Developing evidence-based ethical policies on the migration of health workers: conceptual and practical challenges

Association between Disability and Unmet Food Needs in the Venezuelan Migrant and Refugee Population: Analysis of a Population-Based Survey, 2022

In Peru, Venezuelan migrants and refugees have been exposed to food shortages before their emigration. This problem could have worse outcomes in vulnerable populations (such as people with disabilities); however, the literature on the basic needs of this population is still scarce. The objective was to determine the association between the presence of disability and the unmet need for access to food in the household of the Venezuelan migrant and refugee population residing in Peru. A cross-sectional study was conducted using data from the Second Survey of the Venezuelan Population Residing in Peru (ENPOVE 2022). The outcome variable was unmet need for food, while the independent variable was the presence of disability. Poisson log generalized linear regression models (crude and adjusted for potential confounding variables) were fitted to evaluate the association between the variables of interest, reporting prevalence ratios (PR) and 95% confidence intervals (CIs). A total of 7739 migrants and refugees from Venezuela were included. The proportion of unmet need for access to food in the household was 45.2%, while the proportion of disability was 2.1%. People with disabilities were found to be more likely to have an unmet need for access to food at home (adjusted PR [aPR]: 1.25; 95% CI: 1.08–1.46; p = 0.003). According to our findings, almost half of Venezuelan households were found to have an unmet need for access to food. In addition, Venezuelan migrants and refugees with disabilities were more likely to have an unmet need for this basic need.

Health-care worker retention in post-conflict settings: a systematic literature review

Conflicts affect health-care systems not only during but also well beyond periods of violence and immediate crises by draining resources, destroying infrastructure and perpetrating human resource shortages. Improving health-care worker (HCW) retention is critical to limiting the strain placed on health systems already facing infrastructure and financial challenges. We reviewed the evidence on the retention of HCWs in fragile, conflict-affected and post-conflict settings and evaluated strategies and their likely success in improving retention and reducing attrition. We conducted a systematic review of studies, following PRISMA guidelines. Included studies (1) described a context that is post-conflict, conflict-affected or was transformed by war or a crisis; (2) examined the retention of HCWs; (3) were available in English, Spanish or French and (4) were published between 1 January 2000 and 25 April 2021. We identified 410 articles, of which 25 studies, representing 17 countries, met the inclusion criteria. Most of the studies (22 out of 25) used observational study designs and qualitative methods to conduct research. Three studies were literature reviews. This review observed four main themes: migration intention, return migration, work experiences and conditions of service and deployment policies. Using these themes, we identify a consolidated list of six push and pull factors contributing to HCW attrition in fragile, conflict-affected and post-conflict settings. The findings suggest that adopting policies that focus on improving financial incentives, providing professional development opportunities, establishing flexibility and identifying staff with strong community links may ameliorate workforce attrition.

Perceptions of medical doctors living in Ethiopia about physician migration: a qualitative study

OBJECTIVES

Migration of physicians is one of the most pressing global health problems of our time with the greatest implications in sub-Saharan African countries. Although other studies have explored and produced important quantitative data about the impact of medical migration in the health sector of Ethiopia, the motive behind Ethiopian physician migration have been explored less thoroughly. This article explores the perceptions of a group of physicians about the complicated and continuously evolving driving forces of physician migration in Ethiopia.

DESIGN

Qualitative study using in-depth, virtual semistructured interviews.

PARTICIPANTS

Using purposive sampling, 12 physicians participated.

SETTING

Skype interviews with 12 participants working in Tikur Anbessa Specialised Hospital in Addis Ababa, Ethiopia.

RESULTS

Four themes emerged reflecting the perceptions of Ethiopian medical doctors on the driving forces of physician migration: (1) Economic push and pull factors; (2) Professional push and pull factors; (3) Social and Political push and pull factors and (4) Medical migration governance.

CONCLUSION

The emigration of Ethiopian physicians is made after weighing the push and pull factors. Push factors are more crucial than pull factors, and financial reasons play the leading role. Junior physician unemployment, politicisation of hospital administration, and poor medical migration governance are growing problems. Junior physician unemployment is a recent phenomenon in Ethiopia and with a potential to be a leading push factor if appropriate intervention is not taken. The findings of this study are worrying and urge for comprehensive solutions to be devised by policy-makers to deal with physician migration in Ethiopia.

Attitude towards migration of psychiatric trainees and early career psychiatrists in Iran

INTRODUCTION

Migration of medical professionals has been rapidly increasing in the past decades and it strongly affects origin and destination countries.

OBJECTIVES

We aimed to explore the extent and the reasons of migration among psychiatric trainees and early career psychiatrists in Iran.

METHODS

Our semi-structured 61-items questionnaire inquired participants' demographics, experiences of short-term mobility (from 3 months to 1 year), long-term migration (more than 1 year) and attitudes towards migration (current and future plans).

RESULTS

A total of 184 responses were received. Most (73.4 %) participants were female, and within the age range of 25-65 (Mean: 34.9). Only 15.2 % had a short-term mobility experience, mostly due to academic reasons (35.7 %). Most (75 %) stated that this short-term mobility experience influenced them in favor of migration. The majority (83.7 %) had 'ever' considered leaving Iran, and more than half (57.3 %) stated they 'strongly agree' or 'agree' to leaving the country 'now' (at the time of the study). The main reason to migrate from Iran was first political, followed by work, financial, social, religious, academic, and cultural reasons, and the least ranked were personal reasons. In relation to their 5-year plans, 67.3 % saw themselves in the country they currently live in, Iran. The main features reported for an attractive job were 'pleasant work environment' (97.3 %), 'good welfare and social security' (96.7 %) and 'high salary '(96.2 %).

CONCLUSIONS

This study calls for more support of psychiatric trainees and early career psychiatrists in Iran. Improvements in the political context, work conditions and finances might lower the rate of migratory intention and brain drain.

Health care workers and migrant health: Pre- and post-COVID-19 considerations for reviewing and expanding the research agenda

The main purpose of this article is to review several ways in which health care workers could either impact migrant health or be directly impacted by migration and, based on this, suggest the expansion of the current research agenda on migration and health to address a range of topics that are currently either neglected, insufficiently researched, or researched from different perspectives. To ground this suggestion and emphasize the complexity and significance of migrant health research, we start by briefly reviewing several migration-related notions including the process of migration and its key facilitators and benefits; existing barriers to the provision of migrant health care; and the intricate links between health systems, health professionals, and migrant health. The three areas of research examined in this article address (i) the specific role of health workers in providing care to migrants and refugees and their capacity to do so, (ii) the health problems experienced by health workers who become migrants or refugees, and (iii) the precarious employment conditions experienced by both migrant and non-migrant health care workers. After summarizing the current available evidence on these topics, we discuss key information gaps and strategies to address them, while also incorporating several relevant COVID-19 pandemic considerations and research implications. Expanding the focus of research studies on migration and health could not only enhance the results of current strategies by supplying additional information to support their implementation but also spearhead the development of new solutions to the migrant health problem.

Does the mutual recognition agreement on nursing services accelerate nurse migration in member countries of the Association of Southeast Asian Nations?

Aim

To clarify the situations of nursing education and activity, its affecting factors and the nursing educators' views on nurse migration relating Mutual Recognition Agreement on Nursing Services in the Association of Southeast Asian Nations. Design: Descriptive qualitative research.

Methods

The individual semi-structured interviews with 11 nursing educators, analysed using thematic analysis.

Results

Nursing educators acknowledged that the change in nursing was mainly due to the creation and amendment of laws, acts and regulations regarding nursing and improvements in nursing education systems. Some of these improvements occurred by this mutual agreement. The conceptualization of the progress indicated an improvement in the quality of nursing. Nurse migration to the outside of Southeast Asian countries might be accelerated due to concurrent improvements in the quality of nursing. New trends among nurses working as caregivers in surrounding countries such as China, South Korea and Japan to deal with demographic ageing should be considered.

Magnitude of Intention to Leave and Associated Factors among Health Workers Working at Primary Hospitals of North Gondar Zone, Northwest Ethiopia: Mixed Methods

Background

Human resource is the most crucial resources for the survival of an organization. Intention to leave is an employee's plan to leave their current job in the near future and is used as a proxy indicator for measuring turnover in cross-sectional surveys. In developing countries human resource shortages are not only due to production of health professionals but also because of employee turnover and instability at health facilities.

Objective

This study aimed to assess the magnitude of intention to leave and associated factors among health workers working at primary hospitals of North Gondar Zone, Northwest Ethiopia.

Methods

Institution based cross-sectional mixed methods' (both quantitative and qualitative) study design was conducted among health workers working at primary hospitals of North Gondar zone. Self-administered standardized structured questionnaires for quantitative and interview guide for qualitative were used for data collection. Variables having p-value less than 0.2 during bivariable analysis were entered into multivariable logistic regression model. Thematic analysis was done for qualitative data analysis.

Results

A total of 382 health workers were participated in the study with a response rate of 93.6%. Overall, 67.8% of them were intended to leave their current organization. Age of participants, 20-29 years (AOR=3.96; 95%CI: 1.04, 15.07), living out of family (AOR= 1.73; 95% CI: 1.23, 3.02), opportunity of other job (AOR= 2.04; 95% CI: 1.21, 3.45), performance appraisal system (AOR= 2.97; 95%CI: 1.64, 5.36), and affective commitment (AOR= 3.12; 95% CI: 1.64, 5.92) were the factors affecting health workers intention to leave current organization.

Conclusion

overall, magnitude of health workers intention to leave their current organization was high. Therefore, healthcare managers, supervisors, and policymakers need to develop and implement retention strategies that aim to improve the retaining of healthcare workers at their working organization such as unifying healthcare providers who are living separately with their families, use evidence-based performance evaluation mechanism, and make efforts to develop a sense of ownership in the health workers, which will reduce health professional's intention to leave their organization.

Tracking the leavers: towards a better understanding of doctor migration from Ireland to Australia 2008-2018

BACKGROUND

The recession of 2008 triggered large-scale emigration from Ireland. Australia emerged as a popular destination for Irish emigrants and for Irish-trained doctors. This paper illustrates the impact that such an external shock can have on the medical workforce and demonstrates how cross-national data sharing can assist the source country to better understand doctor emigration trends.

METHOD

This study draws on Australian immigration, registration and census data to highlight doctor migration flows from Ireland to Australia, 2008-2018.

FINDINGS

General population migration from Ireland to Australia increased following the 2008 recession, peaked between 2011 and 2013 before returning to pre-2008 levels by 2014, in line with the general economic recovery in Ireland. Doctor emigration from Ireland to Australia did not follow the same pattern, but rather increased in 2008 and increased year on year since 2014. In 2018, 326 Irish doctors obtained working visas for Australia. That doctor migration is out of sync with general economic conditions in Ireland and with wider migration patterns indicates that it is influenced by factors other than evolving economic conditions in Ireland, perhaps factors relating to the health system.

DISCUSSION

Doctor emigration from Ireland to Australia has not decreased in line with improved economic conditions in Ireland, indicating that other factors are driving and sustaining doctor emigration. This paper considers some of these factors. Largescale doctor emigration has significant implications for the Irish health system; representing a brain drain of talent, generating a need for replacement migration and a high dependence on internationally trained doctors. This paper illustrates how source countries, such as Ireland, can use destination country data to inform an evidence-based policy response to doctor emigration.

Doctors on the move: a qualitative study on the driving factors in a group of Egyptian physicians migrating to Germany

Background

Migration of physicians has become a global phenomenon with significant implications for the healthcare delivery systems worldwide. The motivations and factors driving physician’s migration are complex and continuously evolving. Purpose of this study is to explore the driving forces in a group of Egyptian physicians and final-years medical students preparing to migrate to Germany.

Methods

A qualitative study was conducted based on social constructivism epistemology. In five focus group discussions, there participated a total 12 residents and 6 final-year medical students from 7 different training and workplace locations in Egypt. The participants provided information about their motivation and planning for migration. We applied a coding framework based on the concept of push/pull factors and barriers/facilitators for migration, and used Atlas.ti software for analysis.

Results

The thematic analysis indicated that the migration within the study’s participants results from a specific weighting of push and pull factors. Push factors are considered to be more important than pull factors. Factors related to professional development play a leading role. The route of migration towards Germany is mainly determined by the low hurdle registration and licensing requirements in this destination country compared to other countries. In some cases, Germany is regarded as a “transit country”, a step on the road to other European countries. The intent, planning and preparation of migration is assisted considerably by the local formation of a community and culture of migration with multiple ways for information exchange, identity building and social support through face-to-face and online channels.

Conclusions

This study specifies – in a group of Egyptian physicians and final-year medical students – the perceived push and pull factors which influenced their intent to migrate to Germany. In addition to the general wealth gap, their particular route of migration is mainly determined by the requirements in licensing and registration procedures for foreign physicians in the potential destination country. The planning and preparation of a move is substantially facilitated by their joining a social network and a community of migrating physicians.

Migration motives and integration of international human resources of health in the United Kingdom: systematic review and meta-synthesis of qualitative studies using framework analysis

OBJECTIVE

The aim of this review was to examine the migration motives, the barriers to and facilitators of integration of international dental graduates, compared with nurses and doctors in the United Kingdom.

METHODS

Electronic databases Ovid MEDLINE, EMBASE, PubMed, Web of Knowledge and OECD publications were systematically searched for English language publications from January 2000 to January 2017. A total of 31 qualitative studies were selected and quality appraised and meta-synthesis of the qualitative data was carried out using framework synthesis. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were applied to present the findings.

RESULTS

There were no studies on migration motives and one study on integration experiences of international dentists in the UK. The nursing literature had the highest volume and quality of evidence on nursing workforce, whilst there was limited literature on international doctors in the UK. Migration of health professionals to the UK is determined by personal and professional factors, together with source country-specific and UK drivers. Active recruitment, post graduate training and financial gain act as strong common macro, meso and micro drivers that perpetuate migration into the UK, but the extent to which each of these drivers influence nurses' and doctors' migration is different. Integration experiences for international nurses and doctors differed based on their source country experiences and the work environment they entered. Nurses reported a wider knowledge and skills gap, more multi-level discrimination and less career progression compared to the doctors. The migrants' integration experiences depend on their cultural awareness, discrimination exposure, English language and communication skills, social and professional support networks, social integration and personal attributes.

CONCLUSION

Migration of international health professionals is motivated by macro, meso and micro drivers at the international, national, professional and personal levels. The UK has strong common macro pull factors which attract nurses, doctors and dentists and may impact on the effectiveness of policies to restrict their migration. The integration experiences of nurses and doctors differ and further research is required to understand the integration experiences of dentists, in order to retain these professionals by tailoring policies to each of these professions.

Projecting shortages and surpluses of doctors and nurses in the OECD: what looms ahead

There is little debate that the health workforce is a key component of the health care system. Since the training of doctors and nurses takes several years, and the building of new schools even longer, projections are needed to allow for the development of health workforce policies. Our work develops a projection model for the demand of doctors and nurses by Organisation for Economic Co-operation and Development (OECD) countries in the year 2030. The model is based on a country’s demand for health services, which includes the following factors: per capita income, out-of-pocket health expenditures and the ageing of its population. The supply of doctors and nurses is projected using country-specific autoregressive integrated moving average models. Our work shows how dramatic imbalances in the number of doctors and nurses will be in OECD countries should current trends continue. For each country in the OECD with sufficient data, we report its demand, supply and shortage or surplus of doctors and nurses for 2030. We project a shortage of nearly 400,000 doctors across 32 OECD countries and shortage of nearly 2.5 million nurses across 23 OECD countries in 2030. We discuss the results and suggest policies that address the shortages.

Recruitment of consultant psychiatrists from low- and middle-income countries

The UK's 2-year International Fellowship Programme for consultant doctors has inadvertently highlighted the long-standing issues of the costs and benefits of such recruitment for the countries of origin, and of whether it is ethical for rich countries to recruit health personnel not only from other rich countries but also from low- and middle-income countries. The ‘brain drain’ from poor to rich countries has been recognised for decades; it occurs in the health sector as well as other sectors, such as education, science and engineering. It has had serious ramifications for the health service infrastructure in low-income countries, where poverty, morbidity, disability and mortality are increasing rather than decreasing, and it is a matter of serious concern for both the World Health Organization and the International Monetary Fund (Carrington & Detragiache, 1998; Lee, 2003).

Out-migration and attrition of physicians and dentists before and after EU accession (2003 and 2011): the case of Hungary

This paper employs a large-scale, individual-level, panel dataset to analyse the effect of EU accession on the probability of out-migration on the part of Hungarian physicians and dentists between 2003 and 2011. The study uses event history modelling and competing risk models. The results show that EU accession did not at the time affect the probability of out-migration while after the end of the transitional period of restrictions on the free movement of labour from the new EU member states to Austria and Germany, the probability of doctors' migration increased considerably. Relative wages and peer pressure also exercise a significant role in the out-migration decisions of young medical doctors. We also find that more than half of those medical doctors who left the country during the observation period returned some time later. The data furthermore suggest a massive flow of doctors to domestic jobs outside the health care system.

Heterogeneity in the background and earnings of nurses in India: evidence from a cross-sectional study in Gujarat

It is important to understand the service conditions of nurses because these influence nurses' motivations and ability to provide care. Although nurses are estimated to constitute 30% of India's health workforce, limited empirical information is available about them. This paper attempts to address this gap in research. A cross-sectional survey of 266 nurses in the state of Gujarat was conducted to understand the demographic characteristics, qualifications and employment features of nurses working in India's private and public health sectors. Descriptive and univariate analyses were performed using the collected information. A multivariate regression model was also estimated with monthly earnings as the dependent variable, and workplace, type of employment contract, caste background and years in the nursing workforce as independent variables. The three main findings presented in this article highlight considerable heterogeneity in the background and employment of nurses in India. First, 49% of nurses working in private hospitals and as temporary employees in public facilities belonged to historically disadvantaged social groups (deemed Scheduled Castes and Scheduled Tribes) and were estimated to earn 9% less than similarly qualified and practiced nurses from general caste categories (P = 0.02). Second, 18% of nurses working in private hospitals did not have formal nursing qualifications. Third, nurses working in private hospitals and as temporary employees in public facilities earned less than the minimum wage stipulated by the Government of India. Permanent public sector nurses were estimated to earn 105% more than private sector nurses with the same qualifications, years of work and caste background (P <  0.001). This study finds that the disproportionate presence of women and socially discriminated caste groups in the nursing workforce, coupled with the failure of governmental agencies to regulate the health sector, might help explain the low wages and lack of job security that most nurses in India contend with.

To which countries do European psychiatric trainees want to move to and why?

BACKGROUND

There is a shortage of psychiatrists worldwide. Within Europe, psychiatric trainees can move between countries, which increases the problem in some countries and alleviates it in others. However, little is known about the reasons psychiatric trainees move to another country.

METHODS

Survey of psychiatric trainees in 33 European countries, exploring how frequently psychiatric trainees have migrated or want to migrate, their reasons to stay and leave the country, and the countries where they come from and where they move to. A 61-item self-report questionnaire was developed, covering questions about their demographics, experiences of short-term mobility (from 3 months up to 1 year), experiences of long-term migration (of more than 1 year) and their attitudes towards migration.

RESULTS

A total of 2281 psychiatric trainees in Europe participated in the survey, of which 72.0% have 'ever' considered to move to a different country in their future, 53.5% were considering it 'now', at the time of the survey, and 13.3% had already moved country. For these immigrant trainees, academic was the main reason they gave to move from their country of origin. For all trainees, the overall main reason for which they would leave was financial (34.4%), especially in those with lower (<500€) incomes (58.1%), whereas in those with higher (>2500€) incomes, personal reasons were paramount (44.5%).

CONCLUSIONS

A high number of psychiatric trainees considered moving to another country, and their motivation largely reflects the substantial salary differences. These findings suggest tackling financial conditions and academic opportunities.

Quality of sleep and well-being of health workers in Najran, Saudi Arabia

BACKGROUND

Health care involves taking care of other peoples' lives. Professionals in the field of health care are expected to be at their best all the time because mistakes or errors could be costly and sometimes irreversible.

AIM

This study assessed the quality of sleep and well-being of health workers in Najran city, Saudi Arabia.

MATERIALS AND METHODS

It was a cross-sectional study done among health workers from different hospitals within the kingdom of Najran, Saudi Arabia. The subjects were administered questionnaire that contained sections on demographic and clinical characteristics, sleep quality, and section relating to well-being.

RESULTS

One hundred and twenty-three health workers comprising 29 (23.6%) males and 94 (76.4%) females participated in this study. The majority of the workers 74 (60.2%) were nurses; a quarter were doctors while the remaining 13.6% accounted for other categories of health workers such as the pharmacist and laboratory technicians. Fifty-two (42.3%) of the workers were poor sleepers. Significantly (χ2 = 23.98, P = 0.000), majority of the subjects that were poor sleepers (84.6%) compared with the 42.3% of the good sleepers rated the last 12 months of their profession as a bit stressful or quite a bit stressful. Similarly, 46.2% of the workers that were poor sleepers significantly (χ2 = 24.69, P = 0.000) rated their ability to handle unexpected and difficult problems in their life as fair or poor compared with 14.1% of the good sleepers.

CONCLUSION

Health workers expressed some level of stress in their professional life, and a good proportion of the subjects were poor sleepers. There is, therefore, the need to establish a program within the health-care organization to address social, physical, and psychological well-being at work.

A comparison of physician emigration from Africa to the United States of America between 2005 and 2015

BACKGROUND

Migration of health professionals has been a cause for global concern, in particular migration from African countries with a high disease burden and already fragile health systems. An estimated one fifth of African-born physicians are working in high-income countries. Lack of good data makes it difficult to determine what constitutes "African" physicians, as most studies do not distinguish between their country of citizenship and country of training. Thus, the real extent of migration from African countries to the United States (US) remains unclear. This paper quantifies where African migrant physicians come from, where they were educated, and how these trends have changed over time.

METHODS

We combined data from the Educational Commission for Foreign Medical Graduates with the 2005 and 2015 American Medical Association Physician Masterfiles. Using a repeated cross-sectional study design, we reviewed the available data, including medical school attended, country of medical school, and citizenship when entering medical school.

RESULTS

The outflow of African-educated physicians to the US has increased over the past 10 years, from 10 684 in 2005 to 13 584 in 2015 (27.1% increase). This represents 5.9% of all international medical graduates in the US workforce in 2015. The number of African-educated physicians who graduated from medical schools in sub-Saharan countries was 2014 in 2005 and 8150 in 2015 (304.6% increase). We found four distinct categorizations of African-trained physicians migrating to the US: (1) citizens from an African country who attended medical school in their own country (86.2%, n = 11,697); (2) citizens from an African country who attended medical school in another African country (2.3%, n = 317); (3) US citizens who attended medical school in an African country (4.0%, n = 537); (4) citizens from a country outside Africa, and other than the United States, who attended medical school in an African country (7.5%, n = 1013). Overall, six schools in Africa provided half of all African-educated physicians.

CONCLUSIONS

The number of African-educated physicians in the US has increased over the past 10 years. We have distinguished four migration patterns, based on citizenship and country of medical school. The majority of African graduates come to the US from relatively few countries, and from a limited number of medical schools. A proportion are not citizens of the country where they attended medical school, highlighting the internationalization of medical education.

Human Resources for Treating HIV/AIDS: Are the Preventive Effects of Antiretroviral Treatment a Game Changer?

Shortages of human resources for treating HIV/AIDS (HRHA) are a fundamental barrier to reaching universal antiretroviral treatment (ART) coverage in developing countries. Previous studies suggest that recruiting HRHA to attain universal ART coverage poses an insurmountable challenge as ART significantly increases survival among HIV-infected individuals. While new evidence about ART's prevention benefits suggests fewer infections may mitigate the challenge, new policies such as treatment-as-prevention (TasP) will exacerbate it. We develop a mathematical model to analytically study the net effects of these countervailing factors. Using South Africa as a case study, we find that contrary to previous results, universal ART coverage is achievable even with current HRHA numbers. However, larger health gains are possible through a surge-capacity policy that aggressively recruits HRHA to reach universal ART coverage quickly. Without such a policy, TasP roll-out can increase health losses by crowding out sicker patients from treatment, unless a surge capacity exclusively for TasP is also created.

‘Newness–struggle–success’ continuum: a qualitative examination of the cultural adaptation process experienced by overseas-qualified dentists in Australia

Objectives Overseas-qualified dentists constitute a significant proportion of the Australian dental workforce (approximately one in four). The aim of the present study was to provide a better understanding of the cultural adaptation process of overseas-qualified dentists in Australia, so as to facilitate their integration into the Australian way of life and improve their contribution to Australian healthcare, economy and society. Methods Life stories of 49 overseas-qualified dentists from 22 countries were analysed for significant themes and patterns. We focused on their settlement experience, which relates to their social and cultural experience in Australia. This analysis was consistent with a hermeneutic phenomenological approach to qualitative social scientific research. Results Many participants noted that encounters with ‘the Australian accent’ and ‘slang’ influenced their cultural experience in Australia. Most of the participants expressed ‘fascination’ with the people and lifestyle in Australia, primarily with regard to the relaxed way of life, cultural diversity and the freedom one usually experiences living in Australia. Few participants expressed ‘shock’ at not being able to find a community of similar religious faith in Australia, as they are used to in their home countries. These issues were analysed in two themes; (1) language and communication; and (2) people, religion and lifestyle. The cultural adaptation process of overseas-qualified dentists in Australia is described as a continuum or superordinate theme, which we have entitled the ‘newness–struggle–success’ continuum. This overarching theme supersedes and incorporates all subthemes. Conclusion Family, friends, community and organisational structures (universities and public sector) play a vital role in the cultural learning process, affecting overseas-qualified dentist’s ability to progress successfully through the cultural continuum. What is known about the topic? Australia is a popular host country for overseas-qualified dentists. Migrant dentists arrive from contrasting social and cultural backgrounds, and these contrasts can be somewhat more pronounced in dentists from developing countries. To date, there is no evidence available regarding the cultural adaptation process of overseas-qualified dentists in Australia or elsewhere. What does this paper add? This study provides evidence to support the argument that the cultural adaptation process of overseas-qualified dentists in Australia can be viewed as a continuum state, where the individual learns to adapt to the people, language and lifestyle in Australia. The ongoing role of family and friends is primary to a successful transition process. Our research also identifies the positive role played by community and organisational structures, such as universities and public sector employment schemes. What are the implications for practitioners? A potential implication for policy makers is to focus on the positive roles played by organisational structures, particularly universities and the public sector. This can inform more supportive migration policy, as well as strengthen the role these organisations play in providing support for overseas-qualified dentists, thus enabling them to integrate more successfully into Australia’s health care system, economy and society.

Why do doctors emigrate from Sri Lanka? A survey of medical undergraduates and new graduates

BACKGROUND

Migration of medical professionals is a long recognized problem in Sri Lanka, but it has not been studied in depth. Undergraduate and postgraduate medical education in Sri Lanka is state sponsored, and loss of trained personnel is a loss of investment. This study assessed the intention to migrate among medical students and newly passed out graduates from the largest medical school in Sri Lanka.

METHODS

A cross sectional descriptive study was conducted in the Faculty of Medicine, University of Colombo in September 2013 with the participation of first and fourth year medical students and pre-intern medical graduates. Data was collected using a self administered, pre-tested questionnaire that collected data on socio-demographic details, intention to migrate and factors influencing a decision for or against migration.

RESULTS

There were 374 respondents, 162 from first year (females; 104, 64.2%), 159 from fourth year (females; 85, 53.5%) and 53 pre interns (females; 22, 41.5%). Of the entire sample, 89 (23.8%) had already decided to migrate while another 121 (32.3%) were not sure of their decision. The most cited reasons for migration were a perceived better quality of life, better earnings and more training opportunities in the host country. There were no socio-demographic characteristics that had a significant association with the intention to migrate, indicating that it is a highly individualized decision.

CONCLUSIONS

The rate of intention to migrate in this sample is low when compared to international studies from Africa and South Asia, but is still significant. The core reasons which prompt doctors to migrate should be addressed by a multipronged approach to prevent brain drain.

Aspects of medical migration with particular reference to the United Kingdom and the Netherlands

BACKGROUND

In most countries of the European Economic Area (EEA), there is no large-scale migration of medical graduates with diplomas obtained outside the EEA, which are international medical graduates (IMGs). In the United Kingdom however, health care is in part dependent on the influx of IMGs. In 2005, of all the doctors practising in the UK, 31% were educated outside the country. In most EEA-countries, health care is not dependent on the influx of IMGs.The aim of this study is to present data relating to the changes in IMG migration in the UK since the extension of the European Union in May 2004. In addition, data are presented on IMG migration in the Netherlands. These migration flows show that migration patterns differ strongly within these two EU-countries.

METHOD

This study makes use of registration data on migrating doctors from the General Medical Council (GMC) in the UK and from the Dutch Department of Health. Moreover, data on the ratio of medical doctors in relation to a country's population were extracted from the World Health Organization (WHO).

RESULTS

The influx of IMGs in the UK has changed in recent years due to the extension of the European Union in 2004, the expansion of UK medical schools and changes in the policy towards non-EEA doctors.The influx of IMGs in the Netherlands is described in detail. In the Netherlands, many IMGs come from Afghanistan, Iraq and Surinam.

DISCUSSION AND CONCLUSIONS

There are clear differences between IMG immigration in the UK and in the Netherlands. In the UK, the National Health Service continues to be very reliant on immigration to fill shortage posts, whereas the number of immigrant doctors working in the Netherlands is much smaller. Both the UK and the Netherlands' regulatory bodies have shared great concerns about the linguistic and communication skills of both EEA and non-EEA doctors seeking to work in these countries. IMG migration is a global and intricate problem. The source countries, not only those where English is the first or second language, experience massive IMG migration flows.

Drivers of return migration of Ghanaian health professionals: perspectives from doctors and nurses in urban Ghana

Purpose

– The purpose of this paper is to examine the trend of return migration of health professionals to Ghana and how it is impacting the delivery of health services in the country. It also highlights the challenges facing returnees to the country.

Design/methodology/approach

– A qualitative exploratory case study approach was employed in the study. Data gathered were analysed using the sequential model of qualitative content analysis.

Findings

– It was found that while push factors dominantly influence out-migration, pull factors rather dominated reasons for return migration. Other determinants of return migration include social and financial benefits to the home country, achieving goals for travelling, skills’ improvement and spousal consideration. The paper also highlights some of the challenges returnees usually encounter in the home country.

Social implications

– This paper makes reasonable recommendations regarding how return migration of Ghanaian health professionals might be smoother.

Originality/value

– The study brings to the fore, the necessity for the government to plan for health professionals, who returned to Ghana to contribute to the health system.

Strategies to promote better research on oral health in Africa: A Delphi consensus study

Background:

Research on oral health contributes to improved health outcomes; it is an indispensable tool in health policy. But how to fill the gaps in research oral health and to strengthen its capacity is the question. The main objective of the present study is to identify the current status of oral health research and potential strategies, thereby strengthening the research infrastructure and capacity. Delphi consultation, in the perspective of assisting decision-makers to identify strategies to promote better research on oral health in Africa, was initiated.

Design and Methods:

The panels of 30 experts were asked to complete the questionnaire with 42 items into four groups by web survey. Each indicator statement was considered to be in consensus if the expert's opinion rating was of “A or B” for more than 75% in a scale of seven categories. Quantitative analysis was made from the answers of Delphi round.

Results:

There was a strong consensus about three items concerning the role of oral health research, the development of research policy for oral health going through an effective governance of research institutes, migration of researchers and fund raising.

Conclusion:

This study shows strong many dispersal opinions by experts, but highlights the need for to improve the effectiveness of oral health research capacity strengthening activities. Africa's researchers, policy makers and partners will have to give special attention to ensuring that knowledge generated from oral health research is acted on to improve health for all.

The impact of economic factors on migration considerations among Icelandic specialist doctors: a cross-sectional study

Background

Globalization has facilitated the employability of doctors almost anywhere in the world. In recent years, the migration of doctors seems to have increased. However, we lack studies on doctors’ migration from developed countries. Because the economic recession experienced by many countries might have affected the migration of doctors, research on this topic is important for the retention of doctors. Iceland was hit hard by the economic recession in 2008. Therefore, we want to explore how many specialist doctors in Iceland have considered migrating and whether economic factors at work and in private life, such as extensive cost-containment initiatives at work and worries about personal finances, are related to doctors’ migration considerations.

Methods

In 2010, all doctors in Iceland registered with the Icelandic Medical Association were sent an electronic cross-sectional survey by email. The 467 specialists who participated in this study represent 55% of all specialist doctors working in Iceland. Information on doctors’ contemplation of migration was available from responses to the question: “Have you considered moving and working abroad?” The predictor variables in our logistic regression model are perceived cost-containment initiatives at work, stress related to personal finances, experience of working abroad during vacations, job dissatisfaction, job position, age, and gender.

Results

Sixty-three per cent of Iceland’s specialist doctors had considered relocation abroad, 4% were moving in the next year or two, and 33% had not considered relocating. Logistic regression analysis shows that, controlling for age, gender, job position, job satisfaction, and experience of working abroad during vacations, doctors’ migration considerations were significantly affected by their experiences of cost-containment initiatives at work (odds ratio (OR) = 2.0, p < 0.01) and being stressed about personal finances (OR = 1.6, p < 0.001). Age, job satisfaction, and working abroad during vacations also had an effect, whereas job position did not.

Conclusions

Economic factors affect whether specialist doctors in Iceland consider migration. More studies on the effect of economic recession on migration by doctors are needed.

The effects of midwives' job satisfaction on burnout, intention to quit and turnover: a longitudinal study in Senegal

BACKGROUND

Despite working in a challenging environment plagued by persistent personnel shortages, public sector midwives in Senegal play a key role in tackling maternal mortality. A better understanding of how they are experiencing their work and how it is affecting them is needed in order to better address their needs and incite them to remain in their posts. This study aims to explore their job satisfaction and its effects on their burnout, intention to quit and professional mobility.

METHODS

A cohort of 226 midwives from 22 hospitals across Senegal participated in this longitudinal study. Their job satisfaction was measured from December 2007 to February 2008 using a multifaceted instrument developed in West Africa. Three expected effects were measured two years later: burnout, intention to quit and turnover. Descriptive statistics were reported for the midwives who stayed and left their posts during the study period. A series of multiple regressions investigated the correlations between the nine facets of job satisfaction and each effect variable, while controlling for individual and institutional characteristics.

RESULTS

Despite nearly two thirds (58.9%) of midwives reporting the intention to quit within a year (mainly to pursue new professional training), only 9% annual turnover was found in the study (41/226 over 2 years). Departures were largely voluntary (92%) and entirely domestic. Overall the midwives reported themselves moderately satisfied; least contented with their "remuneration" and "work environment" and most satisfied with the "morale" and "job security" facets of their work. On the three dimensions of the Maslach Burnout Inventory, very high levels of emotional exhaustion (80.0%) and depersonalization (57.8%) were reported, while levels of diminished personal accomplishment were low (12.4%). Burnout was identified in more than half of the sample (55%). Experiencing emotional exhaustion was inversely associated with "remuneration" and "task" satisfaction, actively job searching was associated with being dissatisfied with job "security" and voluntary quitting was associated with dissatisfaction with "continuing education".

CONCLUSIONS

This study found that although midwives seem to be experiencing burnout and unhappiness with their working conditions, they retain a strong sense of confidence and accomplishment in their work. It also suggests that strategies to retain them in their positions and in the profession should emphasize continuing education.

Professional Satisfaction and Desire to Emigrate among Nigerian Physiotherapists

PURPOSE

Physiotherapists from developing countries are attracted to developed countries, where health personnel are in high demand. We investigated Nigerian physiotherapists' desire to emigrate, explored the possible relationship between job satisfaction and emigration, and elucidated common reasons why physiotherapists emigrate to other countries.

METHODS

Nigerian physiotherapists (n=181) were surveyed using a three-part questionnaire. Part 1 elicited socio-demographic information; part 2 assessed satisfaction with work; and part 3 assessed the importance of some possible reasons that physiotherapists choose to emigrate.

RESULTS

Close to half of the physiotherapists surveyed have plans to emigrate, but no relationship exists between job satisfaction level and desire to emigrate. An overwhelming majority felt that better or more realistic remuneration was the most important reason for them to leave their country, whereas age and practice experience were inversely related to physiotherapists' desire to emigrate.

CONCLUSION

Policies aimed at mediating "brain drain" should take age and experience into consideration and should be geared toward creating opportunities for career advancement and continuing education.

Interventions to reduce emigration of health care professionals from low- and middle-income countries

BACKGROUND

The emigration of skilled professionals from low- and middle-income countries (LMICs) to high-income countries (HICs) is a general phenomenon but poses particular challenges in health care, where it contributes to human resource shortages in the health systems of poorer countries. However, little is known about the effects of strategies to help regulate this movement.

OBJECTIVES

To assess the effects of policy interventions to regulate emigration of health professionals from LMICs.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register (searched 15 March 2011), the Cochrane Register of Controlled Trials (CENTRAL) (searched 2 March 2011), MEDLINE (searched 5 March 2011), EMBASE (searched 2 March 2011), CINAHL (searched 5 March 2011), LILACS (searched 7 March 2011), WHOLIS (searched 20 March 2011), SocINDEX (searched 11 March 2011), EconLit (searched 8 March 2011), Science and Social Science Citation Index (searched 8 March 2011), NLM Gateway (searched 31 March 2011) and ERIC (searched March 3 2011). We reviewed reference lists of included studies and selected reviews on the topic, contacted authors of included studies and experts on the field, and reviewed relevant websites.

SELECTION CRITERIA

Randomised controlled trials (RCT), non-randomised controlled trials (NRCT), controlled before-and-after studies (CBA) and interrupted time series (ITS) studies assessing any intervention in the source, the recipient or both countries that could have an impact on the number of professionals that emigrate from a LMIC. Health professionals, such as physicians, dentists, nurses or midwives, should be nationals of a LMIC whose graduate training was in a LMIC.

DATA COLLECTION AND ANALYSIS

One review author extracted data onto a standard form and a second review author checked data. Two review authors assessed risk of bias.

MAIN RESULTS

Only one study was included. This time series study assessed the migration of Philippine nurses to the United States of America (USA) from 1954 to 1990. We re-analysed it as an interrupted time series study. The intervention was a modification of migratory law in the US, called the 'Act of October 1965', which decreased the restrictions on Eastern hemisphere immigrants to the USA. The analysis showed a significant immediate increase of 807.6 (95% confidence interval (CI) 480.9 to 1134.3) in the number of nurses migrating to the USA annually after the intervention. This represents a relative increase of 5000% over the underlying pre-intervention trend. There were no significant differences in the slopes of the underlying trends for the number of nurses migrating between the pre- and postintervention periods.

AUTHORS' CONCLUSIONS

There is an important gap in knowledge about the effectiveness of policy interventions in either HICs or LMICs that could regulate positively the movement of health professionals from LMICs. The only evidence found was from an intervention in a HIC that increased the movement of health professionals from a LMIC.New initiatives to improve records on the migration of health professionals from LMICs should be implemented, as a prerequisite to conducting more rigorous research in the field. This research should focus on whether the range of interventions outlined in the literature could be effective in retaining health professionals in LMICs. Such interventions include financial rewards, career development and continuing education, improving hospital infrastructure, resource availability, better hospital management and improved recognition of health professionals.

The impact of out-migration on the nursing workforce in Kenya

OBJECTIVE

To examine the impact of out-migration on Kenya's nursing workforce.

STUDY SETTING

This study analyzed deidentified nursing data from the Kenya Health Workforce Informatics System, collected by the Nursing Council of Kenya and the Department of Nursing in the Ministry of Medical Services.

STUDY DESIGN

We analyzed trends in Kenya's nursing workforce from 1999 to 2007, including supply, deployment, and intent to out-migrate, measured by requests for verification of credentials from destination countries.

PRINCIPLE FINDINGS

From 1999 to 2007, 6 percent of Kenya's nursing workforce of 41,367 nurses applied to out-migrate. Eighty-five percent of applicants were registered or B.Sc.N. prepared nurses, 49 percent applied within 10 years of their initial registration as a nurse, and 82 percent of first-time applications were for the United States or United Kingdom. For every 4.5 nurses that Kenya adds to its nursing workforce through training, 1 nurse from the workforce applies to out-migrate, potentially reducing by 22 percent Kenya's ability to increase its nursing workforce through training.

CONCLUSIONS

Nurse out-migration depletes Kenya's nursing workforce of its most highly educated nurses, reduces the percentage of younger nurses in an aging nursing stock, decreases Kenya's ability to increase its nursing workforce through training, and represents a substantial economic loss to the country.

Compulsory service programmes for recruiting health workers in remote and rural areas: do they work?

Compulsory service programmes have been used worldwide as a way to deploy and retain a professional health workforce within countries. Other names for these programmes include "obligatory", "mandatory", "required" and "requisite." All these different programme names refer to a country's law or policy that governs the mandatory deployment and retention of a heath worker in the underserved and/or rural areas of the country for a certain period of time. This study identified three different types of compulsory service programmes in 70 countries. These programmes are all governed by some type of regulation, ranging from a parliamentary law to a policy within the ministry of health. Depending on the country, doctors, nurses, midwives and all types of professional allied health workers are required to participate in the programme. Some of the compliance-enforcement measures include withholding full registration until obligations are completed, withholding degree and salary, or imposing large fines. This paper aims to explain these programmes more clearly, to identify countries that have or had such programmes, to develop a typology for the different kinds and to discuss the programmes in the light of important issues that are related to policy concepts and implementation. As governments consider the cost of investment in health professionals' education, the loss of health professionals to emigration and the lack of health workers in many geographic areas, they are using compulsory service requirements as a way to deploy and retain the health workforce.

International migration of doctors, and its impact on availability of psychiatrists in low and middle income countries

BACKGROUND

Migration of health professionals from low and middle income countries to rich countries is a large scale and long-standing phenomenon, which is detrimental to the health systems in the donor countries. We sought to explore the extent of psychiatric migration.

METHODS

In our study, we use the respective professional databases in each country to establish the numbers of psychiatrists currently registered in the UK, US, New Zealand, and Australia who originate from other countries. We also estimate the impact of this migration on the psychiatrist population ratios in the donor countries.

FINDINGS

We document large numbers of psychiatrists currently registered in the UK, US, New Zealand and Australia originating from India (4687 psychiatrists), Pakistan (1158), Bangladesh (149), Nigeria (384), Egypt (484), Sri Lanka (142), Philippines (1593). For some countries of origin, the numbers of psychiatrists currently registered within high-income countries' professional databases are very small (e.g., 5 psychiatrists of Tanzanian origin registered in the 4 high-income countries we studied), but this number is very significant compared to the 15 psychiatrists currently registered in Tanzania). Without such emigration, many countries would have more than double the number of psychiatrists per 100,000 population (e.g. Bangladesh, Myanmar, Afghanistan, Egypt, Syria, Lebanon); and some countries would have had five to eight times more psychiatrists per 100,000 (e.g. Philippines, Pakistan, Sri Lanka, Liberia, Nigeria and Zambia).

CONCLUSIONS

Large numbers of psychiatrists originating from key low and middle income countries are currently registered in the UK, US, New Zealand and Australia, with concomitant impact on the psychiatrist/population ratio n the originating countries. We suggest that creative international policy approaches are needed to ensure the individual migration rights of health professionals do not compromise societal population rights to health, and that there are public and fair agreements between countries within an internationally agreed framework.

Mental disorders, health inequalities and ethics: A global perspective

The global burden of neuropsychiatry diseases and related mental health conditions is enormous, underappreciated and under resourced, particularly in the developing nations. The absence of adequate and quality mental health infrastructure and workforce is increasingly recognized. The ethical implications of inequalities in mental health for people and nations are profound and must be addressed in efforts to fulfil key bioethics principles of medicine and public health: respect for individuals, justice, beneficence, and non-malfeasance. Stigma and discrimination against people living with mental disorders affects their education, employment, access to care and hampers their capacity to contribute to society. Mental health well-being is closely associated to several Millennium Development Goals and economic development sectors including education, labour force participation, and productivity. Limited access to mental health care increases patient and family suffering. Unmet mental health needs have a negative effect on poverty reduction initiatives and economic development. Untreated mental conditions contribute to economic loss because they increase school and work absenteeism and dropout rates, healthcare expenditure, and unemployment. Addressing unmet mental health needs will require development of better mental health infrastructure and workforce and overall integration of mental and physical health services with primary care, especially in the developing nations.

Does a code make a difference--assessing the English code of practice on international recruitment

BACKGROUND

This paper draws from research completed in 2007 to assess the effect of the Department of Health, England, Code of Practice for the international recruitment of health professionals.The Department of Health in England introduced a Code of Practice for international recruitment for National Health Service employers in 2001. The Code required National Health Service employers not to actively recruit from low-income countries, unless there was government-to-government agreement. The Code was updated in 2004.

METHODS

The paper examines trends in inflow of health professionals to the United Kingdom from other countries, using professional registration data and data on applications for work permits. The paper also provides more detailed information from two country case studies in Ghana and Kenya.

RESULTS

Available data show a considerable reduction in inflow of health professionals, from the peak years up to 2002 (for nurses) and 2004 (for doctors). There are multiple causes for this decline, including declining demand in the United Kingdom.In Ghana and Kenya it was found that active recruitment was perceived to have reduced significantly from the United Kingdom, but it is not clear the extent to which the Code was influential in this, or whether other factors such as a lack of vacancies in the United Kingdom explains it.

CONCLUSION

Active international recruitment of health professionals was an explicit policy intervention by the Department of Health in England, as one key element in achieving rapid staffing growth, particularly in the period 2000 to 2005, but the level of international recruitment has dropped significantly since early 2006. Regulatory and education changes in the United Kingdom in recent years have also made international entry more difficult. The potential to assess the effect of the Code in England is constrained by the limitations in available databases. This is a crucial lesson for those considering a global code: without a clear link between explicit objectives of a code, and relevant monitoring capacity, it is not possible to judge the actual impact of a code. A second message for policy-makers is that attempts to use a single country code in other countries where there are a multiplicity of independent, private-sector health care employers, or where there is a federated political and regulatory structure, will be a much more challenging and complex issue than in England, which has one major public sector health care employer and one national point of entry for regulated health professionals. Finally, there is a message about the importance of the "visibility" of any recruitment code--for policy-makers, employers and potential recruits. The Department of Health Code has a good level of recognition in the National Health Service, but would benefit from better dissemination in low-income countries, particularly in Africa, together with further consultation on the appropriateness of its provisions in specific countries. To achieve high visibility and recognition of any global code will be a much bigger challenge.

"Conditional scholarships" for HIV/AIDS health workers: educating and retaining the workforce to provide antiretroviral treatment in sub-Saharan Africa

Without large increases in the number of health workers to treat HIV/AIDS (HAHW) many countries in sub-Saharan Africa will be unable to achieve universal coverage with antiretroviral treatment (ART), leading to large numbers of avoidable deaths among people living with HIV/AIDS. We conduct a cost-benefit analysis of a health care education scholarship that is conditional on the recipient committing to work for several years after graduation delivering ART in sub-Saharan Africa. Such a scholarship could address two of the main reasons for the low numbers of health workers in sub-Saharan Africa: low education rates and high emigration rates. We use Markov Monte Carlo microsimulation to estimate the expected net present value (eNPV) of "conditional scholarships" in sub-Saharan Africa. The scholarships are highly eNPV-positive under a wide range of assumptions. Conditional scholarships for a HAHW team sufficient to provide ART for 500 patients have an eNPV of 1.24 million year-2000 US dollars, assuming that the scholarship recipients are in addition to the health workers who would have been educated without scholarships and that the scholarships reduce annual HAHW emigration probabilities from 15% to 5% for five years. The eNPV of the education effect of the scholarships is larger than eNPV of the migration effect. Policy makers should consider implementing "conditional scholarships" for HAHW, especially in countries where health worker education capacity is currently underutilized or can be rapidly expanded.

Motivation and retention of health workers in developing countries: a systematic review

BACKGROUND

A key constraint to achieving the MDGs is the absence of a properly trained and motivated workforce. Loss of clinical staff from low and middle-income countries is crippling already fragile health care systems. Health worker retention is critical for health system performance and a key problem is how best to motivate and retain health workers. The authors undertook a systematic review to consolidate existing evidence on the impact of financial and non-financial incentives on motivation and retention.

METHODS

Four literature databases were searched together with Google Scholar and 'Human Resources for Health' on-line journal. Grey literature studies and informational papers were also captured. The inclusion criteria were: 1) article stated clear reasons for implementing specific motivations to improve health worker motivation and/or reduce medical migration, 2) the intervention recommended can be linked to motivation and 3) the study was conducted in a developing country and 4) the study used primary data.

RESULTS

Twenty articles met the inclusion criteria. They consisted of a mixture of qualitative and quantitative studies. Seven major motivational themes were identified: financial rewards, career development, continuing education, hospital infrastructure, resource availability, hospital management and recognition/appreciation. There was some evidence to suggest that the use of initiatives to improve motivation had been effective in helping retention. There is less clear evidence on the differential response of different cadres.

CONCLUSION

While motivational factors are undoubtedly country specific, financial incentives, career development and management issues are core factors. Nevertheless, financial incentives alone are not enough to motivate health workers. It is clear that recognition is highly influential in health worker motivation and that adequate resources and appropriate infrastructure can improve morale significantly.

Reasons for migration among medical students from Karachi

CONTEXT

The subject of economic migration among health care professionals has received intense attention. However, the aetiology of this migration has not been rigorously evaluated in Pakistan. Such knowledge can potentially influence health care and academic policies. Our current study proposes to quantify the relative contributions of various personal, professional and economic variables among final-year medical students in Karachi.

METHODS

A self-administered structured questionnaire using a 10-point scale was developed and piloted among Karachi medical students. Additional open-ended questions were included to allow us to capture information not otherwise covered in the questionnaire. SPSS software was used for data entry and analysis.

RESULTS

Over 95% of Aga Khan University (AKU) and over 65% of Baqai University (BU) final-year medical students intend to proceed abroad for their postgraduate training. The 2 most important factors behind this intent as pointed out by the students are poor salary structure (AKU mean score 8.94 +/- 1.73, BU mean score 7.14 +/- 2.6) and poor quality of training in the home country (AKU mean score 9.20 +/- 1.20, BU mean score 8.68 +/- 2.03). Other interesting factors captured through the open-ended questions were the poor work environment and lack of rigor in teaching of residents in domestic university hospitals. Over 50% of final-year medical students cited these issues as major reasons behind their decision to migrate.

Too poor to leave, too rich to stay: developmental and global health correlates of physician migration to the United States, Canada, Australia, and the United kingdom

OBJECTIVES

We analyzed the relationship between physician migration from developing source countries to more developed host countries (brain drain) and the developmental and global health profiles of source countries.

METHODS

We used a cross-section of 141 countries that lost emigrating physicians to the 4 major destinations: the United States, Canada, Australia, and the United Kingdom. For each source country, we defined physician migration density as the number of migrant physicians per 1000 population practicing in any of the 4 major destination countries.

RESULTS

Source countries with better human resources for health, more economic and developmental progress, and better health status appear to lose proportionately more physicians than the more disadvantaged countries. Higher physician migration density is associated with higher current physician (r=0.42, P< .001), nurse (r=0.27, P=.001), and public health (r=0.48, P=.001) workforce densities and more medical schools (r=0.53, P<.001).

CONCLUSIONS

Policymakers should realize that physician migration is positively related to better health systems and development in source countries. In view of the "train, retain, and sustain" perspective of public health workforce policies, physician retention should become even more important to countries growing richer, whereas poorer countries must invest more in training policies.

Human resources for treating HIV/AIDS: needs, capacities, and gaps

Despite recent international efforts to scale-up antiretroviral treatment (ART), more than 5 million people needing ART in low- and middle-income countries (LMIC) do not receive it. Limited human resources to treat HIV/AIDS (HRHA) are one of the main constraints to achieving universal ART coverage. We model the gap between needed and available HRHA to quantify the challenge of achieving and sustaining universal ART coverage by 2017. We estimate the HRHA gap in LMIC using recently published estimates of ART coverage, HIV incidence, health-worker emigration rates, mortality rates of people needing ART, and numbers of HRHA needed to treat 1000 ART patients (based on review studies, 2006). We project the HRHA gap in 10 years (2017) using a simple discrete-time model with a health worker pool replenished through education and depleted through emigration/death; a population needing ART replenished with a given HIV incidence rate; and higher survival rates for treated populations. We analyze the effects of varying assumptions about HRHA inflows and outflows and the evolution of the HIV pandemic in three different regional base cases (sub-Saharan Africa, non-sub-Saharan African LMIC, and South Africa). Current ART coverage for LMIC is around 28%-32% and, other things equal, will drop to 16%-19% by 2017 with constant current HRHA production rates. A naive model, ignoring the increased survival probability resulting from ART, suggests that approximately the current number of HRHA in ART services needs to be added every year for the next ten years to achieve universal coverage by 2017. In a model accounting for increased survival of treated patients, outcomes vary by region; sub-Saharan Africa requires two times, non-sub-Saharan African LMIC require 1.5 times and South Africa requires more than three times their respective current HRHA population to be added every year for the next 10 years to achieve universal coverage by 2017. Even if achieved by 2017, sustaining universal coverage requires further HRHA increases until the system reaches steady state. ART coverage is sensitive to HRHA inflow and emigration. Our model quantifies the challenge of closing the HRHA gap in LMIC. It shows that strategies to achieve universal ART coverage must account for feedback due to higher survival probabilities of people receiving ART. It suggests that universal ART coverage is unlikely to be achieved and sustained with increased HRHA inflows alone, but will require decreased HRHA outflows, substantially reduced HIV incidence, or changes in the nature or organization of care. Means to decrease HRHA emigration outflows include scholarships for healthcare education that are conditional on the recipient delivering ART in a country with high ART need for a number of years, training health workers who are not internationally mobile, or changing recruitment policies in countries receiving health workers from the developing world. Effective organizational changes include those that reduce the number of HRHA required to treat a fixed number of patients. Given the large number of health workers that even optimistic assumptions suggest will be needed in ART services in the coming decades, policymakers must ensure that the flow of workers into ART programs does not jeopardize the provision of other important health services.

The exodus of health professionals from sub-Saharan Africa: balancing human rights and societal needs in the twenty-first century

Increased international migration of health professionals is weakening healthcare systems in low-income countries, particularly those in sub-Saharan Africa. The migration of nurses, physicians and other health professionals from countries in sub-Saharan Africa poses a major threat to the achievement of health equity in this region. As nurses form the backbone of healthcare systems in many of the affected countries, it is the accelerating migration of nurses that will be most critical over the next few years. In this paper we present a comprehensive analysis of the literature and argue that, from a human rights perspective, there are competing rights in the international migration of health professionals: the right to leave one's country to seek a better life; the right to health of populations in the source and destination countries; labour rights; the right to education; and the right to non-discrimination and equality. Creative policy approaches are required to balance these rights and to ensure that the individual rights of health professionals do not compromise the societal right to health.