Table 1 Summary of reasons for, implications of, and recommendations to mitigate the medical brain drain
From: Down the brain drain: a rapid review exploring physician emigration from West Africa
References | West African countries included | Study design | Reasons for emigration | Implications of the brain drain | Recommendations |
|---|---|---|---|---|---|
Astor et al. [12] | Nigeria | Cross-sectional, qualitative study | Low pay/income Limited access to enhanced technology Limited medical jobs Limited opportunities to work in academic environment Less prestige associated with being a physician compared to being a physician in HICs Concerns regarding safety Limited prospect for children | Insufficient medical expertise within supplier country Insufficient number of physicians for population Improvements in medical knowledge and education via increased number of medical schools and increased commercialization of medical schools Promote international collaboration for healthcare research and development Effects are felt worse in rural areas of countries as well as more by public sector than private | Increase physician income Improve physician-working conditions Regulate physician migration through government migration control Require physicians to compensate supplier country if they chose employment abroad Require recipient countries to compensate supplier country Require medical graduates to work in home country for a set amount of time after graduation Increase formal partnership between medical schools of supplier and recipient countries with explicit conditions of return Improve government-level monitoring of physician flow |
Eastwood et al. [13] | Nigeria and Ghana | Commentary | Limited postgraduate training opportunities Underfunding of health-service facilities Poor remuneration Poor governance and health-service management Civil unrest and personal security Considerably ‘easy’ transition to other English-speaking countries | Shortage of healthcare personnel, especially in rural areas of supplier country | Train more doctors in the UK Increase aid and technical assistance via the Department for International Development (DfID) to assist in recruitment and retention of health care professionals in supplier countries (especially rural areas) Restrict duration of training for health workers from supplier countries Reshape and strengthen supplier country incentive schemes for physicians Agreement between recipient countries and the WHO about standard for the minimum HCP training targets in developing countries |
Eliason [2] | Ghana | Cross-sectional, qualitative study | Limited opportunities for professional development Limited socioeconomic compensation High cost for medical education push trainees to emigrate to high-paying countries | N/A | Supplier countries like Ghana should explore funding mechanisms that are less burdensome to the medical trainees and their families |
Hagopian et al. [14] | Nigeria and Ghana | Cross-sectional, qualitative study | Poor working conditions Poor renumeration Limited training and research opportunities Limited post-graduate training opportunities Political and economic conditions of the country Poor working environment and infrastructures Regular labor strikes | Rural and poor communities have limited access to health services Inadequate physician leaders to advance health system Limited ability for the health sector to develop and expand Depletes an important element of the middle class made up by African physicians which leads to an increase of the proportion of the population living in poverty | Improve physician incentives Create barriers for emigration Recoup financial investment losses from emigrating physicians Expand scope of other healthcare providers' work Receive compensation from receiving countries |
Ike [15] | Nigeria | Commentary | These are categorized into three: (1) Global factors: Pressure on health providers in recipient countries who become desperate for more workers especially in rural areas Profit by recruitment agencies Professionals (2) The push factors: Poor working conditions Poor wages Lower standards of living Underutilization of qualified personnel Political instability Declining educational systems Mediocrity and discrimination Limited civil liberties Social insecurity (3) Related determinants: Have family members living abroad Better opportunities for children Ability to send remittances home | Health of population affected | Utilize skills of the other health professionals Enhance remuneration to attract Nigerian health professionals to remain and/or return to the supplier country Collect better data on physician emigration Increase national budget for education and healthcare Invest in infrastructure and rehabilitation of healthcare systems Adapt “virtual participation,” encouraging highly skilled expatriates to contribute their experiences to the development of supplier country without necessarily physically relocating Improve governance, accountability, and transparency within government |
Jenkins et al. [16] | Nigeria, Ghana, Congo, Cameroon, Liberia, Senegal, and Sierra Leone | Cross-sectional, qualitative study | Low salaries Poor occupational safety Inadequacy of facilities and supply of medicines Lack of post graduate training and continuing professional development Lack of a multidisciplinary approach Poor treatment conditions for patients Limited mentors/supervisor for advanced practice | Loss of health system capacity to deliver health care equitably | Increase educational opportunities such as professional development, research opportunities, and scholarships, Improve working environment such as flexible working hours, better facilities and equipment Improve incentives such as provision of housing, transportation, and childcare Improve security Expand other healthcare provider training and roles |
Karan et al. [11] | Nigeria | Commentary | Limited training opportunities Low salaries Political instability and corruption Poor quality of facilities and equipment Concern for family and children’s future | Suboptimal health systems functioning and quality of care | HICs reduce both passive and active recruitment of physicians from LMICs The US and other recipient countries should work to alleviate the physician shortage in supplier country by providing educational loan forgiveness to clinicians working in underserved areas in the US Recipient country pay fee to supplier countries in order to recruit physicians from these countries Expand roles and training for less skilled healthcare workers Customize medical curricula in source countries to be more locally relevant. This could increase social prestige and compensation when physicians remain local Increase opportunities for career advancement |
Loh et al. [20] | Ghana | Cross-sectional, qualitative study | Poor income Better professional prospects and higher standards of living abroad The gap in investigation of the factors related to health care delivery and financing that could drive emigration Public health care delivery and financing may increase physician emigration when compared to private | Drains skilled personnel from already weak health systems Reduces the success of existing primary care and public health activities | Encouraging private health-care delivery and financing may decrease physician emigration. However, may possibly affect the availability and quality of universal health-care coverage |
Mullan 2005 [24] | Nigeria and Ghana | Cross-sectional, quantitative study | Limited medical-training positions Limited opportunity for medical employment | Supplier countries lose important healthcare capabilities Increased health inequity, health disparities such as human immunodeficiency virus (HIV) infection and the acquired immunodeficiency syndrome (AIDS) related deaths | Increase investments by recipient nations in own medical education Assist LMICs to retain physicians and focus training on national needs rather than on the international physician market |
Mullan 2007 [21] | Ghana | Commentary | Poor pay even though the salaries of Ghanaian doctors are better than those in many African countries | Maternal and infant mortality rates (in Ghana) are more than 10 times those of high-income countries | Supplier country train more physicians in the hopes to retain more Receiving country train more physicians for themselves Receiving countries send their physicians to work in supplier countries Increase pay, provide loans and subsidized housing for physicians increases Expand in-country medical residency programs Expand education and training for community health nurses, technical officers, and medical assistants to substitute for doctors in shortage areas |
Nwadiuko et al. [22] | Nigeria | Cross-sectional, quantitative study | Insufficient physical security Lack of economic security | Supplier country’s health systems suffer from the gap left by emigrated physicians Increased HIV mortality related to physician emigration | Outside organizations can partner with emigrated physicians to advise individual and network level contributions For emigrated physicians preparing to permanently relocate back to their countries of origin, the private sector might offer an attractive option, although governmental support remains necessary for their successful integration |
Okeke [23] | Ghana | Cross-sectional, qualitative study | Low wages | Worsened doctor-to-population ratios in LMICs | Increase the salaries of health professionals in LMICs Compensate doctors for overtime work |
Opoku and Apenteng [17] | Ghana | Cross-sectional, quantitative study | Low salary Job dissatisfaction Poor working conditions and living conditions Limited research and working opportunities | Magnify the already existing shortages of healthcare providers Loss of investment for supplier nations countries | Advance data tracking physician emigration Improve remuneration Enhance career development and continuing education opportunities Improve resource availability and working conditions HICs decrease their dependence on international graduates by increasing their own capacity of healthcare workforce HICs compensate LMICs for their human resource loss and/or establish bilateral policies to decrease impact of physician emigration from LMICs to HICs |
Ossai et al. [18] | Nigeria | Cross-sectional, quantitative study | Limited spaces for internships, residencies, and formal employment after training Limited options for specialization in career Nation-wise socioeconomic or political unrest Limited opportunities family and children in supplier country Limited infrastructure, facility, and equipment | Critical shortage of health workers Poor quality health services in supplier countries | More rural placements to increase rural interest Government-level compensation and appreciation for physicians remaining in LMICs Physicians who are trained abroad can also be brought back to advance supplier country’s specialist training |
Udonwa [19] | Nigeria | Commentary | Limited facilities especially in rural areas Limited opportunities for medical specialities Limited economic inequalities that exacerbates salaries between HICs and LMICs Corrupt leadership, political upheaval, and/or civil unrest | Widening difference of healthcare outcomes between rural and urban areas | Mobilize physicians who emigrated to HICs and achieved professional success to undertake short-term consultancies in their countries of origin Train more staff to reduce human capital impact Refrain from erecting legal barriers to the emigration of educated professionals which will only encourage illegal emigration; instead, enact necessary economic reforms that make staying at home rewarding for educated Nigerians Good leadership and policy planning Good governance at the national and international levels Improved security for peoples' lives and property Investment in more research and policy about the causes of the drain and in educating policy makers about the causes Improved wages according to physician qualifications Offering better quality education and expanding educational infrastructure Implement tax to physicians who are wishing to emigrate Government level agreement between LMICs and HICs to discourage physician emigration Contract medical students to refund their education fee if they leave the country before a minimum service period (return of service) |
Woodward [3] | Sierra Leone | Cross-sectional, qualitative study | Sociopolitical unrest Frequent disease outbreaks (like Ebola) Increased workload | Fragile healthcare system becoming more vulnerable and overburdened | Development of postgraduate medical education in low-income and crisis-affected countries |
Wright et al. [25] | Non-specific mention of English-speaking commonwealth countries (which includes multiple West African countries) | Commentary | Low standard of living | Depletion of human resources of health in LMICs | Improve pay Better and safer working conditions Fewer patient caseload Address political instability and personal safety Increase domestic supply of physicians Develop compensatory schemes from receiving countries Policy initiatives to stop recruiting from LMICs |