doi:10.1111/j.1468-2435.2008.00484.

Of Skilled Migration, Brain Drains and Policy Responses*

Ronald Skeldon**

ABSTRACT
Developed countries are increasingly trying to attract skilled migrants, rarely giving any consideration to the impact that this migration might have on countries of origin. The debate on the brain drain is not new but it has taken on greater urgency in the context of a globalizing economy and ageing societies and this article reviews the evidence over time and space. It examines opposing interpretations of the impact of the skilled from countries of origin and goes on to examine the particular case of the migration of health professionals. Health workers are seen to be key to achieving basic welfare objectives in any country and their loss may be critical to countries of origin. Hence, the movement of health professionals may be central to any understanding of a brain drain. However, the case for a brain drain, even in this sector, is not straightforward. Specic country and place of origin of the skilled, place of training, appropriateness of training, t of skills to needs, and the role of return and inmigration of health professionals all need to be taken into consideration. The article examines the case for a two-tiered health training system, one for global markets and the other for local markets. Retention and return of the skilled are examined through the potential for outsourcing in both education and health care. The article concludes with an examination of policy approaches towards skilled migration and offers pointers towards a more balanced and integrated approach by placing the emphasis on development rather than control of migrants.

BACKGROUND
One area of policy convergence in countries in the developed world today is the perceived need to attract increasing numbers of highly
* This article is part of the output of the Development Research Centre for Globalisation, Migration and Poverty at the University of Sussex, which is funded by the Department for International Development, London. ** Department of Geography, University of Sussex. 2008 The Author Journal Compilation 2008 IOM International Migration Vol. 47 (4) 2009 ISSN 0020-7985

Published by Blackwell Publishing Ltd., 9600 Garsington Road, Oxford OX4 2DQ, UK, and 350 Main Street, Malden, MA 02148, USA.

R. Skeldon

skilled workers. This objective has been realized through regular immigration programmes, such as those of Canada or Australia that are based on points to select the skills of migrants, or through the introduction of non-immigration programmes specically targeted at the highly skilled such as the H1-B programme of the United States. In Europe, France, Germany and the United Kingdom have all recently modied their approaches to immigration by specically opening channels for the skilled. At the same time, developed countries have sought to limit or control more effectively the entry of the less skilled. Hence, immigration policy in the developed world is increasingly taking on a dual approach of promoting skilled migration and limiting unskilled migration. Despite weaknesses in the available data, the basic trends appear clear: the volume of skilled migration and its proportion as part of global population movement are increasing. According to Docquier and Marfouk (2006: 168), the proportion of the highly skilled in the migrant population 25 years of age and older living in countries of the Organisation for Economic Co-operation and Development (OECD) increased from 29.8 to 34.6 per cent between 1990 and 2000. In 2000, about 20.4 million migrants in OECD countries had tertiary education, up from 12 million in 1990, and some 56 per cent of these had originated in the developing world. While, in terms of absolute numbers, middle-income developing countries such as India, the Philippines, Mexico and China have dominated the supply of highly skilled migrants, the relative impact of the exodus of smaller numbers is greater in smaller poorer countries. Figures cited by the United Nations show that the proportions of the highly educated labour force of eight large Sub-Saharan countries that lived in OECD countries varied between 33 and 55 per cent (United Nations, 2006: 60). The proportions for island countries such as Haiti, Fiji, Jamaica, and Trinidad and Tobago were above 60 per cent, with that for Guyana touching 83 per cent. Five countries Haiti, Cape Verde, Samoa, Gambia and Somalia are estimated to have lost more than half of their university-educated professionals in recent years according to a further United Nations report (UNCTAD, 2007). In seeking to attract the best and brightest, developed countries rarely consider the likely impact that their policies might have on the countries of origin, and the issue of the brain drain has once again come to prominence in discussions of migration and development. The assumption is that the loss of the skilled will prejudice the countries of origin. Initially, the discussion emerged in the 1960s in the context of the migration of scientists across the Atlantic, primarily from Britain, to the
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Of skilled migration, brain drains and policy responses

United States but was extended to developing countries of origin, and particularly to economies in Asia. One US senator of the time called the brain drain a national disgrace [that] has more than cancelled out the effect and benet of American foreign aid programs (cited in Adams, 1968: 2). More recent work on the impact of the migration of the skilled on countries of origin reects this view of brain drain. For example, Schiff (2006: 221) argues that the early brain drain literature such as, for example, Bhagwati (1976) was close to the mark and stresses the need for policies to slow or stop the exodus of skilled labour. Kapur and McHale (2005: 177) advocate a four-prong policy response, or the four Cs: the need (a) to control the outow; (b) to introduce compensation policies; (c) to create more human capital in origin areas; and (d) to connect origin countries to members of their transnational community. A United Nations agency, in 2007, has warned that the brain drain is undermining progress in the least developed countries (UNCTAD, 2007). However, as with most issues in migration and development, this point of view has been contested. In what might be termed the revisionist approach, it has been argued that the exodus of the highly skilled from the developing world can actually be benecial and can lead to a brain gain for countries of origin, counter-intuitive though this viewpoint might at rst appear. This argument was based on the idea that skilled migrants leaving a country generate an increased demand for higher levels of education among the population at large so that many more, too, might have a chance of emigrating. However, not all would be able to do so and, at the simplest level of generalization, more people with higher education are left in a country at the end of a period of emigration than at the beginning. These ideas are perhaps best expressed in the work of Mountford (1997) and Stark (2004). In this interpretation, it is the possibility of migration that induces individuals in a developing country to acquire higher education (Stark and Fan, 2007: 261). In some cases, this clearly occurs. For example, in the Philippines, where a culture of migration exists (Asis, 2006), individuals do enter certain paths of training such as nursing specically in order to migrate overseas. However, in this case, this culture of migration has been evolving for some considerable time and is driven by the millions of Filipinos already overseas. The government, too, actively pursues a policy of labour export at all skill levels in the expectation that remittances will be returned to the country. For example, in the rst ten months of 2005, some US$ 8.8 billion were remitted through formal channels by overseas foreign workers and, through the 1990s, remittances accounted
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for 20.3 per cent of export earnings and 5.2 per cent of GDP (Go, 2006; Bagasao, 2005: 137). Similar cultures of migration exist for some small island countries in the Pacic and the Caribbean that have seen pronounced migration to developed countries, and it is hardly surprising that in these areas education is seen as a stepping stone to employment overseas. However, in a large country such as India where an estimated one-fth of the annual output of 178,000 engineering graduates leave the country (Kapur and McHale, 2005: 98), it might be stretching a point to argue that the majority embark upon their chosen training with the thought of emigration. Overall, India is ranked as having a low emigration rate for the highly skilled at 4.5 per cent, even with over 1 million skilled overseas (Docquier and Marfouk, 2006: 177). A survey of foreign doctors coming to the United Kingdom, some 42 per cent from India, showed that only a minority considered emigration a factor when embarking upon their career (Kangasniemi et al., 2004). More generally, screening of the skilled by destination countries leaves the origin society with a pool of lower quality, or less-experienced skilled, even if the pool has expanded (Commander et al., 2004). Hong Kong perhaps provides an interesting case, with pronounced emigration of the highly skilled in the late 1980s and early 1990s accompanied by an increasing pool of the skilled within the city itself (Skeldon, 1994: 39). On the face of it, this situation appears to argue the case of the revisionists, that emigration drives the demand for higher levels of education. However, closer examination shows that the demand for tertiary education came from increasing numbers admitted into secondary schools in the early 1980s in a dramatic expansion of secondary education (Cheng, 1991: 303). The tertiary sector was similarly expanded in the 1990s, and, although the rationale was never made entirely clear, migration does seem to have been part of the decision. The government wanted to produce more graduates locally to replace those going overseas, in the way argued by the revisionists, but also expected that university places would be available locally to retain those who might go overseas for their education (Cheng, 1996: 411). However, migration for further education had been a signicant movement before the emigration surge from the then British colony that began from the mid-1980s. In the 1970s, for example, only 3 per cent of the age cohort could pursue higher education in Hong Kong. In Hong Kongs case, the demand for tertiary education had preceded the migration and the latter was a function of the former and not the other way round.
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Although it can be argued that the empirical evidence to support the revisionist view is weak at best (see Lucas, 2005) or lacking (Schiff, 2006), this ignores the point that evidence to provide clear support for the negative impact of the emigration is equally weak. Hence, to attribute either a negative or a positive outcome on development as a result of the emigration of the highly skilled is likely to be deceptive. Association between emigration and the increases in skilled personnel, or with decreases in certain development variables, does not necessarily indicate any causal link. Other factors may be more important and the brain drain may indeed be a red herring, with its role relatively unimportant. Even in the late 1960s, when concerns about a brain drain were rst being discussed, not all views supported the movement of the skilled from countries of origin as negative for their development. Myint (1968) presented a less alarmist view, and, in the same collection of essays, Johnson (1968: 91) went as far as to suggest that the brain drain was a trivial factor in the problem of developing the underdeveloped regions of the world. The results of subsequent research have shown that, from the 1960s through to the 1990s, no brain drain effect can be observed from UK universities (Hatton and Price, 2005: 164). Nevertheless, and taking into consideration current concerns about the brain drain, it may be possible that negative or positive effects can be observed for specic sectors of the skilled, rather than for any category for the skilled as a whole. The acid test may be the health sector, which is so often seen as critical to achieving the targets of several of the Millennium Development Goals. This article will examine the debate about the movement of health professionals and the development of countries of origin: whether the loss to origin countries, or the perceived poaching by developed countries, is prejudicial to the health status of populations of origin. Or, on the other hand, can any case be made for the emigration of health workers as being positive for countries of origin?

BRAIN DRAIN AND HEALTH PERSONNEL: THE EXCEPTIONAL CASE?

Skills in the health sector are seen as essential for the improvement of the basic welfare of any population, and the loss of medical personnel from a developing country is seen as prejudicial to the achievement of this primary development goal. From this point of view, the migration of skilled health professionals is often seen as different from other types
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of skilled migration. A country might be able to bear the loss of a chemist or physicist, for example, but not a doctor. That is, the migration of health professionals is in some way exceptional in the context of the brain drain (Akire and Chen, 2004). Health systems in parts of the developing world, and particularly in Sub-Saharan Africa, are seen to be in crisis as their doctors and nurses opt to move to greater security and higher paid jobs in Europe, North America and Australasia. Thus, it is perhaps through an examination of the exodus of health professionals that the real impact of a brain drain may be most clearly seen. However, as with other aspects of the brain drain discussion, the situation in the health sector, too, is more complex and contradictory than might at rst appear. The one area in which there is no disagreement is the increasing demand for health personnel in developed and ageing societies. If this demand cannot be met from local sources, developed countries will have to import the required skills, perhaps to the detriment of countries of origin. The import of skills in this sector does appear to be growing apace. The proportion of foreign medical graduates practising in the United States rose from around 18 per cent in the 1970s to 25 per cent in 2000, and there could be a shortfall of 800,000 nurses by 2020 (Bach, 2003: 6). Data for the United Kingdom show that, in 2001 02, virtually half of the new entrants to the register of nurses were from overseas (Buchan, 2002) although that proportion has since declined by about half as entrants from local sources increased sharply (Buchan and McPake, 2007). Of the total stock of nurses in the United Kingdom in 2001, however, only one in seven was foreignborn, with one in three doctors born overseas at that time (OECD, 2007: 165). In terms of the absolute numbers of skilled health workers, and similar to the situation with all skilled workers, most originate in middle-income developing countries rather than in the poorest countries. This situation is logical simply because the poorest countries do not have the facilities to train large numbers of skilled workers, irrespective of sector. For example, 11 of 48 Sub-Saharan African countries do not have medical schools that produce graduates recognized by the major destination countries (cited in Clemens, 2007: 15). The World Health Organization (2005) has compiled data that show that India is the major source of supply of foreign doctors to the United States and the United Kingdom, the second source for Australia and the third most important source for Canada. However, the United Kingdom emerges as a major source of doctors for both Australia and Canada, and South Africa is a major source for the United
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Kingdom and Canada. Thus, considerable circulation of skilled medical personnel is taking place. Language is clearly a major factor in accounting for the ows of doctors. Those going to Germany have been dominated by non-Englishspeaking origins in Russia, Iran and Europe. The Philippines and India have emerged as two of the principal sources of nurses to the developed countries in the English-speaking world. For a review of the movement of nurses at the global level, see Buchan, et al. (2003); for a specic examination of the situation in the United Kingdom, see Buchan (2002); and for a series of articles summarizing the main issues of migration and health workers from a fairly balanced point of view, see WHO (2004). The data used to assess the ows have to be used with some caution as they usually only account for those doctors or nurses who are registered with the ofcial professional bodies in the respective countries. Other doctors or nurses may enter countries under different categories and pursue non-medical occupations. The impact that the exodus of medical personnel might have on countries of origin is of greatest interest. South Africa gures prominently as a country of origin of ows of both doctors and nurses to the developed countries of Europe, North America and Australasia. Yet, the pool of all health professionals except nurses in South Africa continued to expand between 1996 and 2001 despite the outow, providing some support for the revisionist point of view. Although the number of nurses in South Africa was virtually stagnant over the same period and some 32,000 vacancies existed in the public sector, it was also estimated that there were within the country another 35,000 registered nurses who were inactive or unemployed (OECD, 2004). These data suggest that migration is but one factor in accounting for losses of personnel in the health sector and there is a movement out of the sector but not out of the country. Given the parlous state of the public sectors in many developing countries, the skilled will opt for higher-paying and better-resourced positions in the private sector. Positions in international organizations at home, in national or international non-governmental organizations or opportunities in business or politics all attract the talented. Public-sector conditions throughout much of Africa appear to be changing for the worse (Owusu, 2005: 172) and the employees can only survive by taking on multiple, income-generating activities or opting out of the public sector altogether. Supportive evidence exists for the loss of the skilled in science and technology, also from South Africa. During the late 1990s and the early years of
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the twenty-rst century, about 2,000 highly skilled workers in science and technology left each year. This gure represented less than 1 per cent of the workforce in that category and annual losses due to mortality ranged from ve to eight times larger than those due to emigration. The pool of the skilled workforce in science and technology increased from 1.6 to 2.5 million between 1996 and 2002. Unemployment among highly skilled workers, although only a fraction of that for all workers, rose from about 9 to 16.5 per cent over the same period (Kahn et al., 2004). While questions remain concerning the relative experience level of those who left compared with those who stayed, it seems clear that, for South Africa, like the economies in East Asia from the 1970s and the United Kingdom in the 1960s, the brain drain is more perceived than real. South Africa is one of the most developed countries in Africa, and it is perhaps more important to assess the impact of a brain drain on health services in those countries where relatively small numbers of medical personnel leave from a very limited skill base in health personnel. This situation applies particularly for other Sub-Saharan countries and for small island economies. For example, it has been estimated that the numbers of doctors leaving Guinea-Bissau, Zimbabwe and Uganda represent more than 30 per cent of the resident stock of doctors (WHO, 2005: 31). Although Ghana is another of the more developed African countries, Ghanaian-born doctors overseas are equivalent to half of the domestic pool. Figures of this type are at the root of the impression that African health services are in crisis and that the countries are on the verge of a public health disaster as a result of migration. Before acquiescing to such an interpretation, we need to examine four critical areas: ) ) ) ) Place of training: many of the foreign-born doctors in developed countries may have received their advanced training in developed countries. Specic places of origin of the doctors: the internal distribution of health personnel needs to be taken into consideration. Linkages between the health sector and health: the state of the health sector and the state of health of populations may be more tenuously related than is often assumed. Inmigration of health professionals: the inmigration of doctors from other countries and the return, temporary or otherwise, of trained nationals.

Any simple association between birthplace data and medical occupation as an indicator of brain drain can be misleading as data to show the
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place of training are difcult to nd. Clemens (2007: 16) clearly shows the difculties in attempting to do so and cites the example of the gure of 195 Egyptian-trained physicians against the number of 750 Egyptianborn physicians practising in Canada in 2001. However, information on the numbers trained outside their country of birth is generally elusive. For skilled migrants in general, not just those in the health sector, it has been estimated that 55 per cent of those from Latin America and the Caribbean employed in the United States had been trained in the United States. Over 40 per cent of those from China and India had received their college degrees in the United States (United Nations, 2006: 60). Some 68 per cent of the foreign-born scientists conducting research in the United States in 1999 had been trained in the United States (Johnson, 2003: 6). In the case of medical personnel, even if basic training had been undertaken in the developing world, advanced training might have been completed in the developed world (Khadria, 2003: 9). The majority of the estimated 300 Ghanaian doctors in Germany had been trained in Germany and had chosen to stay on after completing their studies (Nyonator and Dovlo, 2005: 231). Where a long tradition of medical training exists together with a large number of medical institutions, as in India, it seems likely that the majority of doctors will be trained at source. Nevertheless, over the two years 1996 97 and 1997 98, over 1,500 Indian students left to pursue studies in medicine, pharmacy, dentistry and veterinary science (Khadria, 2003: table 5). In France, while large numbers of practising doctors have been trained in developing countries, the majority of these become naturalized and disappear from the foreign population, further complicating any analysis (WHO, personal communication). It is not just place of training that is important but also the source of funding. The ready assumption is that it is the state of origin that pays. The basic cost of training of a British doctor in the mid-1960s was around 12,000 (about US$ 33,600 at 1965 exchange rates) that was lost to Britain and gained by the United States if that person decided to migrate across the Atlantic upon completion of his or her studies (Last, 1969: 31). In the developing world today, the cost of training may indeed be borne by the state of origin but it could also be funded through scholarships from another state or a private grantawarding body or by the family of the student. Education is becoming increasingly privatized, with the cost of education both at home and overseas being covered by the family. The number of institutions training nurses in the Philippines more than doubled between 2003 and 2006 to some 460 centres, of which some 80 per cent were private
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(Acacio, 2007). With respect to all students, not just those pursuing studies in medicine, it has been shown that 60 per cent of foreign students in the United States depended upon family or personal resources for their studies, a proportion that remained stable from 1979 to 2004 (Kritz, 2006: 7). Of the balance, Kritz shows an increasing proportion paid by US universities from less than 10 per cent in 1979 to 25 per cent in 2004. With respect to postgraduate studies, US universities funded almost 45 per cent of foreign students in that latter year. Such gures raise interesting questions about the whole issue of compensation and who should be reimbursed for the cost of generating skills. The state of origin may not be the main source of funds covering the high costs of advanced training. The issue of accreditation looms large in the medical eld, and doctors and nurses may have to complete bridging courses that local medical authorities require to bring them up to acceptable destination-country standards. Opting to train in a medical school in a developed country clearly obviates this particular problem and, with most doctors still coming largely from elite families in developing countries, this appears to be the ideal strategy for that particular group. Doctors seem increasingly to belong to the transnational class (Sklair, 2001), with more in common perhaps with their colleagues overseas than with their potential patients in poor urban or rural parts of their home countries. Even for those being trained within country of origin, the majority may come from the elite. For example, a survey of those entering medical and nurse training in Ghana showed that virtually two-thirds of entrants had a father with tertiary-level education (Anar and Kwankye, forthcoming). Some 36 per cent of entrants had a mother educated at this level. The specic places of origin of health professionals in developing countries are rarely to be found in the places of greatest deprivation, the rural areas. These medical personnel come, hardly surprisingly, from the urban areas, as it is there that the elite are to be found. Hence, the emigration of doctors is unlikely to be responsible for any reduction in services in the areas of greatest need and, again, the migration as a perceived brain drain is blamed for a wider failure of policy. It is all too easy to use emigration as a scapegoat for a lack of development. It is difcult to encourage medical personnel to serve in the rural areas even in more advanced countries in Africa such as South Africa, and developing countries themselves have to resort to importing doctors from countries such as Cuba to ll the void. In Ghana, 46 per cent of public and private sector doctors are to be found in Greater Accra, with
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a further 23 per cent in the Asante region, in which the second largest city, Kumasi, is located (Nyonator and Dovlo, 2005: 229). These areas, with but one-third of the total population, also encompass over twofths of the nurses in the country. Again, doctors from Cuba help to make up the shortfall in the rural areas, with some 184 doctors in the country in early 2006. This discussion immediately raises the question of the extent to which highly trained medical personnel can truly make a difference in areas where basic facilities are lacking. In that case, should countries be opting for training systems more appropriate to the needs of the majority of poor rural people, in effect producing medical personnel who are not marketable internationally but who are needed locally? Any such approach would have parallels with the Chinese approach to primary health care in the 1960s, where non-professional health personnel, barefoot doctors, were involved in extending health care into isolated areas or where needed. However, such radical approaches need not necessarily form the ideal model, and countries might opt for systems of community-based training of individuals to bring basic health care to places where it is most needed. Equally, developing countries will not wish to introduce what might be perceived as a second-rate system of medical training. Hence, some variant of a two-tier system of training might be considered in which doctors and nurses are trained in one tier to international standards and it is accepted that losses will occur, but many others are trained in another tier to more basic levels of health care. These basic levels are appropriate for areas of high infant and child mortality, and areas where expectation of life is low and where the patterns of morbidity and mortality are different from those in urban and international areas. Attendants are required for those suffering from HIV, rather than doctors with advanced medical training. Even in advanced areas and economies, paramedics and emergency medical technicians (EMTs) have, since the 1970s, provided a vital service in offering basic medical treatment through the emergency services and in hospitals. While no universal training curriculum yet exists, and paramedics and EMTs are trained to various levels, that training is neither as long nor as expensive as that of a doctor. In order to make entry into the local tier attractive, provision would always have to be made to allow those trained to local standards to upgrade their qualications, if desired, so that those in the lower tier do not feel permanently locked into one system.
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The above discussion raises the almost sacrilegious question of the relevance of the advanced medical sector to the health of the populations in the developing world. The medical establishment has become a major threat to health (Illich, 2002). Even if one does not wholly agree with these words, with which the Austrian-Mexican intellectual Ivan Illich opened his scholarly exegesis of medicine, it is not difcult to accept that the state of health of any population does not depend on its medical personnel alone. In terms of skilled workers, the agronomists who work to increase agricultural yields to improve the nutrition that will combat disease, the water engineers who work to supply safe drinking water, the sanitary engineers who build the sewerage systems, the transport engineers who improve communications that allow food to be taken from point of supply to where it is needed, and so on, are as critical as any skilled doctor in improving the health status of a population. To relate the state of a nations health to the increasing emigration of medical professionals, or conversely, to their presence, is to take too narrow a view of how health is delivered to a population. It is not for one moment being suggested here that a country does not need doctors and nurses, simply that any crisis in the state of health in a country is unlikely to be the result of an exodus of skilled medical personnel. Many more professionals are at the root of development in the health of a population and the achievement of the health-related Millennium Development Goals. Thus, in the current brain drain debate, the state of health of a population and the state of the health system in a population are being conated. These are not the same thing. A tendency also exists to draw comparisons between the health sector in developed ageing populations with that of youthful populations at much lower levels of development in terms of doctor or nurse to population ratios. These populations, as stressed above, have very different demands for health services and the need for poor, rural populations is for good basic care. Lastly, there is the issue of the inmigration of doctors from other countries and the return on a temporary or longer-term basis of trained nationals. Brief mention has already been made above to the movement of doctors from developed countries and other parts of the developing world to many poor countries. Since 1971, Doctors Without Borders decins sans Frontie ` res) has sent doctors, nurses and other medical (Me and non-medical personnel to areas where there are humanitarian emergencies, as well as to areas where people are judged as being excluded from health services. Currently, voluntary personnel are working in almost 70 countries and each year personnel are involved in more than 3,400 missions. In terms of origins in the developing world, Cuba is a
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source for medical brigades, primarily to Venezuela and other countries in the Caribbean and Central American region but also to Ghana, South Africa and Zimbabwe. Some 450 Cuban health professionals were in South Africa around the year 2000 (OECD, 2004: 128). These doctors, as emphasized above, often operate in the rural areas where local doctors are reluctant to take up positions. The 535 Cuban medical volunteers in Haiti were sent to compensate for the 90 per cent of local doctors who were estimated to be concentrated in the capital Portau-Prince. There are also the philanthropic motives of professionals in the diaspora. For example, in the United States, some 35,000 practitioners and 10,000 students are members of the American Association of Physicians of Indian Origin, which is a constant source of volunteers for et al., 2003: 151). Hence, a signicant but service back home (Barre indeterminate number of short-term skilled health migrants to the poorer countries appears to exist that can bring health care to places where it is most needed and compensates, at least partially, for the outmigration of national health personnel. The above discussion of the emigration of skilled health workers has raised question marks over whether the health sector is in some way exceptional and whether the migration constitutes a real brain drain. Training is carried out overseas, though to a variable degree, health personnel are concentrated in the largest cities, and any exodus is unlikely to make an impact in the areas of greatest need. The identication of the migration of the skilled as a critical variable in the health of a population seems to oversimplify a complex situation at best and divert attention from the underlying causes of the malaise in the health sector at worst. The last critical question to be considered is whether return and the inmigration of the skilled, in the health sector and more widely, can be promoted and placed on a more sustained and long-term basis, and whether it will make a difference.

OUTSOURCING AND THE HIGHLY SKILLED

A critical dimension of the migration of the skilled is their return to their countries of origin. This return can either be of previous brains lost in the migration or of brains enhanced through training overseas in a brain gain. The evidence for East Asian economies was that the return of students, in particular, increased over time. Central to this return, however, is the fact that there must be something to return to, essentially a stable environment in which the returnee can make a living.
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However, a downturn in the destination economy might also engender return, as in the case of the large number of lay-offs among IT specialists in Silicon Valley, California, in 2001 02 that may have encouraged Indian professionals to return to their own country (Khadria, 2003: 15). Once the process of return is under way, however, these migrants contribute to the development of their economies of origin in a number of ways. Clearly, they are bringing skills, but they can also bring capital and entrepreneurial and political ideas. They are unlikely to be the only key factor in the development of their homeland, but they can nevertheless play a signicant role. Ageing populations and declining rates of labour force growth in developed economies have played a central part in shifting labour-intensive production overseas but migrants, too, have been part of the process. In Asia, the key groups are perhaps the overseas Chinese, non-resident Indians and groups such as the Viet Kieu, and these immediately raise large the idea of the role of the diaspora, or the overseas communities of migrants in the development of origin economies. It is estimated that half of the US$ 48 billion in foreign direct investment to China in 2002 came from the overseas Chinese, although the overseas Indians have invested proportionally much less, US$ 4 billion (data cited in Newland and Patrick, 2004: 6). The reason given for the smaller gure for Indians is the disinterest of the Indian government and the lack of an investorfriendly environment (Newland and Patrick, 2004: 7). In the case of Viet Nam, investment in the country during the early 1990s from the Viet Kieu was initially low, only some US$ 127 million over eight years (Woods, 2002: 182), but this gure had increased dramatically to over US$ 3 billion in 2004 alone, a reection of changing government attitudes and the introduction of a more open economy. While considerable research has been carried out on offshore processing, particularly the IT industry and the role of non-resident Indians (Khadria, 2003; Saxenian, 2006), relatively little research has been done on services such as education and health. The current emphasis has been on moving people to deliver services (Mattoo and Carzaniga, 2003), the intent of the General Agreement on Trades and Services (GATS) mode 4, rather than on moving services to the people that would be covered under GATS mode 2. Like labour-intensive industrial production, basic services such as health can also be outsourced. Ageing populations with their patterns of recurrent and degenerative diseases, personnel shortages in the health sector, rising costs of medical care and increasing waiting times for non-emergency surgery are all factors that might encourage travel
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overseas for treatment. If people used to socialized medicine are forced to use the private sector, costs in developing countries are much lower. Not that there is anything particularly new about travel for health care. Mountain resorts and spa towns have long been established as health centres, and travel in search of a miracle cure has been part of the traditions of pilgrimage. However, today, a global market in health care appears to be emerging with India, South Africa, Cuba, Costa Rica, Malaysia and Thailand all promoting medical care for patients from overseas. The principal market in India for the proposed treatment of those living overseas is likely to be its expatriate community, who can combine non-emergency medical care with trips back home. However, regional markets are emerging, with people from the Middle East going to South and South-East Asia for treatment, and hospitals in Bangkok, for example, serving patients from Hong Kong, Bangladesh and as far away as Australia. What began as medical services for expanding expatriate populations based locally to oversee transnational economic activities or international development and diplomacy has evolved into supplying regional and even global medical care. One example of the potential of this medical tourism comes from Thailand and Bumrungrad Hospital, one of several such hospitals in Bangkok (Bumrungrad, 2005). Initially founded in 1990, Bumrungrad became Asias rst internationally accredited hospital on 25 April 2002. It is a private company listed on the Thai Stock Market that treats 850,000 patients a year, 300,000 of whom are international, from 154 countries, an unspecied proportion of whom, however, are resident in Thailand. Its turnover in 2003 was US$ 114 million. Although the majority of its 600 health professionals have mainly been trained in Thailand, most of them have overseas training and certication, mainly in the United States, and Bumrungrad has an Americanled management team. Like other overseas hospitals, it has reached agreements with leading American and European insurance companies to cover the costs of its medical treatment. The hospital has representative ofces in seven South and South-East Asian countries, plus the Netherlands in Europe. Lest such an operation be seen as diverting attention away from local health needs, the Bumrungrad Hospital Foundation is involved in a wide range of charitable activities to help poor Thais. These range from doctors providing free services in low-income areas to inpatient heart treatment for children, and the foundation estimates that it has provided benets to over 100,000 needy Thais since its inception, a tiny fraction of total treatment but at least demonstrating linkages back into the local community.
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Much of the future potential for the development of this kind of outsourcing depends on the public condence in developed countries in the kinds of treatment being offered. Longer-term aftercare is a problem, for example. Its future potential also presumably depends on the continued availability of relatively cheap international air travel, a future that is not guaranteed given rising costs of fuel and concerns about the environmental impact of air travel. Thus, reports that the medical treatment of overseas patients could be generating US$ 2.1 billion for India by 2012 (The Financial Times, 2 July 2003) may be optimistic. The extent to which programmes to outsource medical care can encourage migrant national doctors to return from overseas or even to retain local talent also remains not proven. In the 1960s, Thailand lost more than 1,500 doctors, over one-third of the number of medical graduates produced, mainly to the United States (Wibulpolparsert, 2003: 171). The Thai government introduced policies such as bonding medical graduates for three years, a system of recruiting medical students in rural areas specically for home-town placement with nancial and career inducements, and the exodus of the skilled declined. It is, however, almost impossible to attribute the slowdown in emigration to the measures introduced as, over the period, Thailand developed at a rapid pace and saw the emergence of many private hospitals such as Bumrungrad that provide an adequate level of living for skilled health practitioners at home. What is important from a policy point of view is that regional markets are emerging for health care as middle-class or middle-income groups emerge in developing economies. A second and critical dimension of the export in basic services in the context of the evolution of middle-income groups is the outsourcing of education. International schools have been a part of the movement of the skilled expatriate since colonial times. The expansion in the number of British boarding schools in the United Kingdom was partially a response to increasing numbers of highly mobile British parents based overseas who wished for some stability in the education of their children or who had no access to quality schools locally. It was a response, too, to an increasing demand for an English education for children of elite members of colonial societies. English schools were also established in the colonies themselves for the children of both expatriate but, more particularly, local families. With the growth in the number of middleincome groups and an acceptance that English is a key skill in a globalizing world, the number of international schools has greatly expanded, teaching to American, British or International Baccalaureate curricula.
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To serve their expatriate populations, French, Swiss-German, Japanese and increasingly, Chinese, international schools are also to be found around the world, although many tend to have English-language streams as an integral part of their programmes. While some of these international schools are government-supported, as some are in Hong Kong, for example, most are private, with independent boards of governors setting terms and conditions, including salaries and benets such as housing and medical care. Increasingly, however, independent schools in developed countries are establishing branch schools in the developing world in order to access the expanding market. For example, both Harrow and Shrewsbury schools of England have established international schools in Bangkok that take children from the earliest years of primary through to the end of secondary. Both day students and boarders of varying duration (from four through seven nights per week) are taken and fees are high. Whether prots are repatriated to help to subsidize the school in the home country remains unclear, but it would seem ironic if the new wealthy of Asia were subsidizing the middle classes of England. Teachers are recruited from English-speaking countries and all education is in English, although in the Bangkok schools Thai language training is compulsory. The immersion of the children of local middle-income groups in an English-style education, where previously the systems were based on rote learning, and the various impacts that this will have on local cultures, identities and ways of thinking are not yet known. The expansion of schools is mirrored in the expansion of western universities into the developing world and, again, particularly into Asia. In some cases, such expansion is highly focused on specic degrees being accredited at existing institutions by overseas universities. In other cases, whole packages of courses developed in North America or Europe are introduced into existing overseas universities. For example, the University of London supports 49 external programmes in about 200 independent institutions in 45 countries that affect some 20,000 students. The arrangements that the home institution has with the overseas institution are highly varied but the common denominator is that the former is expanding its market access transnationally and selling its reputation abroad. The role of alumni as returned migrants in promoting this type of expansion remains to be investigated. Also unknown is the impact that the expansion of international education will have on the ows of students from developing to
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developed countries. Currently, over 1.4 million foreign students are studying in just ve developed countries: the United States, the United Kingdom, Germany, Australia and France. If students can be trained locally, and at lower cost, will they continue to move in large numbers to developed countries for their education? However, again, government policy on liberalizing the education sector will be critical to the expansion but, if success can be achieved, it will provide opportunities for skilled teachers and researchers to return from diaspora communities. What is also clear is that not all countries will be able to adopt strategies of such medical or educational outsourcing to reverse a brain drain, retain skilled staff or simply generate revenue. Such alternatives are only possible where a number of conditions can be met: ) ) ) Where prior demand exists from an expatriate population. Where regional and, ideally, global networks of aviation transport are available. Where, in the case of the medical outsourcing, there is a local supply of high-quality health professionals and in the case of educational outsourcing, where teachers can readily be recruited on acceptable conditions. Where an acceptance by government exists of the signicance of the private sector in promoting health and educational activities.

The combination of such factors is likely to be found only in the larger cities of middle-income developing countries: throughout South-East Asia, coastal China, parts of India, Mexico, coastal Brazil and Argentina, South Africa, North African countries, and Nigeria and possibly Ghana in West Africa. China was host to almost 111,000 foreign students in 2003 04, up from 43,000 in 1998 99 (Kritz, 2006: 47). In 2002, China itself was reported to have some 500,000 students overseas, only about 30 per cent of whom were expected to return (Zhang, 2003: 74). Brain circulation rather than brain drain is an integral part of that countrys rapid development. The number of foreign students in South Africa rose from 12,600 in 1994 to 35,000 in 2001 and over 46,000 in 2003 04 (Kahn et al., 2004: 30; Kritz, 2006: 47). India, Malaysia, Singapore and Cuba appear to be expanding facilities to attract foreign students and it would be na ve to assume that the key centres of excellence in global learning in decades to come will be limited to countries in Europe and North America.

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CONCLUSION: TOWARDS POLICY COHERENCE

This article has reviewed the evidence for a brain drain. At present, more skilled people are moving and more people are moving in order to obtain skills and, given the current policies of developed countries, this migration of the skilled is likely to continue. The impact that this migration has on the development of countries of origin is not so clear. Economies in East Asia that 40 years ago were considered to be at risk of a brain drain have emerged as some of the most dynamic in the world. Nevertheless, we cannot conclude that the brain drain was necessarily good for those economies but simply that it was an integral part of the process of development that these areas were experiencing. The article went on to examine what many consider to be the critical dimension of the brain drain: the exodus of health personnel from poorer parts of the developing world. Here again, the situation was not clear-cut. Country of training, distribution of the skilled within country relative to the distribution of need, and the real nature of the demand for health skills in a poor country all complicate easy conclusions. It is unlikely that the brain drain signicantly changes the course of development for the worse, even in the health sector. The less alarmist viewpoints on the brain drain of some early commentators actually appear to have been closer to the mark than those who saw the migration as a curse for developing countries (Schiff, 2006: 201). Fundamentally, however, location relative to regional and global centres of growth and the size of labour markets are critical to any assessment of the impact of the exodus of the highly skilled. Globalization is redening space, increasingly marginalizing some areas but favouring others. The migration of the skilled is an integral part of this process. Just as many rural areas within countries have been, and are being, depopulated by migration to the cities, so, too, certain countries will stagnate and even depopulate through the international migration of both skilled and unskilled. Small island countries are particularly vulnerable and question marks over the viability of states such as the Cook Islands have already been raised (Connell, 2005). It is possible that large parts of the island world will become the earths empty quarter (Ward, 1989) and many of the worlds mountain areas, too, may be drained of their demographic vitality (Skeldon, 1985). Geography matters, and not all countries have the same potential for development, not all countries generate skills in equal numbers and not all countries will react to the

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emigration of the skilled in the same way. Policy responses will have to be equally varied. It is all too easy to see the brain drain as the explanation for, rather than a consequence of, a lack of development. However, even this interpretation is deceptive, as clearly the emigration of the skilled, initially of students and later of other skilled people, is a direct consequence of the process of development itself. As societies develop economically, the incidence of international mobility increases: initially outwards and then, at certain key nodes in the global system, inwards, as outsourcing of activities from developed economies evolves. The number of these nodes increases over time but cannot be expected to encompass the entire world, and even such development cannot be expected to slow the movement of the highly skilled. The developed economies are signicant sources, as well as destinations, of the highly skilled and our decentralizing, globalized economy depends upon such brain circulation. The United Kingdom, for example, is estimated to have more skilled migrants overseas than any other country, at 1.4 million in 2000 (Docquier and Marfouk, 2006: 175). Just under 10 per cent of the population of the United Kingdom is estimated to be outside the country (Sriskandarajah and Drew, 2006), a proportion not dissimilar to that of the Philippines or Mexico, classic countries of emigration. Of course, not all of those outside the United Kingdom are skilled workers or even in the labour force. Nevertheless, the basic point remains that the emigration of the skilled also characterizes developed countries. The whole concept of brain drain seems deceptive and even the ameliorative brain strain (Lowell et al., 2004) a bit of a smokescreen. Modern societies and their modes of production are predicated upon the mobility of the skilled and implementing policies to reduce their movement is, in effect, to act against the process of development itself, at least in its current globalized form. While the overall thrust of this article might appear to place it more in the revisionist than in the traditional, negative brain drain camp, it also urges more cautionary interpretations. Rather than seeing migration as either causing an increase in the number of skilled or leading to a deterioration of services, it argues that the search for causality needs to be found within the broader context of development itself. Migration had become the key factor in a simple explanation for a lack of development. When faced with a lack of empirical evidence to prove the case, or at least with conicting evidence, the interpretation was turned on its head to demonstrate the converse, that migration leads to an increase in skills.
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Examples of the association of migration with both negative and positive consequences can, no doubt, be found depending upon the size of the area or economy being considered and its location in the global system. Smaller, marginal areas will be affected very differently by the movement of the skilled compared with larger areas closer to centres of economic dynamism. Thus, given that development essentially drives the movement of the highly skilled, what kinds of policy options exist? Direct attempts to control the movement of the skilled clearly would seem to be counterproductive. Such policies would include programmes of ethical recruitment that might appear to be morally impeccable to the extent that they attempt to protect the interests of origin against those of destination states, but they are difcult to implement (Willetts and Martineau, 2004). More importantly, attempts to control or limit the movement of the skilled may force them to seek informal channels of migration through which they cannot practise their skills legally in destination economies. A second approach that again might seem to right apparent wrongs is the issue of compensation: that the developed world recompense the developing world for the skills obtained, an old suggestion that seems to be in the process of resurrection (Bhagwati, 2004: 215; Kapur and McHale, 2005). However, policies of compensation are again difcult to implement and, given that many of the skilled from the developing world are being trained in the developed world with sources of funding not from the state of origin, seem of doubtful validity. Finally, policies that seek to draw on the diaspora are likely to meet with greater success where the development potential of the origin area is high and where it is combined with liberal policies towards the private sector by origin governments. These policies to leverage the diaspora will only achieve their objectives where comprehensive development policies have been effective. Nevertheless, policies do inuence population mobility and those whose primary aims lie elsewhere may make the greater impact. For example, policies to improve the human capital in both origins and destinations are likely to affect migration. Improvements in education are likely to see an increase in emigration of the skilled, as suggested in this article. However, training programmes that are geared to local labour markets, as suggested for lower-level medical personnel above, in the context of improved remuneration and conditions, are likely to have an impact. The principal goal is to improve health delivery locally but if that retains more health workers, then it could be seen as an effective policy
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to stem a loss of key workers. Equally, changing labour market conditions in destination areas can have an effect. The massive investment in public-sector health in the United Kingdom appears to have improved conditions for nurses and drawn more British nurses back into both work and training. The absolute number and the proportion of foreign nurses being registered in the United Kingdom fell markedly between 2001 02 and 2004 05 as the total number registered climbed after several years of steady decline (NMC, 2005; Buchan and McPake, 2007). Such measures will not stop the movement; they may simply re-channel it elsewhere to new destinations or from new origins, but an improvement in health delivery in origins and destinations will surely be an indicator of policy success. The public debate on the brain drain will not go away as it offers a simple solution to a complex problem: that a lack of development is due to the exodus of skilled people. It is to be hoped that policymakers avoid the temptation to seek the equally simple policy responses of control. Where policies seek to accommodate, rather than direct, existing patterns of skilled migration and are consistent with existing development policies, they are likely to be more effective in improving human welfare, irrespective of whether they succeed in inuencing the actual patterns of migration themselves. It is perhaps tting to conclude with the words of and his colleagues. It is time to stop deploring the brain drain Barre from Southern countries to the industrialised world, to stop regarding the departure of researchers and engineers to Northern countries as a pure loss for developing countries (2003: 115).

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