Brain gain: Providing healthcare workers with opportunities to migrate can increase education and supply of medical workers in origin countries
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In observance of the International Migrants Day, Dec 18
The migration of skilled workers, in particular doctors and nurses, often raises the fear of “brain drain” in migrant origin countries. Notwithstanding the benefits of remittances and knowledge transfer, many fear that such migration weakens the provision of healthcare in the origin community. See Gibson and McKenzie (2011) for a broader discussion.
In our study, we examine the brain gain versus brain drain debate in the context of the Philippines, one of the top migrant-origin countries globally, and the world’s largest supplier of foreign nurses. In 2000, the United States dramatically expanded the availability of visas for foreign nurses, but in 2007, suddenly reduced visa availability back to pre-2000 levels. This led to a sudden rise and fall of nurse migration to the United States, as shown in the figure below.
Figure: Number of Nurse Migrants, Post-secondary Enrollees, and Graduates
Source: Abarcar and Theoharides, 2021. Data from Commission on Filipinos Overseas (CFO) and Commission on Higher Education (CHED).
Combining administrative data on all migrant departures and post-secondary institutions in the Philippines, we investigate effects on post-secondary enrollment and graduation. For the Philippines as a whole, total four-year enrollment in nursing programs rose from 90,000 in 2000 to over 400,000 in 2006, before declining again in 2007. The number of new nursing graduates shows a similar pattern, though with a four-year lag due to the time it takes to complete a nursing degree (see above figure).
To isolate the causal impact of the two visa policy changes in the United States, we compare outcomes in Philippine provinces that historically sent a large number of nurse migrants to the United States to those that did not, before and after the policy changes. The intuition behind this strategy is that provinces with strong historical networks to the United States for nurses should be more affected by the policy changes than those without these networks.
Nursing enrollment and graduation increased substantially in response to greater U.S. demand for nurses. We estimate that nursing enrollment increased by 129 percent off a pre-period enrollment rate of 1.35% among the college-aged population, following the U.S. visa expansion in high relative to low nurse migration provinces. It also led to a 247 percent increase in nursing graduates, off a pre-period graduation rate of 0.16 percent among the college-aged population. While new nurses passed the licensure exam at lower rates, so many new individuals took the exam that for each new nurse that moved abroad, nine additional nurses were licensed in the Philippines, suggesting substantial brain gain of nurses. New nurses switched to nursing from other fields of study, but graduated at higher rates than they would have otherwise, resulting in an overall gain in post-secondary educated labor in the Philippines.
The supply of nursing programs expanded to accommodate increased demand for education. This supply response was concentrated among private schools, largely through nursing programs opening at existing private institutions, rather than the opening of entirely new nursing institutions. The effects on enrollment are largely driven by provinces with a large supply of existing post-secondary institutions that did not already have a nursing program. The ability of the supply of schooling to respond to increased demand is key for the brain gain effects we find. Such a response may not be possible in all contexts, for example in sub-Saharan Africa, where the post-secondary education system may not expand as readily in response to increased demand.
Fears of brain drain have led to calls to restrict the recruitment of medical workers from developing countries. Yet, our results suggest that expanded migration opportunities did not deplete the stock of nurses in the Philippines, and in fact, the supply of nurses, as well as the total human capital stock of college-educated labor in the Philippines, increased.
An important caveat is that our results may not translate to all settings, such as the most underdeveloped countries where post-secondary infrastructure may be unable to expand to meet demand. However, our results provide useful evidence for many low- to middle-income countries seeking to emulate the Philippines’ facilitation of labor migration: brain gain can dominate brain drain in the context of medical worker migration. This highlights the potential for well-designed partnerships between destination and origin countries.
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The study undertaken by Abarcar and Theoharides (forthcoming) is timely and appropriate especially in light of the obsession with brain drain (Kapur and McHale, 2005). Although the concept of brain drain is relatively new, it has been occurring for centuries (Hornung, 2014). North-South immigration such as Germany to Brazil after World War II, and current migration from North to countries such as Singapore and China, as well as South-South migration such as Indian teacher migration to Ethiopia has been going on for a long time. However, it only became an issue after predominantly western countries liberalized their immigration policies suggesting that factors other than economics are in play (for a detailed treatise of this see Reece Jones, 2022). Studies on negative impact of skilled immigration on receiving countries have also focused on the North. For details of directions for future research see the following post.
Future research needs to focus on two issues: Globally does skilled migration increase university enrollment in sending countries and does it vary by countries? Do destination countries matter? What is the role of institutions in increasing university enrollment? Does skilled migration result in increases in female enrollment? Finally, does skilled migration by efficiently allocating human resources lift all boats? Does it benefit both the sending and receiving countries? In this regard, remittances, Foreign Direct Investment, innovation and technology transfer and off-shoring are all likely to play a role. The answer to these questions will help us address the complexities of skilled migration rather than focusing just on brain drain and brain loss to sending countries.
Thank you, and I agree that these are future avenues for research.