Brain-Drain and The Health of the Third World

Stian Haklev

Human capital ranks among the four indicators commonly mentioned as factors in a nation’s development process; the other three being levels of technology, natural resources and level of investment. (Berry 2005). Resolving most of the urgent issues facing the third world is dependent on raising the level of human capital. An important part of this is certainly enabling access for all to primary education and basic literacy, but more than this is required. Highly educated people are needed in industry and government, as well as in the health professions if successful development is to occur. As McAuliffe and Maclachlan (2005) state:

“In many developing countries, the value of knowledge is in its capacity to save and enhance human lives. The absence, loss or restriction of such knowledge impacts at the lowest levels of disadvantage and poverty, in death and disease.”

However, as developing countries struggle to upgrade their educational systems and fund the expensive training of specialists, they see their brightest and best leave for jobs in the first world. Some of those who emigrate have received their higher education abroad (often partially funded by the source country), but many of them have received their education in the source country, at a large expense to the state.

The individual reasons for emigrating include considerations about professional opportunities in the source country, security and political stability, discrimination and economic necessity. The net result is a huge out-flux of people with the professional skills and entrepreneurial abilities that countries need, especially in the health sector. Shocking statistics abound:

• There are currently more Ethiopian doctors in Chicago than in Ethiopia (IOM, quoted in Carrington & Detragiache, 1999).

• 10% of all the doctors in Canada come from South Africa (ibid.).

• Of the 600 Zambian medical graduates that have been trained at the medical school in Lusaka, only 50 now work in the Zambian public-sector health service (Bundred & Levitt, 2000).

• It is estimated that the loss to South Africa of educating health personnel that emigrated is roughly equal to one third of the development aid received between 1994 and 2000 (Alkire, S. & Chen, L., 2004).

In discussing the phenomenon of brain drain, the contributing factors are usually divided into push and pull factors. Push factors are the attributes of the source country that propels a professional to seek emigration, and pull factors are the attributes of the host country that attract foreign professionals. Using this division, it becomes clear that the issue needs to be addressed by both the source and host countries. In addition to general improvements in standard of living, security and stability of a source country, there are also policies that could help make it more attractive for professionals to stay in their home country, and for emigrees to return home. Developing countries are also calling upon developed countries to stop “poaching” their graduates. As a step in this direction, the countries of the Commonwealth have agreed on a protocol for fair recruitment of health personnel (Commonwealth, 2003).

One of the reasons for the big exodus of health workers is that even with few resources, developing countries spend large amounts of money on educating a relatively small number of health workers to “international standards”, which means that they can work just as well in a modern hospital in Toronto, as in a village in Harare. An editorial in the British Medical Journal suggested changing the medical education so that it would not be readily transferable. This position was widely criticized as raising sub-standard doctors.

On the other hand, one respondent pointed out that medical training in developing countries, often a relic of their colonial past, is in effect “training in becoming Westernized” (Pang, Lansang & Haines, 2002; Tarracena, 2002). Indeed, doctors in developing countries, following Western standardized literatures and curricula, might be more familiar with the latest development in lung cancer research, than with malaria and intestinal diseases that kill people locally. Often times an “international standard” hospital in the capital of an African country will occupy up to half of the country’s health budget, while people are dying from lack of access to clean water. Training large amounts of para-professionals might thus be a better route to take.

It has also been suggested that doctors who have had their education subsidized by the state be required to work a certain number of years in their source country, or that their education subsidies for overseas-studies are conditional on their returning to their home country; if they chose to stay abroad, they would have to pay back the cost of their studies. It has even been suggested that when South African doctors arrive to Saskatchewan, for example, thereby saving Saskatchewan large sums of money in medical training, the province should be required to pay a “tax” to South Africa.

Certainly, large overseas populations also bring potential benefits. Some skilled workers do return and bring with them foreign experience and contacts. Having members of a diaspora in top positions around the world can promote investment and trade connections, as in the case of China, which has benefited enormously from its diaspora in South-East Asia. And remittances in some cases make up a large percentage of a country’s income (Mexico, Albania and the Philippines come to mind). However, many of these potential benefits apply only to already middle-income countries.

African countries. by and large, seem to have been unable to harness much benefit from their large overseas population. For these countries to be able to develop economically, politically and culturally, they may need to make some important changes:

• Reconsider the aims and priorities of higher education programs so that they better suit national needs.

• Promote policies that aim to retain skilled workers or welcome them back.

• Develop programs that utilize the resource that a diaspora can represent.

Developed countries on the other hand, need to implement ethical guidelines on recruiting abroad.

Alkire, S. & Chen, L. (2004). “Medical Exceptionalism” in International Migration: Should Doctors and Nurses be Treated Differently? Draft paper for Workshop “Global Migration Regimes”, Institute for Future Studies, Stockholm.

Bundred, P. E. & Levitt, C. (2000). Medical migration: who are the real losers? Lancet, 356, 9225: 245-6.

Carrington, J. W. & Detragiache, E. (1999). How Extensive Is the Brain Drain? Finance & Development, 36, 2.

Commonwealth (2003). Companion Document to the Commonwealth Code of Practice for the International Recruitment of Health Workers. Meeting of Commonwealth Health Ministers, Geneva. Berry, A. (2005). Class lecture.

McAuliffe, E. & Maclachlan, M. (2005). ‘Turning the Ebbing Tide’: Knowledge Flows and Health in Low-income Countries. Higher Education Policy, 18, 3.

Morgan, J., Sives, A. & Appleton, S. (2005). Managing the International Recruitment of Health Workers and Teachers: Do the Commonwealth Agreements Provide an Answer? The Round Table, 94, 379.

Pang, T., Lansang, M. A. & Haines, A. (2002) Brain drain and health professionals. British Journal of Medicine, 324: 499-500.

Tarracena, G. A. H. (2002). Trained to become Westernized. Rapid response to Pang, T., Lansang, M. A. & Haines, A. (2002) Brain drain and health professionals. British Journal of Medicine, 324, 499-500. Acccessed on September 30 2005 at http://bmj.bmjjournals.com/cgi/eletters/324/7336/499#20358