1/ Why focus on international migration of doctors? How was the study conducted and which database did you use?

The international migration of skilled persons has been the subject of intense debate around the "brain drain" and their consequences for the origin countries as for the receiving countries. The mobility of African doctors, in particular, is often cited as an example of a very harmful migration for the health systems of the sending countries; a commonly held belief is that "there are more doctors from Malawi in the city of Manchester than in Malawi." Although the consequences in terms of public health of these migrations are no longer ignored, few studies have analyzed the subject in a global manner. One of the reasons frequently evoked is the lack of statistical data on the number of doctors trained abroad and practicing medicine in the major host countries. I have tried to fill this absence through the development, as part of a PhD thesis defended in 2011, of a new and updated database on migration of doctors over the period 1991-2004, based primarily on medical associations records. This database includes a total of 410 664 doctors in 18 host countries, including France, for the most part of the Organization for Economic Cooperation and Development (OECD). This work made it possible to draw up an overview of the migration flows of doctors throughout the world, to study its impacts and economic policy implications.

2/ Could you give an overview of these international migrations ? From where do doctors emigrate and towards which countries? In what proportions?

Not surprisingly, Asian countries send the highest number of doctors overseas: India leads with 71 290 physicians outside its borders in 2004, followed by the Philippines (about 20 000), Canada and the UK (18 635 and 17 759). Both countries are experiencing strong mobility of their doctors because of their language - English - and their proximity to the United States and Canada. France is only in 25th position with 4 311 doctors.
To focus only on the number of doctors emigrating may suggest that these countries suffer from this emigration. However, the study of migration rates - number of emigrating doctors matched with the number trained in the country of origin - reveals a new distribution where two regions stand out: the small Caribbean and Pacific islands and Subsaharan Africa. By comparing emigration rates with the density of doctors in origin countries, we found that Subsaharan Africa had an average emigration rate of 19% in 2004 but that it also had the lowest density of doctors in the world. In 2004, the emigration rate for doctors in France was 2%, which is relatively low.
Concerning the choice of destination, 60% of foreign-trained doctors were located in the United States in 2004, the country receiving the highest number of doctors in the world. In second place is the United Kingdom with 20% of foreign-trained doctors. Alone, these two countries receive 80% of foreign-trained doctors in the world. Australia, Canada and Germany each receive 3% and Belgium 2%. France receives a little over 1% of foreign-trained doctor.

3/ What is the impact of these migrations on the countries of origin, both economically and on health indicators?

This strong emigration of doctors from developing countries to developed countries could be considered deleterious for the low income countries of departure where a decrease in the quality and quantity of health care delivered to the population remaining in the home country is expected. However, the results show that the emigration of doctors does not have a direct impact on infant mortality or vaccination rates. This result is explained by the low number of doctors that emigrate each year confirming the fact that emigration alone does not account for the low density of doctors in developing countries. The results show nevertheless that the density of doctors in the country of departure plays a significant role in the improvement of infant health outcomes. In the precise case of highly vulnerable populations such as children, other health professionals (nurses, midwives), preventive care and sanitary environment (availability of drinking water) play a leading role.
In this debate on the "brain drain", some authors have suggested that emigration could be beneficial "brain gain" particularly by acting as an incentive to education for the populations remaining in the home country. In the case of doctors, the results of our study show that emigration, as an incentive for future generations to become doctors, has a positive and significant effect but of weak magnitude. In other terms, the number of doctors that migrate is never totally compensated for by the number of persons incited to become doctors, which would explain in part the lack of human resources in health experienced by some countries.
Faced with this situation, Governments have often pointed out doctors' low salaries in the countries of departure. However, although financial incentives will always remain an essential tool in keeping medical personnel motivated and productive, among the factors that appear to reduce the emigration of doctors include life-long professional training policies, career enhancement and professional advancement policies, and improved working conditions. All these non-financial measures play a significant role in the decision to emigrate.

Interview by Anne Evans

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