The internationalization of medical education has become a key process shaping the global health workforce, redistributing the costs and benefits of training across countries at different income levels. This chapter offers an integrated assessment of these trends using updated global education-cost estimates, institutional micro-costing, regression-based models of cost-per-graduate, and needs-based workforce forecasts. Recent analyses show that annual global preservice spending now surpasses US$110 billion and produces over half a million new physicians each year. Four main channels of internationalization are examined: cross-border student mobility, health-worker migration, offshore and franchised medical schools, and the globalization of accreditation and knowledge systems. High-income countries gain the most fiscal and workforce benefits, saving significant domestic training costs and addressing shortages by employing international medical graduates. Although this is partially offset by donor aid, these funds typically target vertical disease programs rather than the education systems that train clinical staff.  Middle-income countries (MICs) are major overall losers, due to the combined effect of domestic training costs and brain drain. Low-income countries (LICs) face serious risks, including significant losses of publicly funded training investments and worsening shortages despite being the largest recipients of donor aid.  Both MICs and LICs, however, benefit significantly from the vital transfer of knowledge and know-how, drugs, and medical technology from high- to middle- and low-income countries. The chapter concludes with a performance-evaluation framework that accounts for direct fiscal flows, avoided or lost training costs, remittances, service coverage impacts, and long-term gains from knowledge and technological exchange. These knowledge-related benefits increasingly influence whether internationalization improves or hinders health-system performance. The conclusion suggests market-oriented policy options to maximize benefits and reduce risks. Recommended strategies include competitive capacity-building partnerships, regulated private-sector investment in training, voluntary circular-migration arrangements, incentives for diaspora-led knowledge exchange, and efforts to improve domestic training efficiency. Together, these approaches enable countries to gain from internationalization while supporting sustainable health-system goals.

https://www.linkedin.com/pulse/lost-decade-funding-medical-education-alexander-s-preker-v4r5e