Çağlar Özden
introduction
Existing data indicate that over a quarter of the physicians who were trained in Africa are currently living in Organisation for Economic Co-operation and Development (OECD) countries (Arah, Ogbu, and Okeke 2008; Bhargava, Docquier, and Moullan 2011; OECD 2008). Among the recent studies, OECD (2015) presents data that show similar patterns are continuing. In the presence of severe public health challenges, these numbers create serious concerns and stimulate a lively public debate on the impact this has on Africa and the policy implications of African doctors migrating to OECD countries. This chapter pro-vides an overview of the data needs for the proper analysis of determinants of health professional migration and its implications for the origin countries. It then discusses the existing data along with their conclusions and shortcomings. Finally, the chapter provides two examples of this analysis. The first example combines different data sets in innovative ways to identify career paths of African doctors who immigrate to the United States, considering place of birth, training, and professional practice. The second utilizes a detailed survey of Ghanaian physi-cians to answer some of the most relevant career and migration questions.
The main focus of the chapter is on physicians, since this has received the most
This chapter incorporates some of the work done by the author with Erhan Artuc, Michel Beine, Frederic Docquier, David Phillips, Mirwat Sewadeh, Benjamin Siankam (whose work appears under the name A. B. S. Tankwanchi), and Sten Vermund. I am truly grateful to have worked with them and acknowledge their intellectual contributions, without holding them responsible for any of the mistakes. My col-leagues at the World Bank—Agnes Soucat, Chris Herbst, and Richard Scheffler—provided me with much appreciated comments and suggestions on this chapter and my earlier work in this area. I am also grateful to Hope Steele for her superb editorial support. The standard disclaimer applies: The find-ings, conclusions, and views expressed in this chapter are entirely those of the author and should not be attributed to the World Bank, its executive directors, or the countries they represent.
attention in public policy debates and is where most comprehensive and reliable data are available. While many of the data challenges are similar across different health care professions, the complications posed by physician migration and appropriate policy responses might be different. This confirms one of the key messages of the chapter regarding the need for higher-quality and more compre-hensive data.
The migration of health care professionals, especially physicians from Sub-Saharan African countries to high-income OECD countries, generates significant attention in the academic literature and the policy debate on human resources in health care. The main concern is that “medical brain drain” potentially undermines the quality and delivery of health care services in the region by siphoning off the critical human capital required. Former World Health Organization (WHO) Director-General Lee Jong-wook cap-tured prevailing sentiment with his remarks that “it takes a considerable investment of time and resources to train health workers” and when they emigrate, “there is loss of hope and years of investment” (WHO 2006).
As a result of these sentiments, the migration of health care professionals across national boundaries has become a critical, controversial, emotional, and difficult subject for all parties involved. It is critical because it involves the transfer of human capital in a key area where there are significant global short-ages and imbalances. Lack of access to simple health care services, such as vac-cinations or other treatments, at critical points in time or in critical locations will have long-term consequences for both individuals and societies. Long-term economic growth and development rely significantly on the availability of basic health care services.
This issue is also controversial because health care professionals, quite fre-quently, migrate from developing countries in the South where there are signifi-cant human capital and resource shortages to developed countries in the West where there is relative abundance. In the majority of the cases, medical training in developing countries is financed through limited public funds at considerable opportunity costs. The migration of a physician or a nurse is frequently viewed as an implicit subsidy of a rich country by a poor one.
The migration of health care professionals is also an emotional issue. It is more complicated than the movement of a product, a financial asset, or even other highly skilled professionals because health care is frequently associated with basic citizenship rights. The debate is frequently accompanied by images of children in Sub-Saharan Africa who could be saved with simple and cheap interventions if the medication and the health care professionals were simply available at the right place and time. On the other side, references are made to wasteful medical tests and expenditures in the OECD countries simply because they are available and paid for.
Finally, the migration of health care professionals is a difficult issue. A lack of data means that neither the causes nor the impacts of the phenomenon are well established. The debate and the analysis take place behind a relatively thick veil of ignorance, especially for a subject that receives such public attention. In the
absence of reliable and detailed data, emotions and controversy dominate the policy agenda.
After reviewing the basic reasons that health care professionals migrate, especially those who train in Africa and then move to the OECD countries, the chapter will focus on more analytical issues. More specifically, it will discuss (a) factors that influence migration patterns, (b) the measurement of these factors, and (c) the data constraints policy makers and researchers face in making evidence-based trade-offs.
The data issues that create such challenges are an especially important topic of this chapter. Without high-quality and comprehensive data from origin and destination countries, the policy debate will not lead to feasible and effective solutions. Thus, the chapter will try to answer what kind of data are needed for a well-informed policy debate that would engage all parties involved—the producers and consumers of health care services in both destination and origin countries as well as the migrant health care professionals themselves.
Implementation of efficient and fair public health policies regarding training and employment of health care professionals can take place only with proper and high-quality data. In other words, the modest goal of this chapter is to reduce the level of controversy and emotion in the debate so that fact and analysis gain some ground.
reasons for migration
In some ways the question of why people migrate is very easy to answer.
People have been moving from one location to another—crossing mountains, rivers, and oceans—for as long as humans have lived in communities.
Historical motivations to move—such as more plentiful food, better living conditions, escape from violence and persecution, and natural disasters—exist even today. The world is still full of political refugees and asylum seekers who are willing to take personal risks for basic needs that we take for granted, especially in the West.
When it comes to the migration of health workers or other highly skilled and educated professionals, additional reasons enter the picture. Even though these reasons can be divided into several separate categories to discuss them more easily, they are still closely related to each other. The three main catego-ries are (a) financial motivations, (b) professional development concerns, and (c) personal and family reasons.
Average annual income per capita shows great variation across Africa—
from around $400 in the Democratic Republic of Congo to around $36,000 in Equatorial Guinea, $15,000 in Gabon, and $12,000 in South Africa. Yet the fact that all of the 15 countries at the very bottom of the global per capita income rankings (World Bank 2013) are from Sub-Saharan Africa gives an idea of the low income levels in most African countries. Clearly, Equatorial Guinea and Gabon are outliers because of their small populations and natural resource endowments. Furthermore, significant inequality exists
within each country where the median income is significantly lower than the mean income.
In every country around the world, incomes of health care professionals are naturally linked to overall income levels. However, in Africa, the incomes of health care professionals tend to be significantly higher than the average incomes because of relative shortages and high returns to education. WHO (2006) esti-mates that in most countries in Sub-Saharan Africa, the average income of a doctor is around 20–40 times greater than the average income per capita. Still, even at these relative levels, average physician salaries in the region are quite low when compared with those in Organisation for Economic Co-operation and Development countries. For example, in the United States, the average annual income of a physician ranges between $150,000 and $250,000 depending on the specialization (AMA 2012). These stark wage differences range between 4 and 15 times depending on the African and OECD countries used in the comparison, and they provide some of the most powerful pull factors for African doctors who migrate to Western labor markets.
The second most powerful set of factors can be classified under professional advancement opportunities. The first example is the availability of training during and after medical school to acquire, develop, and practice new findings, technologies, and information. This issue is extremely critical for a field such as medicine, where the pace of development and introduction of new medicines, equipment, and other treatment techniques are quite high. Doctors and other professionals need to keep abreast of new developments and have easy access to them to improve their performance and provide better services to their patients.
Unfortunately this is quite difficult in most of Africa, where many countries are still without medical schools, advanced specialization programs, or easy access to scientific developments in medicine.
Another advantage often cited by African doctors who have migrated to the West is being part of institutions—universities, hospitals, clinics—and being surrounded by accomplished and motivated colleagues in their new positions.
Frequent and close interaction with such colleagues creates knowledge spillovers in high-skill environments, as economics literature has consistently shown. These positive externalities, in turn, increase the level of both productivity and job satisfaction, creating more incentives to migrate.
Another limitation of professional environments in Africa is the financial resource constraints on support staff, equipment, facilities, and medicines.
Doctors in Africa are often forced to practice with very limited resources—older equipment, facilities below internationally accepted standards, and inadequate support staff—relative to their counterparts in the West; at the same time, they must deal with heavier and more dangerous health care burdens (Soucat, Scheffler, and Ghebreyesus 2013). The professional and financial environment in many Western countries is structured to increase the effectiveness of the doctors.
In addition to impacting their productivity, most African doctors cite the demor-alizing effects of these constraints, because they feel helpless (Özden 2012).
The final sets of reasons are personal in nature, as is the case with hundreds of millions of migrants around the world. Doctors want to provide better oppor-tunities for their families, especially for their children. Having lived through difficult environments with limited resources and having achieved relative success, it is natural for parents to want better physical, educational, and financial opportunities for their children. In addition, most migrant professionals send remittances to their extensive families back at home, even at times supporting whole villages. One of the most fascinating findings of the survey of Ghanaian doctors in the West is that they have a large number of nonphysician siblings who also migrated abroad (Özden 2012). Many doctors took advantage of family reunification programs and sponsored their siblings and their families. In short, migration of the doctor was part of a strategy to help the extended family (Özden 2012).
Data needed to analyze health care professional migrations
In other areas of heath economics, education, or public policy, researchers and policy makers have access to vast amounts of data to determine the appropriate costs and benefits of different policies. Unfortunately this is not the case when it comes to analyzing the determinants and consequences of health care profes-sionals’ migration, especially from developing to developed countries. This section lists the ideal data sets that a researcher can ask for when performing such analyses. It is clear that such data sets do not exist in reality or would be cost-prohibitive to collect. The section following this one will identify existing data sources that have been used so far or are available and waiting to be tapped.
Fortunately, medical professions are among the most tightly regulated ones in almost every country. This makes the collection of certain types of data relatively easy, as described in further detail below. However, because of the nature of the data, collaboration and the cooperation of both the origin and destination countries are needed in the collection process. This, unfortunately, may be prob-lematic in many cases.
Data needs can be divided into several categories that track the career paths of health care professionals: their social environment and education prior to medical school, their medical training, and their professional career; and the health care outcomes in their home communities.
Personal and Demographic Variables
The first data category covers personal and demographic backgrounds of the medical professionals that are especially relevant for the future migration decisions. Family and personal reasons for migration were noted earlier: some of these variables enter this category. The place of birth (or even the region of birth within the home country) and other relevant demographic or family vari-ables are some examples. These data—especially place and year of birth—could be obtained from administrative records. However, the only possible way to
collect data for the other variables would be to conduct a detailed survey of the professionals.
Education and Training
The second category covers medical education and training; this includes both formal training at medical or appropriate vocational schools and practical or on-the-job training. This category also includes information related to the specializa-tions chosen and how the education was financed (private versus public) as well as indicators of the quality of training. These data are relatively easier to collect and analyze, especially compared to the other categories, since they would come from the medical school registration records, administrative data collected for licensing requirements, and professional councils.
Professional Career Paths
The third category concerns the career paths that health care professionals pursue after they complete their medical training. Data on current and past geo-graphic locations of their practice would be collected in this section. This would be the main source of data for migration because the data set would track when and where the health care professionals moved. In addition to the data on the county of location, the data set would ideally indicate the specific region to which the migrant moved, which would be important when considering large destina-tion countries such as the United States and Canada.
In the career path category, there would be additional data on professional details along with geographic location. For example, it would be useful to know whether the physician is working in a research lab, a full-service hospital, a small clinic, or in private practice. If the data were collected from a survey, questions on professional activities and links—both personal and professional—with the home country could be included.
ways to measure the relative importance of migration Determinants The previous two sections listed the causes of migration and then the data needed at the individual level of the health workers. Listing the causes—whether they are financial, professional, or personal—of the migration of health care pro-fessionals is actually the easier part. The more difficult and policy-relevant issue is how to measure the relative importance of these factors in determining the migration decision. If this were accomplished, policy makers would be able to determine more easily what policies need to be modified to increase retention in home countries at minimal cost, especially in countries with limited fiscal resources. For example, it would be possible to determine whether an extra dollar spent on equipment, salaries, or advanced medical training is more effective in reducing the likelihood of migration of physicians.
Various methods can measure the relative importance of different motiva-tions, based on the data outlined above. An example is the method employed by Özden (2012) using survey data of Ghanaian doctors both abroad and
at home (survey details are discussed later in the chapter in the section
“Determinants of Migration: Ghana as a Case Study”). The most basic way to identify determinants of migration is to construct a discrete choice model where the dependent variable is the migration status and the explanatory variables are the personal, academic, and professional categories. The single most important issue is that the migrant doctors are not randomly selected. For example, they might be more academically accomplished, come from specific regions, or already have family members abroad. Thus, it is necessary to collect data on both the migrant and nonmigrant doctors to make the appropriate comparison and construct metrics of the various factors that impact migration decision so they can be used in the estimation.
It is also possible that people who want to migrate abroad choose to become doctors since a medical education might make it easier to obtain residency in an OECD country. A two-stage estimation technique might be used where certain personal or family characteristics (that do not influence the migration decision) are used to determine selection into the medical education and then additional variables are used to estimate their effect on the migration decision.
ways to measure the impact of migration
The data categories listed previously pertain to the characteristics of individual health care professionals. The next critical data category relates to the impact of migration on the health outcomes, especially in origin countries. These are pos-sibly the most difficult and costly data to collect. The main cost for an origin country when health care professionals migrate is the potential decline in the quality and quantity of the services provided to the public. Disease burdens, life expectancy, prevalence of infectious diseases, and other health indicators are all examples of potential health outcome indicators that can be used in the analysis.
To link the immigration of doctors and nurses to declines in health outcomes, it is important to collect such public health information with as much detail and frequency as possible.
Data on health outcomes is collected on a regular basis by governments and
Data on health outcomes is collected on a regular basis by governments and