Gaining Accreditation of the World Federation for Medical Education; Training for Employment or License to Brain Drain?

Exodus of medical graduates from low - and middle-income countries to high-income countries also known as “Brain Drain” is a growing global dilemma that has plagued the health industry particularly in poor countries for decades. The observed numbers of graduates migrating from Sub-Saharan African (SSA) origin to the United State alone during the years 2002, 2010, 2013, and 2016 were 7,830, 9,938, 11,787, and 12,846, respectively.[1] The total number of physicians resident in the same 34 SSA countries in 2013, as reported by the World Health Organization (WHO),[1] [2] was 11,519. Comparing the number of doctors who migrated to those who were resident in the same year shows that the health systems in those countries have lost more than 50% of its workforce, and that must represent a very serious dilemma to those fragile health systems.[1] [2] Similar challenges are encountered in retaining other skilled healthcare workers (HCWs) including nursing staff and health technologists in most low- and middle-income countries. Although the current efforts by accrediting bodies in most countries to acquire recognition by World Federation of Medical Education is a welcome step and will raise the standards of medical education all over the world, however, there are concerns regarding how will it impact the rates of migration of healthcare workforce over the coming decades.[3]

The root causes of this insidious “brain drain” could be summarized as follows:

1. Underestimation of healthcare system needs for human resources by most countries despite projected global shortage of 10 million HCWs to achieve Universal Health Coverage by 2030.[2]

2. High cost of medical training, and

3. Lack of promising career prospects, job satisfaction, and adequate financial incentives in lower-income countries. Asante et al found that low salaries, poor working conditions, and a lack of career opportunities as the main reasons for considering emigration of healthcare professionals from Ghana.[4] Similar findings were reported even in higher income countries including Ireland and Poland.[4] [5] [6]

Furthermore, it is customary that graduates seek higher training in developed countries with a promise to gain new skills and experience that they can apply in treating patients in their home countries as they return. However, most of these healthcare professionals choose to stay in the host countries rather than return home. Mullan et al found that a significant proportion of medical graduates from low-income countries who were trained in the United States chose to stay even after completing their higher training.[7] It is rather unfortunate that many of those who fail to progress up the career ladder in the hosting countries abandon their career rather than return home, a process that has been described as “Brain Waste” as the graduates often prefer to change their career path to menial non-medical jobs in order to stay in the host country for a potentially better quality of life and future prospects for their families in terms of social services, better education, healthcare, and probable better economic stability in the long run. The number of these “wasted” graduates is difficult to estimate due to lack of data on either side of the immigration borders!

To address the so called “Brain-Drain” in the healthcare sector, several potential solutions are considered; however, the main solution is to invest in healthcare systems and improve working conditions in poorer countries to create more opportunities and incentives for healthcare professionals to stay home. Recently, Bhargava and Docquier have reported that improvements in working conditions and salaries can help to reduce the likelihood of medical graduates emigrating from low-income countries.[8] Another solution is to promote collaboration and knowledge-sharing between countries, to help build capacity and support the training and retention of healthcare professionals in donor countries. The United Nations and its organizations continue to emphasize the need for international cooperation to address this phenomenon in the healthcare sector; the World Health Organization Global Code on International Recruitment of Health Personnel, 2015, article 3.6, stipulates that member nations “...should strive, to the extent possible, to create a sustainable health work-force and work towards establishing effective health work-force planning, education and training, and retention strategies that will reduce their need to recruit migrant health personnel….”[9] This voluntary Global Code of Practice (GCOP) on International Recruitment of Health Personnel seeks to promote fair and ethical recruitment practices through exchange of information, cooperative arrangements, and joint efforts by source and destination countries to ensure health workforce sustainability and observe the rights and interests of individual health workers.

Since its inception in 2010, GCOP has increased awareness between member states regarding the challenges ahead and improved global data and information on international health worker mobility, yet the actual figures on immigration continue to increase at a rate of around 5% per year from SSA to the United States alone.[10] Fewer WHO member states took meaningful actions beyond diplomatic acceptance of GCOP recommendations. The United States Global Health Initiative (USAID, 2021) has attempted to increase investment in healthcare education and training, improve working conditions at home, and promote collaboration between countries to address the health workforce crisis. However, by 2034, the United States is expected to face a shortfall of as many as 124,000 physicians and therefore the recruitment of the International Medical Graduates (IMGs) will continue for a long time.[11] Furthermore, in the United States there are now advocates calling for legislative changes to allow more non-US IMGs to come and stay. The AAMC and other groups have recently asked the Congress to expand the number of IMGs.[12]

As alluded to earlier, escalation of this dilemma is likely for the inability of National and International Measures and Agreements to curb the exodus of medical graduates from low- and middle-income countries. The prospects of better jobs, career, and economic prospects in developed countries is not all unwelcome, as it is one of the strong incentives for students to seek high-quality university qualifications to allow access to such an inviting job market. Donnelly et al reported on the concept of “higher training for employment” citing the bold attempt in the Minerva University of San Francisco to deliver high-quality higher education at half the cost of traditional universities.[13] Adopting such an approach in the Libyan International and other WFME recognised, more cost-effective Universities could play a role in satisfying the appetite of the international market for high-quality HCWs at lower cost and is likely to expand the number of graduates and enhance employment opportunities for graduates trained in low-income countries. This notion will be further enhanced by recognition of such programs in the developing countries by the WFME.

We must reiterate that WFME accreditation primary aim is to improve the quality of health education and to support the health systems. In fact, most of the recommended reforms are health system-based health education reforms.[13] [14] Governments must take this opportunity to improve their professional health education by aiming for WFME accreditation and to continue addressing the root causes for shortage of HCWs in poor countries. By investing in health systems, better planning of projected needs for HCWs as well as promoting collaboration between countries, it is possible to reduce the need for HCWs to cross borders purely for economical reasons. Exchange of HCWs between countries to gain more experience or acquire advanced clinical skills is to be encouraged; at the same time, initiatives to support healthcare professionals in donor countries will undoubtedly help to improve the quality of care provided to patients and reduce the burden on their colleagues who remain.

The anticipated new actions by some of the developed countries to change legislations and ease immigration rules in order to recruit more IMGS[12] will undoubtedly magnify the problem of brain drain and may need a closer look by the WHO and the United Nations.

Conflict of Interest

None declared.

• References

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Publication History

Received: 14 February 2024

Accepted: 14 February 2024

Article published online:
13 June 2024