Thanks Lauren for this really well thought through and balanced discussion of a really complex topic. This is one of the first times that I’ve seen such a nuanced approach, most articles are banging one side or the other when like you say—its really complicated and I . I have a couple of extra thoughts, which I don’t think add
1. I think this situation is so complicated that it is hard to make worldwide generalisations like “Medical immigation is good” or vice versa. Each country’s situation needs to be assessed differently. The Phillipines is a great example which I think is pretty clearly good for everyone, with a few caveats. In Nigeria I’m pretty uncertain as there are a wide range of positives and negatives there. If the new “double the doctors” training initiative came through I would lean towards positive, but otherwise I would lean a little negative (with enormous uncertainty)
2. A few points where calculations could maybe be improved (not the biggest deal) - You state the cost at $10,000 a year for training doctors, I think its likely to be a lot lower, maybe $5000 to $7000. BUT med school is never 3 years like you’ve estimated, more like 5 or 6 so your end calculation number might be pretty similar!
- You’ve left out internal remittances and potential tax benefits to the government in your remittances calculations—these aren’t insignificant as doctors earn decent wages by low income country standards and do benefit the country. This is a tricky counterfactual but our nurses spend about quarter of their income supporting their family, and doctors here would be similar. So if a doctor was earning 1,000 dollars a month, if they spent 20% on their family that would be $2500 a year. I’m not sure how to take this into account exactly under your calculation but I feel like the money local doctors pour into their less well off family members should be taken into account somehow.
And then there’s tax as well. Personally don’t think each tax dollar is worth much in low income countries—but most experts disagree with me.
3. Even though the literature doesn’t talk about it much, I think there are 2 potential harms of immigration that could be really bg but can be hard to quantify (I’ve banged on about this a few times) - First, often the most experienced and best doctors leave, which opens up leadership vacuums within important institutions. Like if a senior hospital doctor leaves, they aren’t “replacible” immediately. The flow on effects can be way more than just losing a doctor clinically - Second, the “Japa” effect (Nigeria) where everyone wants to leave the country can sow discontent and produce quite a negative environment. Won’t get into this in detail but have discussed before
Anyway thanks heaps for the article and again appreciate you bringing in perspectives from all sides without strawmanning!
Also posted on blog!
Thanks Lauren for this really well thought through and balanced discussion of a really complex topic. This is one of the first times that I’ve seen such a nuanced approach, most articles are banging one side or the other when like you say—its really complicated and I . I have a couple of extra thoughts, which I don’t think add
1. I think this situation is so complicated that it is hard to make worldwide generalisations like “Medical immigation is good” or vice versa. Each country’s situation needs to be assessed differently. The Phillipines is a great example which I think is pretty clearly good for everyone, with a few caveats. In Nigeria I’m pretty uncertain as there are a wide range of positives and negatives there. If the new “double the doctors” training initiative came through I would lean towards positive, but otherwise I would lean a little negative (with enormous uncertainty)
2. A few points where calculations could maybe be improved (not the biggest deal)
- You state the cost at $10,000 a year for training doctors, I think its likely to be a lot lower, maybe $5000 to $7000. BUT med school is never 3 years like you’ve estimated, more like 5 or 6 so your end calculation number might be pretty similar!
- You’ve left out internal remittances and potential tax benefits to the government in your remittances calculations—these aren’t insignificant as doctors earn decent wages by low income country standards and do benefit the country. This is a tricky counterfactual but our nurses spend about quarter of their income supporting their family, and doctors here would be similar. So if a doctor was earning 1,000 dollars a month, if they spent 20% on their family that would be $2500 a year. I’m not sure how to take this into account exactly under your calculation but I feel like the money local doctors pour into their less well off family members should be taken into account somehow.
And then there’s tax as well. Personally don’t think each tax dollar is worth much in low income countries—but most experts disagree with me.
3. Even though the literature doesn’t talk about it much, I think there are 2 potential harms of immigration that could be really bg but can be hard to quantify (I’ve banged on about this a few times)
- First, often the most experienced and best doctors leave, which opens up leadership vacuums within important institutions. Like if a senior hospital doctor leaves, they aren’t “replacible” immediately. The flow on effects can be way more than just losing a doctor clinically
- Second, the “Japa” effect (Nigeria) where everyone wants to leave the country can sow discontent and produce quite a negative environment. Won’t get into this in detail but have discussed before
Anyway thanks heaps for the article and again appreciate you bringing in perspectives from all sides without strawmanning!
Responded on Substack!