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Views from the Center


This week I watched with a queasy stomach as my own research was widely reported in support of a belief that is the exact opposite of my findings. Citing a new journal article of mine, yesterday the BBC trumpeted that Africa is "being drained of doctors", and a separate story on BBC's French-language service implied that health professional emigration is directly responsible for deaths of Africans. (Radio France did a better job.)

All that my study says is that roughly 30% of sub-Saharan African-born doctors work outside Africa. For registered nurses it's closer to 15%.

I can understand why people might make the huge jump from these numbers to believing that there are deleterious staffing and health consequences for Africa. But don't do it. Let us do here what the reporters didn't have the time or interest to do: think clearly and carefully about the links between these numbers and the consequences for Africans.

First and most clearly, a Kenyan nurse working in London is an African who is pursuing a professional opportunity unavailable to her at home, thereby raising her salary by five or ten times. That is a good thing all by itself; African health workers are not "human resources" that can be "exported", they are human beings with families who choose to pursue dreams and aspirations that those of us already living in rich countries take for granted.

Even so, the health situation in Africa is dire and it's appropriate to consider the health consequences of the movement of health care professionals. But health conditions in Africa in fact depend primarily on things other than the total number of highly trained health care providers who reside within the borders of each African country. The toll of the biggest killers such as diarrhea, malaria, respiratory infections, and HIV depends primarily on efforts at prevention rather than care. And while care is also very important, the impact of care on those who need it depends on where the providers are, what they're doing, whom they're serving, what training they have, what resources they have at their disposal, and what incentives they face. The international movement of health care professionals does not determine these things.

Recently I was in Mozambique speaking to doctors, nurses, health ministry officials, and NGO workers. Training a Mozambican physician costs a vast US$80,000 in public funds, and roughly two thirds of physicians in the country live in or near the capital city of Maputo. If a physician leaves for Portugal, does this meaningfully affect the chance that a child will die of diarrhea in Niassa, a thousand miles away in the north of the country? And is the cost to the public coffers caused by the physician's departure, or by the spending of scarce public funds on expensive physician education in a country where roughly half the population does not access even the most basic modern medical care that a nurse's assistant could easily provide? The answers to these questions are not obvious, and they vary enormously from country to country. "Ethical recruitment", the mis-named practice mentioned in the BBC article of taking steps to block the hiring of African professionals, treats Africa as a homogenous mass because it applies to all countries indiscriminately.

If you think that limiting the movement of Ghanaian doctors is justified by the fact that Ghana doesn't have enough doctors, ask yourself: Does Ghana have enough entrepreneurs? Does it have enough engineers? Does it have enough wise politicians? The answer is 'no' across the board, so the logical conclusion of this sort of thinking is that we will somehow develop Ghana if we stand at the airport and prevent all Ghanaians with any kind of skill from leaving, preventing them from accessing the very high-paying jobs to which most of us living in rich countries have access by birthright alone. That is ethically problematic at a minimum, as well as ineffective -- trapping entrepreneurs in Ghana would not produce an efflorescence of investment.

In another paper I try to document, as rigorously I can with rough data, how some of the assumptions exemplified by the press pieces have little empirical support.


CGD blog posts reflect the views of the authors, drawing on prior research and experience in their areas of expertise. CGD is a nonpartisan, independent organization and does not take institutional positions.