Intended for healthcare professionals

Education And Debate

Recruiting doctors from poor countries: the great brain robbery?

BMJ 2003; 327 doi: (Published 16 October 2003) Cite this as: BMJ 2003;327:926

Brain drain and the third world: possible solutions to an intractable problem

Vikram Patel's comments regarding brain drain warrant serious discussion1.
Others have expressed similar sentiments and presented a desperate
picture2. I wish to use Sri Lanka (SL) as an example to stimulate

A tax-based state system funds undergraduate and postgraduate
education in SL, which is "free" to the student. Therefore, there is an
obligation for its under- and postgraduates to pay back, and a duty of the
government to develop mechanisms to receive some degree of compensation if
graduates choose to leave.

Unsystematic migration results in economic drain to countries, which
educate and train the graduates. It is estimated that India loses US 2
billion per year to the US, for software professional3. SL has "exported"
more psychiatrists to London, than it has for the whole country (less than
40 for approximately 19 million). At and individual level, most authors
focus on the financial expediency for migration while ignoring other
reasons. Some left because of war like conflict. Others leave because of
bitter personal experiences with politicians or a stifling baeuracracy.
These are individual decisions and which have to be respected.

The problem with the existing situation is in the system, and less so
with the individual.
Currently, we have a rudimentary procedure to recoup costs of medical
education from migrating skilled persons. Undergraduates are free to leave
immediately after graduation. Postgraduates, educated at state expense
sign an agreement with the government, obligating the latter to serve for
a specified period after training or pay back an agreed amount of money.
Most abide by these procedures, though some leave during their
postgraduate training abroad, without paying back the required sum.

Governments and the World Trade Organization (WTO) can do much to
improve the situation. The World Bank suggested that governments should
offer well-trained expatriates job opportunities with financial and tax
incentives to return home to work5. However, this is not feasible when
considering the extent of disparities between countries: the state-sector
consultant's monthly salary in SL is around 400 US$ tax-free vs. about
10,000 or more in the UK. Moreover, other factors such as social
instability and administrative lethargy affecting work cannot be
compensated by money or tax incentives.

Other options to be discussed include the following3.

a) Exit tax paid by employees or employing firms when visas are granted

b) Loan schemes for higher education, which can be recouped

c) A flat tax where overseas nationals pay a fraction of their income back
to their country

d) A cooperative model, with automatic inter-government transfer of
payroll taxes or income taxes (from adopted country to country of origin)

The last option is very attractive and requires inter-government
agreements but probably the easiest to administer.

A rarely heard option is to liberalize access to service sector
markets. Currently, richer countries offer employment to qualified
personnel from abroad and restrict access to less skilled jobs. If they
are to practice the liberal democracy they preach, these hitherto
protected jobs should be open to all eligible and qualified human beings.


1. Patel V, Recruiting doctors from poor countries: the great brain
robbery? BMJ 2003;327:926-928

2. Levy LF, The first world's role in the third world brain drain. BMJ

3. United Nations Development Programme, Human Development Report 2001:
Understanding human creativity, national strategies. New York, Oxford
University Press. Inc. 2001

4. World Health Organisation, The World Health Report 2002: Reducing
risks, promoting healthy life, Geneva, World Health Organisation, 2002.
The World Bank. World Development Report`1998/99:Increasing our knowledge
of the environment in knowledge for development. New York, Oxford
University Press. Inc.1999

Competing interests:
Submitted and published in Rapid Response an extended and slightly different version titled "The Great Brain Robbery and beyond: a new role for governments and WTO?"

Competing interests: No competing interests

26 October 2003
Saroj Jayasinghe
Associate Professor
Faculty of Medicine, University of Colombo, Kynsey Road, Colombo 08, SRI LANKA