Income Poverty

The World Bank just updated its estimates of the number of people living in poverty to 1996 and 1998, using 1993 Purchasing Power Parities (PPP) and household survey data (see Table 1 and Table 2). The figures for 1998 are preliminary estimates, based on the most recent survey data available (only a few surveys are available for 1997 and 1998) and actual or estimated growth rates in real private consumption per capita; they will be firmed up as new survey data become available. What story do the new figures tell? First, both the share of opulation and the number of people living on less than a dollar a day declined substantially in the mid-1990s, after increasing in the early 1990s. The same is true for those living below two dollars a day. But the numbers rose again in the aftermath of the global financial crisis. The declines in the numbers are almost exclusively due to a reduction in the number of poor people in East Asia, most notably in China. But progress was partly reversed by the crisis, and stalled in China. In South Asia, the incidence of poverty (the share of the population living in poverty) did ecline moderately through the 1990s but not sufficiently to reduce the absolute number of poor. The actual number of poor people in the region has been rising steadily since 1987. In Africa, the share declined and the numbers increased as well. The new estimates indicate that Africa is now the region with the largest share of people living below $1/day. In Latin America the share of poor people remained roughly constant over the period, and the numbers increased. In the countries of the former Soviet bloc, poverty rose markedly-both the share and the numbers increased.

Advantages of using CNG

Appeared like a monster for the first clip in 1999 and threatened all Egyptians, it was immense, unsafe and cruel. So the Egyptian authorities declared the war against it, and started to take serious actions. Now its 2009 but no alteration, it ‘s still there darkening the skies of Cairo from October to December doing a batch of environmental and wellness casualties. Apart from the grey looking skies and atrocious odor distributing in metropoliss, the Monster causes Respiratory jobs. Mahmoud Abdel Majeed, caput of Abbasiya Chest Diseases Hospital, said, † People suffer from take a breathing troubles, coughing and sometimes respiratory failure which requires unreal respiration. † Adding that kids and the aged were the most at hazard. Most of you now know who the monster is, it ‘s the BLACK CLOUD. Funny enough that it ‘s non a natural phenomenon but it is chiefly caused by us! ! Harmonizing to some statistics it ‘s said that 40 % of the pollution is f rom the combustion of rice straws, another 23 % from vehicle exhausts – as Cairo now has about 4.3 million vehicles in its streets. Factory emanations besides cause 23 % and 6 % from combustion of wastes. We need solutions! One of the solutions is to utilize Compressed Natural Gas ( CNG ) as a fuel for autos alternatively gasolene. Natural gas autos are non different from gasolene fuelled autos except that the natural gas autos are fuelled by CNG non gasolene. And its mechanism is so simple ; when u get down your engine, the CNG enters a regulator that reduces the force per unit area before come ining the fuel-injection system. The gas is so assorted with air and injected into the cylinders of the engine where it ‘s ignited by a flicker stopper ensuing in an detonation which is used to drive the Piston. CNG is non merely good for the environment but besides as for persons there are other benefits. Using CNG is a new revolution which has economical, environmental and proficient pros, yet non all people use CNG as a fuel for their autos for different grounds. CNG is rather economical ; it ‘s about tierce of the monetary value of regular gas, good intelligence for the low paid and cab drivers. Besides people who own a natural gas auto will hold some revenue enhancement inducements ; the authorities makes them pay fewer revenue enhancements as a wages for lending in protecting the environment from pollution. Further more, the cost of care of natural gas autos is really low in long term compared to that of gasolene autos. From all sides, CNG is rather more economical than gasolene. The chief advantage of utilizing CNG as a fuel is because it ‘s environmentally friendly. Since it is the cleanest firing fossil fuel, as methane Burnss cleaner than crude oil fuels. Harmonizing to a study by the Air Pollution Research Department at the National Research Center in Cairo, it was found that, â€Å" compared to petrol, CNG has a critical potency to cut down C monoxide, hydrocarbon and C dioxide concentrations in fumes released from electronic fuel-injection and well-carbureted engines by an norm of 73 per centum and 66 per centum, 39 per centum and 31 per centum and 21 per centum and 19 per centum, severally. † With these figures, CNG became a friend to the environment and people every bit good, since it causes no or less negative wellness effects than the crude oil or gasolene. Using CNG besides has some proficient advantages. CNG gives a high compaction ratio, which means that most of the fuel is burnt. The advantage of high compaction ratio is that it gives the engine a higher HP ratio ensuing in a high public presentation engine. One of the best things about CNG is that u can change over your auto to be natural gas fuelled. The transition procedure is an easy procedure ; it is merely fitting storage armored combat vehicles in the bole of the vehicle and put ining injection noses in the engine. After this U will hold a bi-fuel vehicle! Bi-fuel vehicles have the capableness to exchange between utilizing gasolene and other fuel like CNG manually or automatically to run the auto, what do we necessitate more! ! But what makes some people refuse or afraid to change over their autos to natural gas autos? Well, like everything in the universe, CNG has some disadvantages excessively. First, the transition procedure can be dearly-won as he/she will hold to purchase the transition kit and wage for the machinist who will change over it. Yes CNG is cheaper in monetary value, but this is when you replenish your auto but when it comes to transition, it can be dearly-won. Another disadvantage is†¦

Figurative Language versus Literal Language Essay - 9

Figurative Language versus Literal Language - Essay Example The phrase, â€Å"a piece of cake† does not literally mean a task that can be easily completed. As an idiom, however, that is what it means. The image that the idiom conjures up has a lot to do with the meaning that it is given (Amphiboly, n.d.). An amphiboly refers to an ambiguity that is created as a result of the grammatical structure of that sentence. This may be the result of the different meanings that may result from the positioning of marks of punctuation. An analogy refers to a device of figurative language whereby meaning is transferred to make something clear. A certain process or thing is talked of in terms of another to make others understand its essence. One may take the example of the analogy between a tube and the mechanism of water travel within a plant that is often used in botany classrooms, to understand the concept of an analogy. A flame word is something that is used as a substitute for another word or process that can then be used independent of the original word. It can be used since the original word is not used in common parlance or also probably because the flame word is what is used within a coterie of people who may understand the word. It can then be used as a means of developing a group with an understanding of certain secret words (Urban Dictionary, n.d.). One of the most celebrated devices of the figures of speech, metaphor refers to the substitution of one idea with the other so as to qualify the first one. In this device, the characteristics of one object are transferred to the other. The two objects may have no apparent relation and metaphors are often used by poets to shock readers in this way. When a person is referred to as a ‘cheetah on the track’, their exceptional speed is sought to be highlighted through the metaphor. Hyperbole is a figure of speech whereby something is exaggerated to a great extent. The reader is aware of the

Application of specific energy and momentum function Coursework

Application of specific energy and momentum function - Coursework Example Conversely, the increase, in short, smooth step with the change in y within the channel and with the given upstream depth and corresponding discharge, y3 is increased. Y3 is increased due to the expansion and energy loss. A hydraulic jump is utilized for energy dissipation that occurs when the flows transitions from the supercritical to corresponding subcritical mainly due to the spillway and the steep slope to the mild slope. The depth of water downstream from the jump and the location of the jump are computed using the conservation of energy equation (Kiselev, Fomin & Vorozhtsov, 1999). It is expected from y1 that the depth of water to escalate as the specific energy of the prevailing reduces slowly. Moreover, the alternate depths at which the specific energies ought to be identical. Nevertheless, the values collected does not depict that as the underlying values were not adequate to produce the correct and expected graph thus the association was not represented as anticipated. The prevailing graphs derived from the depths of the flow, and corresponding specific energy at the section depicts that the depth escalates as the time elapses linearly with the specific energy indicating that the two underlying variables are linearly associated. The percentage relative head loss for the underlying theoretical outcomes is relatively higher than the corresponding practical percentage relative to the head loss. The difference is due to the depth of water subsequent to the hydraulic jump that was higher than that of the underlying experimental values. The energy is lost because of the turbulent flow implying that the real water depth is relatively lower than prevailing theoretical computations. The trend line depicts the positive correlation amidst the escalation of the Froude number and corresponding y3/y1 values. The experiment was undertaken under the controlled situations in order to

Leadership and Responsibility Essay Example | Topics and Well Written Essays - 750 words - 1

Leadership and Responsibility - Essay Example This paper illustrates that the article strives to demonstrate the relationship between historical leadership style and the leadership proposal of Smith, Montagno, and Kuzmenko and highlighting the support offered by the historical record for the proposal of Smith et al. also forms a part of this article. In an order to represent the important concepts like transformational leadership and servant leadership, the author has chosen to use two historical leaders in his article- Xenophon, who was a transformational leader and Chief Joseph, who was a servant leader. The research contained in this article may be considered valuable considering the efficacy offered by adding a historical approach for understanding such intricate leadership constructs as transformational leadership, which is considered to be more appropriate by the author when a definite organizational change is desired. The author stresses on the fact that the importance of contextual factors has increased in the recent yea rs and that they really play an important role in determining the effectiveness of certain leadership constructs. As Smith et al.’s proposal also stressed on using contextual factors for validating transformational and servant leadership, the research work in this article aims at presenting a historical approach for investigating the contextual complications, which is a strategy that never did appear in any management and leadership article before. According to the author, transformational leadership comes into practice when the interests of each individual become united for the overall interest of an organization. A transformational leader should be able to maintain his/her charisma and should provide a unique vision to his/her followers. The author tries to identify in the article that servant leadership style has some definite deficiencies compared to transformational leadership style because its topmost priority is based on serving others and then considering the step to lead others constructively.

BUSINESS TAXATION ( Uinted KingdomTAX System ) Essay

BUSINESS TAXATION ( Uinted KingdomTAX System ) - Essay Example This often inclusive of the value, which the item was sold at. According a journal therefore understanding the different forms of taxation and meeting their obligations is of great importance to any business. One can save money by understanding what taxation involves in a given type of business whether a sole trader or partnership. As stated in the Tax Advisor (2012), a businessperson would also take advantage of any exemptions that they might be entitled to which would at the end boost the business. This paper will explain the terms and concepts in business taxation that will aid a clear understanding; it will assess the consequences that come as a result of incorporating a sole trader business, recommendations to the trader and finally whether the business qualifies for capital gains tax incorporation relief. A sole trader is a person who runs and operates a business on their own. The sole proprietor is liable for all the assets and liabilities of the business. Moreover, sole traders have full control of their business with all the profit. In 2012, The Tax Chartered Advisor stated that the taxation system for a sole trader in the UK allows one to complete a self assessment of their business. In this form, the sole trader is allowed to show total expenses, the total income and then subtracts to get the losses or profit for the business. Should the company show a loss then it does not owe the government otherwise, the business is taxed depending on the profits earned. An incorporated company is a form of business that is owned by one person who is the director with employees working for the company. This type of business is not solely owned by one person and decisions regarding the company are made as a group. With the new tax rates that were released in the UK, it has been realized that the best way to save money by avoiding paying a lot of taxes is through the start of companies. According to Payroll Practitioner (2009), the tax

Kanban Systems Research Paper Example | Topics and Well Written Essays - 1250 words

Kanban Systems - Research Paper Example This system was introduced in Toyota car plant in Japan as a means through which the company would smooth their produce throughout their production process. Through this system the company aimed at improving productivity of their system. This system will also ensure that the company secures its involvement and participation in realizing its aim of high productivity by acting as a better means of keeping on check flow of products through the production system. Kanban therefore provides highly visible means of keeping on track the build-up of inventory levels with a production system. The system is made up of cards with all the information of what is required to be done on a product at each stage of production. The cards also explain what parts should be inserted in the subsequent process. Through this cards a firm can therefore control a work in progress, its production and smooth flow of its inventory. Through Kanban system therefore a firm can achieve the following objectives among others Kanban systems was invented twenty years ago by the vice president of Japanese car giant Toyota. The main aim was to smoothen the flow of products in the car plants throughout the production system of the firm. Since then the system has gone through vary many modifications as a means of production activity control. As a measure of activity control Kanban system have helps firms to achieve goals of Just-in-time and manage operations of the same. Further, Kanban system helps in relaying crucial information for monitoring and controlling the quantities required by the firm according to its production plans. An effective Kanban system provides a better way for employees of firm to understand how the management want their time to be spent (Louis, 2006). This means a firm can identify where idle time lie easily and make further adjustment as fast as possible. This may come interns of

Informative speech of animals'(dogs) cushing syndrome Essay

Informative speech of animals'(dogs) cushing syndrome - Essay Example hich causes high levels of cortisone to appear  in the blood.   It is also called hypercortisolism, when referring to the human condition, and, as mentioned earlier, hyperadrenocorticism, when referring to the canine condition (CCS), and  these two terms can be used interchangeably.   The condition was named after an American surgeon and endocrinologist named Harvey Cushing (1869-1939) who first discovered the disease in 1932. Now, what is Cortisone? Cortisone, a steroid which is naturally-produced by the adrenal glands, is one of the essential hormones needed by the body. It functions primarily in carbohydrate metabolism. Now being manufactured artificially, Cortisone has been found useful as a drug to cure a number of ailments (Wikipedia,1). Although cortisone may have positive effects on the body like curing certain illnesses, having more than the recommended amount of cortisone can also be harmful. Cortisone is said to stop inflammation and therefore it also stops the healing process, that is, if normal amounts are exceeded. It is said that over-production of cortisone, may cause systemic illness – in this particular case, for canines. Some symptoms of CCS in dogs are: excessive drinking and urination, increased appetite, having a â€Å"pot belly† or abdominal distention, and loss of hair on the trunk. So when you see your pet panting and asking for more water, or always getting hungry and begging for food, do not disregard these tell-tale signs. Most dogs with CCS cannot be satisfied with the amount of fluids or food they take. They always get hungry and thirsty, and because their body cannot absorb what they take in, they usually urinate and defecate a lot. In the advanced stage, the dog usually gains weight, has a distended stomach, shows muscle weakness, and is lethargic. It is therefore imperative that a pet owner should know if his / her pet is not acting normally so that the disease may be treated at its early stage. Now that we have seen

Analysis of Compensation Philosophy Research Paper

Analysis of Compensation Philosophy - Research Paper Example The policies and underlying philosophy governing the company’s compensation program are designed to accomplish the following objectives: Maintain a compensation program that is equitable in a competitive marketplace. Provide opportunities that integrate pay with the company's annual and long?term performance goals. Maintain an appropriate balance between base salary and short and long-term incentive opportunities. Recognize and reward individual initiative and achievements. Provide a clear focus and measurement on key objectives with a meaningful link to rewards. Achieve a performance-driven work culture that generates the company’s growth Provide compensation and benefits levels within our company’s financial ability to pay. Encourage competency building by better linking career development, performance management, and rewards. Provide a non-discriminatory merit-based compensation program. At the same time, the compensation program of Excel Consulting Company is designed to attract, motivate and retain talented employees. This is evident through working towards the company’s success, attracting and retaining the highest performers. According to Martocchio (2011), base pay is set by a formal job hierarchy. The author states that pay rewards should be obtained by merit or seniority, meeting specific goals or completing a specific project or as a result of acquiring new job skills or knowledge. That is why the author states that Excel Consulting strives to provide a competitive base salary that meets the market at the 50th percentile for fully proficient employees who meet expectations. Also, it is evident between the 60th and 75th percentile for employees who consistently perform above expectations and are highly proficient in their roles. New employees that do not meet expectations will be paid below the 50th percentile target (Martocchio,2011). The competitiveness of employees' base salaries will be reviewed on an annual basis and a djustments made when market conditions and financial performance allows. The size of the adjustment will be based on the employee’s experience, performance, and contribution to Excel Consulting Company’s performance as well as the employee’s salary within the marketplace. Also, Excel Consulting will use both annual incentives and long-term incentives to enhance its ability to achieve its mission and its employee compensation objectives. In this case, long-term incentives will be performance-based and will provide equity compensation at the 50th percentile when target goals are met with the potential for awards. However, it will be between the 60th and 75th percentile when long-term goals are exceeded. The payment of an incentive award to an employee will be subject to the employee’s achievement of pre-established targets. Excel consulting compensation programs will also ensure internal equity by considering differences among employees in skills, efforts, responsibilities and working conditions. This implies that visible effective commitment to the Excel consulting Company will also be rewarded. The company will also ensure that its compensation structure is linked to an effective performance management system (Daft et al, 2010).  Ã‚  

INTERNATIONAL ECONOMICS AND FINANCE Essay Example | Topics and Well Written Essays - 2000 words

INTERNATIONAL ECONOMICS AND FINANCE - Essay Example The two eminent theories of Heckscher-Ohlin and Ricardian theory of international trade by David Ricardo have been discussed below. An introspection of the two theories provides an insight of the main controversies in the field of international trade and the current problems in policy that is affecting international trade. The Ricardian model explains comparative advantage in international trade by taking into account factors like natural resources and technology advancements of a country. The factors of comparative labour and capital have not been considered by Ricardo while explaining comparative advantage. The Heckscher-Ohlin model of international trade on the other hand assumes that the labour and capital are abundant resources that vary from one country to another and technology in long term prospects are assumed to be same. Heckscher-Ohlin derived that a country exports such goods that make optimal utilisation of local factors and imports those goods which could not make use o f available factors. David Ricardo: Ricardian theory of international trade International trade is necessary for the sustenance of globalization. ... Ricardian theory, however, holds the underlying assumption that the labour is the primary input for production and the trade at international stage occurs due to relative ratios of labour of the different nations (Rivera-Batiz and   Oliva, 2003, p.4). The other assumptions in the Ricardian model of international trade says that the labour as an input of production of the countries is also inelastic and there is no cost of transportation and no international trade barriers. The theory of comparative advantage has been explained by two factors namely, the opportunity cost and the production possibility frontier. The opportunity cost of the countries can be determined as the loss incurred for a certain production due to increase in another production. In international trade theory, the opportunity cost to a country is the decrease in cost of production arising out of scarcity of some factors for which the country imports goods and services from another country where those factors are present. The countries would carry out international trade in such a way that the opportunity cost is high. This could be done by international exports of goods that have abundant factors available in the boundary of the country and through import of goods that have scarcity of factors in the national boundaries. The production possibility frontier explains that the output of the country remains same for a certain level of technology and international trade takes place due to difference in outputs as a result of different levels of technology achieved by different countries. Heckscher-Ohlin - Heckscher Ohlin theory of international trade Capital and

First flight Essay Example for Free

First flight Essay First flight The warm wind blows past me. Only two colours can be seen in all directions. The bright blue of the mid day sky and the bronze, bare earth carrying on for miles. Across the endless plains are plants speckled by plants that look more like scattered ants from here. I close my eyes and face the sun. Burning rays hit my face. I stand on the edge of a canyon, my bare feet burning on the hot desert sand. My toes curled over the edge. I imagine what may lie at the bottom of this seemingly endless fall. I think of a rushing river ripping at the walls, making the canyon deeper and deeper. I imagine myself falling through the air straight to the bottom of the canyon. I know if I dont do this now I will be stuck to walk this planet like every other being. I tilt my body forward, I start to lose my balance, my heart is racing, and with one last gulp of air and my eyes closed I dive forward. I feel the air separating as I cut through it. My body spinning as I fall. I open my eyes and watch the sides of the gorge rushing past me. It feels nice, no wonderful, superb, and magnificent, as if time has stood still. Faster, faster. I rush towards the end. The end of being trapped, without freedom to do what you want, go where you please. I close my eyes again and enjoy this amazing feeling. Voices mumble in the background. They grow louder as I drift back into reality, turning into shouts. I snap open my eyes. The bottom is very close, a tiny stream trickles through the giant crack in the earth, nothing like I imagined before. Is there anything I can do now? I try to remember what Im supposed to do. Before I could recite her lessons word for word but now when I need them most, my head is only filled with her face. The bottom is so close now I can see the ripples in the water; I can make out the colours of the stones underneath the clear running water. My heart is racing faster than ever before, I want to scream but nothing comes out. I pull my head up and the spinning stops. I realise Im dizzy and everything is swaying back and forth. I pull my wings out just in time and I glide above the tiny stream. The bottom, which was once so far away, my claws dangle just above. I flap my wings, pull my legs in and start to make my way back up to the top. My dizziness fades and I notice as I make my way back to the top, the plants clinging to the side of the beaten walls. When I reach the top I see the terrified look on my mothers face which she is trying to cover up with a smile. I plant my feet on the hot desert sand. I look at her and she shakes her head. I turn to my brothers talking about how amazing I was. Mum turns and they follow her talking about how it will be one of their turns tomorrow. I turn back to the edge of the canyon and face the sky with my eyes close. Ive done it. My first flight.

Economic Impact Of Technology Interventions Streptokinase Economics Essay

Economic Impact Of Technology Interventions Streptokinase Economics Essay About 14 million patients in India suffer from heart attacks every year. Of these, 2.8 million patients can benefit from a clot buster drug which would save the patients life and provide room for further treatment such as medical stents if so required. Coronary heart disease claims over a million lives every year in India. There is a need for a safe and affordable clot buster drug. At the turn of the century, clot buster drug formulations were either imported or based on imported bulk drug and formulated domestically. They were expensive, equivalent to eighteen months (tPA) to two months (Streptokinase) of per capita income at that time. Cost matters more in India unlike in countries with universal health insurance as most Indians spend out of own pocket for health expenses. Given Indias prowess in generic drugs, the production capacity gap in an area of health emergency with severe consequences seems an anomaly. The gap stems from the fact that clot buster drugs are biotechnology dr ugs which require competencies quite different from those of the usual drugs based on chemical synthesis. CSIR-IMTECH, Chandigarh made efforts to develop a process to produce clot buster drugs. Initial efforts were unsuccessful, in part due to the complex nature of the animal sources based protein drug. Subsequent teams picked up the challenge again, chose a simpler molecule and after some misses, could develop a process for natural streptokinase and then recombinant streptokinase, both harnessed from micro-organisms. The misses were important steps providing crucial learning for the process development. Streptokinase technology was transferred to industry partners, natural Streptokinase to Cadila Pharma and recombinant Streptokinase to Shasun Pharma. Implementing the technology on the shopfloor faced difficulties. In the case of recombinant streptokinase, regulatory approvals took time to obtain. The knowing-doing gap was bridged by closing the competency gap through sustained engagement between the CSIR-IMTECH scientists and the managers and technology staff of the licensees. Persevera nce, team perseverance, allowing mistakes, dynamic learning from disciplined failure, give-and-take by both the scientists team and the industrial practitioners team, and a can-do, must-do, done mind-set were the keys to success. Leadership steering at both the Lab and the Industry with a commitment to collaborate and continual collaborating was crucial. This led the transition from the lab scale to industrial scale. The respective products were launched in 2001 and 2009. The results are quite encouraging. Prices have dropped (by 65 percent, to less than one month of per capita income), availability has increased, access to a life-saving medicine has risen, and patients have realized a worth of over Rs. 16,000 crores due to the CSIR-IMTECH/licensees Streptokinase. The economic impact, or the additional benefit that would be lost if this CSIR-IMTECH Streptokinase technology intervention had not been there, is assessed based on medical impact of Streptokinase and using per capita income to be Rs. 2180 crores. The Lab itself accomplished net earnings valued at Rs.1.8 crores and the Industry partners together realized value addition of Rs. 17 crores. Innovating for affordable healthcare is inclusive innovation. The benefits to patients eclipse the benefits to those who generated the technology intervention. This pursuit of innovation continues. CSIR-IMTECH has taken the science of clot-buster drugs to a level where improved Streptokinase (smarter streptokinase) molecules will have the advantages of the far more expensive animal cell line based tPA but will be much more affordable. Similarly, while access has expanded (about 120,000 standard doses), there remain millions of patients in need of this life-saving drug. More needs to be done. Introduction Heart attacks, strokes, respiratory and cardiac failure have a common enemy in blood clots in the bloodstream that can block blood supply to the heart muscle, any part of the brain or the lungs. The consequence of blockage is damage to the heart muscle, the brain cells, or the lung tissue which is usually irreversible and debilitating, if not fatal. Extreme consequences can arise if the treatment is not administered within a window of few hours (3-4.5 hours, Klabunde (2007), Hacke et. al. (2008)). Then, the heart or brain tissue, as the case may be, gets damaged which is mostly irreversible. Treatments range from clot-dissolving medication to surgical intervention such as angioplasty or insertion of stents and open chest bypass surgery. Clot busters, as clot dissolving drugs are called, attack the clot itself to dissolve it and restore blood supply. Angioplasty is an invasive and expensive procedure where blocked arteries are opened up using medical stents thus making more space for the blood supply to be restored. Similarly, bypass surgery is invasive and very expensive (see appendix 1). Prevention in high-risk patients (hardened and narrowed/blocked arteries) is via blood thinner drugs that reduce blood density allowing blood to flow through the reduced space. Despite preventive treatment, clots can form and occlusion in blood vessels can occur. Then, clot buster drugs are life saviours. In India, more than a million patients die due to coronary heart disease every year (appendix 1). Until the year 2001, no domestic production of clot-busters existed. The formulations were imported: among others, the lead formulations of Streptokinase Kabinase by Kabi Pharmacia, Sweden and Streptase by Hoechst Marion Roussel, Germany were priced then between Rs. 3000 to Rs. 4000 per vial (Krishnan (2000)). The dominant drug in this class of drugs, Tissue Plasminogen Asctivator (tPA) cost more than Rs. 30,000 per vial. Thus, clot buster drugs were expensive and the supply was short of requirement. In terms of per capita income at that time, this amounted to eighteen months of income for tPA and about two months of income for Streptokinase. The Streptokinase market was about 21 thousand vials of standard dose of 1.5 miu  [1]  . Lack of affordability could have restricted access. Given Indian pharmaceutical industrys prowess in generic drugs, realized through strengths in organic chemicals synthesis and process engineering, this raises the question about the obstacles. The Indian pharmaceutical industry was essentially based on chemical entities whereas clot buster drugs are based on biotechnology  [2]  which was almost non-existent in India around the turn of the century. Thus, access to affordable life-saving clot buster drugs was limited domestically. To make it affordable, it had to be produced domestically. To produce it domestically, a suitable technology had to be developed. The technology had then to be transitioned from a laboratory scale to an industrial scale. As in the case of affordable chemical drugs, the impetus of finding solutions and creating domestic capacity also came from CSIR Labs. In the case of generic chemical drugs, the core scientists came from Labs such as the NCL, Pune, IICT, Hyderabad and CDRI, Lucknow. These scientists and their industry contemporaries developed and implemented safe and cost effective technologies in a short time span. In the case of biotechnology, processes are being developed by IMTECH, Chandigarh and IICB, Kolkata among others. A program at IMTECH tapped into finding a solution to the problem of an affordable clot buster drug. The program has roots in projects dating back to 1989. The scientists examined the prevalent clot buster drug tissue Plasminogen Activator (tPA) but then chose instead an alternate less complex protein Streptokinase for development. This study examines the benefits realized from the Streptokinase project, specifically, the natural Streptokinase biotechnology drug licensed to Cadila Pharma and the recombinant Streptokinase drug technology licensed to Shasun Pharma Limited, to quantify the value creation and to assess the economic impact. The Industry The Indian pharmaceutical industry is among the top science based industries and focused on quality affordable drugs. It is estimated to be USD 21 billion or about Rs. 105,000 crores with exports accounting for about 40 percent (USD 8.7 billion) in 2009-10 (DOP (2011, 2012)). The industry is growing at over 10 percent per year. It is the sixth largest industry in India ranked by contribution to GDP (CSO (2011)). Globally, it ranks 3rd in terms of volume of production (10 percent of global share) and 14th largest in terms of value (1.5 percent of global share). A reason for the low value share is the lower cost of drugs in India 5 to 50 percent less than in developed countries. Thus, the Indian drugs and pharmaceutical industry is focused on affordable drugs. The Indian pharmaceutical industry is diverse. The number of units is quoted at over 20,000. However, the actual number of drug manufacturing licenses issued is about 5877 (GOI (2003))  [3]  . Registered factories are about 3500 (CSO (2011)), the rest being smaller unregistered units. The units are spread across India and provide depth that accounts for the 10 percent global volume share. Apart from MNCs such as Glaxo Smithkline, Pfizer, Astra Zeneca, several Indian companies Ranbaxy, Dr. Reddys, Cipla, Lupin and others have global operations. Biotechnology based drugs have taken root and are growing. Companies such as Biocon, Serum Institute of India, Panacea Biotec, and Reliance Life Sciences have adopted biotechnology. The biotechnology industry value exceeds Rs. 20,000 crores in 2011-12 (BioSpectrum-ABLE Biotech Survey 2012). Many Indian companies maintain the highest standards in purity, stability and international safety, health and environmental protection in production and supply of bulk drugs to buyer companies, who in turn are subject to stringent assessment by regulatory authorities in importing countries. These companies have secured regulatory approvals from USFDA, MHRA-UK, TGA-Australia, MCC-South Africa for their plants. Quality with certification is also a feature among many Indian pharmaceutical companies. During the last decade, the industry has embraced new technologies and adapted to regulatory regimes more aligned to international regulatory regimes. New business models have emerged to cope with and thrive in this environment. All of these have a bearing on the development of a domestic clot buster drug, namely, Streptokinase. With the advent of product patents in India from the 2005 amendment to the Patents Act, the focus has shifted from process engineering to drug discovery. Process engineering remains important. Several drugs will go off patent over the next few years and supply of cost effective quality generics would benefit the industry and the consumers. However, drug discovery is the new mantra. Drug discovery is a highly uncertain multi-million multi-year activity. For every one new drug molecule approved, the pipeline requires about twelve molecules for clinical trials candidacy. For every molecule reaching clinical candidacy, the pipeline of molecules is three molecules based on current success rates at each stage. The total costs spiral to over USD 600  [4]  million per new drug molecule in the USA over a span of a decade. Patent protection allows recovery of the investment but also makes the drug expensive. In India, the cost per new drug molecule can drop to less than USD 150 million due to lower costs (such as those of clinical trials). This lower cost is encouraging Indian drug enterprises to engage in drug discovery as they adapt to the product regime. However, even at the reduced cost in India, the drug would still be expensive and out of reach of many Indians. Drugs capacity building in India appears to be addressing reduction in costs and so also in the time span for drug discovery. Specialization along the chain of drug discovery via outsourcing is one emerging business model. Thus, RD is being shaped by Contract Research Organizations (CROs), Drug Discovery Development (DDD) and Clinical Trials Organizations (CTO). Manufacturing is by large integrated companies as also by Contract Manufacturers. Marketing is also by Contract Marketers and co-marketing alliances (IBEF (2010), KPMG (2006)). While regulatory changes may be the trigger for drug discovery, demand for drugs for Indian diseases is also an impetus. Chief among these are drugs for infective diseases found in India but not much in developed countries such as tuberculosis, malaria, typhoid, cholera etc. These diseases are far more prevalent in developing countries such as India where affordability is a key issue. Profits from patented multi-billion drug molecules will be tough to realize for these diseases. Thus, effective new molecules for these diseases would have to be developed within India. A major initiative underway in this regard is the Open Source Drug Discovery (OSDD) project of CSIR which seeks to harness talent across boundaries, cutting costs and hopes to reduce drug discovery time. It is open source and thus drug molecules found will be distributed without the higher price due to profits associated with patents. Costs will be cut down to the collaborative nature of the initiative. Incentives to col laborators are based on contributing to drug discovery for debilitating diseases and the recognition among peers. Also important are drugs for the so called lifestyle diseases such as diabetes (about 50 million diabetics in India as per Ramachandran et. al. (2010)) and hypertension (65 million hypertension patients in India as per Gupta (2004)), both high risk factors for emergencies such as heart attacks, strokes and respiratory failure. India is estimated to have about 14 million patients that suffer from myocardial infarction or heart attacks every year, of which 80 percent patients may not be receiving proper medical care (Financial Express (2002)). About 20 percent (2.8 million) of the cardiac patients population in India could use a clot buster drug. Only a fraction (about 200, 000 or under 10 percent) of these patients undergo bypass surgeries or angioplasty. The rest of the patients (2.6 million) could be treated with clot buster drugs administered within a window of 3-4.5 hours to the patient. Recall that there are over a million deaths every year due to coronary heart disease in India. With a growing number of diabetes and hypertension patients in India, and so increasing chances of blood vessel occlusion related deaths, having access to an affordable clot buster drug is going to be increasingly more important. An added advantage is the possibility of exports of these drugs since the diseases addressed are prevalent globally. The Technology Gap, Development and Commercialization A domestic clot buster drug was missing, as discussed earlier. The choice among three prevalent drugs narrowed to Streptokinase. Streptokinase is a 47kD  [5]  protein composed of 414 amino acids produced by several strains of beta hemolytic streptococci. It dissolves a clot occluding blood supply through a 3-step process. First, Streptokinase forms a complex with plasminogen (Pg). This 1:1 complex (the Partner Pg) rapidly becomes proteolytically active. Second, the Partner Pg complex acts on substrate Pg molecules in circulation to convert them to plasmin (Pn), the active form of the pro-enzyme Pg. Plasmin is a protease that is capable of breaking apart cross-links between fibrin molecules, which provide the structural integrity of blood clots. So, third, the plasmin rapidly dissolves the pathological clot occluding blood supply to the heart muscle in case of myocardial infarction, to brain tissue in case of stroke or to the lungs in case of respiratory failure. The Lab, Research Capacity and Technology Development Technology development has been enabled by science research and ongoing (and predecessor) projects at CSIR-IMTECH. The focus is science and technology related to microbial products. A key area is recombinant gene technology based products. One initiative relates to developing a domestic clot buster drug. The initial attempt in late 1980s focused on the prevalent drug tissue Plasminogen Activator (tPA) which is naturally found in the human body in small quantities. Through recombinant gene technology, a pioneer of the field, Professor Collen and his organization Genentech USA produced tPA from animal cell lines in the early 1980s. Attempts to replicate tPA production in IMTECH did not fructify partly due to the volatile external environment prevalent at that time and so the lack of enough scientists to execute the task. During the early 1990s, subsequently, another team of scientists at IMTECH chose an alternative to tPA, namely, Streptokinase for development due to its simpler structure and higher probability of success in developing a novel process for domestic production. The process involved two key competencies protein science and cloning science among others. Technical problems arose again in implementing the recombinant gene technology. The scientists decided to down-shift to developing a process for producing Streptokinase from natural sources. It involves two main processes fermentation (protein production) and purification (separating the protein from the broth, purified to an extent that it is admissible to humans). This effort was successful lending both credibility to the process and boosting the morale of the scientists concerned. The first success helped to delineate the tasks possible from the tasks not possible (appendix 2). This paved the way for producing Streptokinase using re combinant gene technology increasing yield many times over. The key process innovation was the use of 2-step chromatography for purification. Leadership Throughout the years of development spanning 1989 onward, the scientists at CSIR-IMTECH were supported by the science leadership and management comprising four different institute directors and two different director-generals  [6]  . Leadership and institutional continuity combined with scientific ingenuity and perseverance to produce first natural and then recombinant streptokinase. The agenda continues and smart Streptokinase is under development which could be a life-saving and life-enhancing product not only for India and the developing nations but also for the developed countries. The Technology Transfer, Technology Embedding and Commercialization The lab scale success has to be transitioned to industrial scale and commercial success. Subsequent to the transfer of know-how on fermentation and purification processes and the strain, implementation at an industrial scale also faced many hurdles. While the science was established at the Lab with lab scale production, the transition to industrial scale volumes threw up challenges (see appendix 2). As at the Lab level, informed hit and trial, learning from failure, delineating what not to do from what to do helped to transition the technology to industrial scale. Standardization of the industrial biotechnology process entailed initial training, repeated training and embedding the technology in the licensees premises. IMTECH engaged with the licensees and remained engaged thereby providing a lot of handholding in the journey from the lab to factory production. This case is an example of disciplined failure where learning from initial failure led to a course change, technological succ ess, commercial success, and then again picking up the more difficult task and taking it to fruition. CSIR-IMTECH first developed a technology to produce natural Streptokinase from Streptococci. It was developed in 4 years by 1998-99, licensed and transferred in 1999-2000 and launched commercially in 2001-2002. The recombinant Streptokinase was developed in 5 years by the year 2001-2002, licensed and transferred in 2002-2003 and commercially launched in 2009-10. Natural Streptokinase know-how was licensed to Cadila Limited for fees of Rs. 20 lakhs and royalty based on ex-factory sales for 5 years. This drug was launched as STPASE injection in year 2001-02. Subsequently, recombinant gene technology was licensed by CSIR-IMTECH to Shasun Pharmaceuticals Limited, Chennai for a fee of Rs. 1 crore and royalty payments based on ex-factory sales for 5 years. The drug was launched in July 2009 and marketed by Lupin Pharma as LUPIFLO. Comparison with prevalent alternate treatments Prior to adoption of Streptokinase for clot-blockade led heart attacks, the treatments were generalized and included oxygenation and intensive care (appendix 1). Subsequent to studies of randomized controlled trials establishing efficacy and superiority of Streptokinase, it was adopted widely specially in Europe. Later, other clot busting drugs were developed. Still later, open heart bypass surgery and then angioplasty using medical stents were developed. Clot buster drugs are more affordable than surgical treatments. Within the class of clot buster drugs, Streptokinase remains the most affordable. Its costs are lower since its production is micro-organism based unlike the others derived from animal cell lines. Comparison with prevalent competing technologies clot-busters Clot-buster drugs in use are tissue plasminogen activator (tPA), Streptokinase, and Urokinase. Streptokinase competes with tissue plasminogen activator (tPA) which is the prevalent clot buster drug. tPA is preferred for its target (blood clot causing blockade) specificity. The advantage of tPA over Streptokinase is in the extent of systemic fibrinogenolysis generated by each. The resultant side effect of bleeding (due to suppression of clot formation by plasmin) can be higher for Streptokinase. However, studies have established that streptokinase is as effective in saving lives in mycocardial infarction as is tPA, despite the nearly ten-fold higher price of the latter. tPA is expensive enough to be inaccessible to most patients for this life threatening condition. Recombinant tPA reduced prices but the cost remains many times over that of Streptokinase. Cost of treatment is of utmost importance as most Indians health expenditure is out of own pocket. Appendix 1 clearly indicates that while the treatments for myocardial infarction vary from Streptokinase to tPA to angioplasty and bypass surgery, for a vast majority of Indians (with annual income about and below the current per capita annual income of Rs. 60,000), the treatment affordable and so possible is administering of Streptokinase. The alternative to Streptokinase would be a mix of morphine, oxygenation, intensive-care. Comparison with prevalent manufacturers Producers of natural Streptokinase, for several years, were only MNCs such as Behring-werke (Germany) and Lederle (USA). In India, before CSIR-IMTECHs intervention, Streptokinase was imported, Streptokinase injections were sold by MNCs Kabinase by Kabi Pharmacia, Sweden and Streptase by Hoechst Marion Roussel, Germany and priced then between Rs. 3000 to Rs. 4000 per vial in year 2000 (Krishnan(2000)). tPA prices varied from Rs. 30,000 per vial in year 2000-01 to about Rs. 19,000 per vial in 2010-11. In India, CSIR-IMTECH licensee Cadila Pharmaceuticals Ltd. manufactured Streptokinase as STPASE at an ex-factory price of Rs. 900 per vial (standard 1.5 miu dose) in 2001-02. The recombinant Streptokinase which has the same biological properties of natural Streptokinase (but much higher yields) was produced by CSIR-IMTECH licensee Shasun Chemicals and Drugs Limited, Chennai at an ex-factory price of Rs. 465 per vial in year 2009-10. This is the bulk drug price. It is marketed as LUPIFLO by Lupin Pharmaceuticals Limited and as STUKINASE by Samarth Pharma among other formulators. Non-CSIR licensee entry also occurred after the first CSIR licensee entered. There were three entrants, two of whom have already exited. The third entrant, Biocon, is successfully producing recombinant Streptokinase and marketing it as Myokinase. Data and Methodology Lab data are obtained from CSIR-IMTECH. Industry data are obtained through questionnaires and interviews. Market data such as sales value and quantity numbers for Streptokinase formulations/brands along with data on company characteristics such as MNC/Indian, date of launch, size of formulation are from the IMS Health India database on Streptokinase. The data are collected at the stockist level and are representative of the Indian pharmaceuticals market with the exception of sales directly from producers/formulators to the hospitals. Given the retrospective nature of this economic impact study, and the difficulties in collecting past data, the initial methodology proposed was a contemporaneous difference analysis between CSIR licensees and comparable enterprises. However, Streptokinase producer data could not be collected despite mailed questionnaires followed up with interviews  [7]  . Instead, for the industry analysis, market sales and volume data for a panel of 20 years are used to estimate a demand function with pooled OLS regressions. The pooled regressions permit segregation of estimates for CSIR licensees from others, and, of estimates over time  [8]  . Benefits of the Technology Intervention Creating Value Benefits to the Lab CSIR-IMTECH developed a technology and plugged a production capacity gap for a life-saving drug. The first of the series of streptokinase molecules established the credibility of CSIR as a solutions provider based on their science rooted program for technology. IMTECH scientists successfully integrated science and application producing more improved molecules and earned fees and royalty in the process. The total value of fees and royalty received is about Rs. 2.5 crores and the investment in terms of salaries and cost of patents is about Rs. 65 lakhs in 2011-12 prices. The internal rate of return on the Labs cash flows for Streptokinase works out to 36 percent  [9]  . Thus, the technology program is quite cost effective for CSIR. Benefits to CSIR Licensees and the Industry The direct benefit to the licensees in terms of value addition thus far (from 2001-02 to 2011-12) is about Rs. 17 crores in 2011-12 prices, the bulk of it, Rs. 16.5 crores, arising from the first licensee Cadila Pharma Limited. The second CSIR licensee Shasun Limited has limited value added from its two years of Streptokinase operations. The first molecule served as a proof-of-concept for the industry and even more as a proof-of-value creation. It was followed by another successful molecule variant and commercial success with that also. From no producer of Streptokinase in year 2000, there are now at least three producers domestically. The third producer Biocon, a non-CSIR licensee, is among three entrants, the other two having exited already. In 2001, before entry of the first domestic producer, CSIR-IMTECH licensee Cadila Pharma, there were about four Streptokinase brands and sales value was about Rs. 6 crores with about 20 thousand vials of standard dose. The value of the Streptokinase industry is over Rs. 20  [10]  crores in 2011 with about 118 thousand vials in terms of the standard dose of 1.5 miu and about thirty brands (including different vial sizes) marketed. While many factors are responsible for this value increase, demonstration of the proof- of-concept (technology works) and the proof-of-value (commercial success) by CSIR-IMTECH scientists and licensees may have been crucial. Without these, the country may still have been importing the drug at much higher prices. To that extent, the country is also saving foreign exchange. The current market price of STPASE is reported to be about Rs. 1000 per vial and the prices of Streptokinase vials from Shasuns bulk drug vary from Rs.715 to Rs. 2300. Myokinase, the third non-CSIR entrant Biocons product, is reportedly selling at a price of about Rs. 2000 per vial. The average market price is about Rs. 1700 per vial (standard 1.5 miu dose). Prices of streptokinase by CSIR-IMTECH licensees are among the lowest in the industry, where over 30 versions of formulations are now being marketed domestically. Industry Competition With increasing market competition, prices drop and sales increase. Competition can be enhanced more by entry of producers. A pioneering paper (Bresnahan and Reiss 1991) developed an empirical framework for measuring the effects of entry in concentrated markets by studying the relationship between the number of firms in the market, market size, and competition. Their analysis suggests that competitive conduct changes quickly as the number of incumbents increases. In markets with five or fewer incumbents, almost all variation in competitive conduct occurs with the entry of the second or third firm. Surprisingly, once the market has between three and five firms, the next entrant has little effect on competitive conduct. In the absence of data on price-cost margins, they develop another key metric the ratio of break-even sales Sn+1/Sn where n refers to the last incumbent producer and n+1 refers to the entrant. This threshold is equal to one in perfectly competitive markets where the minimum efficient scale of production is quite low relative to the market size and there are no entry barriers. In concentrated markets, the threshold of break-even sales ratio is higher than one due to substantial fixed costs as well as entry barriers. A new entrant could incur higher fixed capital cost and/or higher variable costs (such as marketing costs to establish their product and realize sales). With increasing entry, this threshold break-even sales ratio should decline and approach the value of one as in perfect competition. While we do not observe price-cost margins for all three domestic producers of Streptokinase Cadila (entry in year 2001), Biocon (entry in 2008) and Shasun (entry in 2009) we do have information on sales  [11]  and company provided break-even years. Using the Bresnahan and Reiss (1991) framework, the calculation of break-even sales (quantity of vials) ratio is found to be 2.8 for the second entrant (Biocon, relative to first producer Cadila Pharma) and 1.6 for the third entrant (Shasun Pharma, relative to Biocon)  [12]  . This quick examination points to a decreasing value of the break-even sales ratio and fast increasing competition with just three entrants, much in line with the findings of the Bresnahan and Reiss paper. Benefits to the People and the Economy Price Reduction, Affordability and Access

Medical Brain Drain in Developing Countries

Medical Brain Drain in Developing Countries CHAPTER ONE BACKGROUND The loss of human capital from developing countries to developed countries is not a new phenomenon. It is commonly refer to as brain drain which broadly represents the migration of highly skilled professionals from one country or part of a country to another in search of a better prospect (Sako, 2002). The loss of highly skilled professional attributed to brain drain has been of interest internationally for over four decades (Giannoccolo, 2004). Concern over the international migration of health workers first came to limelight at the Edinburgh Commonwealth Medical Conference in 1965. This situation prompted the World Health Organisation (WHO) in 1970 to examine the global process and flows of doctors and nurses (Mejia, 1978). The report however made little impacts on migration of health workers which has continually been on the increase over the years (Levy, 2003, Pang et al. 2002) The concept of the medical brain drain, that is the migration of doctors and other health professionals from developing economies to developed countries has been the subject of interest and research across a variety of fields including labour economics, human resource studies and human geography (Diallo, 2004, Buchan, 2004 and Stilwell et al., 2004) The migration of medical personnel has been identified by WHO as the most critical problem facing the delivery of health service in developing countries (WHO, 2007), besides the emigration of doctors in particular to other countries have received a more considerable attention (Beecham, 2002) The extent to which health professionals migrate to developed countries has continue to be on the increase in recent years and this has been attributed to an apparent response to demand from the developed countries where medical professional are in short supply to cater for demands due to demographic changes, aging population, growing income, feminisation of workforce amongst others (Pond and McPake, 2006). Foreign-trained medical and nursing workforces are estimated to account for more than a quarter of health professionals of the Australia, Canada, the US, and the UK (OECD, 2002).The quest for highly skilled professionals has been on the increase in many developed countries. According to statistic report from the Global Atlas of Workforce cited in Pond and McPake, (2006), the United Kingdom (UK) was ranked among the least staffed of high income countries with 166 doctors and 497 nurses per 100,000 populations the second lowest doctors density and the fourth nurses lowest density among the Organisation for Economic Cooperation and Development (OECD) countries. Moreover, as at the year 2000, the UK health system currently require about 10,000 physicians and 20,000 more nurses to meet the demand of the NHS plan (Department of Health, 2000). Between the year 1999 and 2004 when the targets was achieved earlier than expected, a new target was set to increase the number of nurses by 35000 ( 10%) and physicians by 15000 (25%) between 2001 and 2008. In order to achieve the new target, several methods were adopted to recruit doctors and nurses from other country to fill the shortage within the NHS. However, the approach created a surge in the international recruitment of health worker (Department of Health, 2004). Conversely, the poor economy condition in the developing countries coupled with poor remunerations, lack of infrastructural facilities, and low morale, emigrating to developed countries by doctors is seen as an opportunity for a better prospect. Furthermore, the continuous rise in disease prevalence, emigration, productivity losses, and shortage of doctors in Sub-Saharan Africa, has resulted in health resource crisis (Aluwihare, 2005). Insufficiency in human capacity for health care delivery in developing countries have been identified as a significant factor that is responsible for the inability to achieve the target set by WHO for the treatment of 3 million HIV infected people by year 2005. (This initiative was tagged 3by5) (WHO, 2005). This has also been identified as a major constraint limiting the progress of Millennium Development Goals (MDGs) Initiatives (IOM, 2005). In response to the migration of health professionals to developed countries and the undermine effect to the economy, social and health status of exporting countries, the Commonwealth Ministers of Health agreed to uphold and keep the Commonwealth values of cooperation, sharing and supporting one another, thus a consensus approach to deal with the problem of international recruitment of health workers was adopted. The Code of Practice for the International Recruitment of Health Workers is intended to provide a framework to governments within which international recruitment should be carried out (Commonwealth Code of Practise, 2003). Similarly, Department of Health (2004), presented a revised policy on code of practise for international recruitment of health care professionals this demonstrated the concerned of the UK government in protecting the health care system of developing countries. The revised code of practise for recruitment addresses role of private employer and agencies in the international recruitment of health professionals from developing countries (Eastwood et al., 2005). Nevertheless, developing countries have made some effort in preventing the emigration of physician to developed countries. In spite of this, addressing factors that encourage emigration, such as large disparity in remunerations, standards of living, opportunities for career development amongst host other benefits are usually difficult to come by. At the 1998 UN Conference on Trade and Development, WHO study indicated that 56% of doctors from developing countries migrate to developed nations, while only 11% migrate in the opposite direction; the imbalance is even greater for nurses. (Chanda, 2002). As a result, further effort is being deployed by developing countries to search for means to manage the migration of the health workforce to developed countries (Hussey, 2007). Despite measures, it may be difficult to totally prevent health professionals from migrating. As the large scale of medical brain drain from developing countries is now having a negative impact on the development process of the health system of those countries, it is however imperative for stakeholders to develop a consequential means to curtail the continual movements of health professionals. Nigeria Health Services Historical Background Nigeria, the most populous black nation in the world with a total population of 140 million people (2006 census). As a country with mono-cultural economy, the major source of foreign earnings is from crude oil. The poor level of resources allocated to the health care sector is one of the main factors responsible for the deplorable health condition in the country (Campbell, 2007). The public health service in Nigeria started in 1946 with a 10-year colonial administration plan; the development came about when treatment was required for soldiers of the West African Frontier Force and the colonial administration staff. In 1975 attempt was made to adopt primary health care under the Basic Health Service Scheme (BHSS). The BHSS aimed to improve the accessibility to heath care in terms location, affordability, increase access to disease prevention and distribution of services, and provision of adaptable health services based on local need and socially acceptable method of technology (Hodges 2001). The Current Health Care System in Nigeria Over the last two decades, the health care system in Nigerias has deteriorated a fact ascribed to the countrys poor governance and leadership which was more pronounced during the military era. This was reflected in budget allocations and the fiscal requirements of the Structural Adjustment Programmes. The deficient of reliable data makes it difficult to provide a detailed assessment of the degree of financial commitment to the health sector (Ali-Akpjiak and Pyke, 2003). According to World Bank source, Nigeria public spending per capita for the health sector is less than $5 USD and is as low as $2 USD in some parts of the country. This is far below the $34 USD recommended by WHO for developing countries within the Macroeconomics Commission Report. Nevertheless the Federal Government recurrent budget on health showed an increasing trend from 1996 to 1998, a decline in 1999 and started to rise again in 2000, available evidence shows that most of the recurrent expenditure is spent on personnel. The Federal Government recurrent expenditure on health as a share of the total Federal Government recurrent expenditure which stood at 2.55% in 1996, 2.96% in 1997, and 2.99% in 1998, declined to 1.95% in 1999 and 2.5% rose in 2000. Beyond budgetary allocations, there is a wide gap in the available between the budgetary figures and the actual amount of funds released from the treasury for health activities (WHO 2009a). The decline in the Nigeria health sector was accompanied by collapse of institutional capacities, poor remuneration and lack of conducive environment, dilapidated equipment and infrastructure have over the years, job dissatisfaction and low motivation, have led to increase migration of health professionals to seek employment in overseas countries. In a bid to curtail the impasse, Nigeria has subscribed to the Commonwealth Code of Practice for the International Recruitment of Health Workers for which a framework of responsibilities is presently being developed (WHO 2009b). Demographic and Health Indicators The demographic data in Nigeria are not very reliable. Data gathered from various exercises such as census, vital registrations and surveys are often inconsistence and sometimes contradictory. Nonetheless, there is evidence that the key indicators have either remained constant or worsened (WHO 2005). Life expectancy declined from 52.6 years for male and 58.8 years for female in 1991 to 45 years and 46 years for both Male and Female respectively in 2004. The infant mortality rate (IMR) in 2004 is 103 per 1000 live births when compared to 87.2 per 1000 live births in 1999. Fifty percent of deaths under 5 years of age have been attributed to malnutrition. The maternal mortality rate (MMR) of 800 per 100,000 births is the second highest in the world after India. This has been attributed partly to shortage of skilled medical personnel. For instance only 41.9 % of primary health facilities is provides antenatal and delivery services. Moreover 57.3% of such health facilities operate without a doctor, midwives or senior community extension worker. The Nigeria health system is one of the worst in sub-Saharan African with a disability life adjusted expectancy of 38.3 years and ranked 187 in the world (WHO 2005) Health Workforce in Nigeria Among the several challenges facing the health system in Nigeria is the lack of competent health care professionals. This has been attributed to inadequate infrastructures and poor remunerations packages, making a sizeable numbers of doctors, nurses and other medical professionals vulnerable to be lured away to developed countries in search of a fulfilling and lucrative employments (Stilwell and Awofeso, 2004, Raufu, A., 2002) There are 52, 408 Nigerian Doctors registered with the Nigeria Medical Council as at December 2007, There are 128,918 nurses and 90,489 midwives on the register, although only a fraction of these pay the required practicing licensing fee. There are 13,199 pharmacists, 840 radiographers, 1,473 physiotherapists, 12,703 medical laboratory scientists, and 19,268 Community Health Officers. All these health workers are required to pay annual practicing licensing fees; however the lists have not been pruned for those have migrated out to foreign countries, deaths, retirements or those that have left the profession for another career entirely. Health workers are poorly distributed and most are in favour of urban areas, southern, tertiary health care services delivery, and curative care. For some cadres of health workers such as doctors and nurses, more than 50% have their place of work in the South Western part of the country with vast majority residing in the commercial city of Lagos (Labiran et. al, 2008). Medical Brain Drain in Nigeria Among the countries in sub-Saharan African, Nigeria is a major export of health professionals. An estimated number of 20, 000 health professionals emigrate from Africa annually. A trend that poses threat to sustainable health care delivery in Nigeria. Statistical data on Nigerian doctors who are legally migrating overseas are scarce and unreliable, this is largely due to the fact that most wealthy nations like Australia currently makes it very difficult for overseas trained doctors to practise in their country primarily on the basis of medical skills. However, hundreds of doctors trained in Nigeria continue to emigrate to developed countries annually (Stilwell and Awofeso, 2004). Better remunerations and medical facilities among other factors are cited as one of the major reason for flight of Nigerian doctors (Raufu, 2002) and also there are limited incentives and encouragement for overseas based Nigerian doctors that is willing to relocate back to the country (Stilwell et al., 2004) . Purpose of the study In sub-Saharan African, there is has been a significant rise in disease burden, loss of productivity and the emigration of medical doctors to developed counties have resulted in the in dearth of the most required health resource (Aluwihare, 2005). Most studies on medical brain drain have examined the subject from the perspective of recipient developed countries and little attention has been paid to the donor developing countries. Thus, scarcity of data from developing country makes it difficult to fully describe the impact of migration on countries of origin (Hagopian et al., 2004). Most studies on doctors migration from Sub-Saharan African have tended to focus on numbers, without exploring the underlying reason for migration, assessing the potential negative impact of migration on the health care systems, or considering means to alleviate the problem. In actual fact, information regarding the extent of migration is usually obtained through data from countries of destination (Stilwel l et al 2003). The migration of medical doctors from Nigeria and other countries in sub-Saharan African generates three areas of major concern. The first is a loss of the basic health services available to the citizen. for instance, Ghana, faced with a ratio of nine doctors to every 100 000 patients and no more than 22 paediatrician are licensed to practise in country and no more than 10 specialists of any kind practising in the remote area. Similarly, Nigeria lack adequate doctors to care for the sick especially patients residing in the rural communities The second effect doctor migration from Nigeria is that it prevent the health sectors the ability to organize and expand. Public health institutions heavily depend on doctors to lead, develop and promote them as they work to advance health care delivery. As obtained in US, doctors are well positioned to serve their organisation by actively involved in managing resources and articulating priorities. It is therefore speculated that as the numbers of available medical doctors in developing countries reduces. The third challenges are that doctors migration depletes a significant element of the middle class in developing countries. As in the developed countries, medical doctors in African comprise of an important segment of the social and economic make up of the middle class. They are generally accorded a lot of respect in the society, as being above corruption, they advocate for improvement in quality of education of public schools and they play a vital role in political (Hagopian et al., 2005). In Nigeria, over 70.2% of the population lives on $1 per day (WHO, 2006) Research aim and objectives The aim of this study is to analyse the causes of medical brain drain from developing countries, benefits and burdens associated with brain drain based largely on the views of Nigerian doctors practising in UK. The objectives are: To identify the factors that influence the decision of medical doctors to migrate to developed countries migration To identify the impacts of migration on healthcare in developing countries CHAPTER TWO LITERATURE REVIEW Concept of Brian Drain Brain drain has been defined by many analysts in different ways. It is not surprising the social phenomenon has been examined and analysed from different perspective, based on their general orientation and or awareness of the subject. Brain drain will be conceived in this study as the loss of medical professionals or significant number of human capital within the health care system to other sector of the economy or country. Migration of skilled professionals differs from one country to another and from time to time it is however misleading to generalise the possible impacts of migration in developing countries. Moreover, it can be argued that various studies have attempted to measure the phenomenon from different perspective. Single analytic measurement cannot be used to justify all migration although migration of highly skilled professionals from developing countries has been attributed to various factors which political, social and economical factors account for a significant reasons behind the phenomenon (AUN report, 2002). The migration of highly skilled workers can justify the use of the term brain drain however the expression should be used cautiously. Replacing drain by a more common and value expression such as migration may generate alternate meaning. The difference in the word may be heightened by saying while all brain drains constitute brain migration notwithstanding, brain migration may not necessarily refer to brain drain. Brain drain denote the de-facto transfer of resources spent on impacting education and developing both technical and professional skills of the drained brain in question by the parent (donor) country to the (recipient) country of transfer. The developed countries thus save financial resources on education and professional training and invariably obtain the service of professionals such as doctors, nurses, engineers, scientists who earn more than their colleague in developing countries with a better comfortable living environment (Glaser and Habers, 1978). Several efforts have been made to define the concept of brain drain, most especially by international organisation. According to United Nations Educational, Scientific and Cultural Organisation (UNESCO report, 1969), the brain drain could be defined as an abnormal form of scientific exchange between countries, characterized by a one- way flow in favour of the most highly developed countries. Approximately four decades later, the definition of brain drain has undergone no significant change with a lot of highly skilled workers still leaving the shores of developing countries in pursuit of greener pastures in the developed nations. Medical doctors, engineers and scientists usually tend to predominate or account for a larger proportion among the migrants. Their higher the level of skills or professional qualification, make them more susceptible to migration. Gillis, et al. (1987) suggested two main reasons why brain drain is detestable to most developing countries. The first is that the calibres of people that migrate represent one of the scarce human resources in these developing countries and secondly the amount of resources, financial cost and time involve in educating these group of people is expensive and heavily subsidise by the government. Such migration to foreign country therefore becomes expensive and costly to the donor countries. In most cases the developing countries completely loose these highly skill professionals to the developed countries (Edokat, 2000). This phenomenon has generated a lot of arguments that have been advanced for or against brain drain; however this is not a concern for this study. All that can be concluded is that migration of highly skilled workers from developing countries to develop countries creates a vacuum in the former countries (Edokat, 2000). Types of brain drain Primary external brain drain occurs when trained professional or skilled human resources emigrate from their country of origin to work in developed countries such as America, Europe and Australia. Secondary external brain drain occurs when a trained professional or skilled human resources leave their country or any other less developed country to work in a another developing country such as Botswana, South Africa, Zimbabwe and Namibia. Internal brain drain occurs when a trained professional or skilled or skilled human resources seek for employment in a field not related to his to his/her expertise or when such individual migrate from the public sector to private sector or to another sector within a particular country. While this may pose a problem for a country, it is however not a loss of human resource to the country or the continent. Brain Drain Theories These theories are based on general migration approaches. In brain drain discussion, these approaches have been referred to briefly or summarized. Occasionally specific remarks will be made to provide more clarity regarding the theories. It is however important to state that nearly the theoretical outlook consists of specific mix of different theories or based on the nature of the dominating factors. On the other hand, the scientific approach in which the theories were founded. Another approach in the use of division based on the level Micro, Meso or Macro. These groups cover greater number of theoretical approaches (Oderth, 2002). This level has been defined as: Micro level the decision making of individual is affected by his or her motives, circumstances and access to information. Meso level an aspect of social ties that affects migration such as the effect of network of friends and relatives on migration Macro level opportunities and constraints available at societal level which include political, socio-cultural and economical factors There is no Grand theory linked with research on brain drain although attempts have been made to integrate the subject with economic and social theory, spatial analysis and social science (Kangasniemi et. al., 2004). The study of brain drain and other behaviour by demographers was able to draw insights from other disciplines such as statistics, history, economy, medicine and anthropology (Oderth 2001). A common example is the push and pull model of labour mobility. The model states that individual migration decision is a combination of family, economic, social and political factors. Categories of factors identified to be affecting migration include: 1) Factors at the point of origin, 2) Factors at point of destination, 3) Intervening obstacles and 4) personal circumstances. The push and pull model has been widely used by scholars in studies. Economic factors of employment and material benefits are regarded to have the strongest influence on migration decision (Oderth 2002) Despite the frequent use of the push and pull model approach in migration literature, the approach has been seen as too mechanical and rational choice based and with less consideration for intervening obstacles or institutional and structural constraints (Massey et al, 1993). Most migration tends to be unidirectional from poor to rich nations. The rate of emigration also differs vary considerately between countries and regions on similar economic level and the poorest or the less educated people hardly ever move. A major challenge for the migration is lack of insights in the interconnectedness of all the processes (Kangasniemi et. al., 2004) Another model is the migration system approach it involves formation of a link that encourages migration between a sender and receivers which are strengthened over a period of time. Such links include economic, political and cultural interaction often based on historical activities. Once a link has been created between the migrant places subsequent migration is facilitated through the links. The migration system approach emphasis that social network of the migration provides the intending migrants with information and assistance to ease migration. An important feature of such system is that immigration to a country is directed to specific regions. Such migration is partly dependent on specific areas (Gillis, et al. (1987)). The scope of medical brain drain The World Health Report (2006) estimated that an approximately 817,992 (138%) health workers would be required In Africa to achieve the coverage of basic health interventions. The rate at which doctors and other health professional migrate differs from country to country. Nevertheless, the pattern of migration shares certain similarities. The severe shortage of doctors particularly in rural health facilities has critical negative effects on accessibility and equitable distribution of health care in sub-Saharan African (Ovberedjo, 2007). Studying a specific group of employments from a pool of migration statistics revealed a substantial net loss of human capital among certain key profession in sub-Saharan African. An obvious and highly skilled professional to emerge from such analysis are medical doctors (SOPEMI, 2008). This particular phenomenon can be described as Medical Brain Drain. However, to what extent doctors migrated from sub Saharan African to developed countries? This section will review the scope of migration among doctors in sub Saharan African. Medical brain drain is important and deserves consideration because it is obvious that any decrease in the labour supply among doctors in any country is bound to generate a significant negative impact on the health system of that particular country. In year 2000, statistical data revealed an average of 18.2% of employed doctors working in OECD countries were foreigners. The United States has the largest number of doctors (about 200,000) born and trained in foreign countries followed by the United Kingdom which account for almost 50,000 and France about 34,000. Health worker in India and Philippine formed a greater percentage of the immigrant health workforce OECD countries. In addition, doctors from India account for 56,000 of foreign born doctors practising in OECD countries while nurses of Philippine origin account for about 110, 000. These represent about 15% each of the total (SOPEMI, 2008). The French and the Portuguese African speaking countries contribute some of the highest emigration rate to OECD countries for medical doctors some of other African countries such as Guinea Bissau, Sao Tome and Principe, Senegal, Carpe Verde, Congo, Benin and Togo rank between 17th and 23rd places with emigration rate of 40%, while the English speaking countries in African such as Malawi, Kenya and Ghana have lower emigration rate ranked 25th, 28th and 38th respectively. South African and Nigeria were the only two countries in sub-Saharan African among the top 25 countries with foreign doctors and nurses practising in the OECD countries. This was due to the fact that most African countries have smaller population of workforce (SOPEMI, 2007). Statistical data from the American Medical Association (AMA) Physician Master file shows that 5, 334 non-federal trained doctors trained in Africa medical schools were licensed to practise medicine in the United States in 2002. Nigeria account for 2,158, while South Africa 1,943 doctors. Another 478 doctors are from Ghana medical schools. Other countries contributing to the list in sub-Saharan African include Ethiopia 257 physician, Uganda 153 doctors, and Kenya 93 doctors. The total number of 5,334 represents 6% of the total number African doctors (Hagopian et al. 2004). After United States, the United Kingdom and Canada are the most common destinations in developed countries for African Physicians, with a total of 3,451 and 2, 151 African trained doctors are recorded to be practising in United Kingdom and Canada respectively. Moreover figures in the UK include only doctors who arrived after 1992 thus the number may probably be higher, other destinations for African-trained doctors include Australia, New Zealand and the Gulf States (Hagopian et al. 2003) Migration of doctors also occurs between countries within African continent. For instance, countries such as South Africa, Senegal and Botswana export doctors to developed countries and likewise import doctors from other African countries to cater for shortfall in medical personnel (EQUINET, 2003). Causes of Brain Drain The factors guiding individual choice of migration is in essence personal and thus susceptible to the prevailing personal circumstances. Nonetheless, the economic and social context of such decision deserves an important consideration. Moreover, the disparity between the economic and social development status of different sectors within a particular country and of different countries within African has countries has broaden over the year (Stilwell, 2004). Brain drain of doctors and other highly skilled professional from Africa has been blame on unfulfilled dream at country of origin caused by strife, corruption and misuse that mark Africas post-colonial history (Bridgewater, 2003 cited in Mbanefoh, 2007). Also according to Dovlo (2003), causes can be linked using six gradients which include job satisfaction, salary, career opportunity, governance, social security and benefit, protection and risk. Furthermore the dualistic nature of the world economy has been found to be a major contributing factor to brain drain, as highly skilled medical professionals particularly doctors try to escape the endemic poverty by migrating to wealthy, developed and technologically advanced countries of the world (Mbanefoh, 2007). Factors guiding individual decision to emigrate are a result of the interplay of economic, cultural, social, political and legal forces. Others factors encouraging cross-border migration are usually considered under two main categories: Push factors (Supply) and Pull factors (Demand) (Kline, 2003). Over time the pattern of migration is facilitated through networks that provide prospective migrants with information about job opportunities in countries of destination as well as offer various support to help adjustment after migration (Matin, 2003). Push factors (Supply) these are conditions that make a doctor to be dissatisfied with work and professional careers in their country of origin. The factors may be evident both in the developed and developing countries facilitating the migration of health care professionals from one country to another which is perceive to offer better opportunities in some way. However, these factors are more prominent in developing countries, and they greatly influence the decision of doctors to emigrate in these countries. Pull factors (Demand) these are conditions in countries of destination that motivate workers to migrate. In the same manner as push factors, pull factors can also influence the migration of doctors from one developed country to another developed country. However, the pull factors has a more pronounced influence on individuals in developing countries for instance, there is surge in migration of nurses to Canada after the review of cost of Medical Brain Drain in Developing Countries Medical Brain Drain in Developing Countries CHAPTER ONE BACKGROUND The loss of human capital from developing countries to developed countries is not a new phenomenon. It is commonly refer to as brain drain which broadly represents the migration of highly skilled professionals from one country or part of a country to another in search of a better prospect (Sako, 2002). The loss of highly skilled professional attributed to brain drain has been of interest internationally for over four decades (Giannoccolo, 2004). Concern over the international migration of health workers first came to limelight at the Edinburgh Commonwealth Medical Conference in 1965. This situation prompted the World Health Organisation (WHO) in 1970 to examine the global process and flows of doctors and nurses (Mejia, 1978). The report however made little impacts on migration of health workers which has continually been on the increase over the years (Levy, 2003, Pang et al. 2002) The concept of the medical brain drain, that is the migration of doctors and other health professionals from developing economies to developed countries has been the subject of interest and research across a variety of fields including labour economics, human resource studies and human geography (Diallo, 2004, Buchan, 2004 and Stilwell et al., 2004) The migration of medical personnel has been identified by WHO as the most critical problem facing the delivery of health service in developing countries (WHO, 2007), besides the emigration of doctors in particular to other countries have received a more considerable attention (Beecham, 2002) The extent to which health professionals migrate to developed countries has continue to be on the increase in recent years and this has been attributed to an apparent response to demand from the developed countries where medical professional are in short supply to cater for demands due to demographic changes, aging population, growing income, feminisation of workforce amongst others (Pond and McPake, 2006). Foreign-trained medical and nursing workforces are estimated to account for more than a quarter of health professionals of the Australia, Canada, the US, and the UK (OECD, 2002).The quest for highly skilled professionals has been on the increase in many developed countries. According to statistic report from the Global Atlas of Workforce cited in Pond and McPake, (2006), the United Kingdom (UK) was ranked among the least staffed of high income countries with 166 doctors and 497 nurses per 100,000 populations the second lowest doctors density and the fourth nurses lowest density among the Organisation for Economic Cooperation and Development (OECD) countries. Moreover, as at the year 2000, the UK health system currently require about 10,000 physicians and 20,000 more nurses to meet the demand of the NHS plan (Department of Health, 2000). Between the year 1999 and 2004 when the targets was achieved earlier than expected, a new target was set to increase the number of nurses by 35000 ( 10%) and physicians by 15000 (25%) between 2001 and 2008. In order to achieve the new target, several methods were adopted to recruit doctors and nurses from other country to fill the shortage within the NHS. However, the approach created a surge in the international recruitment of health worker (Department of Health, 2004). Conversely, the poor economy condition in the developing countries coupled with poor remunerations, lack of infrastructural facilities, and low morale, emigrating to developed countries by doctors is seen as an opportunity for a better prospect. Furthermore, the continuous rise in disease prevalence, emigration, productivity losses, and shortage of doctors in Sub-Saharan Africa, has resulted in health resource crisis (Aluwihare, 2005). Insufficiency in human capacity for health care delivery in developing countries have been identified as a significant factor that is responsible for the inability to achieve the target set by WHO for the treatment of 3 million HIV infected people by year 2005. (This initiative was tagged 3by5) (WHO, 2005). This has also been identified as a major constraint limiting the progress of Millennium Development Goals (MDGs) Initiatives (IOM, 2005). In response to the migration of health professionals to developed countries and the undermine effect to the economy, social and health status of exporting countries, the Commonwealth Ministers of Health agreed to uphold and keep the Commonwealth values of cooperation, sharing and supporting one another, thus a consensus approach to deal with the problem of international recruitment of health workers was adopted. The Code of Practice for the International Recruitment of Health Workers is intended to provide a framework to governments within which international recruitment should be carried out (Commonwealth Code of Practise, 2003). Similarly, Department of Health (2004), presented a revised policy on code of practise for international recruitment of health care professionals this demonstrated the concerned of the UK government in protecting the health care system of developing countries. The revised code of practise for recruitment addresses role of private employer and agencies in the international recruitment of health professionals from developing countries (Eastwood et al., 2005). Nevertheless, developing countries have made some effort in preventing the emigration of physician to developed countries. In spite of this, addressing factors that encourage emigration, such as large disparity in remunerations, standards of living, opportunities for career development amongst host other benefits are usually difficult to come by. At the 1998 UN Conference on Trade and Development, WHO study indicated that 56% of doctors from developing countries migrate to developed nations, while only 11% migrate in the opposite direction; the imbalance is even greater for nurses. (Chanda, 2002). As a result, further effort is being deployed by developing countries to search for means to manage the migration of the health workforce to developed countries (Hussey, 2007). Despite measures, it may be difficult to totally prevent health professionals from migrating. As the large scale of medical brain drain from developing countries is now having a negative impact on the development process of the health system of those countries, it is however imperative for stakeholders to develop a consequential means to curtail the continual movements of health professionals. Nigeria Health Services Historical Background Nigeria, the most populous black nation in the world with a total population of 140 million people (2006 census). As a country with mono-cultural economy, the major source of foreign earnings is from crude oil. The poor level of resources allocated to the health care sector is one of the main factors responsible for the deplorable health condition in the country (Campbell, 2007). The public health service in Nigeria started in 1946 with a 10-year colonial administration plan; the development came about when treatment was required for soldiers of the West African Frontier Force and the colonial administration staff. In 1975 attempt was made to adopt primary health care under the Basic Health Service Scheme (BHSS). The BHSS aimed to improve the accessibility to heath care in terms location, affordability, increase access to disease prevention and distribution of services, and provision of adaptable health services based on local need and socially acceptable method of technology (Hodges 2001). The Current Health Care System in Nigeria Over the last two decades, the health care system in Nigerias has deteriorated a fact ascribed to the countrys poor governance and leadership which was more pronounced during the military era. This was reflected in budget allocations and the fiscal requirements of the Structural Adjustment Programmes. The deficient of reliable data makes it difficult to provide a detailed assessment of the degree of financial commitment to the health sector (Ali-Akpjiak and Pyke, 2003). According to World Bank source, Nigeria public spending per capita for the health sector is less than $5 USD and is as low as $2 USD in some parts of the country. This is far below the $34 USD recommended by WHO for developing countries within the Macroeconomics Commission Report. Nevertheless the Federal Government recurrent budget on health showed an increasing trend from 1996 to 1998, a decline in 1999 and started to rise again in 2000, available evidence shows that most of the recurrent expenditure is spent on personnel. The Federal Government recurrent expenditure on health as a share of the total Federal Government recurrent expenditure which stood at 2.55% in 1996, 2.96% in 1997, and 2.99% in 1998, declined to 1.95% in 1999 and 2.5% rose in 2000. Beyond budgetary allocations, there is a wide gap in the available between the budgetary figures and the actual amount of funds released from the treasury for health activities (WHO 2009a). The decline in the Nigeria health sector was accompanied by collapse of institutional capacities, poor remuneration and lack of conducive environment, dilapidated equipment and infrastructure have over the years, job dissatisfaction and low motivation, have led to increase migration of health professionals to seek employment in overseas countries. In a bid to curtail the impasse, Nigeria has subscribed to the Commonwealth Code of Practice for the International Recruitment of Health Workers for which a framework of responsibilities is presently being developed (WHO 2009b). Demographic and Health Indicators The demographic data in Nigeria are not very reliable. Data gathered from various exercises such as census, vital registrations and surveys are often inconsistence and sometimes contradictory. Nonetheless, there is evidence that the key indicators have either remained constant or worsened (WHO 2005). Life expectancy declined from 52.6 years for male and 58.8 years for female in 1991 to 45 years and 46 years for both Male and Female respectively in 2004. The infant mortality rate (IMR) in 2004 is 103 per 1000 live births when compared to 87.2 per 1000 live births in 1999. Fifty percent of deaths under 5 years of age have been attributed to malnutrition. The maternal mortality rate (MMR) of 800 per 100,000 births is the second highest in the world after India. This has been attributed partly to shortage of skilled medical personnel. For instance only 41.9 % of primary health facilities is provides antenatal and delivery services. Moreover 57.3% of such health facilities operate without a doctor, midwives or senior community extension worker. The Nigeria health system is one of the worst in sub-Saharan African with a disability life adjusted expectancy of 38.3 years and ranked 187 in the world (WHO 2005) Health Workforce in Nigeria Among the several challenges facing the health system in Nigeria is the lack of competent health care professionals. This has been attributed to inadequate infrastructures and poor remunerations packages, making a sizeable numbers of doctors, nurses and other medical professionals vulnerable to be lured away to developed countries in search of a fulfilling and lucrative employments (Stilwell and Awofeso, 2004, Raufu, A., 2002) There are 52, 408 Nigerian Doctors registered with the Nigeria Medical Council as at December 2007, There are 128,918 nurses and 90,489 midwives on the register, although only a fraction of these pay the required practicing licensing fee. There are 13,199 pharmacists, 840 radiographers, 1,473 physiotherapists, 12,703 medical laboratory scientists, and 19,268 Community Health Officers. All these health workers are required to pay annual practicing licensing fees; however the lists have not been pruned for those have migrated out to foreign countries, deaths, retirements or those that have left the profession for another career entirely. Health workers are poorly distributed and most are in favour of urban areas, southern, tertiary health care services delivery, and curative care. For some cadres of health workers such as doctors and nurses, more than 50% have their place of work in the South Western part of the country with vast majority residing in the commercial city of Lagos (Labiran et. al, 2008). Medical Brain Drain in Nigeria Among the countries in sub-Saharan African, Nigeria is a major export of health professionals. An estimated number of 20, 000 health professionals emigrate from Africa annually. A trend that poses threat to sustainable health care delivery in Nigeria. Statistical data on Nigerian doctors who are legally migrating overseas are scarce and unreliable, this is largely due to the fact that most wealthy nations like Australia currently makes it very difficult for overseas trained doctors to practise in their country primarily on the basis of medical skills. However, hundreds of doctors trained in Nigeria continue to emigrate to developed countries annually (Stilwell and Awofeso, 2004). Better remunerations and medical facilities among other factors are cited as one of the major reason for flight of Nigerian doctors (Raufu, 2002) and also there are limited incentives and encouragement for overseas based Nigerian doctors that is willing to relocate back to the country (Stilwell et al., 2004) . Purpose of the study In sub-Saharan African, there is has been a significant rise in disease burden, loss of productivity and the emigration of medical doctors to developed counties have resulted in the in dearth of the most required health resource (Aluwihare, 2005). Most studies on medical brain drain have examined the subject from the perspective of recipient developed countries and little attention has been paid to the donor developing countries. Thus, scarcity of data from developing country makes it difficult to fully describe the impact of migration on countries of origin (Hagopian et al., 2004). Most studies on doctors migration from Sub-Saharan African have tended to focus on numbers, without exploring the underlying reason for migration, assessing the potential negative impact of migration on the health care systems, or considering means to alleviate the problem. In actual fact, information regarding the extent of migration is usually obtained through data from countries of destination (Stilwel l et al 2003). The migration of medical doctors from Nigeria and other countries in sub-Saharan African generates three areas of major concern. The first is a loss of the basic health services available to the citizen. for instance, Ghana, faced with a ratio of nine doctors to every 100 000 patients and no more than 22 paediatrician are licensed to practise in country and no more than 10 specialists of any kind practising in the remote area. Similarly, Nigeria lack adequate doctors to care for the sick especially patients residing in the rural communities The second effect doctor migration from Nigeria is that it prevent the health sectors the ability to organize and expand. Public health institutions heavily depend on doctors to lead, develop and promote them as they work to advance health care delivery. As obtained in US, doctors are well positioned to serve their organisation by actively involved in managing resources and articulating priorities. It is therefore speculated that as the numbers of available medical doctors in developing countries reduces. The third challenges are that doctors migration depletes a significant element of the middle class in developing countries. As in the developed countries, medical doctors in African comprise of an important segment of the social and economic make up of the middle class. They are generally accorded a lot of respect in the society, as being above corruption, they advocate for improvement in quality of education of public schools and they play a vital role in political (Hagopian et al., 2005). In Nigeria, over 70.2% of the population lives on $1 per day (WHO, 2006) Research aim and objectives The aim of this study is to analyse the causes of medical brain drain from developing countries, benefits and burdens associated with brain drain based largely on the views of Nigerian doctors practising in UK. The objectives are: To identify the factors that influence the decision of medical doctors to migrate to developed countries migration To identify the impacts of migration on healthcare in developing countries CHAPTER TWO LITERATURE REVIEW Concept of Brian Drain Brain drain has been defined by many analysts in different ways. It is not surprising the social phenomenon has been examined and analysed from different perspective, based on their general orientation and or awareness of the subject. Brain drain will be conceived in this study as the loss of medical professionals or significant number of human capital within the health care system to other sector of the economy or country. Migration of skilled professionals differs from one country to another and from time to time it is however misleading to generalise the possible impacts of migration in developing countries. Moreover, it can be argued that various studies have attempted to measure the phenomenon from different perspective. Single analytic measurement cannot be used to justify all migration although migration of highly skilled professionals from developing countries has been attributed to various factors which political, social and economical factors account for a significant reasons behind the phenomenon (AUN report, 2002). The migration of highly skilled workers can justify the use of the term brain drain however the expression should be used cautiously. Replacing drain by a more common and value expression such as migration may generate alternate meaning. The difference in the word may be heightened by saying while all brain drains constitute brain migration notwithstanding, brain migration may not necessarily refer to brain drain. Brain drain denote the de-facto transfer of resources spent on impacting education and developing both technical and professional skills of the drained brain in question by the parent (donor) country to the (recipient) country of transfer. The developed countries thus save financial resources on education and professional training and invariably obtain the service of professionals such as doctors, nurses, engineers, scientists who earn more than their colleague in developing countries with a better comfortable living environment (Glaser and Habers, 1978). Several efforts have been made to define the concept of brain drain, most especially by international organisation. According to United Nations Educational, Scientific and Cultural Organisation (UNESCO report, 1969), the brain drain could be defined as an abnormal form of scientific exchange between countries, characterized by a one- way flow in favour of the most highly developed countries. Approximately four decades later, the definition of brain drain has undergone no significant change with a lot of highly skilled workers still leaving the shores of developing countries in pursuit of greener pastures in the developed nations. Medical doctors, engineers and scientists usually tend to predominate or account for a larger proportion among the migrants. Their higher the level of skills or professional qualification, make them more susceptible to migration. Gillis, et al. (1987) suggested two main reasons why brain drain is detestable to most developing countries. The first is that the calibres of people that migrate represent one of the scarce human resources in these developing countries and secondly the amount of resources, financial cost and time involve in educating these group of people is expensive and heavily subsidise by the government. Such migration to foreign country therefore becomes expensive and costly to the donor countries. In most cases the developing countries completely loose these highly skill professionals to the developed countries (Edokat, 2000). This phenomenon has generated a lot of arguments that have been advanced for or against brain drain; however this is not a concern for this study. All that can be concluded is that migration of highly skilled workers from developing countries to develop countries creates a vacuum in the former countries (Edokat, 2000). Types of brain drain Primary external brain drain occurs when trained professional or skilled human resources emigrate from their country of origin to work in developed countries such as America, Europe and Australia. Secondary external brain drain occurs when a trained professional or skilled human resources leave their country or any other less developed country to work in a another developing country such as Botswana, South Africa, Zimbabwe and Namibia. Internal brain drain occurs when a trained professional or skilled or skilled human resources seek for employment in a field not related to his to his/her expertise or when such individual migrate from the public sector to private sector or to another sector within a particular country. While this may pose a problem for a country, it is however not a loss of human resource to the country or the continent. Brain Drain Theories These theories are based on general migration approaches. In brain drain discussion, these approaches have been referred to briefly or summarized. Occasionally specific remarks will be made to provide more clarity regarding the theories. It is however important to state that nearly the theoretical outlook consists of specific mix of different theories or based on the nature of the dominating factors. On the other hand, the scientific approach in which the theories were founded. Another approach in the use of division based on the level Micro, Meso or Macro. These groups cover greater number of theoretical approaches (Oderth, 2002). This level has been defined as: Micro level the decision making of individual is affected by his or her motives, circumstances and access to information. Meso level an aspect of social ties that affects migration such as the effect of network of friends and relatives on migration Macro level opportunities and constraints available at societal level which include political, socio-cultural and economical factors There is no Grand theory linked with research on brain drain although attempts have been made to integrate the subject with economic and social theory, spatial analysis and social science (Kangasniemi et. al., 2004). The study of brain drain and other behaviour by demographers was able to draw insights from other disciplines such as statistics, history, economy, medicine and anthropology (Oderth 2001). A common example is the push and pull model of labour mobility. The model states that individual migration decision is a combination of family, economic, social and political factors. Categories of factors identified to be affecting migration include: 1) Factors at the point of origin, 2) Factors at point of destination, 3) Intervening obstacles and 4) personal circumstances. The push and pull model has been widely used by scholars in studies. Economic factors of employment and material benefits are regarded to have the strongest influence on migration decision (Oderth 2002) Despite the frequent use of the push and pull model approach in migration literature, the approach has been seen as too mechanical and rational choice based and with less consideration for intervening obstacles or institutional and structural constraints (Massey et al, 1993). Most migration tends to be unidirectional from poor to rich nations. The rate of emigration also differs vary considerately between countries and regions on similar economic level and the poorest or the less educated people hardly ever move. A major challenge for the migration is lack of insights in the interconnectedness of all the processes (Kangasniemi et. al., 2004) Another model is the migration system approach it involves formation of a link that encourages migration between a sender and receivers which are strengthened over a period of time. Such links include economic, political and cultural interaction often based on historical activities. Once a link has been created between the migrant places subsequent migration is facilitated through the links. The migration system approach emphasis that social network of the migration provides the intending migrants with information and assistance to ease migration. An important feature of such system is that immigration to a country is directed to specific regions. Such migration is partly dependent on specific areas (Gillis, et al. (1987)). The scope of medical brain drain The World Health Report (2006) estimated that an approximately 817,992 (138%) health workers would be required In Africa to achieve the coverage of basic health interventions. The rate at which doctors and other health professional migrate differs from country to country. Nevertheless, the pattern of migration shares certain similarities. The severe shortage of doctors particularly in rural health facilities has critical negative effects on accessibility and equitable distribution of health care in sub-Saharan African (Ovberedjo, 2007). Studying a specific group of employments from a pool of migration statistics revealed a substantial net loss of human capital among certain key profession in sub-Saharan African. An obvious and highly skilled professional to emerge from such analysis are medical doctors (SOPEMI, 2008). This particular phenomenon can be described as Medical Brain Drain. However, to what extent doctors migrated from sub Saharan African to developed countries? This section will review the scope of migration among doctors in sub Saharan African. Medical brain drain is important and deserves consideration because it is obvious that any decrease in the labour supply among doctors in any country is bound to generate a significant negative impact on the health system of that particular country. In year 2000, statistical data revealed an average of 18.2% of employed doctors working in OECD countries were foreigners. The United States has the largest number of doctors (about 200,000) born and trained in foreign countries followed by the United Kingdom which account for almost 50,000 and France about 34,000. Health worker in India and Philippine formed a greater percentage of the immigrant health workforce OECD countries. In addition, doctors from India account for 56,000 of foreign born doctors practising in OECD countries while nurses of Philippine origin account for about 110, 000. These represent about 15% each of the total (SOPEMI, 2008). The French and the Portuguese African speaking countries contribute some of the highest emigration rate to OECD countries for medical doctors some of other African countries such as Guinea Bissau, Sao Tome and Principe, Senegal, Carpe Verde, Congo, Benin and Togo rank between 17th and 23rd places with emigration rate of 40%, while the English speaking countries in African such as Malawi, Kenya and Ghana have lower emigration rate ranked 25th, 28th and 38th respectively. South African and Nigeria were the only two countries in sub-Saharan African among the top 25 countries with foreign doctors and nurses practising in the OECD countries. This was due to the fact that most African countries have smaller population of workforce (SOPEMI, 2007). Statistical data from the American Medical Association (AMA) Physician Master file shows that 5, 334 non-federal trained doctors trained in Africa medical schools were licensed to practise medicine in the United States in 2002. Nigeria account for 2,158, while South Africa 1,943 doctors. Another 478 doctors are from Ghana medical schools. Other countries contributing to the list in sub-Saharan African include Ethiopia 257 physician, Uganda 153 doctors, and Kenya 93 doctors. The total number of 5,334 represents 6% of the total number African doctors (Hagopian et al. 2004). After United States, the United Kingdom and Canada are the most common destinations in developed countries for African Physicians, with a total of 3,451 and 2, 151 African trained doctors are recorded to be practising in United Kingdom and Canada respectively. Moreover figures in the UK include only doctors who arrived after 1992 thus the number may probably be higher, other destinations for African-trained doctors include Australia, New Zealand and the Gulf States (Hagopian et al. 2003) Migration of doctors also occurs between countries within African continent. For instance, countries such as South Africa, Senegal and Botswana export doctors to developed countries and likewise import doctors from other African countries to cater for shortfall in medical personnel (EQUINET, 2003). Causes of Brain Drain The factors guiding individual choice of migration is in essence personal and thus susceptible to the prevailing personal circumstances. Nonetheless, the economic and social context of such decision deserves an important consideration. Moreover, the disparity between the economic and social development status of different sectors within a particular country and of different countries within African has countries has broaden over the year (Stilwell, 2004). Brain drain of doctors and other highly skilled professional from Africa has been blame on unfulfilled dream at country of origin caused by strife, corruption and misuse that mark Africas post-colonial history (Bridgewater, 2003 cited in Mbanefoh, 2007). Also according to Dovlo (2003), causes can be linked using six gradients which include job satisfaction, salary, career opportunity, governance, social security and benefit, protection and risk. Furthermore the dualistic nature of the world economy has been found to be a major contributing factor to brain drain, as highly skilled medical professionals particularly doctors try to escape the endemic poverty by migrating to wealthy, developed and technologically advanced countries of the world (Mbanefoh, 2007). Factors guiding individual decision to emigrate are a result of the interplay of economic, cultural, social, political and legal forces. Others factors encouraging cross-border migration are usually considered under two main categories: Push factors (Supply) and Pull factors (Demand) (Kline, 2003). Over time the pattern of migration is facilitated through networks that provide prospective migrants with information about job opportunities in countries of destination as well as offer various support to help adjustment after migration (Matin, 2003). Push factors (Supply) these are conditions that make a doctor to be dissatisfied with work and professional careers in their country of origin. The factors may be evident both in the developed and developing countries facilitating the migration of health care professionals from one country to another which is perceive to offer better opportunities in some way. However, these factors are more prominent in developing countries, and they greatly influence the decision of doctors to emigrate in these countries. Pull factors (Demand) these are conditions in countries of destination that motivate workers to migrate. In the same manner as push factors, pull factors can also influence the migration of doctors from one developed country to another developed country. However, the pull factors has a more pronounced influence on individuals in developing countries for instance, there is surge in migration of nurses to Canada after the review of cost of