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 – 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.
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.
Source: All Africa.Com – 10 Feb 2012
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