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.

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)

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.

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).

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.

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

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.

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.

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.