Modeling the effects of physician emigration on human development
Research highlights
▶ This article showed positive effects of migration prospects on medical training though the magnitude was small. ▶ Child mortality rates were negatively associated with the number of physicians per capita after adult literacy rates exceeded 60%. ▶ Results for DPT and measles vaccinations showed the importance of literacy rates and physicians per capita. ▶ Reducing brain drain is likely to have only small benefits for child mortality and vaccination rates.
Introduction
In the Millennium Declaration, the United Nations member states and international organizations agreed to achieve eight human development goals (United Nations, 2008). Improving health, reducing mortality, and reversing the spread of major diseases were among the top priorities.1 Many countries especially in sub-Saharan Africa are likely to fall short in meeting the 2015 targets.2 Although child mortality rates have declined in developing countries, eleven million children die annually from preventable and treatable diseases; over half a million women die during pregnancy or childbirth due to lack of ante-natal care. The access to and quality of medical services in developing countries is a key determinants of health outcomes.3 It is therefore important from a policy standpoint to investigate whether medical brain drain (MBD), i.e. emigration of medical personnel, can significantly affect indicators of human development.
An important hurdle in investigating these issues is the lack of comprehensive databases on medical emigration. While it is difficult to collect data on emigration of nurses, majority of medical associations in high-income countries compile information on the number of foreign-trained physicians. This paper focuses on physician brain drain and the first objective was to provide a harmonized longitudinal data set on physician emigration rates. For each country in the period 1991–2004, we aggregated physician immigration data from 18 major destination countries, and compared the migration of physicians from home country with total numbers of physicians trained. Using this relative measure, physician brain drain seems severe in certain countries in sub-Saharan Africa, South Asia, East Asia, Latin America and the Caribbean.
Further, we investigated if reversing or stopping MBD could help improving health outcomes and access to medical services. This is a complex issue for several reasons. First, migration studies have shown that prospects of high-skilled emigration can stimulate educational investments in developing countries and may be beneficial to the source country (e.g. Stark et al., 1997, Mountford, 1997, Beine et al., 2001). In countries where returns to schooling are low, stopping brain drain could reduce the incentives to acquire transferrable skills and hence the ex post quantity of skilled labor. A net brain gain can be obtained if this ex ante incentive effect exceeds the ex post emigration effect. Evidence of a brain gain effect has been found at micro and macro levels.4 Engman (2010) discussed occupational case studies supporting this mechanism among Egyptian teachers, Indian information technology specialists and Filipino nurses. However, this mechanism seems inapplicable to the medical sector due to limited training capacities in the short and medium terms.5 Second, there have been discussions of the relationships between health indicators and the supply of physicians in the country. Chauvet et al. (2008) found that the number of physicians in the country had no significant effect on child mortality.6 Clemens (2007) argued that Africa's poor public health conditions are the result of factors unrelated to staffing levels. By contrast, Bhargava and Docquier (2008) found that higher MBD rates in sub-Saharan African countries predicted higher adult mortality due to AIDS.
The second objective of this paper was to shed light on the above issues using the improved longitudinal database on medical training and physician emigration in developing countries. We first tested for the existence of migration-induced incentives and net brain gain. We then evaluated the impact of medical brain drain on child mortality and vaccination rates, allowing for quantity and quality effects i.e. decrease in the numbers and average abilities of the remaining physicians. Although panel data analyses have limitations due to interpolations used for constructing child mortality and vaccination rates in databases such as the World Development Indicators (Bhargava and Yu, 1997), they can afford useful insights. For example, MBD rate can be treated as an “endogenous” (correlated with the errors) variable in the models which was also useful in situations where MBD was measured with error.
Our main findings can be summarized as follows: first, there appears to be a positive incentive effect of migration prospects on medical training. However, the effect was too small to generate a net brain gain so that MBD mainly reduced the number of physicians in developing countries. Second, infant and child mortality rates were seen to decrease with the numbers of physicians per capita when adult literacy rates exceeded 60%, which was the case for the majority of countries. The results for DPT and measles vaccinations again underscored the importance of literacy rates and physicians per capita for higher vaccination rates. Third, reducing physician brain drain was likely to generate only small improvements in human development indicators compared to the stated Millennium Development Goals. The paper is organized as follows: Section 2 presents the revised database on physician emigration measures. The empirical models, econometric models and other data sources are described in Section 3. The empirical results are presented in Section 4. Finally, Section 5 concludes with possible extensions of this work.
Section snippets
Assessing the magnitude of physician brain drain
Building on the previous work by Bhargava and Docquier (2008), we evaluated physician brain drain in absolute and relative terms. In absolute terms, the stock of physician emigrants from a given country was evaluated by summing immigration data collected from a set of R major destination countries. Denoting by (Migrants)i,r,t the number of physicians originating from country i and residing in country r at time t, the (absolute) total emigration stock from country i was given by (Migrants)i,t ≡ ∑ r(
Models, econometric framework and the data
This section describes the empirical models, econometric methods and the data used in the analyses of the effects of medical brain drain on child mortality, vaccination rates, and enrollment in medical training in developing countries.
The empirical results
This section presents the empirical results for the growth rates of physicians (Section 4.1), infant and child mortality rates (Section 4.2), and vaccination rates (Section 4.3).
Conclusion
While high-skilled emigration has become an important policy issue in the recent years, emigration of medical personnel deserves special attention partly because of the inter-connections between population health and economic growth in developing countries (Bhargava et al., 2001). This paper presented an analysis of an improved database on emigration of physicians for the period 1991–2004 for all countries in the world, and investigated the effects of physician brain drain on human development
Acknowledgements
This paper describes and analyzes an improved database on physician emigration that is available at http://perso.uclouvain.be/frederic.docquier/oxlight.htm. This research is part of the project “Brain drain, return migration and South–South migration: impact on labor markets and human capital” supported by the Austrian, German, Korean, and Norwegian governments through the Multi-donor Trust Fund on Labor Markets, Job Creation, and Economic Growth administered by the World Bank's Social
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