• Ethics
• Health Personnel
• Health Workforce
• International Migration of Health Professionals
• Political Philosophy

Javier Hidalgo believes that we would be justified in restricting the liberties of health personnel if we had compelling evidence that this would bring about beneficial consequences.1 He is sceptical that this evidence exists or would ever be forthcoming. He seems to have at least two concerns. Given the complexities of interpreting data, we can never have the required evidence because we cannot be sure about the necessary causal claims. A second issue is that policymakers or members of governments would not be in a good position to make the kind of decisions involved in weighing the evidence, given that social scientists themselves disagree.ⁱ Hidalgo therefore supports my position, at least in theory, that where there is good evidence concerning relevant beneficial consequences for remedying important losses associated with high skill migration, we may permissibly restrict health personnel's freedom to migrate through introduction of carefully crafted compulsory service and taxation programmes. So one important issue is whether such evidence is or could ever become available in a form useful to members of government.

By contrast, Phillip Cole expresses significant reservations about the policies I argue are permissible under certain conditions.2 He says: ‘Health workers … should never be called upon to make the kind of sacrifices Brock is looking for’.2 ‘I cannot see that it is fair and reasonable to remove the right to leave or to financially penalize those that do’.2 He worries that health workers are not being sufficiently respected and the measures for which I argue would remove the right of workers to negotiate contracts. His main alternative position is that ‘the international community must make sure that it does not fail in its efforts to address’2 health crises facing low/middle-income countries so that ‘the violation of fundamental human rights is never, in fact, justifiable in practice”.2 He also notes that there are many powerful players who have more responsibilities including multinational corporations, the WHO and the International Organisation for Migration. It is interesting that he points to multinationals' massive tax avoidance in African states as one example of corporations shirking their responsibilities, an example that I too discuss at length in several places.ⁱⁱ

While I certainly understand Cole's perspective, I think, in many ways, it simply fails to engage with the core questions I discuss and that he is hoping we never have to confront. These are the very ones I take seriously in my arguments for which policies, in our decidedly unjust contemporary world, might actually be permissible. So let me retrace some steps to see why we must confront the issues Cole would rather eschew. The central normative question for consideration in ‘Debating Brain Drain’ is a conditional one and it takes seriously the concerns that both Hidalgo and Cole raise:When there are net losses from high skill migration, what may developing countries do to solve their own problems, in a context in which affluent developed states are not complying with the demands of justice?

Note that the key question is one of what low/middle-income countries may permissibly do to solve problems they experience associated with brain drain. The analysis is meant to help them formulate permissible policies that they can implement here and now, without having to wait any longer for non-compliant developed world actors to discharge their duties.

I argue that a poor, legitimate, developing state may implement carefully crafted compulsory service and taxation schemes when five important sets of conditions are met. Importantly, states must be legitimate, certain background conditions must hold and citizens must have relevant responsibilities.ⁱⁱⁱ The skilled citizens have important responsibilities to assist with need satisfaction when seven important considerations all apply (cf. Chapter 4, ‘Debating Brain Drain’). Three highly relevant background conditions are as follows:(BC1). Evidence from the particular country indicates that skilled citizens can provide important services for which there are severe shortages, and their departure considerably undermines efforts to meet citizens' needs. The ways in which citizens' departure exacerbates deprivation may be quite direct (such as failure to provide important services necessary to meeting basic needs) or more indirect (such as when the institutional reforms necessary for development have been hampered by net losses resulting from migration of skilled workers, for instance through the loss of taxation revenue). (BC2). Governments have invested appropriately in training of skilled workers to provide for their citizens' needs and to promote beneficial development. (BC3). Losses that result from skilled workers' otherwise uncompensated departure would not adequately be compensated for by benefits that result from citizens who leave.

For taxation programmes to be justified, in addition to the state's being legitimate and the relevant background conditions and moral responsibilities applying, it must be the case that taxation of those skilled citizens would assist in remedying deprivation. Governments should have made all high-skilled citizens (whether prospective migrants or not) aware of their need to tax such citizens to assist with remedying deprivation and should have made this an explicit condition of student's accepting the opportunity for tertiary-level training in various significant courses of study. The taxation programme should not require unreasonable sacrifices.

For compulsory service programmes to be justified, governments should, in addition to the conditions outlined above, make students aware of the fact that they will be expected to meet needs on completion of their training, at least for a short period such as 1 year and should make this an explicit condition of student's accepting the opportunity for tertiary-level training in various courses of study. In addition, being present in the country must be important for remedying the deprivations; the compulsory service programme should not require unreasonable sacrifices and the costs of staying should not be unreasonable.

The core issue with Cole is whether what I am proposing constitutes an unreasonable burden that migrants can never be asked to bear. In order to answer this question, compare some possible compulsory service programmes that could be implemented:

1. Service in underserved communities is required on completion of the degree for a period of 1 year.

2. There is a delay (such as 1 year) between completing the education necessary to be awarded the degree and the awarding of the degree.

3. There is a requirement to complete a module of underserved community service (of 1 year's duration) as part of the requirements to gain a licence to practice in that state.

4. There is a requirement to complete a 1-year term of underserved community service in order to be considered for postgraduate training.

Shortly I compare all of these programmes with residency requirements that might take this form:

• A 1-year module of underserved community service and training is part of the degree requirements.

Notice that none of options 2–4 removes the right to leave. One may not wish to practice or pursue postgraduate training in that country, so options 3 and 4 present no restriction in such cases. In the case of option 2, many students will choose to spend the 1-year gap between completion and award of the degree within the country and wait to receive the paperwork before leaving, but some may not. They are free to leave. So what about option 1? Is that unreasonable? Would it remove migrants' rights to leave?

A key issue is how these contracts to serve would be enforced. Enforcement for compulsory service might take the form of a delay between completion and awarding of the degree. This is in fact how 64% of compulsory service agreements are actually enforced today for those approximately 70 states that have currently implemented the compulsory service programmes, and it may well be a good option for many countries.8

But let us anyhow consider other enforcement mechanisms. Whatever the form of the compulsory service programme may be, people should be permitted to leave and any breaches of contract should be pursued in the same ways many contracts are enforced when one party fails to comply and leaves the country, for instance through the destination country helping to enforce the contract. This is the case with agreements to enforce child support or alimony orders. Host countries have often used wage garnishments to help enforce contracts.^iv

Is option 1 unreasonable? Compare with option 5, the standard residency requirement. I do not see a material difference between options 1 and 5 in the levels of coercion that are being applied. If option 5 is acceptable, then there is no principled reason why option 1 is not, in my view. All things considered, I believe the details of my programmes take account of Cole's concerns so that no unreasonable sacrifices are required.

So let us turn to the issue of whether there is relevant evidence currently available that Hidalgo might find compelling. First, I should stress that I do not hold the view that there are always net losses from high skill migration nor that empirical results about one state might generalise to others. Evidence is highly particular to different countries. Indeed, recall that both (BC1) and (BC3) take account of this particularity, for instance, (BC1) requires that evidence from the particular country indicates that skilled citizens can provide important services for which there are severe shortages and their departure considerably undermines efforts to meet citizens' needs.

So, is there any relevant current evidence that has a bearing on the issues under discussion? There is a general problem in health services research with trying to show direct evidence of physician impact on population health. There are standard ways around this problem such as using measures that capture enhanced service provision as indicators of success. Here there is relevant evidence. For instance, Mozambique reports that all 148 districts in the country have at least one physician since their compulsory service program has begun, which was not previously the case.8 After implementing their programme, Puerto Rico reported that all 78 municipalities had one doctor.8 Similarly, good results are available from Indonesia and Turkey, with South Africa showing ‘better staffing levels in rural hospitals, shorter patient wait times and more frequent visits to outlying clinics by health workers’.8 Of course, just having a health professional present in the district need not translate to improved health outcomes, but it does remove one important current obstacle to the likelihood of better health outcomes.8 Finally, there is important research on what makes compulsory service programmes effective when they are in place. For instance, when individuals are well trained for the procedures and conditions relevant to working in rural or underserved communities and the support necessary for people to function effectively is available, both within the healthcare system and from the community, these programmes can be effective.8 ^v