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Abstract

Background: Loss of human resources in the health sector through migration has caused many problems in the delivery of healthcare services in developing countries. Objective: The aim of this study was to determine factors influencing intention to migrate in skilled human resources in Iran's healthcare sector. Methods: This cross-sectional study was carried out in 2016 in Iran. The study population included health sector human resources at the Tehran and Iran University of Medical Sciences. Using multi-stage cluster sampling, 827 people were selected for participation. Participants included four groups: hospital staff, health workers, medical students, and postgraduate students (Masters and PhD). Data were collected using a valid and reliable questionnaire and analyzed by descriptive parameters, chi-square and logistic regression test using SPSS version 18. Results: Inclination to migrate, in the study population, was 54.77%. There was a significant relationship between inclination to migrate and age, work experience, employment status, marital status, familiarity with a foreign language, foreign language skills, foreign language courses, having relatives or family living abroad, and prior experience of being abroad (p<0.05). The most important factors influencing inclination to migrate were: reaching out for better life (81.92±21.95), interdisciplinary discrimination (80.83±20.75), and experience of living and studying abroad. (80.55±18.12). Conclusion: Considering the high rate of intention to emigrate in the studied population (54.77%), a lot of whom will emigrate if their situation is ready, it can be a serious problem for the health system in the near future in which it will face lack of skilled health workers, and so requires more attention of health sector authorities.
Electronic Physician (ISSN: 2008-5842) http://www.ephysician.ir
June 2017, Volume: 9, Issue: 6, Pages: 4669-4677, DOI: http://dx.doi.org/10.19082/4669
Corresponding author:
Associate Professor Dr. Department of Health Management and Economics, School of Public Health, Tehran
University of Medical Sciences, Tehran, Iran. Tel: +98.2142933170, Email: ahmadiba@tums.ac.ir
Received: January 19, 2017, Accepted: February 26, 2017, Published: June 2017
iThenticate screening: February 26, 2017, English editing: March 19, 2017, Quality control: May 12, 2017
© 2017 The Authors. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-
NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is
non-commercial and no modifications or adaptations are made.
Page 4669
Factors affecting intent to immigration among Iranian health workers in 2016
Heshmatollah Asadi1, Batoul Ahmadi2, Saharnaz Nedjat3, Ali Akbari Sari4, Hasan Abolghasem Gorji5,
Gholamhossein Salehi Zalani6
1M.Sc. of Health Services Management, Department of Health Management and Economics, School of Public
Health, Tehran University of Medical Sciences, Tehran, Iran
2Ph.D. of Health Services Management, Associate Professor, Department of Health Management and Economics,
School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
3Ph.D. of Epidemiology, Professor, Department of Epidemiology and Biostatistics, School of Public Health, Tehran
University of Medical Sciences, Tehran, Iran
4Ph.D. of Health Policy & Management, Professor, Department of Health Management and Economics, School of
Public Health, Tehran University of Medical Sciences, Tehran, Iran
5Ph.D. of Health Services Management, Assistant Professor, Department of Healthcare Management, School of
Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
6Ph.D. of Psychology, Assistant Professor, Department of Health Technology Assessment (HTA), Deputy of
Curative Affairs, Ministry of Health and Medical Education, Tehran, Iran
Type of article: Original
Abstract
Background: Loss of human resources in the health sector through migration has caused many problems in the
delivery of healthcare services in developing countries.
Objective: The aim of this study was to determine factors influencing intention to migrate in skilled human
resources in Iran’s healthcare sector.
Methods: This cross-sectional study was carried out in 2016 in Iran. The study population included health sector
human resources at the Tehran and Iran University of Medical Sciences. Using multi -stage cluster sampling, 827
people were selected for participation. Participants inclu ded four groups: hospital staff, health workers, medical
students, and postgraduate students (Masters and PhD). Data were collected using a valid and reliable
questionnaire and analyzed by descriptive parameters, chi-square and logistic regression test using SPSS version
18.
Results: Inclination to migrate, in the study population, was 54.77%. There was a significant relationship
between inclination to migrate and age, work experience, employment status, marital status, familiarity with a
foreign language, foreign language skills, foreign language courses, having relatives or family living abroad, and
prior experience of being abroad (p<0.05). The most important factors influencing inclination to migrate were:
reaching out for better life (81.92±21.95), interdisciplinary discrimination (80.83±20.75), and experience of
living and studying abroad. (80.55±18.12),
Conclusion: Considering the high rate of intention to emigrate in the studied population (54.77%), a lot of whom
will emigrate if their situation is ready, it can be a serious problem for the health system in the near future in
which it will face lack of skilled health workers, and so requires more attention of health sector authorities.
Keywords: Immigration, Manpower, Delivery of Health care, Iran
1. Introduction
Human resources are important for a country’s development, and a lack of human resource capital, delays processes
of growth and development, especially in developing countries (1). In recent years, the importance of human
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resources has been neglected in health systems of developing countries (2). Additionally, one of the potential risks in
developing countries is migration of skilled human resources, otherwise known as brain drain that reduces human
resources’ capital (3). Brain drain is the international transfer of resources in terms of human capital and is
ultimately used for the migration of professionals from developing countries (origin) to developed countries
(destination) (4). In terms of economic calculations made by industrialized c ountries, attraction of a well-educated
person with a master's or doctorate degree from a developing country is valued at a million dollars for the
destination country. Hence, it is observed that developing countries, despite having 80% of the world’s popu lation,
have only 20% of global income and hold only 1% of human resources related to the sciences (5). Migration can be
a major cause of decline in the healthcare sector of the source country in terms of capacity of health personnel,
disruption to service provision, dissatisfaction and development of a situation whereby other staff quit, increased
waiting times, rising costs of care, loss of many experienced teachers, loss of active members of the population, and
an increased number of dependents in a society (6, 7). According to reports on statistics showing the extent of
migration in countries of the Organization for Economic Co-operation and Development (OECD): Iran, South Korea
and the Philippines had the most significant statistics. According to this r eport, among the university educated
Iranian population; about 25% was living in countries of the OECD (8). This means that one in four Iranians with a
college degree was working abroad. In 2009, Iran had the highest rate of migration of skilled and educat ed people
among 91 developed and developing countries (9). Various studies have introduced a wide range of variables as
factors affecting human migration. Variables such as social, cultural, economic, professional issues, bureaucracy and
globalization are some causes of migration of skilled human resources (10, 11). Lufterz et al., conducted a study in
2013 in which they found that the most common causes of migration were socioeconomic and political, and that the
most important reason for selecting migration to Canada was family issues (12). Nouri Hekmat et al., revealed that
from the viewpoint of students of Iran University of Medical Sciences, important factors affecting migration
included economic and education considerations as well as administrative, professional, globalization, social and
cultural factors (13). During the last 10 years, only one study has been done on causes of migration in the field of
Medical Sciences in Iran. There exists also, a gap in the available information in this area, so that most of the
available information was from international reports of organizations such as the IMF (International Monetary
Fund). Findings of this study can inform the Iranian policy makers of the factors influencing the migration of the
healthcare workforce and guide the initial step in planning to prevent or reduce migration of Iranian health care
workers. Accordingly, this study was done to determine factors affecting migration of skilled human resources in the
health sector in Iran.
2. Material and Methods
2.1. Research design and selection criteria
The present study was cross-sectional and was conducted in 2016 in Iran in the Eastern Mediterranean region. The
study population included hospital staff, health center staff, medical students and postgradu ate students affiliated to
Tehran and Iran University of Medical Sciences. The inclusion criteria were: 1) being an Iranian, 2) having
completed studies in health sciences or working in healthcare related organizations.
2.2. Sampling
Given that in previous studies (13), the standard deviation of the factors affecting migration was determined (SD
was equal to 0.7), the sample size determined to be 189. Since there were four main classes, the number of samples
was multiplied by the number of groups (four groups). That is to say, the final sample contained 756 subjects and
given that it was probable that some questionnaires would be left unanswered, 850 questionnaires were distributed.
Therefore, sampling was conducted according to the multi-stage cluster method and 827 samples were applied to the
study. Postgraduate students of Iran and Tehran universities and medical students of both Schools of Medicine were
sampled. In addition, three hospitals and four health centers were selected randomly from Iran and Te hran
Universities of Medical Sciences. The hospitals affiliated to Iran University of Medical Sciences included Firoozgar,
Shahid Fahmideh and Shafa Yahyaeian hospitals, and the hospitals affiliated to Tehran University of Medical
Sciences included Roozbeh, Farabi and Sina hospitals. The health centers affiliated to Iran University of Medical
Sciences included Olympics, Saadat Abad, Shahid Kazemian and Shahid Ghafari health centers, and those affiliated
to Tehran University of Medical Sciences included Farmanfarmayan, Akbar Abad, and 14 Masoum and Meysam
health centers.
2.3. Instrument and data collection
Data were collected using a researcher-made questionnaire. The questionnaire was reviewed by seven professors of
Tehran and Iran University of Medical Sciences (four professors from Tehran University of Medical Sciences and
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three professors from the Iran University of Medical Sciences), in order to confirm its validity, and the questionnaire
was revised and redesigned after comments. The test-retest method was used to determine reliability of the
questionnaire. For this purpose, a small group of 20 people was selected out of the main sample, and questionnaires
were distributed among them. After three weeks, questionnaires were re -distributed and then analyzed using the
Intracluster Correlation Coefficient (ICC) test. After calculating ICC of the questions, questions with ICC index
evaluation more than 0.7 were approved, and directly entered into the final questionnaire, but questions with ICC
index evaluation of less than 0.7 were re-examined, therefore, 10 questions were corrected and four were eliminated;
finally, 40 questions were retained in the questionnaire. The questionnaire consisted of 12 key dimensions including:
gaining experience (two questions), strengthening the scientific status of the person (two questions), lack of utilizing
the skills of graduates (three questions), relating to children (two questions), issues related to the workplace (eight
questions), discrimination interdisciplinary (four questions), problems in the research field (three questions),
problems in the field of education (two questions), structure of the Ministry of Health (two questions), reaching for a
better life (two questions), economic and financial situation (three quest ions), and political and social issues (seven
questions). The average score for each dimension could be obtained by assigning the scores to the choices as
follows: "ineffective" = 0, "very low" = 1, "low" = 2, "average" = 3, "high" = 4, and "very high" = 5 . Finally, for a
better comparison between the scores of each dimension with regard to the number of the questions, they were
changed into 0 to 100 scores. After final confirmation of questionnaires and with the necessary permits from the
Tehran and Iran University of Medical Sciences, questionnaires were distributed among the groups of participants
and then collected after a week. Considering the heavy workload of staff (health centers and hospitals),
questionnaires were distributed and collected by researchers during hours and days when there was a lower
workload.
2.4. Ethics
In this study, ethical considerations were taken into account. To this purpose, necessary permits were obtained from
Tehran and Iran Universities of Medical Sciences to distribute t he questionnaires, and the subjects were assured of
the confidentiality of the information at all stages of the research.
2.5. Statistical analysis
After collection of questionnaires, data were analyzed using SPSS version 18 (SPSS Inc., Chicago, Illinois, USA)
using descriptive statistics and chi-square tests, Fisher's exact test, and logistic regression analysis.
3. Results
Among the 827 studied subjects, 453 subjects (54.77%) had an inclination to migrate. Other findings were related to
demographic data, and their relationship with inclination to migrate are presented in Table 1. The findings of this
study demonstrate a significant relationship between inclination to migrate and variables such as age, work
experience, employment status, marital status, familiarity with a foreign language, foreign language skills, foreign
language courses, having relatives or family abroad, and experience abroad (p<0.05). The findings of this study
show that people less than 35 years old and with less than five years’ work experience, informal employment status,
familiarity with more than one foreign language, high level of foreign language skill, relatives living abroad,
experience of being abroad and those who had taken a foreign language course, were the most inclined to migrate
(Table 1). Table 2 shows reasons for inclination to migrate. The results of this study demonstrated that all causes of
migration received top rates (above 70), respectively. The findings also revealed that the most important factors
affecting inclination to migrate in the health sector human resources included reaching out for a better life,
interdisciplinary discrimination, and to experience education or living abroad. Using logistic regression, factors
affecting people's inclination to migrate, shown in Table 3, demonstrate that age, level of skill in a foreign language,
foreign language courses and having relatives living abroad were effective on inclination to migrate.
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Table 1. Demographic characteristics and intention to migrate
Demographic variables
n (%)
Intention to migrate
p-value
Yes (%)
No (%)
Healthcare center
197 (23.82)
93 (47.20)
104 (52.79)
0.062
University (Postgraduate
student)
239 (28.89)
134 (56.06)
105 (43.93)
Hospital
222 (26.84)
123 (55.40)
99 (44.59)
University (Medical
student)
169 (20.43)
103 (60.94)
66 (39.05)
Male
333 (40.26)
183 (54.95)
150 (45.04)
0.932
Female
494 (59.73)
270 (54.65)
224 (45.34)
< 3
630 (77.30)
374 (59.36)
256 (40.63)
0.001
> 35
185 (22.69)
74 (40.00)
111 (60.00)
< 5
525 (64.89)
310 (59.04)
215 (40.95)
0.002
> 5
284 (35.10)
136 (47.88)
148 (52.11)
Permanent
277 (33.65)
131 (47.29)
146 (52.70)
0.002
Primary or Unemployment
546 (66.34)
320 (58.60)
226 (41.39)
Single
458 (56.05)
274 (59.82)
184 (40.17)
0.001
Married
359 (43.94)
174 (48.46)
185 (51.53)
High
32 (3.86)
20 (65.50)
12 (37.50)
0.627
Upper middle
255 (31.44)
136 (47.62)
119 (52.38)
Middle
431 (53.14)
235 (54.52)
196 (45.48)
Lower middle
80 (9.86)
46 (57.50)
34 (42.50)
Low
13 (1.60)
9 (75.00)
4 (25.00)
One language
683 (84.52)
366 (53.58)
317 (46.41)
0.031
At least two language
125 (15.47)
80 (64.00)
45 (36.00)
One skill*
298 (37.81)
130 (43.62)
168 (56.37)
0.001
Two skills**
274 (34.77)
159 (58.02)
115 (41.97)
Three skills***
216 (27.41)
147 (68.05)
69 (31.94)
Yes
264 (37.76)
180 (68.18)
84 (31.81)
0.001
No
435 (62.23)
200 (45.97)
235 (54.02)
Yes
443 (53.95)
279 (62.97)
164 (37.02)
0.001
No
378 (46.04)
172 (45.50)
206 (54.49)
Yes
65 (7.95)
45 (69.23)
20 (30.76)
0.014
No
752 (92.04)
402 (53.45)
350 (46.54)
*having one skill (reading) **having two skills (reading and speaking/writing) ***having three skills (reading,
speaking and writing). Note: Frequency totals may be less than the stated ndue to missing values.
Table 2. Factors influencing intention to migrate in the sample
Influencing Factors
Causes
Mean score* (SD)
Personal factors
Achieving a better life
81.92 (21.95)
Gaining new experiences
80.55 (18.12)
For children
71.86 (27.68)
Occupational factors
Interdisciplinary discrimination
80.83 (20.75)
Strengthening the scientific status
79.95 (19.42)
Workplace problems
76.76 (20.66)
Economic factors
Economic & financial problems
77.46 (25.38)
Structural factors
Educational system problems
77.41 (21.27)
Structural problems arising from Ministry of Health
77.27 (23.34)
Problems in the field of research
74.56 (23.20)
Lack of optimal use of the knowledge and experiences of graduates
71.53 (20.83)
Socio-political factors
Socio-political limitations
74.06 (22.29)
* Attainable score: 0-100
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Table 3. Factors predicting intention to migrate in the studied sample
Variables
OR
95% CI
Designation
Healthcare center (Ref)
1
University (Postgraduate student)
1.050
-0.403, 0.501
Hospital
1.143
-0.296, 0.565
University (Medical student)
1.001
-0.529, 0.532
Age (years)
< 35
2.262
0.301, 1.332
> 35 (Ref)
1
Work experience
< 5
1.010
-0.489, 0.510
> 5 (Ref)
1
Employment status
Permanent (Ref)
1
Primary or Unemployment
1.120
-0.359, 0.586
Marital status
Single
0.771
-0.591, 0.072
Married (Ref)
1
Familiarity to foreign language
One language (Ref)
1
At least two language
1.317
-0.145, 0.697
Foreign language skills
One skill (Ref)
1
Two skills
1.414
-0.009, 0.702
Three skills
1.713
0.123, 0.953
Had taken foreign language courses
Yes
1.807
0.221, 0.946
No (Ref)
1
Having relatives/close friends abroad
Yes
1.790
0.280, 0.884
No (Ref)
1
Have been abroad before as student or for
professional experience
Yes
1.454
-0.216, 0.965
No (Ref)
1
CI: confidence interval; OR: Odds ratio; Ref: Reference
4. Discussion
Iran is a country with a high level of migration and a great number of Iranians migrate to other countries every year
(14). Among students of medical science who were sent abroad from Iran supported by scholarships, 39.6% haven’t
returned to the country (15). Results of the present study reveal that 54.77% of participants had an inclination to
migrate. The results of the present research were consistent with those reported by Lee and Moon about the
inclination to migrate in nursing students (16). Additionally, Alaeddini et al., found similar results in a study to
determine inclination to migration and its causes among Iranian doctors (17).
4.1. Individual factors
These factors include experience, for children’s safety, and to achieve a better life. Yeganeh -Arani et al., in their
study demonstrated that for students of the medical department of Malawi, experience of studyi ng in a better
environment in a foreign country, and achieving a better position were the most important factors on inclination to
migrate (18). Kingma and Buchan found that individual progress was the most important factor influencing
migration of nurses (19). Sheikh et al., also found that having a better life and having better position and
opportunities were reasons for migration among Pakistani doctors (20). Hence, some people tend to migrate because
of their personal situations, and they may emigrate regardless of the conditions of their country.
4.2. Occupational factors
Occupational factors included reasons related to the work environment, to strengthen scientific -professional status
and interdisciplinary discrimination. Reasons related to the work environment were the most frequent cause of
migration in the context of migration of human resources in the health sector. Lack of equipment and facilities in
hospitals, high numbers of patients, high-risk environment, safety at work (21); job satisfaction, better working
environment abroad, better management abroad, pressure of colleagues in the country of origin, high working hours
and heavy workload, job position (22); improvement of workplace status (23); the status of current job satisfaction
(24); poor employment conditions in the country of origin (25) and to advance career and job status (26) were all
reasons related to occupational factors mentioned in various studies as reasons for migration among workers in
health resources. Therefore, to keep employees in the country, work environments must be taken into special
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consideration. Job promotion conditions in the workplace have to be fair so that interdisciplinary discrimination
could be reduced.
4.3. Structural factors
Structural factors included problems caused by misdirected policies and regulations of the Ministry of Health, lack
of optimal utilization of graduates, problems with the education system and problems in some areas of research.
Kolčić et al., introduced the structure of Croatia's healthcare organization as a main reason for inclination of medical
students to migrate (27). A study conducted in Pakistan also showed that working in a better healthcare orga nization
provided motivation for migration (28). Results of other studies revealed reasons for migration of general
practitioners as an unclear role of general practitioners, requirement for physicians to work in rural and underserved
areas, low quality education in the country of origin, higher quality education in destination countries, limited access
or lack of access to specialist training and availability of better research funds in the destination country (29, 30). In
fact, the consistency between the results of different studies and those of the present study indicate that the
importance of these factors in migration of employees is confirmed, and more investment on research needs to be
done in order to keep the employees in the country. Furthermore, education practices have to be reviewed and
cumbersome rules and regulations should be removed from the Ministry of Health.
4.4. Economic and financial reasons
Financial and economic reasons can also be mentioned as important factors in migration. Solberg et al., identified
economic factors as the most important in migration among Icelandic physicians (22). Income, payment, to improve
income, to secure a better rate of pay abroad, inconsistency in level of income, economic factors, higher income,
financial success, the search for more money, economic problems, salary cuts, low wages, more remuneration,
expectation of a higher salary, high-income tax and low salary were the most important factors influencing
migration of health human resources in European, Asian and African countries (28, 31-35).
4.5. Socio-political reasons
It seems that this category of reasons formed the basic idea of migration. Moreover, these factors were completely
beyond the control of the health system, and related to society at the macro level. In a study conducted in Uganda on
migration of physicians, it was found that one reason for inclination to migrate among medical students was political
considerations (21). A study in Pakistan on medical students, revealed that discrimination and religious reasons
caused migration (20). In another study conducted on pharmacists in nine countries, sociopolitical environment of
the country of origin was expressed as a reason for emigration (36).
The World Health Organization (WHO), in a report in 2006, stated that the main factor in decisions to migrate was
to achieve a better life and livelihood. Unhappiness and dissatisfaction with current living and working conditions
were termed push factors that lead to more stimulation for a decision for migration. Additionally, awareness of a
better job elsewhere and the hope of finding better conditions led to intensification of the immigration process, were
termed as pull factors. The WHO emphasizes that factors such as lack of prospect for promotion, p oor management,
high workload and heavy workload, lack of facilities, poor living conditions, and high level of violence and crime
constituted push factors; while hope of earning better pay, promotion of skills and abilities, the aim of obtaining
experience, a more secure environment, and family issues were all considered as pull factors (37).
4.6. Demographic factors
Results of the present research showed a significant inverse relationship between age and inclination to migrate,
while logistic regression results also demonstrated that people under 35 years of age were more likely to migrate.
Other studies also reported a relationship between age and inclination to migrate (16, 18, 38, 39). The results of
Selmer et al., demonstrated that younger people were more motivated by external reasons and when they intended to
migrate, they faced fewer hazards or risks. Also, it was expressed that young people were motivated by adventure,
money and career, and that they placed great value on economic benefits (40). Ad ditionally, there was a significant
inverse relationship between work experience and inclination to migrate and people with less than five years’ work
experience were more likely to migrate. However, people with permanent employment status were less likely to
migrate and these two variables (i.e., work experience and employment status) were interconnected. The results of
this study are consistent with findings of Oyeyemi et al. The study by Oyeyemi et al., also found a significant
inverse relationship between work experience and inclination to migrate in physiotherapists (41). This may have
been because individuals have different dependency considerations within the country. In other words, people with
less experience and informal employment status had less dependency considerations. On the other hand, this issue
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was probably dependent on immigration policy in the destination country because immigration countries have
policies that account for conditions such as age and number of years in employment. Therefor e, it is suggested that
in order to prevent migration of health sector human resources, some action should be taken to provide job security
for recent graduates. Our findings show a significant relationship between marital status and inclination to migrate ,
while single people were more likely to migrate, and similar results are reported in Santric -Milicevic et al., (38).
Ribeiro et al., reports that marital status and marriage were factors that affected non-return to the country of origin
(35). In the present study, there was a significant relationship between inclination to migrate and variables such as
familiarity with foreign language, foreign language skills, and having taken a foreign language course (Table 1).
Moreover, results of logistic regression also showed that people who had more foreign language skills and those
who had passed a foreign language course were more inclined to migrate. Santric -Milicevic demonstrated that the
reasons for Serbian nurses to work abroad were related to foreign language skills (38). Other studies have also
reported that language was effective in selecting a country for immigration, and linguistic similarities facilitate
migration (35). But another study reported that the number of foreign languages that a person could s peak had no
relationship with inclination to migrate (42). The cause of inconsistency between these different studies was
probably due to differences in the studied countries, destination countries, or language of the destination country.
WHO statistics showed that the rate of foreign human resources was higher in English -speaking countries (37). It is
recommended that further research be done to investigate this aspect. Having relatives abroad was also determined
as a contributing factor on inclination to migrate in this study. Other studies (23, 29, 33, 38) also found that having
relatives and friends abroad was related to inclination to migrate. Experience of being abroad was an important
factor influencing inclination to migrate, and has been mentioned i n various other studies (22, 36, 38). The results of
this study, in relation to demographic factors, can be applied to inform policy-makers and health authorities on
identification of whom they should focus on to prevent migration. Therefore, programs desi gned to prevent
migration, should target groups of the population that are the most likely to migrate. These programs should focus
particularly on young people, particularly those who are recent graduates.
5. Conclusions
The findings of the present research show that inclination to migrate was 54.77% among Iran's health professionals.
Achieving a better life, interdisciplinary discrimination, and gaining new experience were considered as the main
reasons for migration among health professionals. It is rec ommended that, as a first step to preventing migration,
certain organizations be developed to assess the immigration status of human resources and to evaluate the policy of
the health system in relation to immigration. Finally, conducting research on approaches to prevent migration of
health human resources in Iran and to study the experiences of other countries, is an appropriate guideline for future
research. One limitation of this study was the lack of cooperation by Shahid Beheshti University of Medical
Sciences that did not permit us to distribute the questionnaires. For this reason, only two universities of Medical
Sciences (Iran and Tehran) were studied.
Acknowledgments:
This study was part of a PhD thesis supported by the Tehran University of Medica l Sciences (TUMS); grant no.
9121532001.
Conflict of Interest:
There is no conflict of interest to be declared.
Authors' contributions:
All authors contributed to this project and article equally. All authors read and approved the final manuscript.
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... Low-or middle-income countries often face a loss of skilled, intellectual and technical labour due to the movement of said workers to more favourable geographic, economic or professional destinations, a phenomenon which is called 'human capital flight' or 'brain drain' (Entezarkheir 2005;Kainth 2009;Panahi 2012;Van Hear et al. 2012;Torbat 2002). Yet, existing evidence suggests that, ultimately, the migrants' intention/decision to emigrate from their native country is the result of the interaction between both push and pull factors (Asadi et al. 2017;Cummings et al. 2015). ...
... unique historical, linguistic and racial characteristics), the country has developed a very distinct culture in the region (Ali and Amirshahi 2002). It is widely known that Iran contains one of the oldest civilizations in the world, but the country also represents one of the fastest growing ones, in relation to emigration, in the world (Asadi et al. 2017). In 2006, it was reported that Iran had the highest rate of emigration of its skilled workers among 91 developed and developing countries. ...
... These findings are consistent with those of previous studies which have identified a list of repulsion and attraction factors associated with emigration from Iran and brain drain (Asadi et al. 2017;Panahi 2012;Rahmandoust et al. 2011;Entezarkheir 2005;Haghighat 2010;Hakimzadeh 2006). ...
Article
It is estimated that almost 244 million people have migrated around the world for a variety of complex reasons. For some, (tertiary) education has been the primary motivating factor. Countries that experience a brain drain as a result of migration may suffer a population and cultural loss. Iran is believed to suffer from such a brain drain in their skilled-labour market, otherwise known in many areas as education immigration. This study was undertaken to explore why Iranian students emigrate to Malaysia and what are the most common causes of migration growth that have accompanied this trend. A descriptive analytical research method, cross-sectional in nature, was applied. A sample of 250 Iranian postgraduate and undergraduate students-who were studying in Malaysia-was selected randomly to participate in this study. A self-administered questionnaire was adapted to collect data, which was tested for validity and reliability based on the research scholars' advice and calculating Cronbach's alpha coefficient (α = 0.90). 'SPSS' v. 19.0 was used to analyse the data. The significance level was set at 0.05. In total, 219 questionnaires were completed. The majority of students (73.5%) were male, and most of them (62.1%) belonged to the age group of 25-30 years. Nearly 65% of the students had been living in Malaysia for 3 years or more. Low tuition fees and living costs (68%), exceptional educational technologies at Malaysian universities (54.3%), the existence of international companies in Malaysia (65.3%), easy entry to Malaysian universities (70.3%), high rankings of Malaysian universities in the world (58%) and greater freedom in social interaction for respondents compared to Iran (49.3%) were the most compelling reasons for these students' emigration to Malaysia. Further analysis revealed that Iranian students' intention to emigrate to Malaysia was significantly correlated with socio-political factors and religious concerns in Iran, reasonable tuition fees in Malaysia and access to advanced technologies and international cooperation in Malaysia. Other contributing factors included the simple process of obtaining an entry visa and subsequent resident visa or work permits for Malaysia and the high rankings of Malaysian universities among international institutions (P value < 0.001). Concern over the issue of immigration continues to mount confounding and challenging legislators, politicians, community leaders, policy-makers and academics to develop solutions to overcome it. In the case of Iran, authorities are required to focus on the big picture of the immigration process and should explore the extent of the challenges Iranian students face. They need to secure the employment of graduates produced by educational institutions to ensure their country does not continue to experience brain drain. A more unified effort is required to stop the brain drain by establishing high-tech, affordable and accessible universities in Iran and offering more freedom in the areas of politics, social and religious activities.
... The lack of skills of new employees leads to a decrease in the quality of services provided to patients (Roche et al., 2015). One study found that, 54.77% of health professionals in Iran have intention to immigrate (Asadi et al., 2017), and statistics from the Iranian Nursing Organization in 2018 show that about 1,000 nurses immigrate annually from Iran (Shari moghaddam, 2018). Perhaps the most important reasons for nursing immigration are dissatisfaction with working conditions, comparison of living standards with destination countries (Valizadeh et al., 2016), economic factors (Zolot, 2019) and the unavailability of support networks . ...
... The study of intention to immigration in nursing students in South Korea showed similar results (Lee and Moon, 2013;Lee, 2016). Asadi et al found similar results in determining the intention to immigration and its reasons among Iranian healthcare professionals (Asadi et al., 2017). While the Freeman's study (2012) showed that 85% of nursing graduates in a city in Canada preferred to work in Canada, and only 15% of them intended to immigrate to other countries (Freeman et al., 2012). ...
... Among other results of this study was the link between work experience, employment status and nurses' intention to immigration, so that nurses with low work experience and non-permanent employment status had more intention to immigration. The results of this study are consistent with the study of Asadi et al (2017) that was conducted on healthcare professionals in Iran (Asadi et al., 2017). This result may be related to job security, which is higher in permanently employed nurses. ...
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Background The immigration of nurses in Iran is increasing day by day, and it seems work-related factors such as workload and healthy work environment are associated with the intention to immigration. Objectives this study was conducted to determine the intention to immigration in nurses and its relationship with workload and healthy work environment. Methods This cross-sectional, descriptive-correlational study was conducted in 2020 by simple random sampling method of 360 nurses working in hospitals in Iran. The study instruments were questionnaires of demographics, Intention to immigration (Lee, 2016), Workload (NASA-TLX) and healthy work environment (AACN, 2005). Data were analyzed by SPSS software and descriptive tests. p value < 0.05 was considered statistically significant. Results The score of intention to immigration was 65.59%, which indicated a high level of intention to immigration in nurses. There was a significant but weak correlation between intention to immigrate, with workload (r = 0.166, p = 0.002) and healthy work environment (r = 0.16, p = 0.002). Conclusion there was a weak but important relationship between the intention to immigration, workload and healthy work environment. More studies on factors related to the intention to immigration are required.
... 12,13 Ambition of working and studying in a country with a developed healthcare system were among the most significant pull factors influenced healthcare workers' decisions for migration to the UK. 14 More than half of the Iranian health workers who intended to migrate were concerned about structural and professional factors such as unfavorable educational environment and inter-professional inequity. 15 Healthcare worker migration could influence both source and destination countries. However, the source countries are most affected by its negative impacts due to loss of skilled human resources. ...
... 41 Societal expectations, marketing of studying abroad advertising by doctors with experience of training abroad and prevalent culture of migration among family and friends living abroad or residents retraining abroad were also among the most important driving factors of migration. 41 The factors inhibiting Family concerns Better future and education for children 15,23,28,34,36,37,39 , partner or parent decision for migration 27 , having a family living abroad 27,32,38,39,41,42 Factors influencing the migration intention of health professionals in low-and-middle income countries Sara Hajian J Contemp Med Sci | Vol. 6, No. 6, November-December 2020: 256-261 migration from countries of origin to countries of destination were termed "repel & retain" factors which were classified into four: (i) individual, (ii) social, (iii) occupational, and (iv) political categories. 41 The inhibitive role of certain barriers such as financial problems, equivalency exams, and visa process as well as the role of social pressure and marketing of abroad training as mediating factors affecting the migration decision of medical graduates have been highlighted. ...
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Objective Migration of healthcare workers could result in shortage of human resources and rising inequalities in service provision in resource poor countries. The aim of this review was to determine the factors influencing the migration decisions of medical and dental graduates migrating from low- and middle-income countries as well as introducing a practical model for health professional’s migration. Methods Google Scholar and PubMed were searched together with relevant journals for English studies from January 2005 to January 2020. The original studies which evaluated the motivational factors of dental and medical graduates migrating from low or middle income countries were included. The migration model was developed by investigating the factors and frameworks of selected studies. Results Twenty-five articles were met the inclusion criteria. Push and pull theory was the most popular way to describe the driving factors of migration. These factors were classified into three macro-, meso- and micro-level with eight key domains. Poor income, unfavorable socio-economic situation, political instability, lack of professional and educational opportunities together with family and personal concerns found as strong common reasons perpetuating migration. Conclusion Despite the fact that health workers migrate for different reasons, they follow a same route for decision to stay or leave their home countries. Un-fulfillment of expectations in mother land in addition to media reconstructed reality of life in foreign land can develop a positive attitude for better quality of life improvement after migration. Once individuals could overpass their national identity and barriers of migration, the final decision toward migration would be more feasible.
... attention to the issues of physicians, such as continuous education, creating employment opportunities, job security, and welfare. While, in developing countries, a host of scientific, economical, technological, and political problems as well as lack of advanced research facilities, welfare, and the inability of the community to use physicians' expertise, stimulates the physicians to leave their homeland (3,5). For example, in Pakistan, low salaries and benefits, poor quality of education, job dissatisfaction, lifestyle, lack of job opportunities, working environment problems, terrorism, social harassment, management weakness, colleagues' pressure, long hours of work, and religious and political variables are the main barriers for retention of physicians (6,7). ...
... Developing societies need skilled health professionals to maintain and improve their health, and motivating them to stay through providing the tools they need to work, the educational opportunities, the support for their colleagues' network, and the recognition of their difficult work facilitate achieving this goal. The presence of an intellectual leader and the activation of a scientific-national community with the help of citizens abroad will make the coherent development of scientific and technological capacities in developing countries more, which will be mutually beneficial (for both educated people and the country) (3,9). ...
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Background: Physicians and health professionals are the cornerstone of health systems and play an indelible role in promoting the health of each community. As mentioned by the World Bank, human capital, particularly elites and highly skilled human resources, is the wealth of countries. Maintaining and preserving them is the prerequisite of sustainable development of the health sector, availability, and quality of health services. Objectives: The main purpose of this study was to identify the effective key variables in the retention of native Iranian physicians and preventing their migration abroad. Methods: This study was conducted using a mixed-method approach based on a sequential exploratory strategy in 2018. In the qualitative section, semi-structured interviews were conducted with 36 faculty members of Shiraz University of Medical Sciences (SUMS). The theoretical saturation was reached via a purposeful sampling and maximum variation by applying conventional thematic analysis method processes. In the quantitative section, a questionnaire was developed, and its validity and reliability were tested and verified. The questionnaire was distributed among a random sample of 158 physicians out of a target population of 283 first-year medical assistants at SUMS. In addition, the data were reviewed by applying a descriptive-survey method, and thematic analysis was used to analyze the data. Results: In total, 60 basic themes, 9 organizing themes, and one global theme were extracted. The strong educational management base for the educational support theme with a factor of 0.91 (P < 0.001) was the best descriptor in the physicians’ preservation model. Conclusions: The following critical variables affect the native physicians’ retention: effective and strong medical education administration as educational support, flexible working hours, availability of complete labor market information, emphasis and attention to creativity and scientific, and research innovations in the medical profession.
... A study conducted in 2016, searching for 'factors affecting the intention of migration among Iranian health workers, described that people who were most likely open to migration were under 35, had less than 5 years' experience of work, had informal employment status, spoke more than one foreign language, had relatives living abroad and previous experience of mobility. The main reasons to migrate, among health workers, were seeking a better life, interdisciplinary discrimination, and wanting to have the experience of migration [22]. Comparing our findings in Iran, with the results from this study from 2013 to 2014 in 33 European countries, it was then reported that 13.3 % of the psychiatric trainees working in Europe were already immigrants (Switzerland, Sweden and UK being the top host countries). ...
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Introduction Migration of medical professionals has been rapidly increasing in the past decades and it strongly affects origin and destination countries. Objectives We aimed to explore the extent and the reasons of migration among psychiatric trainees and early career psychiatrists in Iran. Methods Our semi-structured 61-items questionnaire inquired participants’ demographics, experiences of short-term mobility (from 3 months to 1 year), long-term migration (more than 1 year) and attitudes towards migration (current and future plans). Results A total of 184 responses were received. Most (73.4 %) participants were female, and within the age range of 25–65 (Mean: 34.9). Only 15.2 % had a short-term mobility experience, mostly due to academic reasons (35.7 %). Most (75 %) stated that this short-term mobility experience influenced them in favor of migration. The majority (83.7 %) had ‘ever’ considered leaving Iran, and more than half (57.3 %) stated they ‘strongly agree’ or ‘agree’ to leaving the country ‘now’ (at the time of the study). The main reason to migrate from Iran was first political, followed by work, financial, social, religious, academic, and cultural reasons, and the least ranked were personal reasons. In relation to their 5-year plans, 67.3 % saw themselves in the country they currently live in, Iran. The main features reported for an attractive job were ‘pleasant work environment’ (97.3 %), ‘good welfare and social security’ (96.7 %) and ‘high salary ‘(96.2 %). Conclusions This study calls for more support of psychiatric trainees and early career psychiatrists in Iran. Improvements in the political context, work conditions and finances might lower the rate of migratory intention and brain drain.
... factors that consist of civil rights, religious limitation, discriminations and equalities (Asadi et al., 2017;Rahmandoust et al., 2011;Salmani et al., 2011), and IV) the scientific factors refer to insufficient research budgets and facilities, and the intellectual atmosphere at universities (Kamyab, 2015;Panahi, 2012;Roudgar, 2018). On the other hand, the pull factors mostly relate to I) higher welfare and economic opportunities (Kamyab, 2015;Panahi, 2012), II) better social rights (Kazemi et al., 2018;Panahi, 2012), III) greater research grants and facilities (Kamyab, 2015;Kazemi et al., 2018;Nafari et al., 2017). ...
Article
The brain drain crisis is among the most challenging issues of many developing countries, attributed to the compounding effects of multiple factors. As communities and their challenges become more complex, new sets of mixed research tools that critically investigate these issues as whole systems rather than isolated parts are crucial for future decision makings. In light of this, mixed research approaches offer the chance to overcome most of the limitations of individual methods and provide potential solutions to complicated problems that are more in-depth than a single form of research method. In this paper, by drawing on the complementary characteristics of Causal Layered Analysis and Participatory System Dynamics, a mixed approach for investigating the future behaviors of complex socio-economic systems and exploring the effectiveness of various policy interventions over time is proposed. Moreover, Iran’s brain drain case study is presented for further assessment of the proposed approach. The implication of the proposed approach to skills mobility or the so-called brain drain phenomenon is the undisputable role of human capital efficiency in the future developments of the nation. Through this approach, in the first step, an issue is critically analyzed and unpacked into four layers, namely as litany, structure, worldview, and metaphor. In the second step, a participatory approach is implemented to systematically model the issue based on the results of the previous step via five stages. The utility of this approach is its ability to critically examine the future behaviors of complex systems under the effect of different policy interventions and scenarios. Therefore, the proposed approach will generate theoretical value for researchers in the field of futures studies and harbor practical value for policymakers who seek a better mechanism to critically investigate complex socio-economic systems.
... High skilled workers are more responsive than low skilled to push and pull factors. Therefore interaction between the push and pull factors ultimatel leads to migrants intention to migrate to more favorable places [5]. It is estimated that around 244 million people have emigrated from their home countries which is 3.3% of the world population [6]. ...
Article
Background It is important to understand the perceptions of career plans and attitudes towards migration of nursing students so that it can be possible to review the education programs in this direction and plan an effective health workforce. Aim To determine nursing students’ career future perceptions and attitudes towards migration. Design Descriptive and cross-sectional online survey. Methods The study was completed with 3053 students from 52 universities located in seven different regions of Turkey who agreed to participate in the study. The data were collected using the “Student Information Form”, “Attitude Scale for Brain Drain (ASBD)” and “Career Futures Inventory (CFI)” with an online questionnaire. Descriptive statistics, independent samples t-test, one-way analysis of variance and correlation were used to analyze the data. Results Mean age of the students was 20.29±2.28 and most were females. Students’ mean total scores of ASBD, and CFI were 56.64±12.22 and 91.32±11.71 respectively. There was a statistically significant difference between the total mean scores of ASBD and the region of the university where the students studied, gender, being multilingual, desire to work abroad after graduation and experience of participating in student exchange programs and between the total mean scores of CFI and experience of participating in an exchange program. There was a positive and statistically significant relationship between ASBD and CFI total mean scores (p<0.05). Conclusion Nursing students' attitudes towards migration and perceptions of career future were positive and there was a positive relationship between attitudes towards migration and perceptions of career future.
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Aim To clarify the situations of nursing education and activity, its affecting factors and the nursing educators’ views on nurse migration relating Mutual Recognition Agreement on Nursing Services in the Association of Southeast Asian Nations. Design: Descriptive qualitative research. Methods The individual semi‐structured interviews with 11 nursing educators, analysed using thematic analysis. Results Nursing educators acknowledged that the change in nursing was mainly due to the creation and amendment of laws, acts and regulations regarding nursing and improvements in nursing education systems. Some of these improvements occurred by this mutual agreement. The conceptualization of the progress indicated an improvement in the quality of nursing. Nurse migration to the outside of Southeast Asian countries might be accelerated due to concurrent improvements in the quality of nursing. New trends among nurses working as caregivers in surrounding countries such as China, South Korea and Japan to deal with demographic ageing should be considered.
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The phenomenon of migration of the work force in the medical field has known an increasing development in the past decade, having both intrinsic (the working conditions in the health care system in Romania, its existent infrastructure and the health expenditure of the government which places the national health care system among the last in Europe) and extrinsic determinants (our country's accession to the European Union and the free movement of persons and services within the Single Market). Based on available data from some of the most important institutions in Romania (National Institute of Statistics, Romanian College of Physicians and of Pharmacists) and international organizations (Eurostat, World Health Organization), this paper analyses these determinants and the implications, both economic and social, that migration of medical staff has on the national health care system, by emphasizing the costs of such persons' movement. Although the resulting analysis cannot turn into an exhaustive one, given the breadth of the current situation, it outlines the main shortcomings of the Romanian health care system and it provides as results several actions that could take in order to diminish the loss.
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Background: Uganda has severe shortage of human resources for health despite the heavy disease burden. The country has one of the highest fertility, and population growth rates in the world and is in dire need of trained health workers. The current doctor: patient ratio of 1:15000 is inadequate and this is further constrained by trained health workers leaving the country while others abandon the health sector. The aim of the study was to determine the career intentions of the final year medical students to leave the county and health field after graduating and the associated factors. Methods: We conducted a cross-sectional study among 251 final year medical students from Makerere, Mbarara, Gulu and Kampala International Universities. We enrolled all the eligible final year medical students. The study was conducted using face-to-face questionnaires in each university. We determined the demographics, reasons for leaving the country and health sector and the intended destinations of medical students who planned to leave the country. Data was entered in Epidata then exported and analyzed in stata 12. Results: Of the 251 students enrolled in the study, 28(11.2 %) wanted to leave the health sector, with Mbarara University of Science and Technology (MUST) having the highest percentage, 16.7 % and Kampala International University (KIU) the least, 7.7 %. Of the 28 who intended to leave the health sector, 82.1 % wanted to join the business sector, 10.7 % agriculture, and 7.1 % politics. Reasons given for the intent to leave were; lack of equipment and supplies in hospitals, over whelming patient numbers, very risky working environment, low payment to doctors, and political reasons. Overall, 112 (44.6 %) of the participants wanted to leave the country with 30.3 % intending to migrate to United States of America (USA), 11.9 % to United Kingdom (UK), 11.0 % to South Africa among others. Some of the reasons given were; doctors are paid a high salary abroad, safe working environment, and desire to continue academics. Age was associated with intention to leave the country (OR = 1.64; 95 % CI: 1.00 - 4.82). Conclusions: In a country in dire need of health workers, the study showed high proportion of trainee health workers planning to abandon their professions or emigrate from Uganda after training.
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Context: Higher income countries have an average physician density of 300 physicians per 100,000 people. In stark contrast, lower income countries have an average physician density of 17 physicians per 100,000 people. A major cause of this discrepancy is the migration of health-care professionals from lower income to higher income countries, a phenomenon colloquially known as the " brain drain ". Objective: To explore factors that led International Medical Graduate (IMG) physicians to leave their home countries and migrate to Canada. Methods: An anonymous questionnaire with a mix of open-and close-ended questions was sent to 500 randomly selected IMG physicians practicing in Ontario, Canada. Results were analyzed using a mixed-method design utilizing both descriptive statistics and a thematic analysis approach. Results: 39 physicians met inclusion criteria and completed the survey. The majority were 50 years or older, and over 60% were male. The most common reason for emigration from their home country was the socioeconomic and/or political situation, and the most common reason for selecting Canada was family issues. Suggestions for how brain drain could be stemmed fell into three broad categories: 1) more accurate information about lack of opportunities in Can-ada, 2) more continuing medical education opportunities in home countries, and 3) address issues such as safety and quality of life in home countries. Conclusions: This survey provides insights into the reasons for emigration and immigration for international medical graduates. The results of this survey can assist stakeholders in working toward appropriate and acceptable solutions to the brain drain.
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Recent theoretical work suggests conditions under which a positive probability of migration from a developing country stimulates human capital formation in that country and improves the welfare of migrants and non-migrants alike (Stark et al., 1997, 1998; Stark and Wang, 2002). This ‘brain gain’ hypothesis contrasts with the received, long-held ‘brain drain’ argument, which stipulates that the migration of skilled workers depletes the human capital stock and lowers welfare in the sending country (Usher, 1977; Blomqvist, 1986). The ‘brain gain’ view is that a strictly positive probability of migrating to destinations where the returns to human capital are higher than at origin creates incentives to acquire more human capital in migrant-sending areas.
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Background and Objective: Scholarship is of such a great importance that even the developed countries pay special attention to it, while in developing countries it has been left unattended and there is no appropriate management to benefit from the its advantages. For this, scholarship has to be considered more seriously in the planning system of the country in order to achieve the highest yield beside all expenses. Methods: Using registered documents as one of the best information sources, 366 students awarded scholarship between1997-2003 were enrolled into the study. Student's personal information at the time of going abroad, scholarship granted university, local university and students’ major and duration of study were considered as useful information and excluded carefully from electronic and paper documents under the cooperation of the scholarship office of Ministry of Health and Medical Education. Results: Most of the students were studying in European countries (69.7%) and Australian and Oceania universities (12.6%). The average duration of study was (±0.46) 4.07 years for PhD and (± 0.54)5.12 years for clinical specialty candidates showing a significant difference between the two groups (P‹ 0.001). However, the noticeable point is that non-returning rate has been more than average for students who have received scholarship from those universities and also the ministry, while scholarship holders from level three universities were successful in science generating. Conclusion: The highest number of awarded scholarships belonged to the large universities in the country and based on the available information it is difficult to judge whether scholarship awarding has been distributed fairly among universities or not. Keywords: Scholarship, Degree statue, Medical sciences,