Modeling the effects of physician emigration on human development

Scaling up numbers and competency of graduating medical and dental students in Nigeria: Need to improve medical trainers' competency in teaching

Background

With the increasing medical brain drain in Nigeria, there is a need to train and graduate more doctors to fill in the gaps created to mitigate the effects. To meet this goal, the trainers need to evolve and have the competency to deliver quality training for many more enrollees in medical schools.

Aim

This study aimed to gather information about the perception of medical teachers' need to obtain certification in medical education and what this will achieve in scaling up the competency and number of graduating medical doctors.

Subjects and Methods

Medical teachers in Nigeria participated in this mixed (quantitative and qualitative) study. Four hundred medical consultants and teachers were randomly selected and sent a semi-structured pre-validated questionnaire; also, a panel discussion was conducted with six medical teachers with other special assignments in universities and postgraduate colleges. Quantitative data were analyzed using Statistical Package for the Social Sciences (SPSS) 24, differences in proportions were calculated using the Chi-square test, and P values <0.05 were considered significant.

Results

Two hundred and thirty-eight (59.5%) participants completed the form, 63 (26.5%) had practiced for <5 years, and 114 (47.9%) had >10 years of practice experience. A majority of 168 (70.6%) were physician lecturers in federal or state universities, and 15.5% had obtained certifications of any kind in medical education. Over 80% perceived that medical education training should not be a prerequisite to teach, but a similar percentage believed that faculty medical education training can help scale up the training competency and the number of graduating medical doctors.

Conclusion

To scale up the number and competency of graduating medical doctors, medical teachers need to acquire core teaching competency. The respondents and discussants believe that when these core teaching competencies have been fully developed, it will be easier to increase the number of medical students' enrollees, teach them their curriculum through innovations, and graduate them with improved competencies.

Channeling and Wages Among New US Immigrants from Mexico, India, and the Philippines

National — and local — conversations about immigration are often centered on immigrants’ integration into the US society. One factor that shapes immigrants’ integration is their pre-migration work experience, skills, and training and a series of studies have used “channeling” as a concept to identify immigrants who have worked in the same occupation and/or industry in the destination labor market as they had in the origin labor market, prior to migration. Using the New Immigrant Survey (NIS) and a simultaneous equation model (SiEM) approach, this article expands on this research by exploring the impact of channeling on wages for Asian Indians, Filipino/as, and Mexicans with lawful permanent resident (LPR) status. Contrary to prior findings on the effects of channeling within specific industries, we find that channeling is associated with lower, not higher, immigrants’ wages. The findings are robust to different definitions of channeling, as the negative effects of channeling hold within industrial sectors and occupational groups. Moreover, the results indicate that channeling is not exclusive to the Mexico–US migration stream, but instead may be a feature of various US-bound immigration streams, including those from India and the Philippines.

South African physician emigration and return migration, 1991-2017: a trend analysis

Although critical for understanding health labour market trends in low- and middle-income countries (LMICs), longitudinal LMIC health worker emigration and return migration trends are not routinely documented. This article seeks to better understand SA's trends in physician emigration and return migration and whether economic growth and related policies affect migration patterns. This study used physician registry data to analyse patterns of emigration and return migration only among SA-trained physicians registered to practice in top destination countries such as Australia, Canada, New Zealand, the USA or the UK between 1991 and 2017, which represent the top five emigration destinations for this group. A linear regression model analysed the relationship between migration trends (as dependent variables) and SA's economic growth, health financing and HIV prevalence (as independent variables). There has been a 6-fold decline in emigration rates from SA between 1991 and 2017 (from 1.8% to 0.3%/year), with declines in emigration to all five destination countries. About one in three (31.8% or 5095) SA physicians returned from destination countries as of 2017. Annual physician emigration fell by 0.16% for every $100 rise in SA GDP per capita (2011 international dollars) (95% confidence interval -0.60% to -0.086%). As of 2017, 21.6% (11 224) of all SA physicians had active registration in destination nations, down from a peak of 33.5% (16 366) in 2005, a decline largely due to return migration. Changes to the UK's licensing regulations likely affected migration patterns while the Global Code of Practice on International Recruitment contributed little to changes. A country's economic growth might influence physician emigration, with significant contribution from health workforce policy interventions. Return migration monitoring should be incorporated into health workforce planning.

Recognizing New Trends in Brain Drain Studies in the Framework of Global Sustainability

Scholars had been documenting the Brain Drain phenomenon producing scientific literature for more than 50 years. After three decades of slow but steady progress, literature about this concept has accelerated its progress and growth path, in line with the 9th sustainable development goal “Build resilient infrastructure, promote sustainable industrialization and foster innovation” Thus, the present article aims to define the current theoretical trends about the analysis of advanced intellectual human capital’s international migratory phenomenon. This study uses a scientometric methodology on a corpus of 1212 articles indexed to the JCR-WoS from Social Sciences. The period covered in the study is from 1965 to 2020. The paper looks to understand how researchers studied the brain drain concept over the last 55 years in various disciplines. The report covers 99 categories from the Journal Citation Report (JCR) index. Results show that there is a scientific research critical mass that is studying the brain drain phenomenon. The analysis shows thematic trends at the sources, discourses, and consolidates classic works and some novel authors. Those new scholars and theoretical trends lead to refocused analysis beyond countries with a high development level. Such movement constitutes a new challenge in this line of research toward studying the effects of the brain drain in the peripheral areas of knowledge production.

Medical brain drain: How many, where and why?

We build a new database documenting the evolution of physician migration over a period of 25 years (1990-2014), and use it to empirically shed light on its determinants. In relative terms, the highest emigration rates are observed in small island nations and low-income countries, where needs-based deficits of healthcare workers are often estimated to be most severe. Over time, we identify rising trends in Caribbean islands, Central Asia and Eastern Europe. On the contrary, despite increasing migration flows to Western Europe, physician migration rates from sub-Saharan Africa have been stable or even decreasing. Our empirical analysis reveals that physician migration is a complex phenomenon that results from a myriad of push, pull, and dyadic factors. It is strongly affected by the economic characteristics of origin and destination countries. The sensitivity to these push and pull factors is governed by linguistic and geographic ties between countries. Interestingly, we find that the evolution of medical brain drain is affected by immigration policies aimed at attracting high-skilled workers. In particular, physician migration is sensitive to visa restrictions, diploma recognition, points-based system, tax breaks towards migrants, and the option of obtaining a permanent resident status.

Physicians' brain drain - a gravity model of migration flows

Background

The past two decades have been marked by impressive growth in the migration of medical doctors. The medical profession is among the most mobile of highly skilled professions, particularly in Europe, and is also the sector that experiences the most serious labour shortages. However, surprisingly little is known about how medical doctors choose their destinations. In addition, the literature is scarce on the factors determining the sharp rise in the migration of doctors from Africa, Asia and Eastern and Southeastern Europe, and how the last economic crisis has shaped the migration flows of health professionals.

Methods

We use the new module on health worker migration provided by the Organisation for Economic Co-operation and Development (OECD) for 2000–2016 in order to examine the channels through which OECD countries attract foreign physicians from abroad. We estimate a gravity model using the Pseudo-Poisson Maximum Likelihood estimator.

Results

Our results reveal that a lower unemployment rate, good remuneration of physicians, an aging population, and a high level of medical technology at the destination are among the main drivers of physicians’ brain drain. Furthermore, an analysis of the mobility of medical doctors from a number of regions worldwide shows that individuals react differently on a country-wise basis to various determinants present in the destination countries. Physicians from African countries are particularly attracted to destination countries offering higher wages, and to those where the density of medical doctors is relatively low. Concurrently, a higher demand for healthcare services and better medical technology in the receiving country drives the inflow of medical doctors from Central and Eastern Europe, while Asian doctors seem to preferentially migrate to countries with better school systems.

Conclusions

This study contributes to a deeper understanding of the channels through which OECD countries attract foreign medical doctors from abroad. We find that, apart from dyadic factors, a lower unemployment rate, good remuneration of physicians, an aging population, and good medical infrastructure in the host country are among the main drivers of physicians’ brain drain. Furthermore, we find that utility from migration to specific countries may be explained by the heterogeneity of origin countries.

The impact of physician migration on mortality in low and middle-income countries: an economic modelling study

Background

The WHO estimates a global shortage of 2.8 million physicians, with severe deficiencies especially in low and middle-income countries (LMIC). The unequitable distribution of physicians worldwide is further exacerbated by the migration of physicians from LMICs to high-income countries (HIC). This large-scale migration has numerous economic consequences which include increased mortality associated with inadequate physician supply in LMICs.

Methods

We estimate the economic cost for LMICs due to excess mortality associated with physician migration. To do so, we use the concept of a value of statistical life and marginal mortality benefit provided by physicians. Uncertainty of our estimates is evaluated with Monte Carlo analysis.

Results

We estimate that LMICs lose US$15.86 billion (95% CI $3.4 to $38.2) annually due to physician migration to HICs. The greatest total costs are incurred by India, Nigeria, Pakistan and South Africa. When these costs are considered as a per cent of gross national income, the cost is greatest in the WHO African region and in low-income countries.

Conclusion

The movement of physicians from lower to higher income settings has substantial economic consequences. These are not simply the result of the movement of human capital, but also due to excess mortality associated with loss of physicians. Valuing these costs can inform international and domestic policy discussions that are meant to address this issue.

Doctor retention and distribution in post-apartheid South Africa: tracking medical graduates (2007-2011) from one university

BACKGROUND

Doctor emigration from low- and middle-income countries represents a financial loss and threatens the equitable delivery of healthcare. In response to government imperatives to produce more health professionals to meet the country's needs, South African medical schools increased their student intake and changed their selection criteria, but little is known about the impact of these changes. This paper reports on the retention and distribution of doctors who graduated from the University of the Witwatersrand, South Africa (SA), between 2007 and 2011.

METHODS

Data on 988 graduates were accessed from university databases. A cross-sectional descriptive email survey was used to gather information about graduates' demographics, work histories, and current work settings. Frequency and proportion counts and multiple logistic regressions of predictors of working in a rural area were conducted. Open-ended data were analysed using content analysis.

RESULTS

The survey response rate was 51.8%. Foreign nationals were excluded from the analysis because of restrictions on them working in SA. Of 497 South African respondents, 60% had completed their vocational training in underserved areas. At the time of the study, 89% (444) worked as doctors in SA, 6.8% (34) practised medicine outside the country, and 3.8% (19) no longer practised medicine. Eighty percent of the 444 doctors still in SA worked in the public sector. Only 33 respondents (6.6%) worked in rural areas, of which 20 (60.6%) were Black. Almost half (47.7%) of the 497 doctors still in SA were in specialist training appointments.

CONCLUSIONS

Most of the graduates were still in the country, with an overwhelmingly urban and public sector bias to their distribution. Most doctors in the public sector were still in specialist training at the time of the study and may move to the private sector or leave the country. Black graduates, who were preferentially selected in this graduate cohort, constituted the majority of the doctors practising in rural areas. The study confirms the importance of selecting students with rural backgrounds to provide doctors for underserved areas. The study provides a baseline for future tracking studies to inform the training of doctors for underserved areas.

Individual Responsibilities in Partial Compliance: Skilled Health Worker Emigration from Under-Served Regions

One of the ways to address the effects of skilled worker emigration is to restrict the movement of skilled workers. However, even if skilled workers have responsibilities to assist their compatriots, what if other parties, such as affluent countries or source country governments, do not fulfil their fair share of responsibilities? This discussion raises an interesting problem about how to think of individual responsibilities under partial compliance where other agents (including affluent countries, developing states, or other individuals) do not fulfil their fair share of responsibilities. What is fair to expect from them? Taking health worker emigration as a case in point, I discuss whether the individual health workers’ fair share of responsibilities to address basic health care needs decreases or increases when the other parties do not fulfil their share. First, I review the responsibilities that different stakeholders may hold. Second, I argue that there are strong reasons against increasing or decreasing health workers’ fair share of responsibilities in a situation of partial compliance. I also argue that it is unfair for non-complier states to enforce health workers to fulfil their fair share or take up the slack.

Global Brain Drain: How Can the Maslow Theory of Motivation Improve Our Understanding of Physician Migration?

The migration of physicians from low-resource to high-resource settings is a prevalent global phenomenon that is insufficiently understood. Most low-income countries are severely understaffed with physicians, and the emigration of the already limited number of physicians to other countries can significantly reduce access to healthcare in the source country. Despite a growing interest in global capacity building in these countries by academic and non-governmental organizations in high-income countries, efforts to stem physician migration have been mostly unsuccessful. The authors reviewed the current literature for the motivational factors leading to physician migration in the context of Maslow’s hierarchy of human needs. Our study found that financial safety needs were major drivers of physician emigration. However, factors related to self-actualization such as the desire for professional development through training opportunities and research, were also major contributors. These findings highlight the multifactorial nature of physician motivations to emigrate from low-resource countries. Maslow’s Theory of Motivation may provide a useful framework for future studies evaluating the concerns of physicians in low-income countries and as a guide to incentivize retention.

What is the financial incentive to immigrate? An analysis of salary disparities between health workers working in the Caribbean and popular destination countries

BACKGROUND

The continuous migration of Human Resources for Health (HRH) compromises the quality of health services in the developing supplying countries. The ability to increase earnings potentially serves as a strong motivator for HRH to migrate abroad. This study adds to limited available literature on HRH salaries within the Caribbean region and establishes the wage gap between selected Caribbean and popular destination countries.

METHODS

Salaries are reported for registered nurses, medical doctors and specialists. Within these cadres, experience is incorporated at three different levels. Earnings are compared using purchasing power parity (PPP) exchange rates allowing for cost of living adjusted salary differentials, awarded to different levels of work experience for the chosen health cadres in the selected Caribbean countries (Jamaica, Dominica, St Lucia and Grenada) and the three destination countries (United States, United Kingdom and Canada).

RESULTS

Registered nurses in the destination countries, across all experience levels, have greater spending power compared to their Caribbean counterparts. Recently qualified registered nurses earn substantially more in the UK (86.4%), US (214.2%) and Canada (182.5% more). The highest PPP salary ($) gap amongst more experienced nurses (5-10 years) is found within the US, with a gap of 163.9%. PPP salary gaps amongst medical doctors were pronounced, with experienced cadres (10-20 years of experience) in the US earning 316.3% more than their Caribbean counterparts, whilst UK doctors (183.5%) and Canadian doctors (251.3%) also earning significantly more. Large salary differentials remained for medical specialists and consultants. US specialist salaries were 540.4% higher than their Caribbean based counterparts, whilst UK and Canadian specialists earned 95.2 and 181.6% more respectively.

CONCLUSION

The PPP adjusted HRH salaries in the three destination countries are superior to those of comparable HRH working in the Caribbean countries selected. The extent of the salary gaps vary according to country and the health cadre under examination, but remain considerable even for newly qualified HRH. The financial incentive to migrate for HRH trained and working in the Caribbean region remains strong, with governments having to consider earning potential abroad when formulating policies and strategies aimed at retaining health professionals.

Analysis of the association between millennium development goals 4 & 5 and the physician workforce across international economic strata

BACKGROUND

The Millennium Development Goals (MDGs) are 8 international development goals voluntarily adopted by 189 nations. The goals included health related aims to reduce the under-five child mortality rate by two-thirds (MDG4), and to reduce the maternal mortality ratio by three-quarters (MDG5). To assess the relationship between the healthcare workforce and MDGs 4-5, we examined the physician workforces of countries around the globe, in terms of the Physician Density Level (PDL, or number of physicians per 1000 population), and compared this rate across a number of years to several indicator variables specified as markers of progress towards MDG4 and MDG5.

METHODS

Data for each variable of interest were obtained from the World Bank's Millennium Development Goals and World Development Indicators databases for 208 countries and territories from 2004 to 2014, representing a ten-year period for which the most information is available. We analyzed the relationships between MDG outcomes and PDL, controlling for national income levels and other covariates, using linear mixed model regression. Dependent variables were logarithmically transformed to meet assumptions necessary for multivariate analysis.

RESULTS

In unadjusted models, an increase of every one physician per 1000 population (one unit change in PDL) lowered the risk of not being vaccinated for measles-mumps-rubella (MMR) to 29.3% (p < 0.001, 95% CI: 22.2%-38.7%) and for not receiving diphtheria-tetanus-pertussis (DTaP) vaccination rate decreased to 38.5% (p < 0.001, 95% CI: 28.7% - 51.7%). Maternal mortality rate decreased to 76.6% (p < 0.001, 95% CI: 74.3% - 79.0%), neonatal mortality decreased to 58.8% (p < 0.001, 95% CI: 54.8% - 63.2%) and under-5 mortality rate decreased to 52.1% (p < 0.001, 95% CI: 48.0% - 56.4%), with every one-unit change in PDL. Adjusted models tended to reflect unadjusted risk assessments.

CONCLUSION

The maintenance and improvement of the health workforce is a vital consideration when assessing how to achieve global development goals related to health outcomes.

Causes, consequences, and policy responses to the migration of health workers: key findings from India

BACKGROUND

This study sought to better understand the drivers of skilled health professional migration, its consequences, and the various strategies countries have employed to mitigate its negative impacts. The study was conducted in four countries-Jamaica, India, the Philippines, and South Africa-that have historically been "sources" of health workers migrating to other countries. The aim of this paper is to present the findings from the Indian portion of the study.

METHODS

Data were collected using surveys of Indian generalist and specialist physicians, nurses, midwives, dentists, pharmacists, dieticians, and other allied health therapists. We also conducted structured interviews with key stakeholders representing government ministries, professional associations, regional health authorities, health care facilities, and educational institutions. Quantitative data were analyzed using descriptive statistics and regression models. Qualitative data were analyzed thematically.

RESULTS

Shortages of health workers are evident in certain parts of India and in certain specialty areas, but the degree and nature of such shortages are difficult to determine due to the lack of evidence and health information. The relationship of such shortages to international migration is not clear. Policy responses to health worker migration are also similarly embedded in wider processes aimed at health workforce management, but overall, there is no clear policy agenda to manage health worker migration. Decision-makers in India present conflicting options about the need or desirability of curtailing migration.

CONCLUSIONS

Consequences of health work migration on the Indian health care system are not easily discernable from other compounding factors. Research suggests that shortages of skilled health workers in India must be examined in relation to domestic policies on training, recruitment, and retention rather than viewed as a direct consequence of the international migration of health workers.

A mixed-methods study of health worker migration from Jamaica

BACKGROUND

This study sought to better understand the drivers of migration, its consequences, and the various strategies countries have employed to mitigate its negative impacts. The study was conducted in four countries-Jamaica, India, the Philippines, and South Africa-that have historically been 'sources' of health workers migrating to other countries. The aim of this paper is to present the findings from the Jamaica portion of the study.

METHODS

Data were collected using surveys of Jamaica's generalist and specialist physicians, nurses, midwives, and dental auxiliaries, as well as structured interviews with key informants representing government ministries, professional associations, regional health authorities, healthcare facilities, and educational institutions. Quantitative data were analyzed using descriptive statistics and regression models. Qualitative data were analyzed thematically. Multiple stakeholder engagement workshops were held across Jamaica to share and validate the study findings and discuss implications for the country.

RESULTS

Migration of health workers from Jamaica continues to be prevalent. Its causes are numerous, long-standing, and systemic, and are largely based around differences in living and working conditions between Jamaica and 'destination' countries. There is minimal formal tracking of health worker migration from Jamaica, making scientific analysis of its consequences difficult. Although there is evidence of numerous national and international efforts to manage and mitigate the negative impacts of migration, there is little evidence of the implementation or effectiveness of such efforts. Potential additional strategies for better managing the migration of Jamaica's health workers include the use of information systems to formally monitor migration, updating the national cadre system for employment of health personnel, ensuring existing personnel management policies, such as bonding, are both clearly understood and equitably enforced, and providing greater formal and informal recognition of health personnel.

CONCLUSION

Although historically common, migration of Jamaica's health workers is poorly monitored and understood. Improved management of the migration of Jamaica's health workers requires collaboration from stakeholders across multiple sectors. Indeed, participating stakeholders identified a wide range of potential strategies to better manage migration of Jamaica's health workers, the implementation and testing of which will have potential benefits to Jamaica as well as other 'source' countries.

Giving Back: A mixed methods study of the contributions of US-Based Nigerian physicians to home country health systems

BACKGROUND

There is increased interest in the capacity of US immigrants to contribute to their homelands via entrepreneurship and philanthropy. However, there has been little research examining how immigrant physicians may support health systems and what factors facilitate or raise barriers to increased support.

METHODS

This study used an observational design with paper questionnaire and interview components. Our sample was drawn from attendees of a 2011 conference for US Based Nigerian physicians; respondents who were not US residents, physicians, and of Nigerian birth or parentage were excluded from further analysis. Respondents were randomly selected to complete a follow-up interview with separate scripts for those having made past financial contributions or medical service trips to support Nigerian healthcare (Group A) and those who had done neither (Group B). Survey results were analyzed using Fischer exact tests and interviews were coded in pairs using thematic content analysis.

RESULTS

Seventy-five of 156 (48 %) individuals who attended the conference met inclusion criteria and completed the survey, and 13 follow-up interviews were completed. In surveys, 65 % percent of respondents indicated a donation to an agency providing healthcare in Nigeria the previous year, 57 % indicated having gone on medical service trips in the prior 10 years and 45 % indicated it was "very likely" or "likely" that they would return to Nigeria to practice medicine. In interviews, respondents tended to favor gifts in kind and financial gifts as modes of contribution, with medical education facilities as the most popular target. Personal connections, often forged in medical school, tended to facilitate contributions. Individuals desiring to return permanently focused on their potential impact and worried about health system under-preparedness; those not desiring permanent return centered on how safety, financial security and health systems issues presented barriers.

CONCLUSIONS

This study demonstrates several mechanisms by which health systems may benefit from expatriate engagement. Greater identification of reliable local partners for diaspora, deeper collaboration with those partners and a focus on sustainable interventions might improve the quantity and impact of contributions. Ethnic medical associations have a unique role in organizing and facilitating diaspora response. Public-private partnerships may help diaspora negotiate the challenges of repatriation.

Health worker migration from South Africa: causes, consequences and policy responses

BACKGROUND

This paper arises from a four-country study that sought to better understand the drivers of skilled health worker migration, its consequences, and the strategies countries have employed to mitigate negative impacts. The four countries-Jamaica, India, the Philippines, and South Africa-have historically been "sources" of skilled health workers (SHWs) migrating to other countries. This paper presents the findings from South Africa.

METHODS

The study began with a scoping review of the literature on health worker migration from South Africa, followed by empirical data collected from skilled health workers and stakeholders. Surveys were conducted with physicians, nurses, pharmacists, and dentists. Interviews were conducted with key informants representing educators, regulators, national and local governments, private and public sector health facilities, recruitment agencies, and professional associations and councils. Survey data were analyzed using descriptive statistics and regression models. Interview data were analyzed thematically.

RESULTS

There has been an overall decrease in out-migration of skilled health workers from South Africa since the early 2000s largely attributed to a reduced need for foreign-trained skilled health workers in destination countries, limitations on recruitment, and tighter migration rules. Low levels of worker satisfaction persist, although the Occupation Specific Dispensation (OSD) policy (2007), which increased wages for health workers, has been described as critical in retaining South African nurses. Return migration was reportedly a common occurrence. The consequences attributed to SHW migration are mixed, but shortages appear to have declined. Most promising initiatives are those designed to reinforce the South African health system and undertaken within South Africa itself.

CONCLUSIONS

In the near past, South Africa's health worker shortages as a result of emigration were viewed as significant and harmful. Currently, domestic policies to improve health care and the health workforce including innovations such as new skilled health worker cadres and OSD policies appear to have served to decrease SHW shortages to some extent. Decreased global demand for health workers and indications that South African SHWs primarily use migratory routes for professional development suggest that health worker shortages as a result of permanent migration no longer pertains to South Africa.

A Case Against Taxes and Quotas on High-Skill Emigration

Skilled workers have a rising tendency to emigrate from developing countries, raising fears that their departure harms the poor. To mitigate such harm, researchers have proposed a variety of policies designed to tax or restrict high-skill migration. Those policies have been justified as Pigovian regulations to raise efficiency by internalizing externalities, and as non-Pigovian regulations grounded in equity or ethics. This paper challenges both sets of justifications, arguing that Pigovian regulations on skilled emigration are inefficient and non-Pigovian regulations are inequitable and unethical. It concludes by discussing a different class of policy intervention that, in contrast, has the potential to raise welfare.

The active recruitment of health workers: a defence

Many organisations in rich countries actively recruit health workers from poor countries. Critics object to this recruitment on the grounds that it has harmful consequences and that it encourages health workers to violate obligations to their compatriots. Against these critics, I argue that the active recruitment of health workers from low-income countries is morally permissible. The available evidence suggests that the emigration of health workers does not in general have harmful effects on health outcomes. In addition, health workers can immigrate to rich countries and also satisfy their obligations to their compatriots. It is consequently unjustified to blame or sanction organisations that actively recruit health workers.

Epilepsy in Cambodia-treatment aspects and policy implications: a population-based representative survey

INTRODUCTION

We tested two treatment strategies to determine: treatment (a) prognosis (seizure frequency, mortality, suicide, and complications), (b) safety and adherence of treatment, (c) self-reported satisfaction with treatment and self-reported productivity, and policy aspects (a) number of required tablets for universal treatment (NRT), (b) cost of management, (c) manpower-gap and requirements for scaling-up of epilepsy care.

METHODS

We performed a random-cluster survey (N = 16510) and identified 96 cases (≥1 year of age) in 24 villages. They were screened by using a validated instrument and diagnosed by the neurologists. International guidelines were used for defining and classifying epilepsy. All were given phenobarbital or valproate (cost-free) in two manners patient's door-steps (March 2009-March 2010, primary-treatment-period, PTP) and treatment through health-centers (March 2010-June 2011, treatment-continuation-period, TCP). The emphasis was to start on a minimum dosage and regime, without any polytherapy, according to the age of the recipients. No titration was done. Seizure-frequency was monthly and self-reported.

RESULTS

The number of seizures reduced from 12.6 (pre-treatment) to 1.2 (end of PTP), following which there was an increase to 3.4 (end of TCP). Between start of PTP and end of TCP, >60.0% became and remained seizure-free. During TCP, ∼26.0% went to health centers to collect their treatment. Complications reduced from 12.5% to 4.2% between start and end of PTP and increased to 17.2% between start and end of TCP. Adverse events reduced from 46.8% to 16.6% between start and end of PTP. Nearly 33 million phenobarbital 100 mg tablets are needed in Cambodia.

CONCLUSIONS

Epilepsy responded sufficiently well to the conventional treatment, even when taken at a minimal dosage and a simple daily regimen, without any polytherapy. This is yet another confirmation that it is possible to substantially reduce direct burden of epilepsy through means that are currently available to us.

Why restrictions on the immigration of health workers are unjust

Some bioethicists and political philosophers argue that rich states should restrict the immigration of health workers from poor countries in order to prevent harm to people in these countries. In this essay, I argue that restrictions on the immigration of health workers are unjust, even if this immigration results in bad health outcomes for people in poor countries. I contend that negative duties to refrain from interfering with the occupational liberties of health workers outweighs rich states' positive duties to prevent harm to people in sending countries. Furthermore, I defend this claim against the objection that health workers in poor countries acquire special duties to their compatriots that render them liable to coercive interference.