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This research paper focuses on brain drain. It surveys some of the reasons there are high rates of skilled worker migration from developing countries, the harms and beneﬁts that result from these departures, the kinds of policies that might address the losses, and the agents who have a role to play in working toward solutions. It also covers arguments for some of the key responsibilities and some frequently mentioned objections to promising solutions, along with responses.
A pressing global health issue concerns the lack of human resources able to attend to enormous contemporary healthcare needs. The problems are most acute in developing countries. Consider, for instance, how while Africa has about 10 % of the world’s population, it bears 25 % of the global disease burden that it must service with only 3 % of the world’s global healthcare workforce.
The shortage problems are rendered more pressing when the phenomenon of brain drain exists. This occurs when skilled citizens depart countries at reasonably high rates, leaving behind less skilled (or unskilled) citizens. The problems of brain drain are acutely felt in the health sector as large numbers of healthcare workers choose to leave low-income countries for better prospects in high-income ones. But the problem of brain drain is a broad one and affects many professions such as engineering, information technology, law, or education. Since an effective and legitimate state needs a variety of skilled persons to help provide important goods and services, the departure of many high-skilled citizens can have important effects on those left behind. These include effects on development, educational attainment, levels of income and growth, economic prosperity, and most importantly for the purposes of this research paper , both health outcomes and opportunities for healthcare.
Healthcare workers can often experience signiﬁcant challenges in low-income countries, including lack of adequate resources to practice medicine effectively and few opportunities for professional advancement, so it is understandable that many wish to leave their countries of origin. While the freedom of movement of all, including healthcare professionals, is an important consideration that deserves signiﬁcant weight, so are the healthcare workers’ responsibilities to reciprocate for signiﬁcant beneﬁts received, such as having received costly training at taxpayers’ expense. Balancing these considerations, there are several recommendable policy options that are explored below. To begin the analysis, some of the harms and beneﬁts that result from high levels of skilled worker migration are cataloged. While several beneﬁts are often highlighted, so are notable harms, including harms to healthcare systems, development, and health opportunities and outcomes for those left behind.
Who can be expected to play a role in addressing the losses? Many agents have an important contribution to make. Agents from high-income countries should train sufﬁcient healthcare personnel so that chronic under shortages are reduced. Also, there should be compliance with guidelines for ethical recruitment, ensuring compensation when important losses result. Agents in low-income countries also have important responsibilities. They should do what they can to make staying a more attractive option. In addition, they may permissibly expect migrants to play a role through reasonable compulsory service or taxation programs. This research paper covers some of the arguments as to why such programs may be justiﬁed. The paper also considers several objections to such programs, especially those that maintain any conditions on healthcare workers unfairly limit their freedom. Finally, it shows how carefully crafted compulsory service and taxation programs may be permissible, along with a range of other policies.
History And Development: Background Of The Issue
The lack of healthcare workers able to attend adequately to healthcare needs is one of the most severe global health issues we face today. According to the World Health Organization, there is a global shortage of approximately 4.3 million healthcare workers (Oxfam International 2007). The shortages affect both developing and developed countries alike. However, developing countries experience this problem more acutely as their healthcare needs in the face of a greater disease burden are much more urgent and the rate at which they lose their healthcare workers is sometimes quite alarming. There are many reasons why healthcare workers might wish to leave countries of origin, including the search for better personal and professional opportunities in other, especially high-income, countries. However, healthcare professionals’ departure presents a number of ethical issues for different agents, including for the migrants, those in destination countries, and those in countries of origin.
The World Health Organization has estimated that the minimum number of healthcare workers a country needs to deliver basic health services is 2.5 health workers per 1,000 population (WHO 2006). Sadly, 75 countries (the vast majority of which are in Africa) are below this threshold and are therefore unable to deliver basic healthcare to their citizens. Some of the countries with the most compromised health systems suffer the highest rates of healthcare worker departures, with some well-known cases of countries (such as Ghana and South Africa) losing more healthcare professionals than they are able to train each year. It is widely reported that in 2001 Ghana lost 500 nurses, which is more than double the number of nurses graduated that year. In some countries, especially in sub-Saharan Africa, the rates at which health professionals depart is so high that it threatens the viability of the healthcare system with signiﬁcant consequences for the health of those who live in developing countries.
While some of these professionals travel on their own initiative to high-income countries in search of better job prospects, there is also a highly organized system of active recruitment from high-income countries that facilitates this movement. In fact, high-income countries often rely on dealing with their staff shortages by recruiting from some of the countries suffering the worst shortages.
The Freedom Of Healthcare Workers To Emigrate
Healthcare workers often face signiﬁcant obstacles in their work and personal lives in many low-income countries. Large workloads with insufﬁcient staff to address the huge needs, lack of adequate equipment, facilities, and other resources, or poor conditions of employment such as having to practice in areas with epidemics of serious diseases may make healthcare delivery particularly challenging. Low salaries with few opportunities for further professional training and development may add to the difﬁculties. High levels of violence, instability, government incompetence, or corruption may provide further push factors driving workers to seek better prospects elsewhere. High-income or developed countries frequently appear to offer higher salaries, more professional opportunities, better standards of living, and more generally, opportunities for workers and their families to live secure and prosperous lives. Who could blame such professionals for wanting to move? Surely, all healthcare workers should be free to leave their countries of origin if they choose to do so?
Healthcare workers, like everyone else, should enjoy freedom of movement including the freedom to cross borders. However, their departure can sometimes raise ethical issues about uncompensated losses that result from their actions. There are normative questions about departing citizens’ responsibilities, fair terms of exit, and signiﬁcant losses in educational resources and public funds when citizens receive expensive training from poor countries with limited resources, training which then does not beneﬁt citizens of that country but rather patients from afﬂuent countries. These and other factors are often invoked to marshal a case for the healthcare workers’ obligations to “give back” to the country of origin, in some way or other. The forms this might take and the arguments for the obligation are discussed below. The effects of healthcare worker migration are discussed next.
What Consequences Result From Healthcare Worker Migration?
There is an enormous literature on the effects of healthcare worker migration on home and host countries. Due to space limitations, just some of the main issues are discussed. While there are many studies documenting the net beneﬁts for destination countries and migrants, much of the more mixed results concern the effects for the countries of origin.
Some sectors are especially badly affected by high departure rates. Brain drain in the health sector can be particularly damaging for citizens in developing countries as such countries are typically under resourced with generally weak institutions, so that even small losses can undermine the effectiveness of an entire health system (Bundred and Levitt 2000; Mills et al. 2008). Skilled citizens who depart also facilitate much further damage that can have a more indirect effect on healthcare (Kapur and McHale 2005). There are important ﬁscal losses when skilled workers depart, and this can present a signiﬁcant loss for tax receipts, public revenue available to spend on public goods, and a loss in opportunity for progressive tax regimes. Also, since skilled workers’ knowledge about best practices, technical issues, organizational methods, and so on spreads to others in the economy, their departure can block important knowledge transfer. High-skilled worker migration also reduces income, economic growth, and opportunities for beneﬁcial forms of development. Highly skilled people are important in building institutions, which are in turn crucial in promoting development. Skilled citizens are both important sources of demand and supply for institutional reform. Skilled citizens can also be an important factor in demanding and supplying what is needed for robust democracies. So the departure of skilled citizens can present ﬁnancial losses, losses in skills and services, loss of institution-building assets, and losses for development and robust democracies (Kapur and McHale 2005). All of these general phenomena can have important effects for healthcare delivery in those countries (Brock and Blake 2015).
There is also a vast literature on some of the alleged positive beneﬁts that can accrue from departing individuals (Brock and Blake 2015; Clemens 2007; Docquier and Rapoport 2012; Gibson and McKenzie 2011). It is suggested that there are several ways in which high skill migration can result in positive poverty-reducing effects and can generally beneﬁt countries of origin. Let us review some of these.
First, increased human capital formation. The idea here is that the prospect of departure provides incentives for many to acquire skills they would not otherwise have had if additional training did not present opportunities to leave. Not all of those with newly acquired skills will in fact leave, so countries of origin will beneﬁt from an increased pool of skilled workers. Second, there are network or diaspora effects. Emigrants who live in other countries can be important assets to countries of origin. For instance, they can facilitate new trading opportunities. Third, many migrants return to countries of origin bringing back new skills, ideas, and social or ﬁnancial capital. Fourth, and arguably the most noted beneﬁt, is thought to be remittances. Migrants together send an enormous volume of funds to family and friends back in countries of origin. These payments go directly to individuals whose lives can be considerably enhanced by these revenue streams.
Some are more skeptical about these effects resulting in entirely positive gains for countries of origin. While there is some evidence for the additional training beneﬁting source countries, some argue that the magnitude of the effect is rather small (Bhargava et al. 2011). Brain gain is not always beneﬁcial to source countries as skills are acquired in areas thought to be valuable to destination countries. So geriatric training may receive a boost but not tropical medicine. In addition, any brain gain may not be sufﬁciently great to outweigh all the negative outcomes that result from medical brain drain such as increased adult deaths from AIDS, lower health status, and life expectancy for the general population (Bhargava and Docquier 2008).
Diaspora and network effects can be quite important. Migrants can facilitate the ﬂow of knowledge and goods between countries, as we see with India’s information technology sector. But caution is often advised because what is true for a large country with a highly skilled population may hold not at all for a small country with few skilled citizens (Docquier and Rapoport 2012).
While in theory returning migrants can promote reforms leading to improved institutions, the changes may also be skewed toward the beneﬁt of local and international elites rather than promoting institutional changes conducive to beneﬁcial forms of pro-poor development that help poor, marginalized sectors of the population (Brock and Blake 2015).
Remittances can be beneﬁcial, but they can also facilitate further damage. Remittances are typically sent to family members and, unless highly organized, rarely go toward funding public goods, training replacement workers, or on other ways to address structural forms of poverty or promote the common good, as governments are charged with doing. In fact, since it is the better-off who are usually in a position to migrate, remittance ﬂows can serve to exacerbate existing inequalities. The inﬂow of funds can create a certain dependence for the recipients of funds, can stimulate further migration as citizens become aware of wage differentials, economic activity can be further depressed by more migration, needed economic reforms can fail to take place, remittances tend to go on private consumption-oriented goods rather than public goods able to transform economies into ones likely to promote beneﬁcial development, and remittances tend to decline over time.
Given the huge range of considerations that can affect countries, it is no surprise that whether particular countries experience net losses or gains can vary quite considerably. Levels of skill in source countries, population size, levels of development, and geographic features are just some of the enormous range of factors that will play a part in whether high skill level migration will prove to be a net positive or negative for particular source countries (Gibson and McKenzie 2011; Docquier and Rapoport 2012). Despite the huge mixed literature, there are some important points that can be made, notably that international migration from poor to rich countries is a serious concern for developing countries. So the empirical literature reveals that there are some cases in which important net losses are, undeniably, occurring. When such net losses occur, what may poor developing countries do to remedy such losses? What are developed countries obligated to do? In order to address these issues, some policy options are explored in the next section.
Policy Options To Address Issues Of Brain Drain: Who Can Be Expected To Play A Role In Contributing To Solving These Problems?
What Should Developed World Agents Do?
Developed world agents are sometimes accused of poaching the human resources of poor, developing countries (Mills et al. 2008). Recruitment companies can be rather aggressive in targeting poor, under-resourced developing countries. Aggressive forms include recruitment practices in which recruiters try to entice an entire graduating class of a particular medical faculty or all the staff of a particular medical facility in a community that already suffers from critical shortages.
Without some ethical guidelines on fair recruitment practice, it may be that no genuine solution to the problems of brain drain is possible. Codes of practice that specify fair conduct in recruitment could help provide clear guidelines that could go some way toward stemming the most egregious practices, such as those that aggressively target the limited stock of skilled persons in a particular region (WHO 2010). Various penalties could apply to those found to be in violation, and with government cooperation, perpetrators could be properly held to account for any violations. The International Organization for Migration, the United Nations, or the World Health Organization could assist in monitoring and enforcing codes of practice, helping to facilitate bilateral agreements, and generally assist with policy implementation.
Compensation for luring away scarce skilled professionals should be a part of any fair code of conduct governing recruitment. Compensation could take a variety of important forms including transfer of technology, rotations in which developed world healthcare workers provide service in developing countries for a period, partnerships with healthcare facilities in developed countries that might be able to provide further resources to compensate for lost educational costs and to fund the training of future healthcare workers to stay in countries of origin, development aid, and so on.
Developed countries should consider training more staff themselves to ensure self-sufﬁciency with respect to their healthcare professional needs, so that they do not need to recruit outside of their own countries.
What May Developing Country Governments Defensibly Do In Responding To The Problems Associated With Brain Drain?
Some argue that developing countries may permissibly reform tertiary-level training curricula to ensure citizens are less marketable and more useful to countries of origin. In this regard, locally relevant healthcare training that focuses on cost-effective treatments for local endemic diseases is seen as a justiﬁed response to problems of brain drain. Other educational reforms might include training more healthcare practitioners to do routine jobs such as administering vaccines that do not require lengthy or costly training programs (Brock and Blake 2015).
Given the investment of public resources in funding the training of skilled departing citizens, some argue that it can be entirely reasonable to expect those citizens trained in healthcare work in developing countries to undertake a limited, reasonably short period of compulsory service before degrees are awarded or departure is permissible. Another policy option, ﬁrst made popular by Jagdish Bhagwati, is to argue for the permissibility of various taxation programs for the departing citizens (Bhagwati and Hansen 2009). Conditional education grants repayable on emigration is a further option. The more controversial policies are often thought to be compulsory service and taxation programs. These are discussed further next.
First, what is a compulsory service program? The main idea is that after a course of study is completed, the student is required to undertake a period of service in a particular underserved community –those areas that have difﬁculty attracting sufﬁcient capable staff able to deliver necessary healthcare services, perhaps because they are geographically remote and appear to offer fewer opportunities for the student or her family. While compulsory service can include a variety of types of schemes, there are many counted as such that are more aptly described as incentive programs (rather than compulsory service), such as offering employees subsidized free housing, education for children, low-rate loan opportunities, or higher salaries, in order to work in underserved communities (Frehywot et al. 2010).
One of the most common schemes categorized as compulsory service is one in which there is a delay (such as 1 year) between completing the ofﬁcial education program to be awarded the degree and the actual conferment of the degree.
In practice, many of the newly trained are likely to remain in the country at least until the degree is awarded, and during that period, the healthcare worker might be quite reliant on government-provided opportunities, such as to work in underserved communities. This policy of strategic delay might in effect have the same result as a more explicitly coercive program. In fact, this strategy of withholding certiﬁcation necessary for legal practice within the country is the most common way to enforce service requirements, with 64 % of the compulsory service programs Frehywot et al. surveyed reporting this practice (2010).
Those opposed to such policies argue that it is unfair to expect the burden of building developing societies to fall on those who just happen to be born into them. The duty to assist with development should spread to the world as a whole. In addition, states committed to liberal values cannot consistently coercively prevent its citizens from leaving, either by mandating compulsory service or requiring them to pay taxes as a condition of exit. Further arguments are needed to address such objections.
Why Is It Reasonable To Expect Skilled Emigrants To Play A Part In Solving Problems Associated With Brain Drain?
Some common arguments for migrants’ having important responsibilities to play a part in addressing problems that result from high skilled worker migration are canvassed here. Well governed communities usually make forecasts about health needs and plan to meet such projected needs. They invest in training the necessary personnel so citizens’ current and future health needs can be met. They thereby commit scarce resources with the expectation that their investment will beneﬁt communities. When migrants leave, they tend to disrupt these plans, but more to the point, the migrants can be accused of free riding on the public good without adequate reciprocity. They have beneﬁted from the community’s resources without giving back to it (Brock and Blake 2015).
When skilled citizens leave, there are many costs imposed which communities must now absorb. There are the training costs, typically heavily subsidized by the community. There is the loss of a stream of services she would have provided if she had remained. There is the loss of income from taxed wages which could be allocated to public goods, such as further heath care, and more generally the loss of persons likely to make an important contribution to beneﬁcial development, through contributing to its necessary precursors (e.g., healthcare). Those left behind are therefore worse off in several respects – fewer healthcare workers are available to treat patients, fewer resources are available for healthcare, and as a result, the disease burden may well increase.
Citizens typically receive a number of beneﬁts as a member of a community that is functioning minimally well. While living in her country of origin, she would have received a number of public and private goods of considerable value, such as enjoying a certain level of peace and protection of basic rights; she would also have enjoyed a certain level of education, infrastructure, and so on. So on plausible views about reciprocity and political obligation, she has thereby accumulated debts that are usually discharged by giving back as an adult productive member of that community. If she leaves, or intends to leave, other ways to discharge the debt might be thought appropriate.
Furthermore, detailed arguments can be added to bolster this view that high-skill emigrants have a role to play. Several are offered by Brock and Blake (2015). These include the following: (i) There are arguments from fairness and the requirements of reciprocity: when there has been provision of important beneﬁts, a ﬁtting response is owed which can take the shape of requiring skilled citizens to assume a fair share of burdens. (ii) By leaving without such ﬁtting responses or other adequate forms of compensation, the emigrant creates disadvantage for others. Several disadvantages can be identiﬁed such as a higher workload for those who remain or the loss of revenue that can entail underfunding for core services. Those left behind are made more vulnerable such that the prospect of enjoying adequate healthcare resources could be threatened. (iii) By leaving without adequate compensation for losses, emigrants thwart governments’ attempts to discharge their duties properly through undermining plans they had made to invest resources wisely in ways that would beneﬁt citizens and assist them in meeting core needs. (iv) By undermining governments’ abilities to discharge their duties and provide for citizens’ needs, this can also destabilize states. Remaining citizens can thereby lose conﬁdence in ineffective and dysfunctional governments, and this can undermine citizens’ willingness to support states, leading to destructive behavior, even state failure. (v) Governments are entitled to a fair return on investment when they invest scarce resources to create the human capital necessary for them to take care of citizens’ needs. For governments not to claim a fair return on their investments would be to commit resources unwisely, and governments surely have duties not to squander public resources. Governments are therefore entitled to claim compensation from those who beneﬁt from public resources which they have invested intending to beneﬁt their citizens. The destination country and the emigrants both beneﬁt from their investment, so both can be reasonably expected to play a part in assisting with solving these problems.
One objection is considered before closing this section. Why expect the skilled citizen to absorb costs for her bad luck of being born into a developing country that needs her skills? Why not spread the cost of addressing these losses across all, no matter what their country of birth? What about all those lucky enough to be born into developed countries with superior healthcare resources? Why not expect them to play a part in absorbing costs as well, compensating poor countries for their bad luck (as it were), especially when they have a history of aggressively recruiting scarce healthcare resources away from such countries? Even if it is conceded that developed world agents have a signiﬁcant role to play, this concession does not address the further question of whether the departing healthcare worker can defensibly be asked to play a role as well. Many have important obligations to contribute to addressing the brain drain problem without this entirely canceling or displacing the migrants’ responsibilities.
What Can Reasonably Be Required Of Highskill Citizens Who Wish To Depart?
What constitutes a ﬁtting response for emigrants to make? Suitably measured and crafted programs of compulsory service and taxation can be justiﬁed as a ﬁtting response to these concerns, such as short compulsory service programs (e.g., of 1–2 years) or programs of taxation that levy small taxes on departed citizens for a limited period (e.g., 5 years). Taxation might be thought somewhat easier to justify given that it appears to be less disruptive of emigrants’ plans to relocate. However, others have the view that this lets the emigrant off too lightly as it does not address the central losses developing countries must face, namely, a lack of skilled personnel able to attend to citizens’ health needs. A short period of compulsory service (such as 1 or 2 years) might be thought to constitute an entirely reasonable exchange for those who are trained at the public’s expense. This can be especially plausible when those who accept funding for courses of study sign contracts to serve the community for a short period after training has been completed. This can also be argued as a plausible condition to attach to taking up an opportunity to acquire skills on limited entry programs, even when tuition fees are not paid by the state. After all, taking up a place on limited entry courses still absorbs resources and presents costs, including opportunity costs, should the graduate fail to remain in her country of training.
Any program of compulsory service must carefully balance conﬂicting desiderata that relate to addressing losses created on departure, reciprocity for the beneﬁts received, and fairness to the migrant as well. We must take seriously her needs, rights, interests, and so forth. Asking her to delay plans for 1 year may be entirely reasonable, but lengthy periods such as 20 years may not be. The sacriﬁces we can expect people to make must be reasonable and cannot require them to abandon their life projects and plans completely. Reasonable arrangements typically also allow some ﬂexibility such as the ability to buy out of any compulsory service, for a suitably high but reasonable fee. Some physicians currently use the buy-out method in Iran.
There are a number of caveats that should attend any plausible case for compulsory service. Compulsory service can only reasonably be expected if the costs of staying are not unreasonable, for instance, those who stay would not have their basic human rights protected (Brock and Blake 2015).
Common Objections To Programs Such As Compulsory Service Or Taxation That Place Conditions On – And Therefore Appear To Restrict – The Freedom Of Migrants
Do such programs restrict freedom? One consideration that is offered in response to concerns that such programs do objectionably restrict freedom is that this objection focuses on the freedom of those who choose to leave and ignores the freedom of those left behind. Those who remain are also entitled to enjoy the freedom to live and work in their home country. Without any attempts to deal with losses created by migration, those left behind have signiﬁcantly reduced positive freedom to live decent lives in their home countries. If we take freedom seriously, we should weight everyone’s freedom equally and try to secure for all a genuine opportunity to live and work in their home countries. So on this line of argument, we need to give equal recognition to everyone’s freedom, not just the migrants’, which means taking account of the rights, freedoms, needs, and opportunities of those who remain, whose lives will be made worse off by privileging the migrant’s freedom.
Some argue that freedom of movement is a special liberty that deserves to be given extra weight. We should privilege freedom of movement because in the hierarchy of freedoms it is more important and therefore should not be restricted. Others argue that freedom of movement, when properly understood, already entails signiﬁcant restrictions. We may quarantine people for public health reasons or restrict their movement onto threatened habitats in efforts to protect them. Others’ property rights may restrict others from going where they wish. The scope and content of our freedoms constantly bumps up against others’ defensible interests, and so it is always a further question which of two weighty claims should take precedence in a particular case. Limits to freedom are often placed where they would constitute important harm to others’ interests. In the case of programs of taxation or compulsory service, we have a familiar conﬂict to weigh up and, it is argued, the harms that would result from uncompensated departure are of sufﬁcient magnitude that they should take precedence.
Those opposed to compulsory service often maintain that requiring migrants to remain in countries of origin is counterproductive as this is frequently not the best way for a migrant to help her country of origin. Does requiring presence make sense? Some cite data that suggests many who remain are unemployed and so requiring them to stay helps no one (Hidalgo 2013). At least those who leave will be employed and provide more assistance by remitting funds back to friends and family in countries of origin. One response to this concern is to emphasize that those who are required to stay by the state should be usefully deployed by that state, if the arguments for compulsory service are to hold up. So this observation does not weaken the normative case but rather shows the need for more carefully considered compulsory service programs that do make good use of their healthcare resources.
Some view compulsory service as unusually and especially coercive. However, reasonable compulsory service programs are not necessarily unusually coercive. At least 70 countries in the world deploy compulsory service programs. Mexico introduced the ﬁrst such program in 1936. And they are to be found in developing and developed countries alike, including Singapore, Malaysia, India, and South Africa. So if these programs are coercive, many countries have chosen to adopt coercive programs. However, others argue that these programs are not objectionably coercive. The levels of coercion are not dissimilar to other practices commonly thought permissible. So consider how medical residency often involves long hours of service at others’ discretion for little pay. In fact, laboring for the beneﬁt of others is a familiar part of living in a well-functioning community that has practices of redistributive taxation. Redistributive taxation involves forgoing some income for the beneﬁt of others, income typically received through labor, and it is a widely accepted feature of liberal democracies that such contributions can reasonably be required of us in playing our part to produce communities that we value and that offer appropriate assistance to vulnerable members of our community.
Brain drain is essentially a global problem that will only be effectively solved by global action with many international agents playing a part in working toward solutions. Because of its global dynamics, low-income countries may not be able to solve the complex issues inherent in brain drain unilaterally. Many suggestions about what they may permissibly do have been discussed here, including the permissibility of changing the curriculum to make local students less internationally marketable, compulsory service programs, and taxation schemes. Reforming the way in which international actors behave and the architecture of international institutions also have tremendously important roles to play. The WHO code of practice is a useful development in aiming at solutions. The 2010 WHO’s “Global Code of Practice on the International Recruitment of Health Personnel” offers valuable policy guidelines. Bilateral agreements should encourage cooperating states to discuss reimbursement options for sending countries or other ways in which both countries might gain from patterns of worker migration.
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