news analysis advocacy

Support AfricaFocus and independent bookstores!

Make non-profit your first stop for buying books.
See books recommended by AfricaFocus.


Visit the AfricaFocus
Country Pages

Burkina Faso
Cape Verde
Central Afr. Rep.
Congo (Brazzaville)
Congo (Kinshasa)
Côte d'Ivoire
Equatorial Guinea
São Tomé
Sierra Leone
South Africa
South Sudan
Western Sahara

Get AfricaFocus Bulletin by e-mail!

Format for print or mobile

Africa: Counting the Costs of Brain Drain

AfricaFocus Bulletin
Feb 10, 2012 (120210)
(Reposted from sources cited below)

Editor's Note

According to a study published in the British Medical Journal in November 2011, nine sub-Saharan countries (Ethiopia, Kenya, Malawi, Nigeria, South Africa, Tanzania, Uganda, Zambia and Zimbabwe) invested some $2 billion in costs of educating doctors who subsequently emigrated to the United States, United Kingdom, Australia, or Canada. The receiving countries gained an estimated $4.55 billion from these investments, in savings from medical education that they did not have to finance. The familiar phenomenon of "brain drain," it is clear, should also be seen as a subsidy from developing to developed countries.

This AfricaFocus Bulletin contains excerpts from this new study published in the British Medical Journal, providing quantitative estimates of the losses to nine sub-Saharan African countries (and associated gains to recipient countries) from the emigration of doctors to the United States, United Kingdom, Canada, and Australia, reaching a cumulative total of at least $2 billion. This raises the question of how to compensate the countries who provided these doctors for their de facto subsidies to the countries receiving these skilled workers.

The full study is available on the British Medical Journal website, at

Another AfricaFocus Bulletin, posted on the web today at, but not sent out by e-mail, contains excerpts with an overview on migration and development from a study by the AfricaFocus editor for the Nordic Africa Institute, "African Migration, Global Inequalities, and Human Rights: Connecting the Dots."

For the full text of "African Migration, Global Inequalities, and Human Rights," see

For previous AfricaFocus Bulletins on migration issues, go to

For previous AfricaFocus Bulletins on health issues, go to

++++++++++++++++++++++end editor's note+++++++++++++++++

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

BMJ 2011; 343 doi: 10.1136/bmj.d7031 (Published 24 November 2011)

by Edward J Mills, Steve Kanters, Amy Hagopian, Nick Bansback, Jean Nachega, Mark Alberton, Christopher G AuYeung, Andy Mtambo, Ivy L Bourgeault, Samuel Luboga, Robert S Hogg, Nathan Ford.

[The authors' affiliations, listed in full in the original article, include universities, in Canada, South Africa, Uganda, and the United States. The principal author is E J Mills]


Objective: To estimate the lost investment of domestically educated doctors migrating from sub-Saharan African countries to Australia, Canada, the United Kingdom, and the United States.

Design: Human capital cost analysis using publicly accessible data.

Settings: Sub-Saharan African countries.

Participants: Nine sub-Saharan African countries with an HIV prevalence of 5% or greater or with more than one million people with HIV/AIDS and with at least one medical school (Ethiopia, Kenya, Malawi, Nigeria, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe), and data available on the number of doctors practising in destination countries.

Main outcome measures: The financial cost of educating a doctor (through primary, secondary, and medical school), assuming that migration occurred after graduation, using current country specific interest rates for savings converted to US dollars; cost according to the number of source country doctors currently working in the destination countries; and savings to destination countries of receiving trained doctors.

Results: In the nine source countries the estimated government subsidised cost of a doctor's education ranged from $21,000 in Uganda to $58,700 in South Africa. The overall estimated loss of returns from investment for all doctors currently working in the destination countries was $2.17bn (95% confidence interval 2.13bn to 2.21bn), with costs for each country ranging from $2.16m (1.55m to 2.78m) for Malawi to $1.41bn (1.38bn to 1.44bn) for South Africa. The ratio of the estimated compounded lost investment over gross domestic product showed that Zimbabwe and South Africa had the largest losses. The benefit to destination countries of recruiting trained doctors was largest for the United Kingdom ($2.7bn) and United States ($846m).

Conclusions: Among sub-Saharan African countries most affected by HIV/AIDS, lost investment from the emigration of doctors is considerable. Destination countries should consider investing in measurable training for source countries and strengthening of their health systems.


The migration of health workers from developing countries to developed ones is a well recognised contributor to weak health systems in low income countries and is considered a primary threat to achieving the health related millennium development goals. In 2010 the World Health Assembly unanimously adopted the first code of practice on the international recruitment of health personnel, which recognises problems related to the global shortage of health staff and calls for all countries to mitigate the negative effects from the migration of health workers. The code also calls on wealthy countries to provide financial assistance to source countries affected by the losses of health workers.

The code is particularly important for sub-Saharan Africa where, according to the World Health Organization, the majority of countries are experiencing a critical shortage of doctors, nurses, and midwives. Many doctors from these countries have left to pursue better career opportunities in developed countries. The problem is exacerbated by the continent bearing the greatest burden of diseases such as HIV/AIDS. While Africa experiences 24% of the global burden of disease, it has only 2% of the global supply of doctors, and less than 1% of expenditures are on global health. Countries with a high prevalence of HIV are particularly affected by shortages of health workers for several reasons. Firstly, HIV has been documented as a leading cause of death among health workers - in the first five years of the AIDS epidemic, for example, an estimated 1 in 10 health workers in Malawi died of AIDS. Secondly, HIV leads to health workers' absenteeism owing to illness among staff or their relatives. Finally, the increased workload resulting from HIV/AIDS illness has not been met by a commensurate increase in staff, leading to increased burnout and fatigue.

The shortage of doctors in most African countries is attributed to institutes lacking the capacity to train sufficient numbers of doctors, coupled with an inability to retain doctors, who choose to emigrate for what they consider better career opportunities. Many wealthy destination countries, which also train fewer doctors than are required, depend on immigrant doctors to make up the shortfall. In this way developing countries are effectively paying to train staff who then support the health services of developed countries. Although developed countries often provide development assistance to resource limited countries, the amount that goes into the training of health workers is variable and limited.

Although the code of practice is voluntary, specific recommendations are to report data on the migration of health staff and to establish research programmes on migration. The ability of wealthy countries to produce such data is mixed as non-licensed health workers are often not counted. We estimated the monetary losses incurred by subSaharan African countries secondary to the migration of doctors licensed to practise in Australia, Canada, the United Kingdom, and the United States. These four destination countries were chosen because for more than 50 years they have benefited from the mass immigration of doctors. In the setting of HIV epidemics and related health problems, the loss of these vital members of society undermines both health and social stability in African communities. Quantifying economic losses may help motivate and encourage policy makers to improve working conditions and incentive programmes to retain doctors in the countries where they were trained, and to support improvements in the infrastructure of medical training in sub-Saharan Africa.


We included data on doctors practising in Australia, Canada, the United Kingdom, and the United States who had received their medical education in a selected African country. As the concern about loss of doctors is related to the burden of disease in the countries left, we selected African states according to HIV rates, as determined by WHO, and included those that had an HIV prevalence of 5% or greater or more than one million residents with HIV/AIDS. We excluded countries with no medical schools or those with medical schools too new to have generated doctors.

Data sources

[see full report]

Statistical analysis

[see full report]


Savings in destination countries from recruited doctors

Destination countries do not have to provide medical school training to doctors who successfully pass licensing examinations. Therefore destination countries benefit from not having trained recruited doctors. Based on the number of doctors working from the nine source countries and the average cost of medical education in these countries, this equals a saving of at least $621m for Australia, $384m for Canada, $2.7bn for the United Kingdom, and $846m for the United States; $4.55bn in total. As the United Kingdom had the largest number of African doctors practising, its savings were the largest.


Ethiopia, Kenya, Malawi, Nigeria, South Africa, Uganda, Tanzania, Zambia, and Zimbabwe have lost more than $2bn from training doctors who then migrated to one of the four developed countries: Australia, Canada, United Kingdom, United States. Medical education is typically highly subsidised by the public sector in African nations, with more than half of the medical schools in sub-Saharan Africa either offering free tuition or charging less than $1000 yearly. At the same time, destination countries have saved billions of dollars in training costs by recruiting doctors who have been trained abroad. As international efforts are focusing on strengthening health systems, the development of human resources should be a core component of support from developed nations.

Strengths and weaknesses of the study

Our study has several strengths and limitations. Strengths included the use of conservative estimates of costs and lost investments compared with interest rates often reported by differing international financial institutions; we chose interest rates on the lower end of available data to avoid the overestimation of lost investments. When, for example, we applied a sensitivity analysis examining deposit rates, the lost investment increased to over $10bn. We do not know the number of doctors who emigrated to the destination countries but never entered medical practice nor did we quantify the number of doctors practising outside the four destination countries in settings such as Saudi Arabia, a popular destination for new graduates. Both of these limitations may result in underestimates of the true loss to the source countries under study. However, we did not consider the number of doctors who return to their source countries nor examine the benefits of doctors sending financial resources back to families in the home countries. While these factors may mitigate the losses, little is known about how widespread or systematic they may be. Remittance by all professionals to sub-Saharan Africa in 2010 is estimated at $21.5bn, a growth of 5.5% from the previous year. A recent survey estimated that doctors typically remit $4500 yearly to their source countries. 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.

To the best of our ability we assessed whether education in the source countries is government supported, private, or a combination of the two, but recognise that this may change over differing time periods and differing governments. For example, Uganda has recently changed its public university coverage to focus solely on science, thereby increasing the number of medical school attendees with government coverage. Our study assumes that students go directly from secondary school to medical school and does not account for those who have received previous medical training, including former nurses and clinical officers. We used the current gross domestic product as a proxy of costs for primary and secondary schools. Gross domestic product in sub-Saharan African countries has fluctuated over the past four decades and it is possible that a different gross domestic product would alter our study findings for pre-university education. Finally, although confidence intervals are provided, these assume a fixed interest rate through time. Given the current poor economic climate, these results are conservative and we acknowledge a higher degree of variance.

Comparison with other studies

Three previous studies attempted to quantify the economic value of losing health staff, but these analyses were limited to particular countries (Ghana, Kenya, and Malawi). Other studies found that doctors typically migrate from African countries to more developed countries - namely, Australia, Canada, the United Kingdom, and the United States - but do not attempt to quantify the economic implications of such migration patterns. Our study focused on the direct costs of educating doctors in the source countries.

Additional economic costs to the loss of doctors from these source countries occur, including the lost investment on the education of other health workers. A previous analysis that examined a case study of only Ghanaian doctors in the United Kingdom estimated a saving in current training cost to the United Kingdom of about 65m British pounds from the employment of 293 Ghanaian doctors working in 2004. A recent survey of African doctors working in Canada and the United States showed that most doctors emigrate immediately after training, but, when considering all respondents to the survey, the average number of years working in the source countries was 7.2. The author implies that during this period doctors may have already repaid their debt to the source country. Many of the countries we surveyed employ a lower cadre of health workers for many common health provisions, including the care of people with HIV/AIDS, including non-doctor clinicians, nurses, and community health workers. Other notable economic issues relevant to the lost investment in doctors include the lack of specialised medical care available and the morbidity and mortality associated with it. Although our study examined only doctors, the emigration of nurses and pharmacists from the source countries has also been important. We also recognise that developing countries experience an outmigration of health workers to other developing countries, and future research should attempt to estimate losses in other regions.

Possible mechanisms and implications for clinicians or policy makers

The new code of practice on the international recruitment of health personnel suggests that source and destination countries could benefit by crafting bilateral agreements that acknowledge the transfer of staff from developing countries to developed ones, and provide technical assistance and other support to countries that are losing trained health professionals. Our study highlights that the loss to developing countries is substantial and that any compensation should be more than token: the lost return on investments in medical education is one way to attach a value to the amount of technical or other compensatory assistance that recipient countries should provide. In 2008, the United States' President's Emergency Plan for AIDS Relief (PEPFAR) re-authorisation legislation recognised the need to build an infrastructure for health workers and committed to the expansion of medical training and research capabilities through African academic centres, by contributing $130m to improve and achieve large numbers of health staff over the next five years. Contributions from Australia, Canada, and the United Kingdom to medical education have been substantially lower.

Our results indicate that South Africa incurs the highest costs for medical education and the greatest lost returns on investment for all doctors currently working in destination countries. These findings are supported by statistics on human health resources. South Africa has the highest density of doctors per population. However, the distribution of doctors in South Africa is unbalanced and there is a 14-fold difference in density of doctors between urban and rural settings. Previous estimates indicate that up to 30% of South African doctors have emigrated to the destination countries we examined, many during apartheid. In addition, interviews with health workers revealed that 58% were intending to emigrate to these countries. Thus, South Africa, although producing a large number of doctors, also loses the most to developed countries. Conservative estimates indicate that South Africa requires three times its current workforce to meet the requirements of providing care for AIDS. Any future approaches to improving the numbers of doctors will need to recognise that additional educational opportunities may lead to additional lost investments.

Unanswered questions and future research

Previous research has focused on the number of health workers working in the destination countries and on the ethics of recruitment of health staff. Less research has examined the impact of the density of health workers on morbidity and mortality in the source countries. With a new emphasis on strengthening health systems by major international donors, questions are arising about what investments should be made to strengthen a health system and what measures should be used to determine the strength of a health system. Canada, the United Kingdom, and the United States have clearly stated that maternal and child health will be the focus of present investments, steering away from disease specific investments such as HIV/AIDS. There is a clear need to recognise that measuring the effectiveness of a health system is a complex endeavour that may result in unclear findings. The support for education and retention of health staff represents one major way to ensure that general and specialty healthcare are available in these source countries. With the exception of the United States, our chosen destination countries have not targeted medical or health training as a focused supportive role. Recent studies have indicated that although the capacity for medical education is expanding in Africa, substantial support is needed to improve weaknesses in infrastructure and that retention strategies need to be developed to reinforce the number of teaching staff, who are also among those medical staff who emigrate.


Countries in sub-Saharan Africa are losing considerable investments in medical education through the emigration of doctors to wealthier destination countries. The new voluntary code urges the government, private agencies, and non-government agencies that benefit from the immigration of doctors to increase their technical and financial support to enhance the strengthening of health systems in developing countries with critical shortages in health workforce. Efforts to increase support can include training, financial compensation, and population specific interventions. These should be commensurate with the benefits enjoyed by recipient countries.

What is already known on this topic

  • A lack of adequately trained health workers contributes to weakened health systems
  • African doctors frequently emigrate for better opportunities
  • The impact of doctors' emigration on investments in the health system of individual countries is unknown

What this study adds

  • Among the nine sub-Saharan African countries most affected by HIV/AIDS, more than $2bn of investment was lost through the emigration of trained doctors
  • South Africa and Zimbabwe had the greatest economic losses from such emigration
  • Australia, Canada, the United Kingdom, and the United States benefit importantly from the recruitment and licensure of doctors educated elsewhere

AfricaFocus Bulletin is an independent electronic publication providing reposted commentary and analysis on African issues, with a particular focus on U.S. and international policies. AfricaFocus Bulletin is edited by William Minter.

AfricaFocus Bulletin can be reached at Please write to this address to subscribe or unsubscribe to the bulletin, or to suggest material for inclusion. For more information about reposted material, please contact directly the original source mentioned. For a full archive and other resources, see

Read more on |Africa Health||Africa Economy & Development|

URL for this file: