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BMC Health Services Research
Open Access
Research article
The cost of health professionals' brain drain in Kenya
Joses Muthuri Kirigia*
1,3
, Akpa Raphael Gbary
1
, Lenity Kainyu Muthuri
2
,
Jennifer Nyoni
1
and Anthony Seddoh
1
Address:
1
World Health Organization, Regional Office for Africa, Brazzaville, Congo,
2
School of Public Health, Kenyatta University, Nairobi, Kenya
and
3
Health Financing and Social Protection Unit, Division of Health Systems and Services Development, World Health Organization Regional
Office for Africa, D'Joue Road, P.O. Box 06, Brazzaville, Congo
Email: Joses Muthuri Kirigia* - kirigiaj@afro.who.int; Akpa Raphael Gbary - Gbarya@afro.who.int;
Lenity Kainyu Muthuri - lenitymuthuri@yahoo.co.uk; Jennifer Nyoni - Nyonij@afro.who.int; Anthony Seddoh - Seddoha@afro.who.int
* Corresponding author
Abstract
Background: Past attempts to estimate the cost of migration were limited to education costs only
and did not include the lost returns from investment. The objectives of this study were: (i) to
estimate the financial cost of emigration of Kenyan doctors to the United Kingdom (UK) and the
United States of America (USA); (ii) to estimate the financial cost of emigration of nurses to seven
OECD countries (Canada, Denmark, Finland, Ireland, Portugal, UK, USA); and (iii) to describe
other losses from brain drain.
Methods: The costs of primary, secondary, medical and nursing schools were estimated in 2005.
The cost information used in this study was obtained from one non-profit primary and secondary
school and one public university in Kenya. The cost estimates represent unsubsidized cost. The loss
incurred by Kenya through emigration was obtained by compounding the cost of educating a
medical doctor and a nurse over the period between the average age of emigration (30 years) and
the age of retirement (62 years) in recipient countries.
Results: The total cost of educating a single medical doctor from primary school to university is
US$ 65,997; and for every doctor who emigrates, a country loses about US$ 517,931 worth of
returns from investment. The total cost of educating one nurse from primary school to college of
health sciences is US$ 43,180; and for every nurse that emigrates, a country loses about US$
338,868 worth of returns from investment.
Conclusion: Developed countries continue to deprive Kenya of millions of dollars worth of
investments embodied in her human resources for health. If the current trend of poaching of scarce
human resources for health (and other professionals) from Kenya is not curtailed, the chances of
achieving the Millennium Development Goals would remain bleak. Such continued plunder of
investments embodied in human resources contributes to further underdevelopment of Kenya and
to keeping a majority of her people in the vicious circle of ill-health and poverty. Therefore, both
developed and developing countries need to urgently develop and implement strategies for
addressing the health human resource crisis.
Published: 17 July 2006
BMC Health Services Research 2006, 6:89 doi:10.1186/1472-6963-6-89
Received: 10 March 2006
Accepted: 17 July 2006
This article is available from: http://www.biomedcentral.com/1472-6963/6/89
© 2006 Kirigia et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0
),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Background
Most countries in the African Region of the World Health
Organization (WHO) continue to experience the loss of a
sizeable number of highly skilled health professionals
(physicians, nurses, dentists, and pharmacists) by their
migration to developed countries. There are three catego-
ries of emigrants: scientific trainees (Master's and PhD
level) who go overseas for training but fail to return upon
completion of their studies; health professionals who
obtain advanced training in developed countries, return
upon completion of their studies and then emigrate after
working for some duration; and health professionals who
train in local institutions but emigrate upon completion
of their studies and/or after working for some period of
time.
Emigration results from a combination of push factors (in
source countries) and pull factors (in recipient countries).
The reasons for scientific researchers failing to return to
their home countries after training abroad include: lack of
research funding; poor research facilities; limited career
structures; poor intellectual stimulation; threats of vio-
lence; lack of good education for children in home coun-
try [1,2]; and lack of the evidence-based decision-making
culture, leading to lack of recognition of potential contri-
bution of researchers to national health development.
The key push factors driving out health workers include:
weak health systems; insecurity including violence at the
workplace; poor living conditions; low remunerations;
lack of professional development opportunities (e.g. con-
tinuing education or training); lack of clear career devel-
opment paths [3]; and risk of HIV infection due to lack of
appropriate protective gear when handling specimens,
blood and blood products; nepotism in recruitment and
promotion; political unrest/civil wars; widespread pov-
erty; poor governance; and case overload.
Some of the factors that pull professionals to developed
countries may include: availability of information, easy
access to communication and technology, making it easy
to find jobs or complete visa applications and process;
aggressive targeted recruitment to fill vacancies in richer
countries; availability of employment opportunities; bet-
ter remunerations and working conditions [4]; secure and
conducive living conditions; and opportunities for intel-
lectual growth (e.g. refresher courses, access to Internet
and modern library facilities).
The push and pull factors in tandem have led to brain
drain of health professionals from African countries. This
has exacerbated the already weak national and district
health systems, making it extremely difficult for countries
in the Region to achieve the United Nations Millennium
Development Goals (MDGs) [5,6].
The objectives of this study were: (i) to estimate the finan-
cial cost of emigration of Kenyan doctors to the United
Kingdom (UK) and the United States of America (USA);
(ii) to estimate the financial cost of emigration of nurses
to seven Organization for Economic Co-operation and
Development (OECD) countries (Canada, Denmark, Fin-
land, Ireland, Portugal, UK, USA); and (iii) to describe
other losses from brain drain.
Methods
The data on the cost of non-boarding primary and second-
ary education were obtained from one non-profit reli-
gious mission school in Nairobi, Kenya. The public
primary and secondary schools are heavily subsidized. For
example, in 2003, Kenya decided to implement a free pri-
mary education policy in the entire country. Thus, use of
fees charged in public schools would grossly underesti-
mate the value of investment made by governments and
society in general. The religious mission schools levy fees
just enough to cover fixed and variable costs, earning nei-
ther a profit nor making a loss. At the other extreme are
the private-for-profit schools that aim at making super-
normal profits. The latter schools distort the resource allo-
cation process because they reflect the overpricing of edu-
cation production process. Therefore, among the three
categories of schools, the fees charged by religious schools
in Kenya were thought to be a closer reflection of the cost
of primary and secondary education.
The primary school period is for eight years; and the sec-
ondary school is for four years. Their cost consists of tui-
tion, lunch, transport, textbooks, stationery and uniforms.
The tuition, lunch and transport fees levied by the mission
schools aimed at covering the cost, not making a profit.
The data used to estimate the cost of training nurses and
doctors were obtained from the University of Nairobi (the
oldest national university in Kenya) medical school and
its college of health sciences self-sponsored (unsubsi-
dised) programmes. The other public university in Kenya
that trains medical doctors and nurses is the Moi Univer-
sity. The two universities charge equal fees for training of
doctors and nurses. The fees for government-sponsored
students are heavily subsidized, whereas the self-spon-
sored students pay fees that are equal to the cost of educa-
tion. Although the private universities do not train
medical doctors, some of them (e.g. Methodist University
and University of Eastern Africa) do train nurses. We used
the fees for self-sponsored medical and nursing students
in public universities as a proxy for the unsubsidised cost
of tertiary education.
The nursing programme is made up of four years of train-
ing and one year of internship. The medical doctor pro-
gramme consists of five years of training and one year of
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internship. The cost estimates were made up of unsubsi-
dised tuition fees, accommodation and living expenses.
The statistics on the number of Kenyan nurses working in
OECD countries were obtained from the World Health
Report 2006 [7]. The number of Kenyan doctors emigrat-
ing to various developed countries were obtained from
Stilwell et al. [3].
To obtain the average total cost of producing a doctor
(nurse) we summed up the average cost of medical school
(and nursing school) and the average costs of primary and
secondary schools. That gave us an approximation of the
total cost of training a medical doctor and a nurse.
To obtain the returns from investment foregone by society
when a doctor or a nurse emigrates, we multiplied the
average total cost of educating a health professional by a
compounding factor [8]. In algebraic terms, the lost return
from education investment into an i
th
doctor or nurse
(ILOSS
i = Doctor, nurse
) who decides to emigrate would be:
ILOSS
i = Doctor, nurse
= ATC
i,..
× (1 + r)
t
Where: ATC
i,..
= average total cost of educating a i
th
health
professional, e.g. doctor, nurse; (1 + r)
t
is the compound-
ing factor; 'r' is the interest rate; and 't' is the difference
between the average retirement age and the average age at
emigration. The above formula gives the accumulated
value or future value of the investment made into produc-
ing a doctor or nurse in 't' years.
The Commercial Bank of Africa has a fixed deposit interest
rate (r) of 6% and a mortgage rate of 16%; the East African
Building Society has a fixed deposit interest rate of 8.5%
and a mortgage rate of 16%; the Standard Chartered Bank
has a fixed deposit interest rate of 7.2% and a mortgage
rate of 16.5%; the Stanbic Bank has a fixed deposit interest
rate of 5% and a mortgage rate of 14.5%; the National
Bank has a fixed deposit interest rate of 6.2% and does not
have a mortgage service; and the Commercial Bank of
Kenya has a fixed deposit interest rate of 7.0% and a mort-
gage rate of 15%. The average fixed deposit interest rate is
6.65% per year. The average mortgage interest rate is
15.64% per year. The fixed deposit interest rates and the
mortgage rates were obtained from the banks mentioned
above by one of the authors (LHM) through face-to-face
interviews with the respective customer services managers.
The past studies have attempted to estimate the cost of
brain drain by taking into account only the tertiary cost
and disregarding the primary and secondary school
investments. We believe that this leads to underestima-
tion of the loss of returns from investments into human
resources for health that emigrate. This study takes into
account the total cost of educating a health professional to
be the sum of the cost of primary, secondary and tertiary
education. In order to get the total future value of this
investment that is lost due to brain drain, we applied the
above-mentioned compounding formula to estimate the
cumulative loss of future returns.
Results
Economic loss due to emigration of doctors
A total of approximately 167 medical doctors from Kenya
work in two developed countries. Forty-four per cent of
them work in the UK and 56% in the USA [3].
Table 1 presents the primary and secondary school costs
breakdown per student. Table 2 presents a breakdown of
the costs per nursing and medical students at the Univer-
sity of Nairobi.
Table 3 summarizes the cost of training a single doctor
and a single nurse and the returns from investment lost
when they emigrate to work outside their home country.
The cost of tertiary education of a single doctor in Kenya
is approximately US$ 48,169. The total cost of secondary
education per student is US$ 6,865 and that for primary
education US$ 10,963. Thus, the total education cost per
medical doctor is US$ 65,997 (i.e. US$ 48169+US$
6,865+US$ 10,963). That figure does not represent the
loss incurred by society as a result of emigration of a single
medical doctor. The real loss is the cumulative dollar
value of the investment made by the Kenyan society in
producing a doctor who decides to emigrate for a period
of 't' years.
Let us assume that the average age of emigrating doctors is
30 years [3]; the average statutory pensionable age for
Europe and Americas is 62 years [7]; an emigrant doctor
would work for 32 years before retirement; and the cur-
rent average interest rate on fixed deposits in Kenya is
6.65%. If the amount of US$ 65,997 (i.e. cost of educating
one medical doctor) were put into a commercial bank for
a period of 32 years at a fixed deposit interest rate of
6.65% per annum, the investment will grow to US$
517,931. This is obtained by applying the standard com-
pounding formula: [(initial investment) × (1+r)
t
] = [US$
65,997 × (1+0.0665)
32
]. Therefore, on average, for every
doctor that emigrates, a country loses about US$ 517,931.
The economic loss incurred by Kenya as a result of the
brain drain of 167 medical doctors [3] is US$ 86,494,477,
i.e. 167 doctors × US$ 517,931 per doctor.
Sensitivity analysis of the interest rate
The lowest interest rate for fixed deposits in Kenya is 5%.
Thus, when we use an interest rate of 5% instead of aver-
age interest rate of 6.65%, the returns from investing into
a single doctor equals US$ 314,472, i.e. [US$ 65,997 ×
(1+0.05)
32
]. The return from investment in 167 doctors
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equals US$ 52,516,824, i.e. 167 doctors × US$ 364,041.
The use of an interest rate of 5% instead of 6.65% reduces
the amount of economic loss per doctor by 39.3%.
The average mortgage interest rate in Kenya is 15.64% per
annum. Let us, instead, assume that US$ 65,997 is
invested for 32 years at 15.64% interest rate. At that rate,
the investment for one doctor would yield US$
6,902,125, i.e. [US$ 65,997 × (1+0.1564)
32
]. And the
yield for 167 doctors would be US$ 1,152,654,875, i.e.
167 doctors × US$ 6,902,125. Therefore, the use of an
interest rate of 15.64% instead of 6.65% increases the
amount of economic loss per doctor 13.3-fold.
Sensitivity analysis of the pensionable age (years)
The pensionable age (years) for the health workforce in
the Americas and Europe ranges from a minimum of 55 to
67 years [7]. Assuming the minimum pensionable age of
55 years, if the amount of US$ 65,997 (i.e. cost of educat-
ing one doctor) were invested for a period of 25 years (i.e.
55–30 years), at an interest rate of 6.65% per annum, the
investment will grow to US$ 330,024, i.e. [US$ 65,997 ×
(1+0.0665)
25
]. On the other hand, let's assume a pension-
able age of 67 years. A deposit of US$ 65,997 in a com-
mercial bank for a period of 37 years (i.e. 67–30 years), at
a fixed deposit interest rate of 6.65% per annum, grows to
US$ 714,621, i.e. [US$ 65,997 × (1+0.0665)
37
]. There-
fore, the use of a pensionable age of 67 increases the
amount of economic loss per doctor by 38%.
Economic loss due to emigration of nurses
According to the World Health Report 2006 [7], about
1,213 nurses and midwives trained in Kenya work in
seven OECD countries, i.e. 3.3% (1213/37113) of total
number of nurses and midwives working in Kenya.
The tertiary cost of training one nurse in a Kenyan school
of health sciences is about US$ 25,352. Since the cost of
secondary education is US$ 6,865 and that for primary
education is US$ 10,963, the total cost of educating one
nurse is US$ 43,180, i.e. US$ 25,352 + US$ 6,865 + US$
10,963.
Let us assume that the average age of emigrating nurses is
30 years; the average statutory pensionable age for Europe
and Americas is 62 years [7]; an emigrant nurse would
Table 1: Mission primary and secondary school costs per student
Primary school cost per student
Year Tuition cost per year
(Ksh)
Lunch cost per year
(Ksh)
Transport cost per
year (Ksh)
Cost of textbook+
stationary+ uniforms
(Ksh)
Sub-total costs (Ksh)
1 54 300 19 500 15 000 7 000 95 800
2 54 300 19 500 15 000 7 000 95 800
3 54 300 19 500 15 000 7 000 95 800
4 54 300 19 500 15 000 7 000 95 800
5 57 300 19 500 15 000 7 000 98 800
6 57 300 19 500 15 000 7 000 98 800
7 57 300 19 500 15 000 7 000 98 800
8 57 300 19 500 15 000 7 000 98 800
Total cost (Ksh) 446 400 156 000 120 000 56 000 778 400
Total cost (US$) 6 287 2 197 1 690 789 10 963
Year Mission secondary school cost per student
1 74 300 19 500 15 000 14 000 122 800
2 71 300 19 500 15 000 14 000 119 800
3 71 300 19 500 15 000 14 000 119 800
4 76 500 19 500 15 000 14 000 125 000
Total cost (Ksh) 293 400 7 8000 60 000 56 000 487 400
Total cost (US$) 4 132 1 099 845 789 6 865
Notes: US$1 = 71 Kenya Shillings (Ksh). The statistics in this table represent unsubsidized cost.
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work for 32 years before retirement; and the current aver-
age interest rate on fixed deposits in Kenya is 6.65%. If the
amount of US$ 43,180 (i.e. cost of educating one nurse)
were put into a commercial bank for a period of 32 years,
at a fixed deposit interest rate of 6.65% per annum, the
investment will grow to US$ 338,868, i.e. [US$ 43,180 ×
(1+0.0665)
32
]. Therefore, on average, for every nurse that
emigrates, a country loses about US$ 338,868. Applying
that figure to all the 1,213 Kenyan nurses working in the
seven OECD countries results in an economic loss of US$
411,046,884, i.e. 1213 nurses × US$ 338,868 each.
Sensitivity analysis of the interest rate
The lowest fixed deposit interest rate in Kenya currently is
5% per annum. If we used an interest rate of 5% instead
of 6.65%, the returns from investing in one nurse would
Table 2: Public University parallel programme cost per nursing student and cost per medical doctor
College of health sciences programme cost per nursing student
Year Tuition Cost Per year (Ksh) Accommodation+ Living
expenses (Ksh)
Sub-total cost (Ksh)
1 240 000 120 000 360 000
2 240 000 120 000 360 000
3 240 000 120 000 360 000
4 240 000 120 000 360 000
5 240 000 120 000 360 000
Total cost (Ksh) 1200 000 600 000 1800 000
Total cost (US$) 16 901 8 451 25 352
Year Public university parallel programme cost per medical doctor
1 450 000 120 000 570 000
2 450 000 120 000 570 000
3 450 000 120 000 570 000
4 450 000 120 000 570 000
5 450 000 120 000 570 000
6 450 000 120 000 570 000
Total cost (Ksh) 2 700 000 720 000 3 420 000
Total cost (US$) 38 028 10 141 48 169
Note: The statistics in this table represent unsubsidized cost.
Table 3: Summary of educational cost and lost returns from investment
Institution Doctor Nurse
Primary school cost (US$) 10 963 10 963
Secondary school cost (US$) 6 865 6 865
Tertiary institution cost (US$) 48 169 25 352
Total Cost (US$)
a
65 997 43 180
Total cost compounded at an average interest rate of 6.65% over 32 years (US$)
b
517,931 338,868
Total cost compounded at an interest rate of 5% over 32 years (US$)
c
314,472 205,750
Total cost compounded at an interest rate of 15.64% over 32 years (US$)
d
6,902,125 4,515,869
Notes:
a
This is the money invested in training of a doctor and a nurse.
b
Is the return from investment lost (at 6.65% interest rate) when a single doctor or nurse emigrates.
c
Is the return from investment lost (at 5% interest rate) when a single doctor or nurse emigrates.
d
Is the return from investment lost (at 15.64% interest rate) when a single doctor or nurse emigrates.
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yield US$ 205,750, i.e. [US$ 43,180 × (1+0.05)
32
]. The
use of an interest rate of 5% reduces the amount of eco-
nomic loss per nurse by 39.3%.
The average housing mortgage interest rate in Kenya is
15.64% per year. Let us, instead, assume that the amount
of US$ 43,180 is invested for 32 years at 15.64% interest
rate. At that rate, the investment for one nurse would yield
US$ 4,515,869, i.e. [US$ 43,180 × (1+0.1564)
32
]. There-
fore, the use of an interest rate of 15.64% increases the
amount of economic loss per nurse 12-fold, i.e. compared
to the economic loss at the average interest rate of 6.65%.
Sensitivity analysis of the pensionable age (years)
The pensionable age (years) for the health workforce in
the Americas and Europe ranges from a minimum of 55 to
67 years [7]. Assuming the minimum pensionable age of
55 years, if the amount of US$ 43,180 (i.e. cost of educat-
ing one nurse) were put into a commercial bank for a
period of 25 years (i.e. 55–30 years), at a fixed deposit
interest rate of 6.65% per annum, the investment will
grow to US$ 215,926, i.e. [US$ 43,180 × (1+0.0665)
25
].
On the other hand, let's assume a pensionable age of 67
years. A deposit of US$ 43,180 in a commercial bank for
a period of 37 years (i.e. 67–30 years), at a fixed deposit
interest rate of 6.65% per annum, grows to US$ 467,557,
i.e. [US$ 43,180 × (1+0.0665)
37
]. Therefore, the use of a
pensionable age of 67 increases the amount of economic
loss per nurse by 38%.
Discussion
Key findings
The objectives of this study were: (i) to estimate the
opportunity cost of emigration of Kenyan doctors to the
United Kingdom (UK) and the United States of America
(USA); (ii) to estimate the opportunity cost of emigration
of nurses to seven OECD countries (Canada, Denmark,
Finland, Ireland, Portugal, UK, USA); and (iii) to describe
other losses from brain drain. The key findings were as fol-
lows:
▪ The total cost of educating a single medical doctor from
primary school to university was US$ 65,997.
▪ On average, for every doctor that emigrated, a country
lost about: (i) US$ 517,931, assuming a 6.65% interest
rate; (ii) US$ 314,472, assuming an interest rate of 5%;
and (iii) US$ 6,902,125, assuming an interest rate of
15.64%.
▪ The total cost of educating one nurse from primary level
to college of health sciences was US$ 43,180.
▪ On average, for every nurse who emigrated, a country
lost about: (i) US$ 338,868, assuming a 6.65% interest
rate; (ii) US$ 205,750, assuming an interest rate of 5%;
and (iii) US$ 4,515,869, assuming an interest rate of 15%.
▪ The application of an interest rate of 15.64% instead of
6.65% increases the economic losses resulting from emi-
gration of a doctor and a nurse by 13-fold.
The United Nations Commission for Trade and Develop-
ment (UNCTAD) has estimated that each migrating Afri-
can professional represents a loss of US$ 184,000 [1]. Our
study estimated economic loss incurred by African coun-
tries as a result of emigration of one doctor to be about
US$ 517,931 and one nurse to be US$ 338,868. Thus, our
estimated losses to Kenya as a result of emigration of a sin-
gle medical doctor and a single nurse are two times and
three times the UNCTAD estimate respectively. Our esti-
mates are higher than those of UNCTAD for two reasons:
(i) we take into account the investments made into pro-
duction of doctors and nurses from primary school to ter-
tiary training institutions; and (ii) we take into account
the cumulative financial effects of the lost returns from
investments as a result of the brain drain.
Other losses from brain drain
When health professionals emigrate, Kenya loses far more
than the cost incurred by society to educate them. This is
because there are several other losses that are not captured
in the education-costing methodology. Some of those
losses are:
Loss of health services
Health professionals (especially doctors and nurses) con-
tribute to health promotion, disease prevention, diagno-
sis, treatment and rehabilitation. The ratios of doctors and
nurses to the population in Kenya are very low, and, as a
result, medical practitioners and nurses are usually over-
loaded with work [9]. Thus, the emigration of doctors and
nurses (and other health professionals) exacerbates the
human resource shortage within the national and district
health systems and reduces their capability to perform
their functions (of stewardship, health financing,
resource/input creation and health service production and
provision) and achieve their goals of health improve-
ment, responsiveness to client's legitimate expectations
and fairness in financial contributions.
Loss of supervisors
Practising doctors and senior nurses normally play major
roles in supervising staff in peripheral facilities (e.g. health
centres, dispensaries and health posts) that serve the
majority of populations. Thus, when such doctors and
nurses emigrate, the supervisory capability is lost (or
diminished), contributing to further weakening of the
capacities of such health facilities to provide quality serv-
ices to patients. This compels the staff left behind to
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assume greater responsibilities than they had been trained
for, invariably leading to a decline in the quality of health
services.
Loss of mentors for health sciences trainees
Practising doctors (and senior nurses) train and counsel
(advise) new employees and students doing their intern-
ship. The emigration of either cadre has negative inter-
generational effect on the process of health-related
human capital creation in the country.
Loss in functionality of referral systems
The hierarchical national referral system consists of terti-
ary hospitals (apex), provincial hospitals, district hospi-
tals, health centres, dispensaries, health posts and
community services. It permits movement of patients
from the base of the national health system to the apex
and vice versa. Although the movement of patients
should, in principle, be initiated by health professionals,
in practice, patients move themselves up and down this
system. Patients bypass the cheapest health units (health
centres, dispensaries and health posts) mainly due to lack
of doctors and diagnostic services [10]. Those two factors
create adverse incentives for patients to bypass the cost-
effective health units and to seek care in more expensive
hospitals. Thus, emigration of doctors contributes to inef-
ficiency and weakening of the referral system.
Loss of role models
Children often view doctors and nurses practising in com-
munities as examples to be imitated and emulated. Thus,
external migration not only robs such children of positive
role models, it also negatively affects their dreams and
aspirations and hence the number of children aspiring to
become health professionals.
Loss of public health researchers
Many of the specialized doctors who emigrate are often
among the very few active/published researchers that the
country has. Emigration of such people stifles innovation
and invention in persistent local public health problems,
e.g. HIV/AIDS, tuberculosis and malaria.
Loss of custodian of human rights, especially in rural areas
A recent study on the status of national health research
bioethics committees in the WHO African Region found
that many countries did not have functional ethical
review systems that protected the dignity, integrity and
safety of citizens who participated in research [11].
Authors argued that health professionals who were posted
in rural areas, by virtue of being the most educated, often
bore the burden of assuring that the human rights of their
actual and potential clients were respected and protected
in the course of their clinical work and research carried
out by others.
Loss of savings (investment capital)
In Kenya, health professionals are among the relatively
better-paid persons, and thus they contribute to accumu-
lation of national savings. Those savings are eventually
loaned to entrepreneurs for investment. Thus, emigration
may lead to loss of such savings, except where persons
who emigrate remit their savings back to the country for
investment.
Loss of entrepreneurs
The health practitioners, by virtue of their education and
earnings, quite often set up health-related (e.g. private
clinics, hospitals, pharmacies) and non-health-related
businesses (e.g. retail and wholesale shops). Thus, emigra-
tion reduces the growth of entrepreneurship in affected
countries and the prospects for economic growth.
Loss of employment opportunities
Doctors and nurses usually provide job opportunities for
housekeepers, gardeners and security guards at their
places of residence. Thus, emigration of practising health
professionals usually results in loss of employment
opportunities and income for those poor workers and
their families.
Loss of tax revenue to government
Given the fact that health professionals are among the rel-
atively well-paid persons in Kenya, they are also major
contributors to the country's income-tax collection. Since
the incomes of emigrants are not liable to tax administra-
tion systems of Kenya, emigration leads to a net loss in tax
revenues.
Disruption of families
In some instances, due to immigration restrictions, the
emigrating health professionals are not allowed to take
along their families. Due to spatial distance and loneli-
ness, some of those emigrants may choose to get new mar-
riage partners in their countries of work. This may bring
psychological and economic suffering to family members
left behind in Kenya.
'Internal' brain drain
The brain drain, broadly construed, not merely reduces
the supply of vital health professionals in Kenya, even
more seriously, it diverts the attention of those who
remain from important local problems and goals [12].
These include provision of primary health care services
(including health promotion and primary and secondary
prevention of diseases) and promotion of problem-ori-
ented training and research on important domestic public
health issues. Such needs are often neglected as training
and research get dominated by rich-country ideas as to
what represents true professional excellence. Those highly
educated and skilled Kenyan health professionals who do
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not physically migrate to developed countries 'migrate
intellectually' in terms of the orientation of their activities.
Loss of an important element of the middle class
Arguably, physicians comprise an important segment in
the social and economic make-up of the middle class.
They are generally respected as being above corruption,
they advocate for quality public schools, they provide a
market for consumer goods, and they contribute to polit-
ical, social and economic stability. Furthermore, they cre-
ate demand for democratic institutions [13].
Alleged redeeming features of movement of health workers
abroad
Some middle-income countries like the Philippines train
health workers for international export. The World Health
Report 2006 [7] states that: "The government of the Phil-
ippines has encouraged temporary migration by its pro-
fessionals in recent years and taken measures to turn
remittances into an effective tool for national develop-
ment by encouraging migrants to send remittances via
official channels. In 2004, the Central Bank of the Philip-
pines reported total remittances of US$8.5 billion, repre-
senting 10% of the country's gross domestic product
(GDP)" (p.101).
Unlike the case of the Philippines, where the government
strategically encourages temporary emigration of health
workers for remittances and for acquisition of skills and
expertise, the Kenyan government does not encourage
health professionals to emigrate due to the large unmet
need for their services, especially in rural areas where
about 80% of the population lives. The relatively meagre
remittances by the Kenyan health professionals working
abroad are sent directly to family members and not
through official treasury channels [13]. Those resources
are not available for strengthening of medical (and nurs-
ing) schools and national health systems. Furthermore,
although remittances are beneficial to the emigrants' fam-
ily members, they may contribute to widening the gap
between the rich and poor.
It has also been argued that if health workers return home,
they bring significant skills and expertise back to their
home countries. There is no evidence that Kenyan health
professionals working abroad ever return home after
working for a few years to share the knowledge and skills
acquired abroad.
The 'fiscal space' (budgetary room) [14] in low-income
countries, like Kenya, has often constrained them from
employing all the available human resources for health.
This has often resulted in the paradoxical scenario of
unemployment of some cadres of health professionals
amidst the large unmet need for their services. For exam-
ple, around 4,000 unemployed nurses in Kenya do not
constitute a real surplus since there is a large unmet need
for their services [15].
Heller [14] indicates that countries like Kenya can poten-
tially increase their "fiscal space", for example to employ
the unemployed nurses, in four ways: (i) generation of
additional revenues through increased taxes or strength-
ened tax administration; (ii) efficiency savings or reduc-
tion in unproductive expenditures, e.g. spending on
defence, foreign travel or embassy expenses; (iii) domestic
and/or external borrowing, e.g. sustained and predictable
external grants; and (iv) printing money to finance addi-
tional government spending, which is an undesirable
option since it might fuel inflation.
Even assuming that 'fiscal space' was not an issue, that
there was a real surplus of nurses, and that Kenya decided
to export them to developed countries, the government
should try to negotiate for reimbursement of not just the
training cost of US$43,180 per nurse but the lost returns
from investment of between US$205,750 and
US$4,515,869 per nurse. Those resources can be used to
strengthen the tertiary institutions that produce human
resources for health.
Limitations of the study
Our study had some limitations:
a) Due to the unavailability of data, the study focused on
only two categories of health professionals (i.e. doctors
and nurses) even though there was anecdotal evidence of
brain drain among other cadres.
b) The cost estimates presented in this study were only for
undergraduate programmes, while many of the doctors
and nurses emigrating may have had postgraduate quali-
fications. Thus, by not capturing the postgraduate invest-
ment, we would have underestimated the cost of training,
and hence, the lost returns from investment in postgradu-
ate training.
c) Due to lack of information on the total amounts of
money remitted to Kenya by emigrant doctors and nurses,
it was not possible to estimate the net loss of returns from
investments resulting from emigrating health profession-
als. If the data on remittances were available, the net loss
would have been equal to the total economic loss minus
the total remittances.
Suggestions for further research
The following aspects are in need of further research:
(a) Monitor the trends of the effects of loss of health serv-
ices as a result of external migration of key cadres of
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human resources for health, such as specialist doctors and
nurses, pharmacists and lecturers of medical and nursing
schools.
(b) Establish a database of cost of primary, secondary and
tertiary education of various categories of human
resources for health, and cost of alternative strategies for
stemming the tide of brain drain.
(c) Establish a programme for systematic monitoring of
international migration of different cadres of human
resources for health and tracking of remittances of
income.
(d) Application of the contingent WTP approach in the
valuation of the socioeconomic loss incurred by Kenya
due to brain drain of different categories of human
resources for health. It has also been applied in Africa to
value the benefits of insecticide-treated bednets [16,17],
community-based health insurance [18,19] and health
outcomes of interventions against schistosomiasis [20].
(e) Identify the determinants of health staff motivation,
including their health-related quality of life [21] and
retention through regression analysis.
Conclusion
Our study estimated the economic loss incurred by Kenya
as a result of emigration of one doctor to be about US$
517,931 and one nurse to be US$ 338,868. However, we
suspect that the magnitude of the socioeconomic loss due
to brain drain is likely to be even larger than our estimates.
Therefore, there is need for more precision in the meas-
urement of the magnitude of the socioeconomic loss due
to brain drain, for use in advocacy and policy. We propose
the use of Contingent Valuation to measure the benefits
from investments into specific categories of human
resources for health. Those benefits would be a more accu-
rate indicator of the losses incurred by Kenya due to brain
drain.
Developed countries continue to deprive Kenya of mil-
lions of dollars worth of invaluable investments made in
the production of health workers. If the current trend of
poaching of the scarce human resources for health (and
other forms of human resources) from Kenya is not cur-
tailed, the chances of achieving the Millennium Develop-
ment Goals would remain dismal. Since the limited
human resources for health are the head, heart and hands
of the national and district health systems [22], the con-
tinued plunder of investments embodied in human
resources contributes to: 1) the growing double burden of
communicable and non-communicable diseases (by
weakening health promotion and primary and secondary
prevention); 2) further underdevelopment of Kenya; and
3) keeping a large proportion of the Kenyan population in
the vicious circle of poverty and ill-health.
Economic arguments notwithstanding, ultimately the
price of emigration of human resources for health from
Kenya to developed nations is paid in unnecessary debil-
ity, morbidity, human suffering and premature death
among Kenyan people. This unacceptable situation
should be urgently reversed through joint action by both
developing and developed countries.
Competing interests
The author(s) declare that they have no competing inter-
ests.
Authors' contributions
JMK did the analysis of the data and participated in the
drafting of all sections of the manuscript. ARG, JN and AS
participated in the drafting of the background, methods
and discussion sections. LKM collected the data and par-
ticipated in the background, methods and discussion sec-
tions.
Acknowledgements
We are grateful to the Deans of Faculties of Health Sciences in the Univer-
sity of Nairobi and Moi University and the Heads of Loreto Msongari Pri-
mary and Secondary Schools for providing the cost data that has been used
in this study. We are also grateful to the Customer Services Managers in
the Commercial Bank of Africa, the Commercial Bank of Kenya, the East
African Building Society, the National Bank, the Stanbic Bank, and the Stand-
ard Chartered Bank for providing information on their annual fixed deposit
interest rates and mortgage interest rates. We are grateful for criticisms
and suggestions made by the three peer reviewers (Adamson Muula, Amy
Hagopian and Pascal Zurn) which helped to improve the quality of this
paper. We are grateful to Mr. A Kochar for editorial help. JMK, ARG and
JN owe gratitude to Dr Alimata J Diarra-Nama for creating an enabling
environment in the Division of Health Systems and Services Development
at WHO/AFRO. Finally, we are immensely grateful to Jehovah Jireh for hav-
ing inspired us to undertake the study.
The article contains the analysis and views of the authors only and does not
represent the decisions or stated policies of the World Health Organiza-
tion or the Kenyatta University.
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