Economics of International Graduates

There are many impacts of international graduates. Certainly the loss of any person with professional training represents a great loss for a state or nation. However there are other considerations. More recently there has been media coverage regarding this loss. The United States tends to be the nation that attracts the most numbers of doctors as well as the most attention for this tendency.

Although my own bias is against the "theft" of physicians from other states or nations (see my essay at Perennials vs Annuals), there are some other things to consider:

Points to Ponder

• Doctors born in other countries supply most of the rural health care in some nations such as Canada.
• Doctors from other countries earn much greater income and often send this income back to home countries. It is possible that many send back more cash than they could generate in their home nation. One visiting physician to the Philippines noted that the government exported 80% of their physicians and tolerated this, knowing of the significant resources that were returned to this nation by graduates locating in other nations.
• Even though the article below notes that there are 21,000 Nigerian doctors that have relocated to the US, these 21,000 are not all practicing physicians in the United States. The article does not comment on the lack of support for physicians in many African nations, especially in underserved areas.
• The US has significant numbers of various population groups or cultures that have no current supply of physicians that can serve them or that cannot serve them as well as graduates from other countries that speak the language and understand the culture.
• Many US businesses and health care institutions hire international workforce. This tends to help supply labor that is often in short supply or that is needed in shortage areas, but such hiring practices also keep various wages low for them and for similarly skilled US health profession graduates. If you have not visited a nursing home lately you might be surprised how many nurses there are from foreign nations. 
• Each international medical graduate that goes on to a specialty or area of adequate or oversupply adds tremendously to the US annual cost of health care. Although such graduates may have served 2 or more years in an underserved area in order to remain in the US, they might not have actually delivered as much care as expected, given barriers in facilities, language, and culture.
• Doctors who are likely to leave other nations may also not be the ones likely to serve underserved areas in the nation of their birth. I broached this topic with a health minister from an African nation and there was little awareness of this concept. There are only a handful of nations in the world that are aware of the need to recruit and prepare students from rural areas in order to have a decent chance of returning these graduates to rural areas to practice. This may be because the basic education needed to prepare a physician for medical school is distributed even more poorly than the nation's health professionals.  

Is there any nation that has made a significant effort to grow, graduate, and locate more rural doctors?

Among the nations only Australia stands out as having made the changes needed to get doctors to rural areas. They have increased the numbers from rural areas from 10% in 1989 to 17% in 1997 to 25% in 2000. This is very close to the 28.7% of the population in Australia that resides in rural areas.

In the United States the opposite trend can be seen, with rural background students declining from 27% to 16% over much the same time period, 1991 to 1999 (see graph at Admissions Package). It is interesting that the numbers from rural areas taking the MCAT test have not changed, meaning lower acceptance of candidates from rural areas. Without specialized admissions from such as Duluth and Mercer and Nebraska and others, the situation would be even worse.  Rosenblatt noted the concentration of rural physician graduates from just a few medical schools (25% from 12). Not surprisingly these schools also admit more rural background students.  

Few medical schools seem to be willing to take a chance on a more diverse group of students that would be more likely to meet the needs of rural areas. Wheat noted that students from less prestigious colleges were more likely to meet these needs, but at the risk of twice the failure rate during medical school (10.6 vs 5.3%) Small Colleges and Admissions.

Boom Cycles Vs Bust Cycles

It is very difficult to separate the job and growth factors that seem to benefit some areas while  instability, declining population, and declining education situations seem to plague other regions or states or countries. As declines begin, this has impact on resources such as workforce. With further declines comes loss of services, professionals, and population. Leadership is thrust upon a smaller and older group of individuals each year. It may be difficult to recover from such cycles.

Some states have depended upon in-migration of various professionals for many years. Despite many decades of consistent growth, it only took a few years of recession in the state of Texas to expose a significant state dependence on other states for teachers and nurses. In more prosperous times, such professionals tended to move to the state with their spouses.

Some states and nations never learn. States such as Colorado and Texas take a significant portion of teacher graduates from Nebraska every year. Poor teacher pay in Nebraska is a significant reason. Rural states have had significant problems with "brain drain" as well as challenges in rural education systems and declining population in some rural areas.

Here is the article that stimulated this reflection:

Rich Countries deplete Africa's medical resources

Conservative estimates by Wilma Meeus and David Sanders at the University of the Western Cape’s School of Public Health show that the United States has saved at least U$3,86-million(R30,9 million) in training fees by employing doctors from Nigeria which has lost 21 000 doctors to the superpower.

Nigeria in turn incurred a loss of U$420 million (R3,4 million) while Zimbabwe conservatively lost U$16,8 million (R134,4 million) through the loss of 840 doctors. According to the United Nations, 31 of 53 African countries have less than 32 doctors per 100 000 people with 17 of these countries having less than 10 doctors per 100 000 people.

In 41 countries there are less than 135 nurses per 100 000 people with 17 countries having less than 50 nurses per 100 000 people.

Meeus said researchers had found that Africa was set to become a major source of migrants during the 21st century and that 33 800 people migrated annually from Africa since the beginning of the 1990s, of whom about 20 000 to 23 000 are highly skilled.

She pointed out that the available data was incomplete and that it was not possible to establish over what time period the migration occurred.

A United Nations document published in 2000 it stated: "It can be extrapolated that between 1985 and 1990, on the 60 000 professionals who emigrated, the continent lost U$1,2 billion (R9,6 billion). This represents the reverse of what development aid tries to achieve through transfer of technology and human resources."

The document warned that this development paradox, combined with the inability of the African countries in building, retaining and utilising indigenous capacities critical to Africa’s growth and development would deprive Africa of its vital development resources and make it more heavily dependent on foreign expertise.

In the 1970s, the US government calculated that it gained U$20 000 (R160 000) for every skilled worker from a developing country.

The United Nations Conference on Trade and Development (UNCTAD) estimates that for each professional aged between 25 and 35 years, U$184 000 (R1,5 million) is saved in training costs by developed countries.

Meeus said that the 27 richest developed countries have a workforce of about three million professional educated in developing countries.

Using the conservative figure of U$20 000 (R160 000) per person educated outside these 27 countries, the transfer of wealth from developing to developed countries is about U$60 billion (R480 billion).

The savings to these rich countries is a staggering U$552 billion (R4 416 billion) if the UNCTAD figure of U$184 000 (R1,5 million) is used.

The United Nations also found that Africa spent an estimated 35% of overseas donor assistance annually, about U$4 billion (R32 billion), on salaries of 100 000 foreign experts (all sectors, not only health) to replace lost capacity, to build capacity and/or provide technical assistance.(Source: Anso Thom, Health-e, 04-04-2003)
The complete story can be read at http://www.health-e.org.za/view.php3?id=20030411

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