Monitoring Sub-Saharan African Physician Migration and Recruitment Post-Adoption of the WHO

18 Pages·2015·3.4 MB·English

RESEARCHARTICLE
Monitoring Sub-Saharan African Physician
Migration and Recruitment Post-Adoption of
the WHO Code of Practice: Temporal and
Geographic Patterns in the United States
AkhenatenBenjaminSiankamTankwanchi1¤*,StenH.Vermund2,DouglasD.Perkins1
1 PrograminCommunityResearchandAction,DepartmentofHumanandOrganizationalDevelopment,
PeabodyCollegeofEducationandHumanDevelopment,VanderbiltUniversity,Nashville,Tennessee,
UnitedStatesofAmerica,2 VanderbiltInstituteforGlobalHealthandDepartmentofPediatrics,Vanderbilt
UniversitySchoolofMedicine,Nashville,Tennessee,UnitedStatesofAmerica
¤ Currentaddress:Washington,DistrictofColumbia,UnitedStatesofAmerica
* [email protected]
OPENACCESS Abstract
Citation:TankwanchiABS,VermundSH,PerkinsDD
(2015)MonitoringSub-SaharanAfricanPhysician DatamonitoringisakeyrecommendationoftheWHOGlobalCodeofPracticeontheInter-
MigrationandRecruitmentPost-AdoptionoftheWHO nationalRecruitmentofHealthPersonnel,aglobalframeworkadoptedinMay2010toad-
CodeofPractice:TemporalandGeographicPatterns
dresshealthworkforceretentioninresource-limitedcountriesandtheethicsofinternational
intheUnitedStates.PLoSONE10(4):e0124734.
migration.UsingdataonAfrican-bornandAfrican-educatedphysiciansinthe2013Ameri-
doi:10.1371/journal.pone.0124734
canMedicalAssociationPhysicianMasterfile(AMAMasterfile),wemonitoredSub-Saharan
AcademicEditor:StephaneHelleringer,Johns
African(SSA)physicianrecruitmentintothephysicianworkforceoftheUnitedStates(US)
HopkinsUniversity,UNITEDSTATES
post-adoptionoftheWHOCodeofPractice.Fromtheobserveddata,weprojectedto2015
Received:October1,2014
withlinearregression,andwemappedmigrantphysicians’locationsusingGPSVisualizer
Accepted:March3,2015
andArcGIS.The2013AMAMasterfileidentified11,787activeSSA-originphysicians,rep-
Published:April13,2015 resentingbarely1.3%(11,787/940,456)ofthe2013USphysicianworkforce,butexceeding
Copyright:©2015Tankwanchietal.Thisisanopen thetotalnumberofphysiciansreportedbyWHOin34SSAcountries(N=11,519).Weesti-
accessarticledistributedunderthetermsofthe matedthat15.7%(1,849/11,787)enteredtheUSphysicianworkforceaftertheCodeof
CreativeCommonsAttributionLicense,whichpermits
Practicewasadopted.Comparedtopre-Codeestimatesfrom2002(N=7,830)and2010
unrestricteduse,distribution,andreproductioninany
(N=9,938),theannualadmissionrateofSSAémigrésintotheUSphysicianworkforceis
medium,providedtheoriginalauthorandsourceare
credited. increasing.ThisincreaseisdueinlargeparttothegrowingnumberofSSA-bornphysicians
attendingmedicalschoolsoutsideSSA,representingatrendtowardsyoungermigrants.
DataAvailabilityStatement:Theauthorsdonot
owntherawdataunderlyingthestudy.AMA Projectionestimatessuggestthattherewillbe12,846SSAmigrantphysiciansintheUS
MasterfiledataarecollectedbytheAmericanMedical physicianworkforcein2015,andover2,900ofthemwillbepost-Coderecruits.MostSSA
Associationandarelicensedtothirdparties.The
migrantphysiciansarelocatingtolargeurbanUSareaswherephysiciandensitiesareal-
dataareavailablefromalegitimateAMAMasterfile
readythehighest.TheCodeofPracticehasnotslowedtheSSA-to-USphysicianmigration.
licensee.Theauthorsobtainedthedatafromhttp://
www.redidata.com/,theinteractivemedicaldatabase Tostemthephysician“braindrain”,itisessentialtoincentivizeprofessionalpracticeinSSA
systemofRedi-MailDirectMarketing. anddiminishtheappealofUSmigrationwithbolderinterventionstargetingprimarilyearly-
Funding:Thisworkwassupportedbygrant career(age(cid:1)35)SSAphysicians.
R24TW007988toSHVfromtheFogartyInternational
Center[http://www.fic.nih.gov/Pages/Default.aspx].
Thefundershadnoroleinstudydesign,data
PLOSONE|DOI:10.1371/journal.pone.0124734 April13,2015 1/18
AfricanPhysicianMigrationtoUSAPost-WHOCode
collectionandanalysis,decisiontopublish,or Introduction
preparationofthemanuscript.
Universalhealthcoverage,aprioritygoalfortheWorldHealthOrganization(WHO),cannot
CompetingInterests:SHVisasection/academic beachievedwithout“anadequate,skilled,andmotivatedhealthworkforceworkingwithina
editorforPLOSONE,andaco-principalinvestigator robusthealthsystem”[1–2].IntheWHOAfricaregion,mostofwhichcomprisesInternational
oftheUniversityofZambiaMedicalEducation
MonetaryFund-designated“heavilyindebtedpoorcountries”[3],thehealthworkercrisishas
PartnershipInitiativefundedbytheNationalInstitutes
ofHealthandTheUnitedStates'President beencompoundedbythepersistentmigrationofskilledhealthprofessionalstohigh-income
EmergencyPlanforAidsRelief.Thisdoesnotalter nations[4–9].Theunprecedentedlevelsofinternationalmigrationofhealthworkersinthe
theauthors'adherencetoPLOSONEpolicieson pastfewdecadespromptedtheunanimousadoption,onMay212010,oftheWHOGlobal
sharingdataandmaterials.
CodeofPracticeontheInternationalRecruitmentofHealthPersonnelbyall193WHOmem-
berstatesconveningtheSixty-thirdWorldHealthAssembly[10].Designedasamultilateral
frameworktomitigatehealthpersonnelmigrationanditsnegativeeffectsonhealthsystems
[11–12],theWHOCodeofPractice(CoP)purportstodefineethicalstandardsfortherecruit-
mentofmigranthealthworkers“inamannerthatstrengthensthehealthsystemsofdeveloping
countries,countrieswitheconomiesintransitionandsmallislandstates”[10].Iturgeshigh-in-
comedestinationcountriestoconsiderthespecialcircumstancesandunmetneedsoflow-and
middle-incomecountries(LMICs)experiencingnetemigrationandseverehealthworkforce
shortages,anditchallengesallcountriestoaddresstheirhealthdisparitiesandstaffingneeds
withtheirowndomesticresources.
Additionally,theCoPadvocates“circularmigration”asapartialsolutiontohealthperson-
nelemigration,enablinghealthworkerémigréstoreturnperiodicallytotheirnativecountries
toprovidehealthcareserviceswithoutlosingre-entryprivilegeintheiradoptedcountries.Itis
noteworthythatcircularmigrationmaybehinderedinbothdirections.Throughvisarestric-
tions,a“doctor-receivingcountry”liketheUSmaymakeitdifficultforUS-basedmigrant
healthworkersfromLMICs(e.g.,India,Pakistan,thePhilippines,Nigeria,orSouthAfrica)to
shuttlebetweentheUSandtheirhomecountries,unlikecitizensofmostWesternnationswho
cantravelonshort-termvisits(upto90days)totheUSwithoutvisas[13].
The“sendingcountries”,thepotentialbeneficiariesofcircularmigration,mayalsohinder
émigréphysicians’returntotheirnativecountriesbypreventingthemfromretainingtheirna-
tivenationalitywhentheyacceptcitizenshipinthecountryofimmigration[14].In2009,only
25of54Africancountriesalloweddualcitizenshipfortheirnationalslivingabroad[14].Ina
worldofincreasedtransnationalism[15–16],suchrestrictionslimitthereengagementofémi-
grésintheirnativecountries,makingitdifficultforthemtotravelhomewithoutvisarequire-
ments,andtoparticipateintrade,investment,knowledgeexchange,andhealthtechnology
transferwiththeirhomecountries[14].
AlthoughtheinitialimplementationoftheCoPhasbeendisappointing[17–18],itsaimsre-
flectauniversalawarenessofthedestabilizingeffectsofskilledmigrationonthedevelopment
andhealthsystemsofmanyLMICs[8–9].Atthetime,officialsoftheUSHealthResourcesand
ServicesAdministration(HRSA)andtheUSOfficeofGlobalAffairsobserved:“Duetothepri-
vatizednatureoftheUShealthcareandhealthpersonnelrecruitmentsystems,ourcountry
willfacechallengesintheimplementationoftheWHOCodeofPractice”[19].Suchastate-
mentraisesquestionsastowhetheranon-bindingpolicytoaddresshealthworkforcemigra-
tioncanbeeffectiveinaglobal,oftenprivatizedcontext,wheremanypledgesofaidandother
goodintentionsonthepartofwealthycountriesmaygounfulfilled[20].
Moreover,theCoPdoesnotexplicitlydefine“internationalrecruitment”[21].Thus,con-
flictinginterpretationsmaydiscouragethe“active”recruitmentofhealthpersonnelfrom
LMICswhilecondoningits“passive,”morepervasiveform.Thispassiverecruitmentofhealth
personnelfromLMICshasbeenamodusoperandioftheUS,whichrecruitsinternational
medicalgraduates(IMGs)throughthechannelofitsgraduatemedicaleducation(GME)
PLOSONE|DOI:10.1371/journal.pone.0124734 April13,2015 2/18
AfricanPhysicianMigrationtoUSAPost-WHOCode
Table1. NumbersandpercentagesofUSandnon-UScitizenswhograduatedfrominternationalmedicalschoolsintheNationalResidencyMatch
Programafterthe2010launchoftheCoP.
USIMGs Non-USIMGs Totalmatched
Participants(n) Matched(%) Participants(n) Matched(%) IMGs(n) USIMGs(%) Non-USIMGs(%)
2014Match 5,133 2,722(53%) 7,334 3,633(49.5%) 6,355 42.8% 57.2%
2013Match 5,095 2,706(53.1%) 7,568 3,601(47.6%) 6,307 42.9% 57.1%
2012Match 4,279 2,102(49.1%) 6,828 2,775(40.6%) 4877 43.1% 56.9%
2011Match 3,769 1,884(50.0%) 6,659 2,721(40.9%) 4,605 40.7% 58.9%
Total 18,276 9,414(51.5%) 28,389 12,730(44.8%) 22,144 42.5% 57.5%
Note:CoP,WHOGlobalCodeofPracticeontheInternationalRecruitmentofHealthPersonnel;USIMGs,citizensoftheUSwhograduatedfromnon-US
medicalschools;non-USIMGs,foreignnationalswhograduatedfromnon-USmedicalschools.
Datasources:EducationalCommissionforForeignMedicalGraduates[27–30].
doi:10.1371/journal.pone.0124734.t001
residencytrainingprograms[22–24].EachyearintheUS,followingthetraditionalNational
ResidencyMatchProgram(NRMP)thatassignsmostUSseniormedicalstudentstotheirpre-
ferredresidency/specialtychoices,therearethousandsofunfilledresidencypositionsthatare
thenfilledbyIMGs[25].Ofnote,agrowingnumberofIMGsenteringUSresidencytraining
areinfactUScitizenswhoattendedmedicalschoolsoverseas(mainlyintheCaribbeanislands)
[26].However,asshowninTable1,foreignnationalsarestillthenumericalmajorityofIMGs
participatingandobtainingresidencypositionsthroughtheNRMP[27–30].
BothIMGsandUSmedicalgraduates(USMGs)mustobtainamedicallicensetopractice
medicineintheUS.WhileeachUSstateissuesmedicallicensesunderitsownrulesandre-
quirements,acommonfeatureisthateveryapplicantphysicianmustcompleteaUSGMEresi-
dencytrainingprogram,typicallyofthreeyearsduration,longerforsurgicaldisciplines.This
residencyrequirementappliesevenforIMGswhohavealreadycompletedsuchpost-graduate
specializationtrainingintheirhomecountries.BeforeapplyingforadmissionintoUSGME
residencytraining,IMGsmustbecertifiedbytheEducationalCommissiononForeignMedical
Graduates(ECFMG),theindependentorganizationtaskedwithassessingandcertifyingIMGs’
readinesstobeginresidencyandpursuelicensedpracticeintheUS[31].ManyIMGsdonot
succeedtoobtaintheECFMGcertificationforadmissionintoUSresidencies[31],andmany
ECFMG-certifiedIMGsdonotobtainaresidencyslot[27–30].Despitethesehurdlesandthe
possibilityoffailure,manyIMGsarecontinuouslyluredintotheUSbytheperceivedbenefits
providedbyUSmedicinesuchashighincome,excellentconditionsofservice,state-of-the-art
equipmentandresearchfacilities,steadystreamoffundingforresearch,andopportunitiesfor
familymembers[32–39].Hence,manyforeignphysiciansmigrate,butfailtoobtainalicense
topracticemedicineintheUS.
This“brainwaste”[40–42]ofIMGsintheUSworkforce(doctorswhocannotpracticemed-
icine)ishardtoquantifybecausenocomprehensivedatabasesystemdevotedtotheseunli-
censedphysiciansexistintheUS,unliketheirlicensedcounterpartswhosebiographicrecords
arecollectedeveryyearthroughtheAmericanMedicalAssociationMasterfilePhysicianPro-
fessionalData(AMAMasterfile)[43].TheECFMGistheorganizationmostlikelytopossessa
fairamountofdataonunlicensedIMGsresidingintheUS.However,theECFMGapplication
andcertificationdataareproprietaryandinaccessibletoexternalusers.Thus,inthisstudy,we
describe“internationalrecruitment”astheadmissionofIMGsandforeign-bornnationalsinto
theUSphysicianworkforce.OwingtorestrictedaccesstoECFMGdata,ourdefinitionincludes
onlySSAmigrantphysicianswhoareinlicensedpracticeorinresidencytrainingintheUS.
PLOSONE|DOI:10.1371/journal.pone.0124734 April13,2015 3/18
AfricanPhysicianMigrationtoUSAPost-WHOCode
Datamonitoringandinformationsharingonhealthpersonnelmigrationarevitaltobuild
theevidencebasenecessaryforevaluatingtheeffectivenessandrelevanceoftheCoPwhose
firstcomprehensivereviewisscheduledinMay2015duringthe68thWorldHealthAssembly
[10].Inkeepingwiththesetwokeyrecommendations,wesoughttomonitorthepost-CoPmi-
grationofphysiciansoriginatingfromSub-SaharanAfrica(SSA),theregionofgreatestneed,
andrecruitedintothephysicianworkforceoftheUS.WechosetheUSasthecountrywiththe
largestglobalstockofIMGsinitsworkforce[44–45].WecapturedallSSAimmigrantphysi-
ciansinresidencyorlicensedpracticeintheUSthreeyearspost-adoptionoftheCoP.Wethen
describedtheirgrowthrates,locationpatterns,andprojectednumbersin2015.
Methods
DefiningSSAMigrantPhysicians
Wedefined“SSAmigrantphysicians”or“SSA-originphysicians”as:a)US-basedIMGswho
graduatedfromschoolslocatedintheSSAregion;andb)US-basedSSAnatives(i.e.,SSA-
born)whograduatedfrommedicalschoolslocatedintheUSorinothernon-SSAforeignna-
tionssuchasIndia,Dominica,Grenada,SintMaarten,ortheUK[7],[37].Wedesignatedmi-
grantphysiciansintheformergroup“SSA-trained”(SSA-IMGs),andlabeledthoseinthe
lattergroup“SSA-born,butforeign-trained”.
WhilesomeSSA-born,butforeign-trainedphysiciansmayhavelefttheirnativecountries
aschildrenorteenagers,andhavecompletedtheirmedicaleducationabroadwithnosupport
fromtheirnativegovernments,othersmayhavebeenfundedinpartorinwholebytheirnative
governmentswiththeexpectationthattheywillreturnhometopracticeaftercompletingtheir
trainingabroad[46].A2004studyidentified11SSAcountrieswithnomedicalschooland24
SSAcountrieswithonlyonemedicalschoolatthetime[4].TheUniversityofBotswanaSchool
ofMedicine,theonlymedicalschoolinBotswana,graduatedthefirstBotswana-trainedmedi-
caldoctorsin2014[47–49].TheUniversityNamibiaSchoolofMedicine,theonlymedical
schoolinNamibia,admitteditsfirststudentsin2010[50].Hence,throughnecessity,several
SSAcountrieshavesentmanyoftheirnationalsabroadovertheyearsformedicaleducation
andspecialization.
BecauseSSAmigrantphysiciansadmittedintoUSresidenciesafterMay2010wouldbeex-
pectedtohavespentatmostthreeyearsinresidencytrainingbyDecember2013,wedefined
“post-CoPrecruits”asUS-basedSSA-originphysiciansinfirstthroughthirdresidencyyearsas
ofDecember2013.Wecomparedtheirnumberto“pre-CoPrecruits”—US-basedSSAlicensed
physiciansandSSAresidentphysiciansbeyondtheirthirdyearinresidencytrainingasofDe-
cember2013.
Data
AggregatedataonSSA-originphysicianswerecollectedinDecember2013fromthemedical
databasesystemofanAMAMasterfilelicensee[51].TheAMAMasterfileisthemostcompre-
hensivebiographicdatabaseofallUS-basedlicensedandresidentphysicians,includingUS
medicalgraduates(USMGs)andIMGs,andphysicianswhoareandarenotAMAmembers
[52].Someconcernsvis-à-vistheAMAMasterfileareworthmentioning.Thebirthcountry
variableintheAMAMasterfilecontainsaverylargeproportionofmissingdatavalues[4],[7],
[45];70%ofSSA-IMGsinthe2011AMAMasterfiledidnotreporttheircountryofbirth[7].
Moreover,theAMAMasterfileisproprietary,anditsdataareexpensivetoaccess.Thislimits
dataaccessforresearchersinterestedinanalyzingandpublishingphysicianworkforcedata,a
sinequanonforCoPcompliance.
PLOSONE|DOI:10.1371/journal.pone.0124734 April13,2015 4/18
AfricanPhysicianMigrationtoUSAPost-WHOCode
WhileanunknownnumberofIMGsappearingintheAMAMasterfilemayreturntotheir
countriesoforiginafterresidencytraining,theverylargenumberofforeign-bornandforeign-
educatedphysiciansfoundintheUSphysicianworkforcereflectsapreferencetostayandprac-
ticeintheUSafterresidency[53].Thus,weconsideredallSSA-bornandSSA-educatedresi-
dentphysiciansadmittedintotheUSphysicianworkforceasémigrés.Weincludedinour
analysisonlythosephysiciansreporting“active”or“semi-retired”(working<20hoursper
week)statusintheDecember2013AMAMasterfile.
WithinthecontextofamultifacetedstudyofSSA-to-USphysicianmigration[37],weused
availabledatafromthe2002[4]and2011[7]AMAMasterfilesasbaselinemetricsfortheesti-
mationofphysicianemigrationrates.ToestimatethenumberofSSAmigrantphysiciansin
theAMAMasterfilein2015,weextractedaggregateresidencycompletionsforactiveSSA-ori-
ginphysiciansfrom2000to2012inthe2013AMAMasterfile.Wethenprojectedthreeaddi-
tionalyearsto2015withlinearregression,assumingabalanceofadditions(i.e.,incoming
residents)anddrop-outs(i.e.,inactiveandretiredphysicians).
Geo-spatialAnalysis
IMGsaredistributedacrosstheUSwithcertaingeographicpatterns.Forexample,manyIMGs
arerecruitedintotheUSphysicianworkforcewiththeexpectationthattheymayserveinrural
andmedicallyunderservedareas[54].Althoughtheevidencesuggeststhatthisexpectationis
onlypartiallymet[55–57],thiswastherationalefortheinitialadoptionandsubsequentexten-
sionsoftheUSImmigrationServiceConrad30WaiverprogramwhichgivesH1Bnonimmi-
grantstatustonon-USIMGsonexchangevisa(J-1)iftheyworkatahealthcarefacilitylocated
inanareadesignatedasa“HealthProfessionalShortageArea,”“MedicallyUnderservedArea,”
or“MedicallyUnderservedPopulation”[58–60].Accordingly,wesoughtnotonlytoquantify
thenumberandgrowthrateofSSAmigrantphysiciansintheUS,butalsotodeterminetheir
locationpatterns.WeaggregatedSSA-originphysicians’residentialandprofessionaladdresses
byzipcodesandconvertedzipcodesintoglobalpositioningsystemcoordinatesusingGPSVi-
sualizer[61].WethenappliedArcGis[62],ageographicinformationsystem,toanalyzeandvi-
sualizegeocodeddata.
Results
Sub-SaharanAfricanMigrantsinthe2013USPhysicianWorkforce
IntheDecember2013AMAMasterfile(N=940,456),therewere11,787activeandsemi-re-
tiredSSA-originphysicians.Thistotalrepresents(cid:3)1.3%ofthe2013USphysicianworkforce,
andincludesbothphysicianswhograduatedfromSSA-basedmedicalschools(SSA-IMGs),
andphysicianswhowereborninSSA,butgraduatedfromnon-SSAmedicalschools.Ofthe
abovetotal,19.4%(n=2,295)graduatedfromUSmedicalschools,68%(n=8,003)were
SSA-IMGs,and12.6%(n=1,489)wereSSA-bornIMGsgraduatedfrominternationalmedical
schoolslocatedoutsidetheSSAregion.SSA-originIMGsinthe2013AMAMasterfile
(n=9,492)represented3.7%ofthetotalnumberofIMGs(N=256,739)(Table2),and4.4%of
allnon-USIMGs(N=(256,739–42,007)=214,732)respectively.
Goingbytheirresidencystatus,15.7%(1,849outof11,787)oftheseSSAmigrantphysicians
enteredtheUSphysicianworkforceaftertheMay2010adoptionoftheCoP,reflectingapost-
CoPannualgrowthrateof5.3%.Comparedtopre-CoPannualgrowthrate(3.6%from2002to
2010),post-CoPresidencyadmissiontrendsareupforSSA-originphysicians(Table3).As
suggestedbyFig1,thisoverallincreaseisdrivenmainlybythegrowingnumberofSSA-born,
butforeigntrainedphysicians(i.e.,attendingmedicalschoolsoutsideSSA).
PLOSONE|DOI:10.1371/journal.pone.0124734 April13,2015 5/18
AfricanPhysicianMigrationtoUSAPost-WHOCode
Table2. MedicalgraduatesafromSub-SaharanAfrica(SSA),theUnitedStates,andelsewhereintheDecember2013AmericanMedicalAssocia-
tion(AMA)PhysicianMasterfile.
Internationalmedicalgraduates(IMGs) n Percentofsubtotal Percentoftotal
SSA-originIMGs 9,492 3.7% 1.1%
GraduatesofSSAmedicalschools(SSA-IMGs)b 8,003 3.1% 0.9%
SSA-borngraduatedfromnon-SSAinternationalmedicalschools 1,489 0.6% 0.2%
USIMGsc 42,007 16.4% 4.5%
OtherIMGsd 205,240 79.9% 21.8%
Subtotal 256,739 100% 27.3%
USmedicalgraduates(USMGs)
SSA-borngraduatedfromUSmedicalschools 2,295 0.3% 0.2%
US-borngraduatedfromUSmedicalschools 577,336 84.5% 61.4%
OtherUSMGse 104,086 15.2% 11.1%
Subtotal 683,717 100% 72.7%
Total 940,456 100%
Note:
aIncludeonlyactiveandsemi-retiredphysicians(i.e.,physiciansworkinglessthan20hoursaweek)—about6.5%(62,507)ofactiveandsemi-retired
physiciansinthe2013AMAMasterfilewere>70yearsold.
bWedidnotdetailtheproportionsofSSA-bornvs.non-SSA-bornSSA-IMGsbecauseovertwothirdsofSSA-IMGsfoundintheAMAMasterfiledonot
reporttheirbirthcountries[4],[7].However,inourpreviousanalysisofthe2011AMAMasterfile[7],wereportedthat(cid:3)16%ofSSA-IMGswithcomplete
birthcountrydatawerebornintheUSandinothernon-SSAnations.Althoughwedidnotperformasystematicanalysisoftheirsurnames,wesuspect
thatthemajorityofSSA-IMGsamongthissmallminorityofforeign-bornareoffspringofAfricanimmigrantswhowerelivingabroadatthetimeoftheir
children’sbirth,andreturnedtotheircountriesoforigintoraisethem.
cUSIMGs,CitizensoftheUSwhograduatedfromnon-USmedicalschools.
dOtherIMGsincludenon-SSAIMGs,non-USIMGs,andallIMGswithmissingbirthcountrydata.SomeSSA-bornphysicianseducatedoutsideSSAand
outsidetheUSbutwithmissingbirthcountrydatamaybeinthisgroup.ItisalsopossiblethattherearesomeUSIMGswithmissingbirthcountrydatain
thisgroup.
eOtherUSMGsincludeallnon-SSAforeign-bornphysiciansgraduatedfromUSmedicalschools,andallpotentialUSMGswithmissingbirthcountrydata.
SomeSSA-bornUSMGswithmissingbirthcountrydatamaybeinthisgroup.
Datasource:Redi-MedDataInteractiveMedicalDatabaseSystem[51].
doi:10.1371/journal.pone.0124734.t002
Extrapolatingyearlyresidencycompletiondatato2015yieldedrespectively8,610
SSA-IMGsand4,236SSA-born,butforeign-trainedphysicians(Fig1).Thissuggeststhat,
whenWHOmemberstatesconveneinMay2015atthe68thWorldHealthAssemblytoreport
theirprogressvis-à-vistheCoPimplementation,therewillbeonaggregate12,846activephysi-
ciansoriginatingfromtheSSAregionintheUSphysicianworkforce.Oftheseémigrés,22.7%
(2,908outof12,837)willrepresentpost-CoPresidencyadmissions.Thetrendtowardsyounger
migrantsisapparent;>80%ofmigrantphysiciansgraduatingfromSSAschoolsareestimated
toentertheUSbyage35(Fig2).
Migrants’Locations
Fivemainobservationsarenotedvis-à-visSSAmigrantphysicians’locationsintheUS.1)
TheylocatepredominantlyinmetropolitanareaseastoftheMississippiRiver;exceptforpopu-
lousTexasandCalifornia,westernvenuesreceivecomparativelyfewerSSAmigrantphysicians
(Fig3).2)CentralandMountainstateswithsomeofthelowestphysiciandensities(e.g.,Idaho,
Nevada,Utah,andWyoming)attractthelowestnumbersofSSAmigrantphysicians(Fig3).3)
HigherracialdiversityofthecityseemstoserveasamagnetforSSAmigrantphysicians;more
locatetourbanareaswiththeproportionoftheblackpopulationexceeding20%(Fig3).
PLOSONE|DOI:10.1371/journal.pone.0124734 April13,2015 6/18
AfricanPhysicianMigrationtoUSAPost-WHOCode
Table3. Sub-SaharanAfrican(SSA)immigrantphysiciansappearingintheAmericanMedicalAssociation(AMA)PhysicianMasterfilebeforeand
afterthelaunchoftheWHOGlobalCodeontheInternationalRecruitmentofHealthPersonnel(CoP).
2002AMA 2013AMAdata(active&semi- Pre-CoPrecruitmentgrowth Post-CoPrecruitmentgrowth
data retiredphysicians) rate(2002–2010) rate(2010–2013)
Baseline Pre-CoP Post-CoP Subtotal Overall Annual Overall Annual
dataa recruits recruits percent recruitment percent recruitment
increase growthrate increase growthrate
GraduatesfromSSA 5,334 6,896 1,107 8,003 29.3% 3.9% 16.1% 4.6%
medicalschools
(SSA-IMGs)
SSA-borngraduatesfrom 1,041 1,230 259 1,489 18.2% 2.4% 21.1% 6.2%
medicalschoolsoutside
SSAandtheUnitedStates
SSA-borngraduatesfrom 1,455 1,812 483 2,295 24.5% 3.3% 26.7% 7.6%
USmedicalschools
Total 7,830 9,938 1,849 11,787 26.9% 3.6% 18.6% 5.3%
Note:Post-CoPrecruits,physiciansinfirstthroughthirdresidencyyearsasofDecember2013;Pre-CoPrecruits,licensedandresidentphysiciansbeyond
theirthirdyearofresidencytrainingasofDecember2013;Semi-retiredphysicians,physiciansworkinglessthan20hoursaweek;SSA-IMG,international
medicalgraduatewhocompletedmedicalschoolintheSSAregion;Annualpre-CoPrecruitmentgrowth=2002–2010percentincreasedividedby7.5;
Annualpost-CoPrecruitmentgrowthrate=2010–2013percentincreasedividedby3.5.
aBaselinedatasources:Hagopianetal.[4];Tankwanchi[37];Redi-MediDataInteractiveMedicalDatabaseSystem[51].
doi:10.1371/journal.pone.0124734.t003
4)AsshowninFig4,recentSSAmigrantphysicians,includingpost-CoPrecruits,arefound
primarilyinthesamezipcodesastheirearlierimmigrantcounterparts.Thisclusteringofmost
recentandpioneerSSAmigrantphysiciansinthesamegeographiclocationhascreatedsizable
migrationfieldsofSSAphysiciansinNewYork,Chicago,Atlanta,andtheBaltimore-Wash-
ington,DCregion(Fig3).5)Thesecosmopolitancitiesalsohavesomeofthemostaccessible
residencyinstitutionsforSSAmigrantphysicians,mostnotablyHowardUniversityHospital
(Washington,DC),andHarlemHospitalCenter(NewYork),bothofwhichdrawlargenum-
bersofSSAmigrantphysiciansintotheirresidencyprograms(Fig4).
Discussion
Threefullyearspost-adoptionoftheCoP,evidencefromthe2013AMAMasterfilerevealsan
increasingnumberofSSA-originphysicianshavebeenrecruitedintotheUSphysicianwork-
force,withprojectionsforanevenfurtheraccelerationasnewentrantsmovethroughthepipe-
linewhilelesstimeisspentinpracticeinSSAaftermedicalschoolgraduationbythemore
recentmigrantdoctors[7],[37].WefoundnoevidencethattheCoPhasslowedSSA-to-US
physicianmigration.Instead,weobservedaclusteringofpre-andpost-CoPrecruitsinthe
samelocalities,creatingsizeableSSAphysicianmigrationfieldsinseveralUSmetropolitan
areas,mostnotablyAtlanta,Chicago,Baltimore-Washington,DC,andNewYorkCity.The
settlementpatternsofSSAphysiciansacrosstheUSareconsistentwithvariousmigrationtheo-
ries,mainlyatthemeso-level.Theseincludetheearlyconceptof“chainmigration”anditsre-
centsubstitute/corollary,“migrantnetworks.”Thesetwoconceptsconveytheideathat
migrationisapath-dependentandself-sustainingprocesswherebyearliermigrantsfacilitate
theinflowandadaptationofrecent/prospectivemigrantsthroughsocialsupportnetworksen-
tailinginformational,cultural,financial,andmaterialassistance[64–65].
SomeoftheAfricandoctorsappearingintheAMAMasterfileafterMay2010mayhaveen-
teredtheUSbeforetheadoptionoftheCoP,therebyinflatingpost-CoPestimates.Atthesame
time,amongphysicianswhoimmigratedtotheUSaftertheCoPwasadopted,somemaystill
PLOSONE|DOI:10.1371/journal.pone.0124734 April13,2015 7/18
AfricanPhysicianMigrationtoUSAPost-WHOCode
Fig1.Projectednumbersofactiveandsemi-retiredSub-SaharanAfrican(SSA)migrantphysiciansinthe2015AmericanMedicalAssociation
(AMA)PhysicianMasterfile.Note:Basedonavailableresidencycompletionsandexpectedcompletionsofactiveandsemi-retiredSub-SaharanAfrican
migrantphysiciansinthe2013AMAPhysicianMasterfile[27];SSA-IMGs,internationalmedicalgraduatestrainedinSSA-basedmedicalschools;
SSA-BFTs,SSA-born,butforeign-trainedphysicians(includingUSmedicalgraduatesandinternationalmedicalgraduatestrainedinnon-SSA-based
medicalschools).
doi:10.1371/journal.pone.0124734.g001
becompletingpre-residencyadmissionrequirements,andthereforearenotyetcapturedby
theAMAMasterfile,thusdeflatingpost-CoPestimates.SincetheAMAMasterfilecontainsa
highrateofmissingdataonbirthcountry[4],[7],[45],wemaybeundercountingphysicians
whowereborninSSAbuttrainedintheUSandinothernon-SSAcountries.Moreover,there
isoftenatimelagfordataentryandstatuschangeintheAMAMasterfile,againundercounting
SSAphysicians.Finally,asobservedintheintroduction,unlicenseddoctorsdonotappearin
theAMAMasterfile,anunderestimateofmigration.
Hence,ouremigrationfiguresareveryconservativeestimates.Yearlyreplicationsofour
analysiswouldbehelpfulinconfirmingourimpressionsofthelimitedpolicyimpactofthe
CoPvis-à-visSSA-to-USmigration.AsamatterofCoPcompliance,itmaybenecessaryfor
HRSAandtheUSOfficeofGlobalAffairs,authoritieschargedwiththeimplementationofthe
CoPintheUS,toissuerequestsforproposalstoacademicsandrelevantorganizationstocon-
ductrobuststudiesonhealthworkforcemigrationintheUS.Similarstudiescouldbe
PLOSONE|DOI:10.1371/journal.pone.0124734 April13,2015 8/18
AfricanPhysicianMigrationtoUSAPost-WHOCode
Fig2.CumulativedistributioncurvesforSub-SaharanAfricaninternationalmedicalgraduates’(SSA-IMGs)agesattimeofgraduationandattime
ofentryintotheUnitedStates.Datasource:Fromthe2011AmericanMedicalAssociationPhysicianMasterfiledatainTankwanchi[37].
doi:10.1371/journal.pone.0124734.g002
conductedinotherhigh-incomenationstoprovideamorecompletepictureoftheSSAphysi-
cian“braindrain,”aswellaswithintheAfricancontinent(e.g.,MozambicanorZambiandoc-
torsmigratingtoSouthAfrica).
ThespiritoftheCoP,byallappearances,hasnotpermeatedtheethosofsomeofthemost
influentialhealthorganizationsthatencourageIMGs’migrationtotheUS.TheAMA[66],the
AmericanCollegeofPhysicians[67],theAmericanCollegeofSurgeons[68],theAmerican
HospitalAssociation[69],theAssociationofAmericanMedicalColleges[70],andtheNation-
alRuralHealthAssociation[71],combiningamembershipofover780,000individualsand
morethan6,000hospitalsandhealthsystems,haveallendorsedthe2012ConradState30Im-
provementActandthe2013ConradState30andPhysicianAccessAct[59].Thesebillsin-
tendedtomakepermanenttheConradState30J-1VisaWaiverProgramthathasbeenlawfor
20years.Whilethebillsfailedtopass,thesuccessfulreauthorizationin2013oftheConrad
State30J-1VisaWaiverProgram[60]indicatesahighlypermissivestatusquoinUSpolicy
vis-à-visitsrecruitmentofIMGsfromLMICs.Wespeculatethatthisisperceivedtobeless
PLOSONE|DOI:10.1371/journal.pone.0124734 April13,2015 9/18
AfricanPhysicianMigrationtoUSAPost-WHOCode
Fig3.Geographyofloss:SpatialdistributionofSub-SaharanAfricanmigrantphysiciansacrosstheUnitedStates.Note:SSA-IMGs,international
medicalgraduatestrainedinSub-SaharanAfrican-basedmedicalschools;SSA-BFTs,Sub-SaharanAfrican-born,butforeign-trainedphysicians(i.e.,
graduatesofUSandothernon-SSAforeignmedicalschools).Datasources:Redi-MedDataInteractiveMedicalDatabaseSystem[51];Environmental
SystemsResearchInstitute[62];AssociationofAmericanMedicalColleges[63].
doi:10.1371/journal.pone.0124734.g003
costlythanexpansionoftheUSNationalHealthServiceCorpstomeethealthworkforceneeds
withindigenousmedicalandosteopathicschoolgraduates[72–73].
AlthoughunanimouslyratifiedbyallWHOmemberstates,thenon-bindingnatureofthe
CoPreflectsanall-too-rhetoricalandreactionarypolicy[17],preservingtheinterestsofdoc-
tor-receivingcountrieswhiledenyinganyseriousleveragetosourcecountriesthatlosetheir
healthpersonnel.Inhigh-incomecountriesliketheUSorCanada,immigrationpolicyisinte-
graltonationaleconomicpoliciesandfavorshighlyskilledimmigrants[74–75].Itisnaïveto
expectthatsuchcountriesmayfullyimplementadiscretionarycodethatcouldcompromise
theireconomicandhealthcareinterests.
WithouttheCoP,onemightargue,evenmoreSSAphysiciansmighthavemigrated.How-
ever,datalimitationsstymieourabilitytofullyevaluatetheeffectivenessoftheCoP.Indeed,it
isverychallengingforresearcherstomonitorthemigrationandrecruitmentofforeignhealth
personnelintotheUShealthworkforcewithoutunrestrictedaccesstotheUSDepartmentof
Statevisaapplicationrecordsforforeignhealthworkers,andtoproprietarydatasourcessuch
astheECFMGapplicationandcertificationdatabasesandtheAMAMasterfile.Moreover,the
CoPdoesnotexplicitlydiscouragehealthworkersmigration.Aswehaveobservedpreviously
[21],theCoPinsteadempowersmigranthealthpersonnel,reassertingtheirfundamentalright
PLOSONE|DOI:10.1371/journal.pone.0124734 April13,2015 10/18