Abstract
Background
Uganda has severe shortage of human resources for health despite the heavy disease burden. The country has one of the highest fertility, and population growth rates in the world and is in dire need of trained health workers. The current doctor: patient ratio of 1:15000 is inadequate and this is further constrained by trained health workers leaving the country while others abandon the health sector. The aim of the study was to determine the career intentions of the final year medical students to leave the county and health field after graduating and the associated factors.
Methods
We conducted a cross-sectional study among 251 final year medical students from Makerere, Mbarara, Gulu and Kampala International Universities. We enrolled all the eligible final year medical students. The study was conducted using face-to-face questionnaires in each university. We determined the demographics, reasons for leaving the country and health sector and the intended destinations of medical students who planned to leave the country. Data was entered in Epidata then exported and analyzed in stata 12.
Results
Of the 251 students enrolled in the study, 28(11.2 %) wanted to leave the health sector, with Mbarara University of Science and Technology (MUST) having the highest percentage, 16.7 % and Kampala International University (KIU) the least, 7.7 %. Of the 28 who intended to leave the health sector, 82.1 % wanted to join the business sector, 10.7 % agriculture, and 7.1 % politics. Reasons given for the intent to leave were; lack of equipment and supplies in hospitals, over whelming patient numbers, very risky working environment, low payment to doctors, and political reasons. Overall, 112 (44.6 %) of the participants wanted to leave the country with 30.3 % intending to migrate to United States of America (USA), 11.9 % to United Kingdom (UK), 11.0 % to South Africa among others. Some of the reasons given were; doctors are paid a high salary abroad, safe working environment, and desire to continue academics. Age was associated with intention to leave the country (OR = 1.64; 95 % CI: 1.00 – 4.82).
Conclusions
In a country in dire need of health workers, the study showed high proportion of trainee health workers planning to abandon their professions or emigrate from Uganda after training.
Keywords: Brain-drain, Doctors, Uganda
Background
There is a critical shortage of health workforce in Africa especially in the sub-Saharan region [1–4], estimated at 817,992 [3, 5]. While Africa accounts for more than 24 % of the global disease burden, it has only 3 % of the world’s health workers and spends less than one percent of total global resources dedicated to health. This shortage is worsened by the emigration of doctors [6]. The magnitude of brain drain in Africa has been increasing alarmingly in the past decades [6, 7]. Emigration is likely to lead to deterioration in the working conditions of the doctors who stay behind as it increases the workload for the remaining health workers, compromising access to and quality of health care to the population, and impairs the ability of the health care system to achieve the desired population health objectives [8]. For efficient and effective operation, the health sector requires skilled and competent personnel and as such the emigration of doctors affects the overall effectiveness of the health sector [9, 10]. The doctor: patient ratio in Uganda is 1:15000 [11, 12], which implies that most of the general population may not easily access the much needed basic health care.
Between 2005 and 2011, at least 210 doctors emigrated from Uganda of whom 67.6 % left for work elsewhere, and the others for further studies. Of the 210 doctors who emigrated, 29.0 % left for another African country and the rest for overseas destinations [13]. Several reasons have been advanced as the leading causes for the emigration of doctors. These include “push” and “pull” factors [14]. Identified “push” factors included lack of or poor post-graduate training opportunities, poor working conditions, civil unrest and personal security [15–18]. The “pull” factors include international opportunities for career advancement, greater financial rewards and better working conditions [8, 17, 18]. The sending country incurs two forms of losses; the resources spent in educating the doctor, and the lost value of health care services the doctor would have rendered [2, 8, 19]. It is estimated that the total cost of educating a doctor in an African setting from primary school to graduation from university is about US $66,000 [19, 20] and for every doctor that emigrates, the country loses an equivalent of approximately US $1,900,000 [21].
Uganda has a large and growing population, a huge disease burden and very limited resources including well-trained health workers. In 2006, the Global Health workforce alliance was formed to identify, implement and advocate solutions to the crisis. In 2010, the World Health Organization (WHO) generated a global Code of Practice with the aim of finding solutions to international migration of health professionals. All these strategies were generated without putting into consideration the students’ career inclinations. The migration is still occurring [4]. There is thus need to understand the extent of and reasons for intentions to migrate, and the likely destinations of the future doctors in Uganda if the above strategies are to be successfully implemented. Previous studies have mainly centered on high income countries, and those carried out in low resource environments have focused on graduates and practicing doctors. There is no reliable information with regards to students’ career intentions in low resource environments. Thus our major aim was to explore: 1.) How many students intended to leave the health sector, 2.) How many students intended to migrate after graduation, 3.) what were the destinations for the students that leave the country and 4.) What factors were associated with students’ leaving the country and health sector after graduating.
Methods
Study design and setting
This was a cross-sectional study of Ugandan undergraduate medical students in their fifth and final year of studies at the four medical universities in Uganda; Makerere University College of Health Sciences (MakCHS), Mbarara University (MUST), Gulu University and Kampala International University (KIU). The study enrolled 251 participants and all of these completely answered the semi-structured questionnaires that were used to collect the data. The tool was pretested on 11 non-final year medical students. They were distributed to the students who accepted to participate in the study and provided written informed consent. They were requested to complete them at their convenience. In each of the universities, there was a focal point person who coordinated the process of data collection.
Study variables
Data collected included background information like sex, age, marital status, family income, and academic performance assessed using the Cumulative Grade Progress Average (CGPA).
The questionnaire also ascertained for students intention to work in health sector or otherwise. It was adapted from a previous study among nursing students in Uganda [22]. Students were asked: what factors could influence you to leave the health sector? And the possible responses included: poor working conditions, inadequate supply of equipment, patient overload, low salaries, lack of mentorship, the respect that doctors command and others, specify.
To determine the factors likely to influence the students’ intention to work or leave the country, we asked the students: what factors could encourage you to work abroad? The answering responses were; salary, social/family support, good working conditions, political stability, and better academic opportunities abroad. Special attention was given to factors that encourage students to stay and practice from Uganda; the students who intended to stay were asked: what factors could encourage them to stay and work in Uganda: the answering possibilities were; racism abroad, high cost of living, long emigration process and lack of family and social support abroad, specify others.
Ethics of the study
Approval to conduct the study was obtained from the Makerere University College of Health Sciences, School of Medicine Research and Ethics Committee. Written informed consent was provided by each of the participants before they were enrolled into the study.
Data management and analysis
The data were entered in Epidata Version 3.1, checked, and frozen. It was then exported to stata version 12 for analysis. Data was adjusted for clustering at the level of university. Demographic data was presented as means and percentages. Comparisons were made between students who intended to leave the country and those who intended to stay. For the categorical variables, comparisons were made using chi-squares or Fisher’s exact test while for the continuous data, student t test was used for the parametric data and the Mann Whitney U test for the non-parametric data. The outcome was dichotomized into staying or leaving the country, and staying or leaving the health sectors. Logistic regression models were then run to assess factors associated with leaving the country, and the health sector respectively. Factors that were entered in the multivariate model were based on p value less than 0.2 or less at bivariate analysis previous literature as well as factors shown to significantly influence migration and career choice according to previous literature. Confounding factors were assessed at a 10 % difference between the odds ratios for the unadjusted and adjusted models. The goodness of fit of the final model was assessed using the Hosmer and Lemeshow statistic.
Results
Demographics
Of the 251 students Makerere university provided the largest number (99/251 (39.4 %)) while KIU provided the least, 39 (15.5 %). As shown in Table 1, most of the students (91.2 %) were single, mean age was 25.9 years (SD 0.6). Overall, 87.9 % of the students perceived their socio-economic status as being in the middle class.
Table 1.
Demographic characteristics of 251 final year medical students in Uganda’s universities, 2012–13
| Variable | Categories | N (251) | Percentage |
|---|---|---|---|
| Institution: | MakCHS* | 99 | 39.4 % |
| MUST** | 54 | 21.5 % | |
| Gulu | 59 | 23.5 % | |
| KIU*** | 39 | 15.5 % | |
| Sex | females | 66 | 26.3 % |
| males | 185 | 73.7 % | |
| Marital status | Single | 229 | 91.2 % |
| Married | 20 | 8.0 % | |
| Divorced | 1 | 0.4 % | |
| Widowed | 1 | 0.4 % | |
| Perceived Socio-Economic Status | Poor | 22 | 8.8 % |
| Low-middle class | 135 | 54.2 % | |
| Upper middle class | 84 | 33.7 % | |
| Upper class | 8 | 3.2 % |
*Makerere University College of Health sciences
**Mbarara University of Science and Technology
***Kampala International University
Close to three quarters of the study participants were males (185/251 (73.7 %)). MakCHS had 31.3 % females, MUST 29.6 % females, Gulu 27.1 % females though KIU had only 7.7 % females.
Intention to leave the health sector
Overall 28/251, 11.2 % (7.13 – 16.3) of the students had the intention of leaving the health sector, with MUST having the highest percentage (16.7 %), and KIU having the least (7.7 %) while 9 (16.7 %) and 8 (13.6 %) were from MUST and Gulu respectively. Details are highlighted in Table 2.
Table 2.
Final year medical students intending to leave Uganda after graduating, 2012–13 (n = 251)
| Variable | Categories | Number intending to leave (n = 112) | Percentage |
|---|---|---|---|
| University | MakCHS* | 40/99 | 40.4 |
| MUST** | 26/54 | 48.1 | |
| Gulu | 25/59 | 42.4 | |
| KIU*** | 21/39 | 53.8 | |
| Reason for leaving**** | High salary abroad | 84/112 | 75.0 |
| Good work conditions | 60/112 | 53.6 | |
| Political stability | 41/112 | 36.6 | |
| Go for further studies | 65/112 | 58.0 | |
| Factors for staying**** | Factors that limit going | ||
| Racism abroad | 38/139 | 27.3 | |
| High cost of limiting abroad | 46/139 | 33.1 | |
| Long emigration process | 50/139 | 36.0 | |
| Lack of family support | 41/139 | 29.5 | |
| Factors that encourage staying | |||
| Reward for government scholarship | 58/139 | 41.7 | |
| Satisfied with working conditions | 17/139 | 12.2 |
*Makerere University College of Health sciences
**Mbarara University of Science and Technology
***Kampala International University
****some students gave more than one reason
Of those students that intended to leave the health sector, 23/28 (82.1 %) wanted to join business, 3 (10.7 %) agriculture, and 2(7.1 %) politics.
Reasons given by the students for intention to leave the health sector included; lack of equipment and supplies in hospitals, overwhelming patient numbers, very risky working environment, low payment to doctors, and political reasons.
As highlighted in Table 3, at multivariate analysis, factors that were associated with leaving the health included: CGPA (OR = 0.30; 95 % CI: 0.10 – 0.88), having the intention to leave the country (OR = 3.22; 95 % CI: 1.15 – 9.06) being of lower middle and upper-middle socio-economic status respectively compared to lower class (OR = 0.15; 95 % CI: 0.04 – 0.67 and OR = 0.21; 95 % CI: 0.05 – 0.94) respectively.
Table 3.
Factors associated with medical students’ intention to leave the health sector in Uganda after graduation, 2013. (n = 255)
| Bivariate analysis | Multivariate analysis | ||||
|---|---|---|---|---|---|
| Variable | Categories | OR (95 % CI) | P value | OR (95 % CI) | P value |
| Institution | MakCHS* | 1 | 1 | ||
| MUST** | 1.82 (0.69 – 4.80) | 0.226 | 1.09 (0.37 – 3.20) | 0.874 | |
| Gulu | 1.61 (0.61 – 4.21) | 0.335 | |||
| KIU*** | 0.76 (0.20 – 2.92) | 0.987 | 0.41 (0.03 – 6.06) | 0.520 | |
| Age | 0.96 (0.86 – 1.08) | 0.516 | |||
| Sex | Female | 1 | 1 | ||
| Male | 1.01 (0.43 – 2.38) | 0.981 | 0.89 (0.30 – 2.66) | 0.833 | |
| Marital status | Single | 1 | 1 | ||
| Married | 0.60 (0.19 – 1.92) | 0.393 | 0.50 (0.11 – 2.33) | 0.379 | |
| Perceived social status | Lower class | 1 | 1 | ||
| Lower middle | 0.33 (0.10 – 1.06) | 0.062 | 0.15 (0.04 – 0.67) | 0.012 | |
| Upper middle | 0.36 (0.11 – 1.25) | 0.108 | 0.21 (0.05 – 0.94) | 0.041 | |
| Upper class | 3.40 (0.62 – 18.75) | 0.160 | 2.38 (0.36 – 15.6) | 0.365 | |
| CGPA**** | 0.78 (0.35– 1.74) | 0.543 | 0.30 (0.10 – 0.88) | 0.029 | |
| Want to leave country | 2.95 (1.28 – 6.81) | 0.011 | 3.22 (1.15 – 9.06) | 0.026 | |
*Makerere University College of Health sciences
**Mbarara University of Science and Technology
***Kampala International University
****Cumulative Grade Progress Average
Intention to leave the country after graduation
Overall, 112/251, 44.6 % (38.7 – 61.3) of the students had the intention of leaving the country after graduation. Among females 38/66 (57.6 %) intended to stay in Uganda after graduating compared to 101/185(54.6 %) of the males. KIU which has a high proportion of foreign students had the highest percentage of students intending to leave the country, 21/39(53.8 %) while MakCHS had the least, 40/99 (40.4 %), as shown in Table 3. Major factors that stood out as reasons for the intention to emigrate after graduation included; doctors being paid a higher salary abroad, 84/112(75.0 %), safe/good working environment, 60/112(53.6 %), and desire to continue with academics 65/112 (58.0 %). Of the students who had the intention to leave the country, close to one third (36/118 (30.3 %)) mentioned USA as their intended destination, 14 (11.9 %) UK, 13 (11.0 %) South Africa, followed by Canada and Rwanda with 7(5.9 %) each and 22.0 % did not specifying their intended country of destination (Table. 2). Other countries that were mentioned as destination countries were: Australia, France, Germany, Kenya, Sudan, Botswana, Brazil and Israel. Some students had more than one country as the intended destination.
The reasons given by the students who opted to stay in the country included; family and social ties or influence in Uganda, paying back to the government for sponsoring the student’s education, lack of easy means of living the country, and 17 students were opting to stay and work in Uganda because they were satisfied with the working conditions in Uganda.
A comparison showed that those who intended to stay in the country include significantly more people who want to stay in health field work (130/143, 93.5 %) than do those that intended to leave (93/112, 82.3 %) , chi-square = 6.886, p value 0.017. there were no significant differences between these groups in other characteristic variables mentioned in Table 3.
At multivariate analysis, the only factor significantly associated with leaving the country was age (OR = 1.64; 95 % CI: 1.00 – 4.82). Details are shown in Table 4.
Table 4.
Factors associated with medical students’ intention to leave Uganda after graduation, 2013. ( n = 255)
| Bivariate analysis | Multivariate analysis | ||||
|---|---|---|---|---|---|
| Variable | Categories | OR (95 % CI) | P value | OR (95 % CI) | P value |
| Age | 1.01 (0.98 – 1.03) | 0.623 | 1.64 (1.00 – 4.82) | 0.050 | |
| Sex | Female | 1 | 1 | ||
| Male | 1.14 (0.65 – 2.01) | 0.646 | 0.05 (0.001 -1.59) | 0.087 | |
| CGPA**** | 0.98 (0.89 – 1.07) | 0.626 | |||
| Perceived social status | Lower class | 1 | 1 | ||
| Lower middle | 0.40 (0.16 – 1.01) | 0.053 | 0.02 (0.001 -15.0) | 0.235 | |
| Upper middle | 0.45 (0.17 – 1.18) | 0.105 | 0.03 (0.001 – 4.88) | 0.175 | |
| Upper class | 0.95 (0.73 – 4.17) | 0.957 | |||
| Not satisfied with work conditions | 1.20 (0.55 – 2.62) | 0.640 | 33.6 (0.5 – 2313.6) | 0.104 | |
| Said hospital supplies inadequate | 1.13 (0.59 – 2.17) | 0.704 | 0.92 (0.04 – 19.91) | 0.958 | |
| Said patient load is high | 1.07 (0.60 – 1.89) | 0.830 | 0.1 (0.01 – 2.57) | 0.108 | |
| Said payment is low | 1.44 (0.37 – 5.53) | 0.591 | |||
| Institution affiliation | MakCHS* | 1 | 1 | ||
| MUST** | 1.34 (0.69 – 2.60) | 0.394 | 1.73 (0.07 – 44.73) | 0.740 | |
| Gulu | 1.06 (0.55 – 2.03) | 0.865 | |||
| KIU*** | 1.68 (0.80 – 3.54) | 0.173 | 0.04 (0.003-4.90) | 0.190 | |
| Intends to leave health sector | 2.95 (1.28 – 6.81) | 0.011 | |||
*Makerere University College of Health sciences
**Mbarara University of Science and Technology
***Kampala International University
****Cumulative Grade Progress Average
Discussion
It is gratifying that there are still some students who intend to stay and work in the country. However it is a source of concern that close to one half of the final year medical students trained in Uganda have intentions of leaving the country after graduating. These figures are higher than those reported in other developing countries [23, 24]. The relatively high percentages in KIU could probably be due to the influence from the high number of international students at the university towards the local students. Makerere University has a different curriculum compared to the other medical schools and its students participate in community based education for more than a month during each of the 5 years of medical training. This might contribute to enhancing students’ appreciation of the health needs of the community, and probably instills a spirit of wanting to stay and serve the country [25]. In the rest of the medical universities, the Community Based Education and Services (COBES) program runs for about a month during the entire 5 years of training. Studies have suggested earlier that students who have received substantial training based in rural areas have high chances of being retained and work in the country and that this likelihood correlates with the time of training spent in rural areas [4, 25].
Close to one third of all the students intending to leave the country, had USA as the intended destination, followed by UK. Both are stable developed countries, have advanced medical technology, and much greater availability of resources than Uganda. Only very few students had another African country or a developing country as their destination. This may be due to the fact that these countries share similar problems with Uganda and therefore students consider them less attractive destinations.
The reasons for the students’ decision to leave the health sector or the country were not much different from those found in previous studies [15, 26–28]. According to a WHO report the shortage of the global health workforce was attributed to insufficient recruitment and retention, poor working conditions and inadequate remuneration [29]. By 2009, although the cost of living in Uganda had more than tripled, the salary scales had remained stagnant for more than two decades [30]. Compared to the neighboring East African countries, Ugandan doctors receive the lowest salary [31, 32].
Only 12.23 % were intending to stay because they were satisfied with working condition. These numbers are smaller than those demonstrated in previous studies [33]. Students who wanted to leave the country were more than three times likely to leave the health sector and students of lower socio economic status were more likely to leave the health sector. Other major factors for leaving were the good and safe working conditions abroad and this is also consistent with the earlier studies [8, 10, 17, 18, 27–29]. More than ten percent of the students intended to leave the health sector, and not surprisingly the majority of them intended to join business. This internal brain drain has been demonstrated in other studies [1, 32]. This may in part indicate that the payments that the doctors are receiving are not satisfactory [32] and not motivating the future generation. Whereas medical universities have a role to play in influencing students’ attitudes about working in their home country there are many other extraneous factors that influence the trainees’ decisions [2].
Conclusions
The study has shown the high intention of trainee health workers to abandon the profession and to leave the country after training. Not so many of their final year medical students intend to work in the Ugandan health care. Salaries seem to be an important factor in influencing the decision to leave. As a result of the major limitations in this study, bigger studies are recommended.
Limitations
The study had a small number of participants therefore the possibility of a type 2 error cannot be ruled out. Additionally the study looks at the intentions, which may not necessarily translate into actions.
Acknowledgements
We are so grateful to the students for participating in the study. The project described was supported by the MESAU-MEPI Programmatic Award through Award Number 1R24TW008886 from the Fogarty International Center. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Fogarty International Center or the National Institutes of Health. We are grateful to Makerere University College of health sciences for the administrative support
Abbreviations
- COBES
Community based education and services
- FGD
Focus group discussion
- HIV
Human immunodeficiency virus
- KIU
Kampala International University
- MakCHS
Makerere University College of Health Sciences
- MDGs
Millennium development goals
- MUST
Mbarara University of Science and Technology
- TB
Tuberculosis
- UK
United Kingdom
- USA
United States of America
Footnotes
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
SK conceived and designed the study, collected data, did part of data analysis, drafted and reviewed the manuscript. DM collected data, and drafted and critically reviewed the manuscript, AN collected data, was involved in drafting the manuscript and reviewed the manuscript. JN was involved in collecting data, drafting the manuscript and reviewing the final manuscript. AK was responsible for data analysis, critically reviewing and adding intellectual content to come up with the final manuscript. RK was involved in conceiving, designing the study, drafting and revising the manuscript. Critically analyzed the final manuscript. NS was involved in conceiving and designing the study, he added substantial intellectual content to the study, and extensively reviewed of the manuscript. All authors read and approved the final manuscript.
Contributor Information
Samuel Kizito, Email: somekizito@yahoo.com, Email: mskizito@chs.mak.ac.ug.
David Mukunya, Email: zebdaevid@gmail.com.
Joyce Nakitende, Email: jnakitende20@gmail.com.
Stella Nambasa, Email: desire.stella@gmail.com.
Adrian Nampogo, Email: rionam@gmail.com.
Robert Kalyesubula, Email: rkalyes@yahoo.com.
Achilles Katamba, Email: akatamba@yahoo.com.
Nelson Sewankambo, Email: sewankam@infocom.co.ug.
References
- 1.Lassey AT, Lassey PD, Boamah M. Career destinations of University of Ghana Medical School graduates of various year groups. Ghana Med J. 2013;47(2):87–91. [PMC free article] [PubMed] [Google Scholar]
- 2.Kollar E, Buyx A. Ethics and policy of medical brain drain: a review. Swiss Med Wkly. 2013;143:w13845. doi: 10.4414/smw.2013.13845. [DOI] [PubMed] [Google Scholar]
- 3.Saraladevi N JPRTJE: Shortage Of Health Care Workers in Developing Countries-Africa. Ethinicity and Disease spring 2009, Volume 9.
- 4.Silvestri DM, Meridith B, Afzal AR, Ben A, et al. Medical and nursing students’ intentions to work abroad or in rural areas: a cross-sectional survey in Asia and Africa. Bull World Health Organ. 2014;92:750–9. doi: 10.2471/BLT.14.136051. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Lincolln Chen DE, Tim Evans, Ritu Sadana, Barbara Stilwell, Phyllida Travis, Wim Van Lerberghe, Pascal Zurn: Working Together For Health. In., WHO edn. Geneva Switzerland. 2006;41–150.
- 6.Muula AS. Nationality and country of training of medical doctors in Malawi. Afr Health Sci. 2006;6(2):118–9. doi: 10.5555/afhs.2006.6.2.118. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.So I. The health workforce crisis: the brain drain scourge. Niger J Med July. 2007;16(3):7. [PubMed] [Google Scholar]
- 8.Melanie B: Impact, Regulation, and Health Policy Implication of Physician Migration in OCED Countries. HRH 2004, 2. [DOI] [PMC free article] [PubMed]
- 9.Dovlo D: of The Graduates of The University of Ghana Medical School. A Preliminary Rapid Appraisal. HRH Developement journal 1999, 3.
- 10.Awases M GA, Nyoni J, Chatora R: Migration of Health Professionals in Six Countries: A Synthesis Report. In. Brazaville; 2004, 19–65
- 11.Gupta N, NS K, Kumar Panda A, Anand R, Mishra A. Myotonic dystrophy: an anaesthetic dilemma. Indian J Anaesth. 2009;53(6):688–91. [PMC free article] [PubMed] [Google Scholar]
- 12.Kinfu YPM, Mercer H, Evans DB. The health worker shortage in Africa: are enough physicians and nurses being trained? World Health Organisation. 2009;87:225–30. doi: 10.2471/BLT.08.051599. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Sentongo K: Cerificate of Good Standing In. Uganda Ministry of Health; 2011.
- 14.Eastwood Loss of health professionals from Sub-Saharan Africa. The pivotal role of Uganda. The Lancet. 2005;365:7. doi: 10.1016/S0140-6736(05)66623-8. [DOI] [PubMed] [Google Scholar]
- 15.Okeke EN. Brain drain: Do economic conditions “push” doctors out of developing countries? Soc Sci Med. 2013;98:169–78. doi: 10.1016/j.socscimed.2013.09.010. [DOI] [PubMed] [Google Scholar]
- 16.Likupe G. The skills and brain drain what nurses say. J Clin Nurs. 2013;22(9–10):1372–81. doi: 10.1111/j.1365-2702.2012.04242.x. [DOI] [PubMed] [Google Scholar]
- 17.Julia W. Addressing the migration of health professionals: the role of working conditions and education placements. BMC Public Health. 2009;9:7. doi: 10.1186/1471-2458-9-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.VC Burch DM, J van Wyk, S Kiguli-Walube, D Cameron, FJ Cilliers, AO Longombe, C Mkony CO, B Otieno-Nyunya, PS Morahan: Career Intentions of Medical Students Trained In Six Sub-Saharan African Countries. Education for Health 2011 December, 24(3). [PubMed]
- 19.Kirigia JM, Gbary AR, Muthuri LK, Nyoni J, Seddoh A. The cost of health professionals’ brain drain in Kenya. BMC Health Serv Res. 2006;6:89. doi: 10.1186/1472-6963-6-89. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Joses Muthuri Kirigia ARG, Lenity Kainyu Muthuri, Seddoh JNA: The cost of health professionals’ brain drain in Kenya. BMC Health Serv Res 2006, 6(89). [DOI] [PMC free article] [PubMed]
- 21.Joses M, Kirigia Akpa R, Gbary JN, Anthony S, Muthuri LK. The cost of health-related brain drain to the WHO African Region. Afr J Health Sci. 2006;13:1–13. [Google Scholar]
- 22.Lisa Nguyen SR, Esther Nderitu, Anneke Zuyderduin, Sam Luboga, Amy Hagopian: Intent to migrate among nursing students in Uganda: Measures of the brain drain in the next generation of health professionals. BioMedCentral 2008. [DOI] [PMC free article] [PubMed]
- 23.Mandeville KL, Ulaya G, Lagarde M, Gwesele L, Dzowela T, Hanson K, et al. Early career retention of Malawian medical graduates: a retrospective cohort study. TM & IH. 2015;20(1):106–14. doi: 10.1111/tmi.12408. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Gow J, George G, Mwamba S, Ingombe L, Mutinta G. An evaluation of the effectiveness of the Zambian Health Worker Retention Scheme (ZHWRS) for rural areas. Afr Health Sci. 2013;13(3):800–7. doi: 10.4314/ahs.v13i3.40. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Ebuehi OM, Campbell PC. Attraction and retention of qualified health workers to rural areas in Nigeria: a case study of four LGAs in Ogun State, Nigeria. Rural Remote Health. 2011;11(1):1515. [PubMed] [Google Scholar]
- 26.Sherr K, Mussa A, Chilundo B, Gimbel S, Pfeiffer J, Hagopian A, et al. Brain drain and health workforce distortions in Mozambique. PLoS One. 2012;7(4):e35840. doi: 10.1371/journal.pone.0035840. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Poppe A, Jirovsky E, Blacklock C, Laxmikanth P, Moosa S, De Maeseneer J, et al. Why sub-Saharan African health workers migrate to European countries that do not actively recruit: a qualitative study post-migration. Glob Health Action. 2014;7:24071. doi: 10.3402/gha.v7.24071. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Bidwell P, Laxmikanth P, Blacklock C, Hayward G, Willcox M, Peersman W, et al. Security and skills: the two key issues in health worker migration. Global health action. 2014;7:24194. doi: 10.3402/gha.v7.24194. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Global Health Workforce Alliance: Why are health workers migrating? In.; 2009.
- 30.Mulondo M. The new vision. Kampala: The New Vision Printing and Publishing Co; 2009. Uganda working on living wage policy. [Google Scholar]
- 31.Hagopian A, Zuyderduin A, Kyobutungi N, Yumkella F. Job satisfaction and morale in the Ugandan health workforce. Health Aff. 2009;28(5):w863–75. doi: 10.1377/hlthaff.28.5.w863. [DOI] [PubMed] [Google Scholar]
- 32.Ayebazibwe A. Saturday monitor. Kampala, Uganda: daily monitor; 2013. 2,000 doctors leave country in 10 years. [Google Scholar]
- 33.Luboga S, Hagopian A, Ndiku J, Bancroft E, McQuide P. Satisfaction, motivation, and intent to stay among Ugandan physicians: a survey from 18 national hospitals. Int J Health Plann Manage. 2011;26(1):2–17. doi: 10.1002/hpm.1036. [DOI] [PubMed] [Google Scholar]