There is much public policy concern that low income countries invest large amounts into training health personnel, but do not receive the benefits. How bad is brain drain, really?
Thanks Lauren for this really well thought through and balanced discussion of a really complex topic. This is one of the first times that I've seen such a nuanced approach, most articles are banging one side or the other when like you say - its really complicated and I . I have a couple of extra thoughts, which I don't think add
1. I think this situation is so complicated that it is hard to make worldwide generalisations like "Medical immigation is good" or vice versa. Each country's situation needs to be assessed differently. The Phillipines is a great example which I think is pretty clearly good for everyone, with a few caveats. In Nigeria I'm pretty uncertain as there are a wide range of positives and negatives there. If the new "double the doctors" training initiative came through I would lean towards positive, but otherwise I would lean a little negative (with enormous uncertainty)
2. A few points where calculations could maybe be improved (not the biggest deal)
- You state the cost at $10,000 a year for training doctors, I think its likely to be a lot lower, maybe $5000 to $7000. BUT med school is never 3 years like you've estimated, more like 5 or 6 so your end calculation number might be pretty similar!
- You've left out internal remittances and potential tax benefits to the government in your remittances calculations - these aren't insignificant as doctors earn decent wages by low income country standards and do benefit the country. This is a tricky counterfactual but our nurses spend about quarter of their income supporting their family, and doctors here would be similar. So if a doctor was earning 1,000 dollars a month, if they spent 20% on their family that would be $2500 a year. I'm not sure how to take this into account exactly under your calculation but I feel like the money local doctors would have poured into their less well off family members had they remained in-country should be taken into account somehow, which offsets the benefits of remittances a little..
And then there's the lost money to tax revenue as well. Personally I don't think each tax dollar is worth that much in low income countries - but most experts disagree with me.
3. Even though the literature doesn't talk about it much, I think there are 2 potential harms of immigration that could be really bg but can be hard to quantify (I've banged on about this a few times)
- First, often the most experienced and best doctors leave, which opens up leadership vacuums within important institutions. Like if a senior hospital doctor leaves, they aren't "replacible" immediately. The flow on effects can be way more than just losing a doctor clinically
- Second, the "Japa" effect (Nigeria) where everyone wants to leave the country can sow discontent and produce quite a negative environment. Won't get into this in detail but have discussed before
Anyway thanks heaps for the article and again appreciate the different perspectives.
Yes, I was a bit sloppy in explaining why $30k - that students at public medical schools in Nigeria are likely subsidized somewhat less than $50k (because I assume for-profit institutions are in fact making a profit and therefore the true cost is less than $50k). Since students at private schools are subsidized less/none, the average subsidy might be something like $30k. Subsidies also vary by country - e.g. Zambia provides much less subsidy, even at state institutions. So $50k is an upper bound, $0k is a lower bound, maybe the average is $30k-ish.
As I've mentioned before, I'd love to have more on return migration and senior staff migration than I have data on. If 1/3 of medical personnel in South Africa have practiced outside South Africa, clearly people move back and forth fairly often. Do they spend the early part of their careers abroad? The later part? Some mix?
In other fields, return migrants are valuable for bringing back new skills. This is likely to be true in medical fields as well. For instance, when I did some work on Malawi, there are specialities where you cannot get needed training in Malawi - you have to move to South Africa. If you then move back to Malawi, you're actually more valuable than if you had never left. So some amount of moving abroad early in career could be useful, but if all your senior staff leave, that's not great!
So I'd love to know when people move and how likely they are to move back.
How do LIC medical staff get licensed when they move to a HIC? Presumably it would be relatively easy to introduce compulsory licensing fees or similar so that any employer or the employee themselves had to pay a fee back to the licensing agency or government in the country of origin.
I beleive the cost of training should be divided by years of training - so if $150m is the correct figure, then $50m is the annual cost, which is the correct numerator for GDP which is annual.
Thanks Lauren for this really well thought through and balanced discussion of a really complex topic. This is one of the first times that I've seen such a nuanced approach, most articles are banging one side or the other when like you say - its really complicated and I . I have a couple of extra thoughts, which I don't think add
1. I think this situation is so complicated that it is hard to make worldwide generalisations like "Medical immigation is good" or vice versa. Each country's situation needs to be assessed differently. The Phillipines is a great example which I think is pretty clearly good for everyone, with a few caveats. In Nigeria I'm pretty uncertain as there are a wide range of positives and negatives there. If the new "double the doctors" training initiative came through I would lean towards positive, but otherwise I would lean a little negative (with enormous uncertainty)
2. A few points where calculations could maybe be improved (not the biggest deal)
- You state the cost at $10,000 a year for training doctors, I think its likely to be a lot lower, maybe $5000 to $7000. BUT med school is never 3 years like you've estimated, more like 5 or 6 so your end calculation number might be pretty similar!
- You've left out internal remittances and potential tax benefits to the government in your remittances calculations - these aren't insignificant as doctors earn decent wages by low income country standards and do benefit the country. This is a tricky counterfactual but our nurses spend about quarter of their income supporting their family, and doctors here would be similar. So if a doctor was earning 1,000 dollars a month, if they spent 20% on their family that would be $2500 a year. I'm not sure how to take this into account exactly under your calculation but I feel like the money local doctors would have poured into their less well off family members had they remained in-country should be taken into account somehow, which offsets the benefits of remittances a little..
And then there's the lost money to tax revenue as well. Personally I don't think each tax dollar is worth that much in low income countries - but most experts disagree with me.
3. Even though the literature doesn't talk about it much, I think there are 2 potential harms of immigration that could be really bg but can be hard to quantify (I've banged on about this a few times)
- First, often the most experienced and best doctors leave, which opens up leadership vacuums within important institutions. Like if a senior hospital doctor leaves, they aren't "replacible" immediately. The flow on effects can be way more than just losing a doctor clinically
- Second, the "Japa" effect (Nigeria) where everyone wants to leave the country can sow discontent and produce quite a negative environment. Won't get into this in detail but have discussed before
Anyway thanks heaps for the article and again appreciate the different perspectives.
-
Yes, I was a bit sloppy in explaining why $30k - that students at public medical schools in Nigeria are likely subsidized somewhat less than $50k (because I assume for-profit institutions are in fact making a profit and therefore the true cost is less than $50k). Since students at private schools are subsidized less/none, the average subsidy might be something like $30k. Subsidies also vary by country - e.g. Zambia provides much less subsidy, even at state institutions. So $50k is an upper bound, $0k is a lower bound, maybe the average is $30k-ish.
As I've mentioned before, I'd love to have more on return migration and senior staff migration than I have data on. If 1/3 of medical personnel in South Africa have practiced outside South Africa, clearly people move back and forth fairly often. Do they spend the early part of their careers abroad? The later part? Some mix?
In other fields, return migrants are valuable for bringing back new skills. This is likely to be true in medical fields as well. For instance, when I did some work on Malawi, there are specialities where you cannot get needed training in Malawi - you have to move to South Africa. If you then move back to Malawi, you're actually more valuable than if you had never left. So some amount of moving abroad early in career could be useful, but if all your senior staff leave, that's not great!
So I'd love to know when people move and how likely they are to move back.
How do LIC medical staff get licensed when they move to a HIC? Presumably it would be relatively easy to introduce compulsory licensing fees or similar so that any employer or the employee themselves had to pay a fee back to the licensing agency or government in the country of origin.
I beleive the cost of training should be divided by years of training - so if $150m is the correct figure, then $50m is the annual cost, which is the correct numerator for GDP which is annual.