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January 12, 2008


Random African

Remember it's also possible for doctors to be trained abroad but at their home country's expense (partial or not, direct or not).

One case I once read about with a transfert is Botswana and its nurses who are definetly trained at home at the expense of a government who makes health a priority for obvious reasons, who would definetly be useful (they're nurses and they're usually better allocated than in say Mozambique) and who are leaving for the UK, a country that has been spending less and less on trainning nurses.

Also one has to evaluate the number of african physicians practicing abroad because there is insufficient demand for their speciality in their home country.


What about the idea of taxing international human capital flows or the Bhagwati tax? For the cases where doctors and nurses have been trained domestically this seems to be a fair instrument. On the other hand, I wonder if it's technically feasible and it runs the risk of creating more bureaucratic costs than that it actually raises money.

Arnold Kling

Think about the consequences of clamping down on the freedom of movement of doctors. The main result will be that fewer people in underdeveloped countries will train to become doctors.


"The numbers do not allow us to tell what proportion of African physicians abroad were actually trained in their home countries, at public expense. Since medical education is typically public and highly expensive, the implied transfer from African treasuries to health systems in Europe and America is nothing to scoff at. This, at the very least, is grounds for worry (and action)".--Dani Rodrik

He who takes the King's gold, does the King's bidding.

Governments have every right to insist that they get services in return for paying someones way through medical school. The question of where they are trained isn't relevant. Who pays is.

Perhaps some of the doctor who were trained at the expense of the state feel that their first duty is to help the members of their families. Those who see their duty this way can't make the money necessary to do that if they have to stay home and practice medicine. Besides, he or she may reason, being able to send money back to the country that footed my bills is a way of repaying my society. Won't the money I'm able to send help its economy and allow members of my family to get educations they couldn't have gotten without my help. Won't more wealth for the country and more people being educated help its society more in the long run than my practicing medicine back home.

Perhaps, but that is for the King to decide and not the person who took the King's gold. For those who took it, duty to the needs of society as the government understands those needs trumps their individual liberty to decide differently.


An important policy response, in my view, should take into account the very causes of such flow, which are not limited to economic variables. What about flows within Africa? For example, a large number foreign trained medical professionals from Zimbabwe and Ethiopia work and live in Botswana. Does this tell us something important? At least there is the possibility of, in Daron's terms, "seasaw effect." However, the recent outflow of medical professionals from Germany suggests that there could be another complimntary force behind. Symptoms of deeper problems should not be the prime focus than the very deeper determinant.

At least, as far as the researches I came across, there is no clear support for controlling outflow of professionals over and above creating an environment that lets students pay the full costs of their education( I have a complimentary educational loan in mind) and governments give up the power of fixing the wages of such professionals. In the end, the market has to be the guiding mechanism than entirely relying on government determination of wage.

Most importantly, health isan important public problem! For example, the number of Doctors of Ethiopian origin in Chicago state alone is by far greater than the total number of doctors in the country. However, it is also the case for many professions. Thus the question is whether the outflow of the health professionals is the most important problem that demands the attention of developing countries's, weak and sometimes filled with least trained, bearucracy?

Gunilla Pettersson

It is crucial not to be blinded by these numbers. In many cases the emigration of African health care professionals is a symptom of the real problems underlying the failure of healthcare systems in many African countries, not the cause.
Mismanagement, absenteeism and corruption are likely much more important in explaining why public health systems are not delivering. For an excellent take on this see the paper by Maureen Lewis at the World Bank http://www.cgdev.org/content/publications/detail/5967/.
If the true goal is to significantly improve health outcomes the question is whether training more physicians and professional nurses will have the largest impact. For the majority of people (who often have no access to the formal healthcare system) it could be better to train lower level health workers (cheaper and faster, unlikely to emigrate) who would be well able to deal with the largest killers: diarrhea, malaria, cholera and TB.


Quite a few of my high school friends in Nepal are now doctors. A lot of them and their friends are now studying for MLA tests to come to US. According to my friends majority of doctors whose education is paid by the government end up in the US. I have no numbers to back this up, but certainly hardly any of the government funded people even do the 5 or so yrs required for them to spend in the rural areas. Even the health posts in rural area are devoid of health assistants. Thats probably because there are hardly any HA trained as there are not good infrastructures to train them (most teaching hospitals focus on only teaching doctors). Perhaps the government should spend money making on HAs than on doctors.


The govenment of Mozambique is not spending money wisely. They should train fewer doctors and pay them higher salaries.

Michael Clemens

Thanks Dani. You raise a crucial question about the financial consequences.

As you know, all effects on the fiscus are the result of a particular subsidy policy plus labor movement, not of labor movement alone. It is worth asking: What is the right mix of training subsidies for very highly skilled tertiary care workers (physicians) versus other much less mobile health workers (public health workers, educators, mid-level cadres primary care workers)? What is the right mix of subsidizing training versus subsidizing the rest of the worker's career, especially performance? What is the right mix of public versus private training?

A serious look at African health systems reveals that all of these are very, very far from where they should be, to different degrees in different countries. What, then, is the 'cause' of the fiscal drain engendered by a departing doctor?

A better question for economists is: In a world where there is mobility, what is the optimal subsidy policy for human capital formation? This fascinating question blends fields -- labor, health, development, public finance, and international -- which is perhaps why there is very little research on it.

I make this and other related points here:


dominic corva

how many doctors in Africa are Cuban or trained in Cuba? what are the policy implications of such transfers?

"Between 1963 and 2005 more than 100,000 doctors and health workers intervened in 97 countries, mostly in Africa and Latin America (2) By March 2006, 25,000 Cuban professionals were working in 68 nations. This is more than even the World Health Organisation can deploy, while Médecins Sans Frontières sent only 2,040 doctors and nurses abroad in 2003, and 2,290 in 2004 (3)."


(for example)

Ken Houghton

Marshall Jevons points us to a model that is actually Pareto-optimal:


So the problem may be mitigated some by providing inexpensive flights from Ghana and Cameroon to, say, Portugal.


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mac insleads

What about the ever increasing number of African doctors that once trained are leaving to work abroad in the US or EU? Not a good return of investment for the African countries.

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