|Year : 2007 | Volume
| Issue : 1 | Page : 27
Research on Medical Migration from Sub-Saharan Medical Schools: Usefulness of a Feasibility Process to Define Barriers to Data Collection and Develop a Practical Study
AO Longombe1, V Burch2, S Luboga3, C Mkony4, EO Olapade-Olaopa5, B Otieno-Nyunya6, B Afolabi7, E Nwobodo8, S Kiguli3, WP Burdick9, JR Boulet9, PS Morahan9
1 Universite De Kisangani, DOCS/Goma, Democratic Republic of CONGO
2 University of Cape Town, Capetown, South Africa
3 Makerere University, Faculty of Medicine, Kampala, Uganda
4 Muhimbili University, College of Health Sciences, Tanzania
5 University College Hospital, University of Ibadan, Nigeria
6 Moi University Teaching and Referral Hospital, Eldoret, Kenya
7 University of Lagos, Lagos, Nigeria
8 Nnamdi Azikiwe University, Nnewi, Anambra State, Nigeria
9 Foundation for Advancement of International Medical Education and Research (FAIMER), Philadelphia PA, USA
|Date of Submission||21-Mar-2007|
|Date of Web Publication||24-Apr-2007|
A O Longombe
Universite De Kisangani, DOCS/Goma
Democratic Republic of CONGO
Source of Support: None, Conflict of Interest: None
Context: The maldistribution of physicians in sub-Saharan Africa is having serious impacts on population health. Understanding the effect requires investigation from both donor and recipient countries. However, investigation from the perspective of donor countries has been lacking.
Methods: This brief communication describes a model process for the design of a research project that addresses medical migration issues from the perspective of eight African medical schools. During an international meeting, the participants designed an initial "ideal" study, and then rapidly tested its feasibility through a brief survey, and group discussion through a listserv, teleconferences and one face-to-face meeting.
Findings and practical implications: Innovative research ideas can be followed-up with surveys to test the feasibility of an "ideal" research design, modifying the design accordingly. This is currently occurring with our medical migration survey study.
medical migration, Sub-Saharan Africa, data sources, data sets
|How to cite this article:|
Longombe A O, Burch V, Luboga S, Mkony C, Olapade-Olaopa E O, Otieno-Nyunya B, Afolabi B, Nwobodo E, Kiguli S, Burdick W P, Boulet J R, Morahan P S. Research on Medical Migration from Sub-Saharan Medical Schools: Usefulness of a Feasibility Process to Define Barriers to Data Collection and Develop a Practical Study. Educ Health 2007;20:27
|How to cite this URL:|
Longombe A O, Burch V, Luboga S, Mkony C, Olapade-Olaopa E O, Otieno-Nyunya B, Afolabi B, Nwobodo E, Kiguli S, Burdick W P, Boulet J R, Morahan P S. Research on Medical Migration from Sub-Saharan Medical Schools: Usefulness of a Feasibility Process to Define Barriers to Data Collection and Develop a Practical Study. Educ Health [serial online] 2007 [cited 2021 Feb 26];20:27. Available from: https://www.educationforhealth.net/text.asp?2007/20/1/27/101626
The maldistribution of physicians and other healthcare workers throughout the world can have serious impacts, not only in terms of population health, but in long-term educational and social opportunities for skilled workers (de Castella, 2003; Marchal & Kegels, 2003; Hagopian et al., 2004; Astor et al., 2005; Hagopian et al., 2005; Dovlo, 2005; Norcini & Mazmanian, 2005; Cooper, 2005; Mullen, 2005; Hallock et al., 2003).
In Sub-Saharan Africa, a significant rise in disease burden, emigration, productivity losses, and lack of adequate physician output has resulted in a health resource crisis (Aluwihare, 2005). There are only 72 medical schools (4.1% of world total), with an estimated annual graduating class of <15,000, for 10.6% (678 million) of the global population. In comparison, there are 307 medical schools (about 17% of world total) in North America and the Caribbean, for only 8% (508 million) of the world’s population (FAIMER, 2006). Certainly, if the total number of physicians per unit population are considered, African nations can simply no longer afford to lose doctors to the rest of the world.
Most studies on medical migration have been performed from the perspective of recipient developed countries and not the perspective of donor developing countries. Such a “paucity of sending-country data makes it difficult to fully describe the impact of migration on countries of origin” (Hagopian et al., 2004). Investigation of migration of physicians from Africa (de Castella, 2003; Marchal & Kegels, 2003; and Dovlo, 2005) has tended to focus on numbers, without exploring underlying reasons for emigration, describing characteristics of individuals who seek opportunities elsewhere, estimating the potential negative impact on local healthcare systems, or considering factors and/or incentives to alleviate the problem. Even where quantification of emigration was the focus, data have been difficult to obtain, often incomplete, and typically lack detail with respect to country of origin or birth, medical school attended, etc. In fact, many African country ministries of health and education appear to know the extent of their own emigration through data from destination countries (Stilwell et al., 2003).
Clearly, any workable efforts to stem the physician “brain drain” (Nullis-Kapp, 2005) will require accurate data from both donor and recipient countries. This necessitates accurate counts of graduates from African medical schools, basic demographic information, and some method to track individuals over time. The present report describes the process of: (1) designing an initial “ideal” study; and (2) developing a tool to collect information rapidly in order to determine the feasibility of conducting the proposed research on medical migration within sub-Saharan Africa, given the reports of incomplete databases, and revising the study as necessary.
A group of mid-career clinical and basic science medical educator faculty from developing countries were Fellows of the Foundation for Advancement of International Medical Education and Research (FAIMER) Institute (Norcini et al., 2005; FAIMER, 2006). During a one day session - “Medical Migration: Toward Equitable Medical Expertise Across the World” - within the two and a half week FAIMER Institute in Philadelphia, participants proposed research projects addressing medical migration.
During that day, nine FAIMER Fellows from Sub-Saharan Africa designed a project to follow career progression of medical graduates from graduation through postgraduate training to clinical practice and location, and a survey to assess the feasibility of obtaining the required data to conduct the research. The initial research design was a descriptive study of migration patterns of medical school graduates from 1990 through 2000 at each school representing a FAIMER Fellow, in which databases of sub-Saharan graduates would be linked by name with registration databases of U.S. medical residents and practitioners. The year 2000 was selected as study endpoint anticipating there existed an up to five year gap between graduation and medical registration in a recipient country; however, in the 2004 feasibility survey, graduation data were collected through that current year. The selection of U.S. registration as the migration variable was based on access to data from the Educational Commission for Foreign Medical Graduates (2006). The research questions initially envisioned were: (1) percentage graduates seeking and obtaining registration to practice in the U.S.; (2) percentage graduates who leave and eventually return to their home country; and (3) impact of migration on the economy of donor countries. Analysis of both quantitative (questions 1 and 2) and qualitative (question 3) data would be conducted from information obtained through key informant interviews, survey questions (multiple choice with some short answer), and comparisons of databases in donor and recipient countries.
Within a month, nineteen Fellows from 15 medical schools of eight sub-Saharan African countries (Democratic Republic of the Congo, Ethiopia, Kenya, Nigeria, South Africa, Tanzania, Uganda, and Zambia) received an invitation to participate and the brief feasibility survey to complete. The nine participants who joined the study used two teleconferences to discuss the project, and an electronic listserv to facilitate survey distribution. Five Fellows met about six months later in Kampala, Uganda to analyze survey results.
Findings and Practical Implications
A total of eight feasibility surveys (8/15 potential schools or 52%) were completed. The necessary data to complete the study as originally designed were available only in paper form from seven of the schools. All schools required ethics committee approval for the study. Available demographic data were limited (Table 1). Even basic data, such as names, date of birth, country of birth and nationality were not uniformly available, and most schools did not have data on marital status. Data on ethnicity and origin (urban or rural) of students were either not available, or were defined differently across countries so it was not possible to obtain consistent data.
Table 1. Results of a feasibility survey on studying the medical migration of graduates from eight Sub-Saharan African medical schools.
The magnitude of the proposed data collection was larger than originally anticipated (Table 2). Among the eight schools there were approximately 6300 medical school graduates over the initial proposed study period (1990-2000) and a total of 9500 from 1990 to 2004. Of note, there were quite variable numbers of graduates per annum, dictated by factors such as political instability (DRC, Nigeria), government mandates to increase medical student intake and graduate throughput (Uganda, Nigeria, Tanzania) and variable academic performance (South Africa, Nigeria). In some schools there is a high drop out and failure rate at the end of the third year of the typical six-year program, with some students repeating years subsequently. All these factors obviously impact both the graduation rates and migration plans.
Table 2. Number of records of graduating medical students that would be involved in the originally proposed study.
The results were sobering in their implications for studies of medical migration involving sub-Saharan medical schools. They clearly point out the lack of data and systems for such research, and the need to rethink project scope. Lack of computerized records would necessitate systems and templates, extensive data entry and validation, recruiting and training personnel. Solving this problem still leaves lack of completeness of the medical school databases identified by the collaborators. Finally, ethics approval for this multi-institutional study would require complex coordination among schools, each of which may have different procedures and requirements as has been noted by Morahan et al. (2006).
The model process described here for developing a feasible, low cost , multi-institutional research project on workforce migration from under-resourced Sub-Saharan African medical schools includes: (a) the use of one international meeting to cooperatively identify a research problem and propose an idealized study design; (b) testing the study design validity through a rapid feasibility survey process, together with electronic document sharing and review, group telephone calls and one face-to-face meeting; and (c) modification of the research design based on the survey results.
The rapid survey process itself informed the medical educators in training at FAIMER about research methods for designing and conducting a multi-institutional study among under-resourced schools. Based upon the results, the collaborators have revised the research protocol. A small cross-sectional survey of students in their final year of study, using a convenience sample of medical schools, is now being conducted to identify students’ intended type and location of postgraduate training and clinical practice. It is relatively low cost, involving primarily the time of the collaborating faculty, data entry and statistical expertise within FAIMER. The experience gained will inform a subsequent prospective study to compare the reported intentions of graduating students with what actually occurs in the process of migration to the U.S.
The authors acknowledge the support of FAIMER for participation in the FAIMER Institute and support of the research meeting in Kampala, Uganda, in May 2005. The authors also thank the three reviewers for their time and insightful comments.
ALUWIHARE, AP. (2005). Physician migration: donor country impact. Journal Continuing Education Health Professions, 25(1), 15-21.
ASTOR, A, AKHTAR, T, MATALLANA, M.A., MUTHUSWAMY, V., OLOWU, F.A., TALLO, V., & LIE, R.K. (2005). Physician migration: Views from professionals in Colombia, Nigeria, India, Pakistan and the Philippines. Society Science Medicine, 61 (12), 2492-2500.
COOPER, R.A. (2005). Physician migration: a challenge for America, a challenge for the world. Journal Continuing Education Health Professions, 25(1), 8-14.
DE CASTELLA, T. (2003). Health workers struggle to provide care in Zimbabwe. Brain drain adds to woes of a cash-strapped health-care system. Lancet; 362 (9377), 46-47.
DOVLO, D. (2005). Wastage in the health workforce: some perspectives from African countries. Human Resources Health, 3, 6.
EDUCATIONAL COMMISSION FOR FOREIGN MEDICAL GRADUATES OR ECFMG (2006). Retrieved from ECFMG-website: www.ecfmg.org
FAIMER – FOUNDATION FOR ADVANCEMENT IN MEDICAL EDUCATION AND RESEARCH (2006). International Medical Education Directory (IMED). Retrieved from IMED-database: http://imed.ecfmg.org/search.asp
HAGOPIAN, A., THOMPSON, M.J., FORDYCE, M., JOHNSON, K.E., HART, L.G. (2004). The migration of physicians from sub-Saharan Africa to the United States of America: measures of the African brain drain. Human Resources Health, 2(1), 17.
HAGOPIAN, A., OFOSU, A., FATUSI, A., BIRITWUM, R., ESSEL, A., GARY HART, L., WATTS, C. (2005). The flight of physicians from West Africa: views of African physicians and implications for policy. Society Science Medicine, 61(8), 1750-1760.
HALLOCK, J.A., SEELING, S.S., NORCINI, J.J. (2003). The international medical graduate pipeline. Health Affairs (Millwood), 22(4), 94-96.
MARCHAL, B., & KEGELS, G. (2003). Health workforce imbalances in times of globalization: brain drain or professional mobility? International Journal Health Planning Management, 18 Suppl 1, S89-101.
MORAHAN, P.S., YAMAGATA, H., MCDADE, S.A., RICHMAN, R., FRANCIS, R., & ODHNER, V.C. (2006). New challenges facing interinstitutional social science and educational program evaluation research at academic health centers: A case study from the ELAM program. Academic Medicine, 81, 527-534.
MULLEN, F. (2005). The metrics of the physician brain drain. New England Journal Medicine, 353, 1810-1822.
NORCINI, J.J., BURDICK, W., MORAHAN, P.S. (2005). The FAIMER Institute: creating international networks of medical educators. Medical Teacher, 27, 214-218.
NORCINI, J.J., MAZMANIAN, P.E. (2005). Physician migration, education, and health care. Journal Continuing Education Health Professions, 25(1), 4-7.
NULLIS-KAPP, C. (2005). Efforts under way to stem "brain drain" of doctors and nurses. Bulletin of World Health Organization, 83(2), 84-85.
STILWELL, B., DIALLO, K., ZURN, P., DAL POZ, M.R., ADAMS, O., BUCHAN, J. (2003). Developing evidence-based ethical policies on the migration of health workers: conceptual and practical challenges. Human Resources Health, 1(1), 8.