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CHAPTER ONE

BACKGROUND

The loss of human capital from developing countries to developed countries is not a new phenomenon. It is commonly refer to as "brain drain" which broadly represents the migration of highly skilled professionals from one country or part of a country to another in search of a better prospect (Sako, 2002). The loss of highly skilled professional attributed to brain drain has been of interest internationally for over four decades (Giannoccolo, 2004). Concern over the international migration of health workers first came to limelight at the Edinburgh Commonwealth Medical Conference in 1965. This situation prompted the World Health Organisation (WHO) in 1970 to examine the global process and flows of doctors and nurses (Mejia, 1978). The report however made little impacts on migration of health workers which has continually been on the increase over the years (Levy, 2003, Pang et al. 2002)

The concept of the 'medical brain drain', that is the migration of doctors and other health professionals from developing economies to developed countries has been the subject of interest and research across a variety of fields including labour economics, human resource studies and human geography (Diallo, 2004, Buchan, 2004 and Stilwell et al., 2004)

The migration of medical personnel has been identified by WHO as the most critical problem facing the delivery of health service in developing countries (WHO, 2007), besides the emigration of doctors in particular to other countries have received a more considerable attention (Beecham, 2002)

The extent to which health professionals migrate to developed countries has continue to be on the increase in recent years and this has been attributed to an apparent response to demand from the developed countries where medical professional are in short supply to cater for demands due to demographic changes, aging population, growing income, feminisation of workforce amongst others (Pond and McPake, 2006).

Foreign-trained medical and nursing workforces are estimated to account for more than a quarter of health professionals of the Australia, Canada, the US, and the UK (OECD, 2002).The quest for highly skilled professionals has been on the increase in many developed countries. According to statistic report from the Global Atlas of Workforce cited in Pond and McPake, (2006), the United Kingdom (UK) was ranked among the least staffed of high income countries with 166 doctors and 497 nurses per 100,000 populations - the second lowest doctors' density and the fourth nurses' lowest density among the Organisation for Economic Cooperation and Development (OECD) countries. Moreover, as at the year 2000, the UK health system currently require about 10,000 physicians and 20,000 more nurses to meet the demand of the NHS plan (Department of Health, 2000). Between the year 1999 and 2004 when the targets was achieved earlier than expected, a new target was set to increase the number of nurses by 35000 (10%) and physicians by 15000 (25%) between 2001 and 2008. In order to achieve the new target, several methods were adopted to recruit doctors and nurses from other country to fill the shortage within the NHS. However, the approach created a surge in the international recruitment of health worker (Department of Health, 2004).

Conversely, the poor economy condition in the developing countries coupled with poor remunerations, lack of infrastructural facilities, and low morale, emigrating to developed countries by doctors' is seen as an opportunity for a better prospect.

Furthermore, the continuous rise in disease prevalence, emigration, productivity losses, and shortage of doctors in Sub-Saharan Africa, has resulted in health resource crisis (Aluwihare, 2005). Insufficiency in human capacity for health care delivery in developing countries have been identified as a significant factor that is responsible for the inability to achieve the target set by WHO for the treatment of 3 million HIV infected people by year 2005. (This initiative was tagged '3by5') (WHO, 2005). This has also been identified as a major constraint limiting the progress of Millennium Development Goals (MDGs) Initiatives (IOM, 2005).

In response to the migration of health professionals to developed countries and the undermine effect to the economy, social and health status of exporting countries, the Commonwealth Ministers of Health agreed to uphold and keep the Commonwealth values of cooperation, sharing and supporting one another, thus a consensus approach to deal with the problem of international recruitment of health workers was adopted.

The Code of Practice for the International Recruitment of Health Workers is intended to provide a framework to governments within which international recruitment should be carried out (Commonwealth Code of Practise, 2003).

Similarly, Department of Health (2004), presented a revised policy on "code of practise for international recruitment of health care professionals" this demonstrated the concerned of the UK government in protecting the health care system of developing countries. The revised code of practise for recruitment addresses role of private employer and agencies in the international recruitment of health professionals from developing countries (Eastwood et al., 2005).

Nevertheless, developing countries have made some effort in preventing the emigration of physician to developed countries. In spite of this, addressing factors that encourage emigration, such as large disparity in remunerations, standards of living, opportunities for career development amongst host other benefits are usually difficult to come by. At the 1998 UN Conference on Trade and Development, WHO study indicated that 56% of doctors from developing countries migrate to developed nations, while only 11% migrate in the opposite direction; the imbalance is even greater for nurses. (Chanda, 2002).

As a result, further effort is being deployed by developing countries to search for means to manage the migration of the health workforce to developed countries (Hussey, 2007).

Despite measures, it may be difficult to totally prevent health professionals from migrating. As the large scale of medical brain drain from developing countries is now having a negative impact on the development process of the health system of those countries, it is however imperative for stakeholders to develop a consequential means to curtail the continual movements of health professionals.

Nigeria Health Services

Historical Background

Nigeria, the most populous black nation in the world with a total population of 140 million people (2006 census). As a country with mono-cultural economy, the major source of foreign earnings is from crude oil. The poor level of resources allocated to the health care sector is one of the main factors responsible for the deplorable health condition in the country (Campbell, 2007).

The public health service in Nigeria started in 1946 with a 10-year colonial administration plan; the development came about when treatment was required for soldiers of the West African Frontier Force and the colonial administration staff. In 1975 attempt was made to adopt primary health care under the Basic Health Service Scheme (BHSS). The BHSS aimed to improve the accessibility to heath care in terms location, affordability, increase access to disease prevention and distribution of services, and provision of adaptable health services based on local need and socially acceptable method of technology (Hodges 2001).

The Current Health Care System in Nigeria

Over the last two decades, the health care system in Nigeria's has deteriorated - a fact ascribed to the country's poor governance and leadership which was more pronounced during the military era. This was reflected in budget allocations and the fiscal requirements of the Structural Adjustment Programmes. The deficient of reliable data makes it difficult to provide a detailed assessment of the degree of financial commitment to the health sector (Ali-Akpjiak and Pyke, 2003).

According to World Bank source, Nigeria public spending per capita for the health sector is less than $5 USD and is as low as $2 USD in some parts of the country. This is far below the $34 USD recommended by WHO for developing countries within the Macroeconomics Commission Report. Nevertheless the Federal Government recurrent budget on health showed an increasing trend from 1996 to 1998, a decline in 1999 and started to rise again in 2000, available evidence shows that most of the recurrent expenditure is spent on personnel. The Federal Government recurrent expenditure on health as a share of the total Federal Government recurrent expenditure which stood at 2.55% in 1996, 2.96% in 1997, and 2.99% in 1998, declined to 1.95% in 1999 and 2.5% rose in 2000. Beyond budgetary allocations, there is a wide gap in the available between the budgetary figures and the actual amount of funds released from the treasury for health activities (WHO 2009a).

The decline in the Nigeria health sector was accompanied by collapse of institutional capacities, poor remuneration and lack of conducive environment, dilapidated equipment and infrastructure have over the years, job dissatisfaction and low motivation, have led to increase migration of health professionals to seek employment in overseas countries. In a bid to curtail the impasse, Nigeria has subscribed to the Commonwealth Code of Practice for the International Recruitment of Health Workers for which a framework of responsibilities is presently being developed (WHO 2009b).

Demographic and Health Indicators

The demographic data in Nigeria are not very reliable. Data gathered from various exercises such as census, vital registrations and surveys are often inconsistence and sometimes contradictory. Nonetheless, there is evidence that the key indicators have either remained constant or worsened (WHO 2005).

Life expectancy declined from 52.6 years for male and 58.8 years for female in 1991 to 45 years and 46 years for both Male and Female respectively in 2004. The infant mortality rate (IMR) in 2004 is 103 per 1000 live births when compared to 87.2 per 1000 live births in 1999. Fifty percent of deaths under 5 years of age have been attributed to malnutrition.

The maternal mortality rate (MMR) of 800 per 100,000 births is the second highest in the world after India. This has been attributed partly to shortage of skilled medical personnel. For instance only 41.9 % of primary health facilities is provides antenatal and delivery services. Moreover 57.3% of such health facilities operate without a doctor, midwives or senior community extension worker. The Nigeria health system is one of the worst in sub-Saharan African with a disability life adjusted expectancy of 38.3 years and ranked 187 in the world (WHO 2005)

Health Workforce in Nigeria

Among the several challenges facing the health system in Nigeria is the lack of competent health care professionals. This has been attributed to inadequate infrastructures and poor remunerations packages, making a sizeable numbers of doctors, nurses and other medical professionals vulnerable to be lured away to developed countries in search of a fulfilling and lucrative employments (Stilwell and Awofeso, 2004, Raufu, A., 2002)

There are 52, 408 Nigerian Doctors registered with the Nigeria Medical Council as at December 2007, There are 128,918 nurses and 90,489 midwives on the register, although only a fraction of these pay the required practicing licensing fee. There are 13,199 pharmacists, 840 radiographers, 1,473 physiotherapists, 12,703 medical laboratory scientists, and 19,268 Community Health Officers. All these health workers are required to pay annual practicing licensing fees; however the lists have not been pruned for those have migrated out to foreign countries, deaths, retirements or those that have left the profession for another career entirely.

Health workers are poorly distributed and most are in favour of urban areas, southern, tertiary health care services delivery, and curative care. For some cadres of health workers such as doctors and nurses, more than 50% have their place of work in the South Western part of the country with vast majority residing in the commercial city of Lagos (Labiran et. al, 2008).

Medical Brain Drain in Nigeria

Among the countries in sub-Saharan African, Nigeria is a major "export" of health professionals. An estimated number of 20, 000 health professionals emigrate from Africa annually. A trend that poses threat to sustainable health care delivery in Nigeria. Statistical data on Nigerian doctors who are legally migrating overseas are scarce and unreliable, this is largely due to the fact that most wealthy nations like Australia currently makes it very difficult for overseas trained doctors to practise in their country primarily on the basis of medical skills. However, hundreds of doctors trained in Nigeria continue to emigrate to developed countries annually (Stilwell and Awofeso, 2004). Better remunerations and medical facilities among other factors are cited as one of the major reason for flight of Nigerian doctors (Raufu, 2002) and also there are limited incentives and encouragement for overseas based Nigerian doctors that is willing to relocate back to the country (Stilwell et al., 2004).

Purpose of the study

In sub-Saharan African, there is has been a significant rise in disease burden, loss of productivity and the emigration of medical doctors to developed counties have resulted in the in dearth of the most required health resource (Aluwihare, 2005). Most studies on medical brain drain have examined the subject from the perspective of recipient developed countries and little attention has been paid to the donor developing countries. Thus, "scarcity of data from developing country makes it difficult to fully describe the impact of migration on countries of origin" (Hagopian et al., 2004). Most studies on doctors migration from Sub-Saharan African have tended to focus on numbers, without exploring the underlying reason for migration, assessing the potential negative impact of migration on the health care systems, or considering means to alleviate the problem. In actual fact, information regarding the extent of migration is usually obtained through data from countries of destination (Stilwell et al 2003).

The migration of medical doctors from Nigeria and other countries in sub-Saharan African generates three areas of major concern. The first is a loss of the basic health services available to the citizen. for instance, Ghana, faced with a ratio of nine doctors to every 100 000 patients and no more than 22 paediatrician are licensed to practise in country and no more than 10 specialists of any kind practising in the remote area. Similarly, Nigeria lack adequate doctors to care for the sick especially patients residing in the rural communities

The second effect doctor migration from Nigeria is that it prevent the health sectors the ability to organize and expand. Public health institutions heavily depend on doctors to lead, develop and promote them as they work to advance health care delivery. As obtained in US, doctors are well positioned to serve their organisation by actively involved in managing resources and articulating priorities. It is therefore speculated that as the numbers of available medical doctors in developing countries reduces.

The third challenges are that doctor's migration depletes a significant element of the middle class in developing countries. As in the developed countries, medical doctors in African comprise of an important segment of the social and economic make up of the middle class. They are generally accorded a lot of respect in the society, as being above corruption, they advocate for improvement in quality of education of public schools and they play a vital role in political (Hagopian et al., 2005). In Nigeria, over 70.2% of the population lives on $1 per day (WHO, 2006)

Research aim and objectives

The aim of this study is to analyse the causes of medical brain drain from developing countries, benefits and burdens associated with brain drain based largely on the views of Nigerian doctors practising in UK.

The objectives are:

  • To identify the factors that influence the decision of medical doctors to migrate to developed countries migration
  • To identify the impacts of migration on healthcare in developing countries
  • CHAPTER TWO

    LITERATURE REVIEW

    Concept of Brian Drain

    Brain drain has been defined by many analysts in different ways. It is not surprising the social phenomenon has been examined and analysed from different perspective, based on their general orientation and or awareness of the subject.

    Brain drain will be conceived in this study as the loss of medical professionals or significant number of human capital within the health care system to other sector of the economy or country.

    Migration of skilled professionals differs from one country to another and from time to time it is however misleading to generalise the possible impacts of migration in developing countries. Moreover, it can be argued that various studies have attempted to measure the phenomenon from different perspective. Single analytic measurement cannot be used to justify all migration although migration of highly skilled professionals from developing countries has been attributed to various factors which political, social and economical factors account for a significant reasons behind the phenomenon (AUN report, 2002).

    The migration of highly skilled workers can justify the use of the term "brain drain" however the expression should be used cautiously. Replacing 'drain' by a more common and value expression such as 'migration' may generate alternate meaning. The difference in the word may be heightened by saying while all brain drains constitute brain migration notwithstanding, brain migration may not necessarily refer to brain drain.

    Brain drain denote the de-facto transfer of resources spent on impacting education and developing both technical and professional skills of the drained brain in question by the parent (donor) country to the (recipient) country of transfer. The developed countries thus save financial resources on education and professional training and invariably obtain the service of professionals such as doctors, nurses, engineers, scientists who earn more than their colleague in developing countries with a better comfortable living environment (Glaser and Habers, 1978).

    Several efforts have been made to define the concept of brain drain, most especially by international organisation. According to United Nations Educational, Scientific and Cultural Organisation (UNESCO report, 1969), "the brain drain could be defined as an abnormal form of scientific exchange between countries, characterized by a one- way flow in favour of the most highly developed countries". Approximately four decades later, the definition of brain drain has undergone no significant change with a lot of highly skilled workers still leaving the shores of developing countries in pursuit of greener pastures in the developed nations. Medical doctors, engineers and scientists usually tend to predominate or account for a larger proportion among the migrants. Their higher the level of skills or professional qualification, make them more susceptible to migration.

    Gillis, et al. (1987) suggested two main reasons why brain drain is detestable to most developing countries. The first is that the calibres of people that migrate represent one of the scarce human resources in these developing countries and secondly the amount of resources, financial cost and time involve in educating these group of people is expensive and heavily subsidise by the government. Such migration to foreign country therefore becomes expensive and costly to the donor countries. In most cases the developing countries completely loose these highly skill professionals to the developed countries (Edokat, 2000). This phenomenon has generated a lot of arguments that have been advanced for or against brain drain; however this is not a concern for this study. All that can be concluded is that migration of highly skilled workers from developing countries to develop countries creates a vacuum in the former countries (Edokat, 2000).

    Types of brain drain

    Primary external brain drain - occurs when trained professional or skilled human resources emigrate from their country of origin to work in developed countries such as America, Europe and Australia.

    Secondary external brain drain - occurs when a trained professional or skilled human resources leave their country or any other less developed country to work in a another developing country such as Botswana, South Africa, Zimbabwe and Namibia.

    Internal brain drain - occurs when a trained professional or skilled or skilled human resources seek for employment in a field not related to his to his/her expertise or when such individual migrate from the public sector to private sector or to another sector within a particular country. While this may pose a problem for a country, it is however not a loss of human resource to the country or the continent.

    Brain Drain Theories

    These theories are based on general migration approaches. In brain drain discussion, these approaches have been referred to briefly or summarized. Occasionally specific remarks will be made to provide more clarity regarding the theories.

    It is however important to state that nearly the theoretical outlook consists of specific mix of different theories or based on the nature of the dominating factors. On the other hand, the scientific approach in which the theories were founded. Another approach in the use of division based on the level - Micro, Meso or Macro. These groups cover greater number of theoretical approaches (Oderth, 2002).

    This level has been defined as:

    Micro level - the decision making of individual is affected by his or her motives, circumstances and access to information.

    Meso level - an aspect of social ties that affects migration such as the effect of network of friends and relatives on migration

    Macro level - opportunities and constraints available at societal level which include political, socio-cultural and economical factors

    There is no Grand theory linked with research on brain drain although attempts have been made to integrate the subject with economic and social theory, spatial analysis and social science (Kangasniemi et. al., 2004). The study of brain drain and other behaviour by demographers was able to draw insights from other disciplines such as statistics, history, economy, medicine and anthropology (Oderth 2001). A common example is the push and pull model of labour mobility. The model states that "individual migration decision is a combination of family, economic, social and political factors". Categories of factors identified to be affecting migration include: 1) Factors at the point of origin, 2) Factors at point of destination, 3) Intervening obstacles and 4) personal circumstances. The push and pull model has been widely used by scholars in studies. Economic factors of employment and material benefits are regarded to have the strongest influence on migration decision (Oderth 2002)

    Despite the frequent use of the push and pull model approach in migration literature, the approach has been seen as too mechanical and 'rational choice' based and with less consideration for intervening obstacles or institutional and structural constraints (Massey et al, 1993). Most migration tends to be unidirectional from poor to rich nations. The rate of emigration also differs vary considerately between countries and regions on similar economic level and the poorest or the less educated people hardly ever move. A major challenge for the migration is lack of insights in the interconnectedness of all the processes (Kangasniemi et. al., 2004)

    Another model is the migration system approach - it involves formation of a link that encourages migration between a sender and receivers which are strengthened over a period of time. Such links include economic, political and cultural interaction often based on historical activities. Once a link has been created between the migrant places subsequent migration is facilitated through the links.

    The migration system approach emphasis that social network of the migration provides the intending migrants with information and assistance to ease migration. An important feature of such system is that immigration to a country is directed to specific regions. Such migration is partly dependent on specific areas (Gillis, et al. (1987)).

    The scope of medical brain drain

    The World Health Report (2006) estimated that an approximately 817,992 (138%) health workers would be required In Africa to achieve the coverage of basic health interventions.

    The rate at which doctors and other health professional migrate differs from country to country. Nevertheless, the pattern of migration shares certain similarities. The severe shortage of doctor's particularly in rural health facilities has critical negative effects on accessibility and equitable distribution of health care in sub-Saharan African (Ovberedjo, 2007).

    Studying a specific group of employments from a pool of migration statistics revealed a substantial net loss of human capital among certain key profession in sub-Saharan African. An obvious and highly skilled professional to emerge from such analysis are medical doctors (SOPEMI, 2008). This particular phenomenon can be described as "Medical Brain Drain". However, to what extent doctors migrated from sub - Saharan African to developed countries?

    This section will review the scope of migration among doctors in sub - Saharan African. Medical brain drain is important and deserves consideration because it is obvious that any decrease in the labour supply among doctors in any country is bound to generate a significant negative impact on the health system of that particular country.

    In year 2000, statistical data revealed an average of 18.2% of employed doctors working in OECD countries were foreigners. The United States has the largest number of doctors (about 200,000) born and trained in foreign countries followed by the United Kingdom which account for almost 50,000 and France about 34,000. Health worker in India and Philippine formed a greater percentage of the immigrant health workforce OECD countries. In addition, doctors from India account for 56,000 of foreign born doctors practising in OECD countries while nurses of Philippine origin account for about 110, 000. These represent about 15% each of the total (SOPEMI, 2008).

    The French and the Portuguese African speaking countries contribute some of the highest emigration rate to OECD countries for medical doctors some of other African countries such as Guinea Bissau, Sao Tome and Principe, Senegal, Carpe Verde, Congo, Benin and Togo rank between 17th and 23rd places with emigration rate of 40%, while the English speaking countries in African such as Malawi, Kenya and Ghana have lower emigration rate ranked 25th, 28th and 38th respectively. South African and Nigeria were the only two countries in sub-Saharan African among the top 25 countries with foreign doctors and nurses practising in the OECD countries. This was due to the fact that most African countries have smaller population of workforce (SOPEMI, 2007).

    Statistical data from the American Medical Association (AMA) Physician Master file shows that 5, 334 non-federal trained doctors trained in Africa medical schools were licensed to practise medicine in the United States in 2002. Nigeria account for 2,158, while South Africa 1,943 doctors. Another 478 doctors are from Ghana medical schools. Other countries contributing to the list in sub-Saharan African include Ethiopia - 257 physician, Uganda - 153 doctors, and Kenya - 93 doctors. The total number of 5,334 represents 6% of the total number African doctors (Hagopian et al. 2004).

    After United States, the United Kingdom and Canada are the most common destinations in developed countries for African Physicians, with a total of 3,451 and 2, 151 African trained doctors are recorded to be practising in United Kingdom and Canada respectively. Moreover figures in the UK include only doctors who arrived after 1992 thus the number may probably be higher, other destinations for African-trained doctors include Australia, New Zealand and the Gulf States (Hagopian et al. 2003)

    Migration of doctors also occurs between countries within African continent. For instance, countries such as South Africa, Senegal and Botswana "export" doctors to developed countries and likewise import doctors from other African countries to cater for shortfall in medical personnel (EQUINET, 2003).

    Causes of Brain Drain

    The factors guiding individual choice of migration is in essence personal and thus susceptible to the prevailing personal circumstances. Nonetheless, the economic and social context of such decision deserves an important consideration. Moreover, the disparity between the economic and social development status of different sectors within a particular country and of different countries within African has countries has broaden over the year (Stilwell, 2004).

    Brain drain of doctors and other highly skilled professional from Africa has been blame on unfulfilled dream at country of origin caused by strife, corruption and misuse that mark Africa's post-colonial history (Bridgewater, 2003 cited in Mbanefoh, 2007). Also according to Dovlo (2003), causes can be linked using six gradients which include job satisfaction, salary, career opportunity, governance, social security and benefit, protection and risk. Furthermore the dualistic nature of the world economy has been found to be a major contributing factor to brain drain, as highly skilled medical professionals particularly doctors try to escape the endemic poverty by migrating to wealthy, developed and technologically advanced countries of the world (Mbanefoh, 2007).

    Factors guiding individual decision to emigrate are a result of the interplay of economic, cultural, social, political and legal forces. Others factors encouraging cross-border migration are usually considered under two main categories: "Push" factors (Supply) and "Pull" factors (Demand) (Kline, 2003). Over time the pattern of migration is facilitated through networks that provide prospective migrants with information about job opportunities in countries of destination as well as offer various support to help adjustment after migration (Matin, 2003).

    "Push" factors (Supply) - these are conditions that make a doctor to be dissatisfied with work and professional careers in their country of origin. The factors may be evident both in the developed and developing countries facilitating the migration of health care professionals from one country to another which is perceive to offer better opportunities in some way. However, these factors are more prominent in developing countries, and they greatly influence the decision of doctors to emigrate in these countries.

    "Pull" factors (Demand) - these are conditions in countries of destination that motivate workers to migrate. In the same manner as "push" factors, "pull" factors can also influence the migration of doctors from one developed country to another developed country. However, the pull factors has a more pronounced influence on individuals in developing countries for instance, there is surge in migration of nurses to Canada after the review of cost of living, salaries of nurses became double of what is earned in South Africa, four times more than what is obtained in Ghana and 25th than those in Zambia. Similarly, health care professional will only decide to emigrate if they perceive condition of service is a more superior (or better) to what is available in their home country (Clarke et al, 2006)

    Push and Pull Factors in Health Care Migration

    Push factors

  • Inadequate compensation
  • Lack of career opportunities
  • Lack of opportunities for children
  • Poor quality of life
  • Poor working condition/Job dissatisfaction
  • Work related hazard (HIV/AIDS, tuberculosis, Hepatitis etc)
  • Political instability/War/ ethnic strife/ insecurity etc
  • Pull Factors

  • Safer work environment
  • Greater career opportunities
  • Better compensation
  • Better quality of life
  • Greater career opportunities
  • Political stability
  • Better working condition/greater job satisfaction
  • Impact of medical brain drain

    The impacts of migration health professional are majorly borne by the developing countries that lost a significant numbers of doctors and other healthcare professionals to the developed nations. According to WHO (2002), "health personnel are the people that makes things happen". The loss of these groups of professionals to the developed countries greatly affects both the quality and quantity of health services that is available to the people. Access to effective care is limited and the very few that managed to access the available local facilities; they are welcomed with poor services which could further complicate their present condition.

    The impacts of medical brain drain cut across various sectors of the economy, usually effects of migration of doctors and other health worker from developing countries to the developed nations leave behind largely negative impact on the health system, economy, and even the financial sector of their country of origin. Nevertheless, migrations of doctors to high income have either directly or indirectly contributed positively to specific sectors in the developing countries.

    Impact on Health system

    The apparent effect of shortage of doctors and other health care professionals is that it leads to an early closure of health facilities thereby limiting access to required basic health care. For effective functioning of the health system, a balanced mix of health professionals is required and should be adequately deployed for equitable coverage (Stilwell, 2003).

    A survey of some African countries by Dovlo (1999) shows vacancies level in public health sectors to range between 7.6% - for doctors in Lesotho and 72.9% - for specialist in Ghana. Such vacancies usually translate to inadequate health service coverage with the health need of some population group remain unmet. Emigrations of doctors usually leave a vacuum in the health system and with shortage of health professionals, there is high tendency of finding unqualified health personnel performing tasks and roles for which they have received little or no training (Physician for Human Right, 2004). For instance, in Malawi undertrained staff were deployed to work as ward attendant at some health facilities (Aitken and Kemp 2003), likewise in Ghana, shortage of physician have lead to inadvertent employments of unqualified medical personnel in communities with desperate need (Hagopian 2005) or better still retired physician and surgeon who lacked skills in current medical practises are relied upon for services in some health facilities (Physician for Human Right, 2004)

    Furthermore, There is increased exposure of people to the risk of wrong treatment, misdiagnoses, and poor quality of service while waiting so long to see a doctor who is overworked, contributing to stress, fatigue and perhaps medical errors, in addition, in a very busy health care facilities, little time is spent with each patient, which could limit their ability to fully explore the patient's clinical condition.

    Incessant migration of healthcare professionals to the developed countries increases staff turnover rate thereby resulting in loss of institutional memory. There is continuous reinvention of strategies to manage diseases and illnesses, which is been attributed to shortage of key health professionals and resulting in lack of lack of continuity and formation of gaps within the institution. Loss of institutional memory affect organisation or sector of the economy which limit the ability of health system to build and retain strategies based on experience (Physician for Human Right, 2004).

    At a macro level, shortage of doctors can cause delay in scaling up interventions goals which include the millennium Development Goal (MDG) (WHO, 2002). The World Bank estimated that Tanzania and Chad would need to increase by three to four folds by 2015 in order to be able to render the basic health service in alignment with the MDG (Chen, 2004).

    A major limiting factor affecting the scaling up AIDS treatment in Botswana is shortage of health worker. Botswana government desperately had to recruit doctors from other countries such as India and china to cater for the shortfall (Dugger 2003). Similarly, in South African, the implementation of the National AIDS treatment and care strategy was faced with the same impediment after the first year of its commencement (Wilson et. al., 2006). Importantly, prioritising and scaling up AIDS treatment and other interventions without adequate health professionals may result in a serious negative consequence.

    The major impact of the brain drain is felt among the user of the health service in the remote rural areas, as these groups of are considered lowest in the distribution order of health professionals preferred working location. Any vacancies in the urban area as a result of migration overseas usually result in re-shuffle by doctors from the rural area. The increase erosion of health professionals creates a downward effect and the poor job satisfaction further facilitates health workers to consider emigration (Martineau et al 2004).

    Impact on the economy

    The economy impacts of medical brain drain can be subdivided into the cost and benefits. Cost - The cost of migration of doctors from developing countries are evident. First there is loss of human capital creating a negative spill over effect on the other staff that was left behind (Patel 2003). However these effects are not of significant in cases of temporary migration and in countries with surplus of medical professionals such as Philippines and India. United Nation Conference on Trade and Development survey found out that each migration of doctors and other health professionals represent a financial loss of about US$184,000 to Africa while leaving unfilled vacancies behind. Furthermore, it has been estimated that Africa spends US$ 4billion per year on salaries of 100,000 foreign experts which could have been invested in the development of the health system and other important sector of the economy (Pang et. al., 2002)

    According to The World Health Report (2006), a total of 18,556 medical doctors trained primarily in 10 sub-Saharan African counties (South African, Zimbabwe, Uganda, Cameroon, Ethiopia, Ghana United Republic of Tanzania Angola Nigeria Mozambique are registered and practising in eight OECD countries (Portugal, Canada, Finland, Australia, France, United Kingdom Germany and United States of America).

    The cost of training a medical doctor varies across each country in sub-Saharan Africa; however an average of US$ 65,000 was estimated as the cost of single medical doctor. Estimating the cost of tertiary education to be approximately US$ 48,169 and the cost of primary and secondary education to be US$ 6865 and US$ 10, 963 respectively. South Africa government spends an estimate of US$ 97, 000 to train a medical doctor, thus making an overall loss of approximately US$ 1 billion to investment in medical education which is a third of development aid to South Africa over a period of 1994 - 2000 (Alkire and Chen 2004).

    Considering the cost of education and loss return on investment, a total of US$ 517,931 was spent by Kenya per doctor and US$ 338,862 per nurse (Kingra et. al., 2003). An estimate of US$ 60 million is also spent by Ghana on the training of medical personnel (Martineau et al 2002). According to Chen and Bufford (2005), African looses an estimate of US$ 500 million annually for all skilled workers that emigrated from Africa.

    Further evaluation of this phenomenon shows a net loss of human capital. According an African proverb, "it takes a village to raise a child", in the same manner training of medical doctors require a considerable amount of resources, money, care and other ancillary support. The gradual erosion of the middle class and upper class of the society leaves a social gap which is neither politically economically or culturally healthy for developing countries. Such exodus of skilled professionals deprives African of a solid middle class, a condition that contribute to erosion of democracy (Physicians for Human Rights, 2004). The flight of medical professionals continually put health system in sub-Saharan Africa countries in a state of unending instability and lop-sidedness.

    Benefits - The benefits of migrating from developing or source country usually include, long term professional networks, improved training facilities and also skills acquired may of benefit to the source country upon return (when migration is temporary). Better financial returns in terms of wages, salaries and other emolument and also an increase in financial remittance to home country (World Bank, 2006, Pang et. al., 2002)

    In addition, migrants stand to benefit from further education in view of migration opportunity alongside higher wages. However recent studies show that benefits may be limited and subject to immigration policies (Martine, 2009, Schiff, 2005).

    Migration can also be a source of avenue to relieve pressures from providing employments and other benefits for some categories of skilled worker. For instance a Ghanaian official was cited pointing out that, if all 1,500 doctors practising in other countries were to return home, the government may only be able to accommodate 200 (World Bank 2002, Martine 2009).

    Remittances

    Remittances from migrants constitute an important means through which medical brain drain can be of beneficial effects to developing countries. It is evident that remittances from overseas migrants usually make up a considerable contribution to the Gross National Product (GNP) and also a source of revenue to many developing countries (Docquiliers, 2006).

    It is also been proven that remittances help to improve the economic activity, as well alleviate poverty. For instance, nearly 50% of Indian medical doctors practising in UK remit an average of 16% of their income their home country (Kangasniemi et. al., 2004).

    The financial cost of brain drain to developing countries is partly make up for by remittances that doctors working in high income countries send to their families back their home countries. For instance Ghanaian doctors in Diaspora contribute about US$ 10milllion in remittance. Remittances from doctor are only a fraction of the total remittance that is received from migrants (Physician for Human Rights, 2004).

    Nonetheless, due to the fact that most doctors migrate alongside their families they tend to integrate quickly into the society of their host countries and, the amount they remit is likely to reduce over time (Faini, 2003). Other means of remitting money from overseas is when migrants contribute to their home country by way of investments, business partnerships and also through remittance of foreign currencies.

    Additional skills and knowledge acquired abroad are transferred to their country of origin whenever they returned home. Also among doctors who migrate permanently, some may temporarily return to contribute their skills or may contribute skills and resources through professional networks in Diaspora to the health system of their home countries (Pang et. al., 2002)

    Other benefits accrued to doctors working in developed country include practising in better and much safer working conditions, exposure to use of modern technologies and equipment, opportunities for research and updates with current developments in their profession. Moreover there is a better respect for the civil and political rights of the doctors and their families. Remittances although beneficial to the economy but cannot make up the human capital loss of medical professionals and most often such remittances are sent to family members with none invested in the health care sector especially in the absence of proper functioning health system (Martineau et. al., 2004, Hagopian et. al., 2004, Clarke et. al., 2006).

    Impact of health policies

    The importance of migration among health professionals to the overall effectiveness of the health system in the developed countries cannot be effectively accessed; this has been attributed to limitations in the available data. However there are two key indicators of relative importance to migration and international recruitment of health professionals to a country: by monitoring the inflow of health professionals into a country from their country of origin or by assessing the actual numbers of health in the country at a particular point in time Both the developed and developing country do not currently have any structure in place to accurately monitor the supply and inflow of migrant health professionals. This has limited the capacity to be able to assess in empirical and in clear term the impacts of policies on medical brain drain (Buchan, 2003).

    Although, regarding international migration of doctors, OECD member countries generally prefer long-term policies that enable national self sufficiency to cater for their physician workforce however such policies often entail short to medium term policies to attract doctors from other countries either on a temporary or permanent basis. In order to sustain the adequate supply of doctors in OECD countries, immigration of foreign doctors was considered an important alternative in countries such as Canada, Australia, United States New Zealand and United Kingdom. Conversely, migration of doctors has been perceived in Canada, Sweden and New Zealand to have negatively affected the supply of doctors in their country (OECD, 2002)

    Consequently, an international agreement regulating the migration and employments of doctors was formulated among the OECD countries to regulate the migration of doctors from abroad. One of such agreement that provides temporary immigration for doctors in an OECD country is the General Agreement on Trade in Services (GATS) (Forcier et al, 2004). This comprises of set of legally enforceable rules and regulations that governs trade and services. Mode 4 of GATS agreement addresses the movement of people, and in relation to trade in health services, it also focus on migrant health professionals and the provision of health services within the OECD countries on temporary basis. The possible effect of GATS on health care is controversial however in term of migration of health professionals, such agreement may be of benefit to some countries that often send health workers abroad. On the other hand, the challenges with GATS is that there is no clear definition of "temporary movement" and this may likely affect some migrant from source countries restricting the period for which health professionals can obtain a visa (Stilwell et al 2004).

    Given the limited success of GATS on doctors' migration, OECD countries subsequently adopted specific policies to encourage the immigration of foreign doctors, while making attempt to minimise the negative effect on the home country. Three types of policies were adopted by the OECD countries to encourage migration of foreign doctors. These include international recruitment campaigns of health workers, easing immigration requirement and setting up special programme that encourage shared learning between different health care systems (Adlung and Carzaniga, 2001).

    Requirement for physician migration is reduced in some OECD countries. For instance, the Immigration Act Regulation in Canada favours the migration of doctors and further efforts are been put in place to facilitate the licensure of foreign trained doctors. Similarly, there is relaxation of immigration requirement and conditions for foreign trained doctors in Australia and United States especially to those willing to practise in rural areas. In Ireland, there is existence of mechanism to fast track working visas for foreign doctors (Forcier et al, 2004).

    In addition, the Department of Health launched an International Fellowship Programme in January 2002 to attract experienced specialists from abroad to fill in selected posts in the NHS for periods of one to two years (Department of Health, 2002). Although available information do not indicate the actual number of specialist that was recruited but over 400 application were received. Over 100 psychiatrists were recruited from other countries (largely from India) and were appointed as consultant to the NHS (Patel, 2003).

    The Department of Health in England released an updated code of practice on International recruitment of health worker, it aimed at dissuading NHS employers from recruiting health workers from developing countries, unless an agreement has been made between the two governments (Department of Health, 2004). However, various alternative recruitment routes still exist and are not restricted by the code of practise. These include applicants coming to the United Kingdom for academic purpose rather than employment, staffs which are actively recruited by non NHS employer and individual health workers taking the lead to apply for jobs in the United Kingdom, and some staff actively being recruited by non-NHS employers (Buchan 2004).

    Nonetheless, the Commonwealth countries also adopted Code of Practice for the International Recruitment of Health Workers which is to discourage unethical recruitment of doctors and other health workers from countries which are experiencing shortages. it set out guiding principles for international recruitment of health workers and emphasise mutuality of benefit between the host and home countries. However, few countries among the OECD nations have implemented policies to limit the level of emigration of doctors and there is lack of detail information about the effectiveness of existing policies (Forcier et al, 2004).

    CHAPTER THREE

    RESEARCH METHOD AND METHODOLOGY

    Research design

    The most suitable research design was selected to meet the aims and objectives of the study. The purpose of the study was to conduct a series of interviews to identify the factors that influence the decision the migration of medical doctors to developed countries and the impacts of migration on the health care system in developing country. The focus is analysing the causes and impacts of medical brain drain largely based on the view of Nigerian doctors practising in the United Kingdom.

    Traditionally, science is uniquely quantitative (Streubert and Carpenter, 1999), however the general idea of research is about positioning the researcher in the experiential world and a more practical level it involves relating research question to available data (Punch, 2000). Basically research design is divided into major categories: quantitative and qualitative research method.

    Quantitative research method entails conceptualization of problems in term of experimental comparison, which is based on some intervention or treatment and usually with a clear outcome or variables in mind. It involves the collection and analysis of numerical data and depends on numbers for its conclusion and statistical techniques are often employs for its analysis (Pontin, 2000).

    Qualitative research methods are tools used in understanding and describing the world of human experience. The concept and theoretical elaboration of qualitative research emerge was derived out of words in the collection and analysis of data. Qualitative research design has been selected as the most appropriate method for this study. The reason for adopting this method is due to it creditable nature of analysis and it provides systemic for gaining insights into other persons' views of the social world, 'putting oneself into someone else shoes' (Pogar and Thomas, 2008).

    "Qualitative" as described by Pogar and Thomas, (2008) refers to the nature of data or evidence collected. Qualitative data entail detailed description based on language or recorded pictures by investigator. "Qualitative research method is a research strategy that often emphasise word rather than quantification in the collection and analysis of data. As a research strategy it is inductive, constructionist, and interpretivist" (Bryman, 2008), whereas quantitative researcher does not always subscribe to all the three features. In addition, It can be described as a method of naturalistic enquiry which is often less obstructive than quantitative investigations and does not manipulate research settings. The research method in qualitative research aims at studying people in their natural social setting and to collect a natural occurring data. Demonstrable advantages of qualitative research over quantitative method have been shown in situations in which there is a little pre-existing knowledge (Bowling, 2002).

    Furthermore, Muir Gray (2001) emphasise the usefulness of qualitative research in gaining understanding of health and health services, it also complement and support a quantitative research. The research method is often used in generating hypothesis to solve a problem which be subjected to a test using either a quantitative methods or combination of qualitative and quantitative method (Muir Gray, 2001). Nonetheless, there may be some challenge delineating the nature of qualitative research usually when the link between the theory and research is ambiguous. In qualitative research, theory is usually an outcome of investigation rather than having theory that precedes it (Bryman 2008).

    Sample

    One of the most important decisions required for any research activities is to determine the type of participants essential for the study. As it is usually impossible to sample a whole population, thus researcher select a sample of research subject that represent the whole research population (Polit and Hungler, 1995). Polgar and Thomas (2008), defined sample as a subset of a population while sampling involves the selection of a sample from a population. Sampling method according to Brink and Wood (1998) is a process of selecting the sample form a population in order to obtain information regarding a phenomenon in a way that represents the population of interest. Essentially, if a sample is representative of the study population, A generalise valid sample result to the population can be obtained without going through the expense of studying the whole population.

    Hesse-Biber (2005), argued that the logic of qualitative sampling is concerned with in-depth understanding, working with small sample which is usually a function of the purpose of the study; in light of its sampling frames and of practical constraints. The overall goal of qualitative sampling is to examine the "process" or "meanings" of individual attribute to their given social situation, not necessarily to make generalisations.

    Although, sampling in quantitative research may be probabilistic (if representativeness is important) or purposive (if the focus of the research is to study the relationship between two variables) while qualitative research is often a non probability sampling which is generally restricted to the following method - convenience sampling, purposive sampling, snowball sampling and theoretical sampling (Punch, 2000). The aim of all qualitative method is method is to understand complex phenomena and generate hypothesis, rather than apply the findings to a wider population (Bowling, 2002)

    Sample size

    Samples in qualitative studies are usually small, non random samples; this is due to the use of different consideration in the selection of participants. A critical step in qualitative sampling is the choice of settings with high potential for information richness (Polit and Beck 2000). For instance simple or very detailed studies, single figures may be required; for complex questions large samples and a variety of sampling techniques may be considered. However, in practise, the number of participant required becomes apparent as the study progress Marshall (1996).

    Another important point is that in qualitative studies, individuals are not always considered the unit of analysis. Glaser and Strauss (1967) cited in Polit and Beck, (2000) noted that incidents or experiences are often the basis for analysis. A participant with rich information can therefore contribute dozens of incidents and likewise a small number of participants can generate large samples for analyses (Polit and Beck 2000).

    A total of numbers of eight medical doctors that are of Nigerian origin practising in the UK were recruited for telephone interviews to determine their views about migration of doctors from developing countries to developed countries. Doctors of Nigerian origin were selected by the researcher because of easy accessibility and also the time constraint to undertake this research. Moreover, selection of this particular group of medical professional is special interest to the researcher due of the trend of medical brain drain in Nigeria.

    The inclusion criteria for selecting interviewees were that the participant must be a medical doctor of Nigerian origin, received his/her medical training in Nigeria and practising medicine in the UK. Nigerian doctors who are engaged in other professional activities in UK were excluded from the study.

    A purposive sampling method was used in this study because the research is limited to Nigerian doctors practising in UK. According to Bowling (2002), purposive sampling method aims at sampling a group of people or settings, with particular characteristics. Also it consideration often apply to sampling of cases in which research will be conducted and then to people within those cases. This sampling method is essentially strategic and an entails establishing a good correspondence between the research questions and sampling. It is otherwise known as judgement sampling where the respondents are selected because their knowledge and experience is valuable to the research process (Bryman, 2008). The sampling method can be used in detecting cases within an extreme condition as for certain characteristics or cases within a wide range situation in order to maximize variation (Hesse-Biber, 2005).

    As stated in Bryman (2008), "most writers on sampling in qualitative research based interviews recommend that purposive sampling is conducted". This form of sampling is essentially strategic and entails an attempt to establish a cordial relationship between the research questions and sampling, In other words, the researcher samples on the basis of wanting to interview who are relevant to the research questions. Purposive sampling provides information-rich cases for in-depth study and analysis (Paton 1990).

    However a common disadvantage of this sampling method was that it require an in-depth interviewing, time-consuming data analysis and a rich insight is required in order to understand the social phenomena unlike statistical information (Bowling, 2002).

    In addition to purposive sampling, a snowball sampling method was employed to recruit other participants for the interview based on recommendation from the initials participants. This is a technique used where no sample frame exists and cannot be created. It involves the researcher asking an initial group of respondents to recruit others they know are in the target group (Bowling 2002). Snowball sampling in not sample technique that is employ in quantitative research but within qualitative research (Bryman, 2008). The advantage of snowball sampling is that the initial participants recommends and encourage cooperation and facilitate access to other participants, it is more cost effective and practical and in addition it gives the researcher opportunities to specifies the characteristics that is require of the new participants although the limitation of this approach is that sample may be unrepresentative because sample may be restricted to rather small group or network of contacts (Sapsford and Jupp, 1996)

    Data Collection

    In qualitative studies, data collection is more flexible than in quantitative studies and decisions about what information to collect usually evolve in the field. Qualitative researchers are often prepared for problematic situations that may arise in the process of data collection however the best prearrange plan for data collection sometimes fall through. Essentially, the primary method of collecting qualitative data is majorly through self report, by interviewing other study participants (Polit and Beck, 2008)

    Interviewing remains the principal mode of data collection in qualitative research (May 1991). It is a data collection method in which one person (the interviewer) asks question from people (a responder). Interviews are either conducted by telephone or face-to-face (Polit and Hungler, 1991). The most widely used interview formats are either by semi-structured or open interview methods. In the context of quantitative research study, they are used majorly in preparation of a standardized data collection and the development of data collection tools whereas qualitative interviews play a significant role imparting of expert knowledge about the research field in question, the recording and analysis of the informants' subjective perspective, or collection of data relating to their biography. In actual fact, as a means of acquiring information, interviewing is an element so significant to qualitative methodology (May 1991). Research areas in which qualitative interviews are frequently used include studies of gender-related questions, studies of social and political orientations of different population groups, or studies of access to professions and of professional socialization (Ficks et al, 2004).

    According to Pontin, (2000), three types data are characteristically generated from interviews, these include: peoples experience and account of events; their attitude, perceptions and opinions about phenomena; and biographic and demographic details. This study aim to reflect the doctors' views of Nigerian doctors in terms of reasons, experience, attitude, perception and opinion on "Medical Brian Drain"

    Initial access to Nigerian doctors practising in the UK was through an email to the secretary of Medical Association of Nigerian Specialties and General Practitioners (MANSAG) in the British Isles to seek for volunteers that would be willing to partake in the telephone interviews. Initially, three participants were recruited with the assistance of MANSAG secretary while other participants who participated in the studies were recruited using a snowballing method based recommendation from the initials three participants. These resulted in the selection of eight eligible Nigerian doctors who were willing to participate in the telephone interview. Those fitting the criteria were doctors who trained in Nigeria and are currently practising the medical profession in the UK.

    Individual consent was obtained through an email indicating their interest to participate in the telephone interview. This approach was used as an alternative means of obtaining a writing consent however this method was considered following approval by the Swansea University School of Health Science Research Ethics Committee. Interviews were conducted at scheduled time and of the day which were convenient for the participants. Prior to the commencement of the telephone interview a reaffirmation of the consent were obtained from all the participants.

    Telephone interview was adopted for obtaining detailed information because the participants reside in different location across the UK. Participants felt more comfortable with the approach because of their busy work schedules. The purpose of the study was made clear to the participants and they were encouraged through reassurance to be plain in their response.

    A semi-structured interview schedules with mainly fixed question with no response codes was designed for the interview process and was used flexibly to allow the researcher to probe and also to enable the respondents to raise other relevant issues lacking in the interview schedule. Other importance of semi-structured interview schedules is that it permit the researcher to ask the questions out of order at appropriate opportunities during the interview (Bowling, 2002). The semi-structured telephone interviews were conducted over an average of 20 minutes for each of the participants. The interview process was conversational and interactive in nature.

    The interview was audio recorded and stored in a digital format for easy transcribing. It allowed the researcher to attend to the participants rather than manually recording of all responses. Furthermore, recording and transcribing interviews data has been shown to have the following advantages: it allows a more detailed examination of participants' responses, protects against accusations that analysis might have been influenced by researcher's value or biases. The recording and transcribing of interview data also opens up the data to public scrutiny by other researcher who can carry out a secondary analysis of the obtained data. However, the procedure can be time-consuming, and requires good equipment for the recording and transcribing of data (Bryman, 2008).

    Although the telephone interview is an established and acceptable approach for quantitative data collection; it is a method principally used for survey analysis (Aday, 1996) and is most widely used survey modality in industrialized nations (Pontin, 2005). According to Bowling (2002), interview conducted by telephone appear to have equal accuracy rates to face-to-face interviews in relation to the collection of data on a study on general health status and the prevalence of depressive symptoms. Other major advantages of telephone interviews is that, in theory is economic and relative to time and available resources (Bowling, 2002); there is decreased cost and travel, particularly when compared to face-to-face interviews, respondent are located in their normal environment, it has the ability to reach wide geographically dispersed respondents and greater interviewer safety (Bryman, 2008). Thus, in this study, telephone interviewing made it possible for the interviewer to stay more focused on the interviewee's responses. Furthermore, it gave the participants more anonymity and this seemed to reduce their anxiety about participating. According to Pontin, (2005), "respondents in qualitative interview have been described to be relaxed on the telephone, and willing to talk freely and to disclose intimate information" and also qualitative telephone data have been judged to contain rich, clear, detailed, and of good quality information (Sturges and Hanrahan, 2004).

    Nonetheless, telephone interview is less used compared to face-to-face interviews in qualitative research (Opdenakker, 2006; Sweet, 2002); it may perhaps be an adaptable data collection tool (Carr and Worth, 2001). Notable disadvantages of telephone interviews include lack of visual cues, and the potential for possible distraction of participants by activities in their environments (Opdenakker, 2006), although such distractions may also occur during a face to face interview. Also, the duration for telephone interviews may be short compared to face-to-face interviews which may affect the in-depth of the interview. However this little evidence to support the assertion (Sweet, 2002, Sturges and Hanrahan, 2004)

    Data Analysis

    The purpose of qualitative data analysis is to provide structure, organise, and elicit meaning from research data. Qualitative data analysis is labour intensive activities that require creativity, conceptual sensitivity and rigorous work (Polit and Beck, 2008). Thorme (2000) described qualitative data analysis as the most complex and mysterious of all of the phases of a qualitative project.

    Although qualitative study usually relies on inductive reasoning process to interpret and structure the meaning that are derived from data. Differentiating inductive from deductive inquiry processes is an important step in identifying what is important in qualitative research. Essentially, inductive reasoning makes use of data to generate ideas (generating hypothesis), while in deductive reasoning begins with idea and makes use data to compare the idea (testing hypothesis). However, many quantitative studies uses of inductive reasoning, while good qualitative studies usually requires various types of strategies for data analysis.

    Furthermore, qualitative research often takes the position that an interpretive understanding is only possible by means of revealing the meanings of a phenomenon. Thus, a difference between explaining how something operates (explanation) and why it operates in the manner that it does (interpretation) may be a more effective way to distinguish quantitative from qualitative analytic processes involved in any particular study (Thorne, 2000).

    According to Morse and Field (1995, pg 126) cited in Polit and Beck (2008), qualitative data analysis is a "process of fitting data together, of making the invisible obvious, of liking and attributing consequence to antecedents. It is a process of conjecture and verification, of correction and modification, of suggestion and defence".

    Analysis of data in qualitative study frequently involves analysis of verbatim transcripts of dialogues and narratives (Polgar and Thomas, 2008). It normally begins with a search for broad categories or themes. Themes emerge from data which often develop within categories of data but may also cut across them. The search for themes involves not only for discoveries of common meaning across the participants but also seeking natural variation (Polit and Beck, 2008). A common point of variation for the analysis of transcribed data is developing a coding system. The coding system is used to categorise data into specific classes (Polgar and Thomas, 2008).

    In analysing data, codes that identifies with common themes were used as they emerge from the transcribed data. However most researchers support different approaches to coding but it typically involves in depth studying of the transcribed data and development of close familiarity with the data. During the analytical process, all the ideas concepts and themes are noted to form major categories. Having developed codes for the transcribed data, the reporting of this process often involves detailed description of the categories and their context, with liberal use of examples from the data (Polgar and Thomas, 2008).

    However, in order to identify prominent themes and the patterns among the theme, a qualitative content analysis method was adopted. It involves breaking down data into smaller units, coding and naming the units according to the content, and grouping coded material on shared concepts (Polit and Beck, 2008). According to Hsieh and Shannon (2005), "qualitative content analysis is defined as a research method for the subjective interpretation of the content of text data through the systematic classification process of coding and identifying themes or patterns". Researchers using qualitative content analysis emphasis focus on the characteristics of language as communication with concentration to the content or contextual meaning of the text (Thorne 2000)

    Semi-structured open ended questions were designed in advance for the data collection. The questions were design out of findings from literature review interview to ensure specific research themes are covered.

    Telephone interviews were conducted to determine the view of Nigerian doctors practising in the UK. The interviews were audio recorded to ensure that the interviews data are the actual verbatim responses of the participants and the audio recording was subsequently transcribed over a period of one week. The advantage of transcribing interviews is that aid interpretation by early identification of key themes and increases the familiarity of the researcher with the data (David, 2005, Bryman, 2008).

    Moreover, it is strongly suggested that qualitative interviews be recorded and simultaneously transcribed, rather than depending on interview notes. Note-taking may be incomplete and biased which could be caused by a gap in the researcher's memory recalled time or personal views (Polit and Beck, 2008).

    The transcribed data were read and reread to identify and index themes and also to categories the data: these centred on particular incidents, phrases, or types of activities regarding doctors' migration.

    All relevant data related to each category were identified and, each data was checked and compared with the others to establish different analytical categories. This however involves a coherent and systematic approach (Pope et. al., 2000). Categorisation of the data by theme was done manually, which has the advantage of maintaining close relationship and understanding of the original data by the researcher however this could be time-consuming for large databases (Bowling, 2002).

    Validity, Reliability and Rigor

    Without rigor, research is worthless; it becomes fiction, and loses its effectiveness. Therefore, a great deal of consideration is given to reliability and validity in all research methods (Morse et. al., 2002). Evaluation of research studies is an essential criterion in the application of research findings. Traditionally, such evaluation has focus on assessment of reliability and validity. However, their use in qualitative work has been questioned (Long and Johnson, 2000). The term 'Reliability and Validity' are concept often used in testing or evaluating quality of quantitative research, nonetheless, the idea is often used in virtually all kind of research (Golafshani, 2003, Bryman, 2008).

    According to Patton (2001) validity and reliability are two important factors which any qualitative researcher should put into consideration while designing a study, analysing data and judging the quality of the study. Moreover, Mason (1996:12) cited in Bryman, (2008) argued that reliability, validity and generalisability "are different kinds of measure of the quality, rigor and wider potential of research, which are achieved according to certain methodological and disciplinary conventions and principles".

    However, reliability and validity have been substituted with a parallel concept of "trustworthiness" which is made up of four different criteria: credibility, transferability, dependability, and confirmability. These contain specific methodological strategies for demonstrating rigor in qualitative studies, is often used to evaluate coding, categorizing, or confirming data results with participants, negative case analysis, peer debriefing, structural corroboration, and referential material adequacy (Lincoln & Guba, 1985). In addition to the four trustworthiness criteria, Lincoln and Guba suggest criteria of authenticity.

    Thus this study can be evaluated using the suggested four criteria of trustworthiness of a qualitative inquiry as described by Lincoln and Guba in Polit and Beck (2008):

    Credibility: refers to the confidence in accuracy of the data and its interpretation. The researcher ensured the research was carried out in accordance to the cannons of good practise and findings which can be subjected to further validation by external reader or investigator.

    Transferability: refers essentially to the generalisation of the data, the extent to which finding can be transferred or apply in other settings or groups. The findings of this study were oriented to the appropriate uniqueness and significance of 'Medical Brain Drain' to the aspect of the social world being studied.

    Dependability: refers to the stability (reliability in quantitative research) of data over time and conditions. This entails ensuring proper records of the research process and procedures were properly kept in an accessible manner. These include details of problem formulations, selection criteria of research participants' interview transcripts and data analysis results.

    Confirmability: refers to objectivity which is essential for congruence between two or more people about the data's accuracy, relevance or meaning. While recognising that complete objectivity is impossible in social research, the researcher ensures his personal values or theoretical inclination has not influenced the conduct of the research and its outcome.

    Authenticity: refers to the extent of fairness and faithfulness shown of a range of different realities by the researcher. These were ensured by asking all the participants the same type of semi-structured open ended questions, all the participants belong to the same social setting and were also subjected to the same medium and method of data collections process.

    Ethical issues

    The basic principle governing the ethical issues in social research is that the people should not be at risk as a result of participating in a research and an informed consent should be obtained before being allowed to participate (Richards H. M., and Schwartz L. J., 2002).

    Approval for this study was obtained from Swansea University School of Health Science Research Ethics Committee before the commencement of the study; this was to ensure research ethics was not compromised. Initial contact to the participants was through the secretary of Medical Association of Nigerian Specialist and General Practitioner in British Isles (MANSAG). The participants were contacted and briefed about the study through an email. An information sheet alongside a written consent was sent to the participants via email 2 weeks prior to the interview. This was to allow the participants to make a voluntary decision regarding their participation. Participants gave consent by replying the email stating "I agree to take part in the study" and they also gave their preferred day and time for the telephone interview. This was to ensure there was no interfering with their work or other personal day schedule. Consent was later reaffirmed verbally at the beginning of the interview.

    The telephone interviews were conducted on days and time which were convenient for each of the participants. The semi structured interview questions were flexible enough to allow participants to raise issues regarding "medical brain drain" that were not included in the in the questions and also they were encourage to share their experiences in the UK and in their home country Nigeria, before emigrating, however efforts were made by the researcher to ensure the participants do not lose focus of the objectives of study and the interviews were guided through relevant probe questions.

    All the participants were assured that the data collected would be kept completely anonymous and codes will be used for each participant instead of names. The audio recording and the data transcript from the telephone interview were securely stored in a safe place. The recorded data would be secured for a period of 5years before being destroyed. In addition participants were informed and assured prior to the interview that they retain the right to withdraw from the study at any stage of the process without any reason.

    The researcher ensured the research process was open to scrutiny to address any challenging issues, for example from colleagues and academic supervisor.

    CHAPTER FOUR

    FINDINGS

    This chapter discusses the data findings from the telephone interviews. Several themes emerged out of the data analysis using the process of qualitative content analysis as the title for each category. Each of the themes are analysed individually relative to the literature review in the previous chapter. However, there are some similarities due to the recurrence of some findings in several themes.

    In order to maintain anonymity and confidentiality, each of the participants will be identified with letter 'P' and number (i.e. Participant 1 will be identified as 'P1').

    The findings are analysed under the following themes:

  • Factors that influence the migration of medical doctors from developing countries to the developed countries such as UK.
  • The benefits of practising medicine in the UK
  • The impacts of doctors migration on developing countries
  • Views on how to manage medical brain drain.
  • Factors that influence the migration of medical doctors from developing countries to the developed countries such as UK

    Factors the influence doctors migration to developed countries were collated from interview questions that relate to what the doctors perceived as the causes of medical brain drain, personal reason for migrating, opportunities for residency training and medical practise in the UK. Majority of the doctors cited economic reasons such as poor remunerations and welfare facilities, lack of diagnostic equipment, and the fact that doctors are better appreciated in developed countries. However, none of the doctors interviewed consider opportunities for residency training has a significant factor for doctors migration.

    According to P2, the main factor why most doctors choose to migrate to develop countries is for economic reason, "I was earning less than £250 every month, I needed to go to a place where I would probably be appreciated more or earn more" and this statement was confirmed by P7 who expressed that "doctors are better rewarded in terms of remunerations than in Nigeria" while other reasons cited for migration by P7 are to acquire more skills, comfort, working in an environment with good standard of living. Also, similar to previous factors by other participants, P6 stated his main reason for leaving Nigeria for UK, "is to source for a greener pasture, in terms of better financial reward, stable economy and good living environment". P1 felt that "doctors migrate to the developed countries in search of better qualities of job, better welfare, better working conditions and better innovations". P5 mentioned "job satisfaction, financial incentives, then general standard of living because in most African countries including Nigeria, social amenities is very poor, electricity supply is not regular, the roads are bad and there is no safety in term of protection of life and property".

    In addition to better financial packages P4, felt "the availability of modern diagnostic facilities for laboratory and radiological investigations in UK compared to Nigeria has a lot of influence on doctors migration". Moreover, "working in country like the UK where the standard of health care service that is offered by the NHS is high has a significant influence on doctors' migration". However, according to P3, "I personally chose to migrate to the UK because I have dual nationalities, in addition to being a Nigerian, I have a British citizenship and knowing full well that I would be better appreciated in the UK, I decided to migrate to the UK after my medical education".

    Opportunities for residency training has no major influence on the participants decision to migrate to UK, it is believed "getting a training post both in Nigeria, UK and other developed countries is difficult, however about 1:10 foreign doctors still end up in getting a training post, so speciality training has little or no influence on my decision", stated by P6.

    The benefits of practising medicine in the UK

    These findings were obtained from what doctors perceived they have benefited as result of practising in the UK when compared to Nigeria, their views about the UK health system and their contribution to their home country. The doctors compared the practise of medicine in UK to the way they had practise medicine back in their home country Nigeria.

    P1 thinks "practise of medicine in the UK is far better than the practise back home in Nigeria, they practise evidence based medicine, most of what I was thought in school, that I never saw in terms of investigating equipment, clinical cases were read in textbooks, I have been able to see a lot of them here. P1 further reiterated "I am now more experienced and I think I can efficiently treat patient better even if I returned to my country". P2 also shared the similar opinion, “medical practise is a lot better in the UK although the principle of the practice is the same but in UK there are diagnostic facilities which make the work easier and laboratory results are timely, you work in a good clean environment; monetary wise, in term of new skills, and I can always put the skills into practise. I have been exposed to a lot of new technological innovations in medicine".

    P5 was able to conclude based on personal experience "there is financial benefit, you work, you earn good money, when you look at the bank account you are happy. Life is comfortable because you can afford all the basic amenities, you live in comfortable house there is electricity, the roads are good, and life is comfortable". P3 thinks medical practise in the UK is far better than Nigeria, consistently the mortality and morbidity rate is low; the life expectancy rate is high than in Nigeria and the NHS is one of the best health schemes in the world

    However, P7 did not totally agree with a better practise in the UK "I would not use the word better because medicine is the same only that the facilities are better and you get to see a lot of cases you read in books, the remunerations are better; there are job satisfaction and the availability of modern diagnostic facilities which makes the practise more interesting than in Nigeria". This view was also shared by P4 "medicine is a universal and holistic moreover the cases you see in the two countries are different but the approach to management, the history taking, the investigation are all the same, the only difference is that people do not have money to do basic investigations such as the full blood count, malaria parasite, talk less of the specialise test such as DNA chromosomal analysis, liver function test which are very expensive". Doctors are well paid in UK, their happier, there is job satisfaction, working in safe environment, and there are facilities for investigation.

    According to P6 "you are expose to many clinical cases that you in read in textbook and medicine is practise the way it should be practice coupled with the better remunerations you get for working as a doctor in UK. In addition you gain recognition, if you worked here and got a UK experience and you are better recognized compared to if you had worked in Nigeria or any developing nation".

    In spite of the better remunerations none of the doctors have contributed either directly or indirectly to the development of the health care system in Nigeria however money are sent home to friends and family members for their upkeep. Also, participants remit money to home country for investment purpose. Apart from these, P4 also send money to Nigeria for charity purpose "I was given a Nigerian child by an NGO to be sponsoring, to help the child, to provide education, health care and other basic needs. I give a monthly contribution for the up keep of the child".

    The negative impacts of doctors' migration on developing countries

    The impacts of medical brain drain on developing can be described as overwhelming. The impacts cut across the various sector of national economy. These vary from the negative impacts on the health care system, effect on the social class, the workforce and other economic indicators. The migrations of doctors from developing country often lead to reduction in the number of doctors that should be available to the country. This has been alleged to yield negative consequences on the health care system in developing countries.

    P6 felt migration of doctors to the developed country will cause "a shortage of manpower in the health sector" in term of doctors' patients' ratio. P6 further stated that "there won't be enough doctors to practise and they have to rely on quacks and other paramedics which may not be to the interest of the patient". In addition, P1beleived migration of doctors will cause a decay in the health care system due to shortage of manpower, "if we had limited number of doctors there will be excess workload on available doctors and a lot of malpractices, the health care system will be very expensive because of the law of demand and supply, if the demand is more than supply then the price of services will definitely go up, and moreover, there is no way sick people can be productive or contribute to the development of his country". P4 thinks that the contributions the doctors would have made to the country or to health care are lost because to brain drain. P4 further stated that "medical brain drain was also found to erode some group of people that are suppose to occupy the middle class in the society", their contributions to the country economy is lost and also when there are no doctors to care for the sick, the working population of the country gradually fades away.

    According to P5, when professionals in a country migrate to other country for instance, "when doctors migrate, the hospital become short staffed then the health of the people suffers, the working population would reduced, national income would go down, definitely at some point it would have an impact maybe not immediately but over time it would have a negative impact on the economy". Other views of other participants include: P7 who thinks the depletion of the health workforce which will invariably worsen the poor health indicators such as the morbidity and mortality rates. In addition, "when you have an economy being run by less healthy people it would have a negative influence on the country economy and in the long term it will also affect the possibly the GDP, GNP and other economic indicators of such country".

    Similarly, P2 felt that "when people are sick and they don't see doctors to treat them they can't go to work, when they do not go to work they become unproductive and that will definitely has impact on the GDP and other economic growth factors". However, further effect on the health sector was expressed by P3 who believed the shortage of doctors has also contributed to the increase in mortality and morbidity rate in Nigeria. "People are dying every day from basic illness that should not result to death, a nation with sick people and with higher mortality rate will definitely not have enough people in the productive age group to work. This will definitely have a rebound negative effect on the economy indicators of the country, the more people that are loss to illness or death the greater the effect on the economy of the country".

    Views on managing medical brain drain

    These findings reflect the views of Nigerian doctors practising in the UK on how best to manage medical brain drain both by the developing and the developed countries, awareness about policies on limiting the recruitment of foreign doctors and their perception about returning back to their home countries.

    Only four of the participants had a little knowledge about policies toward restricting the recruitment of foreign doctors in developed countries. According to P5, "I don't know the detail but I know WHO is working on a policy to limit the developed countries from recruiting health care workers from developing countries". P3 mentioned that "doctors are required to get work permit to work and getting a permit is becoming difficult they want to limit the number of work permit that is issued to foreign doctors except when such vacancies cannot be filled by UK or EU citizen". Similarly in term of career development P6 stated that "priority is given to British citizen first then EU member citizen. It is when available opportunities have been filled by this group of people that any other foreign doctors can be considered especially for training post". However P7 felt once you are able to scale through "immigration bottlenecks" and you can write the necessary examinations and get registered with the General Medical Council in the UK. He does not think any available policies should limit such doctors from getting employment. Moreover, P2 did not think such policy would hold because people have that liberty to move around, we all have a right to free movement and such policy would not really work in a democratic society.

    Notwithstanding different approaches were recommended by the participants for managing medical brain drain in the developing country. Most of the recommendations focused on the development of the health care system, provision of diagnostic facilities, improving doctors' welfare packages and also the provision of basic social amenities such as roads electricity and security.

    P7 suggested that African countries should concentrate on developing their healthcare system in such a way that the doctors will not be interested in migrating to other countries. When there is job satisfaction which is usually a combination of many factors like remunerations, working condition and environment, "I think so many doctors will prefer to stay back in their country rather than sourcing for greener pastures elsewhere". In a similar opinion by P6 the developing countries should make the health care system to function, improve infrastructures, better remunerations for doctors and the developed countries can also help to develop the health care system in the developing countries through the donation of facilities to the health care system rather than giving financial aids. P1 thinks the developing countries should improve the welfare of the doctors likewise P3 believes remuneration is the number one reason why most doctors are migrating and further suggested that "to stay back in Nigeria, the pay should be at equal to with is earned in other sectors of the economy such as the IT, banking sector".

    P2 thinks governments in developing countries should concentrate on the development of the health care sector not just paying attention to doctors' issues alone, everyone in the health sector should be well treated; provide the necessary equipments and diagnostic tools. In addition, P4 also advocate the provision of facilities in the hospitals alongside improving the welfare of the doctors and by improving the quality of life of health workers. P5 lay emphasis on prioritisation of health care in developing countries, according to P5, "a lot of fund has to be invested in the health care system and to ensure health is a priority; funding for health is important and they have to implement the taxation system properly so that people can pay tax and can get extra money to fund the health care system".

    However, none of the participants supported placing a restriction on recruitment of foreign doctors by the developed countries rather they advocate the development of the health care system and improvement in remunerations package for health professionals. For instance, P5 opinion regarding limiting foreign doctors from seeking employments in developed countries was that "developed countries should not limit doctors from coming in from developing countries because doctors migrate for different reason." In Nigeria some doctors are leaving the clinical profession to do something else or work in another industry, even if you force them to stay in the country it does not mean they would function as doctors, the idea is government should try and maximize the resources that is available in the country such that doctors would be encourage to stay in the country". In addition, the developed country can also assist developing countries to improve their health care system.

    Regarding returning back to Nigeria to continue medical practise in the nearest future, all the participants expressed their desire to return to Nigeria to contribute to the development of the country in their own little capacity but none is willing to return in the immediate or nearest future.

    CHAPTER FIVE

    Discussions

    analysis of findings

    The factors influencing medical brain drain are complex with no simple strategic measures to mitigate the phenomenon. This study has been able to confirm role of push and pull factors on medical brain drain. The main influencing factors indicate that the cause of medical brain drain are similar and may be difficult to alter. While this findings has shown that opportunities for residency or specialist training has little or no influence on the decision of the participants to emigrate to UK, Forcier, et al. (2004) revealed in his study that doctors migrate abroad for training purposes, either to study medicine or to obtain additional professional qualifications and others to gain experience with standard medical practise, moreover immigration for training and academic purposes have contributed for a substantial number of foreign-trained physicians in a country. Foreign doctors attending postgraduate training in England made up 39.6% of all international medical graduates in the NHS in 1995, 36.2% in 2000 and 37.3% in 2001. Similarly international medical graduates in United States attending postgraduate training comprised 11.9% of all international medical graduates in 1980, 12.1% in 1990, 15.1% in 1995 and 13.1% in 2000. However recent changes in immigration policy regarding restriction of international medical graduates' access to UK postgraduate training could account for the views of the participants (Department of Health, 2008).

    It is apparent that remunerations play a significant role toward emigration of doctors to developed countries. All the doctors admitted to a better financial incentive as an influence toward their decision to migrate to the UK. Poor pay is a widely recognized and most important push factors driving health professionals from low-income countries, although salaries vary significantly within sub-Saharan Africa and as well across health professionals. The findings were consistent with Stilwell et. al., (2004) that salaries might be so low in some country to deny doctor the basic means of caring for himself and his family. Dovlo (2003) broadly agreed that it leads to low morale, job dissatisfaction and poor quality of services as many doctors may find themselves engaging in other activities to supplement their earnings. For instance, the average earnings of an entry level doctor is Nigeria is about £4,800 per annum, this represent the earnings at the State level while their counterpart at the Local government level earn significantly less. Federal Government employees are the top-paid health workers in Nigeria and most private employers pay less than the Governments (Labiran et al 2008) however their counterparts in the United Kingdom earn about £24,960 per annum (Careers BMJ 2009). In another survey the salaries of junior doctors in sub-Saharan countries showed a range of $50 per month in Sierra Leone to $1242 in South Africa (EQUINET 2003) while a general practitioner doctors in Ghana are paid almost triple the salary of nurses, about $575 compared to $172 (Dovlo, 2003).

    In a survey by Kangasniemi et. al., (2007) it was apparent that doctors' salaries in UK are markedly higher in nominal terms, with basic salaries 6 to 10 times higher with substantial allowances in addition. Nevertheless, when price levels are taken into account, the difference in salaries may narrow down considerably. Although, while it may be difficult to compare the incomes of doctors in different countries, it is obvious that the enormous difference in real income will continue to be a motivating factors for emigration of doctors from sub-Saharan Africa (Astor et. al., 2005). Moreover, even when health workers are able to meet their current financial needs, they may worry about their future, particularly their financial security and their children's education. According to a statement by President of the Ghana Medical Association, Dr. Jacob Plange-Rhule cited in Physicians for Human Rights, (2004), "The current situation does not allow them to make adequate savings and really it does not assure any future security. So people are leaving to earn adequate monies to put some away into proper pension schemes. . . ."

    Doctors also emigrate because they do not want to practise medicine in what is regarded as a "second-class health system" where medicine is practised in an unsafe condition, an environment where basic diagnostic equipment is lacking with increasing difficulty meeting the demand of the patients and couple with the lack of basic social amenities, security to lives and properties. In other words, doctors want to live in and work in an environment where they would be better appreciated and given the due recognitions. Evidence from this study was consistent with a study in Zimbabwe in 1998 where it was found that among the principal reason why doctors' are leaving the public sector was that basic diagnostic equipments were lacking, supplies and drugs to offer effective care for their patients were not readily available. Inadvertently, the doctors and other health workers felt they had lost the capacity to heal (EQUINET 2003). Tools are required by health professionals to execute their job. An environment where health professionals have the knowledge and skills to render effective service to their patients, but lack the medicines, equipments and supplies, to apply these skills is extremely demoralizing. However part of the response to brain drain, therefore, traverse with broader agenda of ensuring that necessary physical infrastructure and apparatus including other systems are in place to enable health systems to function effectively.

    Moreover, it is also possible that if other factors are strong enough, such as working in a second-class or a dysfunctional health system, a significant rise in salaries might have little or no effect on decision to emigrate for better opportunities. Many of these push factors are evident cause of medical brain drain among health professionals in sub-Saharan African countries. Nonetheless, other studies showed the effects of the pull factors in developed countries such as the shortages of health professionals largely due to demographics changes which include the aging populations, aging health workers and likewise the growing health care expectations have favoured the employments of foreign doctors in developed countries (Dodani and LaPorte, 2005)

    In spite of various challenges that foreign doctors faced in destination countries before being eligible to practise which include financial implications, passing qualifying examinations and obtaining licences from medical council or board in host countries. Most of the doctors regarded their migration has a worthwhile effort. The study showed that participants have benefited in different capacities as a result of practising medicine in the UK. These are evident in terms of remunerations that are received when compared to what is obtained in home country and likewise the amount of money that is remitted for investments, families and friends in Nigeria. Remittances from foreign doctors living in developed countries constitute a major proportion of foreign exchange revenue for many developing countries (Dodani and LaPorte (2005). It has been estimated that Africans working abroad remit about US$45 billion to their home country yearly. While the significance of remittances for developing countries cannot be over emphasised, it does not account for the social costs and negative impacts on developing economies. Nevertheless, the value of the remittance is increasing and the annual rate of increase has been found to be higher than the record for the annual rate of GDP growth in 119 low and lower middle-income developing countries over the last two decades (Faini, 2007). Furthermore, medical practise in the UK expose migrant doctors to what can be regarded as "standard medical practise". Working in such environment provides adequate exposure to standard diagnostic and laboratory equipments with various opportunities for career development.

    The migration of doctors from developing countries is unquestionably damaging. Many countries in sub-Saharan African have reducing life expectancies partly as a result of shortage of medical personnel's which are continuously being loss to brain drain. Similarly the morbidity and mortality rates have continue to worsen. These however have resulted in untold negative effects on the health system in developing countries. Besides the weak health systems of developing countries, the system may be brought to a halt due to lack of doctors and other qualify health personnel, this invariably may mitigate the achievement of the health related MDG set out by WHO. Mullan (2005) maintained that the weakened physician workforce of many poor countries will limits the ability of those countries to respond adequately to HIV/AIDS infections and other pressing health needs. The most important consequences of medical brain drain are the negative impacts on health care delivery systems due to loss of skill medical personnel's. This has resulted in poor health care services especially in the rural areas that continuously lack trained health staff and are managed by nurse or community health worker with limited competency. The resultant effect is an increase in the workload for the inadequate doctors which can result in burnout, stress and may lead to misdiagnosis of illnesses. According to Awases, (2007), emigration of doctors can be a “skill loss" when doctors with special skills are lost to developed countries. For instance, the lost of a paediatric surgeon may lead to the closing down of paediatric surgical clinic. This may be devastating to the community served by the specialist if no alternative can be sort out.

    It is also observed from this study that apart from the effects brain drain on the health system, there are lost to the economy; migrants' are not able to contribute to their quota to their country's GDP. It also lead to other indirect costs on the country's economy these may include: costs of illness caused or worsened by shortage of medical personnel's, costs of substituting less qualified staff and the enormous cost of importing expatriates to fill the vacant position. Moreover, the enormous resources spent by developing countries in training doctors are lost to the developed countries when such doctors emigrate permanently (Dolvo, 2003). The impact of medical brain drain however differs from nation to nation, but there are always costs to the developing countries in terms of financial and human capital loss. In a survey by Dovlo and Nyonator (1999) the direct cost of training a medical doctor in Africa is $40,000; an estimated costs of US$5.96 million in tuition was lost by Ghana alone from the 61 per cent of medical graduates who emigrated from a single medical school. This excludes costs of pre-medical school training (primary and secondary education) (Dovlo and Nyonator 1999). Consequently, losses to Nigeria and Zimbabwe would have exceeded tens of millions of dollars per year from training doctors who rapidly emigrate in search of greener pastures (Schrecker and Labonte, 2004).

    The factors influencing the international migration of doctors from developing countries suggest that emigration is likely to continue unless effort are made to focus on measures of managing and regulating the phenomenon to confer benefits on both the developing and developed countries. Although it is logical to argue that developing countries cannot compete with the "pull factors" in the developed countries, it is essential for the home countries to recognise their role in developing strategies to attract and retain doctors back to their home country. Nonetheless, two major actions required to motivate health workers, which will have among its affects help to stem brain drain. These actions include improving salaries and benefits, and ensuring the availability of physical infrastructure, tools, and medical equipment, drugs, and medical supplies that support a conducive work environment for the doctors and other health related professionals." (WHO 2002)

    The developed countries however need to put right their desire to recruit doctors from the poor countries and the need to comply with the principle of ethical conduct on recruitment of doctors from overseas countries. Forcier et al., (2004) argued that thus far, the codes of practise on ethical recruitment is yet to produce the expected outcome, given that such codes do not legally apply to all developed countries and moreover, the codes do not prevent recruitment of doctors from identified countries, but prohibits recruitment campaigns in such countries.

    According to the secretary general of the World Medical Association Dr. Otmar Kloiber cited in Lopes (2008), it was argued that there is presently no ideal model for restricting migrations of health workers from developing countries however, a policy has to be redeveloped to improve the economies of developing countries to a service based and also strengthen the entire health care system. Ultimately, there is an urgent need to define obligations and responsibilities between the developed and developing countries in tackling the brain drain phenomenon of doctors. Unless necessary steps are taken, health care delivery in developing countries may be heading for a disaster.

    Limitations of the Study

    According to Patton, (2002), "There are no perfectly research designs", thus all research projects have limitations. Study's limitation demonstrates the researcher understands of reality and prevents the researcher from making a presumptuous generalizability or conclusiveness about the research (Marshall and Rossman, 2006).

    This study was based on a small telephone interviews and subjective views of Nigerian doctors practising in the UK. A small sample of 7 instead of the initial 8 participants could only be accommodated. The last participant opted out after several failed attempts to reschedule a telephone interview with her. This approach nonetheless has some apparent weaknesses; apart from the in-depth nature of the study and the limited time frame, the study was only limited to doctors of Nigerian origin in the UK, the findings however could not be a reflection of general perspectives of other doctors from different low income countries or other nationalities practising in the UK. In addition, the views of doctors living and working in Nigeria and other developing countries in sub-Saharan African were lacking, therefore this study could not determine the true picture of the effects of doctors' migration on health care delivery system in Nigeria and other part of Africa. Thus, the findings of this study could not be generalised. A further study would therefore be recommended on larger scale and across wide boundaries to address the various limitations of this study and to be able to produce a more generalisable outcome. In additions, future study could examine the effectiveness of various policies on migration of health workers such as the Code of Practice for the International Recruitment of Health Workers and other measures to stem the migration of doctors and other health professionals to richer nations.

    This study however shows consistencies with factors that principally influence doctors' migration to developed nations and the significance of impacts of medical brain drain on developing countries particularly in sub-Saharan Africa. Although it fails to explore the effectiveness of policies on ethical recruitment of overseas doctors in UK and other developed countries nonetheless, the inconsistencies were compensated for by determining the perspective of the doctors on how to manage medical brain drain both in the developed and developing countries.

    CHAPTER SIX

    Conclusion

    The emigration of doctors from sub-Saharan Africa to developed countries continues to be an impediment to global health. Although this is a small study within a limited time frame, it has been able to provide valuable evidence to reflect the views Nigerian doctors practising in the UK regarding determining factors and the consequences of medical brain drain in developing countries. In addition, this study has been able to provide suggestions on how brain drain phenomenon among doctors can be managed as part of a solution rather than as a challenge. It is obvious that migration of doctors is influenced by different factors of which some are amendable through strategic interventions. Development of strategies and policies to remove the "push" factors which encourage the migration of doctors and focusing more emphasis on the provision of infrastructures and diagnostic equipments, provision of better working condition; ensuring remunerations are at par with other sectors of the economy, expanding facilities and opportunities for postgraduate medical training and research. In addition, improving the social and living condition in terms of quality education for children, transportation facilities, housing, and security to lives and properties are some of the measures identified in this study that may be employed to a reduce the incidence of medical brain drain in sub-Saharan African and possibly attract migrant doctors back to their home countries.

    The "pull" factors which is more or less a reversal of the aforementioned "push" factors that influence the migrations of doctors from poor countries may likely persist unless insistent actions are taken while the wide gap in the economies of the two worlds will continue to create opportunities that attract doctors from the poor regions of the world for the benefits of the developed nations. However, achieving a meaningful solution to this impasse will require both the developing and developed countries to operate in partnership for mutual benefits. The development of a concerted effort by WHO to proffer urgent measures to emigration of doctors will go a long way in savaging the developing countries from the negative impacts of medical brain drain.

    Overall, this study has provided further insights to the cause, impacts and possible management of medical brain drain among Nigerian doctors practising in the UK. The findings from this study can therefore be used to develop additional strategies to curtail the migration of doctors from sub-Saharan Africa.

    Nonetheless, the limitations of this study needs to be acknowledged. Due to the time restriction, the small sample size and limited scope of this study, an in-depth study would be required t in future on a larger scale to be able to provide a more generalisable findings and to further research into policies and measures to limit the migration of doctors and other health workers from developing to the developed countries of this world.

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