Interventions for controlling emigration of health professionals from low- and middle-income countries

Researchers in the Cochrane Collaboration conducted a review of the effect of interventions to control the emigration of health professionals from low- and middle-income countries. After searching for all relevant studies, they found only one study that met their requirements. The findings of this study are summarised below.

Controlling the emigration of health professionals
Difficult living and working conditions and better opportunities abroad often lead health professionals from poorer countries to migrate to wealthier countries. This is one of several reasons why poorer countries often suffer from a severe shortage of health workers. Governments in these countries have tried a number of approaches to stop this migration, for instance by improving health workers’ working conditions; offering better training, more pay and better career prospects; or by introducing compulsory service for certain periods of time. Governments in a few wealthy countries have also tried to prevent this migration by introducing ethical guidelines for the recruitment of foreign health professionals. In other wealthy countries, however, governments have tried to solve their own health worker shortage by attracting foreign health workers, for instance through active recruitment or special immigration regulations. 

What happens when efforts are made to regulate the emigration of health professionals?
In most cases, efforts to regulate health worker migration have not been properly evaluated. The review authors found only one study that met their stated requirements for types of study designs. This study looked at the impact of United States (US) immigration law on the number of nurses emigrating from the Philippines to the USA. US government immigration laws were changed in the 1960s, giving equal access to European and non-European immigrants. The study measured the number of nurses migrating from the Philippines to the USA in the years before and after the law had changed. The study showed that:

- The change in US immigration laws probably increased the number of nurses migrating from the Philippines to the USA. The quality of this evidence is moderate.

The review shows that there is a huge gap in our knowledge about the effectiveness of policy interventions that attempt to regulate the movement of health professionals from low- and middle-income countries.


Authors' conclusions: 

There is an important gap in knowledge about the effectiveness of policy interventions in either HICs or LMICs that could regulate positively the movement of health professionals from LMICs. The only evidence found was from an intervention in a HIC that increased the movement of health professionals from a LMIC.

New initiatives to improve records on the migration of health professionals from LMICs should be implemented, as a prerequisite to conducting more rigorous research in the field. This research should focus on whether the range of interventions outlined in the literature could be effective in retaining health professionals in LMICs. Such interventions include financial rewards, career development and continuing education, improving hospital infrastructure, resource availability, better hospital management and improved recognition of health professionals.

Read the full abstract...

The emigration of skilled professionals from low- and middle-income countries (LMICs) to high-income countries (HICs) is a general phenomenon but poses particular challenges in health care, where it contributes to human resource shortages in the health systems of poorer countries. However, little is known about the effects of strategies to help regulate this movement.


To assess the effects of policy interventions to regulate emigration of health professionals from LMICs.

Search strategy: 

We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register (searched 15 March 2011), the Cochrane Register of Controlled Trials (CENTRAL) (searched 2 March 2011), MEDLINE (searched 5 March 2011), EMBASE (searched 2 March 2011), CINAHL (searched 5 March 2011), LILACS (searched 7 March 2011), WHOLIS (searched 20 March 2011), SocINDEX (searched 11 March 2011), EconLit (searched 8 March 2011), Science and Social Science Citation Index (searched 8 March 2011), NLM Gateway (searched 31 March 2011) and ERIC (searched March 3 2011). We reviewed reference lists of included studies and selected reviews on the topic, contacted authors of included studies and experts on the field, and reviewed relevant websites.

Selection criteria: 

Randomised controlled trials (RCT), non-randomised controlled trials (NRCT), controlled before-and-after studies (CBA) and interrupted time series (ITS) studies assessing any intervention in the source, the recipient or both countries that could have an impact on the number of professionals that emigrate from a LMIC. Health professionals, such as physicians, dentists, nurses or midwives, should be nationals of a LMIC whose graduate training was in a LMIC.

Data collection and analysis: 

One review author extracted data onto a standard form and a second review author checked data. Two review authors assessed risk of bias.

Main results: 

Only one study was included. This time series study assessed the migration of Philippine nurses to the United States of America (USA) from 1954 to 1990. We re-analysed it as an interrupted time series study. The intervention was a modification of migratory law in the US, called the 'Act of October 1965', which decreased the restrictions on Eastern hemisphere immigrants to the USA. The analysis showed a significant immediate increase of 807.6 (95% confidence interval (CI) 480.9 to 1134.3) in the number of nurses migrating to the USA annually after the intervention. This represents a relative increase of 5000% over the underlying pre-intervention trend. There were no significant differences in the slopes of the underlying trends for the number of nurses migrating between the pre- and postintervention periods.