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The Emigration of Algerian Doctors: A Normal Phenomenon or a Real Exodus?

Ahcene Zehnati
This article is a translation of:
L’émigration des médecins algériens : phénomène normal ou véritable exode ? [fr]

Abstract

The purpose of this article is to understand the phenomenon of medical migration in Algeria over at least three decades. Using different data sources, we have calculated emigration rates overall and in certain specialities. We have also looked at doctors’ salaries in the public sector to assess whether they are well or poorly paid in comparison with executives in the economic sector, doctors in the private sector, and those practising in certain foreign countries. According to our estimates, the emigration of Algerian doctors cannot be considered as a real exodus if we focus on those who qualified in Algeria and practise in France. The migration ratio of this population was 8.63% in 2016. On the other hand, if we consider the place of birth, it rises to 23.35%, a rate close to those recorded by some countries in sub-Saharan Africa which are experiencing a worrying exodus. A shortage of doctors threatens certain specialities particularly affected by emigration, such as radiology (24.69%), nephrology (24.85%), and especially psychiatry (40.27%). Whatever their rank, doctors in the public sector are relatively better paid than executives in the economic sector, but much less than doctors practising in the private sector and those practising in certain foreign countries. Financial reasons alone cannot explain the decision to emigrate taken by many Algerian doctors. It is therefore necessary to seek other reasons for emigration.

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Index terms

Thematic keywords:

health, migration policies, emigration

Geographic keywords:

Algeria
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1. Introduction

1In recent decades, under the effect of the globalization of economies, the migratory movements of skilled workers have shown a notable strengthening of the norms regulating standards for national labour markets, selective migration policies, the internationalization of higher education and the accreditation of diplomas. In addition, technological progress and the circulation of information have accelerated and facilitated plans for migration. For specialists in this area, these factors promote professional mobility.

2The international migration of doctors has become a subject of research and a major concern for developing countries because of the shortages and the health challenges it creates. It is also a subject of major interest to host countries where foreign doctors help cope with shortages in medical personnel, at least in the short term. In fact, the immigration of doctors has long been a more or less explicit means of adjusting human health resources for these countries (Moullan and Bourgueil, 2014). In most member countries of the Organization for Economic Co-operation and Development (OECD), the proportion of doctors trained internationally - mostly in developing countries - is steadily increasing. According to OECD data (2017), it amounts, for example, to 1.84% in Poland, 11.21% in France, 24% in the United States, 28.66% in the United Kingdom, 32.74% in Australia and 42.41% in New Zealand.

3The traditional approach to international migration sees it as part of the ‘brain drain’ paradigm. It views skilled migrants as a source of economic opportunities for the country of origin and for its economy in general (Blomqvist, 1986; Bhagwati and Hamada, 1974; Grubel and Scott, 1968). Therefore, the creation of an emigration tax was suggested in order to compensate for losses to the country of origin (Bhagwati and Dellalfar, 1973). However, a new approach to migration has emerged, one that challenges the findings of the traditional approach. It highlights the beneficial effects for the country of origin (‘brain gain’), such as transfers of funds, investments in the formation of human capital, and the temporary or definitive return of migrants playing a part in the development of that country.

4Specialists in migration issues have not come to any consensus on this new literature on the brain drain. It has been widely criticized theoretically and empirically (Checchi, De Simone and Faini, 2007; Schiff, 2014; Faini, 2002, 2006). Most of the assumptions underlying this approach have been called into question. Empirical evidence that migration by itself contributes to increasing investment in education in the country of emigration is very weak. The most sceptical researchers call for a more careful and detailed analysis of the effects of the diaspora. In addition, the issue of the transnationalism of the population of skilled migrants, and its impact on the economic development of the country of origin, should be studied. To this end, multidisciplinary approaches based on microeconomic surveys are needed. ‘The emergence of scientific and technical diasporas invalidates traditional approaches to the brain drain and enshrines the advent of the circulatory paradigm in the study of international migration’ (Meyer, 2008).

5One of the key factors in the emigration of doctors in developing countries is the size and quality of the health sector in the country of origin (Docquier and Rapoport, 2009). Another lies in demographic reasons: the aging of the population implies an increase in the cohort of elderly people who are the greatest consumers of medical services (OECD, 2008). The gap between the supply and demand of care continues to fuel the phenomenon of migration and stirs up competition between developed countries to welcome doctors from the rest of the world. This has certain consequences for the increase in shortages of doctors in countries of origin (Cooper, 2004).

6Our study focuses on Algeria, but the phenomenon of the migration of doctors is not specific to this country; it affects many others, particularly in sub-Saharan Africa. According to a study by Bhargava and Docquier (2008), the rate of emigration to these countries increased significantly between 1990 and 2004, contributing to the weakening of their health systems and their ability to cope with major pandemics. According to data from the World Health Organization (WHO, 2006a), out of fifty-seven countries with acute doctor shortages, thirty-six were in sub-Saharan Africa. In view of the needs estimated in 2013, the global shortage of doctors was estimated at the time at 2.6 million. This shortage was particularly pronounced in Southeast Asia (1.3 million) and Africa (0.9 million) (WHO, 2016a). In absolute terms, it was in Southeast Asia that it was most glaring, due to the large populations of the countries in this region. However, the most pressing challenges concern Africa, where 1.1 million doctors are needed to meet the health needs of the population (compared to one million for Southeast Asia) (WHO, 2016b). The shortage is expected to worsen between 2013 and 2030.

7In the context of Algeria, there has been little research on this subject (Musette, Abdellaoui and Zehnati, 2016; Zehnati, 2016). The study by Musette and colleagues shows that medical training expenses represent a very heavy burden on countries of origin, without any compensation from the receiving countries. The authors suggest opening up a new social dialogue on migration issues between countries on both shores of the Mediterranean, extended to sub-Saharan countries. Zehnati, for his part, shows that Algerian doctors seem to display a strong inclination towards emigration. Their preferred destination is still France, for historical and cultural reasons (a training system modelled on the French system, the existence of inter-university agreements, etc.).

8The purpose of this paper is to understand the phenomenon of medical migration affecting Algeria. After reviewing the literature on the international migration of skilled workers in general, and of doctors in particular, we will focus on the extent of medical emigration by attempting to measure it in general terms, and then in certain specialities. Finally, we will explain the reasons for the emigration of doctors. In the absence of field surveys that reveal the underlying reasons why health professionals emigrate, we investigate the salaries of doctors in the public sector. Data have been reconstructed to assess their level of remuneration compared to other socio-professional categories. If this explanatory variable does not prove to be relevant, then other motives should be sought. After all, it is unusual for a single factor such as the salary or unemployment differential (Piguet, 2013) to dictate the decision to migrate; migration is a multidimensional phenomenon. Only a multidisciplinary approach based on individual data would provide exhaustive knowledge of the motives behind the emigration of doctors.

2. The international migration of skilled workers in general, and doctors in particular

9The literature on the international migration of skilled workers is quite extensive. Research on this issue has undergone significant development since the 1960s. Initially, pioneering work attempted to measure the effects of these migrations on the country of origin. They report that the emigration of elites is a source of negative externalities. Some authors such as Johnson (1967), Bhagwati and Dellalfar (1973) and Bhagwati (1976) suggested the establishment of compensatory measures to benefit the countries of origin (an emigration tax) in order to compensate the resulting losses. Subsequently, research drawing on the theory of endogenous growth (Miyagiwa, 1991; Haque and Kim, 1995) sought to assess the relationship between human capital, emigration and economic growth. They conclude that emigration negatively impacts the growth rate and the stock of human capital, and strains the growth of gross domestic product per capita in the country of origin.

10This pessimistic vision of the emigration of skilled workers, focused on the negative aspects (the aforementioned brain drain), was counterbalanced in the 1990s and 2000s by a new theory emphasizing the positive effects of the migration of elites for the country of departure: it was no longer a question of brain drain but of brain gain (Docquier and Rapoport, 2007, 2009, 2012; Bhargava, Docquier and Moullan, 2011; Beine, Docquier and Rapoport, 2008, 2010; Stark and Wang, 2002; Stark, Helmenstein and Prskawetz, 1998; Vidal, 1998; Mountford, 1997).

11There are four of these positive externalities. First, before it materializes, the prospect of migration can encourage candidates to train, to upgrade their skills. Whether or not the planned emigration is realized, the incentive to gain a training may offset the negative impact of elite migration on skilled labour resources. The work of Beine, Docquier and Rapoport (2008) analyzes the relationship between investment in human capital and the growth rate of a sample of developing countries. They show that there is a positive indirect effect of migration on human capital. However, this effect varies depending on the level of development of the country of origin. Moreover, the selected immigration policies adopted by certain developed countries are part of this perspective: they encourage workers to invest in training and acquire skills in demand in developed countries in order to be able to enter the labour market on the best terms.

12Second, regions with a low capacity for innovation allow part of their qualified workforce to emigrate temporarily so as to benefit in the long term from technological advances in the host region, through a process of imitation (Domingues Dos Santos, 1999).

13Third, migrants returning to their country - temporarily, seasonally or permanently - can promote its economic development, as research conducted on this issue shows (Ammassari, 2004; ILO, 2010). In addition to the direct financial fallout through migrant remittances, the positive impacts of these returns are visible through knowledge and technology transfers, entrepreneurship and the dissemination of social and institutional norms favourable to development. They can also contribute to individual well-being and to an increase in the standard of living with the purchase of real estate or land thanks to the savings accumulated in the host countries (Benhaddad and Hamouda, 2017). Migration can also be circular, with multiple trips back and forth. Migrants of this type adopt a transnational existence by commuting between two or more regions (Drechsler and Gagnon, 2008). They are considered to be actors in the development of the country of origin thanks to the savings made, the new knowledge and skills acquired and the accumulated social capital.

14Fourth, remittances can be significant. They constitute a vital link between migration and development. For some developing countries, they are the main source of foreign exchange. The amounts transferred may exceed official development assistance. According to figures from the World Bank (2018), the amount of officially recorded remittances to developing countries in 2017 was estimated at 466 billion dollars, while official development assistance stood at 157.67 billions of dollars. Even if these transfers are considered as a form of compensation for the countries of origin, the findings of empirical studies (Faini, 2006; Bollard et al., 2009) show that, overall, a more skilled emigration is correlated with smaller transfers. Ultimately, the international migration of skilled workers is not necessarily a zero-sum game (Domingues Dos Santos, 2006).

15The theses developed by international migration specialists bear witness to the lack of consensus on the effects of the emigration of skilled workers on the country of origin. Thus, the problematization of the brain drain is still relevant. If mobility of talents is necessary, even essential, the phenomenon becomes problematic at a certain threshold of loss, inducing harmful effects for the country of origin (Musette, 2016).

16In the case of the migration of doctors, the empirical studies carried out are few and quite recent, due in particular to the lack of exhaustive databases. Some of this work, of a macroeconomic nature, has focused on the consequences of doctors’ migration on the human development indicators of the country of origin (Bhargava, Docquier and Moullan, 2011; Bhargava and Docquier, 2008). Others have estimated emigration ratios in order to grasp the magnitude of departures of health professionals from developing countries (Moullan and Bourgueil, 2014; Bourgain, Pieretti and Zou, 2010; Bhargava and Docquier, 2008). They report fairly high emigration rates to small islands in the Caribbean and Pacific, and sub-Saharan Africa. Sociological and anthropological research on the motives of these migrations has also been carried out (Cottereau, 2015; Hartzfeld, Boidé and Baumelou, 2009). Finally, a few studies place more emphasis on ethical issues (Kollar and Buyx, 2013; Mills et al., 2008). This work generally focuses on issues of justice, and formulates political solutions to better regulate the recruitment of talent in general, and doctors in particular. Interdisciplinary cooperation is rather rare in the study of the issue of doctors’ migration.

17The view of doctors’ migration as an economic problem dominates the literature. The weight of economic factors in the decision to emigration increased when the World Bank decided to involve itself in global health in the 1980s, believing that health was an economic issue and should be treated as such. This over-representation of the economic perspective in the emigration of doctors is in perfect harmony with the values ​​of neoliberalism, namely money, consumer choice and market-based decision making. Thus, health has become a market product (Fusheini and Eyles, 2016). Several factors, both on the demand and supply side, can lead to an imbalance in the health human resource market (Amorim Lopes, Santos Almeida and Almada-Lobo, 2015). According to this view, doctors are no different from other categories of migrants. They emigrate in order to improve their well-being.

  • 1 The equivalent of an ‘internship’ in developed countries.

18The factors behind doctor migration are well documented in the literature (Docquier and Rapoport, 2012; OECD, 2007; Muula, 2005; Vizi, 1993; Chang, 1992; Portes, 1976). They are both socio-economic and personal in nature and they act as stimuli in the decision to emigrate. A distinction is usually drawn between ‘pull’ and ‘push’ factors. The first relate to the expectations aroused by the countries of destination: a higher level of remuneration, better education for children, good working conditions and better job satisfaction and safety. The migration of doctors from developing countries is also driven by the prospects of acquiring the skills available in developed countries. The push factors are associated with the country of origin: insufficient remuneration compared with other sectors of activity, but also with other countries, the unsatisfied demand for medical education due to the numerus clausus or the limited number of residency positions,1 difficult working conditions, a lack of social recognition and a deleterious political climate. The dynamics of push-pull factors between developed and developing countries have historically generated disparities between the stock and the outflows of health professionals in and between these countries (Driouchi, 2016).

19We do not have any studies or qualitative data on the reasons that push Algerian doctors to emigrate. Cottereau (2015) conducted a survey of a sample of fifty-two practitioners who qualified outside the European Union (PADHUE), including thirteen Moroccan doctors, ten Algerian doctors, six Malagasy doctors, four Lebanese doctors, four Romanian doctors and doctors from twelve other nationalities. The results of this research show that it is difficult to understand all of the elements that lead to the development and implementation of a planned emigration. The motivations for leaving for France differ from one individual to another and the economic factors are only secondary.

20Strong emigration reinforces the difficulties encountered by the health systems of underdeveloped or developing countries, which show structural weaknesses. Contrary to the strictly economic vision of the migration of doctors which sees economic factors as preponderant in the decision to emigrate, qualitative studies, however rare they are, show that the latter must be seen as of lesser significance. There are many motivations at work, combining pull factors in host countries and push factors in countries of origin.

21After this review of the literature on international migration, we analyze in the second part of this paper the quantitative material collected on the emigration of Algerian doctors to France, the main host country. In the third part, we will compare doctors’ pay with that of other socio-professional categories in Algeria and of doctors practising in certain foreign countries.

3. The emigration of Algerian doctors: an attempt at assessment

Estimation of emigration rates2 (overall and by specialization)

  • 2 The rate of emigration is calculated by the following formula: Di,e/ Dih+Di,e where Di,e is the tot (...)

22The elements presented in Table 1 come from the use and cross-comparison of several data sources. Information was taken from the statistical yearbooks of the Algerian Ministry of Health (MSPRH) to estimate the number of doctors working in the public and private sectors. However, the fact that the number of active staff in private clinics is only partially known, unlike those in private practices, limits the value of this data source. The employment survey of the National Institute of Statistics and Economic Studies (Insee, 2016) provided us with overall data on the number of doctors born in Algeria and practising medicine in France. However, data relating to the place of graduation and the speciality practised are not available. Finally, data from the National Council of the Order of Doctors (CNOM, 2017) specify the number of doctors registered on the roll of the Order of Doctors (TOM) by nationality, place of birth and place of graduation. The main limitation of this source is that this information is not available for all specialities. Only data on general medicine and certain medical and surgical specialities are available.

Table 1: Emigration rates of Algerian doctors

General practitioners active (public and private sector in Algeria)

32,241

Specialist doctors active (public and private sector in Algeria)

23 415

Total

55,656

Doctors born in Algeria, settled in France, practising medicine (Insee survey, 2016) (1)

16,954

Doctors born in Algeria, settled in France (registered TOM) (2)

14,025

Doctors qualified in Algeria, settled in France (registered TOM) (3)

5,253

Rate of emigration 1

23.35 %

Rate of emigration 2

20.13 %

Rate of emigration 3

8.63 %

Source: author’s compilation of data from MSPRH, Insee and CNOM.

23The calculated overall emigration rate was 23.35% in 2016. This calculation takes into account all doctors born in Algeria, regardless of their place of training (France or Algeria), and practising in France. If we focus solely on doctors registered on TOM, this rate is 20.13%. The difference is explained by the special status of certain doctors: acting intern (FFI) and associate attached practitioner (PAA). The latter do not fully practise medicine in France and therefore cannot register on TOM. To understand this phenomenon, it is necessary to rely on figures provided by professional associations or on migration statistics in the countries of immigration, although these data are always incomplete as associations only take into account professionals officially authorized to practise (Fifaten Hounsou, 2014). If we consider only the number of doctors who have qualified in Algeria, settled in France and are registered on TOM, the emigration rate drops significantly (8.63%).

24The emigration rate 1 (23.35%) recorded by Algeria (doctors born in Algeria, regardless of their place of training) is close to those recorded by the countries of sub-Saharan Africa in 2006, such as Uganda, Zambia and Ethiopia, which account for 34.3%, 27.9% and 24.6% respectively (WHO, 2006b). The criterion of country of birth is not very relevant because it lists all the doctors born in Algeria, including during the colonial period, those who emigrated to France at an early age and who completed their medical studies there and those who left to study medicine after obtaining their baccalaureate. Note that some specialities are more affected than others by the emigration of doctors, and therefore more threatened with shortage. The lack of radiologists, nephrologists and especially psychiatrists is worrying. The number of available positions in these specialities in French public hospitals is perhaps explained by the over-representation of these specialists among emigrant doctors, and justifies, for example, the fact that psychiatrists trained abroad/in Algeria are exempt from any request for accreditation to practise in France.

25Emigration rates vary from one speciality to another. Table 2 shows the emigration rates in the specialities for which data were available.

Table 2: Emigration rates of doctors in certain specialities in 2007 and 2017

Doctors practising (public + private) in 2007 (1)

Doctors trained in Algeria, settled in France (registered TOM), 2007 (2)

Total (1+2)

Rate of emigration in 2007

Doctors practi-sing (public + private) in 2017 (1)

Doctors trained in Algeria, settled in France (registered TOM), 2017 (2)

Total (1+2)

Rate of emigration in 2017

Cardiology and vascular diseases

469

156

625

24.96 %

1,006

224

1,230

18.21 %

Pneumology

510

98

608

16.12 %

976

127

1,103

11.51 %

Anaesthesia and intensive care

619

155

774

20.03 %

1,416

272

1,688

16.11 %

General medicine

17,100

1,151

18,251

6.31 %

32,241

1 261

33,502

3.76 %

Ophthalmology

766

107

873

12.26 %

1,161

163

1,324

12.31 %

Paediatrics

1 038

177

1 215

14.57 %

2 251

251

2,502

10.03 %

Psychiatry

477

229

706

32.44 %

939

633

1,572

40.27 %

Radiology and medical imaging

578

192

770

24.94 %

851

279

1,130

24.69 %

Nephrology

178

102

280

36.43 %

381

126

507

24.85 %

Source: author’s compilation of data from MSPRH and CNOM.

  • 3 Among the pull and push factors explaining this high rate of emigration, let us cite in particular (...)

26Psychiatry is the speciality most affected by the brain drain3 with an emigration rate of 40.27%, followed by nephrology (24.85%), radiology and medical imaging (24.69%), cardiology (18.21%), anaesthesia-intensive care (16.11%), ophthalmology (12.31%), pulmonology (11.51%) and paediatrics (10.03%). General medicine has the lowest rate with 3.76%, but in terms of staff, it is ranked first with 1,261 practising doctors.

27Between 2007 and 2017, emigration rates fell in most of the specialities studied, and in particular for nephrology (a difference of twelve points), cardiology (six points) as well as pulmonology, anaesthesia-intensive care and paediatrics (four points). The situation remained stable for radiology and medical imaging, and ophthalmology. Finally, psychiatry is an exception since the emigration rate has grown by eight points (32.44% in 2007 against 40.27% in 2017).

28On the basis of the data in Table 2, we have calculated an annual average by speciality (Table 3).

Table 3: Changing numbers of personnel in certain specialities between 2007 and 2017

 

Numbers in 2007

Numbers in 2017

Difference (2007-2017)

Annual average

Cardiology and vascular diseases

156

224

68

7

Pneumology

98

127

29

3

Anaesthesia and intensive care

155

272

117

12

General medicine

1,151

1,261

110

11

Ophthalmology

107

163

56

6

Paediatrics

177

251

74

8

Psychiatry

229

633

404

40

Radiology and medical imagery

192

279

87

9

Nephrology

102

126

24

3

Total of the 9 specialities

2,367

3,336

969

-

Source: author’s compilation of data from CNOM 2017.

29The phenomenon of doctors’ emigration can be put into perspective if we think in terms of annual average. Over all the specialities studied, an average of 100 doctors have left the country each year. Of this number, forty were psychiatrists, twelve anaesthesiologists, eleven general practitioners, nine radiologists and twenty-eight doctors from the other five specialities.

30We can see that specialities are not all affected in the same way by emigration. These data must be cross-referenced with the health workforce needs of the host country. As of 1 January 2019, the number of practising doctors in France stood at 226,859. According to projections by the Department of Research, Studies, Evaluation and Statistics (DREES, 2017), France will need 280,000 practitioners by 2040. Until 2025, the number of doctors is set to increase less rapidly than the health care needs of the population. In the trend it envisages, it estimates that doctors who have qualified abroad and settled in France will represent 6% of all doctors in 2024, and 9% in 2030 (DREES, 2017). In addition, data from CNOM (2017) shows that, between 2007 and 2017, the number of doctors born abroad increased by 14.2%. To cope with their shortage of doctors, the developed countries have opted to recruit foreign doctors. Thus, they have long considered the immigration of doctors as a more or less explicit adjustment variable of health human resources (Moullan and Bourgueil, 2014).

31Table 4 shows the geographical breakdown of doctors born abroad and qualified abroad (outside France and the EU). The data relate to the top ten faculties in which these doctors trained. 23.3% come from the faculty of Algiers, 7.4% from that of Oran and 6.6% from that of Damascus (Syria). Algerian faculties alone represent 34.8% of the total.

Table 4: Geographical breakdown of the ten main faculties in which doctors born outside France trained

Faculty

Numbers

%

TUNIS (TUNISIA)

396

3.2

ANTANANARIVO (MADAGASCAR)

436

3.6

SOUSSE (TUNISIA)

174

1.4

RABAT (MOROCCO)

579

4.7

ORAN (ALGERIA)

914

7.4

ALGIERS (ALGERIA)

2,859

23.3

DAMASCUS (SYRIA)

808

6.6

BEIRUT (LEBANON)

376

3.1

CASABLANCA (MOROCCO)

579

4.7

CONSTANTINE (ALGERIA)

507

4,1

Source: author’s compilation of data from CNOM 2017.

32This geographical breakdown can be explained by historical links (in particular the colonization of these countries by France), geographical proximity, the doctors’ professional and social network, previous professional internships in the host country or linguistic factors (not to mention the recent migrations of political refugees in the case of Syrian doctors).

  • 4 Organized every year since 2009, the EVCs for medical specialists who have qualified abroad take pl (...)

33This enthusiasm for emigration does not seem to be waning, as shown by the number of Algerian doctors registered for the competitions for the so-called verification of knowledge exams (EVC).4 All candidates, regardless of their nationality, are involved in these tests. They constitute the first step in the procedure authorizing them to practise (PAE) for doctors who qualify outside the European Union. For the 2017 session, 5,878 candidates (all lists combined) were registered for the EVCs. More than half (54.7%) did not turn up for the tests and only 525 candidates were selected - an overall selection rate of 19.8% in 2017, as against 22.4% in 2016.

Table 5: Breakdown of candidates by nationality in 2017

Country of origin

Number of candidates registered

Proportion of countries of origin represented in overall figures (in %)

Proportion of women by country (in %)

Algeria

2,453

41.7 %

51.3 %

Tunisia

1,241

21.1 %

53.2 %

Morocco

238

4.1 %

63.4 %

France

643

10.9 %

51.5 %

Total (98 nationalities)

5,878

100 %

49.7 %

Source: author’s compilation of data from the summary of activities of the National Centre for the Management of Hospital Practitioners and Management Staff of the Public Hospital Service, 2017.

34Of the ninety-eight nationalities represented in 2017, four out of ten registered candidates came from Algeria (41.7%). As a reminder, Algerian candidates represented 41.7% in 2016, 40% in 2015 and 41.6% in 2014. They were followed by candidates from Tunisia (21.1% in 2017 against 16.8% in 2016, 12.4% in 2015 and 12.9% in 2014) and candidates of French nationality (10.9% in 2017 against 19.1% in 2016 and 15.5% in 2015). It should be noted that nearly two-thirds of registered Algerian candidates (65.3%) did not turn up at the EVC (49.5% for Tunisian candidates and 58% for Moroccan candidates), in particular because of the slowness in the procedure of obtaining entry visas to French territory and probably also the limited number of places offered in certain specialities. As for Moroccan candidates, they represented 4.1% of the total workforce in 2017. The breakdown by gender shows that parity between men and women was almost reached (50.3% against 49.7%).

4. The causes of doctors’ migration

35As we have seen, the decision to move abroad is often based on many factors. In the absence of qualitative surveys on the reasons for the emigration of Algerian doctors, we have looked at doctors’ salaries in the public sector, as these are more likely to emigrate than their colleagues in the private sector. Moreover, the development of the private sector in low- and middle-income countries contributes to the decline in the emigration rate of doctors, as shown in a study carried out in Ghana, India and Peru (Loh, Ugarte-Gil and Darko, 2013). Thus, the provision and financing of private health care can limit the phenomenon. In Algeria, the attractiveness of the private sector for doctors is not unrelated to income differentials (Zehnati, 2014). It is true that doctors’ salaries in the public sector are not commensurate with the work done. This under-valuation has not only led to a strong shift towards the private sector, but has reinforced the desire to emigrate among young Algerian doctors. However, while financial incentives remain a lever to keep medical staff motivated and productive, their impact remains limited in terms of international migration. Working conditions, career development prospects, the investment (mainly material) required to practise in the private sector (especially for certain specialities such as radiology, anatomy-pathology, etc.) and the socio-demographic characteristics of doctors (gender, age, place of practice, family situation, etc.) are all factors to be taken into consideration.

  • 5 In Algeria, a complete career in the public sector lasts thirty-two years.

36Our goal is to discover the financial position occupied by doctors in the public sector in relation to other socio-professional categories. In Algeria, doctors in the public sector can be divided into two groups. The first is made up of general practitioners and some specialists who have not taken or obtained their master’s degree. They are called ‘public health doctors’ and only receive a salary from the hospital. The second group is made up of ‘university hospital specialists’ who have obtained their master’s degree, and who therefore receive a double salary: a salary from the hospital and a salary paid by the Ministry of Higher Education and Scientific Research by virtue of their participation in the training cycle of medical studies and research activities. In Tables 6 and 7 we present the real salaries received by these two categories of doctors belonging to step 6 (sixteen years of professional experience).5

  • 6 The national minimum wage is 18,000 DA (approx. 130 euros).

Table 6: The real salaries6 of public health doctors (step 6) in 2018

Category

Step

Salary (in DA)

General practitioner

6

80,121

Specialist doctor in public health

6

113,970

Source: author’s compilation of data of the payroll service of the University Hospital Centre of Béni-Messous

Table 7: Real salaries of doctors in hospital universities (step 6) in 2018

Category

Salary paid by hospital (in DA)

Salary paid by the Ministry of Higher Education and Scientific Research (in DA)

Total

Professor

59,163

127,147

186,310

Senior Lecturer A *

49,264

107,058

156,322

Lecturer B **

40,530

96,412

136,942

Assistant Lecturer ***

39 112

74 793

113 905

*Pay for a head of department is 34,000 DA.

** Pay for a head of department is 22,275 DA.

*** Pay for a head of department is 22,275 DA.

Source: author’s compilation of data of the payroll service of the University Hospital Centre of Béni-Messous

  • 7 Parallel activity was made illegal by the new health law. Despite this ban, it is widely practised.

37It is interesting to compare the real salaries of doctors in the public sector (including allowances, except those related to being head of department) with those of executives in other sectors of activity, at an equivalent level of qualification (Bac +5, Bac +7 ) in order to find out whether doctors are indeed poorly paid. If the hypothesis holds true, then the financial question could explain, to some extent, the decision to emigrate or undertake parallel activity in the private sector to compensate for low salaries in the public sector.7 Otherwise, emigration could be seen as disconnected from financial constraint and parallel activity as a strategy for maximizing income or achieving a target income.

Table 8: Monthly net salaries of executives in the national public sector in 2018 by sector of activity

Sector of activity

Amount

Ratio*

Extractive industries

131,022

1.5

Manufacturing industries

70,590

0.81

Production and distribution of electricity, gas and water

67,157

0.77

Building

66,521

0.76

Trade and repair

68,804

0.79

Hotels and Restaurants

60,221

0.69

Transport and Communications

82,532

0.94

Finance

68,034

0.78

Real estate, business services

62,018

0.71

Services from private enterprises provided to communities and individuals

71,415

0.82

Overall

87,571

1

* Ratio of the overall average of qualification

Source: Results of national survey of business salaries, National Office of Statistics (ONS), May 2018.

38In 2018, a general practitioner of public health was paid 80,121 DA per month, a specialist in public health 113,970 DA. As for university hospital doctors, an assistant lecturer received a monthly salary of 113 905 DA, a lecturer B, 136 942 DA, a senior lecturer A, 156 322 DA, and a professor, 186 310 DA. Some also received allowances as heads of department (34,000 DA for a professor and 22,275 DA for a lecturer). Obviously, compared to the income of doctors in the private sector or in developed countries, Algerian doctors in the public sector are poorly paid. Private sector doctors, paid on a fee-for-service basis, are much better off. Their salaries are up to ten times higher than those in the public sector. However, the parallel activity of hospital doctors in the private sector allows them to increase their income, substantially so in certain high-paying specialities.

  • 8 National Office of Statistics (ONS, 2018). Results of national survey of business salaries.

39To situate doctors financially in relation to executives in the economic public sector, we have relied on the latest survey of salaries from the National Office of Statistics (ONS).8 In 2018, the average monthly net salary of executives in the national public sector (excluding agriculture and administration) amounted to 87,571 DA. Salaries varied from one sector to another: the lowest was for executives in the hotel and catering industry (60,221 DA) and the highest for executives in the extractive industries (131,022 DA). If we compare this average salary with the salaries received by doctors in the public sector, we realize that the salary of the general practitioner is below the average. Public health doctors and university hospital assistant lecturers receive 30% more, and the salary of a university hospital professor is double that of an executive in other sectors of the economy. With the exception of general practitioners, regardless of their rank, doctors are therefore relatively better paid than executives in the public economic sector.

40If we compare the situation with neighbouring countries, in 2018, the salary of a specialist doctor was around 14,000 DH (1,300 euros) in Morocco and 3,500 TD (1,100 euros) in Tunisia (Santé-Maghreb, 2019 ). However, salary increases were recently decided by the authorities of these two countries. The remuneration of doctors (general practitioners and specialists) is, in all OECD countries, significantly higher than the average salary of all workers (OECD, 2015). By comparison, in 2018, a hospital doctor in France earned an average of 5,700 euros gross per month, and the average monthly salary of a civil servant was 2,516 euros gross.

5. Conclusion

41According to our estimates, if we look at doctors who qualified in Algeria and practise in France, the emigration of Algerian doctors cannot be considered as a real exodus, with an emigration rate of 8.63% in 2016. On the other hand, if one takes into account the place of birth, this rate rises to 23.35% and thus approaches those recorded by certain countries of sub-Saharan Africa which are experiencing a worrying exodus. In the years to come, certain specialities particularly affected by emigration – such as radiology (24.69%), nephrology (24.85%) and especially psychiatry (40.27%) - may experience severe shortages.

  • 9 A. Zehnati, ‘Les médecins algériens affichent une forte disposition à l’expatriation’, https://www. (...)
  • 10 The medical specialists undergoing training (residents) went on strike for a year. Their main deman (...)

42The active policy of training doctors that has been implemented by the public authorities has already borne fruit. Ultimately, the problem stems more from the poor distribution of doctors across Algeria than from emigration (Zehnati, 2018). The regions of the South and the Hauts Plateaux are already facing localized shortages. However, despite the employment opportunities in the public and private sectors available in their country of origin, young Algerian doctors show a strong disposition to emigrate.9 In addition, the current problems facing the health sector10 may lead to more emigration than has been recorded so far. As for the impact of the migration of Algerian doctors on the health system of the country of origin, this has never been the subject of any evaluation.

43The meagre empirical literature devoted to the emigration of Algerian doctors does not make it possible to clearly establish the causes of emigration. Economic considerations were secondary in the plans to emigrate of the doctors surveyed by Cottereau (2015). Our comparisons of remuneration for doctors and executives in the economic sector show that specialists are generally better paid. However, the pay gap between doctors in the public sector on the one hand and those in the private or foreign sector on the other is significant. This finding may explain why doctors susceptible to financial incentives may opt for private practice or emigration. Either way, the financial motive alone cannot justify the decision to emigrate. It is a safe bet that this results from interactions between individual motivations, professional aspirations and contextual elements of a political, economic and social order. The migration of Algerian doctors to France is encouraged, among other things, by the crisis in the health sector in Algeria as a whole and the country’s socio-economic difficulties (and were encouraged in the context of insecurity during the ‘black decade’). Cultural, linguistic and educational proximity as well as the crisis in French medical demography are also determining factors in the choice of country to emigrate to.

44According to CNOM data (2017), doctors born in Algeria represent the main medical community of foreign origin in France (24%), followed by Moroccans (10.7%), Romanians (8.1%) and Tunisians (7.1%). The number of Romanian doctors practicing in France has continued to increase, especially after Romania’s entry into the European Union in 2007. However, the reasons for emigration may differ. For example, four main factors have prompted Romanian doctors to leave their country: low income combined with a lack of consideration for the profession, the absence of resources and investment in the health system, the pervasiveness of corruption in the medical world and the lack of prospects and security in Romania (Cottereau, 2015). Note that a large number of doctors of French nationality gain their qualifications in Romania or in another European country in order to circumvent the numerus clausus, the quota of students admitted after the first year of medicine established to regulate the number of practitioners. In France, only those who qualify in the European Union are allowed to practise fully in French territory.

45The basic information presented in this paper needs to be supplemented by studies based on surveys conducted among expatriate doctors to better understand their reasons for emigration. As part of the research we are currently conducting, we are trying to understand the future professional choices of students in specialized medicine. This involves collecting and analyzing their motivations and preferences relating to the choice of speciality, the mode of practice (public-private), the location of their practice and a possible desire to emigrate. These desires for career guidance will have direct implications for possible changes in the organization of medical care and access to it.

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Notes

1 The equivalent of an ‘internship’ in developed countries.

2 The rate of emigration is calculated by the following formula: Di,e/ Dih+Di,e where Di,e is the total number of doctors from country i who have emigrated and Dih is the number of doctors from country i who have not emigrated.

3 Among the pull and push factors explaining this high rate of emigration, let us cite in particular the cultural and religious reasons which still make it taboo to consult a psychiatrist in Algeria. Traditional medicine even competes for a market share with psychiatry. Today, it is not easy for a liberal psychiatrist to make his practice profitable, due to the lack of a patient base. In addition, there is a certain disenchantment with this specialty on the part of French students. The number of students opting for psychiatry is below the needs in this area. This gap between supply and demand is filled by émigré psychiatrists, mainly of North African origin. In addition, the presence of a strong North African community in France requires the availability of psychiatrists familiar with the religious and cultural codes of this population.

4 Organized every year since 2009, the EVCs for medical specialists who have qualified abroad take place in September. Registration is free, but applicants must cover travel and accommodation costs.

5 In Algeria, a complete career in the public sector lasts thirty-two years.

6 The national minimum wage is 18,000 DA (approx. 130 euros).

7 Parallel activity was made illegal by the new health law. Despite this ban, it is widely practised.

8 National Office of Statistics (ONS, 2018). Results of national survey of business salaries.

9 A. Zehnati, ‘Les médecins algériens affichent une forte disposition à l’expatriation’, https://www.elwatan.com/edition/actualite/les-medecins-algeriens-affichent-une-forte-disposition-a-lexpatriation-12-08-2018 (accessed 18 January 2021).

10 The medical specialists undergoing training (residents) went on strike for a year. Their main demand was the abolition of the civic service (service civil) system which allows them to practise in a public healthcare structure for a period ranging from one to four years depending on zoning (division of a territory into health regions) before they can practise in the public sector or move into any part of the private sector. The public authorities recently decided to abolish civic service and increase salaries in the public sector for doctors who decide to practise in the wilayat (administrative regions) of the South. At the moment, we lack the perspective necessary to assess the effects of these measures.

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Electronic reference

Ahcene Zehnati, The Emigration of Algerian Doctors: A Normal Phenomenon or a Real Exodus?International Development Policy | Revue internationale de politique de développement [Online], 13.1 | 2021, Online since 15 February 2021, connection on 03 March 2021. URL: http://journals.openedition.org/poldev/4443; DOI: https://doi.org/10.4000/poldev.4443

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About the author

Ahcene Zehnati

Ahcène Zehnati is a health economist, Research Director at the Applied Economics for Development Research Centre (CREAD, Algeria) and associate researcher at the Dijon Economics Laboratory (LEDi, France) where he is a member of the Health Economics Research Team. His doctoral thesis, defended in 2014, focused on an economic analysis of the emergence and development of private healthcare in Algeria. His research activities focus on the organization and financing of health systems, medical demography, the emigration of doctors, social security and drug. He has to his credit several books and publications in national and international journals, including Les Cahiers du CREAD, La Revue Maghreb-Machrek, Mondes en Développement.

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