Memo to the WHO: Blocking health worker migration is not the answer

This guest post is written by Michael Clemens and Amanda Glassman. Through this Sunday, April 17, the World Health Organization (WHO) is seeking comments on its plans to monitor compliance with a global code of practice on the international migration of doctors and nurses.

We think there are better, cost-effective ways to improve health workforces in developing countries than compliance with this code that is self-contradictory, unlikely to help the poor, and ethically problematic.

First, the code contradicts itself. It establishes that all health workers—like all people—have the right to leave their countries to seek a better life (section 3.4) and that the international movement of health workers between two countries benefits both of them (section 3.8), through skill formation and technology transfer… and then it says that such movement must be stopped. It urges all countries to seek zero international movement of health workers—both by filling all their health sector positions with locals (section 5.4) and by stopping the recruitment of health workers from countries facing shortages (5.1), that is, the poorest countries where conditions for health workers are the worst. This contradiction is as baffling as saying: “You may drive anywhere you wish, now that my friends have taken away your car.”

Second, the self-sufficiency and anti-recruitment strategies endorsed by the code—certain to harm poor-country health workers—are unlikely to improve basic health outcomes for others in the most vulnerable poor countries. Blocking a Mozambican surgeon from stepping across the border into South Africa does little to remedy a long list of problems that primarily determine poor health outcomes in Mozambique: poor sanitation, tainted water supplies, lack of malaria prevention, little incentive for health workers to serve rural areas, a disconnect between health workers’ advanced skills and the basic needs of the poorest, risky sexual practices among the public, absenteeism at ostensibly staffed clinics, constraints on income and education that limit the public’s demand for formal health care, lack of pharmaceuticals, needless legal barriers to private practice for underserved communities, and so on.

Finally, while the benefits of forcibly blocking that Mozambican doctor from entering South Africa are unclear, the harm is perfectly clear. It certainly limits her freedom in a way that no one at the WHO would want their own freedoms restricted. Whether her movement is blocked by denying her entry at the border, by eliminating all the jobs she could have taken (self-sufficiency for South Africa), or by concealing from her any information about those jobs (banning anyone from recruiting her), the effect is equally ethically troubling. Her movement is stopped by others, against her will, without consulting her. Worse, it is usually done by people enjoying vastly higher living standards than she can enjoy in Mozambique, living standards that most of them enjoy by birthright.

Fortunately, there are good alternatives to coercive barriers on health worker movement. A team of World Bank health experts recently studied the human resource policies of Kenya, Zambia, Rwanda, and the Dominican Republic, and found several other ways that all four countries could improve the effectiveness of their health workforces:

[S]ignificant weaknesses were found in policies and practices related to recruitment, deployment, transfer, promotion, sanctioning, and payment methods of public sector health workers. Recruitment processes are plagued by delays and not targeted to areas with staff shortages. Salaries and allowances are not being used to provide strong incentives for increasing rural practice and lowering absenteeism. Available wage bill resources are often not fully spent, and even when they are, considerable scope is available to use these resources more strategically. Thus, improving recruitment, deployment, transfer, promotion, and remuneration practices is just as important—and maybe more important—than expanding the health wage bill in addressing health workforce challenges.

In other words, there is much that countries can do to make their health workforces more effective—with the side effect of decreasing health workers’ incentive to emigrate—even without spending much more money.

Likewise, Dr. Churnrurtai Kanchanachitra and co-authors have just offered a long list of ways that developing countries can strengthen health workforces without coercing health workers’ movement. These include creating incentives for health workers to work in rural areas; dealing with other constraints like financial barriers and poor-quality health services that might be even more important in affecting health outcomes; and creating partnerships between hospitals from sending and receiving countries.

The WHO has chosen instead to focus on blunt instruments of coercion in its code of practice. But governments are not bound to the code, and may make better choices. As the WHO considers its guidelines for monitoring compliance with that code, it should reconsider the sections relating to self-sufficiency and anti-recruitment and strike them from the final version. We urge governments and the WHO to work constructively with the many alternative tools available to improve developing-country health outcomes and health systems without the troubling methods of coercion.

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If North Dakota were Zambia...

The Wall Street Journal had an article yesterday about the emptying out of the middle of the US. Controlling for ethnicity, the picture below shows in the darkest shades of red the greatest declines in the white population from 2000 to 2010:

What if we had a law that everybody had to stay in their home state? What if North Dakotans had to stay in North Dakota despite the collapsing economy there? Then wages would collapse and we would have very poor North Dakotans. Happily no one would dream of such a stupid law.  Instead we have middle class North Dakotans moving to other places voluntarily, where employers want to hire them voluntarily. And so (former) North Dakotans stay middle class.

For states...but not for countries. We treat migration usually as a non-option if Zambia has an economic decline, so Zambians stay there and get even poorer as the economy declines.

This is the great point made by Lant Pritchett in a classic article and in a CGD book. Why can't we start treating Zambians like North Dakotans?   If their home economy is declining, let them move to other places voluntarily, where employers want to hire them voluntarily. Why do we recognize the right to live wherever you want for North Dakotans and not for Zambians?

Response to David in comment below: yes things could be good for the North Dakotans left behind BECAUSE OF all the North Dakotans that have left. Just think of supply and demand for labor -- if the spur to migration was a downward shift in demand for labor, then having a lot leave shifts back the supply of labor and wages can remain the same. WITHOUT migration, North Dakota wages would have collapsed, which is what actually does happen in the migration-not-allowed Zambias of the world.

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The secret to fighting poverty is New Zealand

In a new World Bank blog post (h/t @poverty_action), economist David McKenzie explains why he thinks facilitating international migration should be at the top of everyone’s list of effective development interventions. Compared to microfinance, conditional cash transfer programs and cash grants to microentrepreneurs, a seasonal migration program in New Zealand produced WAY larger gains in annual income for program beneficiaries.

The good news doesn’t stop there. The usual fears for or about migrants—that they would be vulnerable to poor treatment, or that they would take advantage of the program to over stay their visas—don’t seem have materialized:

In addition to estimating per-capita income gains of 30-40%, we find that participating in the RSE leads to greater subjective well-being, more durable asset purchases, housing improvements, and in Tonga, a large increase in secondary schooling. Moreover, as a recent evaluation by New Zealand’s labor department found, these gains came with minimal displacement of native workers, and overstay rates of less than 1%.

Previously on this blog, Michael Clemens wrote that the development program known as leaving Haiti has pulled far more Haitians out of poverty than anything else that has ever been tried.

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Why is nobody worried about the Asian brain drain?

Aid-financed scholarships for African students to study in the US or Europe would be worth a lot more than a million "capacity-building" projects. The usual argument against such scholarships is fear of brain drain -- that the African students would not return home. So why is nobody worried about brain drain of the gigantic numbers of Asian students studying in the US?

Source: Institute of International Education

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When the brain drain is healthy for democracy

The endurance of Indian democracy is one of the great Indian puzzles. How has a population so large, so ethnically and linguistically fragmented, and so economically unequal managed to sustain a participatory democracy since 1947? What forces have kept the country politically stable, enabling the rapid economic growth of the past two decades? One intriguing answer comes from political scientist Devesh Kapur, who studies the political effects of skilled migration (the so-called brain drain) on migrants’ home countries (we’ve blogged before about the positive economic effects of the brain drain). In a new book presented yesterday at the Center for Global Development, Kapur finds:

[T]he positive selection of Indian migrants through education has strengthened India's democracy by creating a political space for previously excluded social groups. Because older Indian elites have an exit option, they are less likely to resist the loss of political power at home.

Governments have historically used emigration as a pressure valve, to rid themselves of political dissidents and other undesirables, and preserve stability at home. After the Paris-wide workers riots of 1848, the French government tried shaking their “subversive elements” by offering them land grants in Algeria. Kapur also cites the examples of Cuba and Zimbabwe, where leaders allowed the periodic exodus of discontented citizens as a deliberate strategy to keep their hold on political power while migrants’ remittances helped keep things going economically.

In the decades following independence in India, Kapur argues, the migration of India’s high caste, highly-educated elite allowed more middle and lower caste Indians empowered by new voting rights to seek more political power and a bigger share of economic pie. In the 1990s, as affirmative action threatened elite privileges, the rich let them go with less of a struggle because emigration to Europe or the US gave them other, attractive options. At the same time, though, Kapur says that members of the upper class that chose exit have still retained their voice: their continuing influence in Indian politics perpetuates social inequalities.

Tobias Pfutze (formerly one of our own at DRI) has also worked on this relatively neglected aspect of the brain drain, studying Mexican immigrants to the US and their influence on politics back home. In local elections in 2000 to 2002, Pfutze found that places in Mexico that sent more immigrants to the US were more likely to vote to boot out the authoritarian Institutional Revolutionary Party (PRI), which had dominated Mexican politics since 1929. His work suggests that the influence of Mexican immigrants to the US actually helped facilitate the Mexican transition from a one-party system to democracy.


photo credit

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Many do not realize that New York's thriving Chinatown is a suprisingly recent phenomenon.  Even during America's open immigration years in the late 19th and early 20th centuries, Chinese were not welcome.  The Chinese Exclusion Act of 1882 formalized ugly prejudice.

New York's Chinatown stayed very small, surrounded in the early 20th century by Italian and Jewish immigrants.

Even as late as 1950, Chinatown was small.

Chinese Exclusion stayed in effect de facto until 1965, when the racist provisions of US immigration law were removed, liberalizing immigration by all non-European groups.

Only 5 years later in 1970, Chinatown had already expanded greatly. Italians and Jews had already left for middle-class and upper-class neighborhoods elsewhere

Today Chinatown is one of Manhattan's most thriving neighborhoods. Other East Asian immigrants also congregate there.

The ladder out of poverty continues for today's immigrants, following the Italians and Eastern Europeans, who in turn had followed the Germans and Irish.

The next time I have dim sum at Jing Fong on Elizabeth Street, I'll raise a glass of green tea to immigration freedom.

Credits: The Lower East Side in 1920 map is from Eric Homberger, The Historical Atlas of New York City, Henry Holt and Company, 2005, p. 136. The other maps are from the great software program and database, Social Explorer.
Chinatown in 2007

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Do only democracies have anti-immigrant movements?

This great picture on changing share of foreign-born residents in the NYT today (showing countries with largest increase): You can see why anti-immigration sentiment is a big deal in the European countries shown and in the US. (This is a descriptive statement, I myself hate xenophobia.)

But what about the countries at the top of the graph? Let's exclude the special and controversial case of Israel from all the following statements.

Correct me if I'm wrong, but I have not heard of prominent anti-immigration movements  in any of these countries.

Is that because these are non-democracies in which immigrants can be treated as second-class citizens with little or no rights?

Again, this is just descriptive speculation -- I would certainly NOT recommend that approach to the democracies.  But it does show the complicated political economy you get when you mix xenophobia, democracy, equality before the law, and immigration.

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Before I was white

Nell Irvin Painter is an African-American historian at Princeton. I just finished her fascinating History of White People. The big story is what a slippery category "White" is, and how many today considered "White" used not to be. My German and Scots-Irish ancestors, some of whom probably arrived as indentured servants (i.e. temporary slaves),  were called "guano" (birdsh*t) by Ralph Waldo Emerson in 1851. Emerson of course placed Anglo-Saxon English at the top of the racial hierarchy.

But my ancestors later made it into the top in solidarity against new waves of "black" Irish Catholic immigrants in the mid-19th century, considered to belong to the inferior Celtic race.

Irish Catholics in turn were moved up into whiteness when the "swarthy" southern Europeans and eastern European Jews arrived in the late 19th century and early 20th century. These latter would become "white" in the 20th century, but not before racist hysteria slammed the American immigration door shut just before Jews and others desperately needed to escape from fascism in Europe.

Painter ranges far and wide, detailing efforts to define the poor as a separate race, and poverty a hereditable condition. Not to mention nonsense about skull measurements, and mythical histories of mythical peoples like Saxons, Nordics, and Aryans, all in a desperate attempt to have a bright line between White and non-White.

Now we know that no such line exists, but not before "race experts" spent a couple generations in power in the academic establishment. Good cautionary tale for being careful and modest when we attempt to talk about ethnicity and development today.

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Gujarati hotels and Chaldean liquor stores

UPDATE 2 (3/27, 8:24am EDT) Great academic paper on Jewish domination of the diamond trade (see end of post) UPDATE (3/26, 12:34EDT) Great NYT mag article explaining the details of the Gujarati hotel story (see end of post)

I’ve long been fascinated by the Vietnamese nail salon phenomenon. My female friends report a remarkably high concentration of Vietnamese women in nail salons in US cities. I even heard there was a nail trade magazine for the US market that is in Vietnamese. Alas I was never able to do more to document this systematically. Today I happened to stumble over a University of Chicago Ph.D. dissertation by Martin Mandorff that finally nailed it (bad pun was unavoidable).

Mandorff shows that ethnic specialization is remarkably widespread among US immigrants. The following table from 2000 census data shows the leading specializations (the OVER is how much males from that group are over-represented in the industry,* is for self-employed and ** is for employees).

Gujaratis (already famous worldwide as entrepreneurs and traders) are even more specialized as hotel owners. And then there is a group that I had only vaguely heard of: Chaldeans – they are Aramaic-speaking Roman Catholics from northern Iraq. They’ve got the liquor franchise.

It’s amazing how something so unexpected appears from the spontaneous efforts and social interactions of ethnic entrepreneurs. Mandorff of course has much more detailed and analytical explanations, which you should check out.

The phenomenon of ethnic business networks is of course not new, but it’s far more widespread than most people realize (almost every African nation has an indigenous group known as the entrepreneurs and traders –the Hausa in Nigeria, Gurage in Ethiopia, Serahule in the Gambia, etc.) And it’s too well known to even bother mentioning the famous merchant diasporas like the Jews, the Lebanese, East African Indians, overseas Chinese in SE Asia, and so on. Thomas Sowell has written at least TWO insightful books on the phenomenon: Race and Culture, and  Migrations and Cultures.  Avner Greif's now standard explanation  (at least partial explanation) for ethnic networks was that small ethnic clusters could use the the threat of explusion from the group to enforce contracts and other trustworthy behavior (a more precise version was worked out in his  famous article on the experience of Mediterranean traders called Maghribis --11th century Jews in Cairo).

It’s all a very big hint that social and family relationships, culture, and self-organizing networks are an important part of economic development that has been much neglected by previous generations of development economists. Now the tide is turning – I gave a whole two-hour Ph.D. class on Wednesday that only scratched the surface of recent research by economists on culture, social norms, and development.

UPDATE: just received link to an NYT article by the always amazing Tunku Varadarajan (formerly at Wall Street Journal, now colleague of mine at NYU) explaining where the Gujarati dominance of hotels came from:

70 percent of all Indian motel owners -- or a third of all motel owners in America -- are called Patel, a surname that indicates they are members of a Gujarati Hindu subcaste. ... ''In some American small towns they think 'Patel' is an Indian word for 'motel.'"

{Patels are members of a caste called} vaishyas, or traders, who were once employed to calculate the tithes that were owed to medieval kings by farmers in Gujarat, an Indian state on the Arabian Sea.

More great details follow in Tunku's article on how the "Patel Motel Cartel" came about in America.

UDPATE 2: An academic paper that traces the origins of Hasidic Jews dominating the 47th Street Diamond District in Manhattan all the way back to the 11th century, with some suggested explanations.

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Four Ways Brain Drain out of Africa is a good thing

Conventional wisdom frets that the exodus of skilled workers—the brain drain—is bad for African countries. The share of Africans with college degrees who live outside their home countries is certainly high: nearly half of Ghanaians, about 40 percent of Kenyans, and about one-third of Ugandans. The metaphor of the term itself implies that brain drain is a waste, as if all Africa’s most promising minds were being sucked down some global sink, leaving behind a parched continent. But a paper by William Easterly and Yaw Nyarko, published as a chapter in the new book Skilled Immigration Today: Prospects, Problems, and Policies, explores the arguments for and against brain drain, and builds on previous literature to argue four ways the benefits of brain drain could outweigh the costs to African countries.

1. Gains to migrants themselves. Why is this often ignored in brain drain discussions? Perhaps it reflects a neglect of the rights and well-being of individuals and an overemphasis on the nation-state as the object of development. The migrant is better off with higher living standards, not to mention satisfying her revealed preference to live in a country other than where she was born.

2. Gains to migrants’ families. Remittances is the most obvious and commonly-cited benefit of the brain drain. Even using official figures, which likely far undercount the value of remittances by excluding informal channels, remittances sent back by Africans abroad outweigh the cost of educating them at home. Why pass up a high return opportunity (Africans earning high incomes abroad and remitting) and insist on a low return activity (educated Africans underemployed at home)? Not to mention that families also get satisfaction from seeing their offspring realize their dreams.

3. Brain circulation.  Brains don’t just leave Africa, never to return.  Africans who have been educated or worked abroad do come back to their home countries to visit, to establish dual residence, to start businesses and universities, and, sometimes, to stay. These people bring back new ideas and skills—crucial ingredients to economic growth. Similar processes brought enormous benefits already to Asia and Latin America, so why would donors want to shut down this motor of opportunity only for Africa?

4. Stimulation of skill accumulation (“brain gain”). The possibility of migration and the example of role models who find success abroad (the Kofi Annan factor) provide incentives for young students to work hard and gain skills that will help them overcome the hurdles to migration. The authors argue that the new human capital created through these incentives offsets the loss of skilled people who do eventually leave.

If brain drain is not the bogeyman it is made out to be, those who argue for programs that restrict individual freedom in the name of “staunching the flow of brains” from Africa have even less of a case. (For example, the World Bank and the IMF published a 2007 report noting that “countries concerned about a ‘brain drain’ of their trained physicians to OECD markets might be able to reduce risks by setting national training requirements slightly lower than the rich countries’ standards.” The group Physicians for Human Rights has recommended that “[d]eveloping countries and organizations in developing countries should explore possibilities of limiting recruitment from abroad.”)

A better way to help migrants, and the African countries they come from, would be to increase even more the benefits of the so-called drain. For example, scholarship and exchange programs will increase the likelihood of brain circulation. Regulations and technologies to reduce the transaction costs of remittances sent home will be win-win for all.

Would Americans put up with a program that inhibits them from working in London or Paris? Skilled African migrants don’t need international organizations suggesting restrictions on where they should live and work either.

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TWOFER: Here’s how Haitians can rescue the US from its budget crisis and save themselves

In 2001, I published an obscure paper that concluded “Econometric tests and fiscal solvency accounting confirm the important role of growth in debt crises.” Based on this, I can now say that Haitians can rescue the US from an impending budget crisis. The crisis is already severe, with previously unthinkable warnings that US government bonds might lose their AAA rating. What does this have to do with Haitians? Here’s the longer, more technical version (if you’re impatient, skip to next paragraph): budget solvency is about the future, not just about the present. Our ability to service our government debt is greater the higher is expected growth of the economy, because that means higher expected growth of tax revenues. If you expect tax revenue to be a lot higher tomorrow because of high growth, then you don’t have to worry as much about where you find the tax money tomorrow to pay interest and amortize principal on the debt. Economic growth equals (Growth of GDP per person) PLUS (Growth of Population). So one overlooked aspect of Population Growth is that it is GOOD for preventing budget and debt crises. And population growth is driven in large part these days in the US by immigration from places like … Haiti. Of course it will take more than Haiti alone to supply enough immigrants, but letting in more immigrants to the US from poor countries is desirable already for both us and the immigrants.

Here’s the short version. If you are worried about having enough tax revenue to pay interest on the government debt, find more taxpayers! And look, here are some people volunteering to become new taxpayers: Haitian immigrants fleeing quakes and poverty! So let’s open the door to our Haitian fiscal rescuers, who will also lift themselves out of poverty as dramatized by a previous post. It’s a TWOFER!

NOTES: my attempt to make an exam question out of this did not attract a large response (OK I was mostly just trying to get out of writing the blog post last night). It did produce one very funny satire, and one good two-part answer, the second part of which was the “right” answer (a special virtual Rolex (Aid) Watch prize for Kevin!)


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The best way nobody’s talking about to help Haitians

The following post is by Michael Clemens, a research fellow at the Center for Global Development in Washington, DC, and an affiliated associate professor of public policy at Georgetown University.

The earthquake two weeks ago hit Haiti hard because Haiti is poor. The rich U.S. had similar earthquakes with far less carnage. So, what would do the most to lift Haitians out of poverty?

Start here: What has done the most, to date, to lift Haitians out of poverty? That answer is easy. Leaving Haiti brought more Haitians out of poverty than anything else that has ever been tried: any aid project in Haiti, or any trade preference for Haiti. See my note and video posted the day before Haiti’s catastrophe.

Of all the Haitians who live either in the United States or Haiti, and who live on more than $10 per day—at U.S. prices, adjusted for the fact that things are cheaper in Haiti—how many live in the U.S.? (That’s a barebones poverty standard, just one third of the U.S. “poverty line” for a single adult.)

82 Percent of Haitians above this poverty line are here in the United States. (I calculate this with Lant Pritchett here, ungated version here.) Only the top 1.4 percent of people in Haiti had that living standard even before the quake, and there is no evidence that Haitian emigrants come primarily from the extreme tip-top of the income distribution. So for most of Haitians who left, leaving Haiti was the cause of leaving poverty.

The Obama administration decided that for the next 18 months it will not deport any Haitian. But the U.S. has only been deporting about 1,000 Haitians per year recently. More importantly, the U.S. has forcibly stopped and repatriated about 5,000 Haitians per year for the past 20 years—people who never made it to the U.S. And this policy surely deterred thousands more each year from even trying. When Gallup asked people in Haiti last year if they would leave permanently if given the opportunity, 52 percent said yes. The U.S. is actively blocking the most effective poverty reduction strategy for Haitians.

When I talk about leaving Haiti as a development strategy for Haitians, some thoughtful people argue that this “can’t be the solution for Haiti.” Compared to what we all wish for in Haiti—rapid emergence from poverty for everyone there, in their homeland—leaving Haiti is a terrible solution. But compared to what is actually likely to happen in Haiti, continued poverty for decades at least, leaving Haiti is the principal solution to poverty. This is the right comparison, not the comparison to a prosperous Haiti that must remain a fantasy for now.

The best thing the United States could do for Haitians would be to let them in, either temporarily or permanently. We are now accepting about 21,000 permanent Haitian immigrants per year, and just a few hundred temporary workers per year. If we really wanted to raise Haitians out of destitution, we could absorb many times more than this. To say that we shouldn’t because it wouldn’t be the end-all solution is like saying that a lifeboat shouldn’t fill its ten empty seats just because there are 100 people in the water.

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