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      The financial cost of doctors emigrating from sub-Saharan Africa: human capital analysis

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          Abstract

          Objective To estimate the lost investment of domestically educated doctors migrating from sub-Saharan African countries to Australia, Canada, the United Kingdom, and the United States.

          Design Human capital cost analysis using publicly accessible data.

          Settings Sub-Saharan African countries.

          Participants Nine sub-Saharan African countries with an HIV prevalence of 5% or greater or with more than one million people with HIV/AIDS and with at least one medical school (Ethiopia, Kenya, Malawi, Nigeria, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe), and data available on the number of doctors practising in destination countries.

          Main outcome measures The financial cost of educating a doctor (through primary, secondary, and medical school), assuming that migration occurred after graduation, using current country specific interest rates for savings converted to US dollars; cost according to the number of source country doctors currently working in the destination countries; and savings to destination countries of receiving trained doctors.

          Results In the nine source countries the estimated government subsidised cost of a doctor’s education ranged from $21 000 (£13 000; €15 000) in Uganda to $58 700 in South Africa. The overall estimated loss of returns from investment for all doctors currently working in the destination countries was $2.17bn (95% confidence interval 2.13bn to 2.21bn), with costs for each country ranging from $2.16m (1.55m to 2.78m) for Malawi to $1.41bn (1.38bn to 1.44bn) for South Africa. The ratio of the estimated compounded lost investment over gross domestic product showed that Zimbabwe and South Africa had the largest losses. The benefit to destination countries of recruiting trained doctors was largest for the United Kingdom ($2.7bn) and United States ($846m).

          Conclusions Among sub-Saharan African countries most affected by HIV/AIDS, lost investment from the emigration of doctors is considerable. Destination countries should consider investing in measurable training for source countries and strengthening of their health systems.

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          Most cited references25

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          The metrics of the physician brain drain.

          There has been substantial immigration of physicians to developed countries, much of it coming from lower-income countries. Although the recipient nations and the immigrating physicians benefit from this migration, less developed countries lose important health capabilities as a result of the loss of physicians. Data on the countries of origin, based on countries of medical education, of international medical graduates practicing in the United States, the United Kingdom, Canada, and Australia were obtained from sources in the respective countries and analyzed separately and in aggregate. With the use of World Health Organization data, I computed an emigration factor for the countries of origin of the immigrant physicians to provide a relative measure of the number of physicians lost by emigration. International medical graduates constitute between 23 and 28 percent of physicians in the United States, the United Kingdom, Canada, and Australia, and lower-income countries supply between 40 and 75 percent of these international medical graduates. India, the Philippines, and Pakistan are the leading sources of international medical graduates. The United Kingdom, Canada, and Australia draw a substantial number of physicians from South Africa, and the United States draws very heavily from the Philippines. Nine of the 20 countries with the highest emigration factors are in sub-Saharan Africa or the Caribbean. Reliance on international medical graduates in the United States, the United Kingdom, Canada, and Australia is reducing the supply of physicians in many lower-income countries. Copyright 2005 Massachusetts Medical Society.
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            Financing of global health: tracking development assistance for health from 1990 to 2007.

            The need for timely and reliable information about global health resource flows to low-income and middle-income countries is widely recognised. We aimed to provide a comprehensive assessment of development assistance for health (DAH) from 1990 to 2007. We defined DAH as all flows for health from public and private institutions whose primary purpose is to provide development assistance to low-income and middle-income countries. We used several data sources to measure the yearly volume of DAH in 2007 US$, and created an integrated project database to examine the composition of this assistance by recipient country. DAH grew from $5.6 billion in 1990 to $21.8 billion in 2007. The proportion of DAH channelled via UN agencies and development banks decreased from 1990 to 2007, whereas the Global Fund to Fight AIDS, Tuberculosis and Malaria, the Global Alliance for Vaccines and Immunization (GAVI), and non-governmental organisations became the conduit for an increasing share of DAH. DAH has risen sharply since 2002 because of increases in public funding, especially from the USA, and on the private side, from increased philanthropic donations and in-kind contributions from corporate donors. Of the $13.8 [corrected] billion DAH in 2007 for which project-level information was available, $4.9 [corrected] billion was for HIV/AIDS, compared with $0.6 [corrected] billion for tuberculosis, $0.7 [corrected] billion for malaria, and $0.9 billion for health-sector support. Total DAH received by low-income and middle-income countries was positively correlated with burden of disease, whereas per head DAH was negatively correlated with per head gross domestic product. This study documents the substantial rise of resources for global health in recent years. Although the rise in DAH has resulted in increased funds for HIV/AIDS, other areas of global health have also expanded. The influx of funds has been accompanied by major changes in the institutional landscape of global health, with global health initiatives such as the Global Fund and GAVI having a central role in mobilising and channelling global health funds. Bill & Melinda Gates Foundation.
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              Medical schools in sub-Saharan Africa.

              Small numbers of graduates from few medical schools, and emigration of graduates to other countries, contribute to low physician presence in sub-Saharan Africa. The Sub-Saharan African Medical School Study examined the challenges, innovations, and emerging trends in medical education in the region. We identified 168 medical schools; of the 146 surveyed, 105 (72%) responded. Findings from the study showed that countries are prioritising medical education scale-up as part of health-system strengthening, and we identified many innovations in premedical preparation, team-based education, and creative use of scarce research support. The study also drew attention to ubiquitous faculty shortages in basic and clinical sciences, weak physical infrastructure, and little use of external accreditation. Patterns recorded include the growth of private medical schools, community-based education, and international partnerships, and the benefit of research for faculty development. Ten recommendations provide guidance for efforts to strengthen medical education in sub-Saharan Africa. Copyright © 2011 Elsevier Ltd. All rights reserved.
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                Author and article information

                Contributors
                Role: chair of global health
                Role: statistician
                Role: assistant professor of global health
                Role: health economist
                Role: professor of medicine, and director
                Role: research associate
                Role: research assistant
                Role: research scientist
                Role: professor
                Role: deputy dean, education
                Role: professor of health sciences
                Role: research associate
                Journal
                BMJ
                bmj
                BMJ : British Medical Journal
                BMJ Publishing Group Ltd.
                0959-8138
                1468-5833
                2011
                2011
                24 November 2011
                : 343
                : d7031
                Affiliations
                [1 ]Faculty of Health Sciences, University of Ottawa, Ottawa, Canada K1N6X1
                [2 ]Centre for Evaluation and Clinical Epidemiology, Vancouver, Canada
                [3 ]Department of Global Health, School of Public Health, University of Washington, Seattle, USA
                [4 ]School of Population and Public Health, University of British Columbia, Vancouver, Canada
                [5 ]Centre for Infectious Diseases, Faculty of Health Sciences, University of Stellenbosch, Cape Town, South Africa
                [6 ]British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada
                [7 ]Office of the Dean, School of Medicine, Makerere University, Kampala, Uganda
                [8 ]Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
                [9 ] Centre for Infectious Disease Epidemiology and Research, University of Cape Town, South Africa
                Author notes
                Correspondence to: E J Mills Edward.mills@ 123456uottawa.ca
                Article
                mile874818
                10.1136/bmj.d7031
                3223532
                22117056
                366ea816-3e42-418d-8e6a-2890898820b4
                © Mills et al 2011

                This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/2.0/ and http://creativecommons.org/licenses/by-nc/2.0/legalcode.

                History
                : 23 September 2011
                Categories
                Research
                Infectious Diseases
                Immunology (Including Allergy)
                Sexual Health

                Medicine
                Medicine

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