Key findings
The objectives of this study were: (i) to estimate the opportunity cost of emigration of Kenyan doctors to the United Kingdom (UK) and the United States of America (USA); (ii) to estimate the opportunity cost of emigration of nurses to seven OECD countries (Canada, Denmark, Finland, Ireland, Portugal, UK, USA); and (iii) to describe other losses from brain drain. The key findings were as follows:
▪ The total cost of educating a single medical doctor from primary school to university was US$ 65,997.
▪ On average, for every doctor that emigrated, a country lost about: (i) US$ 517,931, assuming a 6.65% interest rate; (ii) US$ 314,472, assuming an interest rate of 5%; and (iii) US$ 6,902,125, assuming an interest rate of 15.64%.
▪ The total cost of educating one nurse from primary level to college of health sciences was US$ 43,180.
▪ On average, for every nurse who emigrated, a country lost about: (i) US$ 338,868, assuming a 6.65% interest rate; (ii) US$ 205,750, assuming an interest rate of 5%; and (iii) US$ 4,515,869, assuming an interest rate of 15%.
▪ The application of an interest rate of 15.64% instead of 6.65% increases the economic losses resulting from emigration of a doctor and a nurse by 13-fold.
The United Nations Commission for Trade and Development (UNCTAD) has estimated that each migrating African professional represents a loss of US$ 184,000 [1]. Our study estimated economic loss incurred by African countries as a result of emigration of one doctor to be about US$ 517,931 and one nurse to be US$ 338,868. Thus, our estimated losses to Kenya as a result of emigration of a single medical doctor and a single nurse are two times and three times the UNCTAD estimate respectively. Our estimates are higher than those of UNCTAD for two reasons: (i) we take into account the investments made into production of doctors and nurses from primary school to tertiary training institutions; and (ii) we take into account the cumulative financial effects of the lost returns from investments as a result of the brain drain.
Other losses from brain drain
When health professionals emigrate, Kenya loses far more than the cost incurred by society to educate them. This is because there are several other losses that are not captured in the education-costing methodology. Some of those losses are:
Loss of health services
Health professionals (especially doctors and nurses) contribute to health promotion, disease prevention, diagnosis, treatment and rehabilitation. The ratios of doctors and nurses to the population in Kenya are very low, and, as a result, medical practitioners and nurses are usually overloaded with work [9]. Thus, the emigration of doctors and nurses (and other health professionals) exacerbates the human resource shortage within the national and district health systems and reduces their capability to perform their functions (of stewardship, health financing, resource/input creation and health service production and provision) and achieve their goals of health improvement, responsiveness to client's legitimate expectations and fairness in financial contributions.
Loss of supervisors
Practising doctors and senior nurses normally play major roles in supervising staff in peripheral facilities (e.g. health centres, dispensaries and health posts) that serve the majority of populations. Thus, when such doctors and nurses emigrate, the supervisory capability is lost (or diminished), contributing to further weakening of the capacities of such health facilities to provide quality services to patients. This compels the staff left behind to assume greater responsibilities than they had been trained for, invariably leading to a decline in the quality of health services.
Loss of mentors for health sciences trainees
Practising doctors (and senior nurses) train and counsel (advise) new employees and students doing their internship. The emigration of either cadre has negative inter-generational effect on the process of health-related human capital creation in the country.
Loss in functionality of referral systems
The hierarchical national referral system consists of tertiary hospitals (apex), provincial hospitals, district hospitals, health centres, dispensaries, health posts and community services. It permits movement of patients from the base of the national health system to the apex and vice versa. Although the movement of patients should, in principle, be initiated by health professionals, in practice, patients move themselves up and down this system. Patients bypass the cheapest health units (health centres, dispensaries and health posts) mainly due to lack of doctors and diagnostic services [10]. Those two factors create adverse incentives for patients to bypass the cost-effective health units and to seek care in more expensive hospitals. Thus, emigration of doctors contributes to inefficiency and weakening of the referral system.
Loss of role models
Children often view doctors and nurses practising in communities as examples to be imitated and emulated. Thus, external migration not only robs such children of positive role models, it also negatively affects their dreams and aspirations and hence the number of children aspiring to become health professionals.
Loss of public health researchers
Many of the specialized doctors who emigrate are often among the very few active/published researchers that the country has. Emigration of such people stifles innovation and invention in persistent local public health problems, e.g. HIV/AIDS, tuberculosis and malaria.
Loss of custodian of human rights, especially in rural areas
A recent study on the status of national health research bioethics committees in the WHO African Region found that many countries did not have functional ethical review systems that protected the dignity, integrity and safety of citizens who participated in research [11]. Authors argued that health professionals who were posted in rural areas, by virtue of being the most educated, often bore the burden of assuring that the human rights of their actual and potential clients were respected and protected in the course of their clinical work and research carried out by others.
Loss of savings (investment capital)
In Kenya, health professionals are among the relatively better-paid persons, and thus they contribute to accumulation of national savings. Those savings are eventually loaned to entrepreneurs for investment. Thus, emigration may lead to loss of such savings, except where persons who emigrate remit their savings back to the country for investment.
Loss of entrepreneurs
The health practitioners, by virtue of their education and earnings, quite often set up health-related (e.g. private clinics, hospitals, pharmacies) and non-health-related businesses (e.g. retail and wholesale shops). Thus, emigration reduces the growth of entrepreneurship in affected countries and the prospects for economic growth.
Loss of employment opportunities
Doctors and nurses usually provide job opportunities for housekeepers, gardeners and security guards at their places of residence. Thus, emigration of practising health professionals usually results in loss of employment opportunities and income for those poor workers and their families.
Loss of tax revenue to government
Given the fact that health professionals are among the relatively well-paid persons in Kenya, they are also major contributors to the country's income-tax collection. Since the incomes of emigrants are not liable to tax administration systems of Kenya, emigration leads to a net loss in tax revenues.
Disruption of families
In some instances, due to immigration restrictions, the emigrating health professionals are not allowed to take along their families. Due to spatial distance and loneliness, some of those emigrants may choose to get new marriage partners in their countries of work. This may bring psychological and economic suffering to family members left behind in Kenya.
'Internal' brain drain
The brain drain, broadly construed, not merely reduces the supply of vital health professionals in Kenya, even more seriously, it diverts the attention of those who remain from important local problems and goals [12]. These include provision of primary health care services (including health promotion and primary and secondary prevention of diseases) and promotion of problem-oriented training and research on important domestic public health issues. Such needs are often neglected as training and research get dominated by rich-country ideas as to what represents true professional excellence. Those highly educated and skilled Kenyan health professionals who do not physically migrate to developed countries 'migrate intellectually' in terms of the orientation of their activities.
Loss of an important element of the middle class
Arguably, physicians comprise an important segment in the social and economic make-up of the middle class. They are generally respected as being above corruption, they advocate for quality public schools, they provide a market for consumer goods, and they contribute to political, social and economic stability. Furthermore, they create demand for democratic institutions [13].
Alleged redeeming features of movement of health workers abroad
Some middle-income countries like the Philippines train health workers for international export. The World Health Report 2006 [7] states that: "The government of the Philippines has encouraged temporary migration by its professionals in recent years and taken measures to turn remittances into an effective tool for national development by encouraging migrants to send remittances via official channels. In 2004, the Central Bank of the Philippines reported total remittances of US$8.5 billion, representing 10% of the country's gross domestic product (GDP)" (p.101).
Unlike the case of the Philippines, where the government strategically encourages temporary emigration of health workers for remittances and for acquisition of skills and expertise, the Kenyan government does not encourage health professionals to emigrate due to the large unmet need for their services, especially in rural areas where about 80% of the population lives. The relatively meagre remittances by the Kenyan health professionals working abroad are sent directly to family members and not through official treasury channels [13]. Those resources are not available for strengthening of medical (and nursing) schools and national health systems. Furthermore, although remittances are beneficial to the emigrants' family members, they may contribute to widening the gap between the rich and poor.
It has also been argued that if health workers return home, they bring significant skills and expertise back to their home countries. There is no evidence that Kenyan health professionals working abroad ever return home after working for a few years to share the knowledge and skills acquired abroad.
The 'fiscal space' (budgetary room) [14] in low-income countries, like Kenya, has often constrained them from employing all the available human resources for health. This has often resulted in the paradoxical scenario of unemployment of some cadres of health professionals amidst the large unmet need for their services. For example, around 4,000 unemployed nurses in Kenya do not constitute a real surplus since there is a large unmet need for their services [15].
Heller [14] indicates that countries like Kenya can potentially increase their "fiscal space", for example to employ the unemployed nurses, in four ways: (i) generation of additional revenues through increased taxes or strengthened tax administration; (ii) efficiency savings or reduction in unproductive expenditures, e.g. spending on defence, foreign travel or embassy expenses; (iii) domestic and/or external borrowing, e.g. sustained and predictable external grants; and (iv) printing money to finance additional government spending, which is an undesirable option since it might fuel inflation.
Even assuming that 'fiscal space' was not an issue, that there was a real surplus of nurses, and that Kenya decided to export them to developed countries, the government should try to negotiate for reimbursement of not just the training cost of US$43,180 per nurse but the lost returns from investment of between US$205,750 and US$4,515,869 per nurse. Those resources can be used to strengthen the tertiary institutions that produce human resources for health.
Limitations of the study
Our study had some limitations:
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a)
Due to the unavailability of data, the study focused on only two categories of health professionals (i.e. doctors and nurses) even though there was anecdotal evidence of brain drain among other cadres.
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b)
The cost estimates presented in this study were only for undergraduate programmes, while many of the doctors and nurses emigrating may have had postgraduate qualifications. Thus, by not capturing the postgraduate investment, we would have underestimated the cost of training, and hence, the lost returns from investment in postgraduate training.
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c)
Due to lack of information on the total amounts of money remitted to Kenya by emigrant doctors and nurses, it was not possible to estimate the net loss of returns from investments resulting from emigrating health professionals. If the data on remittances were available, the net loss would have been equal to the total economic loss minus the total remittances.
Suggestions for further research
The following aspects are in need of further research:
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(a)
Monitor the trends of the effects of loss of health services as a result of external migration of key cadres of human resources for health, such as specialist doctors and nurses, pharmacists and lecturers of medical and nursing schools.
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(b)
Establish a database of cost of primary, secondary and tertiary education of various categories of human resources for health, and cost of alternative strategies for stemming the tide of brain drain.
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(c)
Establish a programme for systematic monitoring of international migration of different cadres of human resources for health and tracking of remittances of income.
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(d)
Application of the contingent WTP approach in the valuation of the socioeconomic loss incurred by Kenya due to brain drain of different categories of human resources for health. It has also been applied in Africa to value the benefits of insecticide-treated bednets [16, 17], community-based health insurance [18, 19] and health outcomes of interventions against schistosomiasis [20].
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(e)
Identify the determinants of health staff motivation, including their health-related quality of life [21] and retention through regression analysis.