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Analysis of Health Professionals Migration: A Two-Country Case Study for the United Arab Emirates and Lebanon Draft for discussion Fadi El-Jardali, Department of Health Management & Policy, Faculty of
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Analysis of Health Professionals Migration: A Two-Country Case Study for the United Arab Emirates and Lebanon Draft for discussion Fadi El-Jardali, Department of Health Management & Policy, Faculty of Health Sciences, American University of Beirut Diana Jamal, Department of Health Management & Policy, Faculty of Health Sciences, American University of Beirut Maha Jaafar, Department of Health Management & Policy, Faculty of Health Sciences, American University of Beirut Zeinab Rahal, Department of Health Management & Policy, Faculty of Health Sciences, American University of Beirut - October Table of Contents Acronyms 5 I. Acknowledgements 7 II. Executive summary 8 III. Introduction 11 A. Human Resources for Health - International Context 11 Determinants of migration of health professionals 13 B. HRH in the Eastern Mediterranean Region 14 IV. Objectives 16 V. Methods 17 VI. Findings 17 A. Case of UAE Destination Country Context of UAE 17 a) Geography and Demography 17 b) Labor Market 19 c) Health System in UAE Health workforce Existing Stock of Health Workers 30 a) Obtaining Information on the Stock of Health Workers 30 b) Stock of Physicians 30 i. Data from MOH 31 ii. Data from HAAD 31 iii.data from DOHMS 32 iv.discrepancies in number of physicians 33 c) Stock of Nurses 34 i. Data from MOH 34 ii. Data from HAAD 38 iii.data from DOHMS 38 iv.discrepancy in number of nurses 40 d) Data on Midwives Yearly inflow of health workers Shortage in UAE Health Workforce Shortage of National Health Workers 43 a) Potential reasons for shortage of national Physicians 43 b) Potential reasons for shortage of national Nurses Reasons Expatriate Health Workers Come to Work in UAE Graduates from Medical and Nursing Schools 46 a) Medical Schools 47 b) Nursing Schools 48 c) Understanding nurse education programs in UAE 51 i. UAE Nursing Education Programs 51 ii. Problems Related to Nursing Education Programs in the UAE Recruitment of Health Professionals in UAE Turnover among UAE Health Professionals Tawam Hospital Case Study 57 a) Health workers in Tawam 58 b) Staff satisfaction survey Training and Continuing Education of Health Professionals 62 a) MOH 63 b) HAAD 63 c) DOHMS 64 d) The Army Directorate of Medical Services Licensure and Continuing Education Retention of Health Workers in UAE 66 a) Retention Strategies for MOH Facilities 68 b) Strategies to Remedy Shortage of Nurses Self sufficiency in UAE Bilateral Agreements Challenges, Successes and Recommendations in UAE 75 a) Challenges facing UAE 75 b) Successes and Opportunities in UAE 77 c) Recommendations for UAE 78 B. Case of Lebanon Source Country Context of Lebanon 80 a) Geography and Demography 80 b) Economic Profile 82 c) Migration Trends in Lebanon 83 d) Health System Profile Health Workforce in Lebanon 85 a) Stock of Physicians in Lebanon 86 b) Stock of Nurses in Lebanon Graduates from Medical and Nursing Schools 92 a) Medical Schools 93 b) Nursing Schools 94 c) Midwifery Schools HRH Migration from Lebanon 97 a) Physician migration 98 b) Nurse migration Recruitment agencies Retention of health workers in Lebanon 103 a) Research on Nurse Retention in Lebanon 103 b) Research on Nurses Intent to Leave Challenges, Successes and Recommendations for Lebanon 106 a) Challenges facing Lebanon 106 El-Jardali, et al b) Successes and Opportunities in Lebanon 108 c) Recommendations for Lebanon 109 VII. Limitations 111 VIII. Conclusion 112 IX. References 115 X. Appendices 122 Appendix I: Methods 122 Appendix II: Search Strategy 128 Appendix III: Letter sent to schools and universities in UAE 133 Appendix IV: Data collection template for medical, nursing and midwifery schools in UAE 134 Appendix V: Letter sent to Recruitment agencies in UAE 135 Appendix VI: Data collection template sent to Recruitment agencies in UAE _136 Appendix VII: Template for Key Informant Identification (UAE) 137 Appendix VIII: UAE Key informants identified 138 Appendix IX: UAE Key informants interviewed 140 Appendix X: Letter sent to schools and universities in Lebanon 141 Appendix XI: Data collection template for medical, nursing and midwifery schools in Lebanon 142 Appendix XII: Letter sent to Recruitment agencies in Lebanon 143 Appendix XIII: Data collection template sent to Recruitment agencies in Lebanon 144 Appendix XIV: Key informants interviewed in Lebanon 145 Appendix XV: Questions asked during phone interviews with Lebanese nurses working in UAE 146 Appendix XVI: Detailed distribution of physicians registered in DOHMS by nationality 147 Appendix XVII: Detailed distribution of nurses employed in MOH facilities across districts 148 Appendix XVIII: Detailed distribution of nurses registered in DOHMS by nationality 151 Appendix XIX: Detailed response from MOH ION and Institute of Applied Technology 152 El-Jardali, et al Appendix XX: Detailed list of nationalities of physicians and nurses employed in Tawam hospital 153 Appendix XXI: Detailed distribution of 1 st year students and graduates from three branches of the Lebanese University School of Nursing 155 Appendix XXII: Data received from Nursing Schools in Lebanon on program duration, number of students migrating and most preferable destination 156 List of Tables Table 1: National graduates of selected higher educational institutions 21 Table 2: Types of immigration policies in UAE and implementation status 22 Table 3: Breakdown of Health Care Facilities in UAE 23 Table 4: Breakdown of Health Workers in UAE Facilities 28 Table 5: Number of physicians employed in public and private Hospitals in UAE ( ) 31 Table 6: Physicians Working in MOH by Nationality in Table 7: Physicians in DOHMS for the years 1997 to Table 8: Physicians in DOHMS distributed by nationality and gender (2007) 33 Table 9: Distribution of Nurses across Health Authorities 34 Table 10: Distribution of National Nurses working in MOH facilities only across different districts (December 2007) 35 Table 11: Distribution of nurses working in MOH facilities 36 Table 12: Distribution of nurses in MOH facilities by gender 36 Table 13: Distribution of nurses in MOH by nationality 37 Table 14: Nurses registered in DOHMS for the years 1997 to Table 15: Nurses registered in DOHMS distributed by nationality and gender (2007) 39 Table 16: Total number of recruited physicians and nurses in MOH facilities between 1998 and Table 17: Nurses in MOH Facilities (December 2007) 42 Table 18: Performance of Applicants for Registration Examination (MOH 2007) 43 Table 19: List of the educational institutions that were contacted in the UAE, whether they replied or not and whether they are public or private* 46 Table 20: Information collected from Gulf Medical College 47 Table 21: Number of 1 st year students and graduates from nursing schools from 1998 to Table 22: Contribution of nursing schools towards national supply according to sector 50 Table 23: Comparison between number of national and non-national graduates from MOH ION 50 Table 24: Degrees offered by the different nursing schools in UAE 52 Table 25: Nurse Recruitment and Resignation in MOH facilities by district (2006) 57 Table 26: Nurse recruitment and resignation in MOH facilities by facility type (2007) _ 57 Table 27: Distribution of physicians and nurses in Tawam hospital by nationality 58 Table 28: Physician trainees and physicians in rotation at Tawam hospital 59 El-Jardali, et al Table 29: Trends in recruitment and termination of medical and nursing staff in Tawam hospital between 2004 and Table 30: Medical Termination summary for 2007 and Table 31: Reason for termination of medical and nursing staff from 2006 to Table 32: Number of vacancies for physicians and nurses in Tawam 61 Table 33: Issues identified by staff satisfaction survey (Matarelli, 2008) 61 Table 34: DOHMS Continuing Education Department, Scholarship and Higher Education Department 74 Table 35: Population and Health Indicators for Lebanon 81 Table 36: Number of physicians inscribed/year 87 Table 37: Physician numbers by Mohafazat 2005* 88 Table 38: Physician distribution by gender 89 Table 39: Results of data retrieved from the Order of Nurses in Lebanon 91 Table 40: Number of training institutions by type and capacity of enrollment 92 Table 41: Name, type, affiliation and reply status of medical and nursing schools in Lebanon 93 Table 42: Number of 1 st year students and graduates at two medical schools in Lebanon94 Table 43: Number of 1 st year students and graduates from nursing schools in Lebanon between 2000 and Table 44: Number of 1 st year students and graduates from two midwifery schools in Lebanon between 2000 and Table 45: Push and pull factors as reported by medical students (Akl et al. 2007) 98 Table 46: Data on Lebanese Nurses retrieved from four nursing schools 101 List of Figures Figure 1: Health Workers Save Lives (Adapted from World Health Report 2006) 13 Figure 2: Major expatriate nationalities in UAE 18 Figure 3: Distribution of health workers across sectors by nationality 28 Figure 4: Distribution of physicians across different facilities HAAD (2007) 32 Figure 5: Distribution of nurses working in UAE by nationality 35 Figure 6: Distribution of nurses across different facilities HAAD (2007) 38 Figure 7: Distribution of physicians and nurses in the EMR 87 Figure 8: Top Retention Challenges as perceived by Lebanese Nursing Directors 104 Figure 9: Retention strategies adopted by hospitals 105 El-Jardali, et al Acronyms (In alphabetical order) AD CME AUB BSN BT CCS CE CME DHA DMS DOHMS EMR EMRO FDON GAHS GCC GDP GHQ HAAD HIC HRH IBP IMR ION KSA LE LHS LMG LMIC Abu Dhabi Continuing Medical Education American University of Beirut Bachelors of Science in Nursing Baccalaureate Technique Country Cooperation Strategy Continuing Education Continuing Medical Education Dubai Health Authority Directorate of Medical Services Department of Health and Medical Services Eastern-Mediterranean Region Eastern Mediterranean Regional Office Federal Department of Nursing General Authority for Health Services Gulf Cooperation Council Gross Domestic Product Directorate of Defense Medical Services Health Authority-Abu Dhabi High Income Countries Human Resources for Health International Best Practices Infant Mortality Rate Institute of Nursing Kingdom of Saudi Arabia Life Expectancy Lebanese Health Sector Lebanese Medical Graduates Low-Middle Income Countries El-Jardali, et al MD MENA MHIC MMR MOH MOH ION MOPH NNMAC PHC RAK ROV SEHA TS U5MR UAE UAQ UK US USJ WHO Medical Doctor Middle East and North Africa Middle-High Income Countries Maternal Mortality Rate Ministry of Health Ministry of Health Institutes of Nursing Ministry of Public Health National Nursing and Midwifery Advisory Committee Primary Health Care Ras Al-Khaimah Rate of Variation Abu Dhabi Health Services Technique Superieur Under-5 Mortality Rate United Arab Emirates Umm al-qaiwain United Kingdom United States Université Saint Joseph World Health Organization El-Jardali, et al I. Acknowledgements We would like to thank WHO Geneva for supporting and funding this project, specifically Dr. Jean Yan, Dr. Jean-Marc Braichet and Dr. Pascal Zurn. We would also like to thank WHO EMRO for facilitating this work, particularly Dr. Walid Abubaker and Dr. Ghanim Alsheikh. Special thanks to Dr. Maryam Al Marri and Dr. Fatima Al Rifai for helping us identify key informants in UAE. We would also like to extend our thanks and gratitude to all key informants, educational institutions and recruiting agencies in both countries that took the time to participate in this study. El-Jardali, et al II. Executive summary A. Objective The objective of this paper is to analyze and discuss the context and the patterns of health professionals (physicians, nurses and midwives) production, migration, recruitment and retention in the United Arab Emirates (UAE) and in Lebanon. B. Methods Quantitative and qualitative data was collected from several data sources including literature and grey reports, surveys of universities and schools, surveys of recruiting agencies and key informant interviews. Activities pertaining to data collection and analysis spanned from June to August C. Major findings and recommendations 1. United Arab Emirates The UAE is a fast growing country which is heavily reliant on foreign health care professionals who come from different countries. In fact, a reported 82% of health workers in UAE are expatriates whereas nationals only comprise around 18% of all health workers. Despite excessive recruitment of foreign trained health professionals, the UAE still faces severe health workforce shortages. Moreover, the country does not have bilateral agreements for recruitment of foreign-trained health workers. UAE lacks accurate estimates on the actual stock of physicians, nurses and midwives. However, the closest estimates show that an estimated 5,000 physicians and close to 13,000 nurses are currently employed in UAE, the majority of whom are expatriates. Data pertaining to estimates of physicians and nurses in addition to number of graduates from medical and nursing schools was obtained from different sources and are outlined in the findings section of the report. In addition to heavy shortages, health facilities in UAE have high turnover rates and poor staff retention. Our data collection and interviews in UAE showed that no retention strategy exists at a country level. However, some retention initiatives have been El-Jardali, et al taken at the level of health care organizations. This is contributing to the high turnover in UAE and may exacerbate current shortages. Key informants interviewed in UAE further stated that UAE is not self-sufficient and may always have to depend on foreign trained health workers to meet country demand. Several challenges pertaining to the health workforce in UAE were documented, specifically the incomplete and sometimes outdated data; the absence of a health workforce strategy; limited cooperation between health authorities; no self sufficiency; recruitment and retention challenges for both nationals and expatriates including high turnover rate; high number of expatriates; and cultural diversity of health workforce. Some recommendations to remedy these challenges were also outlined by key informants including a health workforce plan for UAE; a strategy for recruitment and retention; better collaboration between health authorities; and engaging the educational sector and improving medical and nursing education programs in UAE. 2. Lebanon Lebanon is characterized by and oversupply of physicians and under-supply of nurses and paramedical personnel. It has the highest physician density in the Eastern Mediterranean Region (EMR) and the 8 th lowest nurse density in the region. Yet, Lebanon lacks clear and accurate numbers on actual stock of physicians, nurses and midwives, and annual supply of such health workers from medical and nursing schools. However, available data shows that over 10,000 physicians and approximately 6,000 nurses exist in Lebanon. More detailed findings are outlined within this report. Lebanon is considered as a source country of health workers. Many physicians and nurses choose to migrate to countries of the Gulf, Europe and North America in search of better job opportunities. Lebanon has a culture of migration, this trend has actually become widely accepted by society. Physicians typically migrate to complete specialty training but very often choose to remain in their destination country. In fact, after adjusting for the country population size, Lebanon ranks second among countries from where physicians in the US graduated. Nurse migration, on the other hand, has reached alarming rates with recent estimates of 1 of every 5 nursing graduates migrating out of Lebanon within one to two years of graduation. Furthermore, 67.5% of currently employed Lebanese nurses reported an intent to leave within the next 1 to 3 years, 36.7% of which disclosed plans to leave the country. El-Jardali, et al Despite the many health workforce challenges in Lebanon, the country lacks a national health workforce strategy. Limited research has been undertaken to understand health workforce challenges and retention; findings are reported in subsequent sections of this report. In light of the above, several key challenges related to the health workforce exist in Lebanon. Key informants interviewed in Lebanon identified several challenges pertaining to the health workforce including professional and geographic mal-distribution; migration brain drain; outdated curricula; lack of re-licensing of health professionals and accreditation of educational curricula; limited opportunities for continuing medical education programs and career development; and limited financial and non-financial incentives. Key informants also identified several recommendations including developing a system to manage out-migration; developing a national HRH plan; rectifying HRH imbalances; revising educational curricula; implementing continuing education and career advancement programs; and creating financial and non-financial incentives. D. Conclusion As documented in this two-country case study, both UAE and Lebanon are facing many challenges in recruiting and retaining their health workforce. This is due to the lack of evidence-based HRH planning and a national strategy for health workforce in both countries. Since the UAE is a dynamic and fast growing country, it will continue to depend on foreign trained health workers to meet current and future needs. On the other hand, Lebanon as a source country will probably continue to lose its health workforce if nothing is done to address HRH challenges particularly push factors. Prioritizing issues related to health workforce in both countries will require solid leadership and a more efficient health sector. Health sector initiatives to improving the health workforce requires strong management and leadership capacities. If the HRH leadership gap continues to exist, both countries will face severe challenges that will impact its health care systems. This two-country case study clearly shows the need for immediate action to address HRH in both countries. El-Jardali, et al III. Introduction A. Human Resources for Health - International Context The early decades of the twenty-first century belong to Human Resources for Health (HRH). HRH issues in several Middle Eastern countries have started to gain more attention after the World Health Organization (WHO) launched in 2006 the health workforce decade and set out strategies and recommendations to respond to urgent HRH needs and challenges. The WHO report also suggested strategies for managing the existing workforce and stressed on the need for each country to develop its own strategies based on its contextual needs. As many developed and developing countries, several Middle Eastern countries have come to realize that the most important asset to any heath system, besides inputs including physical resources, capital and other consumables, is its health workforce without which a health system cannot properly function (Kabene et al., 2006). As detailed in the World Health Report (2006), the health care sector, which is both labor-intensive and labor-reliant, would not function properly without the presence of a well-trained health workforce that can meet population health needs and expectations through delivery of quality health care services (WHO 2006). Furthermore, the quality of services delivered by a system depends highly on the knowledge, skills and motivation of health workers (WHO, 2000). The Kampala declaration which emerged from the First Global Forum on Human Resources for Health held in Uganda (March 2008) focused on the need for immediate action to resolve the accelerating crises in the health workforce around the world, particularly Low and Middle Income Countries (LMICs) which are already crippled by poor health status and unstructured health systems (Global H
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