Solving the problems of medical brain drain

There is a major shortage of human resources available to meet enormous contemporary healthcare needs. The World Health Organization estimates the global shortage to be approximately 7.2 million healthcare workers, with the shortage particularly acute in low-income countries where health needs are greatest.

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These shortages are exacerbated by brain drain, which occurs when skilled citizens leave countries of origin at relatively high rates.

Healthcare personnel often face important challenges in low-income countries, such as inadequate opportunities for professional advancement and lack of resources with which to practise effectively. Seeking to depart such situations can be perfectly understandable. And yet, there are situations in which low-income countries can reasonably expect migrants to play a role in offsetting some of the losses those left behind experience.

Like any complex phenomenon, many agents have an important role to play in addressing losses associated with brain drain. For instance, those in high-income countries should train sufficient healthcare personnel to meet needs in their countries so that they do not have to recruit excessively from low-income countries.

There are some policy measures permissibly available to those in low-income countries focusing on the question of what they may defensibly do to solve their own problems.

Tackling the brain drain adequately must involve addressing some of its root causes, namely the fact that there are vast disparities in life prospects in different countries and some are unable to provide sufficiently good opportunities. So, what needs to change so that citizens in home countries have better prospects for good lives?

Effective states have an important role to play in providing core goods and services – such as healthcare, education, clean water, infrastructure and security – all of which are essential for promoting citizens’ well-being. Skilled workers have an important role to play in helping states to be effective because they contribute enormously both directly and indirectly to the key ingredients states need to be effective.

Policy options

There are a variety of policy options that should be considered in attempting to reduce damage to those left behind. Here I will focus on two: the permissibility of compulsory service programmes and taxation arrangements that target citizens who have departed or those who wish to do so. Both of these would be helpful in providing assistance (service or revenue) directly applicable to the provision of core ingredients for good lives.

The idea with the tax programmes would be that departing citizens would be eligible for taxation for a certain period such as three years after leaving the country of origin.

Compulsory service might take various forms. Here I select just four to give a sense of the range. Some required service may be (1) part of the degree requirements or (2) may be mandated on completion of the degree. A third option is that there is a delay (such as one year) between completing the education necessary to be awarded the degree and the awarding of the degree. A fourth option is that some required service may be necessary to gain a licence to practise in that state.

Under what conditions might compulsory service or taxation for departing citizens be permissible measures for low-income countries to take? Such measures can be permissible when they conform with certain requirements.

First, only legitimate governments that exercise power responsibly – for instance, by using public funds fairly and making good faith efforts to protect human rights – may make use of these measures. Such responsible governments will typically make plans to meet citizens’ needs and invest scarce resources in trying to train sufficient skilled personnel to meet these needs.

Second, the terms and shape of these programmes cannot require unreasonable sacrifices. Neither a one-year compulsory service programme nor a taxation programme of three years' duration would fall afoul of this requirement.

Third, skilled citizens have important responsibilities to assist in remedying deprivation when a number of considerations apply. These include the following:
  • • Governments have invested scarce resources in creating human capital to provide for the needs of citizens and are entitled to a fair return on their investment. By leaving without compensating for losses, emigrants thwart governments’ attempts to discharge their duties.

  • • Citizens have received important benefits during their residence in the state of origin and failure to reciprocate for those past benefits involves taking advantage of others or free riding unfairly.

  • • Citizens leaving without compensation creates important disadvantage for others from which they deserve to be protected.
Freedom vs responsibility

Do compulsory service or taxation programmes unjustifiably restrict the freedom of migrants? This is a common concern, but I believe the details of the programmes can matter to just how much weight should be placed on this issue. In my view, asking migrants to delay plans for a short period or give up some of her future earnings is reasonable, given the severe resource constraints and the need to find policies that can balance several weighty factors.

In addition, the concern with freedom cuts many ways. Even if the freedom of migrants is slightly constrained, it is also relevant to consider the freedom of those left behind.

They are also entitled to relevant freedoms, including the real freedom to live and work in their home country. If we do not attempt to mitigate losses created by migration, those who remain have much-reduced genuine freedom.

Carefully crafted programmes of compulsory service and taxation can reasonably balance the interests, freedoms and opportunities of all who are affected in ways that show adequate respect for migrants’ aspirations and the basic interests of those left behind.

Gillian Brock is professor of philosophy at the University of Auckland in New Zealand. Her recent books on global justice topics include: Debating Brain Drain (Oxford University Press, 2015, with Michael Blake), Global Health and Global Health Ethics (Cambridge University Press, 2011), Global Justice: A cosmopolitan account (Oxford University Press, 2009). During 2013-15 she was a fellow at the Edmond J Safra Center for Ethics at Harvard University where she worked on solutions to institutional corruption.