The financial cost of doctors emigrating from sub-Saharan Africa: human capital analysis

BMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d7031 (Published 24 November 2011)
Cite this as: BMJ 2011;343:d7031

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The authors have estimated the financial cost of ‘brain-drain’ with regards to medical professionals.

Although it may be the case that professionals in medicine make up the majority of loss in investment from the deprived countries, it is not the only field to encounter this phenomenon.Driving the actual total cost of ‘brain-drain’ even higher .

With this in mind it is more than likely that the economical advantage gained will never be truly compensated for. However, what can and should be implemented is a strategy to aid professionals in developing their origin countries' health care system.

By identifying and utilising the skills of the relevant professionals a more long-term solution can be implemented . For example, by facilitating the return of health care professionals for short-term visits to offer their services in hospitals or clinics, in the training of new surgical or medical techniques , and encouraging collaboration on mutually beneficial research projects.

These are some of the many practical ways that the ‘brain drain’ will be felt to offer some lasting benefits to the countries involved, however small .

Competing interests: None declared

Muaad R Abdulla, FY1 junior Dr

Oxford Deanery

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I write as a super-privileged emigre from sub-Saharan Africa.

The article brought back memories of why I and many of my peers left South Africa 30 or so years ago.

One issue was ethically unacceptable practice, which was beyond my power to change. For example, there was a rule, which I thought was unwritten, that white female patients would be advised that they could refuse internal examinations by medical students, but black patients were told that they could not. If the unwritten rule wasn't bad enough, I was deeply dismayed in my final year to discover that this rule was displayed in writing on the notice board of the academic department of O&G, albeit couched in terms that only a doctor or a senior student would understand. And this is but one example - basically students "practiced" on black people in way which would never have been tolerated in the white hospitals.

And then there is the little matter of personal safety. In 1976 (Soweto riots) some friends and I only narrowly escaped being beaten by students from the Rand Afrikaans University, on more than one occasion. Other friends were not so lucky.

At the same time, when I drove to Baragwanath Hospital in 1979 and 1980, stones were often thrown at my car by black youths from Soweto. If you are not alive, you can't practice medicine.

My professors wrote publicly about the shame of the "chicken run", while they were quietly obtaining posts abroad for themselves and their children.

I am sure that we should not recruit actively in developing countries. But when examining the causes of emigration of well trained people, we also need to invite government to look in the mirror. The apartheid regime in South Africa drove many people away, as did Germany and Austria in the 1930s, and Argentina in the days of the junta. Many bad regimes, including homophobic ones in Africa and the Middle East, have to continue to take at least some responsibility for these sad issues.

Competing interests: None declared

Mark Berelowitz, Child and Adolescent Psychiatrist

Royal Free Hospital, Pond Street, London NW3 2QG

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Our study addresses a topic that raises mixed emotions. While few disagree with an individual’s choice to seek better employment opportunities elsewhere, the impact of leaving by some professions is larger than for others. As a result, we note that the rapid responses to this study have been both sympathetic and antagonistic. We appreciate all of the comments made on our paper.

Several of the rapid responses have dealt with the ethics of recruiting physicians from Africa. However, our study does not address ethics. Others, such as Arnold and van Rensburg have very appropriately addressed the reasons that a physician would want to leave Africa. Although this was outside the purview of our study, we agree that it is an important issue to keep in mind.

Clemens raises several points that we a priori considered in our analysis, based on his survey.(1) His opinions are well known, but given that the survey response with which most of the points are drawn had a response rate less than 18%, they cannot be viewed as credible and remain opinions rather than facts. Nevertheless, we had already conducted sensitivity analysis to address many of these points, such as if the length of time remaining in a source country after graduation impacted the overall results (its effect were minor, reported in Table 5). We additionally considered remittances. However, remittances typically go to family members rather than the state and so it is impossible to quantify the impact of remittances on the local economy, clearly noted on page 4. The other points raised are tangential to the study.

Campbell asks that we examine the effect of the WHO Code on practice, but this is an altogether different question. Given that Campbell works in this area himself, it may be a topic sufficiently compelling for him to undertake.

There are many assumptions that one could choose to apply to our analysis that may affect the results, many of these were examined in the sensitivity analyses. Our main analysis is based on as few assumptions as possible.

1) Michael A. Clemens. 2010. The
Financial Consequences of High-Skill Emigration: Lessons from African Doctors
Abroad. In Sonia Plaza and Dilip Ratha, eds. Diaspora
for Development in Africa. Washington, DC: World Bank, pp. 165–182 http://siteresources.worldbank.org/EXTDECPROSPECTS/Resources/476882-1157...

Competing interests: We were authors of the original publication.

Edward J Mills, Associate Professor

Nick Bansback

University of Ottawa, 43 Templeton, Ottawa

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Dear Editors,

The charity ActionAid said the brain drain was "a huge threat" to Africa.

"The UK government could do Africa a real service by upping aid levels for health systems, ensuring that desperately needed doctors and nurses stay where the need is greatest." [7]

Health Minister Lord Warner acknowledged that “Britain has to help developing Countries train their doctors and nurses and keep them there.” [8]

The Conservatives said they would use Aid budgets to support health systems in developing Countries to help solve the problem of doctors immigrating abroad.

The Liberal Democrats said the G8 countries should be working towards an international agreement to limit the number of nurses and doctors being recruited from vulnerable countries. [8]

My exact same conclusion!

Since Mr Peter Frank needs statistical references, though, I am providing here some.

There exist 40,000 junior Indian doctors in the UK. 10,000 more were immigrating every year, until recently, when Home Office issued some restrictions. [1][2]

10,000 more were immigrating in the U.K., every year, from Africa. [8]

Approximately 30% of the doctors in the UK’s National Health Services (NHS) are Indian. [3]

There exist 50,000 Indian doctors in the U.S.A. Furthermore, 10% of medical students in U.S. medical schools are of Indian origin. [4]

More than 23% of America's 771 491 physicians received their medical training outside the USA, the majority (64%) in low-income or lower middle-income countries. They are all receiving research or clinical grants to specialize in the U.S.A. These health professionals will never serve the populations that were taxed to pay for their training. [6]

In sub-Saharan Africa only 13 physicians exist to serve a population of 100,000 [6] while, in India, only 60 physicians serve the same population [5].

Developing Countries lose 40%-80% of their doctors. [7][6]

3.5 million more health workers are needed to deliver essential services worldwide. [14]

And yet, we continue to offer full scholarships to thousands of medical doctors from developing Countries. [9][10][11][12][13]

It is obvious that this practice is counterproductive. Charities, States and Institutions must instead concentrate their funds in well-designed local training programmes.

I have provided some practical and cost-effective examples elsewhere in the BMJ. [15]

References

[1] http://www.expressindia.com/news/fullstory.php?newsid=81547

[2] http://www.telegraph.co.uk/health/healthnews/6931303/NHS-brain-drain-fea...

[3] http://hcilondon.in/biotech.php

[4] http://www.usinpac.com/indian-americans/professions.html

[5] https://www.cia.gov/library/publications/the-world-factbook/geos/in.html

[6] http://www.human-resources-health.com/content/2/1/17

[7] http://news.bbc.co.uk/2/hi/health/7178978.stm

[8] http://news.bbc.co.uk/2/hi/health/4582283.stm

[9] http://www.educationuk.org/scholarships

[10] http://www.scholarshipsinindia.com/international_scholarships_for_indian...

[11] http://www.impeloverseas.com/StudyAbroad/UK/UK-Scholarships.aspx

[12] http://www.studyin-uk.in/scholarships/

[13] http://studyusa.learnhub.com/lesson/11364-scholarships-for-indian-studen...

[14] http://www.bmj.com/content/343/bmj.d6005?tab=full

[15] http://www.bmj.com/content/343/bmj.d6005?tab=responses

Competing interests: Dr Stavros Saripanidis is an active voluntary member of a non-profit organization that fights for women's rights.

Stavros Saripanidis, Consultant in Obstetrics and Gynaecology

Private Surgery, Thessaloniki, Greece

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Dear Editor,

I am writing in response to Dr. Stavros Saripanidis comment. Stavros’s comment is completely off-point and not related to the article in question. Doctors are professionals and are in highly esteemed profession. All the points raised were without reference or statistics. This is medical journal and there is no room for speculations.

It will be nice for Dr. Stavros to provide statistics and breakdown of doctors that received scholarship and are required to go back and did not go back. I will not be surprised if Dr. Stavros may not be aware that not all scholarship required you to go back to your home country.

Dr. Stavros concluded that "Charities, States and Institutions must concentrate their funds in well-designed local training programmes and stop financing counterproductive scholarships in Europe."

If that conclusion must hold, then all charities and funding bodies should stop funding tropical disease or international health institutions based in Europe that are conducting research in and on people in sub-Saharan Africa countries. They should concentrate on developing academic institutions from sub-Saharan Africa countries and stop wasting grants money on counterproductive research collaborations.

Competing interests: None declared

Peter Frank, Freelance Researcher

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This debate on the financial costs and gains to sovereign nations associated with the international migration of health workers is most welcome. Addressing the challenges associated with health worker migration resides at the heart of developing country national priorities, as witnessed most recently at the 2010 World Health Assembly. Indeed, it is an issue that low-income countries have endeavored to address at the international stage since the end of the colonial period. Little in terms of evidence however has been available to monetize the precise cost and gains related to the international migration of health workers. The recent economic analyses, by both those emphasizing the financial costs and those emphasizing financial gains to low-income countries, is thus of great benefit.
Unfortunately, an important aspect of the financial cost and gain analysis continues to be ignored by economic researchers. Foreign health workers, especially physicians, nurses, and pharmacists, practicing in high income countries contribute a significant amount in terms of tax to government coffers annually (without often receiving the same governmental services as provided to nationals.) A lesser amount, due both to lower wages and inefficiency of tax collection, though not insignificant, is lost in government revenue to the country of origin. Renowned economist Prof. Jagdish Bhagwati, an avowed champion of globalization, has since the 1970’s pointed to this tax related gain and loss associated with the international migration of high-skilled workers.
Future economic analyses should take into consideration the gains and financial losses posed by taxation of emigrant health workers/ loss of tax revenue of immigrant health workers. Policy makers would do well, at the very minimum, to consider the merits of Prof. Bhagwati’s long-standing proposal on “Taxing the Brain Drain.”

Competing interests: None declared

Ibadat Dhillon, Global Health Lawyer

Independent Consultant, Plot 1391 Haile Selassie Road, Dar es Salaam, Tanzania

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Dear Editor

I would suggest that the often stated claims about the huge amounts of money that Subsaharan countries spend on training doctors only to lose them to "poachers" from Developed countries is disingenuous at best and dishonest at worst.

Off course it costs money to train a doctor, no-one disputes that. What our Academic colleagues in London do not appreciate is exactly what is expected of a Student and young doctor in a country such as South Africa.

Firstly one should consider the cost of studying to the Student - South Africa's Tertiary Education is extremely expensive to the student and Medicine is one of the most expensive courses. There are very limited opportunities in regards to scholarships and bursaries and in most cases the only option is to find a guarantor and approach a Bank for a Student loan. These loans are offered with a marginal reduction in the Prime lending interest rate and you have to start repaying it immediately once you have graduated (while earning a very poor salary). In most cases this is still insufficient and Students have to supplement their incomes by having one or more jobs while studying fulltime at the same time. Another fact of life is that the reality of Affirmative Action means that previously advantaged groups (under Apartheid) have next to no chance of accessing any sort of subsidy to study at a Tertiary Institution.

Secondly one should consider what is expected of students during their studies. I never cease to be amazed when I observe students here in Australia hanging around the wards (when they are there at all) - in South Africa you are expected to hit the ground running very early on in your studies - work that would in other locations be performed by Nurses, Technicians, RMOs, etc. are performed by students and you are often doing 8-12 hour days, from your 3rd year onwards, during which you would be doing anything from helping to feed patients, clean them, replace their IV lines (that miraculously managed to “tissue” each night because they IV bags ran dry), replace catheters, take blood, assist in theatre, etc. etc. Being on-call would be even worse – you had to creep around in darkened wards to try and find equipment to replace cannulas as you dared not awake the sleeping nursing staff members. Any attempts at actually getting some assistance from the Nursing staff ran the risk of triggering a noisy aggressive confrontation that, at best, would wake and scare the patients or, at worse, trigger one of the violent and destructive strikes that flare up on a very regular basis in this environment.
Thirdly one should consider what happens once you actually qualify. As an Intern, especially in the smaller hospitals, you are thrown in the deep end. I had colleagues in 200-300 bed hospitals that was run by one Medical Officer and two Interns where the Interns were left to their own devices to do a variety of surgical procedures with only a scrub nurse and anaesthetic nurse to back them up. They worked 100h weeks and had minimal, if any back up as the Medical Officer was running around trying to deal with the wards and outpatients. In the mid 1990s we were earning around R 600 a month as an intern so we were working these hours while at the same time having to repay those huge student loans.
Nowadays it is even more interesting as the 12 months Internship has now increased to 24 months. Not only that but these doctors are then forced to do a further year of community service and only then can they try and get a position in a training program of some sort.
That brings me to the fourth point – once again the Political reality of South Africa is that Doctors who are from the previously advantaged groups under Apartheid have great difficulty getting into Training programs. Often the only way that you can become that great surgeon that you always wanted to be is to do the “chicken run” to the UK or Australia.
Leaving the country of your birth is never easy and as Peter Arnold pointed out in his letter the issues are usually “push” factors rather than “pull” factors. This usually happened at least five to ten years after graduation during which we spend even more time working back our “dues” to the System.
Due to various factors, mostly related to theories and concepts exemplified in this article, Foreign qualified doctors have immense financial and academic hurdles to overcome and off course dealing with the various Immigration authorities is no walk in the park either.
We are often seen with the same mistrust and disdain as I recall the Cuban doctors who came to South Africa in the 1990s were treated by the average South African. We persevere however as in my view we have paid our dues to whatever the South African Education System had contributed and we are Medical professionals who are entitled to work where and when we feel like. Having a Medical degree never meant that I have lost my liberty Professionally and Personally and this simplistic and demeaning to those of us who have put blood, sweat and tears into our careers over the last two to three decades.

Competing interests: None declared

Thinus van Rensburg, General Practitioner

123 Tillyard Drive Charnwood, ACT Australia

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Dear Editors,

There is another aspect that needs to be addressed.

Numerous doctors from African Countries receive full, run-through scholarships from Charities, States or Institutions in order to study Medicine in European Universities, specialize in European public hospitals, and then go back to their homeland to contribute to local healthcare necessities, using their acquired skills.

Unfortunately, they never choose to go back!

They do everything in their power not to honour their part of the scholarship agreement:

Many get married and have children, claiming family reasons for not returning.

Many renounce their citizenship by acquiring the European one.

Others avoid the trip back home by evoking imaginary political persecutions from local governments which have funded part of their scholarships!

Others claim food allergies, chronic conditions or even dangerous communicable diseases for refusing to return!

Homosexuality status is often used, especially to avoid returning in prevalently Muslim Countries.

Some even claim they were spies in order to get arrested and avoid deportation, at least for a few years.

Training medical doctors in Africa is much cheaper. Charities, States and Institutions must concentrate their funds in well-designed local training programmes and stop financing counterproductive scholarships in Europe.

Competing interests: Dr Stavros Saripanidis has received numerous State scholarships for academic excellence, always honouring his part of the agreement.

Stavros Saripanidis, Consultant in Obstetrics and Gynaecology

Private Surgery, Thessaloniki, Greece

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The authors (perhaps understandably in an article dealing with numbers and dollars) omit consideration of the reasons for doctors leaving the former colonies.

Many of these doctors have, in recent years, given their reasons in the columns of the BMJ and the Lancet.

My study of 469 South African medical graduates who migrated to Australia, published as a book, A Unique Migration: South African Doctors Fleeing to Australia. Amazon.com 2011, revealed that almost all were 'pushed' from South Africa, and that almost none were 'pulled' to Australia. They had chosen to emigrate. Australia was the destination of choice.

Doctors, like most migrants, do not readily leave home and hearth, families and friends, colleagues and careers. What needs to be looked at is why individuals decide to leave. To see that decision as being based on money is to miss the root causes of many decisions to emigrate.

I have elaborated in my book and, more recently, in an article in the Journal of the Royal Society of Medicine:
"Why the ex-colonial medical brain
drain?" [jrsm.rsmjournals.com/content/104/9/351.full]

No inter-government agreements on migration are going to solve this imbalance unless the root causes of doctor-dissatisfaction are remedied.

To see this migration as 'poaching' is pejorative, ignoring the legitimate concerns of many of the individual migrants.

PS The authors kindly acknowledge some data I provided , but erroneously link me to the Australian Medical Council. I have never held a position with that body.

Competing interests: Author of: A Unique Migration: South African Doctors Fleeing to Australia. Amazon.com 2011

Peter C Arnold, Retired GP

Nil, Ocean St, Edgecliff, Sydney

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Readers may also be interested to view a comprehensive account of the development of the WHO Code of Practice in the period 2004-2010.

This is published in the November 2011 edition of Global Health Governance:

Taylor A.L. and Dhillon I.S. The WHO Global Code of Practice on the International Recruitment of Health Personnel: The Evolution of Global Health Diplomacy.

http://blogs.shu.edu/ghg/2011/11/21/the-who-global-code-of-practice-on-t...

Competing interests: None declared

James Campbell, Director

Instituto de Cooperación Social Integrare (ICSI), Barcelona, Spain

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