Full data were available for nine of 17 countries with prevalence thresholds for HIV/AIDS above 5% or with more than one million patients. Figure 1 shows the flow of countries through the study.
Fig 1Flow of countries through study
Table 1 displays important health indicators and statistics for the medical schools in the African source countries. South Africa, Nigeria, and Kenya had the largest number of people with HIV. South Africa had the highest density of doctors (8 per 10
000 population), whereas Nigeria had the largest number of medical schools (n=21).
Table 1 Statistics on health status and human resources in nine sub-Saharan African countries included in analysis
Using country specific statistics on gross domestic products, the public expenditure on primary and secondary education for each student for primary schools ranged from $490.0 (Zimbabwe) to $8448.5 (South Africa) and for secondary schools ranged from $336.2 (Ethiopia) to $9866.9 (South Africa, table 2).
Table 2 Expenditure on primary and secondary schools in nine sub-Saharan African countries, using the most recent year for which data were available
Table 3 shows the estimated government subsidised tuition costs for a doctor’s education in the nine source countries. Medical school costs for each student were highest in South Africa ($40
383), which also had the highest total education cost for each medical student ($58
698). At the other end of the spectrum, Uganda had the lowest medical school costs ($18
Table 3 Expenditure on medical schools in nine sub-Saharan African countries included in analysis
Table 4 shows the estimated compounded lost investment for each country, calculated using data on age distribution and number of African trained migrant doctors reported by the authorities in Australia, Canada, the United Kingdom, and the United States. The estimated loss of returns from investment for all doctors working in the destination countries was $2.17bn (95% confidence interval 2.13bn to 2.21bn). Table 4 shows the costs for each country. These ranged from $2.16m for Malawi (1.55m to 2.78m) to $1.41bn for South Africa (1.38bn to 1.44bn).
Estimated lost investment from training doctors in nine high prevalence HIV countries who are currently practising in Canada, the United States, the United Kingdom, or Australia
Relative burden on health systems
The estimated compounded lost investment for South Africa, accounting for more than 50% of the estimated compounded lost investment for all nine countries, was much larger than that observed in the other countries. Figure 2 displays the loss in relative terms. The size of each bubble represents the ratio of the estimated compounded lost investment over gross domestic product. From this perspective, Zimbabwe and South Africa seem to have the largest losses. The y axis corresponds to the ratio of (domestically trained) doctors working abroad in the target countries and those currently working domestically. Ethiopia, Zambia, and South Africa faired the worst.
Fig 2Loss of doctors to destination countries, compared with burden of HIV in nine African source countries. Size of each bubble represents ratio of estimated compounded lost investment over gross domestic product, and y axis corresponds to ratio (more ...)
Table 5 shows the results for the sensitivity analysis. Applying the best scenario assumption, the conditions decreased the estimated investment costs to $1.41bn. Compounding over the full length of a doctor’s career and using the deposit rate for each country (the worst scenario) led to substantial increases in investment loss. Half the estimated losses increased by more than 10-fold. In absolute numbers, South Africa had the largest change, from $1.41bn to $9.76bn. In total the countries would have lost $13.53bn.
Sensitivity analysis of estimated lost investment using variations on time working in destination countries, interest rates, and cost of education
Savings in destination countries from recruited doctors
Destination countries do not have to provide medical school training to doctors who successfully pass licensing examinations. Therefore destination countries benefit from not having trained recruited doctors. Based on the number of doctors working from the nine source countries and the average cost of medical education in these countries, this equals a saving of at least $621m for Australia, $384m for Canada, $2.7bn for the United Kingdom, and $846m for the United States; $4.55bn in total. As the United Kingdom had the largest number of African doctors practising, its savings were the largest.