Skilled Health Workforce Emigration

Abstract

Trained and equitably distributed health workers are the foundation for effective and sustainable health systems. The World Health Organization (WHO) developed the Global Strategy on Human Resources for Health: Workforce 2030 with an aim to accelerate progress towards universal health coverage and the United Nations Sustainable Development Goals.1World Health OrganizationGlobal Strategy on Human Resources for Health: Workforce 2030. WHO, Geneva, Switzerland2016Google Scholar To meet the targets for universal health coverage, the world needs at least 43 million additional health workers.2GBD 2019 Human Resources for Health CollaboratorsMeasuring the availability of human resources for health and its relationship to universal health coverage for 204 countries and territories from 1990 to 2019: a systematic analysis for the Global Burden of Disease Study 2019.Lancet. 2022; 399: 2129-2154Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar The most acute health workforce shortages are in sub-Saharan Africa, South Asia, North Africa, and the Middle East.2GBD 2019 Human Resources for Health CollaboratorsMeasuring the availability of human resources for health and its relationship to universal health coverage for 204 countries and territories from 1990 to 2019: a systematic analysis for the Global Burden of Disease Study 2019.Lancet. 2022; 399: 2129-2154Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar Globalization of the labor market facilitates movement of trained health workforce members across borders. Alongside other social, economic, and political factors, this makes it challenging to ensure equitable distribution of the skilled health workforce across countries. Worsening socioeconomic conditions, wars and conflicts, and in the last few years, the coronavirus disease 2019 (COVID-19) pandemic present multiple challenges to the growing health needs of the population worldwide. High-income countries (HICs) such as the United States, Australia, New Zealand, Canada, and the United Kingdom (termed “host countries”) attract foreign-trained skilled health workers from low- and middle-income countries (LMICs) (termed “source countries”),3O’Sullivan B. Russell D.J. McGrail M.R. et al.Reviewing reliance on overseas-trained doctors in rural Australia and planning for self-sufficiency: applying 10 years' MABEL evidence.Hum Resour Health. 2019; 17: 8Crossref Scopus (27) Google Scholar further reducing an already depleted stock of health workers in LMICs.4Mullan F. The metrics of the physician brain drain.N Engl J Med. 2005; 353: 1810-1818Crossref PubMed Scopus (572) Google Scholar We aim to provide an overview of the issue of skilled health workforce emigration and its consequences on the source and the host countries. According to the Organization for Economic Cooperation and Development (OECD) data on health workforce migration,5Organisation for Economic Co-operation and DevelopmentHealth Workforce Migration: OCED; 2022 [updated 19 June, 2022. 2022].https://stats.oecd.org/Index.aspx?DataSetCode=HEALTH_WFMIDate accessed: June 20, 2022Google Scholar 25% to 32% of doctors in Australia, Canada, United Kingdom, and the United States are international medical graduates (IMGs) who have trained from countries in South Asia and Africa. Furthermore, for some specialties, most specialists in HICs are IMGs from LMICs which are already facing severe shortages of specialists. For example, IMGs account for 68% of all nephrology fellows in the United States, whereas countries such as Nigeria6Arogundade F.A. Esezobor C.I. Okafor H.U. et al.Nephrology in Nigeria.in: Moura-Neto J.A. Divino-Filho J.C. Ronco C. Nephrology Worldwide. Springer International Publishing, Cham, Switzerland2021: 41-54Crossref Scopus (1) Google Scholar and India7Bharati J.J.V. Global dialysis perspectives: India.Kidneys 360. 2020; 1: 1143-1147Google Scholar have critical shortages of nephrologists.8Agarwal A. International medical school graduates need an easier path to practice in the US: The Hill 2020.https://thehill.com/opinion/healthcare/509795-international-medical-school-graduates-need-an-easier-path-to-practice-in/?rnd=1596126946Date accessed: June 20, 2022Google Scholar Similarly, IMGs constitute 87% of all pulmonologists in United States. In contrast, surgical specialties in HICs provide fewer opportunities for IMGs. Table 1 includes details on the proportion of domestic and foreign-trained doctors.Table 1Size and Proportion of Domestic And International Medical Graduates Among Selected OECD Countries Between 2009 and 2019aOECD, Organization for Economic Cooperation and Development.CountryDomestic trainedForeign trainedTotalPercentage of foreign-trained doctors20092019200920192009201920092019Australia49737626381746031579676139703925.832.5New Zealand75061015956687538131741769743.042.6United Kingdom103771123337463435805315383819132630.130.3United StatesbData for United States is from the years 2008 and 2016, respectively, as data for 2009 and 2019 were not available.51242864733517153721563068396586296525.125.0Canada604857806818074255317862310458923.024.4a OECD, Organization for Economic Cooperation and Development.b Data for United States is from the years 2008 and 2016, respectively, as data for 2009 and 2019 were not available. Open table in a new tab The Figure shows the growth of domestic and foreign-trained doctors and nurses in selected OECD countries from 2009 to 2019. Although Australia has the highest growth in foreign-trained doctors, the United Kingdom has the highest growth for foreign-trained nurses. In terms of absolute numbers, the United States is the main host country for migrant doctors and nurses.9Organisation for Economic Co-operation and Development (OECD)Recent trends in international mobility of doctors, nurses and medical students.https://www.oecd.org/health/recent-trends-in-international-migration-of-doctors-nurses-and-medical-students-5571ef48-en.htmDate: 2019Date accessed: April 17, 2023Google Scholar Although free movement of people across jurisdictions in search of opportunity and economic gain is a human right, “pull factors” from host countries (eg, lucrative job placements, and/or better lifestyle), combined with “push factors” from source countries (eg, poor salaries and lack of equipment and infrastructure) promotes migration and aggravates the shortages in health workforce in LMICs. Often, the initial motivation for health workers from LMICs to HICs is for training or acquiring new skills. This paradoxically can promote emigration as these trained health care workers (HCWs) may not get opportunities to use these newly acquired skills in their home countries. Immigrant IMGs can also facilitate migration for other HCWs from their geographies (eg, more doctors, nurses, technicians, etc). Together, this contributes to worsened access to health care for citizens of LMICs.10Taylor A.L. Hwenda L. Larsen B.-I. Daulaire N. Stemming the brain drain — A WHO global code of practice on international recruitment of health personnel.N Engl J Med. 2011; 365: 2348-2351Crossref PubMed Scopus (0) Google Scholar, 11Sheikh A.N.S. Sheikh K. Naqvi S.H.S. Bandukda M.Y. Physician migration at its roots: a study on the factors contributing towards a career choice abroad among students at a medical school in Pakistan.Global Health. 2012; 8: 43Crossref PubMed Scopus (0) Google Scholar, 12Shah R.S. The Right to Health, State Responsibility and Global Justice.in: Shah R.S. The International Migration of Health Workers. Palgrave MacMillan, London, UK2010Crossref Google Scholar In fact, Africa houses 3% of the global health workforce while dealing with 24% of the global burden of disease.13Collins F.S. Glass R.I. Whitescarver J. Wakefield M. Goosby E.P. Public health. Developing health workforce capacity in Africa.Science. 2010; 330: 1324-1325Crossref PubMed Scopus (0) Google Scholar Furthermore, there is a perverse transfer of wealth wherein HICs save on training costs while the source country loses the investment. In 2011, the United Kingdom saved $2.7 billon and the United States saved $846 million by importing doctors. All while countries such as Malawi estimated an overall loss of $2 million and South Africa $1.4 billion by investing in training their doctors who migrated to HICs.14Mills E.J. Kanters S. Hagopian A. et al.The financial cost of doctors emigrating from sub-Saharan Africa: human capital analysis.BMJ. 2011; 343: d7031Crossref PubMed Scopus (0) Google Scholar Saluja et al15Saluja S. Rudolfson N. Massenburg B.B. Meara J.G. Shrime M.G. The impact of physician migration on mortality in low and middle-income countries: an economic modelling study.BMJ Global Health. 2020; 5e001535Crossref Scopus (30) Google Scholar have estimated that LMICs lose $15 billion annually due to doctor migration. Migration of skilled health workers results in the loss of access to the health workforce, leading to ill health and consequently, loss of life. The greatest total costs are incurred by India, Nigeria, Pakistan, and South Africa.15Saluja S. Rudolfson N. Massenburg B.B. Meara J.G. Shrime M.G. The impact of physician migration on mortality in low and middle-income countries: an economic modelling study.BMJ Global Health. 2020; 5e001535Crossref Scopus (30) Google Scholar At the same time, the improved health standards in HICs translates into financial gains because of averted mortality and morbidity. Nurses and doctors send remittances to their home country.16Packer C. Runnels V. Labonté R. Does the Migration of Health Workers Bring Benefits to the Countries They Leave Behind?.in: Shah R.S. The International Migration of Health Workers. Palgrave Macmillan, London, UK2010Crossref Google Scholar However, these remittances are private transfers, and the money does not support health system strengthening nor does it have any role in national development or poverty alleviation in the source country.16Packer C. Runnels V. Labonté R. Does the Migration of Health Workers Bring Benefits to the Countries They Leave Behind?.in: Shah R.S. The International Migration of Health Workers. Palgrave Macmillan, London, UK2010Crossref Google Scholar Many host countries depend on IMGs to fulfil their health worker shortages, especially in the underserved, rural, and remote areas. Australia requires IMGs to spend their initial employment in rural areas. Similar policies have been used in Canada and the United States.17McGrail M.R.H.J. Joyce C.M. Scott A. International medical graduates mandated to practise in rural Australia are highly unsatisfied: results from a national survey of doctors.Health Policy. 2012; 108: 133-139Crossref Scopus (24) Google Scholar International medical graduates do not stay in such locations for the long term because these regions may not have the required infrastructure or facilities which attracted them to the host country in the first place. This policy is a disservice to the rural and regional communities as IMGs must understand and know the local culture and community and understand the sociocultural determinants of health.18McGrath P. Henderson D. Tamargo J. Holewa H.A. Doctor-patient communication issues for international medical graduates: research findings from Australia.Educ Health (Abingdon). 2012; 25: 48-54Crossref Scopus (17) Google Scholar,19McGrath P. Henderson D. Phillips E. Integration into the Australian health care system--insights from international medical graduates.Aust Fam Physician. 2009; 38: 844-848PubMed Google Scholar Furthermore, IMGs — when working in “areas of need” — are often isolated and do not have community or professional support. When attracting foreign trained doctors, HICs must invest more in IMGs and provide cultural training, make supervision accessible, and consider long-term solutions for areas of need.19McGrath P. Henderson D. Phillips E. Integration into the Australian health care system--insights from international medical graduates.Aust Fam Physician. 2009; 38: 844-848PubMed Google Scholar Finally, IMGs do not have equitable access to training and jobs in all specialties. For example, many surgical specialties have less than 10% IMGs. To address the migration of skilled health workforce, WHO member states adopted the WHO Global Code of Practice on the International Recruitment of Health Personnel (also known as “the code”) in 2010.10Taylor A.L. Hwenda L. Larsen B.-I. Daulaire N. Stemming the brain drain — A WHO global code of practice on international recruitment of health personnel.N Engl J Med. 2011; 365: 2348-2351Crossref PubMed Scopus (0) Google Scholar The aim of this code is to improve understanding and ethical management of international health personnel recruitment.20World Health OrganizationThe WHO Global CODE of Practice on the International Recruitment of Health Personnel. WHO, Geneva, Switzerland2010Google Scholar The code is voluntary in nature, is not legally binding, and lacks incentives and institutional mechanisms to enable implementation. A review of the code 4 years after its implementation showed no significant policy or regulatory changes to the recruitment of health workers.21Tam V. Edge J.S. Hoffman S.J. Empirically evaluating the WHO global code of practice on the international recruitment of health personnel’s impact on four high-income countries four years after adoption.Global Health. 2016; 12: 62Crossref Scopus (11) Google Scholar There are exceptions, however. Norway has implemented the code by increasing investment in domestic health worker education to ensure sustainability of its workforce and health system, and does not recruit skilled health workers from countries facing critical health workforce shortages.10Taylor A.L. Hwenda L. Larsen B.-I. Daulaire N. Stemming the brain drain — A WHO global code of practice on international recruitment of health personnel.N Engl J Med. 2011; 365: 2348-2351Crossref PubMed Scopus (0) Google Scholar Other examples of mitigating the negative effects of skilled health worker migration on LMICs 22Yakubu K. Durbach A. van Waes A. et al.Governance systems for skilled health worker migration, their public value and competing priorities: an interpretive scoping review.Glob Health Action. 2022; 152013600Crossref Scopus (1) Google Scholar include discouraging active recruitment of health workers from countries with severe shortages and promoting temporary migration as a means of ensuring health workers still get to return to their home countries. The Netherlands and the Republic of Surinam have signed an agreement that allows doctors from Surinam to practice in Netherlands only during training, with return to Surinam required on completion of training.23Joint Action Health Workforce Planning and ForecastingCircular Migration of the Health Workforce. Catholic University of Belgium, Medical University of Varna Bulgaria, 2016https://healthworkforce.eu/wp-content/uploads/2016/03/WP7_M7.2-Report-on-Circular-Migration-of-the-HWF_final.pdfDate accessed: August 8, 2022Google Scholar Some LMIC governments have favored managed migration involving bilateral agreements aimed at setting a limit on the number of skilled health workers that can be recruited at a time. For example, India plans to supply 300,000 doctors, nurses, and allied health professionals to seven HICs.24Kumar S. Exporting Indian healthcare workers to the world.https://www.orfonline.org/expert-speak/exporting-indian-healthcare-workers-world/Date: 2021Date accessed: January 3, 2023Google Scholar This requires that IMGs are treated well in the host country, and that IMGs can still share their experiences and the competencies they gain with their home countries. In addition, there have been multilateral initiatives aimed at supporting health worker development in source countries. Some of this includes training health professional cadres that do not exist in a source country, supporting health workforce exchanges between source and destination countries, and supporting the development of training curricula in these source countries.22Yakubu K. Durbach A. van Waes A. et al.Governance systems for skilled health worker migration, their public value and competing priorities: an interpretive scoping review.Glob Health Action. 2022; 152013600Crossref Scopus (1) Google Scholar Such training contributes to improvement in skills and training, which in turn improves health outcomes for the source countries.25De Silva A.P. Liyanage I.K. De Silva S.T. Jayawardana M.B. Liyanage C.K. Karunathilake I.M. Migration of Sri Lankan medical specialists.Hum Resour Health. 2013; 11: 21Crossref Scopus (16) Google Scholar The pandemic has tested the capacity of health systems and the workforce globally and has forced governments to reassess their health workforce requirements. A quick solution for HICs can be to recruit trained HCWs from LMICs. Although the pandemic disrupted the supply chain of HCWs for a period because of travel restrictions, there are concerns that this has resumed with an increased flow of HCWs to HICs, further worsening the situation in LMICs.26Shaffer F.A. Rocco G. Stievano A. Nurse and health professional migration during COVID-19.Prof Inferm. 2020; 73: 129-130Google Scholar With countries doing their best to protect the public health interests during the pandemic, there seems to be a diminished interest in promoting solidarity and global health equity, values that the WHO code sought to promote. The code has proposed a governance framework for the international recruitment of skilled HCWs and now it monitors the progress of countries. Table 2 provides some recommendations for both HICs and LMICs to strengthen HCW retention.Table 2Recommendations to Improve Skilled Health Worker RetentionaHIC, high-income country; IMG, international medical graduates; LMIC, low- and middle-income country.Recommendations for HICs to decrease reliance on IMGs1.Invest in education of domestic students.2.Provide financial incentives to medical professionals to work in rural and remote regions.3.Allow circular migrationbLMIC health workers can train in HIC and return to their home country on completion of their training, and workers from HIC spend time in LMICs for knowledge exchange. between LMICs and HICs through bilateral or multilateral agreements.4.Invest in diverse skill-mix to promote task-sharing between teams of interdisciplinary professionals.5.Respect the WHO code.Recommendations for LMICs to train and retain health workforce1.Strengthen the health system to provide infrastructure, equipment, and medicines so that health workers can practice without challenges.2.Incentivize health workers to work in rural and remote regions.3.Initiate and enforce return of service schemes.4.Promote circular migration through bilateral or multilateral ties.5.Invest in diverse skill-mix to promote task-sharing between teams of interdisciplinary professionals.a HIC, high-income country; IMG, international medical graduates; LMIC, low- and middle-income country.b LMIC health workers can train in HIC and return to their home country on completion of their training, and workers from HIC spend time in LMICs for knowledge exchange. Open table in a new tab High-income countries must decrease their reliance on IMGs, especially from countries with critical shortages of HCWs. Partnerships to enable workforce training and facilitate circular migration will enhance collaboration and solidarity between countries. Governments must plan and invest in health care teams with diverse skills, including midlevel health providers, especially in the context of primary health care.27Cometto G. Tulenko K. Muula A.S. Krech R. Health workforce brain drain: from denouncing the challenge to solving the problem.PLOS Med. 2013; 10e1001514Crossref Scopus (50) Google Scholar Developing physician assistant, health promotor, or community health worker cadres would enable certain functions such as educating patients, screening, and providing adherence support to be shifted away from busy clinicians who could then focus their time on clinical activities and middle-income countries training and their HCWs than training them for the international HCW to this is to have return of service agreements for skilled HCWs so that after they they the public for few D. S. M. et for health workforce in rural and remote a systematic Resour Health. PubMed Scopus Google B. K. Durbach A. R. and strengthening of could the on global health workforce distribution and shortages in Health. 2020; Scopus Google Scholar Governments must HCWs to promote in rural and remote Silva A.P. Liyanage I.K. De Silva S.T. Jayawardana M.B. Liyanage C.K. Karunathilake I.M. Migration of Sri Lankan medical specialists.Hum Resour Health. 2013; 11: 21Crossref Scopus (16) Google Scholar The World governments health to their of a rural or remote job through choice of such choice would the the choice and for better to and Health Workers in and in Developing Countries A World Scholar Governments must work to and policy for ethical recruitment through bilateral agreements and better of IMGs, and facilitate circular migration through the of and J. J. A. market and the international mobility of health Health accessed: January 3, 2023Google Scholar can as by providing support to governments and as to HCWs to training All governments must aim to be and to meet their health workforce from their J. J. A. market and the international mobility of health Health accessed: January 3, 2023Google Scholar must policies to and health workers and to provide access to health care for its