Really excited to see where this substack goes, but I have to start off with some disagreements! The remittances point is fine, as is return migration. But the literature on brain gain has always seemed pretty uncompelling.
The most obvious problem is that increasing the supply of skilled workers requires both increasing demand for education (which emigration possibilities do) and increasing the supply of education. The latter is _not_ a given in any country. Expanding college enrolment is _hard._ New colleges need staff, instructors, and administrators, all of which are scarce. Government colleges need to be established by a bureaucracy, private colleges need to be regulated and quality-controlled, both of which require a lot of governance capacity by the country. We can't just handwave the claim that if more people want to become doctors, more people can become doctors.
So I'm concerned that there's a site selection bias in the countries studied in this literature. People are writing papers about the countries that did manage to successfully pull off a large educational expansion, so they find that emigration boosted human capital. But for countries that can't pull it off, emigration really might be a brain drain.
How large could this site selection bias be? I pulled some data on college enrolment rates and emigration (net, not for any skill group) and compared India and the Philippines to the rest of them. (There was no data on Cabo Verde, the other country you cited.) Among the top 20 emigrant-sending developing countries, India had one of the highest increases in college enrolment (21 pp) between 1990 and 2015, while the Philippines was a bit above average (13 pp). As a specific contrasting example, Nigeria had only a 7 pp increase in college enrollment during this period. (data: https://github.com/karthiktadepalli1/emigration/blob/main/output/top20_emigrant_senders.csv, graph: https://github.com/karthiktadepalli1/emigration/blob/main/output/enrolment_growth_emigrators.png)
A similar picture emerges when comparing India and the Philippines to developing countries as a whole. India has close to the highest enrolment growth over this period, and the Philippines is still above average, while Nigeria is still below average. (https://github.com/karthiktadepalli1/emigration/blob/main/output/enrolment_distribution.png) So we should not expect Nigeria's brain gain to be anywhere close to that of India or the Philippines.
You could argue that India and the Philippines had higher growth _because_ emigration incentives increased the supply of education. But:
1. The emigration incentives studied by Khanna/Morales and Abarcar/Theoharides are not India-specific or Philippines-specific - this fact is necessary for their estimates to be causal! - so we shouldn't expect these countries to have larger increases in enrolment just from emigration incentives.
2. Even if emigration incentives have a causal effect on the supply of colleges that was for some reason higher in India and the Philippines, I would expect that effect to be small relative to other factors that make governments want to supply more colleges (domestic political projects, trying to attract foreign companies, trying to spur industrial growth). So heterogeneous effects of emigration incentives can't explain much of the difference between these two countries and other developing countries.
In general, I wish there was more nuance around the brain gain hypothesis. I would speculate it has such immediate acceptance because it resolves our conflicting commitments as cosmopolitans: we want people to be able to pursue a better life, we want high-income countries to have more open immigration policy, and we want low-income countries to grow faster. The brain gain hypothesis is alluring because it promises that we can have all of the above. But I think that relies on other things going right that absolutely don't have to go right. And I wish there was more acceptance of that nuance.
OK, first of all, I *love* that you graphed things to argue with me.
I disagree somewhat on site selection. To paraphrase someone (maybe Jason Crawford?), I don't believe in papers, I believe in literatures. Given that this is a pretty consistent empirical finding (there's also Michael Clemens' Fiji paper: https://www.files.ethz.ch/isn/92266/Chand_Clemens_Skilled_Migration-1.pdf), we would need to believe that 1) people only study places where migration is positive, or 2) studies of places where migration is strongly net negative are selectively file drawered. I'm not sure I believe either point. On the first point: the Philippines is maybe an obvious case that this would be positive, but I'm not sure I would predict ex ante that Cape Verde, Fiji or India would have positive impacts. (Especially Fiji perhaps, since there was *a lot* of migration from Fiji.)
Secondly, while it is true that most migration people believe that migration is positive, economics loves its novel findings - I do think a statistically significant finding about the negative effects of migration would find a home. (Borjas keeps getting published!)
I will admit to the bias you specify; I do want migration to be good for the sending country, because it is so obviously good for the migrant. But I don't think that the fact that I want it to be good means that the evidence that it is good is invalid.
Although I agree with your headline points, the argument doesn't consider counter arguments - the potential negatives of immigration aren't properly explored. The only one dealt with is the staff replacement issue. These are 2 potential negatives that I think deserve consideration in this debate.
1. The best people leave, people that could be innovating, inspiring, leading and starting the best businesses that could grow the country. When you skim off the top 1%, you can "replace" them by training others, but you can't replace their natural brilliant traits that could have led them to transform their countries.
2. "Japa" Syndrome and social destabilisation. The "Japa" syndrome in Nigeria and other countries can destabilise the social milleu, slow institution building and potentially reduce individual wellbeing. When everyone is wanting o leave who then is committed building the country and its institutions? Who among young people is committed to improving their own country? Also all those left behind and wanting to leave will probably feel just alittle worse about their own life. This phenomenon has already been fairly well researched by social scientists, and its effect on both institutional growth and individual wellbeing and could be a significant negative to high emigration.
Anecdotally as well talking with Nigerians its a real negative vibe, and I'm happy this phenomenon hasn't yet reached Northern Uganda here!
I think its very fair to argue that remittances and other benefits might well overcome these negatives, but these should be deeply considered and thought through rather than either being quickly dismissed or ignored like they are here, and seem to be in most pro-immigration arguments. These are easier to ignore though because of measurability bias - they are harder to measure than people and money movement. The effect of immigration are more complicated than the common simplistic framings of people-out/people-in and money-in.
Also although I generally agree with much of the replacability argument, I disagree with the Nigerian doctor example. "You might keep a few doctors from moving away, but far fewer Nigerians will want to become doctors."
In Nigeria far more people want to be doctors than can be doctors. The limiting factor isn't aspiration, its training opportunities and your grades. Every year in most countries, thousands of people want to be doctors but can't. Even if the number of doctor places increase by 5x (which would be amazing) I don't think "Aspiration" would be a limiting factor. You could make the argument (like happened in the Phillipines) that training places will increase as a result of demand, but the aspiration argument doen't make sense to me.
Also the data doesn't (as far as I can see) doesn't seem to support this conclusion that we don't need to worry about doctors leaving. The WorldBank dataset (which I don't overly trust), the doctor per person ratio in Nigeria steadily increased from 1870 until 2008 and since then has plateued. There's a high chance that immigration is a core reason for that plateau, and even if there are other causes based on this data its hard to make the argument that immigration is helping Nigeria's doctor situation. Based on this, the reactionary policy of countries like Nigeria trying to keep more of their doctors at home may or may not be bad policy, but I wouldn't call it "completely misplaced."
Also have signed up to your substack, looking forward to more :). I copy pasted this across from the EA forum because engagement seems to be here. Don't feel the need to reply to stuff you've already discussed on other threads!
Very interesting post. Side bar question on remittances: what is the intergenerational impact on remittance flows? For example, I'm an immigrant, have strong family ties and dutifully send money back home. What are the chances my 2 year old kid born in the diaspora will have similar ties and inclinations? How does one keep the remittance flows going as ties to the motherland weaken over generations?
I don't know! I imagine ties are stronger if a migrant returns home (e.g. if your son spent some portion of his life in Kenya, or if you moved back, he would be more likely to send home remittances).
I don't really know at what point remittances die - anecdotally, it seems like my second-gen friends expect to send money to their grandparents abroad (if their parents can't or couldn't) but wouldn't consider sending money to more not-directly-related relatives (cousins, aunts, etc). I would expect that their (third-gen) children probably wouldn't send anything back, but that is... not in any way a data-based conclusion.
I agree with the main point of the text. As someone from a developing country (Brazil), I feel people often worry too much about brain drain, overlooking these equilibrium effects you mentioned. That said, I'd still be concerned about friction costs. The supply of many highly skilled professionals, like specialized physicians, is pretty inelastic in the short term. If a substantial part of them suddenly migrates, it could cause a real shortage, leading to significant economic costs during the adjustment period. I think policymakers do have a role here, but it should be more about easing this transition rather than trying to stop migration outright.
I think this is the same as Peter's point below - that in the short term, you probably do have fewer doctors even if in the medium term, you have more.
I think there are a couple of things policymakers can do:
1) Allow supply to expand quickly. Open new schools and train more people! Respond proactively but *don't* try to keep everyone from leaving.
2) Incentivize return. I cite a couple of studies above that returnees are very valuable to economies. I don't necessarily mean financial incentives; it should be pleasant for people to return. Make it easy to bring their wealth back, their families (who may have mixed citizenship statuses if they've been gone a long time/married/had children); make it easy to buy property. Make their US or European professional certifications transfer easily.
I think its possible that in the medium term we might get more doctors - although it has already been 15 years in Nigeria with no increase so the evidence so far isn't great.
The Oft cited Phillipines example might end up being an outlier rather than a harbinger of things to come - their ability to accelerate their nurse training was impressive. I think in that case there were a lot of schools that can absorb more students, which was a bigger factor than new schools. Opening new medical schools and training more doctors is far far harder than for nurses, at least under current education beuracracies in SSA
Fixing the number of medical school places seems far easier than convincing doctors to stay, though! Or forcing them to stay.
Especially since Nigeria is a bit of a political basket case; I can't imagine doctors are leaving solely for the money. Rather, the underfunded health infrastructure (even relative to countries of the same income), low life expectancy, and high infant mortality make it a terrible job. You can... open more medical schools, or fix all those things so people don't want to leave. One seems far easier than the other.
You can say its a terrible job (which is a whole nother question), but everyone still wants to do it and its highly competitive to get into, so I don't think supply/demand really bears that out.
The easiest thing to do would be to bond doctors in Nigeria for 5 years. Why would this be hard, unlike other solutions you could just legislate it. Then they could committ and work for their country for a while without considering leaving before perhaps going overseas to greener pastures. I highly doubt the number of highly capable people wanting to be doctors would plummet below the capacity of medical schools. I doubt this will happen though despite some efforts to do so, because most doctors are from the richest 5% of Nigerians and their families are highly connected with the political elite - they don't want to shackle their kids.
Without a short term solution like this I think you just get the same situation of the last 15 years of routing of the system.
I definitely agree with opening more medical schools being the best solution, but disagree that its easy. Especially with all the experienced doctors leaving how on earth are you going to staff them? Producing high quality doctors (like Nigeria does) takes enormous planning, infrastructure and expertise - its probably one of the hardest professional courses to run. It will take years to set up and not even get close to the rate of doctors wanting to leave.
I would advocate for both doubling the number of medical schools (over time) and bonding doctors there for 5 years. If it seemed not enough amazing candidates were applying then maybe scrap the bonding?
"For the physicians with the intention to emigrate from Nigeria, poor remuneration (91.3%) is the commonest reported reason, followed by rising insecurity in the country (79.8%), having to do extra work without commensurate pay (61.8%) and lack of diagnostic equipment and facilities (61.8%). Physicians who are undecided about continuing practice in Nigeria are worried about the rising insecurity in the country (94.6%), uncertainty about government’s policies on health (92.9%), inadequacy of funding of the health sector (88.7%), inadequacy of remuneration (87.2%) and lack of diagnostic equipment and facilities (77.1%, Table 22)."
So yes, pay is the most common answer among those who have decided to leave. It is however *not* the most common answer among those uncertain about if they will leave.
See, I would worry a lot about a solution like that would make doctors in Nigeria (again, the vast majority of which already want to leave) less likely to want to return later in their career. As I link above, ~40% of emigrants do return within 10 years, and their experience in the labor market is highly valued (based on salaries of returnees).
I would be very concerned that limiting the options of young, talented people would make them stay for five years - and resent the country that made them do that. (My friends who have done things like https://www.mfa.gov.sg/Career/Scholarship certainly did not have incredibly positive feelings about being forced to return - and Singapore spent quite a lot more on their education than the Nigerian state subsidizes medical education.)
I could see a dissuasion of return for senior clinicians actually being worse for Nigeria than preventing relatively junior people from leaving.
I feel like you changed the ground of argument here. I replied about what would be easier to enact - which i think is a bonding policy vs. more medical schools which I think is actually very difficult to enact.
"Fixing the number of medical school places seems far easier than convincing doctors to stay, though! Or forcing them to stay"
Then you replied with problems with bonding, which is a legitimate but different discussion about which policies are easy/plausible.
I'm dubious about how this 38% figure might apply to Nigerian doctors - I think that's the total international return rate? From the article
"Within five years 33% of migrants return to their origin countries, and 38% return within ten years. As with out-migration, there is substantial heterogeneity across countries in return migration rates. On average, advanced economies such as the
United States and high-income countries in the European Union experience higher return migration rates than other countries."
I couldn't find numbers for Nigeria, but would be very surprised if there was a higher than 25% return rate over 10 years for people who migrated for work (not including education migration)
I agree that resentment will be there and that bonding like that could be a dissuasion to return of senior clinicians returning but I don't think return migration is going to be a very important consideration in policy for increasing the number Nigerian doctors over the next 10 years, first because unfortunately its going to be tiny compared to the number who leave - I'd be pretty sure there will be under 25% return migration of doctors (more likely far less). Second because I think it will be very hard to move the needle on.
I know a bunch of entrepreneurial Nigerians who have returned home to make their country better, which is super cool. Perhaps some doctors will get this sentiment at some stage as well but it seems unlikely.
Interestingly though Nigeria is doing something at least to ring them back! Its not clear what it is but an interesting one at least.
Most of this data seems to come from scenarios where there are some additional barriers erected by the country receiving migrants (for instance, the US requires nurses to have work experience before migration). Do you know if this net increase in the local number of skilled professionals would hold even if migration was very easy? I assume yes, because family ties are the main reason why people choose not to migrate rather than visa problems, but it would still be interesting to get real data on it.
That makes sense- the population of Americans who migrated from a Freely Associated State is maybe 50,000, so you wouldn't have a huge dataset, and a lot of them seem to have migrated for principally manual labor opportunities from what I can find on the Internet.
My friend Ryan Edwards has been doing the best work that I know of on migration from the Pacific (though to Australia, not the US): https://www.ryanbedwards.com/research
This makes sense, but both arguments in favour or brain drain (remittances and more people incentivised to train for some some career) do not seem to fully apply to developed countries where people still have an incentive to move abroad for better salaries. I'm thinking of Italy, where a substantial fraction (but not the majority) of young educated people moves abroad in search of better salaries. It does not seem that their remittances contribute substantially to the economy and I don't think people choose their degrees by pondering which ones would allow them to migrate more easily. There may be an effect of increased demand pulling people to study those courses, but I don't think this is sufficient to fill the need, particularly given the fact that those professions which make it easier to migrate are often the same to those for which there is already a substantial demand - offer gap.
So how should developed economies such as Italy think of brain drain?
Of course, I think that the number of people who want to emigrate from those countries is lower than that of developing economies, so this is a smaller problem to begin with. But curious to hear what you think anyway.
Thanks, that makes sense! Italy has some policies to encourage citizens to move back after a few years abroad which, given what you said, seem reasonable!
Nice piece! I agree almost entirely. My only niggle is the short term public policy challenge of filling urgent gaps in LMIC health services - as the open migration and market response tends to be a medium to long term equilibrium plan. One for your next 'stack?
Next up may be a review of Leah Boustan's Streets of Gold / a "please shut up about low skilled migrants not integrating they're integrating just fine" post, but it's now on the list!
Really excited to see where this substack goes, but I have to start off with some disagreements! The remittances point is fine, as is return migration. But the literature on brain gain has always seemed pretty uncompelling.
The most obvious problem is that increasing the supply of skilled workers requires both increasing demand for education (which emigration possibilities do) and increasing the supply of education. The latter is _not_ a given in any country. Expanding college enrolment is _hard._ New colleges need staff, instructors, and administrators, all of which are scarce. Government colleges need to be established by a bureaucracy, private colleges need to be regulated and quality-controlled, both of which require a lot of governance capacity by the country. We can't just handwave the claim that if more people want to become doctors, more people can become doctors.
So I'm concerned that there's a site selection bias in the countries studied in this literature. People are writing papers about the countries that did manage to successfully pull off a large educational expansion, so they find that emigration boosted human capital. But for countries that can't pull it off, emigration really might be a brain drain.
How large could this site selection bias be? I pulled some data on college enrolment rates and emigration (net, not for any skill group) and compared India and the Philippines to the rest of them. (There was no data on Cabo Verde, the other country you cited.) Among the top 20 emigrant-sending developing countries, India had one of the highest increases in college enrolment (21 pp) between 1990 and 2015, while the Philippines was a bit above average (13 pp). As a specific contrasting example, Nigeria had only a 7 pp increase in college enrollment during this period. (data: https://github.com/karthiktadepalli1/emigration/blob/main/output/top20_emigrant_senders.csv, graph: https://github.com/karthiktadepalli1/emigration/blob/main/output/enrolment_growth_emigrators.png)
A similar picture emerges when comparing India and the Philippines to developing countries as a whole. India has close to the highest enrolment growth over this period, and the Philippines is still above average, while Nigeria is still below average. (https://github.com/karthiktadepalli1/emigration/blob/main/output/enrolment_distribution.png) So we should not expect Nigeria's brain gain to be anywhere close to that of India or the Philippines.
You could argue that India and the Philippines had higher growth _because_ emigration incentives increased the supply of education. But:
1. The emigration incentives studied by Khanna/Morales and Abarcar/Theoharides are not India-specific or Philippines-specific - this fact is necessary for their estimates to be causal! - so we shouldn't expect these countries to have larger increases in enrolment just from emigration incentives.
2. Even if emigration incentives have a causal effect on the supply of colleges that was for some reason higher in India and the Philippines, I would expect that effect to be small relative to other factors that make governments want to supply more colleges (domestic political projects, trying to attract foreign companies, trying to spur industrial growth). So heterogeneous effects of emigration incentives can't explain much of the difference between these two countries and other developing countries.
In general, I wish there was more nuance around the brain gain hypothesis. I would speculate it has such immediate acceptance because it resolves our conflicting commitments as cosmopolitans: we want people to be able to pursue a better life, we want high-income countries to have more open immigration policy, and we want low-income countries to grow faster. The brain gain hypothesis is alluring because it promises that we can have all of the above. But I think that relies on other things going right that absolutely don't have to go right. And I wish there was more acceptance of that nuance.
OK, first of all, I *love* that you graphed things to argue with me.
I disagree somewhat on site selection. To paraphrase someone (maybe Jason Crawford?), I don't believe in papers, I believe in literatures. Given that this is a pretty consistent empirical finding (there's also Michael Clemens' Fiji paper: https://www.files.ethz.ch/isn/92266/Chand_Clemens_Skilled_Migration-1.pdf), we would need to believe that 1) people only study places where migration is positive, or 2) studies of places where migration is strongly net negative are selectively file drawered. I'm not sure I believe either point. On the first point: the Philippines is maybe an obvious case that this would be positive, but I'm not sure I would predict ex ante that Cape Verde, Fiji or India would have positive impacts. (Especially Fiji perhaps, since there was *a lot* of migration from Fiji.)
Secondly, while it is true that most migration people believe that migration is positive, economics loves its novel findings - I do think a statistically significant finding about the negative effects of migration would find a home. (Borjas keeps getting published!)
I will admit to the bias you specify; I do want migration to be good for the sending country, because it is so obviously good for the migrant. But I don't think that the fact that I want it to be good means that the evidence that it is good is invalid.
Although I agree with your headline points, the argument doesn't consider counter arguments - the potential negatives of immigration aren't properly explored. The only one dealt with is the staff replacement issue. These are 2 potential negatives that I think deserve consideration in this debate.
1. The best people leave, people that could be innovating, inspiring, leading and starting the best businesses that could grow the country. When you skim off the top 1%, you can "replace" them by training others, but you can't replace their natural brilliant traits that could have led them to transform their countries.
2. "Japa" Syndrome and social destabilisation. The "Japa" syndrome in Nigeria and other countries can destabilise the social milleu, slow institution building and potentially reduce individual wellbeing. When everyone is wanting o leave who then is committed building the country and its institutions? Who among young people is committed to improving their own country? Also all those left behind and wanting to leave will probably feel just alittle worse about their own life. This phenomenon has already been fairly well researched by social scientists, and its effect on both institutional growth and individual wellbeing and could be a significant negative to high emigration.
Anecdotally as well talking with Nigerians its a real negative vibe, and I'm happy this phenomenon hasn't yet reached Northern Uganda here!
I think its very fair to argue that remittances and other benefits might well overcome these negatives, but these should be deeply considered and thought through rather than either being quickly dismissed or ignored like they are here, and seem to be in most pro-immigration arguments. These are easier to ignore though because of measurability bias - they are harder to measure than people and money movement. The effect of immigration are more complicated than the common simplistic framings of people-out/people-in and money-in.
Also although I generally agree with much of the replacability argument, I disagree with the Nigerian doctor example. "You might keep a few doctors from moving away, but far fewer Nigerians will want to become doctors."
In Nigeria far more people want to be doctors than can be doctors. The limiting factor isn't aspiration, its training opportunities and your grades. Every year in most countries, thousands of people want to be doctors but can't. Even if the number of doctor places increase by 5x (which would be amazing) I don't think "Aspiration" would be a limiting factor. You could make the argument (like happened in the Phillipines) that training places will increase as a result of demand, but the aspiration argument doen't make sense to me.
Also the data doesn't (as far as I can see) doesn't seem to support this conclusion that we don't need to worry about doctors leaving. The WorldBank dataset (which I don't overly trust), the doctor per person ratio in Nigeria steadily increased from 1870 until 2008 and since then has plateued. There's a high chance that immigration is a core reason for that plateau, and even if there are other causes based on this data its hard to make the argument that immigration is helping Nigeria's doctor situation. Based on this, the reactionary policy of countries like Nigeria trying to keep more of their doctors at home may or may not be bad policy, but I wouldn't call it "completely misplaced."
https://data.worldbank.org/indicator/SH.MED.PHYS.ZS?end=2021&locations=NG&start=1960&view=chart
Also have signed up to your substack, looking forward to more :). I copy pasted this across from the EA forum because engagement seems to be here. Don't feel the need to reply to stuff you've already discussed on other threads!
Very interesting post. Side bar question on remittances: what is the intergenerational impact on remittance flows? For example, I'm an immigrant, have strong family ties and dutifully send money back home. What are the chances my 2 year old kid born in the diaspora will have similar ties and inclinations? How does one keep the remittance flows going as ties to the motherland weaken over generations?
I don't know! I imagine ties are stronger if a migrant returns home (e.g. if your son spent some portion of his life in Kenya, or if you moved back, he would be more likely to send home remittances).
I don't really know at what point remittances die - anecdotally, it seems like my second-gen friends expect to send money to their grandparents abroad (if their parents can't or couldn't) but wouldn't consider sending money to more not-directly-related relatives (cousins, aunts, etc). I would expect that their (third-gen) children probably wouldn't send anything back, but that is... not in any way a data-based conclusion.
I agree with the main point of the text. As someone from a developing country (Brazil), I feel people often worry too much about brain drain, overlooking these equilibrium effects you mentioned. That said, I'd still be concerned about friction costs. The supply of many highly skilled professionals, like specialized physicians, is pretty inelastic in the short term. If a substantial part of them suddenly migrates, it could cause a real shortage, leading to significant economic costs during the adjustment period. I think policymakers do have a role here, but it should be more about easing this transition rather than trying to stop migration outright.
I think this is the same as Peter's point below - that in the short term, you probably do have fewer doctors even if in the medium term, you have more.
I think there are a couple of things policymakers can do:
1) Allow supply to expand quickly. Open new schools and train more people! Respond proactively but *don't* try to keep everyone from leaving.
2) Incentivize return. I cite a couple of studies above that returnees are very valuable to economies. I don't necessarily mean financial incentives; it should be pleasant for people to return. Make it easy to bring their wealth back, their families (who may have mixed citizenship statuses if they've been gone a long time/married/had children); make it easy to buy property. Make their US or European professional certifications transfer easily.
I think its possible that in the medium term we might get more doctors - although it has already been 15 years in Nigeria with no increase so the evidence so far isn't great.
The Oft cited Phillipines example might end up being an outlier rather than a harbinger of things to come - their ability to accelerate their nurse training was impressive. I think in that case there were a lot of schools that can absorb more students, which was a bigger factor than new schools. Opening new medical schools and training more doctors is far far harder than for nurses, at least under current education beuracracies in SSA
Fixing the number of medical school places seems far easier than convincing doctors to stay, though! Or forcing them to stay.
Especially since Nigeria is a bit of a political basket case; I can't imagine doctors are leaving solely for the money. Rather, the underfunded health infrastructure (even relative to countries of the same income), low life expectancy, and high infant mortality make it a terrible job. You can... open more medical schools, or fix all those things so people don't want to leave. One seems far easier than the other.
You can say its a terrible job (which is a whole nother question), but everyone still wants to do it and its highly competitive to get into, so I don't think supply/demand really bears that out.
The easiest thing to do would be to bond doctors in Nigeria for 5 years. Why would this be hard, unlike other solutions you could just legislate it. Then they could committ and work for their country for a while without considering leaving before perhaps going overseas to greener pastures. I highly doubt the number of highly capable people wanting to be doctors would plummet below the capacity of medical schools. I doubt this will happen though despite some efforts to do so, because most doctors are from the richest 5% of Nigerians and their families are highly connected with the political elite - they don't want to shackle their kids.
Without a short term solution like this I think you just get the same situation of the last 15 years of routing of the system.
I definitely agree with opening more medical schools being the best solution, but disagree that its easy. Especially with all the experienced doctors leaving how on earth are you going to staff them? Producing high quality doctors (like Nigeria does) takes enormous planning, infrastructure and expertise - its probably one of the hardest professional courses to run. It will take years to set up and not even get close to the rate of doctors wanting to leave.
I would advocate for both doubling the number of medical schools (over time) and bonding doctors there for 5 years. If it seemed not enough amazing candidates were applying then maybe scrap the bonding?
Also, people very much do answer surveys about this: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9764293/
"For the physicians with the intention to emigrate from Nigeria, poor remuneration (91.3%) is the commonest reported reason, followed by rising insecurity in the country (79.8%), having to do extra work without commensurate pay (61.8%) and lack of diagnostic equipment and facilities (61.8%). Physicians who are undecided about continuing practice in Nigeria are worried about the rising insecurity in the country (94.6%), uncertainty about government’s policies on health (92.9%), inadequacy of funding of the health sector (88.7%), inadequacy of remuneration (87.2%) and lack of diagnostic equipment and facilities (77.1%, Table 22)."
So yes, pay is the most common answer among those who have decided to leave. It is however *not* the most common answer among those uncertain about if they will leave.
Yes I was clearly wrong about the survey - have deleted my comment above - would rather have struck through it but couldn't figure out how to do that.
And yeah at 91.3% from the 40% who want to leave, money seems the biggest thing by a stretch.
See, I would worry a lot about a solution like that would make doctors in Nigeria (again, the vast majority of which already want to leave) less likely to want to return later in their career. As I link above, ~40% of emigrants do return within 10 years, and their experience in the labor market is highly valued (based on salaries of returnees).
I would be very concerned that limiting the options of young, talented people would make them stay for five years - and resent the country that made them do that. (My friends who have done things like https://www.mfa.gov.sg/Career/Scholarship certainly did not have incredibly positive feelings about being forced to return - and Singapore spent quite a lot more on their education than the Nigerian state subsidizes medical education.)
I could see a dissuasion of return for senior clinicians actually being worse for Nigeria than preventing relatively junior people from leaving.
I feel like you changed the ground of argument here. I replied about what would be easier to enact - which i think is a bonding policy vs. more medical schools which I think is actually very difficult to enact.
"Fixing the number of medical school places seems far easier than convincing doctors to stay, though! Or forcing them to stay"
Then you replied with problems with bonding, which is a legitimate but different discussion about which policies are easy/plausible.
I'm dubious about how this 38% figure might apply to Nigerian doctors - I think that's the total international return rate? From the article
"Within five years 33% of migrants return to their origin countries, and 38% return within ten years. As with out-migration, there is substantial heterogeneity across countries in return migration rates. On average, advanced economies such as the
United States and high-income countries in the European Union experience higher return migration rates than other countries."
I couldn't find numbers for Nigeria, but would be very surprised if there was a higher than 25% return rate over 10 years for people who migrated for work (not including education migration)
I agree that resentment will be there and that bonding like that could be a dissuasion to return of senior clinicians returning but I don't think return migration is going to be a very important consideration in policy for increasing the number Nigerian doctors over the next 10 years, first because unfortunately its going to be tiny compared to the number who leave - I'd be pretty sure there will be under 25% return migration of doctors (more likely far less). Second because I think it will be very hard to move the needle on.
I know a bunch of entrepreneurial Nigerians who have returned home to make their country better, which is super cool. Perhaps some doctors will get this sentiment at some stage as well but it seems unlikely.
Interestingly though Nigeria is doing something at least to ring them back! Its not clear what it is but an interesting one at least.
"https://punchng.com/tinubu-unveils-policy-to-bring-back-12400-japa-doctors/"
Most of this data seems to come from scenarios where there are some additional barriers erected by the country receiving migrants (for instance, the US requires nurses to have work experience before migration). Do you know if this net increase in the local number of skilled professionals would hold even if migration was very easy? I assume yes, because family ties are the main reason why people choose not to migrate rather than visa problems, but it would still be interesting to get real data on it.
I'm not aware of any cases of developing country -> developed country migration where barriers are minimal!
It seems like the effects are relatively small but probably positive in developed country -> developed country migration with free movement; below I point to papers on migration from Poland (https://discovery.ucl.ac.uk/id/eprint/1468326/1/Dustmann_the_effect_of_emigration_from_poland.PDF) and Lithuania (https://econpapers.repec.org/paper/izaizadps/dp6843.htm). In both cases, people could freely move to other (richer) EU states.
Thanks! Yeah, EU expansion seems like the obvious case for this- maybe Marshallese/Palauan migration to the US would be another example?
Oh, actually, I did ask around about Freely Associated States data a few months ago! Sadly, I'm not aware of any economic work on migration from them.
That makes sense- the population of Americans who migrated from a Freely Associated State is maybe 50,000, so you wouldn't have a huge dataset, and a lot of them seem to have migrated for principally manual labor opportunities from what I can find on the Internet.
My friend Ryan Edwards has been doing the best work that I know of on migration from the Pacific (though to Australia, not the US): https://www.ryanbedwards.com/research
Thanks!
This makes sense, but both arguments in favour or brain drain (remittances and more people incentivised to train for some some career) do not seem to fully apply to developed countries where people still have an incentive to move abroad for better salaries. I'm thinking of Italy, where a substantial fraction (but not the majority) of young educated people moves abroad in search of better salaries. It does not seem that their remittances contribute substantially to the economy and I don't think people choose their degrees by pondering which ones would allow them to migrate more easily. There may be an effect of increased demand pulling people to study those courses, but I don't think this is sufficient to fill the need, particularly given the fact that those professions which make it easier to migrate are often the same to those for which there is already a substantial demand - offer gap.
So how should developed economies such as Italy think of brain drain?
Of course, I think that the number of people who want to emigrate from those countries is lower than that of developing economies, so this is a smaller problem to begin with. But curious to hear what you think anyway.
I haven't looked at brain drain much in developed countries, so the below isn't *terribly* well informed, but I would expect a relatively small effect from brain drain in developed countries. What literature I'm aware of hasn't shown deleterious effects in Poland (https://discovery.ucl.ac.uk/id/eprint/1468326/1/Dustmann_the_effect_of_emigration_from_poland.PDF) or Lithuania (https://econpapers.repec.org/paper/izaizadps/dp6843.htm). Poland and Lithuania seem reasonable comparators to Italy.
I would also suspect that return rates are higher, since the change in wages is smaller than coming from a developing country. So you might go abroad in your 20s and return in your 40s (perhaps when family childcare is relevant). Returnees seem to be valuable to improving productivity (e.g. in the former Yugoslavia: https://www.iza.org/publications/dp/12412/migration-and-post-conflict-reconstruction-the-effect-of-returning-refugees-on-export-performance-in-the-former-yugoslavia). So... I'd tentatively say that Italy shouldn't worry all that much either.
Thanks, that makes sense! Italy has some policies to encourage citizens to move back after a few years abroad which, given what you said, seem reasonable!
Nice piece! I agree almost entirely. My only niggle is the short term public policy challenge of filling urgent gaps in LMIC health services - as the open migration and market response tends to be a medium to long term equilibrium plan. One for your next 'stack?
Next up may be a review of Leah Boustan's Streets of Gold / a "please shut up about low skilled migrants not integrating they're integrating just fine" post, but it's now on the list!