paper aims to to examine policy debates and issues concerning 0the migration of skilled health professionals from the country and to 1991furnish 1992 new 1993 insights 1994 1995 on the 1996 recruitment 1997 1998 patterns 1999 2000 of 2001skilled 2002 health 2003 per- 2004 sonnel. The objectives of the paperYears are twofold: Source: Based on• Docquier To provide and Bhargava, an audit 2006 of the organization and patterns of recruitment of skilled professionals from South Africa in the health sector. The paper draws upon a detailed analysis of recruitment The Study Sampleadvertising appearing in the South African Medical Journal for the period 2000-2004 and a series of interviews conducted with Research Methodologyprivate recruiting enterprises. • Based upon the above analysis and additional interviews with here is no comprehensive list of Zimbabwean doctors working key stakeholders in the South African health sector, the paper abroad which makes it impossible to use probability sampling offers a series of recommendations for addressing the problem of techniques. Instead, the study utilised a public database from the skilled health migration. These recommendations are grounded Godfrey Huggins School of Medicine (GHSM) at the University in both South African experience and an interrogation of inter- Tof Zimbabwe which contained details of 435 emigrant medical graduates national debates and ‘good policy’ practice for regulating recruit- at the time it was accessed in 2008. The GHSM database provides details ment. about the location of individual medical doctors and their email addresses. The paper is organized into five sections. Section Two positions Registration on the site is voluntary. A letter was sent to all doctors on the debates about the migration of skilled health professionals within a site, inviting them to participate in the survey. A total of 115 completed wider literature that discusses the international mobility of talent. questionnaires were returned, an overall response rate of 22%. Section Three reviews research on the global circulation of health pro- The mail-out survey was supplemented by open-ended face-to-face fessionals, focusing in particular upon debates relating to the experience interviews with a smaller sample of physicians practising in South Africa. of countries in the developing world. Section Four moves the focus from Contact details of Zimbabwean doctors in South Africa were obtained international to South African issues and provides new empirical mate- from the Health Professions Council of South Africa (HPCSA). A total rial drawn from the survey of recruitment patterns and key interviews of 21 in-depth interviews were conducted between July and October undertaken with health sector recruiters operating in South Africa. 2008. Six were in Johannesburg, two in Pretoria, six in Durban and seven Section Five addresses the questions of changing policy interventions in in Cape Town. Cost constraints meant that no Zimbabwean physicians South Africa towards the outflow of skilled health professionals and the in small town and rural hospitals were interviewed. Audio-recorded recruitment of foreign health professionals to work in South Africa. The information from the interviews was transcribed and a thematic content analysis was conducted using NVivo software.

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EXECUTIVE SUMMARY Profile of Survey Respondents The majority of the 115 survey respondents are based in South Africa ealth workers are one of the categories of skilled profession- (37% of the sample), followed by the UK (21%), USA (13%) and als most affected by globalization. Over the past decade, Australia (10%) (Table 2). Most are male (83%), a reflection of the gen- there has emerged a substantial body of research that tracks dered nature of the medical profession in Zimbabwe (Table 3). While patterns of international migration of health personnel, H the representation of women in the medical profession has increased assesses causes and consequences, and debates policy responses at global significantly over the past two decades, the number of emigrant female and national scales. Within this literature, the case of South Africa is Zimbabwean medical doctors is still low. More than 64% of the respond- attracting growing interest. For almost 15 years South Africa has been ents are under 50 although there is a marked racial difference. Over 90% the target of a ‘global raiding’ of skilled professionals by several devel- of the black doctors but only 43% of the white doctors are under 50. A oped countries. How to deal with the consequences of the resultant out- slight majority (53%) of the respondents are white, 43% are black and flow of health professionals is a core policy issue for the national gov- 4% are of Asian origin. ernment. This paper aims to to examine policy debates and issues concerning the migration of skilled health professionals from the country and to Table 2: Location of Survey Respondents furnish new insights on the recruitment patterns of skilled health per- % of Total sonnel. The objectives of the paper are twofold: South Africa 36.5 • To provide an audit of the organization and patterns of recruit- UK 20.9 ment of skilled professionals from South Africa in the health USA 13.0 sector. The paper draws upon a detailed analysis of recruitment Australia 10.4 advertising appearing in the South African Medical Journal for Canada 5.2 the period 2000-2004 and a series of interviews conducted with New Zealand 5.2 private recruiting enterprises. Other Europe 3.5 • Based upon the above analysis and additional interviews with Other Africa 3.5 key stakeholders in the South African health sector, the paper N = 115 offers a series of recommendations for addressing the problem of skilled health migration. These recommendations are grounded Table 3: Demographic Profile of Survey Respondents in both South African experience and an interrogation of inter- % of Total national debates and ‘good policy’ practice for regulating recruitment. (a) Gender of Respondent The paper is organized into five sections. Section Two positions Male 82.6 debates about the migration of skilled health professionals within a Female 17.4 wider literature that discusses the international mobility of talent. (b) Age Profile Section Three reviews research on the global circulation of health pro- 31 – 40 years 20.0 fessionals, focusing in particular upon debates relating to the experience 41 – 50 years 44.3 of countries in the developing world. Section Four moves the focus from 51 – 60 years 27.0 international to South African issues and provides new empirical mate- More than 60 years 8.7 rial drawn from the survey of recruitment patterns and key interviews (c) Race of Respondents undertaken with health sector recruiters operating in South Africa. Black/ African 42.6 Section Five addresses the questions of changing policy interventions in White/ European 53.0 South Africa towards the outflow of skilled health professionals and the Indian/ Asian 4.3 recruitment of foreign health professionals to work in South Africa. The N = 115

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EXECUTIVEAlmostSUMMARY three-quarters of the respondents had graduated from the country’s only medical school after 1980 (Table 4). While none of the black doctorsealth had workers graduated are beforeone of independence the categories in of 1980, skilled 60% profession- of those who had graduatedals most afteraffected 1980 by were globalization. black, a shift Over that the reflects past decade, the success of the governmentthere has in emergedmaking higher a substantial education body opportunities of research thatavailable tracks to Hthe majoritypatterns black population of international after independence. migration of health personnel, assesses causes and consequences, and debates policy responses at global Table 4: Employmentand national History scales. in Zimbabwe Within this literature, the case of South Africa is attracting growing interest. For almost 15 years South% of Total Africa has been (a) Year qualifiedthe target as medical of a doctor‘global raiding’ of skilled professionals by several devel- Before 1980oped countries. How to deal with the consequences27.8 of the resultant out- 1980-1990flow of health professionals is a core policy issue for49.6 the national gov- 1991-2000ernment. 19.1 After 2000 This paper aims to to examine policy debates and3.5 issues concerning (b) No. of yearsthe migrationworked in Zimbabwe of skilled before health migrating professionals from the country and to Less than 5furnish years new insights on the recruitment patterns of 68.7skilled health personnel. The objectives of the paper are twofold: 5 – 10 years 22.6 • To provide an audit of the organization and patterns of recruit- 10 – 15 years 5.2 ment of skilled professionals from South Africa in the health More than 15 years 3.5 sector. The paper draws upon a detailed analysis of recruitment (c) Year Migrated advertising appearing in the South African Medical Journal for Before 1980 the period 2000-2004 and a series of interviews16.5 conducted with 1981-1990 private recruiting enterprises. 29.6 1991-2000 • Based upon the above analysis and additional37.4 interviews with 2001-2008 key stakeholders in the South African health16.5 sector, the paper N = 115 offers a series of recommendations for addressing the problem of skilled health migration. These recommendations are grounded Overin two both thirds South of theAfrican respondents experience (69%) and had an workedinterrogation in Zimbabwe of inter- for less thannational 5 years debates before and migrating. ‘good policy’ This practicesuggests thatfor regulating many doctors recruit- leave as ment.soon as they have fulfilled their obligations to the government. NewThe graduates paper is are organized required into to complete five sections. a two Section year housemanship Two positions (or internship)debates about after the which migration they areof skilledentitled health to full professionals medical registration. within a They arewider then literature required that to servediscusses a year the of international community service, mobility frequently of talent. in a ruralSection health Three centre, reviews before research they areon eligiblethe global for circulationa certificate of of health good stand pro- - ing.fessionals, Many thenfocusing leave. in particular upon debates relating to the experience of countriesThe changing in the racial developing profile ofworld. the Zimbabwean Section Four medical moves theprofession focus from isinternational also reflected to in South the profile African of issuesrespondents. and provides About new 95% empirical of those whomate- leftrial beforedrawn independencefrom the survey were of recruitmentwhite (the rest patterns being andAsian). key interviewsThe domi- nanceundertaken of white with doctors health in sector the emigration recruiters streamoperating continues in South throughout Africa. theSection 1980s Five as theyaddresses make theup 88%questions of those of changing who left Zimbabwepolicy interventions during this in period.South 15Africa After towards 1990, however, the outflow black of medicalskilled health migration professionals starts to predomiand the- nate:recruitment 76% of ofthe foreign respondents health whoprofessionals left Zimbabwe to work after in South1990 are Africa. black. The

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EXECUTIVE SUMMARY Profile of Interview Respondents Of the 21 in-depth interviewees, 16 were male and 5 female. The age ealth workers are one of the categories of skilled profession- distribution of the respondents was fairly even: 24% were aged between als most affected by globalization. Over the past decade, 31 and 40 years, 38% were between 41 and 50, and 38% were over 50. there has emerged a substantial body of research that tracks Twelve of the physicians were black and 9 were white (43%). patterns of international migration of health personnel, H Eleven qualified as medical doctors in Zimbabwe between 1980 and assesses causes and consequences, and debates policy responses at global 1990, while 7 qualified after 1991. Only three had graduated before inde- and national scales. Within this literature, the case of South Africa is pendence in 1980. The work profile of the interview participants closely attracting growing interest. For almost 15 years South Africa has been mirrors that of the survey respondents. Seventeen worked in Zimbabwe the target of a ‘global raiding’ of skilled professionals by several devel- for less than five years before migrating. Three worked in Zimbabwe oped countries. How to deal with the consequences of the resultant out- for 5-10 years, while only one had worked in Zimbabwe for 10-15 years flow of health professionals is a core policy issue for the national gov- before migrating. Eight left Zimbabwe before 1990, and thirteen after ernment. 1990. This paper aims to to examine policy debates and issues concerning the migration of skilled health professionals from the country and to furnish new insights on the recruitment patterns of skilled health per- Migration Patterns and Channels sonnel. The objectives of the paper are twofold: • To provide an audit of the organization and patterns of recruit- Causes of Emigration ment of skilled professionals from South Africa in the health common feature of studies on the causes of skills migration is sector. The paper draws upon a detailed analysis of recruitment to ask respondents to identify up to three “causes” and then advertising appearing in the South African Medical Journal for to rank them. This study adopted a more nuanced approach. the period 2000-2004 and a series of interviews conducted with Each respondent was presented with set of possible reasons private recruiting enterprises. Afor leaving and then asked to rate the importance of each of them to • Based upon the above analysis and additional interviews with the decision-making process on a five point scale from ‘strongly agree’ to key stakeholders in the South African health sector, the paper ‘strongly disagree.’ The three factors with the highest levels of concur- offers a series of recommendations for addressing the problem of rence were the bad political environment (74% in agreement), lack of skilled health migration. These recommendations are grounded opportunities for career advancement (73% agreed) and poor economic in both South African experience and an interrogation of inter- conditions in Zimbabwe (71% agreed) (Table 5). Other factors cited by national debates and ‘good policy’ practice for regulating recruit- the majority of respondents were unsatisfactory working conditions, inad- ment. equate remuneration and benefits, the collapse of the health care system The paper is organized into five sections. Section Two positions and a better future for their children. debates about the migration of skilled health professionals within a wider literature that discusses the international mobility of talent. Deteriorating Political Conditions Section Three reviews research on the global circulation of health professionals, focusing in particular upon debates relating to the experience While deteriorating political factors were important to the greatest num- of countries in the developing world. Section Four moves the focus from ber of physicians, their relative importance varied with race and the year international to South African issues and provides new empirical mate- of migration. Overall, political conditions had a greater impact on white rial drawn from the survey of recruitment patterns and key interviews (84% in agreement) than black doctors (59% agreed). Interview data undertaken with health sector recruiters operating in South Africa. corroborated the findings of the survey. Some white doctors probably left Section Five addresses the questions of changing policy interventions in the country after independence because they did not want to live under South Africa towards the outflow of skilled health professionals and the black majority rule. However, sometimes the reasons were more complex. recruitment of foreign health professionals to work in South Africa. The

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ETableXECUTIVE 5: ReasonsS forUMMARY Leaving Zimbabwe Strongly/ Neither agree nor Disagree/ Strongly ealth workersSomewhat are one Agree of thedisagree categories of skilledDisagree professionals most affected %by globalization. Over% the past decade,% Deteriorating political conditionsthere inhas emerged73.9 a substantial body12.2 of research that13.9 tracks the country patterns of international migration of health personnel, Lack of opportunitiesH for career 73.0 12.2 14.8 assesses causes and consequences, and debates policy responses at global advancementand national scales. Within this literature, the case of South Africa is Deterioratingattracting economic conditionsgrowing interest. For71.3 almost 15 years13.9 South Africa has14.8 been in the countrythe target of a ‘global raiding’ of skilled professionals by several devel- Unsatisfactoryoped working countries. conditions How to deal 63.5with the consequences15.7 of the resultant20.9 out- Inadequateflow remuneration of health and professionals is61.7 a core policy issue14.8 for the national23.5 gov- benefits ernment. Collapse of healthcareThis paper system aims in to to examine52.2 policy debates23.5 and issues concerning24.3 Zimbabwe the migration of skilled health professionals from the country and to Better education and future for 52.2 19.1 28.7 children furnish new insights on the recruitment patterns of skilled health per- Social factorssonnel. (e.g. family The in objectives of the17.4 paper are twofold:27.0 55.7 destination) • To provide an audit of the organization and patterns of recruit- Other factors ment of skilled professionals13.9 from South Africa- in the health- N = 115 sector. The paper draws upon a detailed analysis of recruitment advertising appearing in the South African Medical Journal for One whitethe doctorperiod graduated2000-2004 from and medicala series ofschool interviews at the conductedheight of the with Zimbabweanprivate liberation recruiting war. enterprises. White males were being conscripted into the army• irrespective Based upon of thetheir above professional analysis background. and additional Like interviews some of his with peers, he left Zimbabwekey stakeholders to avoid in conscription. the South African16 health sector, the paper Anotheroffers graduated a series of from recommendations medical school for just addressing before independence. the problem17 of He was skilledworking health at a provincial migration. hospital These recommendationsat the time of the Gukurahundiare grounded campaignin (aboth campaign South Africanlaunched experience by the Mugabe and an government interrogation against of inter- ZAPU militants)national debatesin the 1980s. and ‘good As a policy’medical practice doctor forhe attendedregulating to recruit- people whoment. had been victimised by the government’s notorious North Korean-trainedThe paper is Fifth organized Brigade. into Throughout five sections. the Section campaign, Two he positions would hear horrordebates stories about from the migrationthe survivors. of skilled What health made theprofessionals situation worsewithin for a him waswider the literature fact that that the discussesFifth Brigade the internationalwas dispatched mobility to ‘protect’ of talent. civilians atSection the hospital Three wherereviews he research was based. on theEven global though circulation he did not of sufferhealth any pro- abusefessionals, at the focusing hands ofin theparticular Fifth Brigade upon debates himself, relating meeting to them the experienceon a daily basisof countries made him in thefeel developinguncomfortable world. and Section insecure. Four He moves began theto fear focus for from his safetyinternational because tothe South soldiers African were issuesruthless and in providestheir treatment new empirical of suspected mate- insurgentsrial drawn andfrom their the surveysupporters. of recruitment Being white, patterns he reasoned and key that interviews there was aundertaken chance of beingwith healthpersecuted sector for recruiters the acts operatingwhich had in been South committed Africa. dur- ingSection the war Five by addresses the white the regime. questions The ofsense changing of insecurity policy createdinterventions by the in presenceSouth Africa of the towards army at the the outflow hospital of was skilled the healthmain reason professionals for his eventualand the departurerecruitment from of foreignZimbabwe. health professionals to work in South Africa. The

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EXECUTIVE SUMMARY While fewer medical doctors who left Zimbabwe in the 1990s identified the political situation as a major contributing factor in their decision ealth workers are one of the categories of skilled profession- to leave Zimbabwe, the numbers increase again after 2000. These physi- als most affected by globalization. Over the past decade, cians are referring to the political violence which began in the build up there has emerged a substantial body of research that tracks to the 2000 general elections and continued thereafter. Though none of patterns of international migration of health personnel, the doctors who left after 2000 had personally been targets of political H violence, they knew of colleagues who were, not for their own political assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is involvement, but for treating the victims of political violence. In other attracting growing interest. For almost 15 years South Africa has been words, doctors suffered simply for discharging their professional duties. the target of a ‘global raiding’ of skilled professionals by several developed countries. How to deal with the consequences of the resultant out- Lack of Opportunities for Career Advancement flow of health professionals is a core policy issue for the national government. The lack of opportunity for career advancement has often been cited This paper aims to to examine policy debates and issues concerning as a major cause for the migration of newly qualified professionals from 18 the migration of skilled health professionals from the country and to developing countries. The survey showed that this has been a major furnish new insights on the recruitment patterns of skilled health per- factor in the emigration of medical doctors from Zimbabwe (with 73% in sonnel. The objectives of the paper are twofold: agreement). However, it becomes increasingly important over time. Some • To provide an audit of the organization and patterns of recruit- 53% of the doctors who graduated before 1980 left the country to pursue ment of skilled professionals from South Africa in the health further studies abroad. In contrast, 79% who graduated in the 1990s left sector. The paper draws upon a detailed analysis of recruitment because of a lack of opportunity for career advancement. One of the rea- advertising appearing in the South African Medical Journal for sons is that the opportunities for specialisation within Zimbabwe declined the period 2000-2004 and a series of interviews conducted with over time. Enrolment in the medical school in Zimbabwe has grown more private recruiting enterprises. than fourfold since the late 1980s. At the same time, the capacity of the • Based upon the above analysis and additional interviews with medical school to train medical specialists has declined. In 2002, the key stakeholders in the South African health sector, the paper medical school graduated 83 new doctors and had 30 students in special- offers a series of recommendations for addressing the problem of ised programs. By 2006, the number of graduates had increased to 156 skilled health migration. These recommendations are grounded but only 25 students were in specialised programs in a much narrower in both South African experience and an interrogation of inter- range of specialisations (Table 6). national debates and ‘good policy’ practice for regulating recruit- A number of specialisations have not even been offered at the medi- ment. cal school over the past ten years as a direct result of the shortage of suit- The paper is organized into five sections. Section Two positions ably qualified lecturers. Doctors have had to make hard choices between debates about the migration of skilled health professionals within a serving as general practitioners in Zimbabwe or moving to other coun- wider literature that discusses the international mobility of talent. tries where the prospects for specialising are better. Dr Walter Choga, for Section Three reviews research on the global circulation of health pro- example, graduated from medical school in the early 1990s and wanted fessionals, focusing in particular upon debates relating to the experience to specialise in Obstetrics and Gynaecology. Although the specialty was of countries in the developing world. Section Four moves the focus from offered at the medical school, it was almost impossible to get into: international to South African issues and provides new empirical mate- The reason that made me leave personally was the prospects rial drawn from the survey of recruitment patterns and key interviews for advancement were actually getting to zero. At that time undertaken with health sector recruiters operating in South Africa. there was a move that doctors should go and serve in the Section Five addresses the questions of changing policy interventions in rural areas and we were seeing that people who were going South Africa towards the outflow of skilled health professionals and the to work in the rural areas were not coming back to town to recruitment of foreign health professionals to work in South Africa. The specialise. So the prospects for specialising were becoming less and less. 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ETableXECUTIVE 6: Trends Sin UMMARYSpecialisation at Medical School in Zimbabwe 2000 2004 2006 Masters of Science Degreeealth in Clinical workers Biochemistry are one of the categories- of skilled7 profession-- Masters of Science Degreeals in most Medical affected Microbiology by globalization.2 Over the5 past decade,7 Masters Degree in Medicinethere (Anaesthetics) has emerged a substantial10 body of research5 that tracks1 patterns of international migration of health personnel, Masters DegreeH in Medicine (Histopathology) - 1 1 Masters Degreeassesses in Medicine causes (Medicine)and consequences, and debates4 policy responses4 at 3global and national scales. Within this literature, the case of South Africa is Masters Degree in Medicine (Obstetrics & Gynaecology) - 3 3 attracting growing interest. For almost 15 years South Africa has been Masters Degree in Medicine (Paediatrics) 2 3 - the target of a ‘global raiding’ of skilled professionals by several devel- Masters Degree in Medicine (Psychiatry) 2 1 - oped countries. How to deal with the consequences of the resultant out- Masters Degree in Medicine (Radiotherapy & Oncology) - 2 - flow of health professionals is a core policy issue for the national gov- Masters Degreeernment. in Medicine (Surgery) - 3 1 Masters DegreeThis in Medicine paper (Urology)aims to to examine policy debates- and issues2 concerning- Masters in thePublic migration Health of skilled health professionals10 from the country7 and8 to Doctor of Philosophyfurnish new Degree insights on the recruitment patterns- of skilled1 health 1per- Master of Sciencesonnel. Degree The objectivesin Clinical Epidemiology of the paper are twofold:- - - Master of Science• Degree To provide in Clinical an Pharmacology audit of the organization- and patterns- of recruit-- Masters Degree in Medicinement of (Neurosurgery) skilled professionals from South- Africa- in the health- Masters Degree in Medicinesector. (Ophthalmology)The paper draws upon a detailed- analysis- of recruitment- Total (all specialisations)advertising appearing in the South30 African Medical44 Journal25 for No. of new medical graduatesthe period 2000-2004 and a series 83of interviews107 conducted156 with Source: UZ Graduationprivate Yearbooks, recruiting 2000; 2004; enterprises. 2006 • Based upon the above analysis and additional interviews with Southkey Africa, stakeholders in particular, in the became South Africana popular health destination sector, becausethe paper of the easeoffers of registering a series ofin recommendationsspecialised training for programmes. addressing theNearly problem 90% of the Zimbabweanskilled health doctors migration. surveyed These in South recommendations Africa were attracted are grounded by the prospectin of both career South advancement African experience there. HPCSA and an data interrogation for 2008 shows of inter- that more thannational two thirds debates of Zimbabwean and ‘good policy’ doctors practice in South for Africaregulating are specialrecruit-- ists. Of thement. 230 physicians in the database, 62% are specialists, 6% are sub-specialistsThe paper isand organized 3% are undertakinginto five sections. postgraduate Section study. Two positionsThe remain- ingdebates 30% aboutare general the migration practitioners. of skilled health professionals within a widerNot literature all of those that who discusses wanted the to internationalspecialise in South mobility Africa of talent. have been ableSection to do Three so. After reviews 1994, research immigrant on the doctors global from circulation countries of suchhealth as pro- Zimbabwefessionals, foundfocusing themselves in particular being upon excluded debates from relating training to theprogrammes experience inof favourcountries of blackin the South developing Africans. world. Dr TimSection Makombe, Four moves for instance, the focus left from Zimbabweinternational in theto Southearly 1990s African soon issues after and earning provides his medicalnew empirical degree. mate-20 Herial wrotedrawn the from first the part survey of the of specialistrecruitment exams patterns soon afterand key arriving interviews in Southundertaken Africa. with After health passing sector the recruitersexams, he operating got a post in to South specialise Africa. at the UniversitySection Five of Capeaddresses Town the (UCT). questions The of offer changing was withdrawn policy interventions in 1994 and in forSouth the Africanext two towards years thehe could outflow not of get skilled admission health to professionals the specialist and train the- ingrecruitment programme. of foreign Eventually, health he professionals left South Africa to work for thein South UK where Africa. he The managed to pursue his chosen specialisation.

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EXECUTIVE SUMMARY Deteriorating Economic Conditions Declining economic conditions have been cited as a leading cause of ealth workers are one of the categories of skilled profession- migration from Zimbabwe over the last two decades.21 The problems als most affected by globalization. Over the past decade, began with the introduction of the IMF/World Bank led Economic there has emerged a substantial body of research that tracks Structural Adjustment Programme (ESAP) in 1991. They worsened patterns of international migration of health personnel, H considerably with economic mismanagement, the chaotic land reform assesses causes and consequences, and debates policy responses at global programme and the violence that marred the 2000, and subsequent, and national scales. Within this literature, the case of South Africa is elections. The destruction of the productive agricultural sector reduced attracting growing interest. For almost 15 years South Africa has been Zimbabwe from being a food exporter into a food importer and affected the target of a ‘global raiding’ of skilled professionals by several devel- downstream industries dependent on agriculture. The economy went into oped countries. How to deal with the consequences of the resultant out- freefall and inflation soared. Inflation officially peaked at 231 million per- flow of health professionals is a core policy issue for the national gov- cent in 2008, although independent estimates suggest that the inflation ernment. levels at that time were as high as 89.7 sextillion (1021) percent.22 This paper aims to to examine policy debates and issues concerning As might be expected, the relative importance of economic condi- the migration of skilled health professionals from the country and to tions as a primary reason for leaving varies over time. While 71% of the furnish new insights on the recruitment patterns of skilled health per- respondents agreed that this was a major factor in prompting them to sonnel. The objectives of the paper are twofold: leave, the figure rises to 95% of those who left after 2000. As Dr Mary • To provide an audit of the organization and patterns of recruit- Chikomo, who left Zimbabwe in 2003, noted: ment of skilled professionals from South Africa in the health sector. The paper draws upon a detailed analysis of recruitment By the end of 2002 things were really tough. It was tough advertising appearing in the South African Medical Journal for in the sense that the salary was not enough to buy what the period 2000-2004 and a series of interviews conducted with we needed. It was worsened by the fact that we could not private recruiting enterprises. get most of the basic commodities in the shops and to get • Based upon the above analysis and additional interviews with them you had to spend a lot of time queuing up. So we had key stakeholders in the South African health sector, the paper to queue up to get things like maize meal. That was a great offers a series of recommendations for addressing the problem of inconvenience to me.23 skilled health migration. These recommendations are grounded Economic conditions continue to influence the departure of both in both South African experience and an interrogation of inter- skilled and unskilled people to this day. The 2009 power-sharing agree- national debates and ‘good policy’ practice for regulating recruitment between the ruling ZANU PF and the opposition MDC has gone ment. a long way towards restoring economic stability. However, while the rate The paper is organized into five sections. Section Two positions of inflation has dropped to single digit levels and the supply of goods on debates about the migration of skilled health professionals within a the formal market has improved, the salaries of most workers (includ- wider literature that discusses the international mobility of talent. ing medical doctors) remain low. It will be a long time, however, before Section Three reviews research on the global circulation of health pro- Zimbabwe’s economy fully recovers from many years of mismanagement. fessionals, focusing in particular upon debates relating to the experience of countries in the developing world. Section Four moves the focus from international to South African issues and provides new empirical mate- Unsatisfactory Working Conditions rial drawn from the survey of recruitment patterns and key interviews A 2004 survey on health professionals in Zimbabwe showed that the lack undertaken with health sector recruiters operating in South Africa. of resources within the country’s health care system was one of the fac- Section Five addresses the questions of changing policy interventions in tors pushing professionals out of Zimbabwe.24 The factors identified in South Africa towards the outflow of skilled health professionals and the the survey include the shortage of medications, protective clothing, medi- recruitment of foreign health professionals to work in South Africa. The cal equipment and qualified medical professionals. This survey sought to investigate whether physicians outside the country attributed their emigration to these resource-related factors. Lack of medical equipment was 1 14 kkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkk MMIGRATIONigration PPOLICYolicy SERIESeries NOo. 4555

EXECUTIVEthe mostSUMMARY commonly cited deficiency in the health institutions where the physicians worked (50% said that equipment was seldom or never available). Aroundealth 45% workers noted arethat one protective of the categories clothing wasof skilled seldom profession- or never available andals 33% most said affected that medicines by globalization. were seldom Over orthe never past decade,available. Thirty eightthere percent has said emerged that theira substantial institutions body lacked of research a sufficient that tracksnum- ber of qualifiedpatterns medical of international professionals. migration of health personnel, HPerceptions of the availability of medical equipment not surprisingly assesses causes and consequences, and debates policy responses at global variedand national with when scales. the Within physicians this hadliterature, left the the country case of (Table South 7). Africa The is problemattracting of growing the supply interest. of equipment For almost in Zimbabwe’s 15 years South hospitals Africa has has always been beenthe target there. of What a ‘global is unique raiding’ in ofthe skilled current professionals situation is bythe several magnitude devel- of theoped problem. countries. Nearly How 60% to deal of those with whothe consequencesleft in the 1980s of thefelt resultantthat medi out-- calflow equipment of health wasprofessionals always or ismostly a core available policy issue at their for the health national institutions. gov- Thisernment. number fell to 55% of those who left in the 1990s and only 16% of thoseThis whopaper left aims after to 2000.to examine The latter policy spoke debates of their and frustrationissues concerning at the unavailabilitythe migration andof skilled unreliability health ofprofessionals medical equipment. from the Theycountry blamed and tothe situationfurnish new on theinsights deterioration on the recruitment of the economy patterns and of the skilled general health decline per- in thesonnel. country’s The objectives health delivery of the system. paper are twofold: • To provide an audit of the organization and patterns of recruit- Table 7: Resource Availabilityment of skilled at Health professionals Institutions from South Africa in the health sector. The paper draws Yearupon of aDeparture detailed from analysis Zimbabwe of recruitment advertising appearing1980s in the South 1990sAfrican Medical PostJournal 2000 for the period 2000-2004% Always/Mostly and a series% Always/Mostly of interviews %conducted Always/Mostly with private recruitingAvailable enterprises. Available Available Medical equipment• Based upon the above60.6 analysis and additional54.8 interviews15.8 with Protective clothing key stakeholders in51.5 the South African59.5 health sector, the36.8 paper Qualified medical professionalsoffers a series of recommendations72.7 for58.1 addressing the problem26.3 of Availability of medicationsskilled health migration.63.6 These recommendations64.3 are grounded21.1 N = 115 in both South African experience and an interrogation of international debates and ‘good policy’ practice for regulating recruit- The ment.survey also showed that the availability of medications in ZimbabweThe paper deteriorated is organized over into the five years. sections. Over 64% Section of those Two whopositions migrated indebates the 1990s about said the that migration medication of skilled was alwayshealth orprofessionals mostly available, within a areflec- tionwider of literature the new government’sthat discusses drivethe international to make health mobility care accessible of talent. to the previously-disadvantagedSection Three reviews research majority on black the global population. circulation Medical of healthdoctors pro- leavingfessionals, Zimbabwe focusing after in particular 2000 were upon overwhelmingly debates relating dissatisfied to the experiencewith the availabilityof countries of in medication the developing in the world. country’s Section health Four institutions moves the (with focus an from approvalinternational rating to of South only 21%).African They issues described and provides their frustrationnew empirical at the mate- reg- ularrial drawnshortages from of themedications survey of andrecruitment cited this patterns as one ofand the key factors interviews which createdundertaken a stressful with health working sector environment recruiters and operating induced in them South to Africa. leave. SectionThe humanFive addresses resource the base questions of Zimbabwe’s of changing health policy sector interventions has been in decimatedSouth Africa by internationaltowards the outflow migration. of skilled The shortage health professionalsof medical doctors and the inrecruitment Zimbabwe of is foreignboth a causehealth and professionals effect of migration to work insince South migration Africa. The results in a shortage of medical doctors which means heavier workloads

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EXECUTIVE SUMMARY for those who remain, making it more likely that they will leave as well. More than 70% of the respondents who left Zimbabwe in the 1980s said ealth workers are one of the categories of skilled profession- that there were enough qualified health professionals where they worked, als most affected by globalization. Over the past decade, a number that drops to only 26% for those who left after 2000. The situ- there has emerged a substantial body of research that tracks ation became so dire after 2000 that government health service delivery patterns of international migration of health personnel, to rural and previously remote locations came to a standstill and were H often deprived of qualified medical personnel altogether. assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is Zimbabwe’s health care system has been severely burdened by the attracting growing interest. For almost 15 years South Africa has been HIV and AIDS pandemic. An estimated 15.3% of the sexually active the target of a ‘global raiding’ of skilled professionals by several devel- population is affected by the virus, a decline from the peak prevalence oped countries. How to deal with the consequences of the resultant out- rate of 28.9% recorded in 1997 (Figure 2).25 The Joint Learning Initiative flow of health professionals is a core policy issue for the national gov- (JLI) has identified three general impacts of HIV and AIDS on the ernment. health workforce of a country like Zimbabwe.26 First, the health sector This paper aims to to examine policy debates and issues concerning has lost some of its own workers to the disease. Health professionals who the migration of skilled health professionals from the country and to die are not being replaced. Secondly, health professionals are faced with furnish new insights on the recruitment patterns of skilled health per- extra workloads, as People Living with HIV (PLHIV) comprise a majority sonnel. The objectives of the paper are twofold: of their patients. Third, fear of exposure may be a source of attrition in • To provide an audit of the organization and patterns of recruit- the health sector especially when precautionary measures are not strictly ment of skilled professionals from South Africa in the health adhered to and there is a shortage of protective clothing. A previous sector. The paper draws upon a detailed analysis of recruitment study showed that as many as 64% of health professionals in Zimbabwe advertising appearing in the South African Medical Journal for were constantly worried that they would get infected through injury at the period 2000-2004 and a series of interviews conducted with work.27 This was largely blamed on the shortage of protective clothing private recruiting enterprises. such as gloves. • Based upon the above analysis and additional interviews with Again, worries about the supply of protective clothing in Zimbabwe key stakeholders in the South African health sector, the paper increased over time. Around half of the respondents who left Zimbabwe offers a series of recommendations for addressing the problem of in the 1980s said they were satisfied with the supply of protective cloth- skilled health migration. These recommendations are grounded ing at the health institutions where they once worked. The level of sat- in both South African experience and an interrogation of inter- isfaction actually rose to nearly 60% among those who left in the 1990s, national debates and ‘good policy’ practice for regulating recruit- which is a clear indication of the efforts at that time to prevent health ment. workers from contracting diseases at the workplace. Only 38.6% of those The paper is organized into five sections. Section Two positions who left Zimbabwe after 2000 were satisfied with the supply of preventive debates about the migration of skilled health professionals within a clothing. wider literature that discusses the international mobility of talent. The survey revealed that the direct impact of HIV and AIDS on Section Three reviews research on the global circulation of health pro- emigration was relatively slight compared to other factors. Only 8% of fessionals, focusing in particular upon debates relating to the experience the respondents reported that HIV and AIDS influenced their decision of countries in the developing world. Section Four moves the focus from to migrate. However, the figure was 36% amongst those who left after international to South African issues and provides new empirical mate- 2000. Three factors were cited by the respondents. First, HIV and AIDS rial drawn from the survey of recruitment patterns and key interviews drastically increased their workload, increasing the number of hospital undertaken with health sector recruiters operating in South Africa. admissions and raising the patient to doctor ratio. The heavy workload Section Five addresses the questions of changing policy interventions in becomes both a cause of ongoing migration (by increasing the load of South Africa towards the outflow of skilled health professionals and the remaining health professionals) as well as an effect (by reduction of avail- recruitment of foreign health professionals to work in South Africa. The able health professionals). Secondly, the doctors pointed to the stress of working in an environment with so many dying patients. Finally, some feared that they might contract the disease. 1 16 kkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkk MMIGRATIONigration PPOLICYolicy SERIESeries NOo. 4555

FigureEXECUTIVE 2: Adult (15-49)SUMMARY Prevalence of HIV and AIDS in Zimbabwe 35.0 ealth workers are one of the categories of skilled profession- 30.0 als most affected by globalization. Over the past decade, there has emerged a substantial body of research that tracks 25.0 Hpatterns of international migration of health personnel, assesses causes and consequences, and debates policy responses at global 20.0 and national scales. Within this literature, the case of South Africa is

15.0 attracting growing interest. For almost 15 years South Africa has been Percentages the target of a ‘global raiding’ of skilled professionals by several devel- 10.0 oped countries. How to deal with the consequences of the resultant outflow of health professionals is a core policy issue for the national gov- 5.0 ernment. This paper aims to to examine policy debates and issues concerning 0 the migration of skilled health professionals from the country and to 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 furnish new insights on the recruitment patterns of skilled health personnel. The objectives of the paperYears are twofold: Source: UNAIDS• To provide an audit of the organization and patterns of recruitment of skilled professionals from South Africa in the health sector. The paper draws upon a detailed analysis of recruitment Inadequate Remuneraadvertisingtion appearing and Benefi in thets South African Medical Journal for the period 2000-2004 and a series of interviews conducted with Poor remunerationprivate recruiting was cited enterprises. as a strong influencing factor by 62% of the medical• Baseddoctors upon in the the survey, above althoughanalysis and its importance additional interviewsvaried over with time and by race.key stakeholders Remuneration in andthe Southpoor benefits African were health cited sector, as a causethe paper of migrationoffers by 21% a series of those of recommendations who left before 1980,for addressing 44% of those the problem who left of in the 1980s,skilled 81% health of those migration. who left Thesein the 1990srecommendations and nearly 90% are groundedof those who leftin after both 2000. South As African many as experience 90% of the and black an medicalinterrogation doctors, of inter-most of whomnational left the debatescountry andafter ‘good 1991, policy’ agreed practice that poor for salaries regulating were recruit- a major factorment. in the decision to migrate. Dr John Mandaza graduated from medicalThe paperschool is in organized the late 1980sinto five and sections. worked inSection a government Two positions hospital in Bulawayo:debates about the migration of skilled health professionals within a wider Theliterature only thingthat discusses that would the bother international me was mobilitythe money. of talent.The Sectionfinances Three werereviews usually research a problem. on the Forglobal example, circulation for a longof health professionals,time focusingI didn’t havein particular a car and upon when debates I eventually relating managed to the experience to of countriesget one, in Ithe had developing to push it allworld. the timeSection because Four itmoves did not the have focus from internationala starter. to ‘Hill South start’, African as we issues call it and in Zimbabwe. provides new The empirical real material drawnproblem from was the the survey finances, of recruitment the remuneration. patterns andIt was key not interviews good undertakenand we with struggled health a sector lot.28 recruiters operating in South Africa. Section Five addresses the questions of changing policy interventions in InadequateSouth Africa remuneration towards the wasoutflow cited of by skilled only 41%health of theprofessionals white doctors, and the mostrecruitment of whom of leftforeign Zimbabwe health before professionals 1991. to work in South Africa. The The issue of remuneration has long been highly topical amongst medical doctors in Zimbabwe. The first ever strike by medical doctors over 171 kkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkk MIGRATION POLICY SERIES NO. 45 The Engagement of the Zimbabwean Medical Diaspora

EXECUTIVE SUMMARY salaries was as early as 1988.29 The government dealt with the striking workers in a heavy-handed manner and sent the leaders to prison. The ealth workers are one of the categories of skilled profession- doctors were left with a deep sense of injustice as they thought they had als most affected by globalization. Over the past decade, genuine grievances to which the government was turning a blind eye. there has emerged a substantial body of research that tracks Doctor strikes have become frequent since then, with doctors going on patterns of international migration of health personnel, strike at least once a year. Most health professionals spent more than two H thirds of the year on strike in 2008. The strikes of the early 1990s coin- assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is cided with the fall of apartheid in South Africa. The apartheid govern- attracting growing interest. For almost 15 years South Africa has been ment of South Africa had previously restricted the entry of black doctors the target of a ‘global raiding’ of skilled professionals by several devel- into the country. In the early 1990s, the apartheid government relaxed oped countries. How to deal with the consequences of the resultant out- these conditions to allow black doctors to find employment in the rural flow of health professionals is a core policy issue for the national gov- areas shunned by local doctors. The failure of the Zimbabwean govern- ernment. ment to resolve the issue of remuneration led many black doctors to This paper aims to to examine policy debates and issues concerning leave Zimbabwe for South Africa between 1990 and 1994. the migration of skilled health professionals from the country and to furnish new insights on the recruitment patterns of skilled health per- Collapse of Public Healthcare sonnel. The objectives of the paper are twofold: • To provide an audit of the organization and patterns of recruit- After independence, the new Mugabe-led government made concerted ment of skilled professionals from South Africa in the health efforts to ensure that health care institutions were established even in the sector. The paper draws upon a detailed analysis of recruitment most disadvantaged areas. The economic collapse after 2000 eroded most advertising appearing in the South African Medical Journal for of these earlier gains. As many as 52% of those surveyed reported that the period 2000-2004 and a series of interviews conducted with the collapse of the health care system was a major factor in their decision private recruiting enterprises. to leave Zimbabwe. Not surprisingly, 95% of the physicians who departed • Based upon the above analysis and additional interviews with after 2000 gave this as a reason for leaving. key stakeholders in the South African health sector, the paper The collapse of the healthcare system is evidenced by the shortage of offers a series of recommendations for addressing the problem of drugs, medical equipment and qualified medical personnel. This has been skilled health migration. These recommendations are grounded exacerbated by the growing HIV and AIDS crisis that has increased the in both South African experience and an interrogation of inter- demand for healthcare services. In 2008, drugs and medicines were scarce national debates and ‘good policy’ practice for regulating recruit- and a number of hospitals stopped functioning. Even the country’s large ment. central hospitals sent patients home, leaving only the emergency sections The paper is organized into five sections. Section Two positions open. Some of the problems in the health care system were attributed by debates about the migration of skilled health professionals within a the doctors to poor managers without a medical background: wider literature that discusses the international mobility of talent. There was a lot of interference from non-medical people Section Three reviews research on the global circulation of health pro- who would just come and give you instructions on how to fessionals, focusing in particular upon debates relating to the experience treat people. Sometimes, you would find someone being of countries in the developing world. Section Four moves the focus from admitted just for social reasons in place of the deserving sick international to South African issues and provides new empirical mate- patients because there is no one to speak for them. So we rial drawn from the survey of recruitment patterns and key interviews had very little clinical and medical independence. So for me undertaken with health sector recruiters operating in South Africa. that was my biggest trigger to leave the country.30 Section Five addresses the questions of changing policy interventions in South Africa towards the outflow of skilled health professionals and the recruitment of foreign health professionals to work in South Africa. The

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SEtXECUTIVEep MigrationSUMMARY The conventional wisdom on the brain drain is that skilled professionals ealth workers are one of the categories of skilled profession- move directly from a country of origin to a country of destination. The als most affected by globalization. Over the past decade, impacts of this movement for both countries are then assessed. However, there has emerged a substantial body of research that tracks this overly simplistic, unilinear picture fails to capture the complexity of patterns of international migration of health personnel, Hthe migration patterns of Zimbabwean physicians (Figure 3). Only 48 of assesses causes and consequences, and debates policy responses at global the 115 doctors in the survey (42%) had moved directly from Zimbabwe and national scales. Within this literature, the case of South Africa is to their current country of residence. Seventy one percent of the attracting growing interest. For almost 15 years South Africa has been Zimbabwean doctors in South Africa came directly from Zimbabwe. The the target of a ‘global raiding’ of skilled professionals by several devel- rest had first been to a variety of other destinations including the United oped countries. How to deal with the consequences of the resultant out- Kingdom, Australia, Asia and elsewhere in Africa. This suggests that flow of health professionals is a core policy issue for the national gov- there has been “return migration” from overseas, but benefitting South ernment. Africa not Zimbabwe. This paper aims to to examine policy debates and issues concerning the migration of skilled health professionals from the country and to Figure 3: Migration History of Zimbabwean Physicians furnish new insights on the recruitment patterns of skilled health personnel. The objectives of the paper are twofold: South Africa UK USA Australia Canada New Other Other Other • To provide an audit of the organizationZealand Europe and patternsAsia of recruit-Africa ment of skilled professionals from South Africa in the health 42 24 15 12 6 6 4 2 4 sector. The paper draws upon a detailed analysis of recruitment

30 11 2 0 0 6 2 0 3 Destination advertising appearing in the South African Medical Journal for 12 13 13 12 6 6 2 2 1 the period 2000-2004 and a series of interviews conducted with private recruiting enterprises. Other Other SA SA UK SA SA SA UK UK UK UK Asia Europe (11)• Based(6) (5)upon the(7) above(5) analysis(3) and(1) additional(1) interviews(1) (1)with (1) (1) key stakeholders in the South African health sector, the paper

Other UK USA offersOther Asia a seriesUK of recommendationsUK USA for addressingUSA Other Africathe problem of Africa (1) (1) (1) (4) (1) (1) (1) (1) (1) skilled health migration. These recommendations are grounded

in both South African experience and an interrogation of inter-Intermediate country Australia Other Asia Other Africa Other Afria Australia (1) (1) national(1) debates(4) and ‘good policy’(1) practice for regulating recruitment.

The paper is organized intoZimbabwe five sections. Section Two positions debates about the migration of skilled health professionals within a Source wider literature that discusses the international mobilityDirect movesof talent. Section Three reviews research on the global circulationIndirect moveof health to pro- current destination fessionals, focusing in particular upon debates relating to the experience of countriesSome 34 doctorsin the developing (30% of the world. respondents) Section Fourhad moved moves firstthe focusfrom from Zimbabweinternational to Southto South Africa African and thenissues joined and provides the “brain new drain” empirical from Southmate- Africarial drawn and frommigrated the surveyonwards of torecruitment a variety of patterns overseas and destinations. key interviews Less thanundertaken half of thewith doctors health whosector had recruiters migrated operating to the UK in didSouth so directly Africa. from Zimbabwe.Section Five Only addresses 2 out ofthe 39 questions Zimbabwean of changing doctors policyin the USA,interventions Australia, in CanadaSouth Africa and New towards Zealand the outflowcame direct of skilled from Zimbabwe.health professionals South Africa and andthe therecruitment UK are clearly of foreign the mainhealth transit professionals countries to for work medical in South doctors Africa. from The Zimbabwe (Figure 4). In some cases, these two intermediary destinations

191 kkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkk MIGRATION POLICY SERIES NO. 45 The Engagement of the Zimbabwean Medical Diaspora

EXECUTIVE SUMMARY likely act as “stepping stones” to get to the ultimate destination. The intermediate point allows them to specialise in their chosen field which ealth workers are one of the categories of skilled profession- then increases their chances of gaining entry to their ultimate destina- als most affected by globalization. Over the past decade, tion. Furthermore, it enables them to develop networks with similar there has emerged a substantial body of research that tracks professionals located elsewhere who can assist them in making an onward patterns of international migration of health personnel, move. Eventually, a migration chain develops linking the emigrant H Zimbabwean medical doctors in an intermediate country to their coun- assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is terparts located in a more attractive destination. attracting growing interest. For almost 15 years South Africa has been the target of a ‘global raiding’ of skilled professionals by several devel- Figure 4: Intermediate Destinations of Zimbabwean Physicians oped countries. How to deal with the consequences of the resultant out- 6 flow of health professionals is a core policy issue for the national gov- USA ernment. This paper aims to to examine policy debates and issues concerning Southern 4 11 the migration of skilled health professionals from the country and to Africa UK furnish new insights on the recruitment patterns of skilled health per- 1 7 sonnel. The objectives of the paper are twofold: Australia Australia • To provide an audit of the organization and patterns of recruitment of skilled professionals from South Africa in the health 15 32 New 1 6 UK Zimbabwe South Africa USA sector. The paper draws upon a detailed analysis of recruitment Zealand advertising appearing in the South African Medical Journal for the period 2000-2004 and a series of interviews conducted with 1 5 private recruiting enterprises. Canada Canada • Based upon the above analysis and additional interviews with 3 New key stakeholders in the South African health sector, the paper Other 1 Zealand offers a series of recommendations for addressing the problem of Africa skilled health migration. These recommendations are grounded in both South African experience and an interrogation of inter- Other 1 national debates and ‘good policy’ practice for regulating recruit- Europe ment. The in-depth interviews showed that Zimbabwean doctors usually The paper is organized into five sections. Section Two positions took preparatory steps before leaving in order to position themselves with debates about the migration of skilled health professionals within a respect to various migration channels and destinations. For instance, in wider literature that discusses the international mobility of talent. the 1980s some doctors would write both the Zimbabwean and British Section Three reviews research on the global circulation of health pro- exams, a strategy which enabled them to then move directly to the UK fessionals, focusing in particular upon debates relating to the experience to pursue their chosen field of specialisation. This practice declined in of countries in the developing world. Section Four moves the focus from the mid-1980s when the Medical Royal Colleges in the UK stopped rec- international to South African issues and provides new empirical mate- ognising the internship period served by the doctors in Zimbabwe. From rial drawn from the survey of recruitment patterns and key interviews the mid-1980s onwards, some doctors would write examinations which undertaken with health sector recruiters operating in South Africa. entitled them to registration with the Health Professionals Council of Section Five addresses the questions of changing policy interventions in South Africa before moving to that country. While this is still possible, South Africa towards the outflow of skilled health professionals and the the movement of Zimbabwean doctors to South Africa has slowed over recruitment of foreign health professionals to work in South Africa. The the past decade because of South Africa’s policy not to employ health professionals from other developing countries affected by the medical brain drain.31 1 20 kkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkk MMIGRATIONigration PPOLICYolicy SERIESeries NOo. 4555

REecruiXECUTIVEters andSUMMARY Networks A strong and vigorous critique has been mounted by African govern- ealth workers are one of the categories of skilled profession- ments and migration researchers of medical recruiting in Africa by gov- als most affected by globalization. Over the past decade, ernments and private companies in the North.32 However, only 8% of the there has emerged a substantial body of research that tracks physicians in this survey noted that recruitment agencies had been an patterns of international migration of health personnel, Himportant or very important source of information about job opportuni- assesses causes and consequences, and debates policy responses at global ties outside the country (Table 8). There is some evidence that recruit- and national scales. Within this literature, the case of South Africa is ment agencies have become more important over time. For example, they attracting growing interest. For almost 15 years South Africa has been were used by only 6% of the physicians who left Zimbabwe between 1981 the target of a ‘global raiding’ of skilled professionals by several devel- and 1990 but 16% of those who left Zimbabwe after 2000. oped countries. How to deal with the consequences of the resultant out- The migration literature shows how particular migration streams flow of health professionals is a core policy issue for the national gov- develop from migrant social networks.33 Medical students are known to ernment. develop a strong sense of ‘community’ because of the length of time they This paper aims to to examine policy debates and issues concerning spend together at medical school. The friendships formed and the sense the migration of skilled health professionals from the country and to of community that develops can evolve into networks which facilitate furnish new insights on the recruitment patterns of skilled health per- emigration. Those who leave are a reliable source of information about sonnel. The objectives of the paper are twofold: potential migration destinations for those who are still in the country. • To provide an audit of the organization and patterns of recruit- Doctors who do not migrate also begin to compare their living stand- ment of skilled professionals from South Africa in the health ards with those of friends working abroad. The comparisons can be very sector. The paper draws upon a detailed analysis of recruitment immediate and non-vicarious as their friends return home for visits and advertising appearing in the South African Medical Journal for describe their work in other countries. the period 2000-2004 and a series of interviews conducted with Dr Simon Chiremba, for example, graduated from medical school private recruiting enterprises. in Zimbabwe in the late 1980s and worked in Zimbabwe for four years • Based upon the above analysis and additional interviews with before migrating to South Africa. Most of his friends had already left for key stakeholders in the South African health sector, the paper South Africa. They were coming back and telling him how good it was: offers a series of recommendations for addressing the problem of Theskilled hospitals health are migration. well-staffed These and recommendationsyou don’t have to arewalk grounded toin work. both YouSouth can African easily get experience a loan to andbuy ana car. interrogation At that time of inter- carsnational were beingdebates rationed and ‘good in Zimbabwe. policy’ practice Only seniorfor regulating peo- recruit- plement. were getting the cars. You could not get even a simple Themiserable paper is Mazdaorganized 323! into On five the sections. other hand Section my friends Two positions were debateshaving about fun the in migration South Africa. of skilled Some health had even professionals started doing within a wider postgraduateliterature that training discusses and the they international were evidently mobility quite of happy. talent. SectionSo Three the information reviews research kept filtering on the throughglobal circulation and it just of became health professionals,a matter focusing of time in particularbefore I moved upon debatesacross the relating border. to34 the experience of countriesDr Enoch in Togara’s the developing decision toworld. leave Section Zimbabwe Four was moves also thegreatly focus influ from- encedinternational by his friends to South who African had left issues for South and provides Africa: new empirical material drawn from the survey of recruitment patterns and key interviews undertakenI think with another health push sector factor recruiters is when operating you see others in South who Africa. have Sectionmade Five it, addresses maybe a theclose questions friend or of someone changing like policy that, interventions that’s in South whenAfrica you towards start consideringthe outflow the of skilledidea. But health I would professionals probably and the recruitmenthave stayed of foreign longer health in Zimbabwe professionals until to such work a timein South when Africa. it The became more unbearable but it is important to point out that the people you associate with may expose you to 211 kkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkk MIGRATION POLICY SERIES NO. 45 The Engagement of the Zimbabwean Medical Diaspora

EXECUTIVE SUMMARY different things. I knew of several people who had become successful because of migration. In that way, they must have ealth workers are one of the categories of skilled profession- done it for a reason and it had worked well for them. So I als most affected by globalization. Over the past decade, didn’t see a reason why it wouldn’t work out for me either.35 there has emerged a substantial body of research that tracks Friends and colleagues in the diaspora not only provide information about Hpatterns of international migration of health personnel, job opportunities but essentially become a mirror which enables them to assesses causes and consequences, and debates policy responses at global see what their life will be like if they take up the emigration option. and national scales. Within this literature, the case of South Africa is Personal networks play a far more important role than recruiters in attracting growing interest. For almost 15 years South Africa has been helping doctors to secure jobs outside the country. These networks were the target of a ‘global raiding’ of skilled professionals by several devel- the main source of information about job opportunities abroad (impor- oped countries. How to deal with the consequences of the resultant out- tant to 64% of the respondents.) Other sources that were rated as more flow of health professionals is a core policy issue for the national gov- important than recruiters included professional journals/newsletters ernment. (43%), professional associations (29%), the internet (21%) and news- This paper aims to to examine policy debates and issues concerning papers (10%). This is consistent with trends noted in other developing the migration of skilled health professionals from the country and to countries which have experienced an upsurge in the number of medical furnish new insights on the recruitment patterns of skilled health per- professionals being recruited by agents working on behalf of employers in sonnel. The objectives of the paper are twofold: developed countries.36 • To provide an audit of the organization and patterns of recruitment of skilled professionals from South Africa in the health Table 8: Sources of Information Used Prior to Migration sector. The paper draws upon a detailed analysis of recruitment Very Important / Important Not Important advertising appearing in the South African Medical Journal for % of Total % of Total the period 2000-2004 and a series of interviews conducted with Through family, friends/colleagues and relatives 63.5 36.5 private recruiting enterprises. Professional journals/ newsletters 42.6 57.4 • Based upon the above analysis and additional interviews with Professional associations 28.7 71.3 key stakeholders in the South African health sector, the paper Internet 20.9 79.1 offers a series of recommendations for addressing the problem of Newspapers 10.4 89.6 skilled health migration. These recommendations are grounded Recruitment agencies 7.8 92.2 in both South African experience and an interrogation of international debates and ‘good policy’ practice for regulating recruit- Other 4.3 95.7 ment. N = 115 The paper is organized into five sections. Section Two positions What also needs to be emphasised is that Zimbabwean-trained medi- debates about the migration of skilled health professionals within a cal doctors established a good reputation outside the country. Zimbabwe wider literature that discusses the international mobility of talent. only has one medical school but competition for places was always Section Three reviews research on the global circulation of health pro- intense, ensuring high entry standards. The British-inspired training fessionals, focusing in particular upon debates relating to the experience which they received produced well-rounded doctors who could operate of countries in the developing world. Section Four moves the focus from independently with little supervision. The medical school therefore pro- international to South African issues and provides new empirical mate- duced quality doctors who were able to deliver high standards of care. rial drawn from the survey of recruitment patterns and key interviews Consequently, those who moved to South Africa developed a good repu- undertaken with health sector recruiters operating in South Africa. tation which in turn created a demand for more Zimbabwean doctors. As Section Five addresses the questions of changing policy interventions in Dr Sam Mugadza (who left Zimbabwe in the early 1990s) noted, “I had South Africa towards the outflow of skilled health professionals and the friends who were working in the hospitals here (in South Africa). All you recruitment of foreign health professionals to work in South Africa. The needed was a recommendation from them. You would come down and apply for a job and based on the performance of your colleague and his reputation, you could get a job quite easily.”37 1 22 kkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkk MMIGRATIONigration PPOLICYolicy SERIESeries NOo. 4555

IEnformalXECUTIVE LSinksUMMARY with Zimbabwe

Cash Remittancesealth workers are one of the categories of skilled profession- reviousals mostSAMP affected surveys by have globalization. shown that Over migrant the pastremittances decade, play a majorthere role has in emerged ensuring a householdsubstantial survival body of inresearch Zimbabwe. that38 tracks The Himportancepatterns of of remittances international to migrationthe Zimbabwean of health economy personnel, has also assesses beencauses re-affirmed and consequences, in recent studies.and debates39 A notablepolicy responses feature of at previ global- Pousand studiesnational of scales.remitting Within to Zimbabwe this literature, is that the they case do ofnot South ask whether Africa is remittingattracting varies growing by specificinterest. occupation, For almost although15 years Southa previous Africa SAMP has been study doesthe target indicate of athat ‘global professionals raiding’ of tend skilled to remit professionals more than by otherseveral categories devel- ofoped migrant. countries. In other How words, to deal we with do notthe knowconsequences if physicians of the are resultant distinctive out- inflow their of healthremitting professionals behaviour isor a whether core policy they issue follow for the the general national pattern. gov- Thisernment. study therefore focused on whether physicians, who are amongst the highestThis earning paper aims occupational to to examine category policy in thedebates Zimbabwean and issues diaspora, concerning dis- playthe migrationdifferent remitting of skilled practices health professionals than other Zimbabweans.from the country and to furnishThe newsurvey insights found onthat the 60% recruitment of the physicians patterns send of skilled money health to per- Zimbabwesonnel. The while objectives 40% never of the do paper so. The are propensity twofold: to remit was highest •among To medicalprovide doctorsan audit working of the organization in South Africa, and patternswith 79% of sending recruit- money toment Zimbabwe. of skilled Two professionals thirds of doctors from South in the Africa USA remitin the but health only 42% in thesector. UK The and papera third draws of those upon in a Canada. detailed The analysis lowest of propensityrecruitment to remitadvertising is among doctors appearing in New in the Zealand South (only African 17%). Medical To put Journal these figfor- ures in context,the period various 2000-2004 surveys and of Zimbabweansa series of interviews in South conducted Africa have with found thatprivate 85-95% recruiting of migrants enterprises. remit money home.40 Another study of Zimbabweans• Based inupon the theUK above found analysisthat 80% and remitted additional funds interviews to Zimbabwe. with41 This wouldkey seemstakeholders to suggest in thethat South physicians African show health a lower sector, propensity the paper to remit, irrespectiveoffers a series of theirof recommendations location. However, for theaddressing propensity the ofproblem physi- of cians to skilledremit doeshealth vary migration. with the Theseyear of recommendations emigration and with are the grounded racial compositionin both of theSouth migrant African cohort. experience Only a andthird an (29%) interrogation of the doctors of inter- who leftnational Zimbabwe debates in the and 1980s ‘good send policy’ remittances practice compared for regulating to 81% recruit- of those whoment. left in the 1990s and 95% of those who left after 2000. The surveyThe also paper found is organized that only into a third five of sections. white doctors Section remit Two compared positions todebates 100% about of black the doctors. migration The of lack skilled of familialhealth professionalsties in Zimbabwe within is the a strongestwider literature reason thatwhy discussesmany white the doctors international do not mobilityremit goods of talent. or money. AsSection Dr Dan Three Matthews, reviews whoresearch left Zimbabwe on the global in the circulation late 1990s, of noted:health “Ipro- do notfessionals, have any focusing more linksin particular with Zimbabwe; upon debates they arerelating virtually to the non-existent. experience Myof countries family has in left the Zimbabwe, developing I world.am married Section to aFour South moves African the andfocus my from childreninternational are all to here.” South42 African issues and provides new empirical mate- rialIn drawn sum, fromthe proportion the survey of of Zimbabwe’s recruitment black patterns doctors and (andkey interviewsespecially theundertaken most recent with group health of sectoremigrants) recruiters who operatingremit is equivalent in South toAfrica. or in excessSection of Five that addressesof the more the general questions Zimbabwean of changing migrant policy population. interventions The in nextSouth question Africa towardsis whether the physicians outflow of remit skilled at healththe same professionals levels and withand the therecruitment same frequency of foreign as otherhealth migrants. professionals Around to work30% inof theSouth physicians Africa. Theand 50% of those who remit are regular remitters (at least once a month)

231 kkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkk MIGRATION POLICY SERIES NO. 45 The Engagement of the Zimbabwean Medical Diaspora

EXECUTIVE SUMMARY (Figure 5). Another 24% of the doctors send money to Zimbabwe three or more times per year. Again, comparisons are instructive. Mupedziswa ealth workers are one of the categories of skilled profession- found that 64% of migrants in South Africa send remittances home at als most affected by globalization. Over the past decade, least once a month.43 In the UK, Bloch reports that around 41% remit there has emerged a substantial body of research that tracks at least once a month.44 On the receiving end, a national SAMP study patterns of international migration of health personnel, found that 62% of migrant-sending households in Zimbabwe receive H remittances at least monthly.45 Bracking and Sachikonye’s study of urban assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is households in Harare and Bulawayo found that 76% receive remittances attracting growing interest. For almost 15 years South Africa has been at least once a month.46 In other words, while there are differences in the target of a ‘global raiding’ of skilled professionals by several devel- remitting frequency by the location of the remitter (more frequent from oped countries. How to deal with the consequences of the resultant out- South Africa than abroad) and where the household is in Zimbabwe flow of health professionals is a core policy issue for the national gov- (more frequent to urban than rural households), once again there is ernment. nothing particularly unusual or distinctive about the frequency with This paper aims to to examine policy debates and issues concerning which physicians remit. the migration of skilled health professionals from the country and to furnish new insights on the recruitment patterns of skilled health per- Figure 5: Frequency of Sending Remittances to Zimbabwe sonnel. The objectives of the paper are twofold: 45 • To provide an audit of the organization and patterns of recruitment of skilled professionals from South Africa in the health 40 sector. The paper draws upon a detailed analysis of recruitment 35 advertising appearing in the South African Medical Journal for the period 2000-2004 and a series of interviews conducted with 30 private recruiting enterprises. 25 • Based upon the above analysis and additional interviews with 20 key stakeholders in the South African health sector, the paper offers a series of recommendations for addressing the problem of 15 skilled health migration. These recommendations are grounded Percentage sending remittances 10 in both South African experience and an interrogation of international debates and ‘good policy’ practice for regulating recruit- 5 ment. 0 The paper is organized into five sections. Section Two positions Never Once a month A few times Once or Just once Don’t know a year twice a year or twice debates about the migration of skilled health professionals within a wider literature that discusses the international mobility of talent. Comparisons between physicians and other migrants are more difficult Section Three reviews research on the global circulation of health pro- when it comes to the volume of remitting. In theory, we might expect to fessionals, focusing in particular upon debates relating to the experience see physicians remitting more simply on the basis of their greater earn- of countries in the developing world. Section Four moves the focus from ing power. Previous studies have also shown that professionals tend to international to South African issues and provides new empirical mate- remit more than individuals in other occupational categories.47 What rial drawn from the survey of recruitment patterns and key interviews the survey did show is that there is considerable variation in the amounts undertaken with health sector recruiters operating in South Africa. remitted by physicians. In 2008, the remitting doctors were send- Section Five addresses the questions of changing policy interventions in ing US$2,083.10 per annum on average to Zimbabwe (Figure 6). The South Africa towards the outflow of skilled health professionals and the amount ranged from a low of US$100 to a high of US$20,000 per year. recruitment of foreign health professionals to work in South Africa. The If data for the two highest remitting black medical doctors is removed, average remittances by black doctors falls sharply to US$1,919.68 (a

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EXECUTIVEdifferenceSUMMARY of more than US$600). There were considerable racial differences in the amount remitted. The average amount of money sent by black doctorsealth was workers US$2,597.00, are one compared of the categories to only US$838.95of skilled profession- by their white counterparts.als most affected by globalization. Over the past decade, Figure 6: Annual Volume thereof Financial has emerged Remittances a substantial by Race body of research that tracks patterns of international migration of health personnel, 25000H assesses causes and consequences, and debates policy responses at global Black and national scales. Within this literature, the case of South WhiteAfrica is 20000attracting growing interest. For almost 15 years South Africa has been the target of a ‘global raiding’ of skilled professionals by several developed countries. How to deal with the consequences of the resultant out- 15000flow of health professionals is a core policy issue for the national government.

Amount (US$) 10000 This paper aims to to examine policy debates and issues concerning the migration of skilled health professionals from the country and to furnish new insights on the recruitment patterns of skilled health per- 5000sonnel. The objectives of the paper are twofold: • To provide an audit of the organization and patterns of recruit- 0 ment of skilled professionals from South Africa in the health sector.Mean The paperMedian draws upon a detailedMaximum analysis of recruitmentMinimum advertising appearing in the South African Medical Journal for Aroundthe 60%period of 2000-2004the physicians and remitting a series of money interviews to Zimbabwe conducted send with less than $2,000private annually recruiting (Table enterprises. 9). Some of the amounts being sent annually• are small; Based forupon instance, the above 43% analysis send less and than additional US$1,000 interviews to Zimbabwe with annually.key How stakeholders do these figures in the compareSouth African with previous health sector,surveys? the In paper his 2003 study,offers Mupedziswa a series of recommendationscalculated that the for average addressing migrant the inproblem South of Africa remittedskilled health R9,120 migration. (US$1403) These per annum.recommendations48 More recent are groundedstudies show a considerablein both South fall African in the averageexperience amount and anremitted, interrogation ranging of from inter- the R2,723national (US$486) debates per and annum ‘good received policy’ bypractice migrant-sending for regulating house recruit-- holds inment. Zimbabwe in 2005 to the R3,480 (US$550) (in cash and kind) reportedThe paper for Johannesburg is organized ininto 2006. five49 sections. The average Section amount Two positionsremitted has undoubtedlydebates about fallen the migrationbecause the of numberskilled health of poorer, professionals unskilled withinmigrants a inwider South literature Africa hasthat increased discusses considerablythe international in recent mobility years. of This talent. is con- firmedSection by Three SAMP’s reviews finding research that professionals on the global remitted circulation an average of health of pro- R6,043fessionals, (US$1,079), focusing in compared particular to upon R2,472 debates (US$441) relating by tounskilled the experience workers.of countries50 Physicians in the may developing well be sending world. moreSection than Four they moves used to.the As focus Dr from Johninternational Mandaza to noted, South the African demand issues for financialand provides assistance new empirical from people mate- in Zimbabwerial drawn hasfrom increased the survey in recentof recruitment years: “We patterns are probably and key sending interviews more thanundertaken what we with used health to send sector before recruiters the current operating economic in South crisis Africa. set in. BackSection then Five it wasaddresses only the the close questions family of members changing who policy would interventions need financial in assistance.South Africa But towards now the the economic outflow situationof skilled ishealth so bad professionals that the extended and the familyrecruitment also call of askingforeign for health help.” professionals51 This only tomakes work the in Southgap between Africa. the The average remittances of physicians and the migrant population as a whole even larger. 251 kkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkk MIGRATION POLICY SERIES NO. 45 The Engagement of the Zimbabwean Medical Diaspora

EXECUTIVE SUMMARY Table 9: Distribution of Physician Remittances Annual Amount % ealth workers are one of the categories of skilled profession- <$500 15.9 als most affected by globalization. Over the past decade, $501-999 27.5 there has emerged a substantial body of research that tracks $1,000-1,999 18.8 patterns of international migration of health personnel, H $2,000-2,999 11.6 assesses causes and consequences, and debates policy responses at global $3,000-3,999 8.7 and national scales. Within this literature, the case of South Africa is >$4,000 11.6 attracting growing interest. For almost 15 years South Africa has been Not specified 5.8 the target of a ‘global raiding’ of skilled professionals by several devel- N=69 oped countries. How to deal with the consequences of the resultant outflow of health professionals is a core policy issue for the national gov- The vast majority of Zimbabwean migrants use informal channels ernment. when remitting to Zimbabwe.52 In 2003, Mupedziswa found that 59% This paper aims to to examine policy debates and issues concerning of migrants in South Africa used family networks (including personal the migration of skilled health professionals from the country and to transfers) to remit, 31% used informal money changers and 22% used furnish new insights on the recruitment patterns of skilled health per- trader networks.53 Only 8% used money transfer companies and 3% used sonnel. The objectives of the paper are twofold: the Post Office. Use of banks was virtually non-existent. In 2005, SAMP • To provide an audit of the organization and patterns of recruit- found that 74% of migrants preferred to use hand to hand transfers, 12% ment of skilled professionals from South Africa in the health used the mail, 8% used public transport carriers and only 5% preferred sector. The paper draws upon a detailed analysis of recruitment other, formal, channels.54 advertising appearing in the South African Medical Journal for Another popular informal money transfer channel between South the period 2000-2004 and a series of interviews conducted with Africa and Zimbabwe is hand-to-hand money transfer agents who oper- private recruiting enterprises. ate between Zimbabwe and South Africa (called Omalayisha). The word • Based upon the above analysis and additional interviews with Omalayisha means someone who loads and transports items in bulk.55 key stakeholders in the South African health sector, the paper The Omalayisha travel frequently between Zimbabwe and South Africa offers a series of recommendations for addressing the problem of and maintain a well-developed distribution system in Zimbabwe. Their skilled health migration. These recommendations are grounded role is to physically transport financial remittances from the senders in both South African experience and an interrogation of inter- located in South Africa to the recipients located in Zimbabwe. national debates and ‘good policy’ practice for regulating recruit- With close connections among the border security staff, the Omalayisha ment. easily pass through the border with large quantities of cash. A sender in The paper is organized into five sections. Section Two positions South Africa is required to pay a handling fee equivalent to 20% of the debates about the migration of skilled health professionals within a total amount sent. The Omalayisha ensure that the money is personally wider literature that discusses the international mobility of talent. delivered to the recipient anywhere in Zimbabwe. Some Omalayisha limit Section Three reviews research on the global circulation of health pro- their operations to a few major urban areas in Zimbabwe and the recipient fessionals, focusing in particular upon debates relating to the experience has to travel to these cities to pick up their cash. The system is complex of countries in the developing world. Section Four moves the focus from and based on honesty since cases of fraud would result in the Omalayisha international to South African issues and provides new empirical mate- losing their client base. The Omalayisha show that the informal remittance rial drawn from the survey of recruitment patterns and key interviews transfer system can certainly provide a reliable service. undertaken with health sector recruiters operating in South Africa. More recently, Zimbabweans overseas have been able to use an Section Five addresses the questions of changing policy interventions in informal internet remitting service called Mukuru.com. The company South Africa towards the outflow of skilled health professionals and the is based in the UK and offers online remittance transfer services of cash recruitment of foreign health professionals to work in South Africa. The and goods to Zimbabweans worldwide. While Mukuru.com operates as a registered money transfer company in the UK, it operates informally in Zimbabwe through its agents. Essentially, customers of Mukuru.com 1 26 kkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkk MMIGRATIONigration PPOLICYolicy SERIESeries NOo. 4555

EXECUTIVEcompleteSUMMARY the remittance transfer transaction online and the company, through its informal operating agents in Zimbabwe, ensures that the equivalent isealth deposited workers into are the one beneficiary’s of the categories account. of skilledAt the profession-time of the fieldworkals in most 2008, affected Zimbabwe by globalization. was in the midst Over of the a major past decade,economic crisis.56 In Novemberthere has emerged2008, Harare a substantial banks quoted body ofan research exchange that rate tracks of US$1 to Z$944patterns while of the international thriving black migration market ofthe health rate was personnel, as high as HUS$1 to Z$1,200,000. Internet channels such as Mukuru.com allowed assesses causes and consequences, and debates policy responses at global Zimbabweansand national scales.abroad Within to send this money literature, home atthe rates case comparable of South Africa to the is blackattracting market growing exchange interest. rates. For almost 15 years South Africa has been theIn target the latter of a ‘global half of raiding’2008, the of financialskilled professionals crisis in Zimbabwe by several deepened devel- tooped the countries. extent that How it became to deal almostwith the impossible consequences to withdraw of the resultantcash from out- aflow commercial of health bank. professionals The Zimbabwean is a core policy dollar issuebecame for thescarce national in the gov-for- malernment. banks as inflation in the country worsened. Long queues became a permanentThis paper scene aims atto most to examine commercial policy banks debates as the and Zimbabwean issues concerning dol- larthe was migration being diverted of skilled into health the country’sprofessionals growing from informal the country economy. and to Withdrawingfurnish new insights money fromon the the recruitment bank became patterns a real ofstruggle skilled and health remit per-- tancesonnel. companies The objectives such as of Mukuru.com the paper are were twofold: forced to temporarily sus- pend• their To moneyprovide remittance an audit of functions. the organization The company and patterns only resumed of recruit- ser- vice in 2009ment when of skilled a new professionals unity government from South was formed Africa andin the adopted health the US$ as thesector. new The legal paper tender draws in the upon financial a detailed system, analysis thereby of recruitment getting rid of the troubledadvertising Zimbabwean appearing dollar. in the South African Medical Journal for Highly-educated,the period 2000-2004 middle-class and migrants a series of such interviews as physicians conducted might with be expectedprivate to make recruiting more use enterprises. of formal remitting channels such as banks and• money Based transfer upon companies.the above analysis However, and the additional survey found interviews that their with most commonkey stakeholders method of insending the South money African to Zimbabwe health sector, (cited theby 86% paper of the remitters),offers a is series hand of to recommendations hand transfer (Figure for addressing 7). This involves the problem either of the doctorsskilled taking health the migration.money personally These recommendations to Zimbabwe or sending are grounded it throughin friends both orSouth relatives African visiting experience Zimbabwe. and Thean interrogation second most ofpopu inter-- lar method,national cited debates by 46%, and is the ‘good use policy’ of informal practice transfer for regulating channels recruit-such as Mukuru.comment. and the Omalayisha. Formal money transfer companies (suchThe as paperWestern is organized Union and into Money five sections.Gram) are Section used by Two 25%, positions but only 14%debates use aboutbanks. the Commercial migration banksof skilled are healththus the professionals least popular within method a of sendingwider literature financial that remittances discusses to the Zimbabwe. international mobility of talent. SectionMost Threedoctors reviews avoid usingresearch banks on becausethe global of thecirculation high transaction of health costspro- involved,fessionals, which focusing are inmore particular than double upon debatesthe rates relating charged to by the informal experience remittanceof countries transfer in the developingcompanies. world.Furthermore, Section before Four movesthe liberation the focus of fromthe financialinternational system, to Southmoney African sent to Zimbabweissues and providesvia banks new would empirical be converted mate- intorial drawnZimdollars from atthe the survey government of recruitment exchange patterns rate. To and make key mattersinterviews worse,undertaken international with health bank sector transfers recruiters normally operating take about in South seven Africa. working daysSection to process Five addresses which is the a long questions time in of a changing hyper-inflationary policy interventions environ- in ment.South InAfrica comparison, towards formalthe outflow remittance of skilled channels health like professionals Money Gram and and the Westernrecruitment Union of foreigntransfer health money professionals in real-time. to Race work and in geographySouth Africa. play The a major role in determining the choice of remittance-sending method. Around 80% of black doctors use hand to hand transfers, compared 271 kkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkk MIGRATION POLICY SERIES NO. 45 The Engagement of the Zimbabwean Medical Diaspora

EXECUTIVE SUMMARY to only 18% of white doctors. Furthermore, 85% of the doctors using the hand to hand method are located in South Africa. This is primarily ealth workers are one of the categories of skilled profession- because physicians based in South Africa are more likely to travel, or find als most affected by globalization. Over the past decade, friends travelling, to Zimbabwe. there has emerged a substantial body of research that tracks Informal money transfer channels, even those involving the patterns of international migration of health personnel, Omalayisha, were rated as 100% reliable by the physicians. This is an H important finding from a policy perspective. Any policies targeting assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is migrant remittance channels should facilitate rather than discourage the attracting growing interest. For almost 15 years South Africa has been use of informal channels. This is especially relevant in the Zimbabwe case the target of a ‘global raiding’ of skilled professionals by several devel- where informal remittances channels are often criminalised in spite of the oped countries. How to deal with the consequences of the resultant out- role they play in transmitting much needed foreign currency to the coun- flow of health professionals is a core policy issue for the national gov- try. Furthermore, informal channels involving the Omalayisha are able to ernment. extend their services to remote locations which are not covered by formal This paper aims to to examine policy debates and issues concerning channels such as banks. the migration of skilled health professionals from the country and to The research on Zimbabwean remittances to date clearly shows furnish new insights on the recruitment patterns of skilled health per- that the bulk of it is spent on household survival needs with very little sonnel. The objectives of the paper are twofold: investment of the proceeds.57 The question is whether remittances from • To provide an audit of the organization and patterns of recruit- physicians are any different. The simple answer is no. Over 90% of the ment of skilled professionals from South Africa in the health respondents who send cash remittances do so to meet the day to day sector. The paper draws upon a detailed analysis of recruitment expenses of family members in Zimbabwe including food purchase, rent advertising appearing in the South African Medical Journal for and the cost of electricity and water (Figure 8). Health and educational the period 2000-2004 and a series of interviews conducted with expenses are another major use of remittances as the costs of education private recruiting enterprises. and health have skyrocketed over the past decade and are now beyond • Based upon the above analysis and additional interviews with the reach of most people in Zimbabwe. Dr Simon Chiremba summed up key stakeholders in the South African health sector, the paper the situation: “I don’t know how they could have survived up to now if I offers a series of recommendations for addressing the problem of wasn’t here.”58 skilled health migration. These recommendations are grounded Figure 7: Methods of Sending Money to Zimbabwe in both South African experience and an interrogation of inter- 90 national debates and ‘good policy’ practice for regulating recruit- 80 ment. The paper is organized into five sections. Section Two positions 70 debates about the migration of skilled health professionals within a 60 wider literature that discusses the international mobility of talent. Section Three reviews research on the global circulation of health pro- 50 fessionals, focusing in particular upon debates relating to the experience 40 of countries in the developing world. Section Four moves the focus from 30 international to South African issues and provides new empirical mate- Percentage using method rial drawn from the survey of recruitment patterns and key interviews 20 undertaken with health sector recruiters operating in South Africa. 10 Section Five addresses the questions of changing policy interventions in 0 South Africa towards the outflow of skilled health professionals and the Hand-to-hand Informal money Formal money Via bank Other recruitment of foreign health professionals to work in South Africa. The transfers transfer transfer company Note: Question allowed multiple responses 1 28 kkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkk MMIGRATIONigration PPOLICYolicy SERIESeries NOo. 4555

FigureEXECUTIVE 8: Use of MigrantSUMMARY Remittances Sent to Zimbabwe 100 ealth workers are one of the categories of skilled profession- 90 als most affected by globalization. Over the past decade, 80 there has emerged a substantial body of research that tracks 70Hpatterns of international migration of health personnel, assesses causes and consequences, and debates policy responses at global 60 and national scales. Within this literature, the case of South Africa is 50attracting growing interest. For almost 15 years South Africa has been 40the target of a ‘global raiding’ of skilled professionals by several devel-

Percentage of senders 30oped countries. How to deal with the consequences of the resultant outflow of health professionals is a core policy issue for the national gov- 20 ernment. 10 This paper aims to to examine policy debates and issues concerning 0the migration of skilled health professionals from the country and to furnishMeeting new insightsPay health on thePay recruitmentschool Build, patterns ofStart skilled healthFor savings per- day to day costs fees maintain or or run sonnel.expenses The of objectives of the paper arerenovate twofold: business •household To provide an audit of the organizationdwelling and patterns of recruitment of skilled professionals from South Africa in the health Note: Question allowedsector. multiple The responses paper draws upon a detailed analysis of recruitment advertising appearing in the South African Medical Journal for At thethe same period time, 2000-2004 the doctors and noted a series that of thereinterviews was an conducted expectation with in Zimbabweprivate that recruiting they could enterprises. meet all the needs of those who remained behind.• BasedAs Dr uponTim Makombethe above cynicallyanalysis andnoted: additional “Zimbabwe interviews is like awith bot- 59 tomless keypit: stakeholdersit keeps on swallowing in the South money.” African Dr health Mavis sector, Makoni the observed paper that peopleoffers in aZimbabwe series of recommendations believe that “if one for goes addressing outside thethe problemcountry of they (are)skilled sitting health on a migration.silver sea and These have recommendations an endless supply are of groundedresourc- 60 es.” Inin her both view, South there African was a much experience too romanticised and an interrogation view of the of dias inter-- pora. Thosenational in the debates diaspora and with ‘good good policy’ jobs practiceare seen foras well-endowedregulating recruit- with resourcesment. which can be shared with those in Zimbabwe. In practice, the constantThe paper requests is organized for cash placeinto five a burden sections. on theirSection own Two family positions budgets. Asdebates Dr Enoch about Togara the migration observed: of skilled health professionals within a wider Previously,literature that if my discusses parents the were international to come here mobility it would of be talent. for Sectionleisure Three or reviews holiday. research They were on workingthe global and circulation everything of was health professionals,okay focusing for them. in They particular would upon just comedebates here relating just to to sight-see. the experience of countriesWe could in the buy developing things such world. as clothes Section and Four maybe moves some the elec focusfrom internationaltronic appliances to South Africanto take backissues home and providesto Zimbabwe. new empirical But now material drawninstead from of theleaving survey with of arecruitment suit we have patterns to give andsome key sugar, interviews undertakensome flourwith andhealth things sector like recruiters that. For operating now people in haveSouth to Africa. get Sectionby…The Five addresses other thing the questionsis that we of have changing been here policy for interventions a long in South timeAfrica and towards the family the outflowhas been of growing. skilled healthWhen professionalsI came here Iand the recruitmentwas a bachelorof foreign but health now professionalsI have my own to kidswork and in Southso I have Africa. to The factor in all those things.61

291 kkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkk MIGRATION POLICY SERIES NO. 45 The Engagement of the Zimbabwean Medical Diaspora

EXECUTIVE SUMMARY Hyper-inflationary conditions in Zimbabwe were given as a major impediment to investment of remittances by the physicians. Some had ealth workers are one of the categories of skilled profession- tried to establish business ventures but quickly ran into difficulties. Dr als most affected by globalization. Over the past decade, John Mandaza, for example, once ran an insurance business but it col- there has emerged a substantial body of research that tracks lapsed when the economic crisis began. Dr Paul Pande had operated a patterns of international migration of health personnel, chicken raising project but he abandoned it when he encountered prob- H lems in securing chicken feed. It is also particularly difficult for someone assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is based outside Zimbabwe to run a project successfully because of the high attracting growing interest. For almost 15 years South Africa has been level of informalisation of the economy. An informal economy requires a the target of a ‘global raiding’ of skilled professionals by several devel- dedicated person on site so that decisions can be made quickly to match oped countries. How to deal with the consequences of the resultant out- rapidly shifting demands and opportunities. flow of health professionals is a core policy issue for the national government. Remittances of Goods This paper aims to to examine policy debates and issues concerning the migration of skilled health professionals from the country and to Slightly over half of the respondents also remit goods to Zimbabwe, furnish new insights on the recruitment patterns of skilled health per- especially food and clothing. As with cash remittances, the likelihood sonnel. The objectives of the paper are twofold: of sending goods varies with the age, race and year of emigration of the • To provide an audit of the organization and patterns of recruit- physician. For instance, 61% of those below 50 send goods compared to ment of skilled professionals from South Africa in the health only 39% of those over 50. Or again, 88% of black doctors send goods sector. The paper draws upon a detailed analysis of recruitment compared to only 26% of the white doctors. Finally, 71% of those who advertising appearing in the South African Medical Journal for left after 1990 remit goods compared to only 28% of those who left the period 2000-2004 and a series of interviews conducted with before 1990. Doctors who live in South Africa are far more likely to send private recruiting enterprises. goods than those located elsewhere: as many as 79% of the respondents • Based upon the above analysis and additional interviews with in South Africa send goods to Zimbabwe, compared to 47% of those in key stakeholders in the South African health sector, the paper the USA and only 25% of those in the UK (Figure 9). Goods are not sent offers a series of recommendations for addressing the problem of as frequently as cash remittances with only 17% of respondents sending skilled health migration. These recommendations are grounded goods every month. The majority send goods home a few times a year. in both South African experience and an interrogation of international debates and ‘good policy’ practice for regulating recruit- Figure 9: Proportion Remitting Goods by Country of Residence ment. 90 The paper is organized into five sections. Section Two positions 80 debates about the migration of skilled health professionals within a wider literature that discusses the international mobility of talent. 70 Section Three reviews research on the global circulation of health pro- 60 fessionals, focusing in particular upon debates relating to the experience 50 of countries in the developing world. Section Four moves the focus from international to South African issues and provides new empirical mate- 40 rial drawn from the survey of recruitment patterns and key interviews 30 undertaken with health sector recruiters operating in South Africa.

Section Five addresses the questions of changing policy interventions in Percentage (per individual country) 20 South Africa towards the outflow of skilled health professionals and the 10 recruitment of foreign health professionals to work in South Africa. The 0 South Africa USA Other UK Average

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EXECUTIVETheSUMMARY physicians send a wide array of goods to Zimbabwe (Figure 10). The most important items are food products. Foodstuffs have become very expensiveealth in workersZimbabwe are and one the of thediaspora categories has played of skilled a major profession- role in meeting theals food most needs affected of their by families.globalization. Two thirdsOver theof those past sendingdecade, food products arethere located has inemerged South Africa.a substantial Clothing body is theof research other major that itemtracks remitted, sentpatterns by 71% of ofinternational doctors. Again, migration the proximity of health of personnel,South Africa is Ha factor: 57% of those sending clothes are based in South Africa. assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is Figure 10: Typeattracting of Goods growing Remitted interest. to Zimbabwe For almost 15 years South Africa has been 90 the target of a ‘global raiding’ of skilled professionals by several developed countries. How to deal with the consequences of the resultant out- 80 flow of health professionals is a core policy issue for the national gov- 70 ernment.

60 This paper aims to to examine policy debates and issues concerning the migration of skilled health professionals from the country and to 50 furnish new insights on the recruitment patterns of skilled health per- 40 sonnel. The objectives of the paper are twofold: • To provide an audit of the organization and patterns of recruit- 30 ment of skilled professionals from South Africa in the health Percentage of total remitters 20 sector. The paper draws upon a detailed analysis of recruitment

10 advertising appearing in the South African Medical Journal for the period 2000-2004 and a series of interviews conducted with 0 private recruiting enterprises. Food Clothing Houshold Petrol Electronic Bedding Carpets Medication Furniture Books Other • Basedappliances upon the abovegoods analysisor towels and additional interviews with key stakeholders in the South African health sector, the paper offers a series of recommendations for addressing the problem of They use various channels to send goods to Zimbabwe. As in the case skilled health migration. These recommendations are grounded of financial remittances, most transfers are made by hand. Bus companies in both South African experience and an interrogation of inter- and the Omalayisha also transport goods to Zimbabwe for a fee. They national debates and ‘good policy’ practice for regulating recruit- avoid having to pay duties by bribing customs officials. Most have a limit- ment. ed number of collection points, while others claim to be able to transport The paper is organized into five sections. Section Two positions goods to any location in Zimbabwe. The doctors who have used these debates about the migration of skilled health professionals within a services agreed that the agents are very reliable and are able to deliver wider literature that discusses the international mobility of talent. the goods timeously. Another channel for sending goods are companies Section Three reviews research on the global circulation of health pro- involved in the selling and distribution of goods in Zimbabwe. These fessionals, focusing in particular upon debates relating to the experience ‘companies’ operate from South Africa and supply retailers in Zimbabwe of countries in the developing world. Section Four moves the focus from with goods. They also enable migrants based in South Africa to send international to South African issues and provides new empirical mate- food and household items to Zimbabwe (known as food hampers or food rial drawn from the survey of recruitment patterns and key interviews packs). The packs are purchased and paid for over the phone. Individuals undertaken with health sector recruiters operating in South Africa. located overseas use online shops such as Mukuru.com. Most online Section Five addresses the questions of changing policy interventions in shops have agents in South Africa (for the procurement of goods) and South Africa towards the outflow of skilled health professionals and the Zimbabwe (for their distribution). The online shops typically sell food recruitment of foreign health professionals to work in South Africa. The items, fuel, cell phones, as well as satellite television subscriptions.

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EXECUTIVE SUMMARY Value of Remittances Extrapolating from the survey findings on average remittances and data ealth workers are one of the categories of skilled profession- on the number of Zimbabwean abroad, it is possible to arrive at estimates als most affected by globalization. Over the past decade, of total annual remittances by geographical location and race. Zimbabwe there has emerged a substantial body of research that tracks receives about US$2.5 million annually in cash remittances from medi- patterns of international migration of health personnel, H cal doctors working abroad (Table 10).62 Nearly 40% of this comes from assesses causes and consequences, and debates policy responses at global physicians in South Africa and 33% from those in the UK. Black doctors and national scales. Within this literature, the case of South Africa is remit over 90% of the total amount sent. attracting growing interest. For almost 15 years South Africa has been the target of a ‘global raiding’ of skilled professionals by several devel- Table 10: Estimated Value of Cash Remittances oped countries. How to deal with the consequences of the resultant out- Country Black (x = $2,597) White (x = $838.95) Total Remittances flow of health professionals is a core policy issue for the national gov- South Africa 918,429.05 71,305.98 989,735.03 ernment. This paper aims to to examine policy debates and issues concerning UK 789,877.55 61,325.36 851,202.91 the migration of skilled health professionals from the country and to USA 335,662.25 26,060.51 361,722.76 furnish new insights on the recruitment patterns of skilled health per- Australia 138,549.95 10,756.89 149,306.84 sonnel. The objectives of the paper are twofold: New Zealand 85,701.00 6,653.75 92,354.75 • To provide an audit of the organization and patterns of recruit- Canada 78,559.25 6,099.27 84,658.52 ment of skilled professionals from South Africa in the health Portugal 17,140.20 1,330.75 18,470.95 sector. The paper draws upon a detailed analysis of recruitment Belgium 8,570.10 665.37 9,235.47 advertising appearing in the South African Medical Journal for Spain 1,428.35 110.90 1,539.25 the period 2000-2004 and a series of interviews conducted with Total Remittances 2,373,917.70 184,308.76 2,558,226.46 private recruiting enterprises. • Based upon the above analysis and additional interviews with The same methodology can be used to calculate the total value of key stakeholders in the South African health sector, the paper goods which the doctors send to Zimbabwe annually. Black doctors remit offers a series of recommendations for addressing the problem of an average of $2,061 worth of goods per annum while white doctors send skilled health migration. These recommendations are grounded about $776 worth per annum. Table 11 extrapolates from these figures in both South African experience and an interrogation of inter- to provide a racial and geographical breakdown of the value of the goods national debates and ‘good policy’ practice for regulating recruit- sent. The total value of the goods amounts to an estimated US$1.79 mil- ment. lion per annum. Summing cash remittances and the value of The paper is organized into five sections. Section Two positions remittances in kind, Zimbabwe’s medical diaspora remits almost US$4.3 debates about the migration of skilled health professionals within a million worth of cash and goods each year (Table 12). wider literature that discusses the international mobility of talent. Even if the average individual remittance figure of US$2,616 per Section Three reviews research on the global circulation of health pro- annum was sustained over a 30 year period, the total remittances fessionals, focusing in particular upon debates relating to the experience from one individual would still be significantly less than the estimated 63 of countries in the developing world. Section Four moves the focus from US$97,000 needed to train a medical doctor in Africa. Thus, the remit- international to South African issues and provides new empirical mate- tances sent by the emigrant doctors certainly do not compensate for their rial drawn from the survey of recruitment patterns and key interviews training costs. As discussed below, the diaspora option offers Zimbabwe undertaken with health sector recruiters operating in South Africa. better hope in terms of securing reasonable returns from emigrant profes- Section Five addresses the questions of changing policy interventions in sionals. South Africa towards the outflow of skilled health professionals and the recruitment of foreign health professionals to work in South Africa. The

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ETableXECUTIVE 11: EstimatedSUMMARY Value of Remitted Goods Country Black (x = $2,061.30) White (x = $776) Total Value of Goods South Africa ealth 641,048.75workers are one of the52,742.84 categories of skilled693,791.59 profession- UK als most550,353.75 affected by globalization.44,986.54 Over the past595,340.29 decade, USA there 232,921.25has emerged a substantial19,390.75 body of research252,312.00 that tracks patterns of international migration of health personnel, Australia H 96,878.75 7,756.30 104,635.05 New Zealandassesses causes and59,776.25 consequences, and debates4,653.78 policy responses64,430.03 at global and national scales. Within this literature, the case of South Africa is Canada 53,592.50 4,653.78 58,246.28 attracting growing interest. For almost 15 years South Africa has been Portugal 12,367.50 775.63 13,143.13 the target of a ‘global raiding’ of skilled professionals by several devel- Belgium 6,183.75 775.63 6,959.38 oped countries. How to deal with the consequences of the resultant out- Spain 2,061.25 0.00 2,061.25 flow of health professionals is a core policy issue for the national gov- Total Valueernment. of Goods 1,654,317.61 136,110.60 1,790,428.21 This paper aims to to examine policy debates and issues concerning Table 12: Estimatedthe migration Total Value of skilled of Remittances health professionals from the country and to Country furnish newBlack insights (x = $4,658.30) on the recruitmentWhite (x = $1,614.60)patterns of skilledTotal healthRemittances personnel. The objectives of the paper are twofold: (= $2,616.5) South Africa • To provide1,560,386.75 an audit of the organization124,053.59 and patterns1,684,440.34 of recruit- UK ment1,339,841.75 of skilled professionals 106,229.89from South Africa in1,446,071.64 the health USA sector. 567,934.25The paper draws upon45,398.20 a detailed analysis of613,332.45 recruitment Australia advertising234,519.75 appearing in the South18,662.65 African Medical253,182.40 Journal for New Zealand the period145,477.25 2000-2004 and a series11,365.38 of interviews conducted156,842.63 with Canada private131,502.50 recruiting enterprises.10,526.43 142,028.93 Portugal • Based upon30,546.50 the above analysis2,453.53 and additional interviews33,000.03 with Belgium key stakeholders13,974.75 in the South 1,614.58African health sector,15,589.33 the paper Spain offers a series4,658.25 of recommendations0.00 for addressing the4,658.25 problem of Total Remittances skilled4,028,235.31 health migration. These320,419.37 recommendations4,348,654.68 are grounded in both South African experience and an interrogation of international debates and ‘good policy’ practice for regulating recruit- Informal Servicesment. The paper is organized into five sections. Section Two positions Thedebates skills about and trainingthe migration of emigrant of skilled doctors health are professionals usually viewed within in the a ‘brainwider literaturedrain’ literature that discusses as an absolute the international loss to the countrymobility of of origin. talent. However,Section Three this study reviews found research that emigrant on the global doctors circulation still attend of tohealth the medi pro-- calfessionals, needs of focusing family and in particular friends in uponZimbabwe. debates They relating frequently to the provideexperience long-distanceof countries in medical the developing and some world. ‘practice’ Section informally Four moves when thethey focus visit from Zimbabwe.international Dr toMary South Chikomo, African for issues example, and provides travels tonew Zimbabwe empirical at mate- least oncerial drawn a year: from “When the surveyI go home, of recruitment my neighbours patterns come and to keyme withinterviews all sorts ofundertaken problems –with ringworms, health sector migraines, recruiters whatever. operating If I have in South basic Africa.medication, ISection give them. Five However, addresses most the questions of the time of Ichanging refer them policy to a interventionsmedical facility in becauseSouth Africa I would towards not have the alloutflow the necessary of skilled tools health to performprofessionals a proper and diag the- nosisrecruitment on them.” of foreign64 Sometimes health the professionals doctors feel to helpless work in because South Africa. their con The- nections in Zimbabwe have weakened over time. For instance, Dr Mavis

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EXECUTIVE SUMMARY Makoni used to know a lot of doctors at Masvingo General Hospital when she was still in Zimbabwe, but most of them have since left the ealth workers are one of the categories of skilled profession- country.65 Now when she visits Zimbabwe she does not have many con- als most affected by globalization. Over the past decade, tacts to refer her sick relatives to for medical attention. Some relatives there has emerged a substantial body of research that tracks come to her with clear cases of HIV and AIDS but her ability to help is patterns of international migration of health personnel, limited because she does not know whether there are any antiretroviral H (ARV) programmes in the area. assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is In South Africa, medical doctors are sometimes asked to attend attracting growing interest. For almost 15 years South Africa has been to Zimbabwean patients on an informal basis. Dr Chikomo works for the target of a ‘global raiding’ of skilled professionals by several devel- a research organisation in South Africa and is not involved in clini- oped countries. How to deal with the consequences of the resultant out- cal practice.66 However, the people within her social network (mostly flow of health professionals is a core policy issue for the national gov- Zimbabweans) know that she is a medical doctor and consult her about ernment. minor ailments. They also consult her on the medical conditions of rela- This paper aims to to examine policy debates and issues concerning tives in Zimbabwe and want to find out what medication they can get for the migration of skilled health professionals from the country and to their sick relative. Medical services provided to family by colleagues in furnish new insights on the recruitment patterns of skilled health per- Zimbabwe are sometimes paid for by the emigrant doctors in the form of sonnel. The objectives of the paper are twofold: goods in South Africa. According to Dr Walter Choga, if any of his rela- • To provide an audit of the organization and patterns of recruit- tives in Zimbabwe require medical attention they visit one of his medi- ment of skilled professionals from South Africa in the health cal friends in Zimbabwe and are not required to pay for the service.67 sector. The paper draws upon a detailed analysis of recruitment However, the doctors are paid by Dr Choga in kind when they visit advertising appearing in the South African Medical Journal for South Africa, who buys goods and medicines for them to take back to the period 2000-2004 and a series of interviews conducted with Zimbabwe. private recruiting enterprises. The knowledge which emigrant Zimbabwean doctors have gained • Based upon the above analysis and additional interviews with over the years also places them in a position to provide medical advice key stakeholders in the South African health sector, the paper to their professional colleagues in Zimbabwe. Professional advice (which offers a series of recommendations for addressing the problem of ranges from consultation to mentorship) is most pronounced amongst skilled health migration. These recommendations are grounded recent migrants who are largely black and have contact with other pro- in both South African experience and an interrogation of inter- fessionals working in Zimbabwe. A number of the doctors who have national debates and ‘good policy’ practice for regulating recruit- been outside the country for a long time also maintain a fair amount of ment. contact with their counterparts in Zimbabwe. Dr Leonard Jordan, for The paper is organized into five sections. Section Two positions example, is sometimes consulted by his medical friends in Zimbabwe debates about the migration of skilled health professionals within a when they encounter difficult plastic surgery cases, which is his specialty. wider literature that discusses the international mobility of talent. Effectively, he acts as a specialist referral base for his medical friends in Section Three reviews research on the global circulation of health pro- Zimbabwe.68 Zimbabwean-based doctors sometimes phone or send emails fessionals, focusing in particular upon debates relating to the experience to Dr Ben Carter, a shoulder surgeon, when they need medical advice.69 of countries in the developing world. Section Four moves the focus from Some doctors even send patients down to him, especially those with international to South African issues and provides new empirical mate- shoulder problems. rial drawn from the survey of recruitment patterns and key interviews undertaken with health sector recruiters operating in South Africa. Section Five addresses the questions of changing policy interventions in South Africa towards the outflow of skilled health professionals and the recruitment of foreign health professionals to work in South Africa. The

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EngagingXECUTIVE tSheUMMARY Diaspora

Return Migrationealth workers are one of the categories of skilled profession- eturnals most migration affected is increasinglyby globalization. seen asOver an importantthe past decade, feature ofthere contemporary has emerged migration a substantial dynamics body with of researchpositive developthat tracks- Hmentpatterns impacts. of international70 Diaspora engagement migration of has health been personnel, increasingly assesses causesadvanced and consequences,as a possible solution and debates to the policy skills responsesproblems facingat global Rdevelopingand national countries. scales. Within71 In Zimbabwe, this literature, the diaspora the case option of South arguably Africa offers is theattracting most sensible growing policy interest. prescription For almost since 15 ityears entails South the Africause of hasthe beenskills ofthe the target diaspora of a ‘globalwithout raiding’ requiring of skilledthem to professionals return home by permanently. several devel- However,oped countries. while theHow use to ofdeal the with diaspora the consequences resources is seen of the by policy-makersresultant out- asflow a viable of health way professionalsof ensuring that is a acore sending policy country issue for benefits the national from its gov- citi- zensernment. abroad, the reality is that it is dependent on the goodwill of the emigrantThis paper professionals. aims to toThis examine section policy of the debates report thereforeand issues explores concerning the extentthe migration of current of skilleddiaspora health engagement professionals by emigrant from the physicians country andand theirto thoughtsfurnish new about insights the future. on the recruitment patterns of skilled health personnel.The doctorsThe objectives in the survey of the divided paper are almost twofold: equally between those who agreed• that To provide they had an an audit important of the organizationrole to play in and the patterns future of of Zimbabwe recruit- (43%) andment those of skilled that did professionals not (41%) (Figurefrom South 11). Africa in the health sector. The paper draws upon a detailed analysis of recruitment Figure 11: Have Importantadvertising Role to appearingPlay in the Futurein the of South Zimbabwe African Medical Journal for 35 the period 2000-2004 and a series of interviews conducted with private recruiting enterprises. 30 • Based upon the above analysis and additional interviews with key stakeholders in the South African health sector, the paper 25 offers a series of recommendations for addressing the problem of skilled health migration. These recommendations are grounded 20 in both South African experience and an interrogation of international debates and ‘good policy’ practice for regulating recruit-

Percentage 15 ment. 10 The paper is organized into five sections. Section Two positions debates about the migration of skilled health professionals within a 5 wider literature that discusses the international mobility of talent. Section Three reviews research on the global circulation of health pro- 0 fessionals, focusing in particular upon debates relating to the experience Strongly Somewhat Neither agree Somewhat Strongly Don’t know of countriesagree in agreethe developingnor disagree world.disagree Section Fourdisagree moves the focus from international to South African issues and provides new empirical material drawn from the survey of recruitment patterns and key interviews undertakenAge, race, with period health of absence sector recruitersand current operating location in all South had anAfrica. influence onSection their Fivethinking. addresses Nearly the 60% questions of those of under changing 50 years policy agreed interventions with the in propositionSouth Africa compared towards tothe only outflow 19% ofof skilledthose over health 50. professionals As many as 73%and theof therecruitment black doctors of foreign were healthin agreement professionals compared to work to only in South21% of Africa. white andThe Asian doctors. Sixty one percent who left the country after 1990 agreed

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EXECUTIVE SUMMARY they had an important role to play compared to only 23% of those who left before 1990. Finally, 65% of the doctors in South Africa agreed con- ealth workers are one of the categories of skilled profession- curred compared to 33% of those in New Zealand, 25% in Australia, 25% als most affected by globalization. Over the past decade, in the UK, 17% in the USA and 17% in Canada. there has emerged a substantial body of research that tracks From a policy-making point of view it would make most sense to patterns of international migration of health personnel, intensify diaspora initiative strategies amongst more recent black doctors H in South Africa where the level of interest in future engagement is great- assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is est. The doctors interviewed in South Africa identified a number of areas attracting growing interest. For almost 15 years South Africa has been in which they could see emigrant doctors engaging without the need to the target of a ‘global raiding’ of skilled professionals by several devel- physically return to Zimbabwe or simply by returning for short periods oped countries. How to deal with the consequences of the resultant out- of time (Figure 11). These included short term teaching contracts at the flow of health professionals is a core policy issue for the national gov- medical school and short-term hospital placements, exchange and schol- ernment. arship programmes, fundraising and sourcing medical equipment. This paper aims to to examine policy debates and issues concerning Likelihood of return is strongly related to four main variables: race, the migration of skilled health professionals from the country and to age, year of migration and current country of residence: furnish new insights on the recruitment patterns of skilled health per- • 53% of black physicians said they are likely to return to sonnel. The objectives of the paper are twofold: Zimbabwe compared to only 11% of white physicians. Conversely, • To provide an audit of the organization and patterns of recruit- 70% of the whites said they would never return compared to ment of skilled professionals from South Africa in the health only 16% of the blacks. In other words, the potential for return is sector. The paper draws upon a detailed analysis of recruitment higher amongst black physicians and only a small minority (16%) advertising appearing in the South African Medical Journal for definitely ruled out the possibility. the period 2000-2004 and a series of interviews conducted with • the possibility of return is highest amongst the younger doctors: private recruiting enterprises. 78% in the 31-40 age group said they are likely to return, com- • Based upon the above analysis and additional interviews with pared to 23% in the 41-50 age group, 10% in the 51-60 age group key stakeholders in the South African health sector, the paper and none over the age of 60. offers a series of recommendations for addressing the problem of • the year of emigration is positively correlated with the possibility skilled health migration. These recommendations are grounded of return. The likelihood of return is higher amongst more recent in both South African experience and an interrogation of inter- graduates (dominated by black doctors) than amongst earlier national debates and ‘good policy’ practice for regulating recruit- migrants (dominated by white doctors). Only 5% of the doctors ment. who emigrated before 1980 are likely to return, compared with The paper is organized into five sections. Section Two positions 12% of those who left in the 1980s, 30% of those who left in the debates about the migration of skilled health professionals within a 1990s and 79% of those who left after 2000. wider literature that discusses the international mobility of talent. • possibility of return varies with a doctor’s current country of Section Three reviews research on the global circulation of health pro- residence. Return was more likely among those located in South fessionals, focusing in particular upon debates relating to the experience Africa (40%) than those in the UK (21%) or in the USA (13%). of countries in the developing world. Section Four moves the focus from Perhaps surprisingly, specialisation does not have a significant impact international to South African issues and provides new empirical mate- on likelihood of return. More than two-thirds of the emigrant doctors rial drawn from the survey of recruitment patterns and key interviews have managed to specialise since leaving Zimbabwe. However, the undertaken with health sector recruiters operating in South Africa. proportion of specialists and general practitioners who said return was Section Five addresses the questions of changing policy interventions in likely was almost the same (29% versus 30%). At the same time, return- South Africa towards the outflow of skilled health professionals and the ing specialists are more likely to establish their own private practices in recruitment of foreign health professionals to work in South Africa. The urban areas which would reduce the impact of return migration on the public health system in Zimbabwe.

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EXECUTIVETheSUMMARY wariness of many doctors about returning permanently to Zimbabwe can be attributed to several factors. Some doctors reported that they knewealth of workers individuals are onewho of had the unsuccessfully categories of skilledtried to profession- return to Zimbabwe. Theyals most fear affected that premature by globalization. return would Over also the endpast in decade, failure because thethere factors has which emerged drove a substantialthem out in body the firstof research place have that not tracks been addressed.patterns of international migration of health personnel, HIntegration in destination countries is probably the strongest fac- assesses causes and consequences, and debates policy responses at global torand hindering national scales.return, Withinparticularly this literature,amongst older the casephysicians. of South As Africa Dr John is Mandazaattracting noted: growing interest. For almost 15 years South Africa has been the targetThere of area ‘global a lot ofraiding’ things ofthat skilled would professionals make it difficult by several for me developed countries.to simply uprootHow to and deal go. with Coming the consequences here (to South of Africa)the resultant outflow ofis health not like professionals a visit. You iscome a core here policy and youissue have for the to settlenational as government.much as possible. And if you are settled you cannot just Thisleave, paper it’s aims not tothat to easy.examine I mean, policy the debates banks will and be issues interested concerning the migrationin knowing of skilled where healthI am going professionals – we have from got thecar countryloans, hous and- to furnishes new on mortgages,insights on bank the recruitment overdrafts, contractspatterns ofthat skilled are running health personnel.and The so objectivesforth. So even of the if paperthings arewere twofold: to be okay today and I •really To provide want to an go audit back ofhome the organizationit would take and me patternsa bit of time of recruit- toment clear of up skilled all my professionals obligations.72 from South Africa in the health sector. The paper draws upon a detailed analysis of recruitment Closelyadvertising related to appearing the issue inof theintegration South African is that ofMedical lifestyle. Journal Generally, for the standardthe period of living 2000-2004 which the and respondents a series of interviewsenjoy outside conducted Zimbabwe with would notprivate be duplicated recruiting if enterprises. they moved back. Some doctors also feel that in their• Basedabsence upon they the have above lost analysisthe ability and to additional cope with interviewsthe rapidly with changing economickey stakeholders situation in in Zimbabwe: the South African health sector, the paper Theoffers biggest a series problem of recommendations about going back for to addressing Zimbabwe the is thatproblem of whenskilled you health leave migration.you lose your These street recommendations skills. You lose the are grounded skillsin both you Southneed to African live there experience because andit’s not an interrogationeasy to live in of inter- a nationalcountry likedebates Zimbabwe. and ‘good You policy’ have to practice know where for regulating you can recruit- buyment. petrol, groceries and so forth. In Zimbabwe, you can’t Thejust paper walk is into organized any shop into and five buy sections. what you Section want. Two And positions when debatesyou about are outthe ofmigration the country of skilled for a longhealth period professionals of time and within the a wider placeliterature changes that sodiscusses rapidly theyou international lose those abilities. mobility You of can’t talent. go Sectionfrom Three a place reviews like researchthis and liveon the there global easily. circulation73 of health professionals, focusing in particular upon debates relating to the experience Registration in Zimbabwe is another factor that inhibits return. A num- of countries in the developing world. Section Four moves the focus from ber of doctors left without fulfilling the mandatory requirements from the international to South African issues and provides new empirical mate- health ministry, including internship and community service. On return, rial drawn from the survey of recruitment patterns and key interviews they would be required to work in government hospitals under supervi- undertaken with health sector recruiters operating in South Africa. sion before they could register for independent practice. Specialists, in Section Five addresses the questions of changing policy interventions in particular, are unlikely to want to work in government hospitals and South Africa towards the outflow of skilled health professionals and the under the supervision of less qualified individuals. recruitment of foreign health professionals to work in South Africa. The Some physicians felt they would inevitably face hostility from resent- ful colleagues who would see them as ‘traitors’ who left at the height of a

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EXECUTIVE SUMMARY major crisis in Zimbabwe and returned when stability was restored: Some guys tried to go back but they found the environment ealth workers are one of the categories of skilled profession- so hostile in several ways. Any professional returning to als most affected by globalization. Over the past decade, Zimbabwe is bound to face open hostility from fellow pro- there has emerged a substantial body of research that tracks fessional colleagues who will look at you and say ‘you are a Hpatterns of international migration of health personnel, traitor why don’t you stay at your overseas bases.’74 assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is This resentment would be exacerbated if returning physicians had superior attracting growing interest. For almost 15 years South Africa has been qualifications and were viewed as a ‘threat’ by those who did not migrate. the target of a ‘global raiding’ of skilled professionals by several devel- Zimbabwe does not recognise dual citizenship. The Citizenship of oped countries. How to deal with the consequences of the resultant out- Zimbabwe Amendment Act No. 12 of 2001 requires Zimbabweans who flow of health professionals is a core policy issue for the national gov- were once citizens of other countries or whose parents were once forernment. eigners to formally renounce that foreign citizenship in order to qualify This paper aims to to examine policy debates and issues concerning for Zimbabwean citizenship. Political commentators observed that the the migration of skilled health professionals from the country and to law was meant to strip the citizenship of Zimbabweans of European furnish new insights on the recruitment patterns of skilled health per- origin and blacks on white owned farms whose parents originated from sonnel. The objectives of the paper are twofold: neighbouring countries.75 These groups were identified as being sup- • To provide an audit of the organization and patterns of recruit- porters of the opposition MDC party. Crucially, many white medical ment of skilled professionals from South Africa in the health doctors lost their citizenship by default as their parents were born out- sector. The paper draws upon a detailed analysis of recruitment side Zimbabwe. It became extremely difficult for white Zimbabweans advertising appearing in the South African Medical Journal for to obtain a Zimbabwean passport and many were forced to adopt the the period 2000-2004 and a series of interviews conducted with citizenship of their host countries. There is therefore little chance of the private recruiting enterprises. white Zimbabwean doctors who lost their citizenship ever returning to • Based upon the above analysis and additional interviews with Zimbabwe because they feel disenfranchised and unwanted. key stakeholders in the South African health sector, the paper Closely connected to the foregoing is the legacy of the chaotic fast offers a series of recommendations for addressing the problem of track land reform programme. The farms targeted for violent occupa- skilled health migration. These recommendations are grounded tion during the land reform exercise were owned by white commercial in both South African experience and an interrogation of inter- farmers. Some of the doctors were affected directly as their families were national debates and ‘good policy’ practice for regulating recruit- forced out of the country. Others, like Dr Dan Matthews, had originally ment. harboured thoughts of returning to Zimbabwe but found themselves The paper is organized into five sections. Section Two positions without any familial links because their families had left the country. In debates about the migration of skilled health professionals within a the absence of familial links, a number of white Zimbabwean doctors are wider literature that discusses the international mobility of talent. likely to stay permanently abroad. Section Three reviews research on the global circulation of health pro- In sum, a wide range of factors militate against the return of fessionals, focusing in particular upon debates relating to the experience Zimbabwean medical doctors from abroad. Even with political and eco- of countries in the developing world. Section Four moves the focus from nomic stability, there is no guarantee that the emigrant professionals international to South African issues and provides new empirical mate- would return as they have become socially and economically entrenched rial drawn from the survey of recruitment patterns and key interviews in various other countries. In fact, the longer the political and economic undertaken with health sector recruiters operating in South Africa. upheavals persist, the more the doctors are likely never to return. Given Section Five addresses the questions of changing policy interventions in that return migration is highly unlikely for many Zimbabwean physicians South Africa towards the outflow of skilled health professionals and the and strictly conditional for the rest, the question is whether there are recruitment of foreign health professionals to work in South Africa. The other forms of engagement through which the physicians might assist the reconstruction and development of Zimbabwe.

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MEXECUTIVEedical TrainingSUMMARY and Capacity-Building One of the ways in which the Zimbabwean medical diaspora noted that ealth workers are one of the categories of skilled profession- they could contribute to the development of Zimbabwe’s health delivery als most affected by globalization. Over the past decade, system would be to teach students at the medical school. The coun- there has emerged a substantial body of research that tracks try’s only medical school has suffered a massive loss of professors as a patterns of international migration of health personnel, Hresult of the current economic and political crisis. This has negatively assesses causes and consequences, and debates policy responses at global affected the quality of training programmes and increased the workload and national scales. Within this literature, the case of South Africa is of the remaining professionals. The emigrant doctors believe that train- attracting growing interest. For almost 15 years South Africa has been ing help is the best way towards solving the human resource crisis fac- the target of a ‘global raiding’ of skilled professionals by several devel- ing Zimbabwe’s health delivery system. Dr Cathy Marriot, for example, oped countries. How to deal with the consequences of the resultant out- noted: flow of health professionals is a core policy issue for the national government.The doctors who are outside Zimbabwe can definitely offer Thisintellectual paper aims help. to to If examinethey could policy spend debates time lecturing and issues and concerning the migrationif you could of skilled get doctors health to professionals go to Zimbabwe from andthe helpcountry with and to furnishthe new training insights of ondoctors the recruitment there, even patternsif it’s short-term... of skilled healthIf you personnel.could The goobjectives for a week of theand paperlecture, are I twofold:would certainly be willing •to To go provide back and an do audit something of the organization like that.76 and patterns of recruit- Five mentof the of medical skilled doctorsprofessionals interviewed from South in South Africa Africa in thehad health already made contactsector. with The thepaper medical draws school.upon a Threedetailed had analysis offered of to recruitment teach certain courseadvertising modules appearing free of charge. in the South African Medical Journal for Dr Timthe Makombeperiod 2000-2004 plans to andorganise a series the ofdoctors interviews based conducted in South Africawith so that theyprivate could recruiting help with enterprises. the teaching load at the medical school.77 Though• Basedhis plans upon have the not above yet analysisbeen put and into additional practice, theyinterviews represent with an innovativekey idea stakeholders that could in significantly the South African improve health the quality sector, of the training paper at the medicaloffers a school. series of Such recommendations short term working for addressing visits could the have problem several of beneficialskilled impacts health on themigration. country. These The emigrant recommendations doctors are are based grounded in more sophisticatedin both South health African systems experience and are likelyand an to interrogation pass on the skills of inter- and knowledgenational which debates they have and acquired ‘good policy’ abroad practice to Zimbabwean for regulating medical recruit- stu- dents. Furthermore,ment. since the emigrant doctors are knowledgeable about the Theconditions paper isin organized Zimbabwe, into they five are sections. likely to Section pass on Twomore positions useful knowl- edgedebates compared about the to professionalsmigration of trainedskilled healthelsewhere. professionals within a widerEfforts literature are already that discusses under way the in international Zimbabwe to mobilitytap into ofthe talent. professional skillsSection of emigrantThree reviews doctors. research The IOM’s on the Sequenced global circulation Short Term of health Return pro- offessionals, Health Personnel focusing inProgramme particular targetsupon debates medical relating professionals to the suchexperience as doctors,of countries nurses, in themedical developing laboratory world. technologists Section Four and moves pharmacists. the focus The from programmeinternational has to two South main African components. issues and78 The provides first focuses new empirical on bringing mate- backrial drawn lecturers from for the short survey periods of recruitment of time (2-4 patterns weeks) andto teach key interviewsat the medi- calundertaken school. In with future, health the sectorprogramme recruiters will incorporateoperating in virtual South learningAfrica. (or e-learning)Section Five in addresses which the the lecturers questions teach of changingstudents atpolicy the medical interventions school inin ZimbabweSouth Africa from towards their bases the outflow abroad. of IOM skilled does health not pay professionals the participating and the doctorsrecruitment a salary of foreign for their health services professionals but offers themto work a basic in South living Africa. allowance The and pays their travel costs. At the time of the study, the programme had

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EXECUTIVE SUMMARY just started and they had managed to bring back temporarily three lecturers to teach at the medical school. Health institutions had not benefit- ealth workers are one of the categories of skilled profession- ted because they were still awaiting permission from the government. To als most affected by globalization. Over the past decade, facilitate the learning process, IOM intends to provide material support there has emerged a substantial body of research that tracks to the medical school in the form of medical equipment and educational patterns of international migration of health personnel, books. The other component focuses on health institutions such as H hospitals and clinics in rural areas. This component aims to bring medi- assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is cal doctors back to Zimbabwe to work in medical institutions for short attracting growing interest. For almost 15 years South Africa has been periods. IOM works with diaspora associations to contact the emigrant the target of a ‘global raiding’ of skilled professionals by several devel- health professionals. In the UK, the Zimbabwe Health Training Support oped countries. How to deal with the consequences of the resultant out- Trust is helping the IOM recruit doctors to participate in the programme. flow of health professionals is a core policy issue for the national gov- Short term returns provide a number of important potential benefits. ernment. First, they provide much needed professional expertise in institutions, This paper aims to to examine policy debates and issues concerning such as the medical school, that have been hard hit by the brain drain. the migration of skilled health professionals from the country and to Secondly, they utilise the professional expertise of the medical doctors furnish new insights on the recruitment patterns of skilled health per- who are knowledgeable about conditions in Zimbabwe and who are sonnel. The objectives of the paper are twofold: willing to be part of the solution to the country’s brain drain problem. • To provide an audit of the organization and patterns of recruit- Thirdly, (re)introducing medical doctors to Zimbabwe’s health system lit- ment of skilled professionals from South Africa in the health tle by little may eventually turn into a permanent solution to the brain sector. The paper draws upon a detailed analysis of recruitment drain since it allows the medical doctors to form their own impressions of advertising appearing in the South African Medical Journal for the country, which might lead to an eventual decision to return perma- the period 2000-2004 and a series of interviews conducted with nently. private recruiting enterprises. A significant number of emigrant Zimbabwean doctors are employed • Based upon the above analysis and additional interviews with in academic institutions abroad. These individuals can facilitate key stakeholders in the South African health sector, the paper exchange programmes which would mutually benefit medical students offers a series of recommendations for addressing the problem of from both sides. Promising medical students from Zimbabwe could enter skilled health migration. These recommendations are grounded into exchange programmes with overseas universities which would expose in both South African experience and an interrogation of inter- them to medical technology not yet available in Zimbabwe. In addition, national debates and ‘good policy’ practice for regulating recruit- they would learn the latest techniques in the field of medicine from these ment. countries to pass on to their colleagues on their return to Zimbabwe. The paper is organized into five sections. Section Two positions On the other hand, students from developed countries can be exposed debates about the migration of skilled health professionals within a to new disease profiles prevalent in tropical countries and gain surgi- wider literature that discusses the international mobility of talent. cal experience in the process. As Dr Webster Jacobs, who is based in Section Three reviews research on the global circulation of health pro- Durban, suggested: fessionals, focusing in particular upon debates relating to the experience What you would do is you go to the professor of the depart- of countries in the developing world. Section Four moves the focus from ment and say, in Zimbabwe we have a lot of patients who international to South African issues and provides new empirical mate- need surgery but there are a few doctors. Give us some of rial drawn from the survey of recruitment patterns and key interviews your senior students or graduated doctors who are now undertaken with health sector recruiters operating in South Africa. training in specialisation... You pick them up and put them Section Five addresses the questions of changing policy interventions in in Zimbabwe where they will get lots of surgical experience. South Africa towards the outflow of skilled health professionals and the But then you get a Zimbabwean doctor who has got lots of recruitment of foreign health professionals to work in South Africa. The surgery experience but not enough academic training and send him to Canada or whichever country so that you have reciprocity.79 1 40 kkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkk MMIGRATIONigration PPOLICYolicy SERIESeries NOo. 4555

EXECUTIVEThus,SUMMARY a programme could be put in place to ensure that senior medical students from developed countries come to Zimbabwe to obtain surgical experienceealth under workers the are supervision one of the of categories Zimbabwean of skilled medical profession- doctors. They wouldals be mostoperating affected on realby globalization. people with real Over problems the past and decade, would also help in therealleviating has emerged the human a substantial resource crisisbody inof theresearch country’s that healthtracks sector. patterns of international migration of health personnel, HTwo of the medical doctors interviewed in South Africa are heads assesses causes and consequences, and debates policy responses at global ofand department national scales. at medical Within schools. this literature, They are theworld-renowned case of South academics Africa is whoattracting once headedgrowing the interest. colleges For of almost their various 15 years specialties South Africa in South has beenAfrica. Suchthe target individuals of a ‘global can offer raiding’ technical of skilled assistance professionals in the revampingby several devel-of the medicaloped countries. school and How may to dealhelp withcreate the new consequences training programmes. of the resultant One of out- themflow ofis healthalready professionals working with is an a coreoverseas policy college issue infor trying the national to set up gov- a specialisternment. training programme in Malawi. Being Zimbabwean, he hopes to extendThis paper the programme aims to to examineto Zambia policy and Zimbabwe,debates and linking issues upconcerning the three countriesthe migration in one of integratedskilled health training professionals programme. from the country and to furnishThe newactivities insights of Professor on the recruitment Jacobs, an ex-Zimbabweanpatterns of skilled doctor health at per- anothersonnel. TheSouth objectives African medicalof the paper school, are are twofold: of relevance. According to a colleague,• To Professorprovide an Jacobs audit would of the “go organization out of his wayand topatterns publish of a recruit- paper in the Centralment African of skilled Medical professionals Journal andfrom he South would Africa go out in of the his health way to employ ex-Zimbabweanssector. The paper as draws registrars. upon Soa detailed he had lotsanalysis of Zimbabwean of recruitment registrars thatadvertising he took appearingon board to in specialise. the South He African would Medical go out of Journal his way for to go and presentthe period at conferences 2000-2004 and ato series teach of in interviews Harare.”80 conducted with The privateemigrant recruiting doctors saidenterprises. they could also help students at the medical •school Based by sourcing upon the and above donating analysis books. and Aadditional number ofinterviews the emigrant with Zimbabweankey stakeholders doctors are employedin the South in the African academic health field sector, and havethe paper accu- mulatedoffers a lot ofa series books of which recommendations the students atfor the addressing medical theschool problem might of find useful.skilled They health can alsomigration. source medicalThese recommendations textbooks from their are groundedcolleagues at their inacademic both South institutions. African Evenexperience those notand in an the interrogation academic field of inter- reportednational having adebates number and of useful‘good policy’texts which practice they for would regulating be willing recruit- to donate toment. the medical school’s library. The paper is organized into five sections. Section Two positions Short-Termdebates Visi aboutts the migration of skilled health professionals within a wider literature that discusses the international mobility of talent. AllSection of the Three doctors reviews identified research short-term on the hospitalglobal circulation visits as one of healthway in pro- whichfessionals, they focusing could give in somethingparticular uponback debatesto Zimbabwe. relating Dr to Mbiri, the experience a black Zimbabweanof countries inmedical the developing doctor based world. in Tasmania,Section Four returns moves to Zimbabwethe focus from forinternational varying periods to South of time African and volunteers issues and inprovides the public new hospitals. empirical At mate- onerial drawnpoint he from spent the nearly survey six of monthsrecruitment working patterns at a public and key hospital interviews in Zimbabwe.undertaken Many with healthmore would sector be recruiters willing to operating consider inthis South option. Africa. As Dr SimonSection Chiremba Five addresses noted, the “most questions of us would of changing be happy policy to go, interventions say when I amin onSouth leave, Africa to help towards for a theweek outflow or two of with skilled difficult health cases professionals or even easy and ones, the 81 justrecruitment to clear upof foreignsome of health the operations professionals that toneed work to bein Southdone.” Africa. Some The of the doctors expressed interest in spending part of their annual vacation

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EXECUTIVE SUMMARY providing essential medical help to Zimbabwean patients. They could either work in selected hospitals or be organised into medical teams ealth workers are one of the categories of skilled profession- that go around the country conducting specialised medical procedures. als most affected by globalization. Over the past decade, Currently, the Zimbabwean government does not have the capacity to there has emerged a substantial body of research that tracks support such a mission. To make this arrangement work, resources would patterns of international migration of health personnel, need to be mobilised from the international community to ensure that H the volunteer doctors do not bear the full burden of the cost of their stay assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is in Zimbabwe. attracting growing interest. For almost 15 years South Africa has been the target of a ‘global raiding’ of skilled professionals by several devel- Raising Funds and Sourcing Supplies oped countries. How to deal with the consequences of the resultant outflow of health professionals is a core policy issue for the national gov- Fundraising was identified as another possible area of involvement by ernment. the emigrant medical doctors. A concerted effort would be required to This paper aims to to examine policy debates and issues concerning help kick-start the health system in Zimbabwe and the emigrant doctors the migration of skilled health professionals from the country and to are well placed to play an important role in this respect. They can help furnish new insights on the recruitment patterns of skilled health per- raise funds by either contributing directly or by participating in the drive sonnel. The objectives of the paper are twofold: to raise funds to equip hospitals in Zimbabwe with medical equipment • To provide an audit of the organization and patterns of recruit- and medicines. Some of the medical doctors interviewed were worried ment of skilled professionals from South Africa in the health that medical education was getting beyond the reach of the poor due sector. The paper draws upon a detailed analysis of recruitment to the ever-increasing tuition fees. Emigrant professionals might initiate advertising appearing in the South African Medical Journal for programmes that would fund the education of students from poor back- the period 2000-2004 and a series of interviews conducted with grounds at the medical school. Dr Cathy Marriot suggested that “some private recruiting enterprises. doctors can get together and raise funds to support a certain student – • Based upon the above analysis and additional interviews with they could sponsor a student through the medical school. They can also 82 key stakeholders in the South African health sector, the paper sponsor a clinic and some doctors here have done that.” offers a series of recommendations for addressing the problem of Another area in which the emigrant medical doctors said they could skilled health migration. These recommendations are grounded help develop Zimbabwe’s health delivery system is through the sourc- in both South African experience and an interrogation of inter- ing of drugs and equipment. Many of the emigrant Zimbabwean doctors national debates and ‘good policy’ practice for regulating recruit- work in developed countries where technology is constantly changing ment. thereby making redundant equipment that might still be in a good and The paper is organized into five sections. Section Two positions usable state. The hospitals in such countries are willing to give away debates about the migration of skilled health professionals within a such equipment if it is going to be put to good use. As Dr Henry Porter wider literature that discusses the international mobility of talent. observed: “The doctors can also help by sourcing equipment from their Section Three reviews research on the global circulation of health pro- hospitals which is not being used. Most of the equipment is still usable fessionals, focusing in particular upon debates relating to the experience but is lying idle in some hospitals. These could be utilised in the hospitals 83 of countries in the developing world. Section Four moves the focus from in Zimbabwe.” international to South African issues and provides new empirical mate- Technical expertise is another area in which the emigrant doctors rial drawn from the survey of recruitment patterns and key interviews might help re-develop Zimbabwe’s health system. Knowledgeable indi- undertaken with health sector recruiters operating in South Africa. viduals are needed to set up specialised units. This would cost a lot of Section Five addresses the questions of changing policy interventions in money if private contractors are hired but some emigrant doctors are pre- South Africa towards the outflow of skilled health professionals and the pared to offer their services for free. Dr Leonard Jordan, for instance, said recruitment of foreign health professionals to work in South Africa. The he is willing to help set up a plastic surgery unit in the public health institutions in the country: “Setting up a plastic surgery unit is a huge amount of work. But I know how to do it. I know what theatre tables to get, what 1 42 kkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkk MMIGRATIONigration PPOLICYolicy SERIESeries NOo. 4555

EXECUTIVElights,S instruments,UMMARY machines, what post-operative care the patient needs and what kind of anaesthesia they need… if they hired a consultant from the US to doealth that workers kind of arework one it wouldof the costcategories them millionsof skilled of profession- rands.”84 als most affected by globalization. Over the past decade, ‘Virtual Return’: thereTelemedicine has emerged a substantial body of research that tracks patterns of international migration of health personnel, HThe growth of telecommunication technology is revolutionising the way assesses causes and consequences, and debates policy responses at global inand which national medicine scales. is Withinpracticed. this One literature, of the productsthe case of Souththe information Africa is age,attracting telemedicine, growing involves interest. the For “use almost of electronic 15 years South information Africa andhas beencom- municationthe target of technologies a ‘global raiding’ to provide of skilled and professionalssupport healthcare by several when devel- dis- 85 tanceoped countries.separates theHow participants.” to deal with the In theconsequences developed ofworld, the resultantit has been out- usedflow toof healthprovide professionals healthcare in is rurala core areas, policy online issue continuing for the national education gov- forernment. physicians in these areas, and special medical services for the elderly, the Thishandicapped paper aims and to terminally to examine ill policypatients debates at home. and In issues most concerning cases, the participantsthe migration communicate of skilled health in real professionals time through from a network the country that allowsand to for two-wayfurnish new or multiple insights face-to-faceon the recruitment video and patterns interactive of skilled communication. health personnel.In the The developed objectives world, of the telemedicine paper are twofold: has been advocated as a way for medical• To providedoctors anto reduceaudit of their the organizationcarbon footprint. and patternsIn the period of recruit- 2001- 2006, overment 1,000 of skilled consultations professionals were heldfrom withSouth patients Africa in in Queensland, the health Australia,sector. which The eliminated paper draws about upon 1.4 amillion detailed kilometres analysis of patientrecruitment 86 travel, reducingadvertising carbon appearing emissions in the by 39South tonnes African per year. Medical The Journal use of forvir- tual systemsthe period in medical 2000-2004 practice and is evidenceda series of byinterviews the growth conducted of technology with supportedprivate disciplines recruiting such enterprises.as teleneurology, teleradiology, telecardiology, telenursing,• Based and upon telematics, the above used analysis to monitor and additional patients with interviews heart condi with- tions or keydiabetes stakeholders remotely. in the South African health sector, the paper One offersof the a interviewees series of recommendations noted that telemedicine for addressing represents the problem a way in of which emigrantskilled health doctors migration. could contribute These recommendations to Zimbabwe’s health are grounded delivery system: in both South African experience and an interrogation of inter- Younational can explore debates some and new ‘good ways policy’ of using practice the skillsfor regulating of medi- recruit- calment. doctors who are based overseas; I mean ways that do Thenot paper require is organized them to beinto physically five sections. present Section in Zimbabwe. Two positions I debatesthink about telemedicine the migration offers of skilledan exciting health option professionals as it allows within the a wider doctorsliterature who that are discusses in Zimbabwe the international to connect withmobility the overseasof talent. Sectionbased Three specialists. reviews researchI think it on is quitethe global an interesting circulation option. of health87 professionals, focusing in particular upon debates relating to the experience Doctors in Zimbabwe would be able to consult Zimbabwean special- of countries in the developing world. Section Four moves the focus from ists abroad via video-link in the presence of the patient. The specialists international to South African issues and provides new empirical mate- would offer useful advice to both the general practitioner and the patient rial drawn from the survey of recruitment patterns and key interviews on the best way to address the medical condition. undertaken with health sector recruiters operating in South Africa. Even though this option might seem attractive, there are several Section Five addresses the questions of changing policy interventions in obstacles to its adoption in Zimbabwe. First, telecommunication tech- South Africa towards the outflow of skilled health professionals and the nologies are poorly developed, particularly in rural areas which have the recruitment of foreign health professionals to work in South Africa. The greatest need for telemedicine. However, if a policy to develop telemedicine is put in place, this could provide an impetus to make telecommuni-

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EXECUTIVE SUMMARY cation technologies available in the country’s rural areas. The use of telemedicine could have a positive impact on the supply of doctors in rural ealth workers are one of the categories of skilled profession- areas, who avoid such locations because of fears of professional isolation. als most affected by globalization. Over the past decade, Telemedicine ensures that the medical doctors posted in such areas have there has emerged a substantial body of research that tracks back-up staff to contact either via phone/email or via video-conferencing patterns of international migration of health personnel, so that they could obtain real-time information on certain medical proce- H dures. The move towards telemedicine should be supported not only for assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is professionals based in remote locations but also for those located in major attracting growing interest. For almost 15 years South Africa has been cities as it encourages the sharing of ideas with the professionals overseas. the target of a ‘global raiding’ of skilled professionals by several devel- Secondly, some emigrant doctors based in Southern African nations oped countries. How to deal with the consequences of the resultant out- face the same problem of poor internet connectivity. Thirdly, the system flow of health professionals is a core policy issue for the national gov- supporting telemedicine is expensive to set up. Governments of poor ernment. countries are not likely to be able to afford such expensive systems. The This paper aims to to examine policy debates and issues concerning involvement of international donor organisations in setting up tele- the migration of skilled health professionals from the country and to medicine infrastructure is therefore crucial. Fourthly, internet-based furnish new insights on the recruitment patterns of skilled health per- technologies are prone to ‘electronic snooping’ and specialised informa- sonnel. The objectives of the paper are twofold: tion technology personnel would need to monitor and protect the system. • To provide an audit of the organization and patterns of recruit- Finally, there have been concerns about the ethics of telemedicine on ment of skilled professionals from South Africa in the health issues such as confidentiality and access to medical records of patients.88 sector. The paper draws upon a detailed analysis of recruitment advertising appearing in the South African Medical Journal for Obstacles to Engagement the period 2000-2004 and a series of interviews conducted with private recruiting enterprises. A number of obstacles could hinder the success of diaspora initiatives in • Based upon the above analysis and additional interviews with Zimbabwe. For a start, medical doctors would need to be registered by key stakeholders in the South African health sector, the paper the MDPCZ before they could legally practice, even for a short period offers a series of recommendations for addressing the problem of of time. A number of emigrant Zimbabwean medical doctors left the skilled health migration. These recommendations are grounded country before completing either their housemanship or community in both South African experience and an interrogation of inter- service. They have since acquired additional qualifications abroad and national debates and ‘good policy’ practice for regulating recruit- have become specialists in their respective fields. The MDPCZ insists ment. that such individuals need to complete a year of working in government The paper is organized into five sections. Section Two positions service first before they could be fully licensed to practice. Still others left debates about the migration of skilled health professionals within a Zimbabwe after earning their professional qualification but their registra- wider literature that discusses the international mobility of talent. tion with the MDPCZ has lapsed. All these doctors would need to renew Section Three reviews research on the global circulation of health pro- their registration before they could practice. Under current conditions, fessionals, focusing in particular upon debates relating to the experience they would need to work under supervision in Zimbabwe for a period of of countries in the developing world. Section Four moves the focus from up to a year before they can be allowed to re-register. This is likely to be international to South African issues and provides new empirical mate- the major hindrance in recruiting emigrant doctors to work temporarily rial drawn from the survey of recruitment patterns and key interviews in the country. As Dr Mavis Makoni indicated: undertaken with health sector recruiters operating in South Africa. I have friends who were in my class at the medical school Section Five addresses the questions of changing policy interventions in who went back to Zimbabwe. They were so disappointed. South Africa towards the outflow of skilled health professionals and the They had to come back because they couldn’t register...I recruitment of foreign health professionals to work in South Africa. The think if Zimbabwe is going to realise benefits from the doctors abroad, things have to change. They have to realise that

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EXECUTIVE SinUMMARY order to get something out of these people they have to be reasonable about professionals who are coming back and planningealth to workers be registered are one and of workthe categories in Zimbabwe. of skilled89 profession- Changesals would most need affected to be by made globalization. to the current Over regulations the past decade, so that medical doctorsthere who has areemerged practising a substantial in reputable body health of research systems that can tracks regis- Hter to work patternsin Zimbabwe of international with minimal migration effort. Even of health though personnel, the registrar ofassesses the MDPCZ causes andmaintained consequences, that all and the debatescases are policy dealt responseswith differently, at global newand nationalguidelines scales. clearly Within need to this be literature,put in place the so case that of the South qualifications Africa is earnedattracting abroad growing can beinterest. verified For and almost easily 15 credited years South to the Africa professionals has been wishingthe target to ofre-register a ‘global in raiding’ Zimbabwe. of skilled The professionalsMDPCZ could by even several take devel- a lead byoped registering countries. unconditionally How to deal with all known the consequences Zimbabwean of medical the resultant doctors out- abroadflow of whohealth are professionals working in the is a medical core policy field issueafter forverifying the national their qualifi gov- - cationsernment. with their respective boards. Such a measure would make it easy for theThis emigrant paper aims doctors to to to examine pursue policyshort term debates contracts and issues without concerning having tothe go migration through theof skilled trouble health of securing professionals registration. from the country and to furnishAnother new potentialinsights on obstacle the recruitment to diaspora patterns engagement of skilled is the health attitude per- ofsonnel. medical The doctors objectives who ofare the in Zimbabwe.paper are twofold: The interview respondents indicated• To that provide those an taking audit part of the in theseorganization programmes and patterns are likely of to recruit- face hostilityment from oftheir skilled counterparts professionals in Zimbabwe. from South First, Africa some in see the those health in the diasporasector. as The‘sell-outs’ paper whodraws left upon when a detailedthe conditions analysis in of the recruitment country were difficultadvertising and now appearing want to in come the Southback when African there Medical are signs Journal that thefor economythe is recovering.period 2000-2004 Secondly, and they a series have of charted interviews their conducted own path within trying circumstancesprivate recruiting and doenterprises. not want someone coming to tell them that they• need Based to make upon certain the above changes analysis at the and health additional institutions interviews which with they run. Thiskey element stakeholders of protectiveness in the South may African lead in-country health sector, professionals the paper to resent theoffers short-term a series ofreturnees: recommendations for addressing the problem of skilled health migration. These recommendations are grounded Youin bothget resistance South African from your experience colleagues; and theyan interrogation don’t want you of inter- there.national I know debates of somebody and ‘good who policy’ has offeredpractice to for run regulating a clinic recruit- butment. no one is interested. So it’s quite a difficult one. There Theare paper a lot is of organized problems into that fiveneed sections. to be sorted Section out Twofirst, positionsa lot of debatesegos about that the need migration to be straightened of skilled health out before professionals you get thingswithin a wider toliterature run properly. that discusses Everyone the is internationalalways scared mobilityof what are of talent.your 90 Sectionulterior Three motives; reviews researchthere is a on lot the of suspicionglobal circulation on both sides.of health professionals,A further focusing issue concerns in particular the impact upon debates of the reinvigorationrelating to the of experience Zimbabwe’sof countries healthin the systemdeveloping on the world. livelihood Section of Fourthe doctors moves thatthe focusare in from Zimbabwe.international Almost to South all the African senior issues doctors and that provides remain new in Zimbabweempirical mate-serve inrial private drawn hospitals from the in survey addition of recruitment to their public patterns service and jobs. key It interviews is common practiceundertaken for thewith doctors health to sector use public recruiters hospitals operating as a sourcein South of patientsAfrica. for theirSection private Five surgeries.addresses Ifthe a patientquestions needs of changing specialised policy treatment interventions that can -in notSouth be Africaoffered towardsin public the hospitals outflow they of skilled refer them health to professionalstheir surgery andor to the a surgeryrecruitment run by of oneforeign of their health close professionals friends. In thisto work way, in the South doctors Africa. generate The business for their private practices as well as surgeries run by their close

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EXECUTIVE SUMMARY connections. Assuming that the emigrant doctors were to come back and probably mobilise equipment from their overseas bases, the capacity ealth workers are one of the categories of skilled profession- of the public hospitals to cater for difficult cases will be increased. This als most affected by globalization. Over the past decade, would mean that the cases that the doctors would have referred to their there has emerged a substantial body of research that tracks private practices will be reduced and this will affect their income. Dr patterns of international migration of health personnel, Mary Chikomo observed that senior medical doctors in Zimbabwe “have H had their territories charted and they wouldn’t want to be destabilised assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is by returning people. Say you go back to Zimbabwe and set a state of the attracting growing interest. For almost 15 years South Africa has been art surgery near to someone’s surgery that will surely create unnecessary the target of a ‘global raiding’ of skilled professionals by several devel- chaos.”91 oped countries. How to deal with the consequences of the resultant outflow of health professionals is a core policy issue for the national gov- Conclusion: Brain Drain or Brain Gain? ernment. This paper aims to to examine policy debates and issues concerning imbabwe has lost at least 50 percent of its medical doctors over the migration of skilled health professionals from the country and to the past two decades. Their departure has left the country’s furnish new insights on the recruitment patterns of skilled health per- health institutions severely understaffed and severely affected sonnel. The objectives of the paper are twofold: the quality of service delivery. Most of them are unlikely to ever Zreturn permanently to Zimbabwe even with economic and political sta- • To provide an audit of the organization and patterns of recruitment of skilled professionals from South Africa in the health bility in the country. At the same time, few have cut their ties with the sector. The paper draws upon a detailed analysis of recruitment country. The clearest sign of this is their remitting behaviour. advertising appearing in the South African Medical Journal for The majority of physicians outside the country continue to remit cash the period 2000-2004 and a series of interviews conducted with and goods to their families at home. However, the direct developmental private recruiting enterprises. impact of the remittances is questionable since they are used mostly for • Based upon the above analysis and additional interviews with poverty alleviation and not productive investment. Some have made key stakeholders in the South African health sector, the paper the argument in other contexts that the development impact of remit- offers a series of recommendations for addressing the problem of tances is always more indirect, as they are used to buy goods which pro- skilled health migration. These recommendations are grounded motes growth and stimulates demand.92 This argument is problematic in in both South African experience and an interrogation of inter- the Zimbabwe case for a number of reasons. Zimbabwean industry has national debates and ‘good policy’ practice for regulating recruit- ground to a halt and most of the goods being sold are from South Africa. ment. Middlemen, retailers and South African-based manufacturers are the The paper is organized into five sections. Section Two positions main beneficiaries. Recent literature suggests that migrant remittances debates about the migration of skilled health professionals within a compensate for the loss of skilled professionals such as medical doctors.93 wider literature that discusses the international mobility of talent. However, doctors are expensive to train and the volume of remittance Section Three reviews research on the global circulation of health pro- flows certainly does not match the cost of training a physician in the first fessionals, focusing in particular upon debates relating to the experience place.94 of countries in the developing world. Section Four moves the focus from Given the low likelihood of permanent return, diaspora engagement international to South African issues and provides new empirical mate- offers the best policy alternative for Zimbabwe. The study has shown that rial drawn from the survey of recruitment patterns and key interviews there is a large amount of goodwill amongst the medical diaspora. There undertaken with health sector recruiters operating in South Africa. are a lot of emigrant doctors willing to contribute in various ways to the Section Five addresses the questions of changing policy interventions in re-development of Zimbabwe’s health delivery system. This does not South Africa towards the outflow of skilled health professionals and the mean that they necessarily want to come back to Zimbabwe permanently recruitment of foreign health professionals to work in South Africa. The but they are willing to contribute for short periods of time and go back to their bases abroad. Specifically, Zimbabwe can benefit through the

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EXECUTIVEprovisionSUMMARY of professional expertise at the medical school and professional expertise in the country’s health institutions. In addition, the professionals could offerealth technical workers help are inone setting of the up categories various units of skilled that areprofession- not pres- ently availableals mostin Zimbabwe. affected byTelemedicine globalization. is also Over likely the topast yield decade, considerable results thereprovided has theemerged relevant a substantial support structures body of researchare available. that tracks The diasporapatterns option of international could potentially migration yield positiveof health results personnel, for HZimbabwe. However, there is a need to address the obstacles to greater assesses causes and consequences, and debates policy responses at global engagementand national and scales. to disaggregate Within this diasporaliterature, initiatives the case accordingof South Africato the is expectedattracting participation growing interest. levels For of thealmost emigrants. 15 years Diaspora South Africa initiatives has beenneed tothe appeal target to of those a ‘global who raiding’ are interested of skilled in returningprofessionals to the by severalhome country devel- temporarilyoped countries. and Howalso those to deal who with would the wantconsequences to participate of the from resultant their out- basesflow ofoutside health the professionals country. If isthe a coreprofessionals policy issue are madefor the aware national of the gov- rangeernment. of options available to them, there is likely to be great interest in diasporaThis paperengagement. aims to However,to examine these policy benefits debates will and only issues be fully concerning realised inthe a migrationstable economic of skilled and health political professionals environment. from the country and to furnish new insights on the recruitment patterns of skilled health per- Endnotsonnel.es The objectives of the paper are twofold: • To provide an audit of the organization and patterns of recruit- 1 M. Awases, A.ment Gbary, of skilled J. Nyoni professionals and R. Chatora, from SouthMigration Africa of Health in the health Professionals insector. Six Countries: The paper A drawsSynthesis upon Report a detailed (Brazzaville: analysis WHO of recruitment Regional Office for Africa,advertising 2004); appearingB. Liese and in G.the Dussault, South African The State Medical of the JournalHealth for Workforce in Sub-Saharanthe period 2000-2004 Africa: Evidence and a seriesof Crisis of interviewsand Analysis conducted of Contributing with Factors (Washington,private recruiting DC: World enterprises. Bank, 2004); L. Ogilvie, J. E. Mill, B. Astle, A. Fanning• and Based M. uponOpare, the “The above Exodus analysis of Health and additional Professionals interviews from Sub- with Saharan Africa:key Balancing stakeholders Human in the Rights South and African Societal health Needs sector, in the the Twenty- paper First Century”offers Nursing a series Inquiry of recommendations 14(2) (2007): 114–124. for addressing the problem of 2 M. Clemens andskilled G. Pettersson,health migration. A New These Database recommendations for Health Professional are grounded Emigration fromin bothAfrica South (Washington, African experienceD.C: Centre and for an Global interrogation Development, of inter- 2006). national debates and ‘good policy’ practice for regulating recruit- 3 J. Connell, “Towardment. a Global Health Care System?” In J. Connell, eds., The InternationalThe Migration paper is organized of Health intoWorkers five (New sections. York: Section Routledge, Two 2008),positions pp. 1-29.debates about the migration of skilled health professionals within a 4 Ibid. wider literature that discusses the international mobility of talent. 5 D. Kapur,Section “Remittances: Three reviews The research New Development on the global Mantra?” circulation In S. of M. health Maimbo pro- and D.fessionals, Ratha, eds., focusing Remittances: in particular Development upon debates Impact relatingand Future to theProspects experience (Washingtonof countries DC: inWorld the developingBank, 2005), world. pp. 331-360.Section Four moves the focus from 6 OECDinternational, The Looming to Crisis South in African the Health issues Workforce: and provides How Cannew OECDempirical Countries mate- Respond?rial (Paris:drawn fromOECD, the 2008); survey A. of Tanner,recruitment Emigration, patterns Brain and Drain key interviews and Development:undertaken The withCase healthof Sub-Saharan sector recruiters Africa (Helsinki: operating Migration in South Africa.Policy Institute,Section 2005); Five United addresses Nations, the questions International of changing Migration policy and Development: interventions in ReportSouth of the AfricaSecretary-General towards the (Geneva: outflow ofUnited skilled Nations, health professionals2006). and the 7 Awasesrecruitment et al, Migration of foreign of Health health Professionals professionals in Six to Countrieswork in South; J. Mufunda, Africa. R.The Chatora, Y. Ndambakuwa, C. Samkange, L. Sigola and P. Vengesa, “Challenges

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EXECUTIVE SUMMARY in Training the Ideal Doctor for Africa: Lessons Learned from Zimbabwe” Medical Teacher 29(9) (2007): 878-81; A. Chikanda, “The Migration of Health ealth workers are one of the categories of skilled profession- Professionals from Zimbabwe” In Connell, International Migration of Health als most affected by globalization. Over the past decade, Workers, pp. 110-128. there has emerged a substantial body of research that tracks 8 T. Martineau, K. Decker and P. Bundred, Briefing Note on International patterns of international migration of health personnel, Migration of Health Professionals: Levelling the Playing Field for Developing H Country Health Systems (Liverpool: Liverpool School of Tropical Medicine, assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is 2002). attracting growing interest. For almost 15 years South Africa has been 9 H. Grant, “From the Transvaal to the Prairies: The Migration of South African the target of a ‘global raiding’ of skilled professionals by several devel- Physicians to Canada” Journal of Ethnic and Migration Studies 32(2006): 681- oped countries. How to deal with the consequences of the resultant out- 96. flow of health professionals is a core policy issue for the national gov- 10 Medical and Dental Practitioners Council of Zimbabwe, Unpublished ernment. Database (Harare: MDPCZ, 2008). This paper aims to to examine policy debates and issues concerning 11 Clemens and Pettersson, New Database for Health Professional Emigration from the migration of skilled health professionals from the country and to Africa. furnish new insights on the recruitment patterns of skilled health per- 12 J-C. Dumont and P. Zurn, “Immigrant Health Workers in OECD Countries in sonnel. The objectives of the paper are twofold: the Broader Context of Highly-Skilled Migration” In International Migration • To provide an audit of the organization and patterns of recruit- Outlook (Paris: OECD, 2007), pp. 162-228. ment of skilled professionals from South Africa in the health 13 F. Docquier, and A. Bhargava, The Medical Brain Drain: A New Panel Data Set sector. The paper draws upon a detailed analysis of recruitment on Physician’s Emigration Rates (1991-2004) (Washington, DC: World Bank, advertising appearing in the South African Medical Journal for 2006). the period 2000-2004 and a series of interviews conducted with 14 Interview with Dr Walter Choga, Johannesburg, 12 August 2008 (Note: To private recruiting enterprises. protect the identity of respondents, all names used in this report are pseudo- • Based upon the above analysis and additional interviews with nyms). key stakeholders in the South African health sector, the paper 15 L. M. Zinyama, “International Migrations to and from Zimbabwe and the offers a series of recommendations for addressing the problem of Influence of Political Changes on Population Movements, 1965-1987” skilled health migration. These recommendations are grounded International Migration Review 24 (4) (1990): 748-67. in both South African experience and an interrogation of inter- 16 Interview with Dr Webster Jacobs, Durban, 8 September 2008. national debates and ‘good policy’ practice for regulating recruit- 17 Interview with Dr Brian Adams, Johannesburg, 20 August 2008 ment. 18 S. Mahroum, “Highly Skilled Globetrotters: Mapping the International The paper is organized into five sections. Section Two positions Migration of Human Capital” R&D Management 30(1) (2000): 23-32; A. debates about the migration of skilled health professionals within a Portes, and J. Borocz, “Contemporary Immigration: Theoretical Perspectives wider literature that discusses the international mobility of talent. on its Determinants and Modes of Incorporation” International Migration Section Three reviews research on the global circulation of health pro- Review 23(3) (1989): 606-630. fessionals, focusing in particular upon debates relating to the experience 19 Interview with Dr Walter Choga, Johannesburg, 12 August 2008. of countries in the developing world. Section Four moves the focus from 20 Interview with Dr Tim Makombe, Cape Town, 22 October 2008. international to South African issues and provides new empirical mate- 21 D. Tevera and J. Crush, The New Brain Drain from Zimbabwe. SAMP rial drawn from the survey of recruitment patterns and key interviews Migration Policy Series No. 29, Cape Town, 2003; A. Bloch, “Emigration from undertaken with health sector recruiters operating in South Africa. Zimbabwe: Migrant Perspectives” Social Policy and Administration 40(1) (2006): Section Five addresses the questions of changing policy interventions in 67-87; J. McGregor, “Children and ‘African values’: Zimbabwean Professionals South Africa towards the outflow of skilled health professionals and the in Britain Reconfiguring Family Life” Environment and Planning A 40 (2008): recruitment of foreign health professionals to work in South Africa. The 596 – 614. 22 S. Hanke, New Hyperinflation Index (HHIZ) Puts Zimbabwe Inflation at 89.7 Sextillion Percent (Washington, D.C: Cato Institute, 2008). 1 48 kkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkk MMIGRATIONigration PPOLICYolicy SERIESeries NOo. 4555

23EXECUTIVE Interview withSUMMARY Dr Mary Chikomo, Cape Town, 26 October 2008. 24 Chikanda, “Migration of Health Professionals from Zimbabwe.” 25 UNAIDS, Reportealth on the workers Global HIV/AIDSare one of theEpidemic categories 2008 of(Geneva: skilled profession- UNAIDS, 2008). als most affected by globalization. Over the past decade, 26 Joint Learning Initiative,there has Human emerged Resources a substantial for Health: body Overcomingof research thethat Crisis tracks. (Cambridge (MA):patterns Harvard of internationalUniversity Press, migration 2004). of health personnel, 27 A. ChikHanda, “Nurse Migration from Zimbabwe: Analysis of Recent Trends assesses causes and consequences, and debates policy responses at global and Impacts”and national Nursing scales. Inquiry Within 12(3) this (2005): literature, 162-174. the case of South Africa is 28 Interviewattracting with Drgrowing John Mandaza,interest. For Pretoria, almost 27 15 August years South 2008. Africa has been 29 R. Gaidzanwa,the target Voting of a ‘global with their raiding’ Feet: ofMigrant skilled Zimbabwean professionals Nurses by several and Doctors devel- in the Eraoped of Structural countries. Adjustment How to deal (Uppsala: with the Nordiska consequences Afrikainstitutet, of the resultant 1999). out- 30 Interviewflow withof health Dr Walter professionals Choga, isJohannesburg, a core policy 12 issue August for the 2008. national gov- 31 Departmenternment. of Health, Policy Recruitment and Employment of Foreign Health ProfessionalsThis in paper the Republic aims to of to South examine Africa policy (Pretoria: debates Foreign and issues Workforce concerning Managementthe migration Program, of skilled National health Department professionals of Health, from the 2006). country and to 32 Awasesfurnish et al, newMigration insights of Healthon the Professionalsrecruitment in patterns Six Countries of skilled; J. Buchan, health per- T. Parkinsonnel. and The J. Sochalski, objectives International of the paper Nurse are twofold:Mobility: Trends and Policy Implications• (Geneva: To provide WHO, an audit ICN of and the RCN, organization 2004); Connell and patterns et al, ofToward recruit- a Global Healthment Care of System. skilled professionals from South Africa in the health 33 J. Fawcett, “Networks,sector. The Linkages paper draws and Migrationupon a detailed Systems” analysis International of recruitment Migration Reviewadvertising 23(3) (1989): appearing 671-80; in the D. South Gurak, African and F. Caces,Medical “Migration Journal for Networks andthe the period Shaping 2000-2004 of Migration and aSystems” series of Ininterviews M. Kritz, conducted L. Lim, and with H. Zlotnik, eds.,private International recruiting Migration enterprises. Systems: A Global Approach (Oxford: Clarendon• Press, Based 1992), upon pp.the 150-176; above analysis G. Mohan, and additional “Diaspora interviewsand Development” with In J. Robinson,key ed., stakeholders Displacement in andthe SouthDevelopment African (Oxford: health Oxfordsector, the University paper Press in associationoffers a with series the of Openrecommendations University, 2002), for addressing pp. 77-139. the problem of 34 Interview withskilled Dr Simon health Chiremba, migration. Durban, These recommendations15 September 2008. are grounded 35 Interview within Drboth Enoch South Togara, African Durban, experience 17 September and an interrogation 2008. of inter- 36 C. Rogerson andnational J. Crush, debates “The and Recruiting ‘good policy’ of South practice African for regulating Health Care recruit- Professionals”ment. In Connell, International Migration of Health Workers, pp. 199- 224. The paper is organized into five sections. Section Two positions 37 Interviewdebates with about Dr Sam the Mugadza,migration Johannesburg,of skilled health 26 professionalsAugust 2008. within a 38 D. Tevera,wider J.literature Crush and that A. discusses Chikanda, the “Migrant international Remittances mobility and of talent.Household SurvivalSection in Zimbabwe” Three reviews In J. Crushresearch and on D. the Tevera, global eds., circulation Zimbabwe’s of health Exodus: pro- Crisis,fessionals, Migration, focusing Survival .in (Kingston particular and upon Ottawa: debates SAMP relating and to IDRC the experience 2010), pp.307-323;of countries W. Pendleton, in the developing J. Crush, world.E. Campbell, Section T. Four Green, moves H. Simelane, the focus D.from Teverainternational and F. de Vletter, to South Migration, African Remittances issues and andprovides Development new empirical in Southern mate- Africarial. SAMP drawn Migration from the Policysurvey Series of recruitment No. 44, Cape patterns Town, and 2006. key interviews 39 A. Bloch,undertaken “Zimbabweans with health in Britain: sector Trecruitersransnational operating Activities in South and Capabilities” Africa. JournalSection of Ethnic Five and addresses Migration the Studies questions 34(2) of (2008): changing 287–305; policy interventionsS. Bracking, in and L.South Sachikonye, Africa towards “Migrant the Remittances outflow of skilledand Household health professionals Wellbeing in and the Urbanrecruitment Zimbabwe” of International foreign health Migration professionals 48 (5) (2009):to work 203-227; in South UNDP, Africa. The The Potential Contribution of the Zimbabwe Diaspora to Economic Recovery. Working Paper 11 (Harare: UNDP, 2010). 491 kkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkk MIGRATION POLICY SERIES NO. 45 The Engagement of the Zimbabwean Medical Diaspora

EXECUTIVE SUMMARY 40 R. Mupedziswa, “Diaspora Dollars and Social Development: Remittance Patterns of Zimbabwean Nationals Based in South Africa” Global Development ealth workers are one of the categories of skilled profession- Studies 5(3-4) (2009): 229-272; D. Tevera and A. Chikanda, “Development als most affected by globalization. Over the past decade, Impact of International Remittances: Some Evidence from Origin Households there has emerged a substantial body of research that tracks in Zimbabwe” Global Development Studies 5(3-4) (2009); D. Makina, patterns of international migration of health personnel, “Zimbabwe in Johannesburg” In Crush and Tevera, Zimbabwe’s Exodus, pp. H 225-43; Tevera et al, “Migrant Remittances and Household Survival in assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is Zimbabwe”; S. Bracking and L. Sachikonye, “Remittances, Informalisation and attracting growing interest. For almost 15 years South Africa has been Dispossession in Urban Zimbabwe” In Crush and Tevera, Zimbabwe’s Exodus, the target of a ‘global raiding’ of skilled professionals by several devel- pp.324-45. oped countries. How to deal with the consequences of the resultant out- 41 A. Bloch, “Transnational Lives: The Experiences of Zimbabweans in Britain” flow of health professionals is a core policy issue for the national gov- In ” In Crush and Tevera, Zimbabwe’s Exodus, pp.156-79. ernment. 42 Interview with Dr Dan Matthews, Durban, 26 September 2008. This paper aims to to examine policy debates and issues concerning 43 Tevera et al, “Migrant Remittances and Household Survival in Zimbabwe”, p. the migration of skilled health professionals from the country and to 308. furnish new insights on the recruitment patterns of skilled health per- 44 Bloch, “Transnational Lives,” p. 168 sonnel. The objectives of the paper are twofold: 45 Mupedziswa, “Diaspora Dollars and Social Development.” • To provide an audit of the organization and patterns of recruit- 46 Bracking and Sachikonye, “Remittances, Informalisation and Dispossession” p. ment of skilled professionals from South Africa in the health 332. sector. The paper draws upon a detailed analysis of recruitment 47 Tevera et al, “Migrant Remittances and Household Survival in Zimbabwe”, p. advertising appearing in the South African Medical Journal for 313. the period 2000-2004 and a series of interviews conducted with 48 Mupedziswa, “Diaspora Dollars and Social Development”, p. 256. All currency private recruiting enterprises. conversions are at the Rand: USD exchange rate prevailing at the time. • Based upon the above analysis and additional interviews with 49 Tevera et al, “Migrant Remittances and Household Survival in Zimbabwe”, p. key stakeholders in the South African health sector, the paper 313; Makina, “Zimbabwe in Johannesburg”, p. 236. offers a series of recommendations for addressing the problem of 50 Tevera et al, “Migrant Remittances and Household Survival in Zimbabwe”, p. skilled health migration. These recommendations are grounded 313 in both South African experience and an interrogation of inter- 51 Interview with Dr John Mandaza, Pretoria, 27 August 2008. national debates and ‘good policy’ practice for regulating recruit- 52 A. Bloch, The Development of Potential Zimbabweans in the Diaspora: A Survey ment. of Zimbabweans living in the UK and South Africa. Migration Research Series The paper is organized into five sections. Section Two positions No. 17 (Geneva: International Organisation for Migration, 2005); F. Maphosa, debates about the migration of skilled health professionals within a “Remittances and Development: The Impact of Migration to South Africa on wider literature that discusses the international mobility of talent. Rural Livelihoods in Southern Zimbabwe” Development Southern Africa 24(1) Section Three reviews research on the global circulation of health pro- (2007): 123-136; Tevera et al, “Migrant Remittances and Household Survival fessionals, focusing in particular upon debates relating to the experience in Zimbabwe.” of countries in the developing world. Section Four moves the focus from 53 Mupedziswa, “Diaspora Dollars and Social Development”, p. 258. international to South African issues and provides new empirical mate- 54 Tevera et al, “Migrant Remittances and Household Survival in Zimbabwe”, p. rial drawn from the survey of recruitment patterns and key interviews 311. undertaken with health sector recruiters operating in South Africa. 55 Maphosa, “Remittances and Development” Section Five addresses the questions of changing policy interventions in 56 Hanke, New Hyperinflation Index (HHIZ) Puts Zimbabwe Inflation at 89.7 South Africa towards the outflow of skilled health professionals and the Sextillion Percent; S. Hanke, and A. Kwok, “On the Measurement of recruitment of foreign health professionals to work in South Africa. The Zimbabwe’s Hyperinflation” Cato Journal 29(2) (2009): 353-364. 57 Mupedziswa, “Diaspora Dollars and Social Development”, pp. 261-63; Tevera et al, “Migrant Remittances and Household Survival in Zimbabwe”, p. 316-8. 1 50 kkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkk MMIGRATIONigration PPOLICYolicy SERIESeries NOo. 4555

58EXECUTIVE Interview withSUMMARY Dr Simon Chiremba, Durban, 15 September 2008. 59 Interview with Dr Tim Makombe, Cape Town, 22 October 2008. 60 Interview with Drealth Mavis workers Makoni, are Durban,one of the 16 categoriesSeptember of 2008. skilled profession- 61 Interview with Drals Enoch most affectedTogara, Durban,by globalization. 17 September Over 2008.the past decade, 62 For further detailsthere of the has methodology emerged a substantial used in extrapolation, body of research see A. that Chikanda, tracks “Emigration of Medicalpatterns Doctors of international from Zimbabwe: migration Migrant of health Experiences, personnel, TransnationalH Linkages and Prospects for Diasporic Engagement” PhD Thesis, assesses causes and consequences, and debates policy responses at global Universityand national of Western scales. Ontario, Within 2010. this literature, the case of South Africa is 63 S. Alkireattracting and L. growing Chen, “Medical interest. ExceptionalismFor almost 15 years in International South Africa Migration: has been Shouldthe Doctors target ofand a ‘globalNurses raiding’ be Treated of skilled Differently?” professionals In K. Tamasby several and devel-J. Palme, eds., Globalisingoped countries. Migration How Regimes: to deal withNew theChallenges consequences to Transnational of the resultant Cooperation out- (Aldershot:flow of Ashgate, health professionals 2004), pp. 100-17. is a core policy issue for the national gov- 64 Interviewernment. with Dr Mary Chikomo, Cape Town, 26 October 2008. 65 InterviewThis with paper Dr Mavis aims toMakoni, to examine Durban, policy 16 Septemberdebates and 2008. issues concerning 66 Interviewthe migration with Dr Mary of skilled Chikomo, health Cape professionals Town, 26 fromOctober the country2008. and to 67 Interviewfurnish with new Dr insights Walter Choga,on the recruitmentJohannesburg, patterns 12 August of skilled 2008. health per- 68 Interviewsonnel. with The Dr objectivesLeonard Jordan, of the Capepaper Town,are twofold: 20 October 2008. 69 Interview• with To Dr provide Ben Carter, an audit Cape of theTown, organization 27 October and 2008. patterns of recruit- 70 E. Thomas-Hope,ment “Returnof skilled Migration professionals to Jamaica from South and its Africa Development in the health Potential” Internationalsector. The Migration paper draws 37(1) upon (1999): a detailed 183-207; analysis A. Padarath, of recruitment C. Chamberlain,advertising D. McCoy, appearing A. Ntuli, inM. the Rowson South and African R. Loewenson, Medical Journal Health for Personnel in Southernthe period Africa: 2000-2004 Confronting and aMaldistribution series of interviews and Brain conducted Drain. with EQUINET Discussionprivate recruiting Paper No. enterprises. 3 (Harare: EQUINET, 2003); Tanner, Emigration,• Brain Based Drain upon and the Development above analysis. and additional interviews with 71 M. Orozco, “Diasporaskey stakeholders and Development: in the South Issues African and health Impediments” sector, the In paperJ. Brinkerhoff ed.,offers Diasporas a series and of recommendations Development: Exploring for addressing the Potential the (Boulder problem of and London: skilledLynne healthReinner migration. Publishers, These 2008), recommendations pp. 207-30; J. Brinkerhoff, are grounded “The Potentialin ofboth Diasporas South Africanand Development” experience Inand Brinkerhoff, an interrogation Diasporas of inter- and Developmentnational, pp. 1-27; debates Y. Kuznetsov,and ‘good policy’“Leveraging practice Diasporas for regulating of Talent: recruit- Toward a Newment. Policy Agenda” In Y. Kuznetsov, ed., Diaspora Networks and the InternationalThe paper Migration is organized of Skills: into How five Countries sections. Can Section Draw Two on Theirpositions Talent Abroaddebates (Washington, about the DC: migration World Bank, of skilled 2006), health pp. 221-237;professionals D. McKenzie, within a “Beyondwider Remittances: literature that The discusses Effects of the Migration international on Mexican mobility Households” of talent. In Ç. ÖzdenSection and Three M. Schiff reviews eds., research International on the Migration, global circulation Remittances, of andhealth the Brainpro- Drainfessionals, (Washington focusing DC and in particularBasingstoke: upon World debates Bank relating and Palgrave to the experienceMacmillan, 2006),of pp. countries 123-147. in the developing world. Section Four moves the focus from 72 Interviewinternational with Dr John to South Mandaza, African Pretoria, issues and27 August provides 2008. new empirical mate- 73 Interviewrial drawn with Dr from Brian the Adams, survey ofJohannesburg, recruitment 20patterns August and 2008. key interviews 74 Interviewundertaken with Dr with Simon health Chiremba, sector recruitersDurban, 15 operating September in South2008. Africa. 75 B. Raftopoulos,Section Five “Nation, addresses Race the and questions History ofin changingZimbabwean policy Politics” interventions In S. in Dorman,South D. AfricaHammett, towards P. Nugent the outflow eds., Making of skilled Nations, health Creating professionals Strangers: and the Statesrecruitment and Citizenship of foreign in Africa health (Leiden: professionals Koninklijke to workBrill NV, in South 2007), Africa. pp. The 191-194; B. Rutherford, “Shifting Grounds in Zimbabwe: Citizenship and

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EXECUTIVE SUMMARY Farmworkers in the New Politics of Land” In S. Dorman, D. Hammett, P. Nugent eds., Making Nations, Creating Strangers: States and Citizenship in Africa ealth workers are one of the categories of skilled profession- (Leiden: Koninklijke Brill NV, 2007), pp. 105-122. als most affected by globalization. Over the past decade, 76 Interview with Dr Cathy Marriot, Cape Town, 8 October 2008. there has emerged a substantial body of research that tracks 77 Interview with Dr Tim Makombe, Cape Town, 22 October 2008. patterns of international migration of health personnel, 78 Interview with a Programme Officer at IOM Zimbabwe, Harare, 11 November H 2008. assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is 79 Interview with Dr Webster Jacobs, Durban, 8 September 2008. attracting growing interest. For almost 15 years South Africa has been 80 Interview with Dr Ron Johnson, Johannesburg, 6 August 2008. the target of a ‘global raiding’ of skilled professionals by several devel- 81 Interview with Dr Simon Chiremba, Durban, 15 September 2008. oped countries. How to deal with the consequences of the resultant out- 82 Interview with Dr Cathy Marriot, Cape Town, 8 October 2008. flow of health professionals is a core policy issue for the national gov- 83 Interview with Dr Henry Porter, Cape Town, 27 October 2008. ernment. 84 Interview with Dr Leonard Jordan, Cape Town, 20 October 2008. This paper aims to to examine policy debates and issues concerning 85 F. Wang, “The Role of Cost in Telemedicine Evaluation” Telemedicine and the migration of skilled health professionals from the country and to e-Health 15(10) (2009): 949-955. furnish new insights on the recruitment patterns of skilled health per- 86 A. Smith, R. Kimble, A. O’Brien, J. Mill and R. Wootton, “A Telepaediatric sonnel. The objectives of the paper are twofold: Burns Service and the Potential Travel Savings for Families Living in Regional • To provide an audit of the organization and patterns of recruit- Australia” Journal of Telemedicine and Telecare 13(3) (2007): 76-79. ment of skilled professionals from South Africa in the health 87 Interview with Dr Ron Johnson, Johannesburg, 6 August 2008. sector. The paper draws upon a detailed analysis of recruitment 88 R. Silverman, “Current Legal and Ethical Concerns in Telemedicine and advertising appearing in the South African Medical Journal for E-medicine” Journal of Telemedicine and Telecare 9(1) (2003): 67–69; B. the period 2000-2004 and a series of interviews conducted with Stanberry, “The Legal and Ethical Aspects of Telemedicine. Confidentiality private recruiting enterprises. and the Patient’s Rights of Access” Journal of Telemedicine and Telecare 3 • Based upon the above analysis and additional interviews with (1997): 179–187. key stakeholders in the South African health sector, the paper 89 Interview with Dr Mavis Makoni, Durban, 16 September 2008. offers a series of recommendations for addressing the problem of 90 Interview with Dr Simon Chiremba, Durban, 15 September 2008 skilled health migration. These recommendations are grounded 91 Interview with Dr Mary Chikomo, Cape Town, 26 October 2008. in both South African experience and an interrogation of inter- 92 R. Adams, “Remittances, Poverty, and Investment in Guatemala” In Özden national debates and ‘good policy’ practice for regulating recruit- and Schiff, International Migration, Remittances, and the Brain Drain, pp. 53-80; ment. R. Adams and J. Page, “Do International Migration and Remittances Reduce The paper is organized into five sections. Section Two positions Poverty in Developing Countries?” World Development 33(10) (2005): 1645-69. debates about the migration of skilled health professionals within a 93 T. Staubhaar, and F. Vadean, “International Migrant Remittances and their wider literature that discusses the international mobility of talent. Role in Development” In The Development Dimension: Migrant Remittances and Section Three reviews research on the global circulation of health pro- Development (Paris: OECD Publishing, 2005), pp. 13-33. fessionals, focusing in particular upon debates relating to the experience 94 Alkire and Chen, “Medical Exceptionalism in International Migration.” of countries in the developing world. Section Four moves the focus from international to South African issues and provides new empirical material drawn from the survey of recruitment patterns and key interviews undertaken with health sector recruiters operating in South Africa. Section Five addresses the questions of changing policy interventions in South Africa towards the outflow of skilled health professionals and the recruitment of foreign health professionals to work in South Africa. The

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MEXECUTIVEigration SPUMMARYolicy Series

1. Covert Operations:ealth Clandestine workers are Migration, one of the Temporary categories Work of skilled and profession-Immigration Policy in South Africaals most (1997) affected ISBN by 1-874864-51-9globalization. Over the past decade, 2. Riding the Tiger:there Lesotho has emergedMiners and a substantial Permanent body Residence of research in South that Africatracks (1997)H ISBN 1-874864-52-7patterns of international migration of health personnel, 3. Internationalassesses causes Migration, and consequences, Immigrant Entrepreneurs and debates and policy South responses Africa’s at Small global Enterpriseand national Economy scales. (1997) Within ISBN this 1-874864-62-4 literature, the case of South Africa is attracting growing interest. For almost 15 years South Africa has been 4. Silenced by Nation Building: African Immigrants and Language Policy in the the target of a ‘global raiding’ of skilled professionals by several devel- New South Africa (1998) ISBN 1-874864-64-0 oped countries. How to deal with the consequences of the resultant out- 5. Left Outflow in of the health Cold? professionals Housing and is aImmigration core policy inissue the for New the South national Africa gov- (1998)ernment. ISBN 1-874864-68-3 6. Trading Places:This paper Cross-Border aims to to Traders examine and policy the South debates African and issues Informal concerning Sector (1998)the ISBN migration 1-874864-71-3 of skilled health professionals from the country and to 7. Challengingfurnish Xenophobia:new insights Mython the and recruitment Realities aboutpatterns Cross-Border of skilled health Migration per- in Southernsonnel. Africa The (1998) objectives ISBN of 1-874864-70-5 the paper are twofold: 8. Sons of Mozambique:• To provide Mozambican an audit of Miners the organization and Post-Apartheid and patterns South of recruit- Africa (1998) ISBN ment1-874864-78-0 of skilled professionals from South Africa in the health sector. The paper draws upon a detailed analysis of recruitment 9. Women on the Move: Gender and Cross-Border Migration to South Africa advertising appearing in the South African Medical Journal for (1998) ISBN 1-874864-82-9. the period 2000-2004 and a series of interviews conducted with 10. Namibians onprivate South recruitingAfrica: Attitudes enterprises. Towards Cross-Border Migration and Immigration• Policy Based (1998)upon the ISBN above 1-874864-84-5. analysis and additional interviews with 11. Building Skills:key Cross-Border stakeholders Migrants in the South and theAfrican South health African sector, Construction the paper Industry (1999)offers ISBN a series 1-874864-84-5 of recommendations for addressing the problem of 12. Immigration &skilled Education: health Internationalmigration. These Students recommendations at South African are grounded Universities andin both Technikons South African (1999) experienceISBN 1-874864-89-6 and an interrogation of international debates and ‘good policy’ practice for regulating recruit- 13. The Lives and Times of African Immigrants in Post-Apartheid South Africa ment. (1999) ISBN 1-874864-91-8 The paper is organized into five sections. Section Two positions 14. Still Waitingdebates forabout the the Barbarians: migration South of skilled African health Attitudes professionals to Immigrants within aand Immigrationwider literature (1999) ISBN that discusses1-874864-91-8 the international mobility of talent. 15. UnderminingSection ThreeLabour: reviews Migrancy research and Sub-contracting on the global circulation in the South of health African pro- Gold fessionals,Mining Industry focusing (1999) in particular ISBN 1-874864-91-8 upon debates relating to the experience 16. Borderlineof countries Farming: in Foreignthe developing Migrants world. in South Section African Four Commercial moves the focus from Agricultureinternational (2000) toISBN South 1-874864-97-7 African issues and provides new empirical mate- 17. Writingrial Xenophobia: drawn from Immigrationthe survey of and recruitment the Press patterns in Post-Apartheid and key interviews South Africaundertaken (2000) ISBN with 1-919798-01-3 health sector recruiters operating in South Africa. Section Five addresses the questions of changing policy interventions in 18. Losing Our Minds: Skills Migration and the South African Brain Drain (2000) South Africa towards the outflow of skilled health professionals and the ISBN 1-919798-03-x recruitment of foreign health professionals to work in South Africa. The 19. Botswana: Migration Perspectives and Prospects (2000) ISBN 1-919798-04-8

531 kkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkk MIGRATION POLICY SERIES NO. 45 The Engagement of the Zimbabwean Medical Diaspora

EXECUTIVE SUMMARY 20. The Brain Gain: Skilled Migrants and Immigration Policy in Post-Apartheid South Africa (2000) ISBN 1-919798-14-5 ealth workers are one of the categories of skilled profession- 21. Cross-Border Raiding and Community Conflict in the Lesotho-South African als most affected by globalization. Over the past decade, Border Zone (2001) ISBN 1-919798-16-1 there has emerged a substantial body of research that tracks 22. Immigration, Xenophobia and Human Rights in South Africa (2001) Hpatterns of international migration of health personnel, ISBN 1-919798-30-7 assesses causes and consequences, and debates policy responses at global 23. Gender and the Brain Drain from South Africa (2001) ISBN 1-919798-35-8 and national scales. Within this literature, the case of South Africa is attracting growing interest. For almost 15 years South Africa has been 24. Spaces of Vulnerability: Migration and HIV/AIDS in South Africa (2002) the target of a ‘global raiding’ of skilled professionals by several devel- ISBN 1-919798-38-2 oped countries. How to deal with the consequences of the resultant out- 25. Zimbabweans Who Move: Perspectives on International Migration in flow of health professionals is a core policy issue for the national gov- Zimbabwe (2002) ISBN 1-919798-40-4 ernment. 26. The Border Within: The Future of the Lesotho-South African International This paper aims to to examine policy debates and issues concerning Boundary (2002) ISBN 1-919798-41-2 the migration of skilled health professionals from the country and to 27. Mobile Namibia: Migration Trends and Attitudes (2002) ISBN 1-919798-44-7 furnish new insights on the recruitment patterns of skilled health personnel. The objectives of the paper are twofold: 28. Changing Attitudes to Immigration and Refugee Policy in Botswana (2003) • To provide an audit of the organization and patterns of recruit- ISBN 1-919798-47-1 ment of skilled professionals from South Africa in the health 29. The New Brain Drain from Zimbabwe (2003) ISBN 1-919798-48-X sector. The paper draws upon a detailed analysis of recruitment 30. Regionalizing Xenophobia? Citizen Attitudes to Immigration and Refugee advertising appearing in the South African Medical Journal for Policy in Southern Africa (2004) ISBN 1-919798-53-6 the period 2000-2004 and a series of interviews conducted with 31. Migration, Sexuality and HIV/AIDS in Rural South Africa (2004) private recruiting enterprises. ISBN 1-919798-63-3 • Based upon the above analysis and additional interviews with 32. Swaziland Moves: Perceptions and Patterns of Modern Migration (2004) key stakeholders in the South African health sector, the paper ISBN 1-919798-67-6 offers a series of recommendations for addressing the problem of skilled health migration. These recommendations are grounded 33. HIV/AIDS and Children’s Migration in Southern Africa (2004) in both South African experience and an interrogation of inter- ISBN 1-919798-70-6 national debates and ‘good policy’ practice for regulating recruit- 34. Medical Leave: The Exodus of Health Professionals from Zimbabwe (2005) ment. ISBN 1-919798-74-9 The paper is organized into five sections. Section Two positions 35. Degrees of Uncertainty: Students and the Brain Drain in Southern Africa debates about the migration of skilled health professionals within a (2005) ISBN 1-919798-84-6 wider literature that discusses the international mobility of talent. 36. Restless Minds: South African Students and the Brain Drain (2005) Section Three reviews research on the global circulation of health pro- ISBN 1-919798-82-X fessionals, focusing in particular upon debates relating to the experience 37. Understanding Press Coverage of Cross-Border Migration in Southern Africa of countries in the developing world. Section Four moves the focus from since 2000 (2005) ISBN 1-919798-91-9 international to South African issues and provides new empirical material drawn from the survey of recruitment patterns and key interviews 38. Northern Gateway: Cross-Border Migration Between Namibia and Angola undertaken with health sector recruiters operating in South Africa. (2005) ISBN 1-919798-92-7 Section Five addresses the questions of changing policy interventions in 39. Early Departures: The Emigration Potential of Zimbabwean Students (2005) South Africa towards the outflow of skilled health professionals and the ISBN 1-919798-99-4 recruitment of foreign health professionals to work in South Africa. The 40. Migration and Domestic Workers: Worlds of Work, Health and Mobility in Johannesburg (2005) ISBN 1-920118-02-0

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41.EXECUTIVE The QualitySUMMARY of Migration Services Delivery in South Africa (2005) ISBN 1-920118-03-9 42. States of Vulnerability:ealth workers The Future are oneBrain of Drainthe categories of Talent of to skilled South profession- Africa (2006) ISBN 1-920118-07-1als most affected by globalization. Over the past decade, 43. Migration and Developmentthere has emerged in Mozambique: a substantial Poverty, body Inequalityof research and that Survival tracks (2006)H ISBN 1-920118-10-1patterns of international migration of health personnel, assesses causes and consequences, and debates policy responses at global 44. Migration, Remittances and Development in Southern Africa (2006) and national scales. Within this literature, the case of South Africa is ISBN 1-920118-15-2 attracting growing interest. For almost 15 years South Africa has been 45. Medicalthe Recruiting:target of a ‘globalThe Case raiding’ of South of skilled African professionals Health Care by Professionals several devel- (2007)oped ISBN countries. 1-920118-47-0 How to deal with the consequences of the resultant out- 46. Voicesflow From of the health Margins: professionals Migrant Women’s is a core Experiences policy issue in for Southern the national Africa gov-(2007) ISBNernment. 1-920118-50-0 47. The HaemorrhageThis paper of aimsHealth to Professionals to examine Frompolicy South debates Africa: and Medicalissues concerning Opinions (2007)the ISBN migration 978-1-920118-63-1 of skilled health professionals from the country and to 48. The Qualityfurnish ofnew Immigration insights on and the Citizenship recruitment Services patterns in Namibia of skilled (2008) health per- ISBNsonnel. 978-1-920118-67-9 The objectives of the paper are twofold: • To provide an audit of the organization and patterns of recruit- 49. Gender, Migration and Remittances in Southern Africa (2008) ment of skilled professionals from South Africa in the health ISBN 978-1-920118-70-9 sector. The paper draws upon a detailed analysis of recruitment 50. The Perfect Storm:advertising The Realities appearing of Xenophobia in the South in Contemporary African Medical South Journal Africa for (2008) ISBN the978-1-920118-71-6 period 2000-2004 and a series of interviews conducted with 51. Migrant Remittancesprivate and recruiting Household enterprises. Survival in Zimbabwe (2009) ISBN 978-1-920118-92-1• Based upon the 2009 above analysis and additional interviews with 52. Migration, Remittanceskey stakeholders and ‘Development’ in the South in Lesotho African (2010) health sector, the paper ISBN 978-1-920409-26-5offers a series of recommendations for addressing the problem of 53. Migration-Inducedskilled HIV health and AIDSmigration. in Rural These Mozambique recommendations and Swaziland are grounded (2011) ISBN 978-1-920409-49-4in both South African experience and an interrogation of inter- 54. Medical Xenophobia:national Zimbabwean debates and Access ‘good to policy’ Health practice Services for in Southregulating Africa recruit- (2011) ISBN ment.978-1-920409-63-0 The paper is organized into five sections. Section Two positions debates about the migration of skilled health professionals within a wider literature that discusses the international mobility of talent. Section Three reviews research on the global circulation of health professionals, focusing in particular upon debates relating to the experience of countries in the developing world. Section Four moves the focus from international to South African issues and provides new empirical material drawn from the survey of recruitment patterns and key interviews undertaken with health sector recruiters operating in South Africa. Section Five addresses the questions of changing policy interventions in South Africa towards the outflow of skilled health professionals and the recruitment of foreign health professionals to work in South Africa. The

551 kkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkk Published by:

southern AfricAn MigrAtion ProgrAMMe Idasa and the University of Cape Town Cape Town, South Africa and Southern African Research Centre Kingston, Ontario, Canada