No, British Medical Journal, the Emigration of African Doctors Did Not Cost Africa $2 Billion

Last week the respected British Medical Journal published a back-of-the-envelope calculation by Mills et al. suggesting that the emigration of physicians from Africa cost the continent billions of dollars and saved billions for the countries of destination. I share and appreciate the authors’ concern for strengthening health care systems in Africa. But the numbers they calculate are deeply flawed, and their unfortunate arithmetic should be ignored by policymakers.Mills et al. simply add up the number of African medical graduates living in other countries, multiply by the cost of those Africans’ primary, secondary, and tertiary (medical) education, and—voilà—they arrive at the “financial cost of doctors emigrating from sub-Saharan Africa.” They go on to estimate the “savings” to the destination countries as the amount that it would have cost to train those African doctors in the country of destination.It makes me sad to see such unscientific analysis in a respected scientific forum like the British Medical Journal. Here are several reasons why.First, the study assumes zero economic effects from African doctors’ remittances to Africa, deeming those effects “impossible to quantify.” This is indefensible, because those positive financial effects are at least as large as the “costs” that Mills et al. wish to measure. African doctors in the United States and Canada remit to their home countries, on average, at least double the cost of their education, as I learned when I took the trouble to survey them. This average figure includes those who send no money.No, most of that money does not go immediately and directly into state coffers. But it is a direct benefit to the African country, and an indirect benefit to its state coffers. To see this, note that the vast majority of remittances to Africa are spent on goods and services produced inside the African recipient country, re-spent by the Africans who sold them those goods and services, and so on through several cycles. The resulting “multiplier” effect means that each dollar remitted adds between 2 and 4 dollars to the economies of many of the African countries the doctors came from, with positive consequences for public finance via various taxes. These economic plus fiscal benefits are enormous—they are at least as large as the proximate fiscal effects in the arithmetic of Mills et al.—and to assume that they are zero is a serious mistake.Second, Mills et al. calculate the “savings” to countries of destination including the United States as the amount that it would have cost those countries to train each doctor. This is an incoherent concept of “savings.” Most medical education in the United States, a very large and important destination country, is privately financed. If the Nigerian-trained doctor now working in the United States had instead arrived as a child and been trained in the United States, she would most likely have paid for her medical education. This would not have imposed a “cost” on Americans, so her training abroad does not confer a “savings” on Americans. Yet Mills et al. tell us that this “savings” amounts to almost $1 billion.Third, the study includes the cost of each emigrant’s primary and secondary education in the economic “loss” caused by physician migration. This assumes that the only reason to give even first-grade education to an African child is the subsequent economic effects of that education in loco, what Mills et al. call the “return on investment.” I strongly disagree with that assumption. An important reason to give basic education to an African child—I would argue, the most important reason—is the same reason to give basic education to all children everywhere: so that those children can fully realize their potential as human beings, regardless of where that occurs. That is the “return on investment.” If you live far from your own primary school, was the full price of your primary schooling “lost” or “wasted”? Are you certain that you have reimbursed, dollar-for-dollar, the people who provided it to you? Are you certain that you should?Fourth, African-trained doctors in the United States and Canada typically departed their country of training roughly 5–7 years after graduation. (Most medical students also provide care in some form before graduation.) Does funding a person’s education confer on the funder a permanent, lifelong property right in that person’s brain, growing exponentially over decades with compound interest—as Mills et al.’s calculations assume? Requiring a few years of home service is an appropriate balance between ensuring returns on higher education investment and basic freedoms for professionals; countries including Brazil and Turkey do this. But the typical African doctor leaving Africa has already performed much more home service than that. The typical publicly funded African émigré doctor has already fulfilled any reasonable expectation of home service.Fifth, even if all this public investment were “lost” to Africa, to say that “migration” causes that loss is like saying that tires cause a car’s movement. Many other things must happen for a car to move. Likewise, many things besides migration must happen to create fiscal loss. Many countries in Africa have no system of student loans that would allow medical graduates to pay for their own educations even if they wanted to, and influential elites have little incentive to alter the system of no-fee higher education as it often results in a large transfer of public money to their own children. The current system of education finance is as much a “cause” of any fiscal losses as is graduates’ movement. Creating a financial mechanism whereby émigré doctors can pay for their inexpensive training out of later high earnings abroad would end any fiscal drain that does occur. Therefore movement itself cannot be “the cause” of losses. Migration is a convenient scapegoat when policymakers would prefer to ignore other problems, because migrants by definition have little political representation.Sixth, the same forces that push many African medical graduates to emigrate—abysmal working conditions, low wages, absent performance incentives, inadequate tools and facilities, training divorced from local public health realities—are often the more fundamental cause of the emigrants’ decisions, as a car’s motor is the more fundamental cause of tires’ movement. They are the same forces that make most publicly funded South African doctors work in that country’s private sector, in far greater numbers than those who emigrate. Why, then, focus on those who move internationally? Again, perhaps this is because migrants by definition have little political voice. Movement is a symptom, not a disease.The economic effects of international movement by African professionals are complex, as are the ethical issues that surround them. Policy must not be based on simplistic arithmetic and unjustified economic assumptions, but on a fuller economic consideration of the subject.