Of Brain Drain and Policy Responses

Of Skilled Migration, Brain Drainsand Policy Responses*

Ronald Skeldon**

ABSTRACT

Developed countries are increasingly trying to attract skilled migrants, rarelygiving any consideration to the impact that this migration might have oncountries of origin. The debate on the ‘‘brain drain’’ is not new but it hastaken on greater urgency in the context of a globalizing economy and ageingsocieties and this article reviews the evidence over time and space. It exam-ines opposing interpretations of the impact of the skilled from countries oforigin and goes on to examine the particular case of the migration of healthprofessionals. Health workers are seen to be key to achieving basic welfareobjectives in any country and their loss may be critical to countries of origin.Hence, the movement of health professionals may be central to any under-standing of a brain drain. However, the case for a brain drain, even in thissector, is not straightforward. Specific country and place of origin of theskilled, place of training, appropriateness of training, fit of skills to needs,and the role of return and inmigration of health professionals all need to betaken into consideration. The article examines the case for a two-tieredhealth training system, one for global markets and the other for local mar-kets. Retention and return of the skilled are examined through the potentialfor outsourcing in both education and health care. The article concludes withan examination of policy approaches towards skilled migration and offerspointers towards a more balanced and integrated approach by placing theemphasis on development rather than control of migrants.

BACKGROUND

One area of policy convergence in countries in the developed worldtoday is the perceived need to attract increasing numbers of highly

* This article is part of the output of the Development Research Centre for Globalisation,

Migration and Poverty at the University of Sussex, which is funded by the Department for

International Development, London.

** Department of Geography, University of Sussex.

� 2008 The AuthorPublished by Blackwell Publishing Ltd., Journal Compilation � 2008 IOM9600 Garsington Road, Oxford OX4 2DQ, UK, International Migration Vol. 47 (4) 2009and 350 Main Street, Malden, MA 02148, USA. ISSN 0020-7985

doi:10.1111/j.1468-2435.2008.00484.x

skilled workers. This objective has been realized through regular immi-gration programmes, such as those of Canada or Australia that arebased on points to select the skills of migrants, or through the introduc-tion of non-immigration programmes specifically targeted at the highlyskilled such as the H1-B programme of the United States. In Europe,France, Germany and the United Kingdom have all recently modifiedtheir approaches to immigration by specifically opening channels for theskilled. At the same time, developed countries have sought to limit orcontrol more effectively the entry of the less skilled. Hence, immigrationpolicy in the developed world is increasingly taking on a dual approachof promoting skilled migration and limiting unskilled migration.

Despite weaknesses in the available data, the basic trends appear clear:the volume of skilled migration and its proportion as part of global popu-lation movement are increasing. According to Docquier and Marfouk(2006: 168), the proportion of the highly skilled in the migrant popula-tion 25 years of age and older living in countries of the Organisation forEconomic Co-operation and Development (OECD) increased from 29.8to 34.6 per cent between 1990 and 2000. In 2000, about 20.4 millionmigrants in OECD countries had tertiary education, up from 12 millionin 1990, and some 56 per cent of these had originated in the developingworld. While, in terms of absolute numbers, middle-income developingcountries such as India, the Philippines, Mexico and China have domi-nated the supply of highly skilled migrants, the relative impact of theexodus of smaller numbers is greater in smaller poorer countries. Fig-ures cited by the United Nations show that the proportions of the highlyeducated labour force of eight large Sub-Saharan countries that lived inOECD countries varied between 33 and 55 per cent (United Nations,2006: 60). The proportions for island countries such as Haiti, Fiji,Jamaica, and Trinidad and Tobago were above 60 per cent, with thatfor Guyana touching 83 per cent. Five countries – Haiti, Cape Verde,Samoa, Gambia and Somalia – are estimated to have lost more thanhalf of their university-educated professionals ‘‘in recent years’’ accord-ing to a further United Nations report (UNCTAD, 2007).

In seeking to attract the ‘‘best and brightest’’, developed countries rarelyconsider the likely impact that their policies might have on the countriesof origin, and the issue of the ‘‘brain drain’’ has once again come toprominence in discussions of migration and development. The assump-tion is that the loss of the skilled will prejudice the countries of origin.Initially, the discussion emerged in the 1960s in the context of the migra-tion of scientists across the Atlantic, primarily from Britain, to the

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Journal Compilation � 2008 IOM

United States but was extended to developing countries of origin, andparticularly to economies in Asia. One US senator of the time called thebrain drain a ‘‘national disgrace [that] has more than cancelled out theeffect and benefit of American foreign aid programs’’ (cited in Adams,1968: 2). More recent work on the impact of the migration of the skilledon countries of origin reflects this view of brain drain. For example,Schiff (2006: 221) argues that the early brain drain literature such as, forexample, Bhagwati (1976) was ‘‘close to the mark’’ and stresses the needfor policies to slow or stop the exodus of skilled labour. Kapur andMcHale (2005: 177) advocate a four-prong policy response, or the fourCs: the need (a) to control the outflow; (b) to introduce compensationpolicies; (c) to create more human capital in origin areas; and (d) toconnect origin countries to members of their transnational community.A United Nations agency, in 2007, has warned that the brain drain isundermining progress in the least developed countries (UNCTAD,2007).

However, as with most issues in migration and development, this pointof view has been contested. In what might be termed the ‘‘revisionistapproach’’, it has been argued that the exodus of the highly skilled fromthe developing world can actually be beneficial and can lead to a ‘‘braingain’’ for countries of origin, counter-intuitive though this viewpointmight at first appear. This argument was based on the idea that skilledmigrants leaving a country generate an increased demand for higher lev-els of education among the population at large so that many more, too,might have a chance of emigrating. However, not all would be able todo so and, at the simplest level of generalization, more people withhigher education are left in a country at the end of a period of emigra-tion than at the beginning. These ideas are perhaps best expressed in thework of Mountford (1997) and Stark (2004). In this interpretation, it isthe ‘‘possibility of migration that induces individuals in a developingcountry to acquire higher education’’ (Stark and Fan, 2007: 261). Insome cases, this clearly occurs. For example, in the Philippines, where a‘‘culture of migration’’ exists (Asis, 2006), individuals do enter certainpaths of training such as nursing specifically in order to migrate over-seas. However, in this case, this culture of migration has been evolvingfor some considerable time and is driven by the millions of Filipinosalready overseas. The government, too, actively pursues a policy oflabour export at all skill levels in the expectation that remittances willbe returned to the country. For example, in the first ten months of2005, some US$ 8.8 billion were remitted through formal channels byoverseas foreign workers and, through the 1990s, remittances accounted

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for 20.3 per cent of export earnings and 5.2 per cent of GDP (Go, 2006;Bagasao, 2005: 137). Similar cultures of migration exist for some smallisland countries in the Pacific and the Caribbean that have seen pro-nounced migration to developed countries, and it is hardly surprisingthat in these areas education is seen as a stepping stone to employmentoverseas.

However, in a large country such as India where an estimated one-fifthof the annual output of 178,000 engineering graduates leave the country(Kapur and McHale, 2005: 98), it might be stretching a point to arguethat the majority embark upon their chosen training with the thought ofemigration. Overall, India is ranked as having a low emigration rate forthe highly skilled at 4.5 per cent, even with over 1 million skilled over-seas (Docquier and Marfouk, 2006: 177). A survey of foreign doctorscoming to the United Kingdom, some 42 per cent from India, showedthat only a minority considered emigration a factor when embarkingupon their career (Kangasniemi et al., 2004). More generally, screeningof the skilled by destination countries leaves the origin society with apool of lower quality, or less-experienced skilled, even if the pool hasexpanded (Commander et al., 2004).

Hong Kong perhaps provides an interesting case, with pronounced emi-gration of the highly skilled in the late 1980s and early 1990s accompa-nied by an increasing pool of the skilled within the city itself (Skeldon,1994: 39). On the face of it, this situation appears to argue the case ofthe revisionists, that emigration drives the demand for higher levels ofeducation. However, closer examination shows that the demand for ter-tiary education came from increasing numbers admitted into secondaryschools in the early 1980s in a ‘‘dramatic expansion of secondary educa-tion’’ (Cheng, 1991: 303). The tertiary sector was similarly expanded inthe 1990s, and, although the rationale was never made entirely clear,migration does seem to have been part of the decision. The governmentwanted to produce more graduates locally to replace those going over-seas, in the way argued by the revisionists, but also expected that univer-sity places would be available locally to retain those who might gooverseas for their education (Cheng, 1996: 411). However, migration forfurther education had been a significant movement before the emigrationsurge from the then British colony that began from the mid-1980s. Inthe 1970s, for example, only 3 per cent of the age cohort could pursuehigher education in Hong Kong. In Hong Kong’s case, the demand fortertiary education had preceded the migration and the latter was a func-tion of the former and not the other way round.

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Although it can be argued that the empirical evidence to support therevisionist view is weak at best (see Lucas, 2005) or lacking (Schiff,2006), this ignores the point that evidence to provide clear support forthe negative impact of the emigration is equally weak. Hence, to attri-bute either a negative or a positive outcome on development as a resultof the emigration of the highly skilled is likely to be deceptive. Associa-tion between emigration and the increases in skilled personnel, or withdecreases in certain development variables, does not necessarily indicateany causal link. Other factors may be more important and the braindrain may indeed be a red herring, with its role relatively unimportant.Even in the late 1960s, when concerns about a brain drain were firstbeing discussed, not all views supported the movement of the skilledfrom countries of origin as negative for their development. Myint (1968)presented a ‘‘less alarmist view’’, and, in the same collection of essays,Johnson (1968: 91) went as far as to suggest that the brain drain was‘‘a trivial factor in the problem of developing the underdevelopedregions of the world’’. The results of subsequent research have shownthat, from the 1960s through to the 1990s, no brain drain effect can beobserved from UK universities (Hatton and Price, 2005: 164).

Nevertheless, and taking into consideration current concerns about thebrain drain, it may be possible that negative or positive effects can beobserved for specific sectors of the skilled, rather than for any categoryfor ‘‘the skilled’’ as a whole. The acid test may be the health sector,which is so often seen as critical to achieving the targets of several ofthe Millennium Development Goals. This article will examine the debateabout the movement of health professionals and the development ofcountries of origin: whether the loss to origin countries, or the perceived‘‘poaching’’ by developed countries, is prejudicial to the health status ofpopulations of origin. Or, on the other hand, can any case be made forthe emigration of health workers as being positive for countries oforigin?

BRAIN DRAIN AND HEALTH PERSONNEL: THE EXCEPTIONAL

CASE?

Skills in the health sector are seen as essential for the improvement ofthe basic welfare of any population, and the loss of medical personnelfrom a developing country is seen as prejudicial to the achievement ofthis primary development goal. From this point of view, the migrationof skilled health professionals is often seen as different from other types


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of skilled migration. A country might be able to bear the loss of a chem-ist or physicist, for example, but not a doctor. That is, the migration ofhealth professionals is in some way ‘‘exceptional’’ in the context of thebrain drain (Akire and Chen, 2004). Health systems in parts of thedeveloping world, and particularly in Sub-Saharan Africa, are seen to bein crisis as their doctors and nurses opt to move to greater security andhigher paid jobs in Europe, North America and Australasia. Thus, it isperhaps through an examination of the exodus of health professionalsthat the ‘‘real’’ impact of a brain drain may be most clearly seen. How-ever, as with other aspects of the brain drain discussion, the situation inthe health sector, too, is more complex and contradictory than might atfirst appear.

The one area in which there is no disagreement is the increasingdemand for health personnel in developed and ageing societies. If thisdemand cannot be met from local sources, developed countries willhave to import the required skills, perhaps to the detriment of coun-tries of origin. The import of skills in this sector does appear to begrowing apace. The proportion of foreign medical graduates practisingin the United States rose from around 18 per cent in the 1970s to 25per cent in 2000, and there could be a shortfall of 800,000 nurses by2020 (Bach, 2003: 6). Data for the United Kingdom show that, in2001 ⁄02, virtually half of the new entrants to the register of nurseswere from overseas (Buchan, 2002) although that proportion has sincedeclined by about half as entrants from local sources increased shar-ply (Buchan and McPake, 2007). Of the total stock of nurses in theUnited Kingdom in 2001, however, only one in seven was foreign-born, with one in three doctors born overseas at that time (OECD,2007: 165). In terms of the absolute numbers of skilled health work-ers, and similar to the situation with all skilled workers, most origi-nate in middle-income developing countries rather than in the poorestcountries. This situation is logical simply because the poorest coun-tries do not have the facilities to train large numbers of skilled work-ers, irrespective of sector. For example, 11 of 48 Sub-Saharan Africancountries do not have medical schools that produce graduates recog-nized by the major destination countries (cited in Clemens, 2007: 15).The World Health Organization (2005) has compiled data that showthat India is the major source of supply of foreign doctors to theUnited States and the United Kingdom, the second source for Aus-tralia and the third most important source for Canada. However, theUnited Kingdom emerges as a major source of doctors for both Aus-tralia and Canada, and South Africa is a major source for the United

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Kingdom and Canada. Thus, considerable circulation of skilled medi-cal personnel is taking place.

Language is clearly a major factor in accounting for the flows of doc-tors. Those going to Germany have been dominated by non-English-speaking origins in Russia, Iran and Europe. The Philippines and Indiahave emerged as two of the principal sources of nurses to the developedcountries in the English-speaking world. For a review of the movementof nurses at the global level, see Buchan, et al. (2003); for a specificexamination of the situation in the United Kingdom, see Buchan (2002);and for a series of articles summarizing the main issues of migrationand health workers from a fairly balanced point of view, see WHO(2004). The data used to assess the flows have to be used with some cau-tion as they usually only account for those doctors or nurses who areregistered with the official professional bodies in the respective countries.Other doctors or nurses may enter countries under different categoriesand pursue non-medical occupations.

The impact that the exodus of medical personnel might have on countriesof origin is of greatest interest. South Africa figures prominently as acountry of origin of flows of both doctors and nurses to the developedcountries of Europe, North America and Australasia. Yet, the pool of allhealth professionals except nurses in South Africa continued to expandbetween 1996 and 2001 despite the outflow, providing some support forthe revisionist point of view. Although the number of nurses in SouthAfrica was virtually stagnant over the same period and some 32,000vacancies existed in the public sector, it was also estimated that there werewithin the country another 35,000 registered nurses who were inactive orunemployed (OECD, 2004). These data suggest that migration is but onefactor in accounting for losses of personnel in the health sector and thereis a movement out of the sector but not out of the country. Given the par-lous state of the public sectors in many developing countries, the skilledwill opt for higher-paying and better-resourced positions in the privatesector. Positions in international organizations at home, in national orinternational non-governmental organizations or opportunities in businessor politics all attract the talented. Public-sector conditions throughoutmuch of Africa appear to be changing for the worse (Owusu, 2005: 172)and the employees can only survive by taking on multiple, income-gener-ating activities or opting out of the public sector altogether.

Supportive evidence exists for the loss of the skilled in science and technol-ogy, also from South Africa. During the late 1990s and the early years of


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the twenty-first century, about 2,000 highly skilled workers in science andtechnology left each year. This figure represented less than 1 per cent ofthe workforce in that category and annual losses due to mortality rangedfrom five to eight times larger than those due to emigration. The pool ofthe skilled workforce in science and technology increased from 1.6 to 2.5million between 1996 and 2002. Unemployment among highly skilledworkers, although only a fraction of that for all workers, rose from about9 to 16.5 per cent over the same period (Kahn et al., 2004). While ques-tions remain concerning the relative experience level of those who leftcompared with those who stayed, it seems clear that, for South Africa, likethe economies in East Asia from the 1970s and the United Kingdom in the1960s, the brain drain is more perceived than real.

South Africa is one of the most developed countries in Africa, and it isperhaps more important to assess the impact of a brain drain on healthservices in those countries where relatively small numbers of medicalpersonnel leave from a very limited skill base in health personnel. Thissituation applies particularly for other Sub-Saharan countries and forsmall island economies. For example, it has been estimated that thenumbers of doctors leaving Guinea-Bissau, Zimbabwe and Uganda rep-resent more than 30 per cent of the resident stock of doctors (WHO,2005: 31). Although Ghana is another of the more developed Africancountries, Ghanaian-born doctors overseas are equivalent to half of thedomestic pool. Figures of this type are at the root of the impression thatAfrican health services are in crisis and that the countries are on theverge of a public health disaster as a result of migration. Before acqui-escing to such an interpretation, we need to examine four critical areas:

) Place of training: many of the foreign-born doctors in developedcountries may have received their advanced training in developedcountries.

) Specific places of origin of the doctors: the internal distributionof health personnel needs to be taken into consideration.

) Linkages between the health sector and health: the state of thehealth sector and the state of health of populations may be moretenuously related than is often assumed.

) Inmigration of health professionals: the inmigration of doctorsfrom other countries and the return, temporary or otherwise, oftrained nationals.

Any simple association between birthplace data and medical occupationas an indicator of brain drain can be misleading as data to show the

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place of training are difficult to find. Clemens (2007: 16) clearly showsthe difficulties in attempting to do so and cites the example of the figureof 195 Egyptian-trained physicians against the number of 750 Egyptian-born physicians practising in Canada in 2001. However, information onthe numbers trained outside their country of birth is generally elusive.For skilled migrants in general, not just those in the health sector, it hasbeen estimated that 55 per cent of those from Latin America and theCaribbean employed in the United States had been trained in the UnitedStates. Over 40 per cent of those from China and India had receivedtheir college degrees in the United States (United Nations, 2006: 60).Some 68 per cent of the foreign-born scientists conducting research inthe United States in 1999 had been trained in the United States (John-son, 2003: 6). In the case of medical personnel, even if basic traininghad been undertaken in the developing world, advanced training mighthave been completed in the developed world (Khadria, 2003: 9). Themajority of the estimated 300 Ghanaian doctors in Germany had beentrained in Germany and had chosen to stay on after completing theirstudies (Nyonator and Dovlo, 2005: 231). Where a long tradition ofmedical training exists together with a large number of medical institu-tions, as in India, it seems likely that the majority of doctors will betrained at source. Nevertheless, over the two years 1996 ⁄97 and1997 ⁄98, over 1,500 Indian students left to pursue studies in medicine,pharmacy, dentistry and veterinary science (Khadria, 2003: table 5). InFrance, while large numbers of practising doctors have been trained indeveloping countries, the majority of these become naturalized and ‘‘dis-appear’’ from the foreign population, further complicating any analysis(WHO, personal communication).

It is not just place of training that is important but also the source offunding. The ready assumption is that it is the state of origin that pays.The basic cost of training of a British doctor in the mid-1960s wasaround £12,000 (about US$ 33,600 at 1965 exchange rates) that was‘‘lost’’ to Britain and ‘‘gained’’ by the United States if that persondecided to migrate across the Atlantic upon completion of his or herstudies (Last, 1969: 31). In the developing world today, the cost of train-ing may indeed be borne by the state of origin but it could also befunded through scholarships from another state or a private grant-awarding body or by the family of the student. Education is becomingincreasingly privatized, with the cost of education both at home andoverseas being covered by the family. The number of institutionstraining nurses in the Philippines more than doubled between 2003 and2006 to some 460 centres, of which some 80 per cent were private


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(Acacio, 2007). With respect to all students, not just those pursuingstudies in medicine, it has been shown that 60 per cent of foreignstudents in the United States depended upon family or personalresources for their studies, a proportion that remained stable from 1979to 2004 (Kritz, 2006: 7). Of the balance, Kritz shows an increasingproportion paid by US universities from less than 10 per cent in 1979 to25 per cent in 2004. With respect to postgraduate studies, US univer-sities funded almost 45 per cent of foreign students in that latter year.Such figures raise interesting questions about the whole issue of compen-sation and who should be reimbursed for the cost of generating skills.The state of origin may not be the main source of funds covering thehigh costs of advanced training.

The issue of accreditation looms large in the medical field, and doctorsand nurses may have to complete ‘‘bridging’’ courses that local medicalauthorities require to bring them up to acceptable destination-countrystandards. Opting to train in a medical school in a developed countryclearly obviates this particular problem and, with most doctors still com-ing largely from elite families in developing countries, this appears to bethe ideal strategy for that particular group. Doctors seem increasingly tobelong to the transnational class (Sklair, 2001), with more in commonperhaps with their colleagues overseas than with their potential patientsin poor urban or rural parts of their home countries. Even for thosebeing trained within country of origin, the majority may come from theelite. For example, a survey of those entering medical and nurse trainingin Ghana showed that virtually two-thirds of entrants had a father withtertiary-level education (Anarfi and Kwankye, forthcoming). Some 36per cent of entrants had a mother educated at this level.

The specific places of origin of health professionals in developing coun-tries are rarely to be found in the places of greatest deprivation, therural areas. These medical personnel come, hardly surprisingly, from theurban areas, as it is there that the elite are to be found. Hence, the emi-gration of doctors is unlikely to be responsible for any reduction in ser-vices in the areas of greatest need and, again, the migration as aperceived ‘‘brain drain’’ is blamed for a wider failure of policy. It is alltoo easy to use emigration as a scapegoat for a lack of development. Itis difficult to encourage medical personnel to serve in the rural areaseven in more advanced countries in Africa such as South Africa, anddeveloping countries themselves have to resort to importing doctorsfrom countries such as Cuba to fill the void. In Ghana, 46 per cent ofpublic and private sector doctors are to be found in Greater Accra, with

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a further 23 per cent in the Asante region, in which the second largestcity, Kumasi, is located (Nyonator and Dovlo, 2005: 229). These areas,with but one-third of the total population, also encompass over two-fifths of the nurses in the country. Again, doctors from Cuba help tomake up the shortfall in the rural areas, with some 184 doctors in thecountry in early 2006.

This discussion immediately raises the question of the extent to whichhighly trained medical personnel can truly make a difference in areaswhere basic facilities are lacking. In that case, should countries beopting for training systems more appropriate to the needs of the major-ity of poor rural people, in effect producing medical personnel who arenot marketable internationally but who are needed locally? Any suchapproach would have parallels with the Chinese approach to primaryhealth care in the 1960s, where non-professional health personnel, ‘‘bare-foot doctors’’, were involved in extending health care into isolated areasor where needed.

However, such radical approaches need not necessarily form the idealmodel, and countries might opt for systems of community-based train-ing of individuals to bring basic health care to places where it is mostneeded. Equally, developing countries will not wish to introduce whatmight be perceived as a ‘‘second-rate’’ system of medical training.Hence, some variant of a ‘‘two-tier’’ system of training might be consid-ered in which doctors and nurses are trained in one tier to internationalstandards and it is accepted that losses will occur, but many others aretrained in another tier to more basic levels of health care. These basiclevels are appropriate for areas of high infant and child mortality, andareas where expectation of life is low and where the patterns of morbid-ity and mortality are different from those in urban and internationalareas. Attendants are required for those suffering from HIV, ratherthan doctors with advanced medical training. Even in advanced areasand economies, paramedics and emergency medical technicians (EMTs)have, since the 1970s, provided a vital service in offering basic medicaltreatment through the emergency services and in hospitals. While nouniversal training curriculum yet exists, and paramedics and EMTs aretrained to various levels, that training is neither as long nor as expen-sive as that of a doctor. In order to make entry into the local tierattractive, provision would always have to be made to allow thosetrained to local standards to upgrade their qualifications, if desired, sothat those in the lower tier do not feel permanently ‘‘locked’’ into onesystem.


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The above discussion raises the almost sacrilegious question of the rele-vance of the advanced medical sector to the health of the populations inthe developing world. ‘‘The medical establishment has become a majorthreat to health’’ (Illich, 2002). Even if one does not wholly agree withthese words, with which the Austrian-Mexican intellectual Ivan Illichopened his scholarly exegesis of medicine, it is not difficult to acceptthat the state of health of any population does not depend on its medi-cal personnel alone. In terms of skilled workers, the agronomists whowork to increase agricultural yields to improve the nutrition that willcombat disease, the water engineers who work to supply safe drinkingwater, the sanitary engineers who build the sewerage systems, the trans-port engineers who improve communications that allow food to betaken from point of supply to where it is needed, and so on, are as criti-cal as any skilled doctor in improving the health status of a population.To relate the state of a nation’s health to the increasing emigration ofmedical professionals, or conversely, to their presence, is to take toonarrow a view of how health is delivered to a population. It is not forone moment being suggested here that a country does not need doctorsand nurses, simply that any crisis in the state of health in a country isunlikely to be the result of an exodus of skilled medical personnel.Many more professionals are at the root of development in the health ofa population and the achievement of the health-related MillenniumDevelopment Goals. Thus, in the current brain drain debate, the stateof health of a population and the state of the health system in a popula-tion are being conflated. These are not the same thing. A tendency alsoexists to draw comparisons between the health sector in developed age-ing populations with that of youthful populations at much lower levelsof development in terms of doctor or nurse to population ratios. Thesepopulations, as stressed above, have very different demands for healthservices and the need for poor, rural populations is for good basic care.

Lastly, there is the issue of the inmigration of doctors from other coun-tries and the return on a temporary or longer-term basis of trainednationals. Brief mention has already been made above to the movementof doctors from developed countries and other parts of the developingworld to many poor countries. Since 1971, Doctors Without Borders(Medecins sans Frontieres) has sent doctors, nurses and other medicaland non-medical personnel to areas where there are humanitarian emer-gencies, as well as to areas where people are judged as being excludedfrom health services. Currently, voluntary personnel are working inalmost 70 countries and each year personnel are involved in more than3,400 missions. In terms of origins in the developing world, Cuba is a

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source for ‘‘medical brigades’’, primarily to Venezuela and other coun-tries in the Caribbean and Central American region but also to Ghana,South Africa and Zimbabwe. Some 450 Cuban health professionals werein South Africa around the year 2000 (OECD, 2004: 128). These doc-tors, as emphasized above, often operate in the rural areas where localdoctors are reluctant to take up positions. The 535 Cuban medical vol-unteers in Haiti were sent to compensate for the 90 per cent of localdoctors who were estimated to be concentrated in the capital Port-au-Prince. There are also the philanthropic motives of professionals inthe diaspora. For example, in the United States, some 35,000 practitio-ners and 10,000 students are members of the American Association ofPhysicians of Indian Origin, which is a constant source of volunteers forservice back home (Barre et al., 2003: 151). Hence, a significant butindeterminate number of short-term skilled health migrants to thepoorer countries appears to exist that can bring health care to placeswhere it is most needed and compensates, at least partially, for theoutmigration of national health personnel.

The above discussion of the emigration of skilled health workers hasraised question marks over whether the health sector is in some wayexceptional and whether the migration constitutes a ‘‘real’’ brain drain.Training is carried out overseas, though to a variable degree, health per-sonnel are concentrated in the largest cities, and any exodus is unlikelyto make an impact in the areas of greatest need. The identification ofthe migration of the skilled as a critical variable in the health of a popu-lation seems to oversimplify a complex situation at best and divert atten-tion from the underlying causes of the malaise in the health sector atworst. The last critical question to be considered is whether return andthe inmigration of the skilled, in the health sector and more widely, canbe promoted and placed on a more sustained and long-term basis, andwhether it will make a difference.

OUTSOURCING AND THE HIGHLY SKILLED

A critical dimension of the migration of the skilled is their return totheir countries of origin. This return can either be of previous brains lostin the migration or of brains enhanced through training overseas in a‘‘brain gain’’. The evidence for East Asian economies was that thereturn of students, in particular, increased over time. Central to thisreturn, however, is the fact that there must be something to return to,essentially a stable environment in which the returnee can make a living.


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However, a downturn in the destination economy might also engenderreturn, as in the case of the large number of lay-offs among IT special-ists in Silicon Valley, California, in 2001 ⁄02 that may have encouragedIndian professionals to return to their own country (Khadria, 2003: 15).Once the process of return is under way, however, these migrants con-tribute to the development of their economies of origin in a number ofways. Clearly, they are bringing skills, but they can also bring capitaland entrepreneurial and political ideas. They are unlikely to be the onlykey factor in the development of their homeland, but they can neverthe-less play a significant role.

Ageing populations and declining rates of labour force growth in devel-oped economies have played a central part in shifting labour-intensiveproduction overseas but migrants, too, have been part of the process. InAsia, the key groups are perhaps the overseas Chinese, non-residentIndians and groups such as the Viet Kieu, and these immediately raiselarge the idea of the role of the diaspora, or the overseas communitiesof migrants in the development of origin economies. It is estimated thathalf of the US$ 48 billion in foreign direct investment to China in 2002came from the overseas Chinese, although the overseas Indians haveinvested proportionally much less, US$ 4 billion (data cited in Newlandand Patrick, 2004: 6). The reason given for the smaller figure for Indiansis the disinterest of the Indian government and the lack of an ‘‘investor-friendly’’ environment (Newland and Patrick, 2004: 7). In the case ofViet Nam, investment in the country during the early 1990s from theViet Kieu was initially low, only some US$ 127 million over eight years(Woods, 2002: 182), but this figure had increased dramatically to overUS$ 3 billion in 2004 alone, a reflection of changing government atti-tudes and the introduction of a more open economy.

While considerable research has been carried out on offshore processing,particularly the IT industry and the role of non-resident Indians(Khadria, 2003; Saxenian, 2006), relatively little research has been doneon services such as education and health. The current emphasis has beenon moving people to deliver services (Mattoo and Carzaniga, 2003), theintent of the General Agreement on Trades and Services (GATS) mode 4,rather than on moving services to the people that would be covered underGATS mode 2. Like labour-intensive industrial production, basic servicessuch as health can also be outsourced. Ageing populations with theirpatterns of recurrent and degenerative diseases, personnel shortages inthe health sector, rising costs of medical care and increasing waiting timesfor non-emergency surgery are all factors that might encourage travel

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overseas for treatment. If people used to socialized medicine are forced touse the private sector, costs in developing countries are much lower. Notthat there is anything particularly new about travel for health care.Mountain resorts and spa towns have long been established as healthcentres, and travel in search of a miracle cure has been part of the tradi-tions of pilgrimage. However, today, a global market in health careappears to be emerging with India, South Africa, Cuba, Costa Rica,Malaysia and Thailand all promoting medical care for patients fromoverseas. The principal market in India for the proposed treatment ofthose living overseas is likely to be its expatriate community, who cancombine non-emergency medical care with trips back home. However,regional markets are emerging, with people from the Middle East goingto South and South-East Asia for treatment, and hospitals in Bangkok,for example, serving patients from Hong Kong, Bangladesh and as faraway as Australia. What began as medical services for expanding expatri-ate populations based locally to oversee transnational economic activitiesor international development and diplomacy has evolved into supplyingregional and even global medical care.

One example of the potential of this ‘‘medical tourism’’ comes fromThailand and Bumrungrad Hospital, one of several such hospitals inBangkok (Bumrungrad, 2005). Initially founded in 1990, Bumrungradbecame ‘‘Asia’s first internationally accredited hospital’’ on 25 April2002. It is a private company listed on the Thai Stock Market thattreats 850,000 patients a year, 300,000 of whom are ‘‘international’’,from 154 countries, an unspecified proportion of whom, however, areresident in Thailand. Its turnover in 2003 was US$ 114 million.Although the majority of its 600 health professionals have mainly beentrained in Thailand, most of them have overseas training and certifica-tion, mainly in the United States, and Bumrungrad has an ‘‘American-led’’ management team. Like other overseas hospitals, it has reachedagreements with leading American and European insurance companiesto cover the costs of its medical treatment. The hospital has representa-tive offices in seven South and South-East Asian countries, plus theNetherlands in Europe. Lest such an operation be seen as divertingattention away from local health needs, the Bumrungrad Hospital Foun-dation is involved in a wide range of charitable activities to help poorThais. These range from doctors providing free services in low-incomeareas to inpatient heart treatment for children, and the foundation esti-mates that it has provided benefits to over 100,000 needy Thais since itsinception, a tiny fraction of total treatment but at least demonstratinglinkages back into the local community.


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Much of the future potential for the development of this kind of out-sourcing depends on the public confidence in developed countries inthe kinds of treatment being offered. Longer-term aftercare is a prob-lem, for example. Its future potential also presumably depends on thecontinued availability of relatively cheap international air travel, afuture that is not guaranteed given rising costs of fuel and concernsabout the environmental impact of air travel. Thus, reports that themedical treatment of overseas patients could be generating US$ 2.1billion for India by 2012 (The Financial Times, 2 July 2003) may beoptimistic. The extent to which programmes to outsource medical carecan encourage migrant national doctors to return from overseas oreven to retain local talent also remains not proven. In the 1960s,Thailand lost more than 1,500 doctors, over one-third of the numberof medical graduates produced, mainly to the United States (Wibul-polparsert, 2003: 171). The Thai government introduced policies suchas bonding medical graduates for three years, a system of recruitingmedical students in rural areas specifically for home-town placementwith financial and career inducements, and the exodus of the skilleddeclined. It is, however, almost impossible to attribute the slowdownin emigration to the measures introduced as, over the period,Thailand developed at a rapid pace and saw the emergence of manyprivate hospitals such as Bumrungrad that provide an adequate levelof living for skilled health practitioners at home. What is importantfrom a policy point of view is that regional markets are emerging forhealth care as middle-class or middle-income groups emerge in devel-oping economies.

A second and critical dimension of the export in basic services in thecontext of the evolution of middle-income groups is the outsourcing ofeducation. International schools have been a part of the movement ofthe skilled expatriate since colonial times. The expansion in the numberof British boarding schools in the United Kingdom was partially aresponse to increasing numbers of highly mobile British parents basedoverseas who wished for some stability in the education of their childrenor who had no access to quality schools locally. It was a response, too,to an increasing demand for an English education for children of elitemembers of colonial societies. English schools were also established inthe colonies themselves for the children of both expatriate but, moreparticularly, local families. With the growth in the number of middle-income groups and an acceptance that English is a key skill in a global-izing world, the number of international schools has greatly expanded,teaching to American, British or International Baccalaureate curricula.

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To serve their expatriate populations, French, Swiss-German, Japaneseand increasingly, Chinese, international schools are also to be foundaround the world, although many tend to have English-language streamsas an integral part of their programmes.

While some of these international schools are government-supported, assome are in Hong Kong, for example, most are private, with indepen-dent boards of governors setting terms and conditions, including salariesand benefits such as housing and medical care. Increasingly, however,independent schools in developed countries are establishing branchschools in the developing world in order to access the expanding market.For example, both Harrow and Shrewsbury schools of England haveestablished international schools in Bangkok that take children from theearliest years of primary through to the end of secondary. Both day stu-dents and boarders of varying duration (from four through seven nightsper week) are taken and fees are high. Whether profits are repatriated tohelp to subsidize the school in the home country remains unclear, but itwould seem ironic if the new wealthy of Asia were subsidizing the mid-dle classes of England. Teachers are recruited from English-speakingcountries and all education is in English, although in the Bangkokschools Thai language training is compulsory. The immersion of thechildren of local middle-income groups in an English-style education,where previously the systems were based on rote learning, and the vari-ous impacts that this will have on local cultures, identities and ways ofthinking are not yet known.

The expansion of schools is mirrored in the expansion of western univer-sities into the developing world and, again, particularly into Asia. Insome cases, such expansion is highly focused on specific degrees beingaccredited at existing institutions by overseas universities. In other cases,whole packages of courses developed in North America or Europe areintroduced into existing overseas universities. For example, the Univer-sity of London supports 49 external programmes in about 200 indepen-dent institutions in 45 countries that affect some 20,000 students. Thearrangements that the home institution has with the overseas institutionare highly varied but the common denominator is that the former isexpanding its market access transnationally and selling its reputationabroad. The role of alumni as returned migrants in promoting this typeof expansion remains to be investigated.

Also unknown is the impact that the expansion of internationaleducation will have on the flows of students from developing to


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developed countries. Currently, over 1.4 million foreign students arestudying in just five developed countries: the United States, theUnited Kingdom, Germany, Australia and France. If students can betrained locally, and at lower cost, will they continue to move in largenumbers to developed countries for their education? However, again,government policy on liberalizing the education sector will be criticalto the expansion but, if success can be achieved, it will provideopportunities for skilled teachers and researchers to return from dias-pora communities. What is also clear is that not all countries will beable to adopt strategies of such medical or educational outsourcing toreverse a brain drain, retain skilled staff or simply generate revenue.Such alternatives are only possible where a number of conditions canbe met:

) Where prior demand exists from an expatriate population.) Where regional and, ideally, global networks of aviation trans-

port are available.) Where, in the case of the medical outsourcing, there is a local

supply of high-quality health professionals and in the case of edu-cational outsourcing, where teachers can readily be recruited onacceptable conditions.

) Where an acceptance by government exists of the significanceof the private sector in promoting health and educational activ-ities.

The combination of such factors is likely to be found only in the largercities of middle-income developing countries: throughout South-EastAsia, coastal China, parts of India, Mexico, coastal Brazil and Argen-tina, South Africa, North African countries, and Nigeria and possiblyGhana in West Africa. China was host to almost 111,000 foreign stu-dents in 2003 ⁄04, up from 43,000 in 1998 ⁄99 (Kritz, 2006: 47). In 2002,China itself was reported to have some 500,000 students overseas, onlyabout 30 per cent of whom were expected to return (Zhang, 2003: 74).Brain circulation rather than brain drain is an integral part of thatcountry’s rapid development. The number of foreign students in SouthAfrica rose from 12,600 in 1994 to 35,000 in 2001 and over 46,000 in2003 ⁄04 (Kahn et al., 2004: 30; Kritz, 2006: 47). India, Malaysia,Singapore and Cuba appear to be expanding facilities to attract foreignstudents and it would be naıve to assume that the key centres of excel-lence in global learning in decades to come will be limited to countriesin Europe and North America.

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CONCLUSION: TOWARDS POLICY COHERENCE

This article has reviewed the evidence for a brain drain. At present,more skilled people are moving and more people are moving in orderto obtain skills and, given the current policies of developed countries,this migration of the skilled is likely to continue. The impact that thismigration has on the development of countries of origin is not soclear. Economies in East Asia that 40 years ago were considered to beat risk of a brain drain have emerged as some of the most dynamic inthe world. Nevertheless, we cannot conclude that the brain drain wasnecessarily ‘‘good’’ for those economies but simply that it was an inte-gral part of the process of development that these areas were experi-encing. The article went on to examine what many consider to be thecritical dimension of the brain drain: the exodus of health personnelfrom poorer parts of the developing world. Here again, the situationwas not clear-cut. Country of training, distribution of the skilledwithin country relative to the distribution of need, and the real natureof the demand for health skills in a poor country all complicate easyconclusions. It is unlikely that the brain drain significantly changes thecourse of development for the worse, even in the health sector. Theless alarmist viewpoints on the brain drain of some early commenta-tors actually appear to have been closer to the mark than those whosaw the migration as a ‘‘curse for developing countries’’ (Schiff, 2006:201).

Fundamentally, however, location relative to regional and global centresof growth and the size of labour markets are critical to any assessmentof the impact of the exodus of the highly skilled. Globalization is rede-fining space, increasingly marginalizing some areas but favouring others.The migration of the skilled is an integral part of this process. Just asmany rural areas within countries have been, and are being, depopu-lated by migration to the cities, so, too, certain countries will stagnateand even depopulate through the international migration of both skilledand unskilled. Small island countries are particularly vulnerable andquestion marks over the viability of states such as the Cook Islandshave already been raised (Connell, 2005). It is possible that large partsof the island world will become the ‘‘earth’s empty quarter’’ (Ward,1989) and many of the world’s mountain areas, too, may be drained oftheir demographic vitality (Skeldon, 1985). Geography matters, and notall countries have the same potential for development, not all countriesgenerate skills in equal numbers and not all countries will react to the


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emigration of the skilled in the same way. Policy responses will have tobe equally varied.

It is all too easy to see the brain drain as the explanation for, ratherthan a consequence of, a lack of development. However, even this inter-pretation is deceptive, as clearly the emigration of the skilled, initially ofstudents and later of other skilled people, is a direct consequence of theprocess of development itself. As societies develop economically, theincidence of international mobility increases: initially outwards and then,at certain key nodes in the global system, inwards, as outsourcing ofactivities from developed economies evolves. The number of these nodesincreases over time but cannot be expected to encompass the entireworld, and even such development cannot be expected to slow the move-ment of the highly skilled. The developed economies are significantsources, as well as destinations, of the highly skilled and our decentraliz-ing, globalized economy depends upon such brain circulation. The Uni-ted Kingdom, for example, is estimated to have more skilled migrantsoverseas than any other country, at 1.4 million in 2000 (Docquier andMarfouk, 2006: 175). Just under 10 per cent of the population of theUnited Kingdom is estimated to be outside the country (Sriskandarajahand Drew, 2006), a proportion not dissimilar to that of the Philippinesor Mexico, classic countries of emigration. Of course, not all of thoseoutside the United Kingdom are skilled workers or even in the labourforce. Nevertheless, the basic point remains that the emigration of theskilled also characterizes developed countries.

The whole concept of brain drain seems deceptive and even the amelio-rative ‘‘brain strain’’ (Lowell et al., 2004) a bit of a smokescreen. Mod-ern societies and their modes of production are predicated upon themobility of the skilled and implementing policies to reduce their move-ment is, in effect, to act against the process of development itself, atleast in its current globalized form. While the overall thrust of this arti-cle might appear to place it more in the revisionist than in the tradi-tional, negative brain drain camp, it also urges more cautionaryinterpretations. Rather than seeing migration as either causing anincrease in the number of skilled or leading to a deterioration of ser-vices, it argues that the search for causality needs to be found within thebroader context of development itself. Migration had become the keyfactor in a simple explanation for a lack of development. When facedwith a lack of empirical evidence to prove the case, or at least with con-flicting evidence, the interpretation was turned on its head to demon-strate the converse, that migration leads to an increase in skills.

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Examples of the association of migration with both negative and posi-tive consequences can, no doubt, be found depending upon the size ofthe area or economy being considered and its location in the global sys-tem. Smaller, marginal areas will be affected very differently by themovement of the skilled compared with larger areas closer to centres ofeconomic dynamism.

Thus, given that development essentially drives the movement of thehighly skilled, what kinds of policy options exist? Direct attempts tocontrol the movement of the skilled clearly would seem to be counter-productive. Such policies would include programmes of ethical recruit-ment that might appear to be morally impeccable to the extent that theyattempt to protect the interests of origin against those of destinationstates, but they are difficult to implement (Willetts and Martineau,2004). More importantly, attempts to control or limit the movement ofthe skilled may force them to seek informal channels of migrationthrough which they cannot practise their skills legally in destinationeconomies. A second approach that again might seem to right apparentwrongs is the issue of compensation: that the developed world recom-pense the developing world for the skills obtained, an old suggestionthat seems to be in the process of resurrection (Bhagwati, 2004: 215;Kapur and McHale, 2005). However, policies of compensation are againdifficult to implement and, given that many of the skilled from thedeveloping world are being trained in the developed world with sourcesof funding not from the state of origin, seem of doubtful validity.Finally, policies that seek to draw on the diaspora are likely to meetwith greater success where the development potential of the origin areais high and where it is combined with liberal policies towards the privatesector by origin governments. These policies to ‘‘leverage the diaspora’’will only achieve their objectives where comprehensive development poli-cies have been effective.

Nevertheless, policies do influence population mobility and those whoseprimary aims lie elsewhere may make the greater impact. For example,policies to improve the human capital in both origins and destinationsare likely to affect migration. Improvements in education are likely tosee an increase in emigration of the skilled, as suggested in this article.However, training programmes that are geared to local labour markets,as suggested for lower-level medical personnel above, in the context ofimproved remuneration and conditions, are likely to have an impact.The principal goal is to improve health delivery locally but if thatretains more health workers, then it could be seen as an effective policy


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to stem a loss of key workers. Equally, changing labour market condi-tions in destination areas can have an effect. The massive investment inpublic-sector health in the United Kingdom appears to have improvedconditions for nurses and drawn more British nurses back into bothwork and training. The absolute number and the proportion of foreignnurses being registered in the United Kingdom fell markedly between2001 ⁄02 and 2004 ⁄05 as the total number registered climbed after severalyears of steady decline (NMC, 2005; Buchan and McPake, 2007). Suchmeasures will not stop the movement; they may simply re-channel itelsewhere to new destinations or from new origins, but an improvementin health delivery in origins and destinations will surely be an indicatorof policy success.

The public debate on the brain drain will not go away as it offers a sim-ple solution to a complex problem: that a lack of development is due tothe exodus of skilled people. It is to be hoped that policymakers avoidthe temptation to seek the equally simple policy responses of control.Where policies seek to accommodate, rather than direct, existing pat-terns of skilled migration and are consistent with existing developmentpolicies, they are likely to be more effective in improving human welfare,irrespective of whether they succeed in influencing the actual patterns ofmigration themselves. It is perhaps fitting to conclude with the words ofBarre and his colleagues. ‘‘It is time to stop deploring the ‘brain drain’from Southern countries to the industrialised world, to stop regardingthe departure of researchers and engineers to Northern countries as apure loss for developing countries’’ (2003: 115).

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