Brain drain from developing countries: how can brain drain be converted into wisdom gain?

J R Soc Med 2005;98:487-491
© 2005 Royal Society of Medicine


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J R Soc Med 2005;98:487-491
© 2005 The Royal Society of Medicine


Sunita Dodani
Ronald E LaPorte

Department of Epidemiology, Graduate School of Public Health, University
of Pittsburg, 3512 Fifth Avenue, Room 313, Pittsburgh, PA 15101, USA

Correspondence to: Sunita Dodani MD, FCPS, MSE-mail:


Brain drain is defined as the migration of health personnel in search of
the better standard of living and quality of life, higher salaries, access to
advanced technology and more stable political conditions in different places
worldwide. This migration of health professionals for better opportunities,
both within countries and across international borders, is of growing concern
worldwide because of its impact on health systems in developing countries. Why
do talented people leave their countries and go abroad? What are the
consequences of such migrations especially on the educational sector? What
policies can be adopted to stem such movements from developing countries to
developed countries?

This article seeks to raise questions, identify key issues and provide
solutions which would enable immigrant health professionals to share their
knowledge, skills and innovative capacities and thereby enhancing the economic
development of their countries.


Brain drain is the migration of skilled human resources for trade,
education, etc.1
Trained health professionals are needed in every part of the world. However,
better standards of living and quality of life, higher salaries, access to
advanced technology and more stable political conditions in the developed
countries attract talent from less developed areas. The majority of migration
is from developing to developed countries. This is of growing concern
worldwide because of its impact on the health systems in developing countries.
These countries have invested in the education and training of young health
professionals. This translates into a loss of considerable resources when
these people migrate, with the direct benefit accruing to the recipient states
who have not forked out the cost of educating them. The intellectuals of any
country are some of the most expensive resources because of their training in
terms of material cost and time, and most importantly, because of lost

In 2000 almost 175 million people, or 2.9% of the world’s population,
were living outside their country of birth for more than a year. Of these,
about 65 million were economically
active.2 This form
of migration has in the past involved many health
nurses and physicians have sought employment abroad for many reasons including
high unemployment in their home country.

International migration first emerged as a major public health concern in
the 1940s when many European professionals emigrated to the UK and
USA.4 In the 1970s,
the World Health Organization (WHO) published a detailed 40-country study on
the magnitude and flow of the health
According to this report, close to 90% of all migrating physicians, were
moving to just five countries: Australia, Canada, Germany, UK and

In 1972, about 6% of the world’s physicians (140 000) were located
outside their countries of origin. Over three-quarters were found in only
three countries: in order of magnitude, the USA, UK and
Canada.6 The main
donor countries reflected colonial and linguistic ties, with a dominance of
Asian countries: India, Pakistan and Sri Lanka. By linking the number of
physicians per 10 000 population to gross domestic product (GDP) per
, the countries that produced more physicians than they had the
capacity to absorb were
identified7 as
Egypt, India, Pakistan, Philippines and South Korea. However, the lack of
reliable data and the difficulties of defining whether a migrant is
‘permanent’or ‘temporary’ still exist.

One may claim that this migration from developing countries is both useful
and unavoidable. There are definite advantages—enabling the migrant to
spend time in other countries—but at the same time, the very low
emigration rate of professionals from USA or UK may be as disturbing
a sign as the high rates of immigration to these countries.

Young, well-educated, healthy individuals are most likely to migrate,
especially in pursuit of higher education and economic
The distinction between ‘push’ and ‘pull’ factors has
been recognized.10
Continuing disparities in working conditions between richer and poorer
countries offer a greater ‘pull’ towards the more developed
countries. The role of governments and recruitment agencies in systematically
encouraging the migration of health professionals increases the
pull.10 Migrant
health professionals are faced with a combination of economic, social and
psychological factors, and family
choices11, and
reflect the ‘push–pull’ nature of the choices underpinning
these ‘journeys of hope’. De-motivating working conditions,
coupled with low salaries, are set against the likelihood of prosperity for
themselves and their families, work in well-equipped hospitals, and the
opportunity for professional

In many cases, the country is not only losing its investment in the
education of health professionals, but also the contribution of these workers
to health care. For example, healthcare expenditure in India is 3% of GDP
compared to 13% of GDP in the USA and the ratio of doctor to patients in India
is 1:2083 compared to the USA where the ratio is
1:500.13 Moreover,
in many developing countries healthcare systems are suffering from years of
underinvestment, which, for health professionals, has resulted in low wages,
poor working conditions, a lack of leadership and very few

Employers in receiving countries take a different position; they have their
own shortages of skilled people in specific fields and can drain a developing
country of expertise by providing job
Kupfer et al. provided the strategies to discourage migration to the
USA, a major recipient
country.16 However,
keeping the social, political and economic conditions in the developing
countries in mind, can we stop the brain drain?Probably not!

Higher education is one of the principal conduits of permanent
emigration.17 The
majority of doctors acquire specialized and postgraduate professional
qualifications in the host country. Half of the foreign-born graduate students
in France, UK and USA remain there after completing their
studies.18 Among
the doctoral graduates in science and engineering in the USA in 1995, 79% of
those from India and 88% from China remained in the
USA.19 The recent
study on brain drain from 24 major countries published by the World
Bank20 also
presented data on South Asian immigration to the USA
(Table 1). Migration to OECD
(Organization for Economic Cooperation and Development) countries is also
shown in Table 2. Yet more data
showing the momentum and demand for skilled people by high tech and research
and development (R&D) industries illustrating accelerated flows of highly
skilled workers to OECD countries are shown in
Figure 1.

View this table:
[in this window]
[in a new window]
Table 1. Number of South Asian immigrants (age 25 and older) to the USA by level
of educational attainment, 2000

View this table:
[in this window]
[in a new window]
Table 2. Stock of foreign students in OECD countries, 1998 (obtained from OECD

View larger version (28K):
[in this window]
[in a new window]
Figure 1. Employment of scientists and engineers with doctoral degrees in academia
in the USA, 1973–1999.
(Adopted from National Science Board.
Science and engineering indicators, 2002



These statistics suggest that if developing countries provided world-class
education and training opportunities, as well as opportunities for career
advancement and employment, the migratory flow could be
reduced.21 However,
in reality, this may not make much difference. On the plus side, foreign-born
graduates acquire expensive skills which are not available within their
countries. On the negative side, these skills and knowledge never migrate back
to their own countries.


Besides the pull–push factors described earlier, some researchers
from developing countries cite other reasons for not returning after training
which include: lack of research funding; poor facilities; limited career
structures; poor intellectual stimulation; threats of violence; and lack of
good education for children in their home
Incentives for migrants to return to developing countries have been
insufficient to override the limitations at home—both real and
perceived—and the attraction of opportunities found abroad. Many of
these countries have made significant investments in infrastructure and
education but have not achieved the scientific development, technological and
innovative capability either to retain or to recover the human capital that
they have generated. Is there a solution to this problem? This raises the
question of whether one can justify losing human capital or whether one should
make the additional investment in science and technology and bring about the
innovations that will stop the loss and convert itinto wealth generation.


Developing countries, especially South Asia, are now the main source of
healthcare migration to developed countries. This trend has led to concerns
that the outflow of healthcare professionals is adversely affecting the
healthcare system in developing countries and, hence, the health of the
population. As a result, decision-makers in source countries are searching for
policy options to slow down and even reverse the outflow of healthcare
professionals. Is it possible to do so? Maybe not, bearing in mind the current
political and economic situations of the source countries and globalization.
The increasing demand for health care in the higher income countries is
fuelled to a large extent by demographic trends, e.g. the ageing of the

The opening up of international borders for goods and labour, a key
strategy in the current liberal global economy, is accompanied by a linguistic
shift from ‘human capital flight’ and ‘brain drain’ to
‘professional mobility’ or ‘brain
Solutions should therefore be based on this wider perspective, interrelating
health workforce imbalances between, but also within developing and developed

At current levels, wage differentials between source and destination
country are so large that small increases in healthcare wages in source
countries are unlikely to affect significantly the supply of healthcare
migrants. According to the results of a study in Pakistan, a small proportion
of people funded for a doctorate face on return major nonfinancial
disincentives for good
performance.23 Thus
the financial component of such flows is only part of the picture and in some
cases not the major push or pull factor. Moreover, there is a need to review
the social, political, and economic reasons behind the exodus, and to provide
security and opportunities for further development locally. Lowering of
standards should not be accepted; instead local conditions should be reviewed
and rectified.


It is time to understand and accept that health professionals’
mobility is part of life in the 21st century. Countries need to recognize that
they compete with the best institutions in the world for quality manpower. It
is time to bury the archaic concept of brain drain and turn to assessing the
performance of health professionals and systems, wherever they are in the
world. The turn of the 21st century has not only brought technology, but also
modes by which scientists around the world can be connected in no time. In
this globalized world the physical location of a person may or may not have
any relation to the ability to make an impact on human health. Health
professionals in the developed world may have most of their work portfolios in
the developing world. Easy communication, quick travel, and greater
collaborations between developed and developing countries are increasingly
more common and we need to develop ways in which foreign professionals can
contribute to their countries of origin.

Remittances from expatriates living abroad constitute a significant
proportion of foreign revenue for many developing
countries.24 In
Bangladesh for example US$ 2 billion is received from citizens who have
emigrated overseas, and these remittances are the second largest source of
foreign revenue.25
The transfer and management of remittance revenues are potentially exploitable
factors in plumbing the brain drain. Formalizing the transfer of remittances
might permit the generation of revenues that could be invested nationally in
the social and economic development of the developing home country. However,
the magnitude and economic importance of remittances, economic development and
growth, and ultimately social equity, depend on the endogenous capacity of
each nation’s human resources. If only a small percentage of the
multimillion dollar sums sent home by emigrants could be invested in research
and development, might not opportunities for highly skilled and educated
nationals improve at home? And would this not in turn spur economic
development? Maybe to some extent—but without resources and skills, this
may not have a huge impact on healthand disease prevention.

It has been estimated that foreign scientists from developing countries who
are involved in research and development produce 4.5 more publications and 10
times more patents than their counterparts at
home.26 Why is
there such a vast difference in productive capacity? The context and
conditions in which science and technology are able to prosper require
political decisions, funding, infrastructure, technical support, and a
scientific community; these are generally unavailable in developing countries.
The value and effectiveness of individuals depends on their connection to the
people, institutions and organizations that enable knowledge creation, and
together constitute a propitious environment. These expatriate scientists and
healthcare professionals can contribute their knowledge, clinical and research
skills to their native countries by developing collaborative training
programmes, research projects and teaching their own countrymen. This requires
the commitment of foreign scientists and receptiveness at the other end.
Scientists, political leaders and decision-makers in developing and developed
countries, and international development agencies, need to appreciate the
social and synergistic nature of knowledge sharing so that policies and
education systems are designed to promote and enable research and

Healthcare services are a rapidly growing sector of the world economy and
trade in health services has created diverse means of accessing these services
across borders. For example, information technology can provide telemedicine
services and telepreventive services. These information technologies can be
used as a mode of sharing knowledge and research skills in a cost-effective

One such large network is already in place called supercourse
which has connected more than 20 000 scientists, healthcare professionals and
researchers together through IT connectivity, and they share their knowledge
in the form of teaching lectures (currently there are more than 2000 lectures)
for free to a global audience. A similar kind of connectivity needs to be
developed by expatriate citizens who can contribute their knowledge and skills
to their countries of origin without any major costs. Policies are needed to
ensure that these favourable outcomes are realized as an equitable access to
the benefits of the international tradein health services.

The availability of both high-quality education and opportunities in
research are the keys to retaining and attracting regional talent. The steps
taken by China towards becoming a leader in biological research and
biotechnology illustrate the empowerment. The scientific leadership positioned
China to become the only developing country participating in the Human Genome
Experience gained through the participation of its institutions in the Human
Genome Project (including large-scale sequencing, the use of bioinformatics
and the coordination of multi-centre research protocols) provided the platform
for developing biotechnology that can be applied to human diseases and
agriculture. The opportunities generated by the Chinese in biotechnology
attract both international collaboration in joint ventures and gifted
scientists from Chinaand abroad.

A similar example can be replicated in other developing countries with the
help of their foreign expatriate citizens who have developed skills in
research that are needed in their native countries. This approach to creating
targeted educational opportunity together with political decision and
investment in science and technology infrastructure provides a good example of
a resourceful way of redirecting the brain drain. It is tempting to think that
such on-site programmes involving national talent at home and abroad coupled
with creative distance learning strategies could create networks of
expatriates thus enabling their countries of origin to gain access to a
world-class education in specificdisciplines in the developing world.


Scientists who have emigrated for several reasons are recoverable assets
who can play a part in developing opportunities at home. However, recovery
requires the opening of diverse and creative conduits. The health services in
the developing world must be supported to maintain their skilled personnel.
Only when health staff, whatever their cadre, have the tools they require to
do their job, training opportunities, a network of supportive colleagues, and
recognition for the difficult job they do, are they likely to feel motivated
to stay put when opportunity beckons from elsewhere. Foreign professionals
could be used to develop innovative graduate education opportunities at home
and technology to be transfered to areas of national priorities for research
and development. Ultimately, involving individuals who are living abroad in
creating opportunities at home favours both the retention and repatriation of
national talent. Building an enlightened leadership and an enabling national
scientific community, with the help of expatriate citizens, for the coherent
development of scientific and technological capacity in developing countries
willbe mutually beneficial.


We are grateful to all Aga Khan University alumni at AKU Karachi, Pakistan
and AKU USA for their valuable help.


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