Physician Emigration from Sub-Saharan Africa to the United States: Analysis of the 2011 AMA Physician Masterfile

<div><p>Background</p><p>The large-scale emigration of physicians from sub-Saharan Africa (SSA) to high-income nations is a serious development concern. Our objective was to determine current emigration trends of SSA physicians found in the physician workforce of the United States.</p><p>Methods and Findings</p><p>We analyzed physician data from the World Health Organization (WHO) Global Health Workforce Statistics along with graduation and residency data from the 2011 American Medical Association Physician Masterfile (AMA-PM) on physicians trained or born in SSA countries who currently practice in the US. We estimated emigration proportions, year of US entry, years of practice before emigration, and length of time in the US. According to the 2011 AMA-PM, 10,819 physicians were born or trained in 28 SSA countries. Sixty-eight percent (<i>n</i> = 7,370) were SSA-trained, 20% (<i>n</i> = 2,126) were US-trained, and 12% (<i>n</i> = 1,323) were trained outside both SSA and the US. We estimated active physicians (age ≤70 years) to represent 96% (<i>n</i> = 10,377) of the total. Migration trends among SSA-trained physicians increased from 2002 to 2011 for all but one principal source country; the exception was South Africa whose physician migration to the US decreased by 8% (−156). The increase in last-decade migration was >50% in Nigeria (+1,113) and Ghana (+243), >100% in Ethiopia (+274), and >200% (+244) in Sudan. Liberia was the most affected by migration to the US with 77% (<i>n</i> = 175) of its estimated physicians in the 2011 AMA-PM. On average, SSA-trained physicians have been in the US for 18 years. They practiced for 6.5 years before US entry, and nearly half emigrated during the implementation years (1984–1999) of the structural adjustment programs.</p><p>Conclusion</p><p>Physician emigration from SSA to the US is increasing for most SSA source countries. Unless far-reaching policies are implemented by the US and SSA countries, the current emigration trends will persist, and the US will remain a leading destination for SSA physicians emigrating from the continent of greatest need.</p><p><i>Please see later in the article for the Editors' Summary</i></p></div

Foreign medical schools located outside Sub-Saharan Africa with the highest number of Sub-Saharan African-born medical graduates practicing in the United States.

<p>Data source: American Medical Association <a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001513#pmed.1001513-American3" target="_blank">[115]</a>.</p

Emigration trends among Sub-Saharan African-trained medical graduates with complete birth country data in the 2011 AMA Physician Masterfile.

<p>Data source: American Medical Association <a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001513#pmed.1001513-American3" target="_blank">[115]</a>.</p

Sub-Saharan African-born physicians who graduated from US-based medical schools (SSA-USMGs).

<p>Data source: American Medical Association <a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001513#pmed.1001513-American3" target="_blank">[115]</a>.</p>a<p>Each of these 24 sub-Saharan African countries had <20 USMGs, except Somalia which had 32 USMGs but had <15 SSA-IMGs in the 2011 AMA Physician Masterfile, and as such was not included among the top 12 sub-Saharan African source countries.</p

Change in the number of Sub-Saharan African-trained international medical graduates (SSA-IMGs) appearing in the US physician workforce between 2002 and 2011.

<p>Data sources: World Health Organization <a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001513#pmed.1001513-World4" target="_blank">[5]</a>; 2002 AMA Physician Masterfile as per Hagopian et al. <a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001513#pmed.1001513-Hagopian1" target="_blank">[19]</a>; American Medical Association <a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001513#pmed.1001513-American3" target="_blank">[115]</a>.</p>a<p>2002 data were reported by Hagopian et al. <a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001513#pmed.1001513-Hagopian1" target="_blank">[19]</a> except for the numbers of IMGs trained in Cameroon, Tanzania, and Sudan. Their numbers are included in brackets because they are not part of the total counts reported in the last row of the table. These migrants were identified among SSA-IMGs in the 2011 AMA Physician Masterfile who completed residency by 2002. But the number of physicians available in Cameroon, Sudan, and Tanzania in 2002 came from the Hagopian et al. paper. In their dataset, “other” includes 12 countries with “at least one graduate in the US.” In our 2011 dataset, except otherwise specified, “other” refers to the 16 sub-Saharan African countries with fewer than 15 SSA-IMGs each in the 2011 AMA Physician Masterfile. The numbers of physicians in source countries for the year 2011 are from the Global Health Workforce Statistics of the World Health Organization <a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001513#pmed.1001513-World4" target="_blank">[5]</a>. “Active” emigration rate is the emigration rate among potentially active physicians. We defined all migrant physicians age ≤70 as potentially active.</p

Graduation trends among Sub-Saharan African-born graduates of medical schools located in the United States.

<p>Data source: American Medical Association <a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001513#pmed.1001513-American3" target="_blank">[115]</a>. As reflected by the exponential equation and the determination coefficient (R²) of the smoothed line displayed on the chart, the distribution of the data approaches an exponential curve, reflecting a rapid numerical increase of sub-Saharan African natives graduating from medical school in the US.</p

Graduation and residency trends among Sub-Saharan African-born international medical graduates educated outside Sub-Saharan Africa.

<p>Data source: American Medical Association <a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001513#pmed.1001513-American3" target="_blank">[115]</a>.</p

US residency institutions that trained the highest number of Sub-Saharan African physicians appearing in the US physician workforce in 2011.

<p>Data source: American Medical Association <a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001513#pmed.1001513-American3" target="_blank">[115]</a>.</p>a<p>SSA-IMGs, sub-Saharan African-trained medical graduates; SSA-USMGs, US-trained medical graduates born in sub-Saharan Africa; Other IMGs, sub-Saharan African-born internationals medical graduates trained outside sub-Saharan Africa.</p

Trends in primary specialty among Sub-Saharan African-trained medical graduates with complete birth country data in the 2011 AMA Physician Masterfile.

<p>Data source: American Medical Association <a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001513#pmed.1001513-American3" target="_blank">[115]</a>.</p

Primary specialty choices among Sub-Saharan African migrant physicians appearing in the US physician workforce in 2011.

<p>Data source: American Medical Association <a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001513#pmed.1001513-American3" target="_blank">[115]</a>.</p>a<p>SSA-IMGs, sub-Saharan African-trained medical graduates; SSA-USMGs, US-trained medical graduates born in sub-Saharan Africa; Other IMGs, sub-Saharan African-born internationals medical graduates trained outside sub-Saharan Africa.</p