Brain Drain of Health Professional in Zimbabwe

Brain Drain of Health Professionals in Zimbabwe

Brain Drain is described in the work of Lowell and Findlay (2001) as something that can occur "...if emigration of tertiary educated persons for permanent or long-stays abroad reaches significant levels and is not offset by the 'feedback' effects of remittances, technology transfer, investments or trade. Brain drain reduces economic growth through unrecompensed investments in education and depletion of a source country's human capital assets." (p.6) Dolvo (2003) writes that the African continent is facing an unprecedented health crisis due to the HIV / AIDS epidemic and the "re-emergence of old communicable diseases such as TB and Malaria, and the apparent paradox of increasing levels disorders linked to changing lifestyles and degenerative diseases." (p.1) Added to this are other problems that impact the health system and that arise from economic challenges, which result in low health care service funding combined with health service infrastructure deterioration. (Dolvo, 2003, paraphrased) It is reported that estimations state that 17 out of 48 African countries reported a reduction in life expectancy between the years of 1981 and 1999. Dolvo states the significant fact that the health worker is "operating within the difficult milieu." (2003, p.1) The health worker is "a critical part of the health system and perhaps the most essential of the health sector's resources, whose motivation and effective utilization enhances the efficiency and effectiveness with which all the other resources are used." (Dolvo, 2003, p.1) Dolvo also reports that the numbers of health professionals who are experiencing brain drain has peaked in previous years largely due to the high demands that come from the developing countries and that these "demands are such that were occasioned by demographic changes, aging populations as well as a reduction in attracting recruits into the health workforce." (2003, p.3) In addition, reported are additional needs for longer work hours meaning that there has been an increase in the demand for doctors and nurses. Stated specifically is that the "brain drain of professionals, combined with the health crisis described...together threatens the entire development process" on the African continent. (Dolvo, 2003, p.3) The flight of professional and skilled people from Zimbabwe is reported by the UN Development Programme (UNDP) to be such that has reached alarming levels and a study conducted by the Scientific and Industrial Research and Development Centre (SIRDC) under contract from the National Economic and Consultative Forum, to measure the rate and level of the brain drain" in Zimbabwe. The study confirms that the "level and trend of the brain drain in Zimbabwe has risen to heights described as levels that were too high. (IRIN News, 2011) Also reported is that the study revealed that Zimbabwe "dropped to 145th place out of 175 countries in the Human Development index in 2004" which is described as a "composite measure of average achievement in three basic dimensions of human development: a long and healthy life, education and a decent standard of living." (IRIN, 2011) According to the SIRCDC study there are 479,348 Zimbabweans 'in the Diaspora" although there were many that could not be contacted. Most of these individuals are reported as having a bachelor's degree with 20% having master's degrees and 5% holding PhD degrees." (IRIN, 2011) The brain drain issue has accelerated in the past ten years and the reasons stated for this by the Southern African Migration Program (SAMP) and it is reported that care is a requirement in the interpretation of the data and policy recommendations for the reasons stated as follows:

Uncertainty over the numbers involved. The extent of the drain is certainly not captured in official statistics.

Most projections about future trends are based on faulty methodological assumptions that tend to exaggerate the likelihood of emigration.

There is a common notion that emigration means departure for good. Many who depart do not intend to stay away permanently. And many who leave retain strong economic and social links with home.

A distinction must be made between a sizable intra-regional brain drain and emigration from the region. Some countries are disadvantaged by both (Zimbabwe). Some may gain what others lose (South Africa, Botswana). For the region as a whole, within-SADC brain drain means no net loss.

The "demand" side means that some sectors are harder hit than others.

There is little concrete evidence about the actual economic and social impact of the brain drain, even in sectors hardest hit.

The reality that most countries in the region have eschewed "brain grain" strategies in the form of proactive immigration policies and search for replacement skills. The impact of the brain drain of citizens is exacerbated as a result. (SAMP, 2010)

It is reported that state responses to the brain drain "have been control-oriented in character and not informed by research on the actual perceptions and intentions of the skilled." (SAMP, 2010) Reported as a "notable exception…South Africa's Health Professionals Recruitment and Retention Strategy…" is working toward the development of a "broad-based and multi-faceted set of interventions which includes addressing social and economic push factors. Ironically, this strategy cannot address a major cause of emigration (crime and personal insecurity). And it makes no comment on the desirability of developing a strategy for replacement immigration. Restrictions on outward movement are not generally feasible in states that guarantee freedom of movement to citizens. Instead, Southern African states have also sought to exercise leverage over the pull factors by (ineffectual) appeals to the morality of industrial countries or entering into bilateral or multi-lateral agreements with western governments to control recruiting or hiring of professionals on a sectoral basis. The effectiveness of such agreements has yet to be properly tested." (SAMP, 2010) South African media is reported to have been "profiling what it calls the 'brain gain' of returning South Africans. There is little concrete evidence, however, that this return is either large or sustainable. The only attempt to tap the Diaspora to date is the SANSA project, set up by the University of Cape Town and taken over by the National Research Foundation. SANSA was designed to match diasporac South Africans with local employers for short-term assignments and employment. The intention was never to encourage permanent return. " (SAMP, 2010) SAMP reports that the initiative's success is presently unknown. Other initiatives have been reported to seek "to encourage the return of the disasporic citizens by offering incentives and job-matching programs and specifically the 'Return and Reintegration of Qualified African Nationals (ROAN) Program' of the IOM which was inclusive of Zimbabwe and which served to assist the return of a miserly total of 2,009 professionals to Africa as a whole over a 17-year period. On the evidence of ROAN, these kinds of programs are likely to be rather ineffectual at best." (SAMP, 2010) The IOM is reported to have "initiated a more flexible skills transfer program called MIDA (Migration for Development in Africa) with the IOM acting as a kind of "go-between." While this program seems, in principle, to have a higher likelihood of success, its effectiveness has yet to be tested. In general, it seems likely that formalized skills return or linkage schemes coordinated by international organizations are not going to have a major impact in reversing or ameliorating the effects of the brain drain." (SAMP, 2010) While South Africa could use replacement recruitment strategies that leaves South Africa in a quandary because "In order to mount a case against other countries recruiting its health professionals, it needs not to be seen as a poacher in other fields. Hence, in late 2001, South Africa undertook not to recruit any physicians or nurses, except under specific agreements with countries of origin. At the same time, the country has concluded agreement with Cuba and Germany for the temporary import of doctors. There are now close to 500 Cuban doctors practicing in rural areas and townships. The country is also seeking to negotiate bilateral and multilateral agreements with destination countries to stop recruiting of health professionals in South Africa." (SAMP, 2010) SAMP reports that while there has been a great deal of focus on the South African brain drain that this area of study can be noted due to the absence of good research on which policy matter can be based that would bring about necessary changes for those who are poverty level. Reported is the need for an effort that is "more systematic and comprehensive" in order to (a) document the extent of the brain drain by examining data in the region and in major host countries;

(b) inventory the overseas skills base and, through survey work, determine the potential for return and the nature of backward linkages (financial and social);

(c) a systematic assessment of the economic impact and resource implications of the brain drain by sector (with particular emphasis on health implications for the poor); and (d) working with government and private industry to develop retention, replacement, brain train and attraction strategies to mitigate the impact of skills loss on development prospects." (SAMP, 2010)

1.1 Research Background

The brain drain problem is one of the major forces shaping the 21st century as skilled professional are increasingly migrating from developing to developed or industrialised countries as cited by the World Bank (2000). The 'brain drain', also referred to as 'talent flow' (Hooks et al., 2005) and the 'Diaspora' (Bryant and Law, 2004), is the flow of skilled human capital out of a country at a considerable rate. Africa is faced with this growing problem (Mutizwa-Mangiza, 1996; Bloom & Standing, 2001) and has witnessed decades of wasted development potential, however it has also been experienced in other nations throughout history e.g. USA and Europe and is currently happening in Ireland. This migration has been blamed for worsening the human capital crisis in Africa (Wadda, 2000). The continent has suffered and continues to suffer problems of extreme poverty and lack of both human and institutional capacity. There has been massive influx of emigration from Zimbabwe since the late 90's and this research aims to explore and address this considering the current political situation in Zimbabwe.

Author Stephen Bach points to healthcare professionals as occupying a rather unique position within the brain drain problem. This is to say that Bach argues that healthcare professionals are a very necessary part of a country's infrastructure, and economies and groups of people tend to suffer more from these professionals' departures than from many others. It is easy to understand as healthcare professionals are needed to staff hospitals and clinics and help to guarantee a certain standard of living for the citizens." (Bach, 2008, p.203) Bach (2008) argues that governing bodies in African nations need to identify a clear path toward first keeping the healthcare professionals in country and then attracting more from outside their borders. Building on this assertion, Bach continues to outline some solutions by helping to point to the numbers of registered healthcare professionals within the country's borders as a measure of the health of the industry and numbers of working professionals themselves (Bach, 2008, 205).

1.2 Research Purpose

The purpose of the research in this study is to examine brain drain in South Africa.

1.3 Research Question

The research question addressed in this study is that which asks the question of what is the most important factor of brain drain?

1.4 Research Aim

The aim of this study is to engage in a comparative case study analysis of healthcare professionals to explore the relative significance of economic and political conditions as a motivation for the 'brain drain' problem. As well, this work intends to investigate the political and economical environment as drivers of brain drain.

1.5 Research Objectives

The objectives of the research in this study include:

(i) Investigation of the causes of political instability;

(ii) Evaluation of cause and migration;

(iii) Examination of the push and pull factors determining the movement of health personnel.

1.6 Significance of the Study

The significance of this present study is within the knowledge that will be added to the already existing knowledge base in the study of brain drain and what causes and potentially prevents brain drain in a region or country.

1.7 Theoretical Framework

The primary framework of this research is based on migration theory and literature. The neo-classical economic theory is the oldest theory of migration and has emphasis on wage differences between regions being the main cause for migration (Bauer and Zimmermann, 1995; Borjas, 1989; Massey et al., 1993, 1998). Analyses on migration are such that examines migration as being a strategic familial or group occurrence focused toward diversification of income sources and reduction of household risks. Within this framework international migration is a method used to make up for the absence of certain types of markets in countries that are still developing. In this model, international migration is a way to recompense for the lack of particular types of markets in developing countries. Labor market theory from a dual perspective sets out that low-level worker demand in countries characterized by higher levels of development is the most critical aspect impacting migration on the international level. This model reiterates that migration is initiated by the governmental recruitment policies in destination areas. The other theory for this research is the world-systems approach to international migration. Massey et al. 1993: 444 discusses a global division of regions into a core which rich in capital, raw materials and labor and a semi-periphery that coalesces elements from core and periphery. Migration, according to this approach, is the inevitable result of the issues that are produced by capitalist growth.

Chapter 2: Literature Review

2.1. Introduction

Brain drain is a problem examined, by various writers and researchers. The importance of understanding this phenomena is the fact that brain drain depletes a region or country of its professional practitioners which in turn results in less than optimal outcomes in the society of that country of region due to lack of these professionals in their line of work and in this case specifically are professional health care service providers. According to the IRIN Global News source over fifty percent of those who had responded to a study examining emigration in Zimbabwe stated that they had emigrated for reasons relating to work. (54.5%) The most common stated reason linked to work for emigration is reported as low salaries in Zimbabwe as well as the exchange rate and better career advancement opportunities. The Zimbabwe dollar is reported to have depreciated sharply against major currencies and currencies of Zimbabwe's neighbors. It is reported that 8% of respondents noted political factors as their primary reason for emigration. The report states specifically as follows:

"If the Zimbabwe government does not do something to make staying at home more attractive and rewarding, the brain drain will continue unabated," the study warned. The forces driving people out of the country were as powerful as the opportunities luring them away. There was no alternative but to enact "necessary economic reforms that make staying at home attractive and rewarding" for skilled and educated Zimbabweans. The shrinking economy was not only forcing productive Zimbabweans abroad but had also resulted in what the authors of the report termed an "internal brain drain." The deteriorating economy in Zimbabwe has forced some professors, lecturers, medical doctors, and scientists to operate minibuses, taxicabs or operate beer parlors. It is a form of internal brain drain to have many architects, accountants, and pharmacists underemployed." (IRIN, 2003)

Also stated is that the health and teaching professions are those most impacted by the brain drain and that the examination of professions of those leaving Zimbabwe shows "a sizeable proportion of them are doctors, teachers, and nurses. In fact, the health care sector is the most affected. Many are leaving because health care and education spending cuts across the board have denied them a place to stay and work in Zimbabwe." (IRIN, 2003) The report found that the flight of doctors had been "so overwhelming that the Ministry of Health and Child Welfare has had to recruit hundreds of Cuban doctors who are paid in foreign currency to fill the gap." (IRIN, 2003) It is reported, "Many professionals leave Zimbabwe for the brighter opportunities offered abroad, complaining that Zimbabwe is too corrupt, and needs more politicians of high moral standards. The dilemma is that Zimbabwe will not advance in development if the majority of qualified people continue to leave." (IRIN, 2003) The stated reason why certain professionals are leaving Zimbabwe is because they believe that working at home is synonymous with supporting the current government and not the people. (IRIN, 2003)

The work of Nepachem (2009) entitled "The Impact of the Brain Drain on Health Service Delivery in Zimbabwe: A Response Analysis" reports "The poor economic situation prevailing in Zimbabwe has led to multiple and complex migration issues characterized by high levels of brain drain, cross-border mobility and irregular migration. The economic decline over the past five years has precipitated a growing exodus of professionals from the country in search of better economic opportunities." (p.6) The majority of Zimbabweans are reported to migrate to South Africa, the United Kingdom, and Botswana." (Nepachem, 2009, p.6)The worst affected is the health sector in Zimbabwe with both professionals and semi-skilled workers in the sector migrating in search of better employment opportunities." (Nepachem, 2009, p.6) Nepachem states that the 2009 Health Task Force Report "observed that the health sector is characterized by overall failure by public sector hospitals to perform their intended functions; failure to retain local well-trained health care professionals; inability to recapitalize/re-equip the entire health sector; inability to provide reliable and consistent basic supplies of medicines; inability to maintain, upgrade, develop, and implement a sustainable health professional training policy; inadequate coverage of benefits by health care insurance providers and failure to carry out regular preventive vaccinations." (Nepachem, 2009, p.7) The Government of Zimbabwe published a document in 2009 entitled "The Short-Term Emergency Recovery Program (STERP) themed "Getting Zimbabwe Moving Again" which is reported to have "acknowledged the many problems bedeviling the health sector arising from the economic crisis. These include a sharp decrease in funding for the health sector, leading to the loss of experienced health professionals and deterioration of infrastructure, shortages of drugs and drastic decline in the quality of public health services. The STERP notes that high vacancy rates in the health sector have lead to the overburdening of remaining personnel. Consequently there is a rising challenge in dealing with diseases such as malaria, AIDS, cholera, and tuberculosis among others." (Nepachem, 2009, p.7) This information illustrates the extent of the challenges faced by Zimbabwe due to migration of health professionals and the impact that this migration has on the service delivery in Zimbabwe. It is reported that Nepachem's study "identified a critical shortage of staff in the medical field. According to the Ministry of Health and Child Welfare figures for December 2008, Zimbabwe had 1.7 health workers per 1,000 people, which is below World Health Organization (WHO) Africa regional average of 2.6. The critical shortage of staff was also highlighted by the WHO staffing fact sheet of 2008." The doctor-patient ration of 0.16 is reported for health doctors per 1,000 people compared to 0.22 doctors to 1,000 patients for South Africa on the average." (2009, p.8) The following table lists the Zimbabwe WHO core health indicators.

Figure 1

Zimbabwe WHO Core Health Indicators

Source: (Nepachem, 2009)

The Zimbabwe government health trainee capacity is reported and the information stated as shown in the following table.

Figure 2

Zimbabwe government health trainee capacity

Source: Nepachem (2009)

Health worker vacancy trends for Zimbabwe are shown in the following table.

Figure 3

Health Worker Vacancy Trends

Source: Nepachem (2009)

A situational and gap analysis in Zimbabwe's Health Sector revealed the information displayed in the following table.

Figure 4

Situational and Gap Analysis for the Health Sector of Zimbabwe

Source: Nepachem (2009)

The results of the survey show that the flight of health professionals from Zimbabwe "has mainly been driven by "a combination of push-pull factors, both socio-economic and political in character." (Nepachem, 2009) When asked why they had left Zimbabwe it is reported that 82% of respondents cited three or more reasons as follows:

(1) Low salaries in Zimbabwe -- 90%

(2) General economic conditions in Zimbabwe -- 88%

(3) Poor working conditions -- 82%. (Nepachem, 2009)

Other push factors included the following:

Political problems in Zimbabwe -- 65%

Poor working facilities leading to redundancy -- 57%

Bad relations with management -- 54%

Poor workplace safety -- 51%

Pull factors cited included those as follows:

Better advancement opportunities -- 62%

Joining family members -- 27%

Joining friends -- 20% (Nepachem, 2009)

Figure 5

Push and Pull Factors for Leaving Zimbabwe

Source: Nepachem (2009)

In the area of professional advancement of health professionals after Emigration, it is reported that 52% of respondents indicated that they had assumed responsibilities that are more senior after emigration. It is reported that 12% state that their responsibilities following emigration were more or less equal to their responsibilities previous to emigration. Reporting that their responsibilities were junior those following emigration was 27% of respondents. (Nepachem, 2009, paraphrased) In addition there is reported to be a "noticeable salary improvement among respondents after emigration with proportionately more individuals (86%) indicating that they were earning more in host countries than what they used to in Zimbabwe. More than half the respondents also indicated improved changes in benefits (76%) and type of work (57%). Eighty one per cent of respondents had indicated that they earned USD 500 or less in Zimbabwe compared to only 5 per cent earning USD 500 or less in the Diaspora." (Nepachem, 2009) It is reported that the proportion of earnings of "USD 2,001 or more was higher in the Diaspora, 82 per cent compared to 6 per cent when they were still in Zimbabwe. Twenty three per cent of individuals in the Diaspora reported current earnings of over USD 5,000, while only 2 per cent reported earnings of this magnitude before leaving Zimbabwe." (Nepachem, 2009) Respondents in the United States reported earning the highest salaries "with 84 per cent reporting monthly incomes of USD 3,001 or more compared to 71 per cent in Australia, 63 per cent in the UK, 37 per cent in South Africa, and 25 per cent in Botswana for the same salary scale. The highest earning professions were specialist doctors and general practitioners." (Nepachem, 2009) Improvements in other benefits included those in the areas of housing and transport following emigration. Specifically reported is "The proportion reporting housing benefits of over USD 100 or more increased from 10 per cent while still in Zimbabwe to 37 per cent in the Diaspora. Thirty five per cent of respondents reported current transport benefits of over USD 100 a month compared to 6 per cent before emigrating." (Nepachem, 2009)

Figure 6

Salary, Benefits, and Type of Work Changes After Emigration

Source: Nepachem (2009)

Figure 7

Non-Monetary Benefits Before and After Emigration

Source: Nepachem (2009)

Training opportunities are reported to have increased after emigration from Zimbabwe with 78% of respondents reporting that they had acquired new skills following emigration. In addition, it is reported that there was an increase in the level of support provided to family members still living in Zimbabwe since the respondents had emigrated from Zimbabwe. Reported specifically is "Forty per cent of respondents indicated supporting family members back in Zimbabwe by contributing at least USD 1,001 a month. This compares to 19 per cent before respondents moved from Zimbabwe. This support to family members in Zimbabwe suggests respondents' strong links to their home country, and might therefore be willing to combine short assignments to Zimbabwe with visits their extended or immediate families." (Nepachem, 2009)

The work of Chimbari, et al. (2008) entitled "Retention Incentives for Health Workers in Zimbabwe" reports a study conducted in various health institutions within Zimbabwe, including public, private, and faith-based health institution. The institutions examined in this study include those listed in the following figure.

Figure 8

Health Institutions Participation in Study reported by Chimbari (2008)

The administrative provinces and major cities in Zimbabwe are listed and shown in the following figure.

Figure 9

Zimbabwe's Administrative Provinces and Major Cities

Chimbari reports that there were five focus group discussions within different trainee groups including primary care nurses and general nurses in addition to environmental health technicians and fifth-year medical students from the University Of Zimbabwe College Of Health Sciences. The focus group discussions focused on the perception of trainees of retention packages. Results of the informant interviews are stated to include that key informants of the government are "generally optimistic about the creation of the ZHSB seeing that their working conditions would improve, with measures to top up salary increments by 20-30%, recognition and pay for postgraduate/basic qualifications, the introduction of a medical allowance and steps to unify the nursing services within public sector. Promotions, especially for those in acting positions, have motivated staff and cases of misconduct were reported to now be dealt with expeditiously." (Chimbari, et al., 2008) It is additionally reported that the lack of clarity "on the division of responsibilities between the ZHSB, MoH&CW and PSC was reported to have delayed action in some cases, and while the ZHSB was felt to have potential, its impact on retention was noted to still be limited. Local authority and private sector key informants, in contrast, were not familiar with the operations of the ZHSB, while those in missions noted that it had had a beneficial effect in harmonizing the health workers' payroll." (Chimbari, et al., 2008) The summary of the views of key informants in regards to the strengths and weaknesses of government policies and strategies in retaining CHPs in Zimbabwe are shown in the following table labeled Figure 10.

Figure 10

Figure 11

Opinions of Key Informants on Financial Incentives

Dodson (2002) writes in the work entitled "Gender and the Brain Drain From South Africa" that South Africa is experiencing a "Substantial 'brain drain' underestimated in official emigration statistics." (p.1) It is reported that no one is yet certain as to why some leave and why some stay. The study reports a survey questionnaire that was focused on motives for emigration. The primary findings of a gender-based analysis include the following findings:

(1) There was remarkable gender agreement in people's level of satisfaction or dissatisfaction with a range of "quality of life" indicators. Economic factors such as taxation and the cost of living, along with social concerns such as safety and security, are the main sources of dissatisfaction for both men and women.

(2) Within this broad overall concurrence, the categories for which skilled women expressed higher levels of dissatisfaction relative to men were employment-related factors such as their job, income, job security and prospects for professional advancement; and aspects of everyday family life such as access to acceptable housing, schooling and medical services.

(3) Overall women seem to be slightly more satisfied with their present quality of life than are men, reinforcing the finding of women's lower emigration potential.

(4) High levels of dissatisfaction on the part of both genders across a number of quality-of-life indicators confirm that there are several push factors that might encourage skilled emigration. Most respondents also anticipate a decline in social and economic conditions over the next five years, especially in education and health care. Such pessimism was higher among men than among women.

(5) The biggest "push" factors for both men and women were crime and lack of security. There was a small gender difference in the relative significance of factors that would encourage people to stay in South Africa: men ranked improved security first, followed by "family" and "patriotism," whereas more women ranked "family" as the primary consideration that would prevent them from emigrating. (Dodson, 2002, p. 1-2)

Reported is that the decision for emigration to South African is dependent upon "the interactions of a host of forces" and that these are experienced and perceived differently depending upon the gender of the individual. (Dodson, 2002, paraphrased) Dodson's study emphasizes two critical factors to understanding migration behavior in relation to brain drain in South Africa:

(1) Migration takes place within social institutions of marriage, family, household, and inter-personal relations. Attitudes and opinions on emigration are the outcome of discussion and negotiation between men and women, particularly life partners.

(2) Migration attitudes and behavior are strongly influenced by economic factors such as employment and income status. A focus on skilled migration automatically leads to certain attitudinal similarities within the sample population, regardless of gender. (Dodson, 2002, p.27)

It is reported that women were found to "have a lower emigration potential than men" and that this is due to women "feeling stronger ties to home and family and having less confidence about their own ability to succeed in a new social and economic movement." (Dodson, 2002, p. 27) Permanent partners and family dependents are a factor in emigration of men. Gender relations are stated to be critical factors in determination of a household's emigration potential. Dodson states as follows: "Intuitively, one of the policy implications [of the study reported] might be that greater affirmative action on gender grounds could be an effective strategy for reducing South Africa's brain drain. If women nurses and teachers are less likely to emigrate, the same might be true for women doctors, engineers and IT specialists. Training and employing more women might therefore reduce the risk of losing skills through emigration. However, if affirmative action were to lead to real or perceived disadvantaging of men, the strategy might prove counter-productive, encouraging skilled males to emigrate, taking their female partners with them." (Dodson, 2002, p.27) Dodson reports that a flaw in the "simplistic gender-based strategy to reduce the brain drain is that the gender differences identified in the survey may have been caused by factors other than gender alone. The women in the sample of skilled South African nationals were racially, professionally, socially and economically different from the male sample. More of them were black; fewer of them were married; more of them were in occupations such as teaching and nursing; more of them occupied lower income categories. It may have been these factors, rather than their gender per se, that reduced the likelihood of their emigration." (Dodson, 2002, p.27) Dolvo (2003) writes that the African continent is facing an unprecedented health crisis due to the HIV / AIDS epidemic and the "re-emergence of old communicable diseases such as TB and Malaria, and the apparent paradox of increasing levels disorders linked to changing lifestyles and degenerative diseases." (p.3) Added to this are other problems that impact the health system and that arise from economic challenges, which result in low health care service funding combined with health service infrastructure deterioration. (Dolvo, 2003, paraphrased) It is reported that estimations state that 17 out of 48 African countries reported a reduction in life expectancy between the years of 1981 and 1999. Dolvo states the significant fact that the health worker is "operating within the difficult milieu." (2003, p.4) The health worker is "a critical part of the health system and perhaps the most essential of the health sector's resources, whose motivation and effective utilization enhances the efficiency and effectiveness with which all the other resources are used." (2003, p.4) Dolvo also reports that the numbers of health professionals who are experiencing brain drain has peaked in previous years largely due to the high demands that come from the developed countries and that these demands are such that were "occasioned by demographic changes, aging populations as well as a reduction in attracting recruits into the health workforce." (2003, p.5) In addition, reported are changes in working hours and conditions, which means that there has been an increase in the demand for doctors and nurses. Stated specifically is that the "brain drain of professionals, combined with the health crisis described...together threatens the entire development process" on the African continent. (Dolvo, 2003, p.5) The following table lists the registered doctors of registration status and county of quantification in selected developing countries as of May 27, 2003.

Figure 12

Source: (Dolvo, 2003)

As shown in the following chart there appears to be many full registration doctors in Africa however, full and specialist registration doctors are much lower with no limited and only 80 provisional registration doctors. Dolvo reports that there are many countries in the Africa region including South Africa that have recruited from other countries outside of the African continent. 27% of South Africa doctors were reported as non-citizens and most of sub-Sahara African countries use the Cuban medical corps. Retirement ages have been changed in some countries with some countries allowing professionals to work past sixty years of age, which is presently a compulsory retirement age. It is also reported that there are a variety of locally designed health professionals in Africa with Clinical Officer in Malawi and Zambia, Surgical and Medical Technicians in Mozambique, and Assistant Medical Officers with surgical and obstetric skills in Tanzania and Medical Assistants in Ghana. (Dolvo, 2003, p.6) Dolvo states that the traditional health professions have been slow to accept these substitutes. (Dolvo, 2003, p.6) Professionals have been encouraged by the International Organization for Migration with a focus appearing on the affordability of the limited or temporary returns by professionals to offer skills and services. (Dolvo, 2003, p.6) Arguments state that migration results in benefits to donating countries. Training strategies are reported to have been proposed including the use of quotas or geographical criteria in candidate selection for training of health professionals. It is reported that academic merit has been criticized in African for the production of elitist professionals as rural candidates many times attend schools that have infrastructure that is poor or whom cannot be under expectations to compete with high schools in cities with elite attendance. (Dolvo, 2003, paraphrased) In addition, it is reported that community-based "student-cantered problem solving and other approaches to health professional education and most particularly medical education have been held up as producing professionals with locally relevant skills and a community service orientation." (Dolvo, 2003, p. 6) There is reported to be a large and difficult need for reorientation of educators in medical and health care to modify existing educational traditions that place emphasis on euro-centric or international standards and methods of health professional education. (Dolvo, 2003, p.7) This is reported to been the primary and quick response to brain drain. It is stated that the expansion of production while failing to seal the leak is not a response that is efficient and that due to the infrastructure being rustic and the loss of lecturers the larger numbers in training groups is likely to result in quality of products that are poor and emigration increases. (Dolvo, 2003, paraphrased)

The work of Labonte et al. (2006) states that Sub-Saharan Africa has seen a "resurgence of various diseases that were thought to be receding and public health systems are still inadequately staffed with a need for more than 700,000 physicians stated. Many of the health professions that remain are not motivated due to the workload, poor pay, being poorly equipped with career opportunities that are limited. (Labonte, et al., 2006, paraphrased) A large body of research exists documenting the fact that the migration of the skilled professionals from developing countries to developed countries is large and that the number is rapidly rising. It has been concluded by the Joint Learning Initiative on Human Resources for Health "the future of global health and development in the 21st century lies in the management of the crisis in human resources for health." (Labonte, et al., 2006, p.1) The Joint Learning Initiative has indicated that there will be at least one million health workers needed over the next ten years for delivering basic health interventions in SSA. The 2005 UK Commission for Africa has called for the world's richest nations for the provision of $7 billion in developing Africa's health infrastructure. Stated specifically is "The overall impact of international recruitment and retention difficulties in SSA source countries is difficult to assess because of the absence of reliable data. However, the summary country profiles below allow us to form a general picture." (Labonte, et al., 2006, p.2) The figures shown in the following table labeled Figure 2 in this study show the extent of physician shortages and nurses in Sub-Saharan African countries.

Figure 13

Source: Labonte, et al. (2006)

South Africa is stated to be in a "new and unenviable position. It has traditionally been a country that both sends and receives migrants, but its rate of export of human capital is now far higher than its rate of import." (Labonte, et al., 2006, p. 8) It is estimated by the South African Medical Association that at least 5,000 South African doctors moved abroad in 2002.23 According to DENOSA, the largest nursing union in the country, 300 nurses leave South Africa each month." (, p.8) The head of National Nursing Services for Netcare, Eileen Brannigan, one of the largest South African private hospitals states that more than 25% of the 90,000 registered nurses in South Africa left the country in 2002 alone." (Labonte, et al., 2006, p. 8)

Brannigan additionally relates that the South African Nursing Council receives approximately, "300 queries a month from nurses who have registered or who are querying about registration overseas." (Labonte, et al., 2006, p.8) It was reported by BBC in May 2005 on the extent to which South Africa's health service has been hit by an exodus of nurses seeking better pay in countries such as the UK and Saudi Arabia. Through DENOSA, nurses went on strike on 2 May 2005 demanding better pay, including a basic uniform allowance of R1, 500 (U.S.$241)." (Labonte, et al., 2006, p.8) South Africa's Health Attache to the IOM has encouraged the use of bilateral arrangements to manage migration of health care workers, using the example of the Memo of Understanding between South Africa and the UK.27." (Labonte, et al., 2006, p. 8)

Retention Strategies

In order to better understand what it is that retains health care employees including physicians and nurses in South Africa this literature review turns to the study of Madhina, Nyamangara, Mtandwa, and Damba (2008) entitled "Retention Incentives for Health Workers in Zimbabwe" which investigates the impact of the framework and strategies to retain critical professionals." (p.2) The government has put these incentives in place to attempt to retain staff in public and private institutions in Zimbabwe. The report states that the work was initiated by the regional program on incentives for health workers retention in the Regional Network for Equity in Health in East Southern Africa (EQUINET) in cooperation with Regional Health Secretariat for East, Central and Southern Africa (ECSA). The program is reported to be coordinated by "University of Namibia, Namibia, with support from University of Limpopo and Training and Research Support Centre, and the ECSA Technical Working Group on Human Resources for Health. The study sought to investigate the causes of migration of health professionals; the strategies used to retain health professionals, how they are being implemented, monitored, and evaluated, and their impact, in order to make recommendations to enhance the monitoring, evaluation and management of non-financial incentives for health worker retention." (Madhina, Nyamangara, Mtandwa, and Damba, 2008, p.3)

The strategic plan of the ZHSB for 2005-2010 is one that makes provision of a framework that enables the incentive program to be monitored and evaluated for CHPs in Zimbabwe, however this program has certain challenges in implementation of data and data availability. Reported is that efforts have been the focus in attempting to make the data collection stronger. Included in the research is a desk review as well as field-data collection through a non-interventional, descriptive cross-sectional survey and a review workshop. (Madhina, Nyamangara, Mtandwa, and Damba, 2008, p.3) Included in the study was a public, private and faith-based examination of urban and rural health institutions and reported to be in "three administrative provinces and two major cities in Zimbabwe. (Madhina, Nyamangara, Mtandwa, and Damba, 2008, paraphrased)

The focus of the study was on critical health professionals and primary doctors, nurses and pharmacists, as well as radiographers, laboratory technicians, dentists, opticians, nutritionists, and therapists. A key informant in each of the organizations were interviewed. There were 196 questionnaires completed as well. The study additionally reports five focus group discussions, which were held with various groups of trainees with a focus on the perceptions of trainees on the retention packages in half-day workshops for discussion of findings. (Madhina, Nyamangara, Mtandwa, and Damba, 2008, paraphrased)

The study found that the most experienced CHPs are emigrating in Zimbabwe and qualified staff seek to migrate for the purpose of gaining experience. (Madhina, Nyamangara, Mtandwa, and Damba, 2008, paraphrased) Migration was taking place at all levels in Zimbabwe including at the primary, district, provincial, central and private sector levels of the health care delivery system. Zimbabwe emigrants were found to migrate to Botswana, Namibia, Australia, the UK, New Zealand and South Africa. Economic hardship of the CHPs were found to be the primary factors driving out-migration. (Madhina, Nyamangara, Mtandwa, and Damba, 2008, paraphrased)

Most CHPs from Zimbabwe migrate to South Africa, Botswana, Namibia, Australia, United Kingdom and New Zealand. (Madhina, Nyamangara, Mtandwa, and Damba, 2008, paraphrased)

The major factor driving out-migration was found to be the economic hardship that the CHPs are facing due to the deterioration of the country's economy. Other factors identified, including poor remuneration, unattractive financial incentives and poor working conditions. (Madhina, Nyamangara, Mtandwa, and Damba, 2008, p.4)

Chimanikire, et al. (2005) reports that Zimbabwe was at one time one of the top nations in Africa in terms of is level of education and skills however, Zimbabwe presently is reported to run "the risk of being turned into a society of expatriates because of an unprecedented exodus of professionals fleeing a plethora of worsening ills." ( ) Chimanikire et al. (2005) states that the findings in the study conducted by Prof. C.J. Chetesnaga of the Scientific and Industrial Research and Development Centre, Harare (SIRDC) (2003) on "An Analysis of the Causes and Effects of Brain Drain in Zimbabwe," revealed the following:

(1) The study was able to establish that there were 479,384 Zimbabweans in the Diaspora although the study team was aware that there were a large number of Diasporans that it could not contact for various reasons. The Diaspora destination of the majority of Zimbabweans is the United Kingdom, Botswana and South Africa;

(2) The study showed that most of the respondents held bachelor's degrees, followed by those who were polytechnic graduates. About 20% held masters degrees, while 5% held Ph.D degrees;

(3) The health and teaching professions are the most affected while accountants constitute a significant proportion (16.9%) of the total number of Zimbabweans in the Diaspora;

(4) The most common work-related reasons for emigrating given by 34% of the respondents, were the low salaries in Zimbabwe, followed by the exchange rate mentioned 32.55%, while 29% gave better career advancement opportunities as reason for emigrating;

(5) All those in the clergy expressed the desire to come back to Zimbabwe after 5 years. Half of the farmers wanted to return after 5 years, while 37.5% of engineers wanted to return within 2 years. (Chimanikire, 2005) The World Health Organization in its study of six countries and the reasons for migration states of Zimbabwe that most of the professionals "would like to emigrate so that they can receive better remuneration in the intended country of destination (55.0%) or would like to save money quickly in order to buy a car, pay off a homeland or for a similar reason (54.1%). (WHO, 2004) Other reasons stated for emigration include: (1) achieving better living conditions (47.2%); (2) lack of resour4ces and facilities within the health care system of Zimbabwe (45%); (3) no future for them in Zimbabwe (45%); and (4) declining health care services in the country (42.9%). (WHO, 2004)

The work of Chetsanga and Muchenje (nd) entitled "An Analysis of the Cause and Effect of Brain Drain in Zimbabwe" a study conducted on the brain drain of Zimbabwe stating that Zimbabwe has lost "thousands of talented professionals crucial to its development needs." (p.6) The importance of the study is stated as due to the fact that no country "can ignore this systematic loss of skills..." which have a "clear negative impact on a country's development system." (Chetsanga and Muchenje, nd, p.8) Chetsanga and Muchenje report that some of the reason for the migration of these professionals "stem from poor domestic capacity building policies, which result in a skewed balance between labour supply and demand." (p.8) According to Chetsanga and Muchenje brain drain can occur in several forms as follows:

i) Primary external brain drain occurs when human

resources leave their country (Zimbabwe) to go and work overseas in developed countries such as Europe, North

America and Australia.

ii) Secondary external brain drain occurs when human

resources leave their country (Zimbabwe) to go and work elsewhere in their region e.g. South Africa, Botswana,

Namibia etc.

iii) Internal brain drain occurs when human resources are not employed in the fields of their expertise in their own country or when human resources move from the public sector to the private sector or within a sector e.g. when university lecturers become commuter bus drivers or nurses become informal traders, etc. (Chetsanga and Muchenje, nd, p.9)

Findings stated in the work of Chetsanga and Muchenje (nd) include those as follows:

(1) The study was able to establish that there are 479-348 Zimbabweans in the Diaspora although the study team is aware that there is a large number of Diasporans that it could not contact. The Diaspora destinations of a majority of Zimbabweans are the United Kingdom, Botswana, and South Africa.

(2) The highest proportion of respondents to the questionnaire were from Mashonaland (26.7%) while Manicaland contributed the least proportion of the respondents (15.1%).

(3) The study shows that most of the respondents held bachelor's degrees, followed by those who were polytech graduates. About a 20% held masters degrees, while 5% held Ph.D degree.

(4) The Health and teaching professions are the most affected, while accountants constitute a significant proportion (16.9%) of the total number of Zimbabweans in the Diaspora.

(5) More than half of the respondents emigrated due to work related factors. About a quarter had emigrated due to the need to attend school in their new country of abode. A tenth gave marriage/relationship factors as the reason for emigrating, while 8% mentioned political factors.

(6) The most common work-related reasons for emigrating given by 34.5% of the respondents, were the low salaries in Zimbabwe, followed by the exchange rate mentioned by 32.5%, while 29% gave better career advancement opportunities as a reason for emigrating.

(7) The majority of the respondents (62.5%) intended to return to Zimbabwe. About a quarter of the respondents were not sure whether they would return to Zimbabwe or not.

(8) All those in the clergy expressed a desire to come back to Zimbabwe after 5 years. Half of the farmers would like to come back within 2 years. Half of the nurses would like to return after 5 years, while 37.5% of engineers would like to return within 2 years.

(9) Nearly half of the respondents in the middle age group clusters of 30-39 and 40-49 were not sure about when they were going to return home. About 40% and 33% of the young (20-29 years) and old (50 + years) respondents respectively, expressed a desire to return to Zimbabwe within the next two years. Less than a third of respondents in all age groups indicated a desire to return to Zimbabwe within 3 to 5 years.

(10) Finally, the study also shows an increasing trend in the number of people leaving Zimbabwe. The trend exhibited by the curve suggests that the process has not yet leveled off. (Chesanga and Muchenje, nd)

Chetsanga and Muchenje state the conclusions as follows:

(1) The brain drain in Zimbabwe is based on the global problem associated with man's quest for better opportunities in life. Its ongoing increase has evoked widespread calls for policy responses. If the Zimbabwe government does not do something to make staying at home more attractive and rewarding, the brain drain will continue unabated. The driving force seems to be as powerful as the force pulling professionals and others away from Zimbabwe. These two forces appear to be operating with mutual reinforcement.

(2) At the social level, Zimbabweans in the Diaspora indicated that they suffer discrimination and often find themselves relegated to third class citizenship. Most Zimbabweans in the Diaspora informed the study team that they were not happy to leave Zimbabwe, but were forced to do so by economic factors.

(3) Proportionately, some professions have small numbers of people who have emigrated, but these emigrants are highly skilled and therefore critical to Zimbabwe's development agenda. The experience of Zimbabwean companies has been that most of the people they are losing to job offers elsewhere, were the highest paid in the company. Their departure was therefore a major loss not only to Zimbabwean companies, but also as taxpayers to the Zimbabwe government.

(4) Some emigrants are leaving to work in countries where research and development (R&D) is actively done with the latest generation of equipment and support is guaranteed. There are about 20,000 scientists and engineers in Zimbabwe. Zimbabwe still needs more scientists. There are now more Zimbabwean-born scientists and engineers working in the Diaspora than there are in Zimbabwe. One reason for there being fewer scientists left in Zimbabwe is that government and private-sector spending on R&D is only about 0.2% of the gross national product. This is one of the lowest percentages of funding for R&D support in the world. Instead, a minimum of one percent of Zimbabwean gross national product should be spent on scientific and technological development.

(5) An examination of the professions of those who are leaving the country shows that a sizable share is made up of teachers and nurses. Indeed, according to the survey, the health care sector is the most affected. Many are leaving because health care and education spending cuts have denied them reasonable salary levels in Zimbabwe.

(6) Erecting legal barriers to the emigration of educated professionals will only encourage illegal emigration and discourage bright Zimbabweans from seeking to better themselves through overseas education in the first place. Enacting necessary economic reforms that make staying at home attractive and rewarding for educated Zimbabweans can arrest the brain drain problem. There is no alternative to this option if the brain drain is to be arrested.

(7) Even if brain drain is a valid concern, the main thrust of public policies in Zimbabwe should be driven by objectives of domestic equity, efficiency, and economic growth rather than becoming hostage to the threatening waves of emigration. (Chetsanga and Muchenje, nd)

Recommendations stated by Chetsanga and Muchenje (nd) include those as follows:

(1) On the basis of the data assembled during the study, it is possible to have a reliable database of Zimbabwean professionals in the Diaspora by profession, field of study, competencies, and experience. These data will enable the Zimbabwean Government, Universities, and institutes of higher learning, hospitals, and the private sector to attempt to lure back this array of expertise.

(2) There is an urgent need to win back the confidence of the large community of Zimbabweans of good will who are in the Diaspora. They felt abandoned when no clear provision was made for them to vote during the March 2002 Presidential election.

(3) The demand for qualified and skilled labor for national development has become a critical global issue. It is compelling to both the rich and the poor countries across the continental divide to develop policies and strategies to satisfy their human resource demands.

(4) Since other countries are competing with Zimbabwe for similar qualified human resources, a potentially rewarding solution might be to formulate a skills export and import policy that promotes and provides the framework for the training of human resources in Zimbabwe for the labour markets of both target countries and Zimbabwe.

(5) Both governments and private sectors should show a commitment to solving the brain drain problem in Zimbabwe and jointly play a pivotal role in formulating national policies to utilize the skills and other resources of Zimbabweans in the Diaspora for the development in Zimbabwe.

(6) The increase in the activities of the parallel foreign currency exchange market, needs to be eliminated. It is important to establish a sustainably effective exchange rate mechanism that will remove the distortions that are endemic in the country's current economic system.

(7) In order to build on the findings of the present study, the Government of Zimbabwe should launch a comprehensive National Human Resources Survey (NHRS) to ascertain the current human resource base and employment situation in all the sectors of the economy to enable them to make informed projections of future human resources requirements for the country. (Chetsanga and Muchenje, nd)

Methodology for Analyzing Literature

The methodology utilized in this study involves an examination of push and pull factors that impact emigration of Zimbabwe health care workers in what is a synthesis of the literature on health care worker emigration in Zimbabwe. The work of Thielemann (2011) states Underlying some of the most prominent theories and models of international migration (Massey et al., 1993) is the so-called 'push -- pull model'. It is a conceptual framework that suggests that there are push factors in countries of origin that cause people to leave their country and pull factors that attract migrants to certain receiving countries." Pull factors are described as "circumstances in the home environment that make a person think about leaving his normal place of abode for another part of the same country, neighbouring countries or for a more distant place like the United Kingdom or the United States. (Smyke, 2001) Push factors are described as factors that "...draw people to particular destinations." (Chimanikire, 2005) The work of Haas (2008) entitled "Migration and Development: A Theoretical Perspective" reports that over the last century there have been several theoretical perspectives on migration which have evolved however, these views have "evolved in isolation from one another, and shown important differences in their level of analysis as well as paradigmatic and thematic orientation." (Smyke, 2001) Stated as one reason for the "lack of coherence" is the fact that migration "has never been the exclusive domain of one of the social sciences, but has been studied by most of them. Differences in disciplinary and paradigmatic orientation and level of analysis have led to widespread controversy on the nature, causes, and consequences of migration." (Smyke, 2001) Smyke (2001) notes that Massey et al. (1993) reported that contemporary views on international migration is such that remains "mired in nineteenth-century concepts, models and assumptions...a full understanding of contemporary migration processes will not be achieved by relying on the tools of one discipline alone, or by focusing on a single level of analysis. Rather, their complex, multifaceted nature requires a sophisticated theory that incorporates a variety of perspectives, levels, and assumptions." (Smyke, 2001) There has been an emphasis placed by researchers on the lack of a migration theory that is comprehensive in nature with many calls going out for the development of a general migration theory. It is difficult to generalize about the causes of migration and the consequences as well due the complexity and diversity of the problem and the complexity in the separation of migration from other processes that are political and socioeconomic in nature. Until the early 1980s, it is reported that the theoretical debate on migration had a tendency to be "rather polarized with neo-classical views on the one hand and historical-structuralist views (neo-Marxist, dependency, world systems) on the other. Since then, however, under the influence of postmodernism, the debate has become less polarized and has been characterized by increasing synergy between migration theorists from different disciplines and paradigmatic backgrounds. Moreover, it has been frequently argued that it is possible to (eclectically) combine and integrate different theoretical perspectives on migration, which are not necessarily mutually exclusive (Massey et al. 1993)." (Smyke, 2001) The push-pull framework is reported to be "of much analytical use..." (Smyke, 2001) The push-pull framework is a descriptive model therefore this study has used a qualitative methodology and specifically that of collecting and analyzing secondary data in the form of a literature review which is appropriate for use in this type of study or that of attempting to understand a social problem such as emigration of Zimbabwe health care professionals.

Limitations

The push-pull framework is a descriptive model and as such "tend to have the character of ad-hoc explanations forming rather ambiguous depository of migration determinants." (Smyke, 2001) The push-pull model also has a tendency to confuse different scales of analysis ranging from individual to global therefore not allowing for assignation of relative weights to the various factors affecting migration decisions." (Smyke, 2001)

Summary of the Literature Review

The reasons for migration of the majority of health professionals were socio-economic and political reasons as well as self-advancement and specifically for furthering their education and seeking better conditions for work and study opportunities. The goals for emigration of health professionals is due to better pay and because they are able to assume more senior responsibilities and undergo specialist training to receive better remuneration. Findings additionally show that health professionals who have migrated would given consideration to returning to Zimbabwe however, unless the combined factors that pushed them toward emigration are addressed in Zimbabwe, these individuals do not think they would consider returning on a permanent basis. The health sector in Zimbabwe is characterized by overall failure of the public sector hospitals to conduct their functions as intended including failure to retain local well-trained health professionals, the inability to recapitalize and re-equip the healthcare sector, the inability to provide reliable and consistent basic medicine supplies and the inability to maintain as well as upgrade, develop and implement a sustainable health professional training policy. Finally, the healthcare sector in Zimbabwe is unable to provide coverage of health insurance benefits and to carry out regular preventive vaccinations. Personnel who remain employed in the Zimbabwean health care sector are overburdened due to the shortage of health care workers. Health care worker migrations also are impacted and driven by the challenge of dealing with diseases including malaria, AIDS, cholera, and tuberculosis. The push and pull factors are found in the literature reviewed in this study to have an equal impact on migration of Zimbabwe health workers.

Brain Drain of Health Professionals in Zimbabwe

Chapter 3

Methodology

This chapter will describe and discuss the various methods of gathering data and the advantages and disadvantages as well as the preferred method in each case that will be undertaken. The research in this study is both qualitative and quantitative research including primary research based on interview and questionnaires and secondary data analysis. Both qualitative and quantitative research methods have their own inherent strengths and weaknesses.

Research Methods

The methods used for research in this study include the problem having been defined and secondary sources having been reviewed including previous studies on brain drain, theoretical papers, and academic books and journals the objectives of the research serves to form the basis of the research methods.

Theoretical Framework

The expression Brain Drain was first coined by the British Royal Society in the 1950s with the first studies that analyzed this problem focused on the political and social effects of brain drain. The study results show that the primary motivations for migration were political and social in nature and that the effects of the migrations are negative for the welfare or the social structure of the country from which individuals were leaving. The solution stated was the need to create and solidify the role of the International Organizations and Institutions that had the capacity to manage the flows of migration. (Giannoccolo, 2006)

Sriskandarajah (2005) states that brain drain presents two primary research challenges and specifically first stated is "to devise methodologies for differentiating between brain drain per se and a subset of cases that might best be termed 'brain strain'. The latter are cases in which the net outflow of highly skilled workers from a particular sector in a particular country is actually hampering or is very likely to hamper economic development or the pursuit of important socioeconomic goals."

Sriskandarajah goes on to state that the second challenge is to devise "a more robust methodology for understanding the overall net impacts of migration. The rationale for why such a methodology is needed is clear: if brain strain occurs when the negative impacts of migration outweigh the positive impacts of migration, then finding a way of calculating these impacts is imperative." (2005) Sriskandarajah states that the development of such a methodology will make a requirement of a "massive, multidisciplinary effort" and further will involve the "collection of considerable, context-specific evidence such as information on vacancy rates in key sectors, historical and comparative changes in the distribution of certain key workers, the size and nature of the sending economy, and the migration experience of those who leave." (2005) Sriskandarajah states that involved will be "quantitative as well as qualitative methodologies: modeling demand/growth in training for particular sectors, modeling the rate of growth in wages and conditions, and surveying migration and return intentions. It will rely as much on econometric methods for isolating migration's impacts -- for instance, within the context of sub-Saharan Africa's HIV pandemic and health care systems -- as on a broad understanding of the obstacles to economic development in the countries in question." (2005) Sriskandarajah goes on to state that this type of model will be complex in nature and will necessarily take into account "…returns as well as new inflows and outflows of people. It will also need to be comparative and look at progress towards achieving key public policy targets, such as reducing mortality or increasing literacy in comparable cases where emigration has not been as important. And it will also need to be dynamic, examining current as well as future scenarios." (2005) Sriskandarajah states that the dual task of "identifying cases of brain strain and calculating the overall impacts of migration are daunting to say the least." (2005)

Qualitative Research

The strength of qualitative research is reported as its ability to make provision of "complex textual descriptions of how people experience a given research issue." (Qualitative Research Methods: A Data Collector's Field Guide, nd) Qualitative research is a type of scientific research and as such consists of an investigation that:

(1) attempts to answer questions;

(2) systematically uses a predefined set of procedures to answer the question;

(3) collects evidence;

(4) produces findings that were not determined in advance;

(5) produces findings that are applicable beyond the immediate boundaries of the study. (Qualitative Research Methods: A Data Collector's Field Guide, nd)

Qualitative research additionally "seeks to understand a given research problem or topic form the perspectives of the local population it involves" and it particularly effective in gaining culturally specific information concerning the "values, opinions, behaviors, and social contexts of particular populations." (Qualitative Research Methods: A Data Collector's Field Guide, nd) Qualitative research makes provision of information concerning the 'human' side of an issue or in other words, "the often contradictory behaviors, beliefs, opinions, emotions and relationships of individuals." (Qualitative Research Methods: A Data Collector's Field Guide, nd) In addition, qualitative methods are effective in providing identification of features that are intangible including such as "social norms, socioeconomic status, gender roles, ethnicity, and religion." (Qualitative Research Methods: A Data Collector's Field Guide, nd)

Qualitative research seeks to explore phenomena and is descriptive in nature. The advantages of qualitative research include that open-ended questions used in qualitative research have the ability to evoke responses that are "meaningful and culturally salient to the participant" and that are "unanticipated by the researcher" as well as that are "rich and explanatory in nature." (Qualitative Research Methods: A Data Collector's Field Guide, nd)

The primary ethical considerations for qualitative research include

(1) Respect for persons requires a commitment to ensuring the autonomy of research participants, and, where autonomy may be diminished, to protect people from exploitation of their vulnerability. The dignity of all research participants must be respected. Adherence to this principle ensures that people will not be used simply as a means to achieve research objectives.

(2) Beneficence requires a commitment to minimizing the risks associated with research, including psychological and social risks, and maximizing the benefits that accrue to research participants. Researchers must articulate specific ways this will be achieved.