Plugging the medical brain drain

The fourth round of reporting on the WHO Code of Practice on the International Recruitment of Health Personnel indicates that about 15% of health and care workers globally are working outside their country of birth or first professional qualification.6 In Mozambique, for example, the annual incidence of physician migration was estimated to be 3·7% in 2012, but internal migration accounted for more cases of physician loss than external migration.7 Internal migration in Malaysia, for instance, has resulted in 36% of specialists working in the private health sector providing care for 30% of the population.8 Physician migration not only threatens health systems and patient safety and exacerbates inequitable access to quality care, but also weakens health profession education and perpetuates a cycle that prevents the expansion of a high-quality and effective health workforce. [...]in Nigeria an estimated 2000 physicians leave the country annually, further widening the existing physician-to-patient ratio of four doctors per 10 000 population.9 In a study documenting physician migration over 25 years, India and Pakistan had an estimated 88 000 and 26 500 physician emigrants in 2014 compared with 46 000 and 7752, respectively, in 1990.10 This increase partly reflects the UK National Health Service's historical and continuing reliance on doctors from these two countries.10 The situation is likely to worsen with the intensifying health workforce shortage in the UK and the resultant recruitment of doctors from LMICs.11 Apart from the impact on the health system, at an average cost for medical and nursing education in 2018 of US$114 000 per physician and$32 000 per nurse, the financial price of physician and nursing migration to the health workers’ country of origin has been enormous.2 Previous reported total estimated loss of returns from investment for doctors’ education ranged from $2·16 million for Malawi to$1·41 billion for South Africa.12 More recently, Saluja and colleagues conducted a modelling estimate of the added cost of excess mortality associated with physician migration to HICs and reported an annual loss of $15·86 billion to LMICs, with the greatest total costs incurred by India, Nigeria, Pakistan, and South Africa.13 This modelling analysis, however, may not represent the true cost to the health system, given the scale of the problem and the large burden of diseases in these countries. The accelerated adoption of such medical education and improved digital connectivity and the development of global collaborative networks, which have accelerated during the COVID-19 pandemic, will provide transnational paths for the expansion of medical education even to rural areas, such as Project ECHO which is now implemented in many countries around the world and is showing promising impacts on patient and community health outcomes.19 Although these North–South partnerships are necessary and beneficial, to sustainably stem the medical brain drain from LMICs, policy makers in source countries must address the underlying social and economic issues that prompt individuals to leave in the first place.