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A perverse subsidy: African trained nurses and doctors in the NHS

Mackintosh, M   Raghuram, P   Henry, L

Soundings   34 103-113

November 2006

Published without an abstract. From the introduction: What would constitute an ethical policy towards the recruitment of African-trained health professionals for the NHS?

‘The story goes that there are more Malawian doctors in Birmingham than there are in Malawi.’ Gareth Thomas (international development minister) and Rosie Winterton (health minister).

‘They say we don't need to hire overseas any more. We have trained enough British doctors and nurses and they have to have jobs.’ NHS manager, in conversation, 2006

In recent years there has been increasing concern about the 'poaching' of African doctors and nurses by UK health services. The scale of emigration undermines health care in very poor countries with very severe health problems. The UK government's response was to institute an 'ethical' recruitment policy that banned active recruitment by UK health service employers in staff-short African countries. Public debate about this policy response, including commentary from politicians, journalists, trades unions and also the World Health Organisation (see the latest World Health Report 2006: Working Together for Health WHO, Geneva), has thrown up some complicated ethical and political issues.

In this extremely unequal world, there are conflicts between the human rights of African health workers, of British health services users and the African populations who need health services. Migration undermines health services in African countries of origin. Blocking migration by African health professionals, however, undermines their right to move away from their country of origin; it also plays into the prejudices of anti-immigration lobbies in Britain. Employment by the NHS of doctors and nurses trained in Africa constitutes a 'perverse subsidy' to British health service users - that is, a flow of subsidy from poor to rich. The movement from Ghana to the UK alone subsidises the UK health services to the order of £39 million per year.

Yet 'ethical recruitment' policy solutions lack a sound ethical basis and are potentially discriminatory in their effects, since they focus on restricting mobility rather than ensuring equality of health care. A recent sharp and unheralded switch in immigration policy that phases out training opportunities for migrant overseas-educated doctors and limits entry of all but the most highly qualified doctors has been the latest (and perhaps the most significant) change in this respect. And it has been played out in the fertile territory of debates around ethical health provision. In this article we unpack some of the ethical, political and economic issues that surround this debate and map out some possibilities for picking our way through this troubled terrain.