Cálculo de Ganancia (pérdida) por acción:

Earlier we saw that brain drain can result in significant losses (costs) for source

countries. In particular, it can lead to a loss of economic investment from expenditure in nurse training, loss of fiscal (tax) income, direct budget burden, and health system effects such as under-provision of healthcare services and increased pressure and workloads on those who remain (Ikenwilo 2007). The economic effects of nurse migration are felt by the source country in two ways. Firstly, the loss of the economic investment in the training of a nurse who then leaves the country (Serour 2009, Kline 2003); and secondly, the additional costs faced by the country to address the shortfall caused by migration (Mitchell 2006). Globally, low-income countries have spent an estimated 500 million USD training health workers who have then migrated (Kuehn 2007 cited in Serour 2009). Academics in Malawi estimate that for each RN who

migrates, the investment lost ranges from 241,508 to 25.6 million USD at 7 percent and 25 percent interest rate per annum for 30 years, respectively (Muula et al 2006)10. It is difficult to measure the exact cost of the professional education of health workers because of data issues in sub-Saharan Africa (Robinson 2007). In any case, the economic loss can be significant since health worker training is costly because of its long duration and high material expenses (Connell et al 2007), and countries are often unable to recoup their investments (Pagett and Padarath 2007).

The country also faces an additional budget burden, through the recruitment or training of a replacement workforce (Tanner 2005). The hiring of expatriates to fill nursing or tutoring positions is a costly endeavour, even with donor support. Africa employs up to 150,000 expatriate professionals to fill general human resources gaps at a cost of USD 4 billion a year (Tebeje 2005). However, this solution is considered to be effective especially when workforce depletion is severe, and has even formed part of Malawi’s Emergency Human Resources Programme.

The negative consequences of nurse migration are strongly felt in the healthcare system of the source country. They can be divided into those affecting healthcare delivery and those affecting remaining health workers. As health workers are a

fundamental part of the healthcare system, any decline in number will have a profound negative impact (Paradath et al 2003, Clark et al 2006). A number of studies (including DENOSA 2001 and Yan 2002 cited in Buchan 2006) have found that when too many nurses migrate the health system in the source country is not able to function

10

effectively. In this situation, a population may be forced to rely on alternative ways to obtain healthcare, such as seeking treatment outside the country (Serour 2009). Inability to access treatment has far-reaching consequences beyond the health status of a population. Good health is widely acknowledged to be a critical factor in poverty reduction and economic development (WHO Commission on Macro-Economics and Health cited in Conroy 2006b).

In Malawi, the loss of nurses to migration has resulted in high vacancy rates, leading to inadequate healthcare coverage threatening the functioning of the healthcare system and the health of the population (Stillwell et al 2003). In many cases, educational capacity is not large enough to support increased out-migration and increased

domestic supply (Vujicic et al 2004), contributing further to high vacancy rates. As we saw earlier, infectious diseases such as HIV/AIDS increase health care demands, placing an even greater strain on the healthcare system. There are concerns that the scaling up of ART in Malawi will be constrained by the lack of adequately trained nurses (Muula et al 2006). Staff shortages are also an important obstacle to the

attainment of the health-related targets for the Millennium Development Goals (Rolfe et al 2008, ten Hoope-Bender et al 2006, Gerein et al 2006), and observers have noted that if MDG 5 (maternal and child health) is not met, then neither will the other goals (Serour 2009). Success stories in the reduction of maternal mortality point to HRH as a crucial factor (Chilopora et al 2007, Dogba and Fournier 2009), as many maternal clinical interventions can only be successfully achieved within a functioning health system with skilled birth attendants and emergency back-up services. Maternal health is a vital component of health care services in Malawi, especially as 65 percent of the population are children under 14 or women in childbearing years (Burgess 1984). Despite ongoing interventions maternal mortality remains high and the sheer absence of staff and facilities is considered to be the most substantial barrier to progress to improving maternal health (Kachale 2007 personal communication, Bradley and McAuliffe 2009).

Not only is the capacity to deliver quality healthcare diminished, the net effect of out- migration is to increase the workload on remaining health workers (IOM 2007a). There is a strong consensus that difficult conditions and heavy workloads worsen when nurses migrate, and remaining health workers may deliver lower quality care because of time constraints (Kingma 2006, Muula et al 2006). The workload burden can also lead to demotivation and stress, and in turn encourage health workers to migrate or resign. Nurses may also experience difficulties in coping with the knowledge that their

colleagues abroad may be having a better life (Buchan 2006). In addition, migration can create an experience gap affecting the recruitment and training of health workers (Bach 2006 cited in IOM 2007a). The departure of teaching staff - often the most qualified and experienced nurses in the country - has caused a decline in the quality of education in nursing schools, and a lack of supervision and mentoring (WHO 2006c). The remaining teachers are often unable to cope with the demand, especially if training output is increased in response to staff shortages, as has been the case in Malawi.