In Ugandan villages where non-governmental organisations (NGOs) hired away the existing government health worker, infant mortality went up.
This happened in 39% of villages that already had a government worker. The NGO arrived with funding and good intentions, but the likelihood that villagers received care from any health worker declined by ~23%.
Brain Misallocation
“Brain drain”, - the movement of people from poorer countries to wealthier ones, has been extensively discussed for decades. But there’s a different dynamic that gets far less attention: “brain misallocation”.
In many low- and middle-income countries (LMICs), the brightest talents are being incentivised towards organisations that don’t utilise their potential for national development. They’re learning how to get grants from multilateral alphabet organisations rather than build businesses or make good policy. This isn’t about talent leaving the country. It’s about talent being misdirected and mistrained within it.
Examples
Nick Laing in northern Uganda describes the talent drain:
Last year, one of our best nurses left one of our rural health centres. With no warning and without telling anyone. It was the 3rd nurse that year who left for an NGO job. We rushed to replace him, but it put the only remaining nurse there under a lot of stress, and I’m sure patients weren’t cared for as well in the meantime. Our replacement wasn’t as good. I didn’t hear the nurse who left again until 6 months later, last week. He came to apologise for leaving abruptly. He said he felt really bad about it, that he had let his fellow staff and the patients down. He’s a great guy and it was good to catch up and reconcile everything. When I asked him why he left for the NGO job, he looked at me as if it was a stupid question.
“The money was too much, of course”
This same dynamic affects would-be entrepreneurs and private sector workers, not just government employees and local health centres.
The wage differential driving this is substantial. Ivan Gayton’s experience with Médecins Sans Frontières in Burundi illustrates the scale. In 2003, MSF paid unskilled labour $1/day when the local market rate was 25 cents.
Ivan: …I mentioned…this back of the envelope calculation that we were 75% of the local economy…we destroyed and distorted the local economy completely; as development practice that would’ve been utterly and completely unethical.
The only justification for doing something like that is an acute emergency, which it was, it was nigh on a hundred thousand people with literally no access to healthcare whatsoever. The amount of avoidable suffering and death that was going on that we could actually alleviate was something that, you know, in sort of humanitarian practice, I guess we arrogate to ourselves the idea that we can, in a sufficiently emergency situation, justify doing things that would be unethical development practice.
Elizabeth: Do you think the village was worse off for having the hospital located in their village?
Ivan: oh yeah. Because we obviously brought this flood of money in, but where does the money go? The doctors and nurses, they’re not even local. They’re from the capital city. So you’re bringing in people from the capitol who then lord it over the local people, price of food jumps up, price of accommodation goes insane. The trickle down opportunities are to be sex workers and cleaners and, you know, servants for these, for these newly created royalty.
Elizabeth: you might hope that if the price of food goes up, but their wages are also going up because they’re working for the hospital or tangentially, then that would compensate?
Ivan: Well yeah. For the people who are already, you know, have access to the labor market and are already able to sort of get in on that. Sure. I mentioned that I actually, I deliberately kind of rotated through the villagers to give lots of people a chance, but still, if you’re not one of the people who gets a chance or even ever had a chance, or was somebody who’s, you know, on the outs with the local powerful people, then we, as these foreigners providing these jobs, we never even see those people.
They don’t even get to apply for a job with us. We never even know of their existence. So those people, now, the price of everything is jumped. There’s a bunch of newly, much more wealthy people around them, and they’re excluded from that. They don’t see any of the benefit and all of the harm. So it’s, it’s terrible.
While MSF could justify this as an acute emergency response, the economic distortion was huge. These wage premiums, sustained over time across thousands of NGOs, fundamentally reshape who works where and develops what skills.
Kenya alone has over 11,000 NGOs employing 70,000+ people. That’s roughly equivalent to staffing 15 mid-sized hospitals, 700 secondary schools or hundreds of larger companies. Instead, it’s distributed across thousands of small projects, many of which are likely less effective than the services they replace.
The Incentive Trap
This isn’t about NGOs being malicious, they’re responding to incentives. So are workers. But rational individual decisions can create collective dysfunction.
No one is making deliberately bad choices. A talented graduate earning $150/month gets offered $600/month by an international NGO. She takes it. Why wouldn’t she? An NGO needs skilled staff and can afford to pay. Why wouldn’t they hire her?
But multiply this by thousands of decisions, and you get a system where the brightest people learn to write grant proposals instead of build businesses and satisfy donor reporting requirements instead of navigating local politics.
When a significant chunk of a country’s most educated young people end up in the NGO ecosystem, several patterns might emerge.
- Accountability runs upward, not downward
- Staff learn to focus on reporting metrics, not respond to community needs or political/business realities. The skills for navigating aid bureaucracy don’t transfer to navigating citizen or customer demands
- Scattered impact
- Rather than concentrating intellectual capital in sectors that could drive economic growth, talent gets distributed across numerous small initiatives with limited scale
- Skills mismatch
- The skills NGOs cultivate such as grant writing, donor reporting, international frameworks, aren’t the ones most needed for building competitive local enterprises or effective public institutions
- Wrong networks for local impact
- Career advancement in NGOs means building relationships with other international organisations, donors and expatriate staff. The connections that matter for building local institutions are less developed
- Sector hopping following funding waves
- When donor priorities shift from health to education to climate, talented people follow. There is less deep expertise in one sector because career incentives reward flexibility to chase funding trends
When Help Becomes Harm
A study in Ghana found that when NGOs entered communities, government funding decreased by 6.8% in NGO-active sectors (even as it increased by 7.4% in areas where the NGO was not focused). Money flowed away from government institutions that villagers had previously relied upon and into new programs sponsored by the NGO.
This led to overall villager well-being (measured across food security, education, health, nutrition, environment and economic livelihood) decreasing by 0.1 standard deviations after the NGO’s arrival. These villagers had historically relied more on government institutions, so when the NGO displaced those without providing better alternatives, they suffered most.
One theory for the underperformance was that the NGO encouraged citizens to spend more time engaging with relatively powerless local authorities rather than the higher-level political work that could actually improve wellbeing.
Conclusion
This could be wrong. Maybe NGO experience provides valuable skills people later use elsewhere. Maybe in contexts with few good jobs, NGOs are the best available option for keeping talented people in-country and employed.
There are also variations in government pay as well with some countries having relatively high pay for government workers with very little extra productivity to show for it.
But if there’s something to the idea of brain misallocation, it could reframe how we think about development aid effectiveness. Not just “does this project work?” but “what is this doing to local human capital allocation?”
I think NGOs and donors need to ask uncomfortable questions. When you pay staff 2x local rates, where are those people coming from? What would they be doing otherwise? Are you strengthening or weakening regional capacity? What role are you playing in the broader talent ecosystem?
Also job seekers in LMICs facing this choice deserve better options. The problem isn’t that NGOs pay too much, it’s that private sector opportunities pay too little or don’t exist. This is ultimately about governance and economic development failures, with NGO salaries as a symptom not a cause.
Thanks so much for writing this @DavidNash. I think that this awkward but important negative externality is little discussed in EA Global health circles, and I've never seen seen this included as a negative adjustment in a cost-effectiveness analysis (would be tricky tho). Hiring the best people away from their burgeoning new business or a government job could cause a horrendous counterfactual of lost value - that of course you'll never see or know.
I think many NGOs unfortunately see their hiring situation a kind of failure of game theory. For the individual NGO the best option seems to be to hire the best worker they can for a high salary. NGOs don't co-operate and pay market wage, so most NGOs just defect and they all pay more. You then get a weird NGO world which operates on a different plane from the local market. When I talk to NGO leader and they mostlyadmit that paying so much is bad for the reasons you outline, but then shrug and respond.
"what choice do we have to get the best staff"
I think in general though the NGOs are wrong even about having to pay this much to get super capable people. Unemployment rates are so high in LMICs, that there are thousands of super talented and capable people that would happily take a 30% or 50% lower salary that than they are paying - and with support and guidance would often do a great job. This might not be the case at top management level, but holds at most other levels of an organisation.
Pushback - Government pays HIGH
One pushback I have, is that "There are also variations in government pay as well with some countries having relatively high pay for government workers" misrepresents the situation - government pay is usually much higher than the market. In Uganda, government jobs are seen as the "Mecca" because they pay so much more than the market, and often at least as much as NGO jobs. Many NGOs then make the mistake of benchmarking to government salaries even though that doesn't represent market salaries at all. I think many government salaries are absurdly high in Uganda, and this matches the situation in other countries. This International Labour Org listshows that in most Sub-Saharan African countries government salaries average more than double the private market, which is kind of crazy...
And to back that up here's my experience of certificate nurse salaries in Uganda.
Goverment - $350 monthly
NGO - $300 monthly (and you have to work harder than in government)
Us - $130 monthly (junior staff)
Other private - $100 monthly
I think your arguments against the problem are weak, you say "This could be wrong. Maybe NGO experience provides valuable skills people later use elsewhere. Maybe in contexts with few good jobs, NGOs are the best available option for keeping talented people in-country and employed. This seems like a straw man to me, because the counterfactual isn't hiring no-one, its paying people less. Why not just hire 2 people at slightly above the market rate rather than one for double the rate as is common practice. Then more people get the skills to later use elsewhere and more people get decent jobs which could keep them in-country.
I think NGOs could largelty solve this problem through benchmarking against similar private sector salaries, then maybe add 20%-30% to that. This should be a good balance where you can
1. Hire great staff
2. Retain your staff
3. Avoid misallocation of staff from other more (or similarly) important work
One positive development is that NGO salaries have reduced over the last few years, in Uganda at least. I think that NGO budgets have been tighter, and also NGOs have realised they don't actually need those high salaries to retain staff. Post USAID I hope this situation improves even more.
One area salaries are still stupid-high is in research projects run by foreign universities/institutions. I think foreign researchers are usually so far removed from local realities they have even less of a clue about the local economy than NGOs. At OneDay Health we've been involved in a couple of research projects recently, and salaries people in this field have been wanting are even higher than I've seen in NGOs - sometimes close to on par with Western Salaries. I actually cracked up laughing on the phone at one salary request (probably rude of me).
A parting shot
I want to call out EA-affiliated orgs as often no better than the average here. GiveWell funded Orgs like Clinton Health Access Initiative (CHAI) and PATH follow the pattern @DavidNash describes. One time a staff from (i think, can't remember 100 percent( one of these orgs exclaimed...
"we have this amazing ex-government worker who really knows how government works and can help us make change there".... Sad story...
When I balked at the high salaries in a CHAI Project here, @GiveWell responded with their unusually wonderful transparency.
"Our understanding is that salaries are set based on globally-benchmarked salary ranges and localized equity adjustments to account for organizational equitable pay standards and differential cost of living across different geographies. A portion of the compensation costs is also due to benefits (such as health insurance) that may be standard to each location.
To which I would respond - yes if that's the approach, you'll end up paying extremely high salaries and often pinch staff from similarly/more important work. Better to benchmark against the market, not "Organisational equitable pay standards". Also (by the by) I would doubt that health insurance is "standard" in any Sub-Saharan country.
Interesting, are there NGOs in LMICs that pay their staff 20% more than the market pay?
hey there interesting question! As a policy I would doubt it. interestingly sometimes NGO policies pay as minority of jobs at or below market rate. for example a NGO hospital close to my home pays everyone with a degree the same amount. So most of their staff then get 50 to 100 percent more than they market rate, but they struggle to even hire radiographers (there's a shortage) who get paid double other degree holders on the open market. The health center I work at (which pays 20% more than market) recently had to hire a radiographer paid twice as much as the in-charge of the facility!
At OneDay health we do something like that, although it's not an official policy. Although In management positions I'll be honest that we pay a bit more and say I'm partially guilty of my own accusations. Not even in the ballpark of many NGOs though.
Interesting. Thank you for explaining!