Academic journal article Bulletin of the World Health Organization

Medical and Nursing Students' Intentions to Work Abroad or in Rural Areas: A Cross-Sectional Survey in Asia and Africa/ Intentions Des Etudiants En Medecine et En Soins Infirmiers Concernant le Travail a L'etranger Ou Dans Les Zones Rurales: Une Enquete Transversale En Asie et En Afrique/ la Intencion De Trabajar En El Extranjero O En Zonas Rurales De Los Estudiantes De Medicina Y Enfermeria: Una Encuesta Transversal En Asia Y Africa

Academic journal article Bulletin of the World Health Organization

Medical and Nursing Students' Intentions to Work Abroad or in Rural Areas: A Cross-Sectional Survey in Asia and Africa/ Intentions Des Etudiants En Medecine et En Soins Infirmiers Concernant le Travail a L'etranger Ou Dans Les Zones Rurales: Une Enquete Transversale En Asie et En Afrique/ la Intencion De Trabajar En El Extranjero O En Zonas Rurales De Los Estudiantes De Medicina Y Enfermeria: Una Encuesta Transversal En Asia Y Africa

Article excerpt

Introduction

Shortages of physicians and nurses jeopardize health system advances in many low- and middle-income countries (LMIC). (1,2) Sub-Saharan Africa has only 2 doctors and 11 nurses or midwives per 10 000 people, compared with approximately 30 physicians and 84 nurses or midwives per 10 000 people in high-income countries. (3,4) Emigration of health professionals from LMIC to countries with less need of such professionals exacerbates the global workforce imbalance. (1,2,5) Meanwhile, rural-to-urban migration of those professionals continues to increase provider shortages in rural areas where the need is the greatest. (6,7)

To address the human resource problems in LMIC's health sector, the Global Health workforce alliance was formed in 2006 to identify, implement and advocate solutions to the crisis. (8) Then in 2010, the World Health Organization (WHO) issued a global Code of Practice that intended to curb international migration of health professionals. (9) WHO has also published recommendations for attracting, recruiting and retaining health workers in rural areas. (6) Since then, partnerships between governments, institutions and funding organizations have emerged to strengthen LMIC health workforces. (10-12) New medical and nursing schools have been established and existing ones expanded, (13) while curricular reforms have been instituted to enhance graduate retention. (13,14)

Yet, these investments have been made without systematic analysis of the students' migration intentions. We know very little regarding the characteristics of students inclined to work in rural areas or remain in the country in which they train. (6) Without such information, resource-intensive interventions might promote training of graduates with no plans to practice in areas of need. Scholarship-bonding schemes and compulsory service obligations to work in areas with professional shortages struggle to achieve long-term retention, (15) with most of the health-care professionals leaving shortly after required service terms. (16) Greater understanding of factors associated with students' intentions to work in high-demand regions is needed, (6,17) and this could help direct admissions' policies towards selecting individuals most likely to serve in these settings long-term.

Previous studies on health worker retention are mainly from high-income countries (18-20) and are not applicable to LMIC. Compared to graduates in high-income countries, LMIC graduates face greater resource disparities between rural and urban settings, as well as the additional lure of providing support to family through remitted salaries earned abroad. Assessments from LMIC are limited in size and fail to compare class years, degree programmes, institutions and countries. (6) To address this research gap, we conducted a multinational assessment of medical and nursing students' migration intentions in LMIC by surveying first- and final-year students at leading government institutions (Appendix, available from: http://biostat.mc.vanderbilt.edu/ StudentMigration).

Methods

Study Design

We considered countries in sub-Saharan Africa and south-east Asia that were classified by WHO as having a critical shortage of health service providers (less than 2.28 physicians, nurses, or midwives per 1000 population). (2) To avoid confounding effects of language on migration intentions and because most health professional emigration is to English-speaking nations, (21,22) we included only countries where English is the language of instruction. To limit the influence of conflict and political turmoil on the results, (22) we excluded countries with an active United Nations peacekeeping mission or bottom-decile rank in either the Global Peace Index or World Bank Worldwide Governance Indicators. (23-25)

To enhance similarity between study institution governance structure and founding principles, we excluded countries without both a government medical and nursing school, or in which either school was established after 1993. …

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