|
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 http://www.bmj.com/content/343/bmj.d7031
Another AfricaFocus Bulletin, posted on the web today at
http://www.africafocus.org/docs12/bd1202b.php, 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 http://www.africafocus.org/editor/nai-migration.php
For previous AfricaFocus Bulletins on migration issues, go
to http://www.africafocus.org/migrexp.php
For previous AfricaFocus Bulletins on health issues, go
to http://www.africafocus.org/healthexp.php
++++++++++++++++++++++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)
http://www.bmj.com/content/343/bmj.d7031
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 Edward.mills@uottawa.ca]
Abstract
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.
Introduction
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.
Methods
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.
Discussion
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.
Conclusions
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 africafocus@igc.org.
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 http://www.africafocus.org
|
