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HIF-net at WHO
Problems and issues
Additonal brain drain notes


See also Health Information Forum: Improving access to information for
nurses and midwives in developing countries

22 August 2003 - 19 February 2004

This is a HIF-net at WHO 'living summary', maintained on a regular basis by Christine Porter (see below). What are your views on this topic? Send your comments to the email forum [email protected] and your comments will be integrated into the summary for the benefit of others.

The notes below summarize input from HIF-net at WHO participants in response to the discussion paper 'Improving Access to Information and Knowledge for Nurses and Midwives', which was posted to the list on 22 August 2003. Additions made since 23 September 2003 are in italics.


  • 'Information blackout' (Nester Moyo) in rural areas; isolation of rural health workers from the health community due to poor communications infrastructure and lack of information access.
  • Brain drain to urban areas and developed countries.
  • How to justify investing in ICTs when a country cannot meet basic health needs?
  • Difficulty in leaving posts to attend trainings, especially longer courses.
  • Some inappropriate training, particularly when framed by international standards rather than local needs.
  • Need ways to generate NEW knowledge in the nursing and midwife communities.
  • Is there a problem with information from abroad being perceived as more valid or important than local materials?
  • Are 'all those non-registered health care workers who carry out nursing duties' (Rebecca Penzer) included in this debate?



  • Fantsuam Foundation in Nigeria provides computer literacy training and has established the first rural Internet Service Provider.
  • A discussant gave a talk on "Enhancing Nursing Practice Through Information Technology" to a group of 170 nurses at the Health Advance Institute in South Africa.
  • Safe Childbirth programme for the former Soviet Union from the UK-based HealthProm. HealthProm also set up the regional League of Midwives with computer and email access.
  • An Anglo-Russian Neurological Partnerships includes an information exchange between Kingston University and Pavlov's St Petersburg Medical University.
  • University of the Witwatersrand in South Africa offers face-to-face nursing short courses for practitioners and, in partnership with an NGO, is starting a television programme for clinics that addresses patients in the morning and nurses in the afternoon.
  • The BMJ West Africa has created a Health Information Resource Centre to provide paper and e-resources, IT training, and run workshops on integrating research into practice.
  • The Perinatal Education Programme <> has been used by over 20,000 midwives in South Africa (and 15,000 doctors and medical students). The Perinatal HIV/AIDS course is online.
  • Fantsuam Foundation also works to network the Nigerian medical diaspora, universities and the government to improve information access for health professionals in the north of Nigeria
  • POPLINE offers the 'Essentials of Contraceptive Technology' handbook and poster to nurses and midwives in developing countries at no charge in 4 languages. 750,000 have been sent to date <[email protected]>.  A guide to health counselling and email alerts from their e-zine are also available.
  • DynaMed ( provides evidence-based medical reference information online, free for health care professionals in resource-poor countries.
  • The International Skin care Nursing Group (ISNG) is networking nurses with an interest in skin care through conferences, connecting with other health networks, and tapping existing nursing networks and nursing schools.
  • International Confederation of Midwives (ICM) is sourcing funds to develop a HIV/AIDS binder for midwives (to be updated biannually with new pages) and to provide advisory service to ICM member associations in disseminating this information to and running continuing education workshops with rural health centres.
  • The Hesperian Foundation (of Where There Is No Doctor fame) has published A Book for Midwives. It is available in 6, soon to be 8, languages.
  • There is greater understanding of the roles of nurses and mid-level health workers. See, for example, Mid-level and nurse practitioners in the Pacific: Models and issues:
  • Include nurses and midwives on review panels, planning committees and other health collaborations. E.g., Nurses collaborate with BMJ West Africa on running workshops and a nurse is on that journal's editorial board. Nurses also form part of DynaMed's review board.
  • Tap and link existing networks. E.g., the ISNG programme above.
  • Rural practitioners provide often the single health voice of authority on fronts from health education to infectious disease, and yet they are isolated from the rest of medical community.
  • Leaving rural areas for further training is expensive and the practitioners risk losing a farming season.
  • In Russia, one contributor comments that nurses have little responsibility for patient well-being and that (perhaps as a result) motivation to access and apply information to improve care could be stronger in some cases.
  • In South Africa, 90% of nurses don't feel equipped to manage HIV positive patients.
4. HOW TO IMPROVE ACCESS? Including how to: a. Strengthen the local production, translation, adaptation, and dissemination process? b. Strengthen nursing and midwifery library and information services? c. Facilitate global and country-level sharing of experience and lessons learned? d. Improve access to information about existing materials?
  • Include training in use of new information and communication technologies (ICTs) in nursing and midwife curricula.
  • Tap into the diaspora of 'brains that have drained' to send information 'home'.
  • Invest in the technologies and training that will link nurses and midwives to communication and information services.
  • Tap donors for ICT investments because investments from governments not meeting basic health needs might generate a backlash. Infrastructure billed for telemedicine might also be more accepted.
  • Two-way communication and personal contacts keep people involved, informed and enthused.
  • Provide national standard training and practice guidelines for nurses and midwives, ideally set by the national nursing and midwives associations.
  • Support governments in officially recognising that nurses do much of the prescribing, as a first step in training and supporting them in that role.
  • Tap and widen the communication path from central offices (which tend to be the most networked) through provincial and district offices to the community-based rural health centres (which are the most isolated). Train and staff the central and provincial centres to act as 'agents' to collect requests and adapt and disseminate information. This kind of shift will require a change in mind-set, and training should begin in pre-service.

5. WHAT DELIVERY MEDIA ARE APPROPRIATE? This discussion raised examples of using nearly all kinds of technologies -both new and old - for communication and information transfer. Several discussants mention that both print and electronic means are needed and appropriate.


  • Developed countries are pushing for internationalised standards, which would likely hasten brain drain.
  • Drain is not just to abroad, but also to urban areas from rural ones.
  • Investment in health services overall is insufficient, also contributing to the drain.
  • This drain may be an incentive for government health institutions to NOT invest in further education for nurses and midwives, particularly if it will earn them qualifications that are valid abroad or make them more employable in urban areas.
  • Ready access to communication with colleagues and to information would reduce isolation for rural practitioners, and perhaps help to stem the drain.
  • Feeling more valued and appreciated, financially but also otherwise, might also help reduce the drain.
  • Economic lures from abroad will always play a role, regardless of policy and practice at home.
CONTRIBUTORS The original discussion paper, 'Improving Access to Information and Knowledge for Nurses and Midwives', was provided by Neil Pakenham-Walsh of INASP, Jackie Lord and Caroline Hyde-Price of the Royal College of Nursing, Pat Hughes of the International Council of Nurses, and Petra ten Hoope-Bender of the International Confederation of Midwives.

BRIAN ALPER is the Medical Director of DynaMed <>,  a database that has information on nearly 1800 clinical topics with a primary care focus.

JOSEPH ANA is a GP Principal in Leighton Buzzard, Bedfordshire. He originally trained in Nigeria and is a member of the British Association of Urological Surgeons. He is a pioneer trustee-director of the Nigerian Medical Forum UK, the charity that initiated the publication of BMJ West Africa Edition in 1996. He is particularly interested in the setting-up and sustainance of continuing professional development schemes in Nigeria and West Africa for isolated doctors in rural medical/health institutions.

GRETA BERESFORD is a midwife teacher and coordinates the Safe Childbirth programme of HealthProm, a London-based non-government organization which aims to improve healthcare for vulnerable people in the former Soviet Union.

CANDICE BODKIN works at the Department of Nursing Education, Women's Health & Advanced Midwifery, University of the Witwatersrand, South Africa.

JOHN DADA is a nurse and director of the Fantsuam Foundation, Nigeria, which supports rural communities to set up their own Community Learning Centres. He is also setting up a mobile Community Telecentre to provide distance learning for frontline health workers, staff and students in rural schools where there are no phone lines or electricity. He is particularly interested in the provision of IT training and email access for frontline healthcare workers, most of whom are women.

PEGGY D'ADAMO is a librarian at the Johns Hopkins University Center for Communication Programs, which is a project of the JHU School of Public Health, Baltimore, USA. Her particular interest is in health communication materials and providing better access to health education materials. <

CARMEN DOLEA works for the department of Organization of Service Delivery at WHO headquarters, Geneva. <[email protected]>

ROGER DREW is a health and development consultant based in the UK. A medical graduate, he worked for 10 years in Zimbabwe, first as medical superintendent of Elim Mission Hospital, then as Projects Director of Family AIDS Caring Trust (FACT), Zimbabwe's largest AIDS service organization. Since returning to the UK he has worked as a freelance consultant, as a manager within The Children's Society, and most recently as executive director of Healthlink Worldwide. He is interested in issues relating to poverty, equity and social determinants of health.

LISA GONZALVES works at the Hesperian Foundation, publisher of 'Where There Is No Doctor' and of 'A Book for Midwives.' <

KATHY HOLLOWAY works in the Department of Essential Drugs and Medicines Policy at the World Health Organization in Geneva.

NOLWAZI MBANANGA works for the Medical Research Council in South Africa. Interests: health informatics research and development.

PAULINE MONRO is a retired neurologist and co-founder and co-chairman of the Neurology International Partnership Programme, which links neurology departments in those parts of the world where there are difficulties in obtaining health information with those in which there is no such problem, with the purpose of transfer of information and exchange of personnel (for a brief description of this programme, see <>) . She has been closely involved with healthcare providers in USSR/Russia, particularly in St Petersburg, since 1988. Since 1995 she has worked, with support of the Know How Fund, as coordinator of the Anglo-Russian Neurological Partnership, arranging health information transfer by personnel exchange, translation, and publication of books and articles.

NESTER MOYO is a programme manager with the International Confederation of Midwives, The Netherlands. She is a midwife from Zimbabwe and has extensive experience in midwifery and midwifery education.

AMUNGWA ATHANSIUS NCHE works as a principal senior nurse in Bamenda, Cameroon. He is also Chief of Bureau Research and Documentation.

REBECCA PENZER is a member of the ISNG Advisory Group (International Skin-Care Nursing Group). She works as a freelance dermatology specialist nurse and has her own business called Opal Skin Solutions. Rebecca has an honorary research fellow position at the University of Southampton.

CHRISTINE PORTER provided this summary. She recently completed her MA dissertation, entitled 'Networking for Health-a r/evolution: Using new ICTs to support health professionals in developing countries'. She works as a consultant on using ICTs to support further education, health and development. Her core clients include Cornell University's eLearning subsidiary and an academic research funding and networking service <>.  She is interested in how new ICTs are, can and should be used by and for development professionals in the field. <

CLEMET SAB works at the University of Buea, Faculty Of Health Science, Cameroon. His interests include community nutrition, food security, and impact of HIV/AIDS on the food security systems of countries in transition in sub-Saharan Africa.

DAVE WOODS, is Head of Neonatal Medicine at the University of Cape Town in South Africa.

[Note from moderator: Many thanks to Christine Porter for summarizing this discussion, and to all who took part. The summary raises a number of questions:

  • How can nurses and midwives have a greater voice in policy development, and, specifically, health information and training development in developing countries?
  • In particular, how can the voice of isolated, rural nurses and midwives be amplified?
  • How can nurses and midwives be better linked to existing communication services and information resources?
  • How might the diaspora be better supported and coordinated to assist their colleagues in their home countries?
  • How can governments be encouraged to recognise officially that nurses do much of the prescribing, as a first step in training and supporting them in that role? Further contributions are welcome, and will be integrated into an 'Infobrief', which will be maintained on the INASP website at  Thanks, Neil PW]

'HIF-net at WHO': working together to improve access to reliable information for healthcare workers and health professionals in developing and transitional countries. Send list messages to [email protected].  To join the list, send an email to [email protected]  with name, organization, country, and brief description of professional interests.


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