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

Deception Point Page 74

â€Å"Smart people like yourself don't have the luxury of playing stupid, Dr. Harper. You're in trouble, and the senator sent me up here to offer you a deal. The senator's campaign took a huge hit tonight. He's got nothing left to lose, and he's ready to take you down with him if he needs to.† â€Å"What the devil are you talking about?† Gabrielle took a deep breath and made her play. â€Å"You lied in your press conference about the PODS anomaly-detection software. We know that. A lot of people know that. That's not the issue.† Before Harper could open his mouth to argue, Gabrielle steamed onward. â€Å"The senator could blow the whistle on your lies right now, but he's not interested. He's interested in the bigger story. I think you know what I'm talking about.† â€Å"No, I-â€Å" â€Å"Here's the senator's offer. He'll keep his mouth shut about your software lies if you give him the name of the top NASA executive with whom you're embezzling funds.† Chris Harper's eyes seemed to cross for a moment. â€Å"What? I'm not embezzling!† â€Å"I suggest you watch what you say, sir. The senatorial committee has been collecting documentation for months now. Did you really think you two would slip by undetected? Doctoring PODS paperwork and redirecting allocated NASA funds to private accounts? Lying and embezzling can put you in jail, Dr. Harper.† â€Å"I did no such thing!† â€Å"You're saying you didn't lie about PODS?† â€Å"No, I'm saying I bloody well didn't embezzle money!† â€Å"So, you're saying you did lie about PODS.† Harper stared, clearly at a loss for words. â€Å"Forget about the lying,† Gabrielle said, waving it off. â€Å"Senator Sexton is not interested in the issue of your lying in a press conference. We're used to that. You guys found a meteorite, nobody cares how you did it. The issue for him is the embezzlement. He needs to take down someone high in NASA. Just tell him who you're working with, and he'll steer the investigation clear of you entirely. You can make it easy and tell us who the other person is, or the senator will make it ugly and start talking about anomaly-detection software and phony work-arounds.† â€Å"You're bluffing. There are no embezzled funds.† â€Å"You're an awful liar, Dr. Harper. I've seen the documentation. Your name is on all the incriminating paperwork. Over and over.† â€Å"I swear I know nothing about any embezzlement!† Gabrielle let out a disappointed sigh. â€Å"Put yourself in my position, Dr. Harper. I can only draw two conclusions here. Either you're lying to me, the same way you lied in that press conference. Or you're telling the truth, and someone powerful in the agency is setting you up as a fall guy for his own misdealings.† The proposition seemed to give Harper pause. Gabrielle checked her watch. â€Å"The senator's deal is on the table for an hour. You can save yourself by giving him the name of the NASA exec with whom you're embezzling taxpayers' money. He doesn't care about you. He wants the big fish. Obviously the individual in question has some power here at NASA; he or she has managed to keep his or her identity off the paper trail, allowing you to be the fall guy.† Harper shook his head. â€Å"You're lying.† â€Å"Would you like to tell that to a court?† â€Å"Sure. I'll deny the whole thing.† â€Å"Under oath?† Gabrielle grunted in disgust. â€Å"Suppose you'll also deny you lied about fixing the PODS software?† Gabrielle's heart was pounding as she stared straight into the man's eyes. â€Å"Think carefully about your options here, Dr. Harper. American prisons can be most unpleasant.† Harper glared back, and Gabrielle willed him to fold. For a moment she thought she saw a glimmer of surrender, but when Harper spoke, his voice was like steel. â€Å"Ms. Ashe,† he declared, anger simmering in his eyes, â€Å"you are clutching at thin air. You and I both know there is no embezzlement going on at NASA. The only liar in this room is you.† Gabrielle felt her muscles go rigid. The man's gaze was angry and sharp. She wanted to turn and run. You tried to bluff a rocket scientist. What the hell did you expect? She forced herself to hold her head high. â€Å"All I know,† she said, feigning utter confidence and indifference to his position, â€Å"is the incriminating documents I've seen-conclusive evidence that you and another are embezzling NASA funds. The senator simply asked me to come here tonight and offer you the option of giving up your partner instead of facing the inquiry alone. I will tell the senator you prefer to take your chances with a judge. You can tell the court what you told me-you're not embezzling funds and you didn't lie about the PODS software.† She gave a grim smile. â€Å"But after that lame press conference you gave two weeks ago, somehow I doubt it.† Gabrielle spun on her heel and strode across the darkened PODS laboratory. She wondered if maybe she'd be seeing the inside of a p rison instead of Harper. Gabrielle held her head high as she walked off, waiting for Harper to call her back. Silence. She pushed her way through the metal doors and strode out into the hallway, hoping the elevators up here were not key-card operated like the lobby. She'd lost. Despite her best efforts, Harper wasn't biting. Maybe he was telling the truth in his PODS press conference, Gabrielle thought. A crash resounded down the hall as the metal doors behind her burst open. â€Å"Ms. Ashe,† Harper's voice called out. â€Å"I swear I know nothing about any embezzlement. I'm an honest man!† Gabrielle felt her heart skip a beat. She forced herself to keep walking. She gave a casual shrug and called out over her shoulder. â€Å"And yet you lied in your press conference.† Silence. Gabrielle kept moving down the hallway. â€Å"Hold on!† Harper yelled. He came jogging up beside her, his face pale. â€Å"This embezzlement thing,† he said, lowering his voice. â€Å"I think I know who set me up.† Gabrielle stopped dead in her tracks, wondering if she had heard him correctly. She turned as slowly and casually as she could. â€Å"You expect me to believe someone is setting you up?† Harper sighed. â€Å"I swear I know nothing about embezzlement. But if there's evidence against me†¦ â€Å" â€Å"Mounds of it.† Harper sighed. â€Å"Then it's all been planted. To discredit me if need be. And there's only one person who would have done that.† â€Å"Who?† Harper looked her in the eye. â€Å"Lawrence Ekstrom hates me.† Gabrielle was stunned. â€Å"The administrator of NASA?† Harper gave a grim nod. â€Å"He's the one who forced me to lie in that press conference.† 88 Even with the Aurora aircraft's misted-methane propulsion system at half power, the Delta Force was hurtling through the night at three times the speed of sound-over two thousand miles an hour. The repetitive throb of the Pulse Detonation Wave Engines behind them gave the ride a hypnotic rhythm. A hundred feet below, the ocean churned wildly, whipped up by the Aurora's vacuum wake, which sucked fifty-foot rooster tails skyward in long parallel sheets behind the plane. This is the reason the SR-71 Blackbird was retired, Delta-One thought. The Aurora was one of those secret aircraft that nobody was supposed to know existed, but everyone did. Even the Discovery channel had covered Aurora and its testing out at Groom Lake in Nevada. Whether the security leaks had come from the repeated â€Å"skyquakes† heard as far away as Los Angeles, or the unfortunate eyewitness sighting by a North Sea oil-rig driller, or the administrative gaffe that left a description of Aurora in a public copy of the Pentagon budget, nobody would ever know. It hardly mattered. The word was out: The U.S. military had a plane capable of Mach 6 flight, and it was no longer on the drawing board. It was in the skies overhead.

Sir Gawain And The Green Knight Essay - 1521 Words

Joelle Duvinsky Fall 16 Donnelly Many years ago, knights were expected to form a certain type of relationship with their king, this relationship was otherwise known as fealty. Fealty is a knight’s sworn loyalty to their king (in other words a loyal relationship should be formed between the two). The use of this relationship is shown in the poem called â€Å"Sir Gawain and the Green Knight† ( the author is unknown). This poem has a classic quest type of formula, with a knight receiving a challenge and then going out on a journey to pursue that challenge, leading to a return home to report the results of his quest. This story begins at Christmas time when a knight (who is completely green) rides into King Arthur s hall. The Green Knight proposes a game to those who are around him which is that â€Å"Any knight brave enough to strike off the Green Knight s head may do so, but that man must accept a return stroke in approximately one year’s time†. Gawain accepts the challenge because he w ill not allow King Arthur to accept this. Gawain manages to then cut off the Green Knight s head. The knight then picks up his severed head and leaves, telling Gawain to look for the Green Chapel when it is time for Gawain to fulfill the other half of the challenge that he has accepted. Near the end of the chosen year, Gawain sets out in search of the Green Chapel because he must complete the given challenge. On his journey in search of the Green knight, he finds a castle in the wilderness. TheShow MoreRelatedSir Gawain And The Green Knight1359 Words   |  6 PagesIn the poem â€Å"Sir Gawain and The Green Knight,† a protagonist emerges depicting an Arthurian knight named Sir Gawain. Sir Gawain, King Arthur’s nephew, takes initiative by accepting the challenge requested by the Green Knight in place of his uncle. He undergoes a perilous adventure, seeking for the Green Knight to receive the final blow. 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Reflection Paper On Biblical Leadership - 1578 Words

Introduction Leadership is a topic high on many agendas today, whether in politics, business or the church. A biblical leader is one that has God given capacity and God has given responsibility to influence a specific group of God’s people toward attaining his purpose for the group. In Biblical leadership, God chooses and calls the leader while our work is to answer God s call (75:6-7). The reason why this class is very important is that it contains vital information that can help one grow in the area of leadership and management as an emerging teacher or counselors. Since the inception of the class, my knowledge on how to evaluate one’s personal spiritual life growth has been the most important aspect of being in this class. My†¦show more content†¦Furthermore, there are five stages as explained by Robert Clinton that give a big picture on how to identify the development level seen in an emerging leader. This is called the general development timeline. These five levels involve sovereign foundation, inner life growth, ministry maturing, life maturing and convergence level of development. i. Sovereign foundation or phase I: this is a stage in the life of a leader in which they are responding to the call from God. The character of the leader is being reshaped by God and most of the actions taken by the aspiring leader are controlled by God. ii. Inner life growth or phase II: is the stage whereby the aspiring leader is seeking to have an intimate relationship with God. The leader grows in the area of praying and studying God s words. The aspiring leader grows in the area of discernment, understanding, and obedience in doing the will of God (p 37-38). God continues to test the character of the emerging leader in order to know where the person s loyalty lies in. iii. Ministry Maturing or phase III: This is the stage whereby the emerging leaders reach out to other people around, Here the person begins to discover their gifts and also learn how to apply these gifts toShow MoreRelatedTheology And Pastoral Leadership : Theology Essay1506 Words   |  7 Pages(2009). Theol ogy and Pastoral Leadership. Anglican Theological Review, 91(1), 11-30 Beeley makes the argument that theology lies at the center of Christian leadership. It sites early theologians from the past, later theologians in the Anglican and other traditions. The author provides the relationship between theology and practicalities of leaders work, the ministry of the word, pastoral interpretation of Scripture, and the regular study of the work of Christian leadership. He points out in the articleRead MoreChristian Reflections On The Leadership Challenge868 Words   |  4 PagesChristian Reflections on the Leadership Challenge is an essential book for ministry leaders. 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Sampling Strategy and Sample Size for a Qualitative...

Sampling Strategy and Sample Size for a Qualitative Research Plan Sampling strategy and sample size is distinctly influenced by the research approach taken. This applies both to the overall research direction appropriate for a proposed study (quantitative, qualitative, and mixed methods) as well as to the technique applied to explore the phenomenon under investigation. Moreover, even though Ms. Lynn noted that quantitative and qualitative research methods exist on a continuum, where different methods reflect the amount of data and information available, literature and practice demonstrate significant differences in research strategy and sampling (Laureate Education, n.d.). The following assignment will discuss the sampling strategy and†¦show more content†¦To further elucidate, the study seeks to understand changes in political participation, explore the spaces of interaction and policy formation, and investigate possible consequences associated with the same. 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Do or die Free Essays

Good and evil, are two separate things. Good represents virtue, righteousness, and honor where as evil represents hatred, anger, and cruelty. The Crucible shows characters that represent not only goodness, but evil as well. We will write a custom essay sample on Do or die or any similar topic only for you Order Now The ones who represent true love and good are John Proctor and Elizabeth Proctor. They both show what goodness is in Salem and who is the real witch or devil. Abigail Williams is a young irl who claims she is cursed by the devil and that people are sending devils to kill one another. Abigail represents evil in Salem in the worst ways possible. In the novel The Crucible, written by Arthur Miller, shows how John Proctor and Elizabeth Proctor are representing the angels that portray love and respect, as Abigail Williams represents the role of the devil’s child which portrays hatred. Love comes from deep affection as a mother, sister, or even a child. The two married couple, Elizabeth and John Proctor both represents what real love and goodness is in this book. â€Å"l have no love for Mr. Parris. It is no secret. But God I surely love† (94). In this quote, it shows the honesty John Proctor claims. Everyone in Salem keeps up with rumors and never speaks up the truth. John Proctor does not act as a hypocrite and rather expresses his feeling of honesty towards Mr. Parr’s. â€Å"Do what you will. But let none be your Judge. There is no higher Judge under Heaven than Proctor 39). In this quote Elizabeth Proctor explains that although everyone Judge the Proctors, John should know only God is his Judge, and under heaven there is no Judge higher than himself. Although goodness expresses love and care, there is always evil in everyone’s life. Hatred expresses extreme aversion or hostility. Abigail Williams is a young girl who claims her and a group of girls have been possessed by witch craft. Abigail shows her affection by accusing innocent civilians in Salem claiming†¦ How to cite Do or die, Papers

Impact of Emerging Markets on Marketing free essay sample

Jagdish N. Sheth Impact of Emerging Markets on Marketing: Rethinking Existing Perspectives and Practices The core idea of this article is that five key characteristics—market heterogeneity, sociopolitical governance, chronic shortage of resources, unbranded competition, and inadequate infrastructure—of emerging markets are radically different from the traditional industrialized capitalist society, and they will require us to rethink the core assumptions of marketing, such as market orientation, market segmentation, and differential advantage. To accommodate these characteristics, we must rethink the marketing perspective (e. . , from differential advantage to market aggregation and standardization) and the core guiding strategy concepts (e. g. , from market orientation to market development). Similarly, we must rethink issues of public policy (e. g. , from compliance and crisis driven to purpose driven) and the marketing practice (e. g. , from glocalization to fusion ma rketing). Keywords: emerging markets, affordability, sustainability, inclusive growth T he purpose of this article is to analyze and propose the impact of emerging markets on existing marketing perspectives and practices. As Zinkhan and Hirscheim (1992) and, more recently, Sheth and Sisodia (1999) point out, marketing is a contextual discipline. Context matters, and historically the discipline has adapted well in generating new constructs and schools of thought unique to the marketing discipline (Hunt 1991). As emerging markets evolve from the periphery to the core of marketing practice, we will need to contend with their unique characteristics and question our existing practices and perspectives, which have been historically developed largely in the context of industrialized markets. Most emerging markets are highly local and governed by faithbased sociopolitical institutions in which public policy matters. They also suffer from inadequate infrastructure and chronic shortage of resources. Most of the competition comes from unbranded products or services, and consumption is more of a make versus buy decision and less about what brand to buy. Therefore, many beliefs that are fundamental to marketing, such as market segmentation, market orientation, and brand equity, are at odds with the realities of emerging markets. At the same time, the growth of emerging markets offers great opportunities to develop or discover new perspectives and practices in marketing, which may become valuable for the neglected and economically nonviable markets in advanced markets. This will require a mind-set change in the way we perceive emerging markets. This article is divided into four parts. In the first part, I describe why and how growth of emerging markets is Jagdish N. Sheth is Charles H. Kellstadt Professor of Marketing, Goizueta Business School, Emory University (e-mail: [emailprotected] com). The author is grateful to Bernard Jaworski, Ajay Kohli, and Richard Lutz for their insightful comments and thoughtful suggestions. inevitable. In the second part, I focus on the five unique characteristics of emerging markets and their inherent comparative advantages. In the third part, I discuss how we will need to rethink marketing theory, strategy, policy, and practice in light of the unique nature of emerging markets. I also offer several propositions for further research. In the final section, I provide implications for marketing practice, function, and research. Growth of Emerging Markets A major recent context is the growth of emerging markets (Gu, Hung, and Tse 2008; Hitt et al. 2000; Hoskisson et. al. , 2000). It is estimated that by 2035, the gross domestic product of emerging markets will permanently surpass that of all advanced markets (Wilson and Purushothaman 2003). On a purchasing power parity index, China is already equivalent in market power to the United States, and India is the third largest market, according to International Monetary Fund 2008 data. Just as the last century was all about marketing in the advanced economies, this century is likely to be all about marketing in the emerging markets (Engardio 2007; Sheth 2008; Sheth and Sisodia 2006). Therefore, the fundamental question to consider is this: Will the emerging markets be driven by marketing as we know it today, or will the emerging markets drive future marketing practice and the discipline? Several factors are responsible for the growth of the emerging markets. First, economic reforms in Brazil, Russia, India, and China (BRIC) have unlocked markets protected by ideology and socialism. As a result, some of the best capitalist markets today are ex-communist or ex-socialist countries. This policy change has resulted in creating altogether new markets for branded products and services. Second, all advanced countries are aging, and aging very rapidly. As a consequence, their domestic markets are either Journal of Marketing Vol. 75 (July 2011), 166–182 2011, American Marketing Association ISSN: 0022-2429 (print), 1547-7185 (electronic) 166 stagnant or growing very slowly. Their future growth seems more destined to come from emerging markets. Third, worldwide liberalization of trade and investment, bilateral trade agreements, and regional economic integrations such as the ASEAN, Mercosur, and the European Union have resulted in global competition and global product and service offerings with unprecedented choices of branded products, especi ally in emerging markets. Finally, the emergence of the new middle class, especially in large population markets such as China and India, is creating large-scale first-time buyers of everything from processed foods, soaps and detergents, and personal care products to appliances, automobiles, and, of course, cell phones. The numbers are staggering. China is destined to become the largest single market for virtually all products and services in both household and business markets. It has already surpassed 700 million cell phone subscribers, more than three times that of the U. S. market, and still continues to grow. India has already reached 500 million subscribers and is adding at least 100 million net new subscribers each year. This is also true of consumer electronics, appliances, and automobiles as well as industrial raw materials, such as cement, steel, and petrochemicals. This growth is further enabled by the democratization of information, communication, and technology and by the spectacular rise of local entrepreneurs, especially in the BRIC countries. It has generated unprecedented wealth in a very short time. For example, China has now more than one million millionaires, and India is not far behind. In a recent survey, Forbes declared Carlos Slim from Mexico the richest billionaire in the world, surpassing both Warren Buffet and Bill Gates. What is also unique about the emerging markets is that they have produced large-scale domestic enterprises (native sons), which are often larger in their domestic markets than the largest multinational corporations from the United States, Japan, Europe, South Korea, Canada, and Australia. For example, Haier just surpassed the largest global appliance maker, Electrolux, in units sold, and China Mobil has more subscribers than Vodafone. Similarly, Huawei Technologies surpassed both Alcatel-Lucent and Ericsson-Nokia in telecommunications infrastructure manufacturing. Similar patterns are replicated by Russia in the energy sector, by India in the tractor and motorcycle industries, and by Brazil in the beer industry (Ramamurthi and Singh 2009). Marketers from the emerging markets are now globally expanding, especially in other emerging markets, such as Africa, Latin America, Central Asia, and the Middle East. They are also becoming major global competitors in advanced markets through acquisitions and organic growth. While this seems parallel to what happened in Japan and South Korea, with companies such as Komatsu, Mitsubishi, Toyota, Sony, Hyundai, LG Industries, and Samsung, the domestic scale advantage in favor of the Chinese, Indian, and Russian multinationals is far greater. Most important, these large domestic enterprises have been innovative, nontraditional, and nationalistic in their marketing strategy and tactics and often contrarian to marketing practices of advanced markets. Extant Research on International Marketing The marketing discipline has a rich history of both empirical research and conceptual thinking on international markets (Jain 2003). This research can be classified into four areas: 1. Why do products flourish here and fizzle there? Failure of well-established products in emerging markets is attributed to lack of sensitivity to local cultures (Ghemawat 2001; Hofstede 2001; Sommers and Kernan 1967). 2. Should a company extend its marketing mix (the four Ps of marketing), or should it adjust it to suit the local markets? This question has sparked significant debate and research on what is labeled the â€Å"standardization versus localization debate† (Jain 1989; Keegan 1969; Levitt 1983) and ultimately in a compromise called â€Å"glocal† marketing (â€Å"Think global, Act local†), first suggested by Honda Motors (Quelch and Hoff 1986). Most recently, Schilke, Reinmann, and Thomas (2009) have empirically concluded that several organizational factors moderate whether standardization is positively correlated with performance. 3. Are there country-of-origin effects, especially in emerging markets in which the image of an advanced country is often an advantage? Numerous studies, both experimental and empirical, have demonstrated how â€Å"Made in† labels create differential advantage. Examples include French wines, German cars, Italian leather goods, and Swiss watches. This line of research has also focused on how countries have transformed themselves from having an image of being makers and marketers of low-quality/low-price products to makers and marketers of high-quality/high-price products, including products made in Japan, Korea, and, more recently, China and India. Finally, there is some research on country-of-origin effects in counterfeit products and the emergence of gray markets. 4. Can brands be global or should they be local or regional? While there is little debate about the globalization of corporate brands such as IBM, Hewlett-Packard, Toyota, Samsung, Sony, Vodafone, Accenture, and Siemens, there is still significant controversy at product levels, particularly in consumer packaged goods. In general, there is worldwide rationalization of brands into a few master global brands to gain economic efficiency of branding, packaging, and marketing. The typical antecedents in research on international marketing are marketing variables such as positioning, segmentation, pricing, advertising, and distribution; typical moderating variables have been culture, government policy, administrative rules and regulations, and level of economic development. The most common outcome variables are entry failure or success, premium pricing, market share, and profitability. Finally, the most common mediating variables are consumers’ predisposition and local competition. The tone of this research seems to be colonial in its mind-set about emerging markets, probably because they are former colonies of Europe—in particular, France and the United Kingdom. This colonial mind-set conjures up the images of African tribal chiefs, the natives in the Americas, snake charmers in India, fake products (knockoffs) in Impact of Emerging Markets on Marketing / 167 China, and adulterated products offered by nonregulated vendors with a great deal of haggling and price negotiations. Markets are viewed as informally organized into bazaars, which specialize in product categories such as fish, fresh produce, jewelry, garments, and agriculture commodities (e. g. , rice, wheat, lentils). In my view, marketing as a discipline will benefit enormously if it can transcend the prevailing beliefs, stereotypes, and research traditions about the emerging markets. Fundamentally, emerging markets must be viewed as core and not tangential or peripheral to a company’s mission and strategy. New learning and research opportunities are abundant if only we are willing to change our mind-set about emerging markets. Characteristics of Emerging Markets I have identified five dimensions on which emerging markets are distinctly different from mature markets. Each one has significant impact on at least one of the four areas of marketing (theory, strategy, policy, and practice) and often on all four areas. Each of the following five subsections describes these dimensions (see Figure 1). Market Heterogeneity Emerging markets tend to have very large variance relative to the mean across almost all products and services. This is because markets are local, fragmented, low scale, and mostly served by owner-managed small enterprises. They reflect the reality of preindustrialization and, therefore, reflect characteristics of market heterogeneity comparable to a farming economy. Heterogeneity of emerging markets is further compounded by large skewness (as much as 40%–50%) toward what is referred to as the â€Å"bottom-of-the-pyramid† consumers, who are below the official poverty level of less than two dollars a day income. These consumers have no access FIGURE 1 Five Characteristics of Emerging Markets to electricity, running water, banking, or modern transportation; until recently, they had no access to telephone or television. Most of them are still illiterate and, therefore, do not read newspapers, magazines, or books. More important, heterogeneity of emerging markets is less driven by diversity of needs, wants, and aspirations of consumers and more driven by resource constraints, such as wide range of haves and have-nots with respect to both income and net worth. Similarly, the diversity with respect to access to products and services tends to be enormous between urban and rural households. This suggests that affordability and accessibility may be more important for differential advantage than a superior but expensive product or service with limited access. In short, it is less of a case of demand generation and more a case of demand fulfillment. Sociopolitical Governance Emerging markets tend to have enormous influence of sociopolitical institutions. These include religion, government, business groups, nongovernmental organizations (NGOs), and local community. Markets are more governed by these institutions and less by competition. It is not unusual to have numerous government-owned and -operated enterprises serving the markets with monopoly powers. For example, until recently, most communist markets were served only by government enterprises as monopolies with limited or no choice. Even today, it is important to understand the rise of these enterprises as global competitors. Examples include Gazprom (Russia), Petrobras (Brazil), CNOOC (China), and India Coal (India) in the energy sector alone. Similarly, a few highly diversified trading and industrial groups dominate the emerging markets. Examples include the Tata, Birla, and Reliance Groups in India; the Koch Group in Turkey; the Perez Companc Group in Argentina; and many similar business groups in Mexico, Indonesia, and Brazil. Furthermore, these highly diversified business groups have access to, and influence on, government’s planning and policy changes. They are also often considered favorite sons or crown jewels of the nation. In many of the subsistence markets, defined as rural households with income less than two dollars a day, the closed-loop system of the merchant consumer also generates local market submonopolies with affective, continuance, and normative commitments between producers, merchants, and consumers (Viswanathan, Rosa, and Ruth 2010). Therefore, it is difficult for a new entrant to break into these markets. Finally, there are many emerging markets anchored to faith-based political governance, such as Saudi Arabia and several Gulf countries in the Middle East and parts of Africa. This situation often results in an asymmetric faithbased market power. Therefore, sociopolitical institution perspective is important to understand and incorporate in our research as emerging markets become more accessible through liberalization, privatization, or economic integration. This market imperfection and asymmetry of market power by national marketers ! 68 / Journal of Marketing, July 2011 (both government and business groups) will require us to rethink our theories of competitive advantage anchored to industry structure or resource advantage perspective. Unbranded Competition As much as 60% of consumption in emerging markets so far has been for unbranded products and services, for at least two reasons. First, many branded products and services are still not available in rural markets for a variety of reasons, including lack of access, poor infrastructure, and higher cost of doing business. A second, and more important, reason is that a household is not just a consumption unit but also a production unit. There is an enormous valueadd through labor on making consumable products from raw materials for all basic necessities; for example, households cooking, cleaning, building their own homes, and sewing their own clothes is still prevalent in most subsistence markets and also among the urban poor consumers, such as the slum dwellers. Outsourcing is minimal, partly due to availability of labor at home (women and children) and partly due to lack of affordability of branded products and services. Even when a given value-added activity is outsourced, such as making garments, it is done by a tailor who makes and supplies a nonbranded custom garment. The same is true for lenders (deposits and borrowing), barbers, butchers, and bakers. Milk is also often delivered at home unbranded, as are fresh fruits and vegetables. It is also surprising that as much as 50%–65% of the market for jewelry, liquor, luggage, appliance, personal computers, and some consumer electronic products is served by unbranded producers. A second aspect of unorganized competition is the prevalence of used products as direct competitors. Products tend to have longer life cycle than ownership. Similarly, adulteration, duplication, and imitation are far more prevalent due to lack of regulation, standardization, compliance, and enforcement. A third aspect of unbranded competition for products and services is the prevalence of barter exchange or reciprocal offerings. In other words, market price as a mechanism to address market efficiency from a transaction cost economics perspective, as proposed by Williamson (1976), may require adding a second dimension to the continuum between market and hierarchy. Unbranded products and services as a unique characteristic of emerging markets suggests that market creation (from making to buying) and market development may be more necessary (and potentially more profitable) than market orientation. Chronic Shortage of Resources Emerging markets tend to have a chronic shortage of resources in production, exchange, and consumption. For example, chronic shortage of power (electricity), spotty supply of raw materials, and lack of skill-based labor tend to make production sporadic, inconsistent, and nonreplicable. Consequently, it results in diseconomies of scale. Similarly, exchange has high transaction costs as a result of lack of scale and inadequate financial, physical, and other support mechanisms. Finally, consumption also tends to be constrained with respect to time and location because of the lack of electricity, running water, and physical space. Resource improvisation perspective may be a key to the future of product innovation, product distribution, and product usage. Therefore, our current perspectives of resourceor capability-based advantage may need to be supplemented by resource improvisation advantage. This means innovating low-cost, affordable products and services that are also consumption efficient and versatile in alternate access and exchange. Inadequate Infrastructure Just as there is a chronic shortage of resources and a disproportionate size of below-poverty-level consumers (subsistence economy), another characteristic of emerging markets is inadequate infrastructure. Infrastructure includes not only physical roads, logistics, and storage but also market transaction enablers, such as point-of-sale terminals, and basic banking functions, let alone credit cards. It also means lack of communication, information, and transaction technologies, such as telephones and electricity. While the large metro areas may have adequate infrastructure, in general this is not the case in the rest of the market. The exchange of goods and services called â€Å"commerce† has been a central concern of society for endless centuries. Humans realized long ago that creating a centrally located â€Å"hub† for such exchange was the most efficient way to organize commerce. As a result, ancient civilizations often flourished around cities rather than countries. Athens, Rome, Babylon, Venice, and Florence—all city-based Western civilizations—were also major trading centers of their time. Each had a natural location advantage around which it organized an elaborate system to facilitate trading. In the agriculture days, the natural location advantage was usually access to water-based transportation, namely, rivers and seaports. Around that, an infrastructure was usually developed that became the local exchange—the bazaar. In conducting business in well-developed markets, marketers take the presence of an exchange infrastructure for granted. The elements of such an infrastructure include a sophisticated logistical system for the distribution of goods, a transportation system that enables customers to reach stores easily, ubiquitous telecommunication services, financial services to expedite monetary exchange, the availability of well-targeted broadcast and print media, and so forth. Although such infrastructure is now widespread throughout much of the industrialized world, its absence in emerging markets can derail a marketing manager’s efforts to facilitate efficient and profitable exchange (Sheth and Sisodia 1993). Therefore, nontraditional channels and innovative access to consumers may be both necessary and profitable in emerging markets. For example, the most profitable and largest market for Avon Products is now Brazil because it has been able to organize one million independent agents as its sales and delivery force. Impact of Emerging Markets on Marketing / 169 Comparative Advantage of Emerging Markets The rise of the emerging markets is less than three decades old. However, enough observational evidence, case studies, and professional books exist to catalog new learning and suggest significant new research opportunities for marketing scholars. There are three areas in which the emerging markets seem to have comparative advantage (Hitt et al. 2000; Hoskisson et al. 2000). I describe these three areas in the following subsections. Policy-Based Comparative Advantage Without economic reforms and strong industrial policy, emerging markets would have remained stagnant, as evidenced by remarkable transformation through economic reforms in Eastern Europe, Russia, Central Asia, Latin America, and, of course, China and India. Therefore, a fundamental research question in marketing is, What is the role of overnment policy in organizing markets? How does it differ from the free market forces or the Darwinian theory of population ecology? Is it more efficient and effective for government-mandated standards to create markets than the traditional competitive free market forces? For example, it was the Pan European government-mandated standard that resulted in GSM as the dominant standard for the cell phone industry. Ironically, while the United States invented the cellular technology and successfully commercialized it, the competitive market processes resulted in multiple standards (e. . , AMPS, TDMA, CDMA, GSM) and eventually a disadvantage to the industry and the nation. This is because it resulted in lack of scale in an industry that is otherwise primarily fixed-cost. As a consequence, in the handset business, Motorola, a pioneer, lost the market leadership to Nokia and more recently to Samsung. In short, policy matters. Ironically, unlike in advanced countries, it is the stateowned enterprises of emerging markets—especially in China, Russia, Mexico, Brazil, and India—that have emerged as domestic market leaders and are now aspiring to become global leaders. As mentioned previously, they include Gazprom, Petrobras, Huawei Technologies, China Mobil, State Bank of India, India Post, and ONGC. The range of government policy as a comparative advantage is also impressive. It ranges from government as the largest customer to providing economic incentives for exports to protecting fledgling domestic industries from foreign competition to developing special economic zones. Indeed, the success of China, similar to that of Singapore, Japan, and Korea in the recent past, is directly attributed to its export-oriented industrial policy as well as use of special economic zones. More recently, Turkey has initiated a multimillion-dollar marketing initiative called TURQUALITY to globalize its world-class domestic Turkish brands. This includes providing total quality management and branding expertise as well as modern management education to selected companies (mostly family-owned enterprises) over several years. Another key aspect of government policy is the injection of 170 / Journal of Marketing, July 2011 social objectives in marketing, especially in education and health care. Finally, many governments have negotiated bilateral free-trade agreements or regional economic integration to provide greater market access. Despite this vast influence of government policy in opening and organizing markets, it is surprising that we have very limited empirical research or conceptual theory about government policy as comparative advantage. Kotler (1986) was the first marketing scholar who suggested the role of public policy by adding two more Ps—policy and public relations—to the four Ps of marketing. Perhaps the most insightful articulation of how President Lincoln’s policy of transforming the United States from an agricultural to an industrial society and its relevance to emerging markets is by Robert Hormats (2003). In marketing, while we have a good understanding of impact of regulations on marketing such as unfair trade practices, product safety, and advertising to children, what we need is a much deeper understanding of government policy in organizing markets. Raw Material–Based Comparative Advantage Emerging markets have enormous raw material advantages ranging from human capital (China, India), industrial raw materials (Brazil, Central America), energy (Russia, Nigeria), and other natural resources (Peru, Africa). Many of these markets also have strong agricultural (Brazil) and cattlebased natural resources (India). In addition, most of the emerging markets today have access to capital and technology to do value-add on these resources rather than export them as raw materials. Combine this with the rise of entrepreneurship, and it is inevitable that raw material–based advantage will be key for research in marketing strategy. Ricardo (1817) was the first economist to advocate a resource-based view of comparative advantage with a nonintuitive strategy of outsourcing or exiting an industry even if the country was the lowest cost producer or had a differential advantage. This is because it could do more valuable economic activity with its resources and move up the value chain from agriculture to industrial economy. This implies investing in emerging markets for access to raw materials (supply chain and sourcing) as well as participating in local markets, as a strategic advantage. We need to understand if and how raw material–based comparative advantage may accrue to marketers from the emerging markets both domestically and globally. For example, out of nowhere, India recently became a dominant country for the global information technology (IT) and ITenabled service outsourcing industry because of its large pool of English-speaking software engineers. It seems now poised to be the global hub for other professional services, such as accounting, legal, investment banking, and consulting, as well as design and research and development, across numerous sectors of the economy. And of course, China is already a large manufacturing and sourcing destination for the world. Similar examples include Tata Tea (with acquisition of Tetley Tea), which has become the number two marketer in the world because of its access to, and ownership of, tea plantations. Should a company exit an industry even though it is globally competitive to redeploy its resources and capabilities to take advantage of higher-valued emerging technologies, either homegrown or strategically acquired? IBM seems to have followed this strategy successfully by exiting the low-margin personal computer business and aggressively investing in IT and consulting services. This also seems to be the case for most industries that are permanently shifting from analog to digital technologies and from hardware to software services. More recently, General Electric has restructured itself from a highly diversified conglomerate to a focused global enterprise in infrastructure, capital, and health care markets by exiting its traditional lighting and appliances businesses. In short, we need empirical research on exit strategy based on the theory of comparative advantage to enhance market capitalization value. Such research will be invaluable in the media industry, in which both newspaper and broadcast media are permanently shifting to broadband and social media. In some ways, the enormous success of Google, Apple, and Amazon. com in creating a strong market franchise, developing customer loyalty, and consequently commanding a premium in market valuation needs to be scientifically researched as part of marketing strategy. NGO-Based Comparative Advantage Kotler and Levy (1969) coined the phrase â€Å"social marketing† in the marketing discipline. It was based on the observation that many of the tools and concepts of marketing, such as branding, positioning, and targeting, can be easily extended to the nonprofit sectors, including arts, culture, museums, public libraries, and parks and recreation, in addition to education and health care. In short, the nonprofit sector can and should embrace marketing practices even though there is no profit motive. Kotler (1972) further extended the generic concept of marketing, articulating that marketing as we know it today is generalizable to all types of market and social transactions that result in xchange or some form of reciprocity. Surprisingly, the reverse seems to be occurring in emerging markets. The NGOs in emerging markets are pioneering new and nontraditional marketing practices on a scale unimagined at one time. They are also reaching inaccessible markets. Examples include the Grameen Bank (microlending) in Bangladesh and AMUL (dairy cooperative), Pratham (Urban Slums), and Jai pur Foot in India. The NGOs worldwide seem to have blended the modern business practices with social purpose. As Mahajan and Banga (2005) point out, 86% of the population in emerging markets has yet to experience the benefits of the Industrial Revolution, such as running water and electricity. Similarly, Prahalad and Hammond (2002) articulate how the base-ofthe-pyramid market can be very profitable for traditional products and services if business can innovate on affordability and accessibility to the vast untapped markets, especially in the rural areas (Anderson, Markides, and Kupp 2010; Cachani and Smith 2008; Garrett and Karnani 2010). There are two key concepts with respect to the NGOs from emerging markets, which may be very useful for research in marketing. The first is â€Å"inclusive marketing. † In other words, how can one serve a vast majority of consumers who are below the poverty level of two dollars a day with innovative access and make products or services affordable to them? While the traditional examples of packaging shampoos into single serve units or reducing the size of Coca-Cola to a smaller size are useful, the real breakthroughs and nontraditional concepts and practices seem to be with the newer NGOs. For example, NGOs such as the Gates Foundation and the McArthur Foundation are now emerging as large multinationals capable of acquiring or investing in some of the best for-profit consumer companies. A second key concept is â€Å"public–private partnership,† in which both the government and the private sector agree to pool resources and expertise to focus on societal needs that the free market processes and marketing fail to address. Led by the World Bank, this public–private partnership model of serving unserved markets on a sustainable basis is a fascinating area of research in marketing. Worldwide experiments in countries such as Mexico, Peru, India, Malaysia, and parts of Africa offer a very large pool of data for research opportunities in marketing. Rethinking Existing Perspectives and Practices Rethinking Marketing Theory Marketing theory presumes that customers have choices and that the role of marketing for a company is to make its offerings the customer’s choice. Therefore, it presumes that in a monopoly, there is no need to market because customers have no choice. Conversely, in contestable markets, the role of marketing is critical, and it must create a differential advantage, which is presumed to result in superior financial performance. Over the years, several marketing scholars have proposed their own theories or perspectives on how marketing can create a differential advantage, or they have used frameworks developed in other disciplines—most notably, economics and sociology—to empirically test them in the marketing context (Hunt 2010). I briefly discuss three of them in the following subsections and then suggest how the context of emerging markets, with its unique characteristics, may require some rethinking (see Table 1). From differential advantage to aggregation advantage. Wroe Alderson believed that a company must grow to survive, and to grow, it must constantly struggle to develop, to maintain, or to increase its differential advantage (for a discussion, see Hunt 2010). Alderson believed that differentiation was the foundation of marketing theory. Given the heterogeneity of demand and competition for differential advantage, heterogeneity of supply is the likely outcome, resulting in variety in offerings, including many variations or stockkeeping units of the same generic kind of good. It also means segmenting the market. While heterogeneity is one of the key characteristics of emerging markets, the inference that can be drawn is quite the opposite. As discussed previously, emerging markets Impact of Emerging Markets on Marketing / 171 TAblE 1 Rethinking Existing Perspectives and Practices Product Category Marketing theory a. . c. a. b. c. a. b. c. a. b. c. From Differential advantage Industry structure Resource possession Market orientation Relationship marketing Customer satisfaction Compliance Excessive consumption Finance driven marketing Glocalization Diffusion of innovation Country of origin advantage ? To a. Aggregation advantage b. Government policy c. Resource improvisation a. Market development b. Institutional market ing c. Convert nonusers to users a. Inclusive growth b. Mindful consumption c. Purpose driven marketing a. Fusion b. Democratization of innovation c. Nation brand advantage Marketing strategy Marketing policy Marketing practice tend to be high in market heterogeneity and therefore are highly fragmented. They also tend to have a skewness of 40%–50% of subsistence consumers. This is further compounded by family-owned businesses, which perpetuate or add to fragmentation for the sake of family succession planning. The consequence, contrary to Alderson’s conclusion that differential advantage results in better margins or profits for the firm, is simply not true in emerging markets. There is too much competition, and margins tend to be paper thin. Businesses exist more on cash flows and wageless family labor. They survive not as much for growth as they do simply for survival. What is needed in emerging markets, therefore, is greater standardization by reducing the variety and aggregating demand to achieve scale efficiency and better returns on investment (Levitt 1983). What a company needs, therefore, is aggregation and standardization advantage. How a company standardizes and aggregates demand from highly fragmented and disbursed demand across thousands of rural villages and remote locations is key to growth and survival. It is not surprising that Wal-Mart, which has mastered the art of aggregating and standardizing rural demand with its hub and spoke logistics system, has become the largest retailer in the United States in fewer than 30 years, surpassing powerful incumbents including Sears, Kmart, and Kroger. P1: In a highly heterogeneous demand and heterogeneous supply market, aggregation advantage results in better financial performance than differential advantage. From industry structure to government policy. The industrial organization perspective maintains that the profitability of an industry is determined by ive forces of competition (Porter 1980). These include rivalry among existing competitors, threat of new entrants, threat of substitute products and services, bargaining power of suppliers, and the bargaining power of customers. Therefore, choosing an industry that is less competitive will, by definition, generate better profitability. Industry concentration is a good indicator of low comp etition, and it is typically measured by market share distribution. In addition, a company even in a very competitive industry can earn superior returns if it chooses 172 / Journal of Marketing, July 2011 he right strategy among three mutually exclusive strategies: cost leadership, differentiation, and focus. Finally, a company must focus on activities in its value chain (both primary and support activities) to offer a superior value in its chosen strategy (cost leadership, differentiation, or focus). If value is defined as what the market is willing to pay, superior value stems from offering lower prices than competitors for equivalent benefits or providing unique benefits that more than offset a higher price (Hunt 2010). Sheth and Sisodia (2002) propose an alternative industry structure model. Each industry consists of three full-line generalists (constituting an oligopoly) that have volume and velocity advantage, as well as numerous product or market specialists (monopolistic competition) that have the margin advantage through selection and service. Thus, each industry is a combination of part oligopoly and part monopolistic competition. Both generate above-average returns relative to others. Therefore, a firm must decide whether it wants to be a full-line generalist or a multiproduct–multimarket specialist. In retailing, it means whether a firm wants to be Wal-Mart or Target, or does it want to be a specialty retailer, such as Foot Locker (product specialist) or The Limited (market specialist). Because strategies and capabilities are different, a firm must decide between these two choices and gain the respective competitive advantage. Uslay, Altintig, and Windsor (2010) have recently tested Sheth and Sidodia’s model of competition empirically. The presumption of industry structure theory is that market size is fixed and is a zero-sum game of gaining market share. However, it is the opposite situation for emerging markets, in which growing the market with increasing competition is likely to result in greater profitability and, even more important, in the market cap of the company. The best example is the Indian wireless industry, in which privatesector participation expanded the total market and has delivered profitable growth at the lowest prices in the world, and the market valuation of both private and state enterprises is far greater than the industry price–earnings ratio. P2: In markets in which growth has been regulated by government policy, growing the total market demand by policy changes results in better financial performance than industry concentration. From resource possession to resource improvisation. The resource-based view maintains that resources are both significantly heterogeneous across firms and imperfectly mobile. Therefore, a firm that possesses resources that are valuable, rare, imperfectly mobile, and inimitable will gain competitive advantage (Wernerfelt 1984). Resource-based advantage theory has become popular in marketing, with a focus on intangible assets such as brands and customers. As discussed previously, a key characteristic of emerging markets is a chronic shortage and heterogeneity of resources: If necessity is the mother of invention, then resource shortage is the father of innovation. In emerging markets, therefore, a company gains advantage by learning to improvise with scarce resources and, in the process, to become more innovative relative to its competition. Innovation through improvisation may occur with respect to each of the four Ps of marketing: product, price, place, and promotion. It also includes improvisation as a consequence of a lack of primary and enabling infrastructures, a lack of skilled workforce, and a lack of access to low-cost capital. This is referred to as juggad in India. There are numerous case histories that validate this observation, such as the Grameen Bank in Bangladesh, milk cooperatives such as AMUL in India, and Avon products in Brazil, as mentioned previously. It also includes the recent success of General Electric in medical instruments in China and India. P3: In markets with a chronic shortage of resources, improvisation results in better financial performance than possession of differentiated resources. Rethinking Marketing Strategy In this section, I focus on three marketing strategies that have become mainstream for empirical research in marketing: market orientation, relationship marketing, and customer satisfaction. I suggest how the rise of emerging markets will affect each of them. From market orientation to market development. Recently, the market orientation perspective articulated by Narver and Slater (1990) and by Kohli and Jaworski (1990) has become a dominant paradigm in marketing. â€Å"The fundamental imperative of market orientation strategy is that, to achieve competitive advantage and, thereby, superior financial performance, firms should systematically (1) gather information on present and potential customers needs and (2) use such information in a coordinated way across departments to guide organization wide responsiveness to meet or exceed them† (Hunt 2010, p. 413). Market orientation can be traced back to the marketing concept articulated and developed in the early 1960s, in contrast to production or sales orientation. â€Å"The marketing concept maintains that all areas of the firm should be customeroriented, (b) all marketing activities should be integrated, and (c) profits, not just sales, should be the objective. Knowing one’s customers and developing products to sat- isfy their needs, wants and desires, has been considered paramount† (Hunt 2010, p. 413). As discussed, emerging markets include the consumption of, and competition from, unbranded products and services. Indeed, most consumers make products at home. Many consumers have no brand or product knowledge. Often, they do not even know how markets operate. They largely depend on an intermediary, who provides selective information, selective choices, and cash flow financing. Therefore, it is difficult to generate market intelligence pertaining to current and future customer needs. It seems that in emerging markets, markets are created by shaping customer expectations, not by assessing them. Indeed, it is often a â€Å"field of dreams†: If you build it, they do come. This has clearly been the case in China for fast foods and automobiles. The same seems to be true in Russia and India. Because markets are informal and unorganized as a result of a lack of adequate infrastructure, what matters most in emerging markets is market development strategy: marketing accessible and affordable branded products and services. As mentioned previously, Avon Products has taken this approach in Brazil with a million-plus agents by organizing selling and distribution systems along with microfinancing. Similarly, market development has been the backbone for public telephones in India, which uses a franchise system. Similar stories abound for Bata Shoes in Africa and in India. Indeed, this has been the strategy of Huawei Technologies in the telecommunications infrastructure industry in Africa and for Life Insurance Corporation of India, which offers life policies in rural markets. Probably the best example is the success of Western Union, which has organized a global money transfer system for migrant workers. Historically, franchising has been the most popular approach to market development, such as the pioneering success of Holiday Inn, McDonald’s, and Ace Hardware in the United States. P4: In markets consisting of unbranded competition for products and services, market development delivers better financial performance than market orientation. From relationship marketing to institutional marketing. Since the growth of the services economy, there has been a shift in marketing toward understanding and managing long-term relationships with individual customers. Specifically, in many service industries, such as telephone, utilities, and banking, once a customer establishes an account, he or she stays in the relationship unless there is an exogenous event, such as physical move or divorce. Alternatively, some disruptive change initiated by the service provider destabilizes the relationship. Therefore, postsales activities and experiences through customer support are crucial in relationship marketing. Also, rather than fight for market share, marketing strategy shifts toward â€Å"share of wallet† by offering the same customer a portfolio of services. This is common in financial services and in telephone services, including bundling, for example. This leads to calculating the lifetime value of the customer and customer profitability analysis (Kumar and Peterson 2005). Relationship marketing establishes competitive advantage by attracting, developing, and maintaining relationImpact of Emerging Markets on Marketing / 173 ships with customers through building trust and making commitment of resources to customers (Hunt 2010). In emerging markets, the concept of relationship marketing is very useful. However, the target may not be the end customer. Given that emerging markets are governed by sociopolitical and aith-based institutions such as the government, religion, NGOs, and the local community, it becomes necessary to attract, develop, and maintain relationships with institutions and their leadership. This has been well documented in research on the diffusion of innovation in the farming community, in which it is important to establish a relationship with opinion leaders of the community. This has been also found to be true in the medical community for adoption of new drugs. In other words, establishing and sustaining a relationship with market makers is as important as with customers. Fortunately, there is a well-established theory of institutional economics that may be useful in developing institutional marketing strategy (Gu, Hung, and Tse 2008; Hoskisson et. al. 2000). P5: In markets governed by sociopolitical institutions, it is more important to attract, develop, and maintain relationships with institutions and their leaders than with end customers for superior financial performance. From customer satisfaction to converting nonusers into users. Customer satisfaction emerged as a key marketing strategy in the 1980s as a way to regain global competitiveness after the first energy crisis of the late 1970s. Because Japan had emerged as a successful global competitor to the United States in many industries, including television, watches, and automobiles, the Malcolm Baldrige Quality Award from the U. S. government, anchored on customer satisfaction, became a part of corporate strategy. While satisfaction was a key construct in Howard and Sheth’s (1969) theory of buyer behavior as a way of understanding how postpurchase experience compared with prepurchase expectations (attitude) reinforced the decision resulting in brand loyalty, it became part of marketing strategy only in the 1980s. This led to growth of J. D. Power’s customer satisfaction index in the automobile industry and eventually virtually across all consumer and some business products and services. Finally, Fornell et al. (2006) developed a cross-industry aggregate index at a national level. They also linked their customer satisfaction index to a company’s financial performance, including market cap of the company. Several professional books by Frederick Reicheld and the development of Net Promoter Score gained top management attention. As mentioned previously, the concept of CLV and profitability at the individual customer level resulted in modeling the economic value of customer centricity (Kumar and Peterson 2004; Kumar and Shah 2009). It also led to developing customer equity as an intangible asset as important as brand equity. The stream of research still continues to grow with access to large-scale end-customer data (especially in the telephone and banking industries) and affordable data-mining tools and techniques. It has become a core part of modeling research in marketing. 74 / Journal of Marketing, July 2011 Emerging markets, with their unique characteristics of unorganized markets and lack of adequate infrastructure, including media and distribution, suggest that what is equally important is to convert nonusers into first-time users. The real challenge and opportunity is to convert nonusers to users, whether it is for automobiles, motorcycles, cell phones, television sets, banking and insurance, or househ old products and services. The real competition lies in the make versus buy decision. Therefore, it is necessary to develop a marketing strategy around the economic, social, and emotional value of outsourcing. As Williamson (1976) points out, transaction cost economics is fundamentally the economics of make versus buy choices on a continuum from markets (outsourcing) to hierarchy (insourcing). In emerging markets, it is the reverse shift: What motivates consumers to outsource (buy) homemaking activities, such as cooking, cleaning, and child care? Is it strictly an economic decision, or is it influenced by social and behavioral considerations? For example, why do rural farmers buy branded blue jeans and T-shirts when, at the same time, they consume unbranded daily necessities? Are there social or emotional reasons emerging-market consumers tend to be more brand conscious? What matters most from a marketing perspective in outsourcing decisions is informing, educating, and enabling customers through workshops, social media, and channel development. This is similar to what happens for new technology breakthroughs such as personal computers, industrial automation, and operating software systems. In short, what matters most is creating first-time users. It requires homogenization of expectations through framing, incentives, and development (Sheth and Mittal 1996). P6: In markets that largely consist of self-made products and services, converting nonusers to first-time users results in better financial performance than satisfying existing users. Recent examples of success by Starbucks, McDonald’s, and Coca-Cola in China, and similar successes by Subway and Domino’s Pizza in India, provide validation of this proposition. Rethinking Marketing Policy Historically, marketing policy has been compliance driven with respect to each of the four Ps. Product is regulated by multiple agencies (the Food and Drug Administration, U. S. Department of Agriculture, and the Product Safety Commission) with regard to safety, disclosure, and labeling. Similarly, pricing is regulated by multiple agencies (the Federal Trade Commission and the U. S. Department of Justice’s Antitrust Division) for predatory pricing, price fixing, monopoly pricing, and unit pricing. Promotion, which includes advertising, sales promotions, and personal selling, is regulated for deception, intrusion, and partial disclosure. This includes truth in lending, truth in advertising, privacy protection, and the Do No Call Registry for telemarketing. Most regulation has been legislated to protect consumer rights as a consequence of marketing malpractice or market failures, such as redlining or subprime lending. In addition, marketing regulation and policy issues have arisen from financial (e. g. , home mortgages) and physical (toys made in China and salt in processed foods) crises as well as from negative press (e. g. , BP, Toyota). It has also arisen from consumer advocates and consumerism. Peter Drucker very aptly observed that presence of consumerism is the shame of marketing (e. g. , Uslay, Morgan, and Sheth 2009). With the growth of emerging markets comprising a large percentage of consumers below the poverty level, as well as the emergence of new brand-conscious middle-class consumers who are first-time buyers of everything from cell phones to television sets to automobiles and homes, marketing policy can, and must, take on three new roles to positively encourage and participate in shaping public policy (De Figueiredo 2010). I discuss these in the following subsections. From compliance to inclusive growth. The first role is related to inclusive growth. Historically, marketing has been driven by markets and financial outcomes. This has resulted in neglect or abandonment of markets such as rural or disadvantaged urban consumers, especially for health, education, and lending (Anderson, Markides, and Kupp 2010). In turn, this eglect has resulted in the creation and coexistence of unorganized and exploitative marketers whose practices generate marketing’s negative image (Garrett and Karnani 2010). By definition, inclusive growth implies proactive inclusion of all consumers, not just those who can afford existing market prices. As mentioned previously, Mahajan and Banga (2005) point out that 86% of the population in emerging markets has yet to experience the benefits of industrial innovations such as running water and electricity. There are four approaches to achieving inclusive growth. The first is the deployment of corporate social responsibility initiatives specifically targeted at inclusive growth in areas such as consumer literacy, microfinancing, and social entrepreneurship. A second approach is public– private partnership in which both the government and the private sector agree to pool resources and expertise to focus on the societal needs that free market processes and traditional marketing fail to address. Led by the world agencies such as the World Bank, this public–private partnership model of serving the unserved markets on a sustainable long-term basis is an important area of research in marketing policy. As mentioned previously, worldwide experiments in countries such as Mexico, Peru, India, and parts of Africa provide a large pool of data for research opportunities in marketing. A third, and more recent, approach to inclusive growth is large-scale investment by younger but wealthier NGOs, including the MacArthur Foundation and the Gates Foundation. In addition, the Grameen Bank (microlending) in Bangladesh and Pratham (urban slums) and Jaipur Foot (prosthetics for polio victims) in India have demonstrated how low-cost innovation in products and distribution can achieve inclusive growth. Again, while the traditional successful marketing examples of packaging shampoo in single-serve units (Sachet) or repackaging Coca-Cola as a smaller serving to make them more affordable are useful, the real breakthrough and nontraditional concepts and practices seem to be with these newer NGOs. Here, again, access to data for empirical research is likely to be less problematic. The fourth approach is market-based affordable products and business innovations. Emerging markets are becoming hotbeds of innovation, according to a recent special report on innovation in emerging markets in The Economist (2010, p. 3): â€Å"They are coming up with new products and services that are dramatically cheaper than their Western equivalents: $3,000 cars, $300 computers, and $30 mobiles phones that provide nationwide service for just 2 cents a minute. The Economist describes what it refers to as â€Å"charms of frugal innovation† by citing two examples. First, there is a handheld electrocardiogram (ECG) called the Mac 400, invented in General Electric’s laboratory in Bangalore (India), which it calls a masterpiece of simplification. It also sells for $800 instead of $2,000 for a conventional ECG and has reduced the cost of an ECG test to just $1 per patient. A second, equally exciting innovation is a low-tech device for water purification that uses rice husks (a waste product), innovated by Tata Consulting Services. It is not only robust and portable but also relatively cheap, giving a large family an abundant supply of bacteria-free water for an initial investment of about $24 and a recurring expense of about $4 for a new filter every few months. Tata chemicals, which is making the device, is planning to produce over 1m next year and hopes for an eventual market of 100m† (The Economist 2010, p. 6). P7: A company’s policy that is anchored to inclusive growth generates better financial performance in emerging markets than its free market process. From excessive to mindful consumption. A second major area of concern (and research opportunity) is mindful consumption (Sheth, Sethia, and Srinivas 2010). With more than 4 billion consumers in the emerging markets, all aspiring to become first-time buyers and consumers of modern technological products, sustainability will become a key challenge for marketing and business. As I point out in Chindia Rising (Sheth 2008), it is neither technology nor capital that will be the showstopper for the growth of China and India: It will be the environment. The biggest consequence of the Industrial Revolution was the location divorce of production from consumption. While it resulted in modern commerce and trade, which are the roots of marketing, it also generated more than 70% of the total carbon footprint from three basic areas of consumption: processed foods, modern homes, and personal vehicles. As mentioned previously, the first Industrial Revolution benefited only a small percentage of the world population. If we add the size and rapid growth of the new middle class of emerging markets, it is likely to have both short- and long-term consequences for ustainability (Sheth and Parvatiyar 1995). Current marketing practices that are friendly to the environment are conservation and green marketing. Conservation is anchored to the three Rs of consumption: reduce, reuse, and recycle. Green marketing includes products that are less harmful to the environment, such as low-emission motor vehicles and energy-efficient appliances, homes, and Imp act of Emerging Markets on Marketing / 175 factories. However, these practices are not sustainable if marketing policy also embraces inclusive growth. Unfortunately, with efficiency in producing and marketing of products and services and with the customer-centric accommodation of heterogeneous expectations, marketing has encouraged unnecessary purchasing and consumption by offering endless variety, 24/7 convenience, and aggressive sales promotions. In terms of policy, marketing may have to reduce choices and regulate consumption either voluntarily or by compliance through new regulations. Just as we have worked to demarket smoking cigarettes and ban text messaging while driving, it will become increasingly necessary for marketing to be socially responsible in its own practices. A major area of marketing policy for sustainability is to encourage mindful consumption. This includes developing a caring mind-set among consumers and customers—that is, caring for the self, caring for the community, and caring for the environment. Similarly, marketing through policy can encourage moderation in product acquisition, replacement, and disposal. It is well documented in medical research that the modern lifestyle and consumption habits have become self-destructive as well as harmful to the society and the environment. From a policy perspective, it will be in the self-interest of marketing to inculcate and encourage mindful consumption. This may require reinforcing consumers who are mindful of their consumption, using incentives and disincentives for reducing excessive and unnecessary consumption (especially of resources such as water, electricity, and gasoline), educating consumers about the consequences of their consumption, and partnering with policy makers to regulate consumption, as we have done with smoking and other mandatory deconsumption issues. P8: A firm’s marketing policy anchored to mindful consumption generates better financial performance than free-marketbased excessive consumption First, it will require extending marketing to a company’s stakeholders (community, employees, channel partners, suppliers, and investors) and not just its customers. The stakeholder perspective of marketing is likely to result in balancing diverse and sometimes conflicting goals and perceptions of different stakeholders. It will mean developing marketing skills for employee branding as well as community branding and communication. A second area of research is related to developing purpose-driven brands. While most brands are historically anchored to product attributes, and some have transcended to focus on customer benefits, how do we embed purpose and meaning in brands for customers and other stakeholders that go beyond product attributes and customer benefits? Do purpose-driven brands outperform other brands? Does a purpose-driven brand command a greater asset value than others? Is the lifetime value of purpose-driven brands greater than that of other brands? A third aspect of purpose-driven marketing is to redefine the raison d’etre of marketing as trustee and steward for each of its assets (branding and customers). In other words, how can marketing attract, nurture, and retain trust of customers, community, employees, and other stakeholders? What are marketing’s roles and activities as brand steward for a company’s products, services, and reputation? P9: (a) Purpose-driven marketing delivers better financial performance than finance-driven marketing. (b) Purpose-driven marketing generates greater brand and customer equity than finance-driven marketing. c) Purpose-driven marketing wins greater share of heart of customers than financedriven marketing. Rethinking Marketing Practice Marketing practice is partly driven by theory, partly by strategy, and partly by policy. As described previously, there are four substantive areas of research related to international marketing. (1) Why do products flourish here and fizzle t here? (2) Should a company extend or adjust its marketing mix to suit the local markets? (3) Are there countryof-origin effects, especially in emerging markets in which image of an advanced country is often an advantage? 4) Can brands be global or should they be local or regional? This section focuses on how the rise of emerging markets will affect marketing practice, including redefining the role of the chief marketing officer and reorganizing the marketing function. From glocalization to fusion marketing. The old debate of whether, when, and how to extend or adjust marketing mix based on local cultures and regulation is giving way as a result of more bilateral and regional free-trade agreements and globalization of competition. Markets are less regulated than they were in the 1980s, especially after the abolition of the General Agreement on Tariffs and Trade; establishment of the W