Doctor's Brain Drain in Nepal:
Exploring Patterns, Causes, Consequences &Solutions

July 21, 2013
Bed Raj Phuyel
GraSPP, MPP/IP
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57 Countries with a Critical Shortage of healthservice providers (Doctors, nurses andmidwives)
Nepal

Source: WHO, The World Health Report2Research Questions
 How many Doctors are migrating?

 Why they are migrating?
 What are the consequences?

 What could be the practical solutions?

3

Data, Method and Variables
 Data:◦ Bhargava A.,DocquierF., & MoullanY.(2010).. Emigration
data: data set1991-2004◦ Zimmerman M. et al. 2012. Institute of Medicine graduates’
migration data set for 1983-2004
Descriptive method with qualitative analysis

Doctors’ emigration - dependent variable

Immigration policy of receiving country,
Push/Pull/enabling factors – independent variable4Hypotheses
 Thereis significant prevalence ofdoctors brain drain in Nepal.

 Receiving country’s immigration policy

is the key factor for the doctors’
emigration from Nepal.

 There are adverse effects of doctors’

emigration on heath outcomes,
coverage and educational investment.
5How many doctors aremigrating?
140Number of Emigrated Physicians from Nepal
120100806040200year

Data source: Bhargava et al.
2012
6Migration rate?
0.100
0.090

Physician Emigration Rate

0.080
0.070

Fraction

0.060
0.050
0.040

0.030
0.020
0.010
0.000

Year

Data source: Bhargava et al.
20127

Migration rate?
Institute of Medicine (IoM) Graduates practicing in and outside
Nepal

Source: Zimmerman et al. 20128

Why?
Where are they going?
90

Receiving country wise Emigration Number80
7060504030

In 2002 UK
lunched point
based immigration
for professional

In 1994 USA started
Diversity Visalottery in Nepal

20100
1991

1992

1993

Australia

1994

1995

Italy

1996

1997 1998
YearSweden

1999
UK

2000

2001
USA

2002

2003

2004

S.Africa

Data source: Bhargava et al.
2012

9Why they are migrating?
 Push Factors◦ Lower employment opportunity◦ Lower wage
◦ Poor work environment◦ Less opportunity for Professional
development◦ Political instability(Nair & Webster, 2012)◦ Sociocultural change about profession◦ Security threats- physical attack, donation
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Why..?
 Pull Factors◦ Selective Immigration policy◦ High wage rate- >18 times in USA◦ Employment opportunities and careerdevelopment◦ Proximity and family links(Nair and Webster, 2012) Enabling Factors◦ Democracy- enter into globalized world◦ Internet - 199311

Consequences…heath outcomesSome Health related Millennium Development targets and their progress

1990

2000

2005

2010 2015 (Target)

GOAL: 4 REDUCE CHILD MORTALITY
Reduce by two thirds, between 1990 and 2015, the under-five
mortality rate
Under-five mortality rate 162

91

61

50

54

Infant mortality rate

10864

48

41

34

Proportion of one-year
olds immunized against
measles
4271

85

85.6

>90

MDG GOAL 5: REDUCE MATERNAL MORTALITY
Target 5.A: Reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio
Maternal Mortality Ratio
(MMR)
850

415281229

213

Proportionofbirths
attended by skilled healthpersonnel
7111928.8

60

Source: MDGs Progress Report Nepal,201012

Consequence.. Investment forgone
Estimation:
Each year government of Nepal is losing
its 10.85 to 18.2 million USD direct
investment- tuition fee waived-fromdoctors emigration.
Assumptions: 350 doctors emigrate each year Tuition subsidy- 31,000- 52,000 USD(1 USD=95.59 NPR July 20, 2013 rate)
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Consequences.. In population coverage
Physician per 1000 Population
0.080
0.070
0.060
0.050
0.040
0.030
0.020

0.010
0.000

Year

Data source: Bhargava et al.
201214Conclusions


Doctors emigration has been rapidly increasing , (>50 %) in
recent years.

USA and UK are the major receiving countries for Nepalese
doctors.



Selective Immigration policy of USA and UK seems to act as
a dominant pull factor for doctors emigration in Nepal.

Despite high emigration rate, health outcomes seem to be notaffected adversely.. Further analysis required .

The estimate loss of investment (10.85-18.2 million USD) is asignificant loss for Nepal.
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Policy recommendations


Nepal’s policy stand should be clear- producing doctors
for domestic market or international market?

If domestic market is priority- then the findings ofZimmerman et al.(2012) are practical to implementselecting rural based or paramedics student…..



Before being late, Nepal should initiate bilateralnegotiations with USA and UK to reduce the loss basedon International code of practices to make win-win
situation.

National demand focused curriculum should be madeand Psycho-social courses may be desirable, at least tomitigate
thefollowing
kindsofexisting
consequences…………..
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SevereShortage ofdoctors has
affected the
medicalservices at theKoshi Zonal
Hospital
Biratnagar (thesecond largest
city in Nepal)

Source: The Kathmandu
Post, July 15, 2013

…It is hard to finddoctors who arewilling to work forgovernment
hospitals becauseof low pay. Even
the Health Ministry
has not been able
to fill the vacantposts.

ReferencesBhargava A.,DocquierF., & MoullanY.(2010). Modeling the Effects of Physician Emigration on
Human Development.Retrieved from http://siteresources.worldbank.org/INTINTERNATIONAL/Resources/1572846-1283439445793/73682911283443649876/BDM_MPS.pdf
Nair M. and Webster P. 2012. Health Professionals’ migration in emerging market economies:patterns, causes and possible solutions. Journal of Public Health. 35(1):157-163.
Doi:10.1093/pubmed/fds087

World Health Organization. (2006). Working together for health: the World Health Report
2006. Geneva: World Health Organization. Retrieved fromhttp://www.who.int/whr/2006/whr06_en.pdf
Zimmerman M. et al. 2012. Medical students’ characteristics as predictors of career practicelocation: retrospective cohort study tracking graduates of Nepal’s first medicalcollege. British Medical Journal. 345: e4826

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Questions
Comments
Suggestions
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WMA statement
 “The World Medical Association at its General

Assembly meeting held in Helsinki, Finland in
September 2003 adopted a statement
declaring that every country should do its
utmost to educate adequate number ofPhysicians taking into account its needs andresources. No country should rely onimmigration from other countries to meet its
needs. Countries wishing to recruit
physicians from another country should only
do so through a Memorandum ofUnderstanding between the concernedcountries”
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