标题：Too Poor to Leave, Too Rich to Stay: Developmental and Global Health Correlates of Physician Migration to the United States, Canada, Australia, and the United Kingdom
摘要：Objectives. We analyzed the relationship between physician migration from developing source countries to more developed host countries (brain drain) and the developmental and global health profiles of source countries. Methods. We used a cross-section of 141 countries that lost emigrating physicians to the 4 major destinations: the United States, Canada, Australia, and the United Kingdom. For each source country, we defined physician migration density as the number of migrant physicians per 1000 population practicing in any of the 4 major destination countries. Results. Source countries with better human resources for health, more economic and developmental progress, and better health status appear to lose proportionately more physicians than the more disadvantaged countries. Higher physician migration density is associated with higher current physician ( r =0.42, P < .001), nurse ( r =0.27, P =.001), and public health ( r =0.48, P =.001) workforce densities and more medical schools ( r =0.53, P <.001). Conclusions. Policymakers should realize that physician migration is positively related to better health systems and development in source countries. In view of the “train, retain, and sustain” perspective of public health workforce policies, physician retention should become even more important to countries growing richer, whereas poorer countries must invest more in training policies. The World Health Organization’s (WHO’s) 2006 world health report, Working Together for Health , highlighted the workforce issues facing health systems. 1 Both developed and developing countries have pressing shortages of nurses and physicians. Unfortunately, such staffing shortages, lack of specialist training in poorer countries, and the financial lure of the West have resulted in the migration of physicians and nurses from the mostly developing source countries to the more developed host or destination countries. Between 23% and 28% of physicians in the 4 large English-speaking countries—the United States, Canada, the United Kingdom, and Australia—are international medical graduates (i.e., they received medical degrees outside of their host countries), 40% to 75% of whom come from low- to middle-income countries. 2 The reasons for the emigration of these health workers and the impact of these so-called fatal flows 3 or brain drains have been enumerated. 4 – 7 Perhaps the most worrisome aspect of this migration is that the source countries, which are largely poor and with higher disease burden than the host countries, 2 , 5 can ill afford to lose their physicians. 1 – 8 Understandably, managing physician migration remains a sore point in the pursuit of an effective and equitable health workforce and, ultimately, policies responsible for the performance of health systems. 3 , 8 – 16 We profile the source countries that have been reported to supply the most physicians to the United States, Canada, Australia, and the United Kingdom. 2 Although previous studies have pointed out that destination countries are generally richer than source countries, they have not shown whether there are recognizable differentials in migration patterns among the source countries. We specifically address the question of whether source countries with better profiles of human resources for health, economic and developmental progress, and health status lose proportionately more or fewer physicians to these 4 destination countries than source countries with poorer profiles. It seemed possible that, as source countries became marginally richer, without careful planning, their often meager facilities would allow them to train, but not retain or sustain, better-quality physicians, who would then migrate to take up residency positions in the United Kingdom, Canada, Australia, the United States, and other affluent countries.
