Patrick Cockburn
The British government pretends that, despite the drastic cut to its foreign aid budget, subsidies flow in one direction only, which is from the UK to poor countries. At the G7 summit, Boris Johnson is making much of Britain’s generosity in donating surplus vaccines to places where health systems are collapsing under the impact of the pandemic.
But the nasty secret about British aid is that, in reality, the subsidies are often going in the opposite direction because Britain deliberately trains far fewer doctors and nurses than it needs. It makes up the difference by recruiting great numbers of trained medical staff from impoverished countries where they are already in critically short supply.
In Kenya, for instance, where 20 million people live in extreme poverty, on less than $1.25 (89p) a day, the country loses $518,000 for every doctor and $339,000 for every nurse who emigrates to the UK. Britain gives substantial aid to Ghana to fight malaria and reduce infant mortality, but these sums are exceeded by the £65m Britain saves by employing 293 doctors trained in Ghana and a further £38m saved on 1,021 Ghanaian nurses who work here.
“The situation will never be turned around until we train more doctors here,” says Rachel Jenkins, professor emeritus of epidemiology and international mental health policy at King’s College London, who has long campaigned on the issue.
What makes the government’s position so culpable is that the Treasury is well aware of the financial advantages of training too few doctors and filling the gap by recruiting doctors and nurses who have already been trained at some other country’s expense.
A precise figure for the shortfall is difficult to calculate, but the then health secretary, Jeremy Hunt, told the Health Select Committee in 2017: “It is interesting that Health Education England estimates that we were training about 6,500 doctors a year and we needed to train about 8,000 a year to be self-sufficient.” Hunt’s expressed concern was not about the damage to poor countries of losing scarce doctors, but that there might not be enough of them to recruit.
Prof Jenkins says that Hunt’s figure is an underestimate of the number of doctors needed in Britain, particularly of GPs, psychiatrists and in emergency care. There is no shortage of people in the UK who want to become doctors and nurses, but the government has been unwilling to spend the money to train them. “Loads of people are disappointed because they cannot get into medical schools,” she says. “They should double the number of places for medical students.”
The reason this has not happened is the high cost of medical training, which in 2005 was already £220,000 for a doctor and £125,000 for a nurse, and has greatly increased since then. Medical schools are expensive and the training period is long. Even with what amounts to the poaching of trained medical staff from abroad, the number of doctors in the UK per capita is still one of the lowest in Europe, second only to Poland. A study by the Organisation for Economic Cooperation and Development (OECD) shows that the UK has 2.8 doctors for every 1,000 people compared with an average of 3.5 doctors in the OECD’s member countries as a whole.
For all the self-congratulatory talk about Britain donating vaccines to the world’s poor, it is in practice knowingly parasitic on their ill-funded health systems. Of the 289,000 licensed doctors in the UK in 2021, two-thirds were trained in this country and one-third trained elsewhere. The losers are overwhelmingly poor and middle-income countries in southeast Asia and the Middle East, with the largest number of doctors coming from India, Pakistan, Nigeria, Sudan, South Africa and Ghana.
Because of the desperate need for more medical staff during the Covid-19 pandemic, Britain – along with other rich countries – has eased visa restrictions and stepped up active recruitment by the NHS, so doctors in the Philippines are retraining as nurses in order to emigrate. The country is now so short of nurses that hospital wards are shutting down.
Ways of mitigating this drainage of health professionals from poor countries to the rich include discouraging recruitment in countries where there is a critical shortage of health workers, and a ban on any recruitment at all in the 57 poorest. This is something that Britain long ago pledged to do under the World Health Organisation code of practice, which says that countries should create an adequate health workforce of their own through long-term planning, education, training and retention, so they will not rely on raiding the healthcare systems of others.
“The UK has failed massively on all these counts,” says Prof Jenkins. She suggests that Britain should pay compensation to countries that lose the benefits of expensive and ill-afforded investment in medical training and then suffer the consequences of having an understaffed health system in a time of crisis.
The NHS – and the health services of other well-off countries – can claim that doctors and nurses emigrate voluntarily, but this argument is disingenuous. Impoverished governments unable to pay decent salaries or provide modern working and living conditions are never going to be as attractive to medical staff as places able to provide these advantages.
The poaching of doctors and nurses has grown worse since the 1980s, but the outflow from poor countries has become a flood since the start of the pandemic. In the last 18 months, the number of doctors trained abroad but licensed to practice in the UK has risen from 66,000 to 80,000.
This is bad news for everybody. It has become a cliche to say that in dealing with a disease as infectious as Covid-19, nobody is safe until everybody is safe. The idea is to discourage rich countries from monopolising vaccine supplies and to make sure the poorer ones get enough to inoculate their populations. But this saying applies equally to rich nations ensuring that they have sufficient trained doctors and nurses at the expense of others. This hidden subsidy from the poor to the rich means that countries in the former category will become strongholds for Covid-19, where it can develop variants with which to renew the attack on the rest of the world.
A gain for an importer of medical expertise such as Britain is a loss for an exporter where already-inadequate healthcare provision is disproportionately degraded by the loss of skills. When one psychiatrist emigrated from Nepal to Britain some years ago, Nepal lost a quarter of all its trained psychiatrists.
Cutting foreign aid is popular among voters who feel that charity should begin at home and suspect its utility abroad. But training more British doctors and nurses, even though vastly expensive, would get far greater public backing and would provide an effective way of aiding poorer countries instead of covertly leeching off their overstrained healthcare systems.
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