BRAIN DRAIN TO BRAIN GAIN - WHO · 2 Brain Drain to Brain Gain Acknowledgements The authors wish to thank the Minister of Health, the Permanent Secretary, the Director-General, the

CASE STUDY | UGANDA

C=68 M=85 Y=0 K=26

Case study on the stock and flow of the surgical workforce in Uganda

C=68 M=85 Y=0 K=26

BRAIN DRAIN TO BRAIN GAIN

The authors of this report are Patrick Kadama, Henry Mwebesa, Robert Odedo, Katumba Sentongo, John Wakida, Francis Omaswa,

Peter Eriki, Geraldine Agirembabazi and Belinda Nabukalu (African Centre for Global Health and Social Transformation)

© African Centre for Global Health and Social Transformation (ACHEST), all rights reserved.

Comments on an earlier draft were provided by James Buchan (University of Technology, Sydney) and Giorgio Cometto (WHO).

WHAT THE STATE OF KERALA TELLS US ABOUT THE PRODUCTION, STOCK AND MIGRATION OF THE HEALTH WORKFORCE 1

Contents

Acknowledgements ...................................................................................................... 2

1. Background .................................................................................5 1.1 Introduction .................................................................................................... 5

1.2 Global context .................................................................................................. 6

1.3 Surgical workforce: Uganda context ..................................................................... 6

2. Methodology: protocol stages .......................................................7 2.1 Protocol stage 1: stakeholder mapping and engagement .......................................... 7

2.2 Protocol stage 2: data acquisition ........................................................................ 8

2.3 Protocol stage 3: data verification and analysis ...................................................... 9

2.4 Protocol stage 4: data gap identification ..............................................................10

2.5 Protocol stage 5: minimum data source identification ............................................10

3. Results .................................................................................... 10 3.1 Minimum data set ............................................................................................11

3.2 Additional data ...............................................................................................14

3.3 Qualitative information .....................................................................................14

4. Discussion and recommendations ............................................... 10

Bibliography ............................................................................................................. 28

Annex 1. Tables on migration flows ...............................................................................21

BRAIN DRAIN TO BRAIN GAIN: CASE STUDY ON THE STOCK AND FLOW OF THE SURGICAL WORKFORCE IN UGANDA 1

2 Brain Drain to Brain Gain

Acknowledgements

The authors wish to thank the Minister of Health, the Permanent Secretary, the Director-General, the councils and all the stakeholders in Uganda who participated and contributed useful data and information during this study.

Funding for the development of this report was provided through the project Brain Drain to Brain Gain: Supporting the WHO Code of Practice on International Recruitment of Health Personnel for Better Management of Health Worker Migration, co-funded by the European Union (DCI-MIGR/2013/282-931) and Norad, and coordinated by WHO. The contents of this document are the sole responsibility of ACHEST, and can under no circumstances be regarded as reflecting the position of the European Union or WHO.

Funding for the development of this report was provided through the project Brain Drain to Brain Gain: Supporting the WHO Code of Practice on International Recruitment of Health Personnel for Better Management of Health Worker Migration, co-funded by the European Union (DCI-MIGR/2013/282-931) and Norad. The contents of this document are the sole responsibility of WHO, and can under no circumstances be regarded as reflecting the position of the European Union.

1. Background1.1 IntroductionUganda is one of the 57 countries identified by the World Health Report 2006 as experiencing a critical shortage of health workers (less than 2.3 physicians, midwives and nurses per 1000 population).1 Since 2006, the national production of some cadres of health workers has steadily increased, with over 55 health training institutions opened. The supply of health workers, however, is not necessarily matched by government demand: the poor absorptive capacity of the health sector and labour mar-ket imbalances lead to a pool of qualified health workers that are unemployed. The health workforce in Uganda stands at 81 982 qualified health workers available for recruitment in both the public and private sectors. Records from the health professional councils show that 42 530 (52%) are currently employed in the public sector, at least 9798 (12%) are employed in the private-not-for-profit sector, while about one third (29 654) are private practitioners, are unemployed or have emigrated.2

As a result of the factors above, international migration of health workers from Uganda is a major issue, though precise figures are not available. The issue has recently attracted national and global attention due to controver-sy arising from plans to send skilled health workers to Trinidad and Tobago (Box 1).

1 The World Health Report 2006: working together for health. Geneva: World Health Organization; 2006. http://www.who.int/whr/2006/en/index.html.

2 Ministry of Health and USAID/SHRH project reports, 2015.

1.2 Global contextThe Lancet Commission on Global Surgery, in its Global Surgery 2030 report, describes the role of surgical and anaesthesia care as being very critical in improving the health of individuals and the economic productivity of countries.3 The report presents findings on the state of surgical care in low- and middle-income countries, as well

3 Global Surgery 2030: evidence and solutions for achieving health, welfare and economic development. Lancet Commission; 2015.


BOX 1. MIGRATION OF SKILLED HEALTH WORKERS: THE TRINIDAD AND TOBAGO CASE

The Government of Uganda, through the Ministry of Foreign Affairs, has tentatively agreed to send around 300 skilled health workers to Trinidad and Tobago in exchange for oil and gas industry training and financial support for its police. The proposed agreement generated negative reactions from national civil society because of health workforce shortages and maldistribution in Uganda. Parliament requested further discussion on the matter, emphasizing that a final decision had not been made. Several development partners also raised their concern, with Belgium’s Cooperation Minister proposing to put on hold the disbursement of development assistance to the Government of Uganda in support of the health sector. There has been extensive negative media coverage of this initiative both in the country and globally, including in the mainstream and specialist press.

Source: Concept note for a stakeholders’ meeting on international mobility of Uganda’s health workforce, April 2015.

Case study on the stock and flow of the surgical workforce in Uganda

BRAIN DRAIN TO BRAIN GAIN


as a framework of recommendations, indicators and tar-gets needed to achieve the Lancet Commissions vision of universal access to safe, affordable surgical and anaesthesia care when needed. The report findings create a powerful argument for governments in low- and middle-income countries to strengthen surgical services and the national health systems that provide them. The study further underscores the importance of surgical care, given that treatment for surgical conditions represents approxi-mately 30% of the global burden of disease, yet surgical services remain out of reach for the majority of the world’s population, resulting in loss of life and reduced welfare for millions of people.

It is against this backdrop that the decision was made to focus on the surgical workforce in the first year of the project Brain Drain to Brain Gain: Supporting the (World Health Organization) WHO Code of Practice on International Recruitment of Health Personnel for Better Management of Health Worker Migration.

The WHO Global Code of Practice on the International Recruitment of Health Personnel was adopted by the Sixty-third World Health Assembly on 21 May 2010, with the overall aim of achieving better understanding and management of health worker migration. Member States are encouraged to publicize and implement the Global Code in collaboration with all stakeholders, to incorporate the Global Code into applicable laws and policies, to consult with all stakeholders in the deci-sion-making process, and to involve them in other ac-tivities related to the international recruitment of health personnel. The purpose of the Brain Drain to Brain Gain project in Uganda is to generate momentum and accelerate progress in the implementation of the Global Code in the country, including through conducting a case study in the first year with the objective of examin-ing the migratory patterns of the surgical workforce and its determinants in Uganda.

1.3 Surgical workforce: Uganda contextIn the Uganda context, the surgical workforce is not limited to specialist surgeons but also includes general practitioners, clinical officers and midwives, all of whom play critical roles in essential surgical health care deliv-ery, especially in the light of human resource shortages, particularly in rural facilities.

2. Methodology: protocol stages

In Uganda, first year activities under the project followed a six-step process, as prescribed in the project protocol for core data collection. Initial mapping of stakeholders involved in data management and in efforts and mechanisms for tracking and managing health workforce availability, distribution and migratory flows was undertaken. This included identifica-tion of key stakeholders to engage in the project activities, including national professional councils, namely the Uganda Medical and Dental Practitioners Council and the Uganda Nurses and Midwives Council, and national data managers in the Ministry of Health. This was followed by identification of health workforce data and acquisition of human resources for health data sets relevant to monitoring stocks and flows.

A consultation and inception workshop bringing together major actors and stakeholders in human resources for health in Uganda served as an entry point for a national-level policy dialogue on health workforce mobility.

2.1 Protocol stage 1: stakeholder mapping and engagement

An initial mapping of continuing stakeholder involvement in data management and in efforts and mechanisms for tracking and managing health workforce availability, distribution and migratory flows was undertaken. This included contacting the national authorities and identifying key stakeholders to be engaged in the project activities, including national professional councils and the designated national authori-ties for reporting on the WHO Global Code, and sourcing human resources for health data sets relevant to monitoring stocks and flows. An implementation task force was con-stituted, consisting of a broad range of relevant stakehold-ers, including the Commissioner for Health Services, the Assistant Commissioner Health Services (Human Resources Development), the Assistant Commissioner Health Services (Quality Assurance), the Principal Biostatistician of the Ministry of Health, the Registrar of the Uganda Medical and Dental Practitioners Council, the Registrar of the Uganda Nurses and Midwives Council, the Commissioner for Nursing at the Ministry of Health, the Assistant Commissioner for Planning, and the Principal Training Officer, Ministry of Health.


Two technical subcommittees were also constituted with the responsibility of sourcing health workforce data relating to medical and dental practitioners and nurses and midwives. Table 1 shows stakeholders engaged and mapped and data sources identified thus far under first year activities.

2.2 Protocol stage 2: data acquisitionIn the second stage, the project team acquired the data sets from stakeholders identified in the initial mapping. Following engagement with two regulatory bodies (Uganda Medical and Dental Practitioners Council and Uganda Nurses and Midwives Council), data sets were accessed on health workforce entry, exist and exit. These

sources were augmented with available data on online registers for both councils.

Prior to this, all available data sources were identified as summarized in Table 2. The identified sources of migra-tion data show applicability in relation to migration flows according to the entry, exist, or exit groupings.

2.3 Protocol stage 3: data verification and analysis

The third stage was for an audit to be undertaken of the data sets that were acquired to assess their validity, accuracy, completeness and timeliness for the purposes of the project. This was undertaken by the technical

TABLE 1. TEMPLATE A: RECORD OF STAKEHOLDER ENGAGEMENT AND DATA IDENTIFICATION

Stakeholder Person to contactLevel of engagement/data availability

Engaged, data available

Engaged, no data

Contacted but not engaged

Not contacted NA

Designated national authority

–Designated national authority for Uganda not yet appointed

Professional councils

Uganda Nurses and Midwives Council

Registrar √

Uganda Medical and Dental Practitioners Council

Registrar √

National data managers in Ministries of Health

Planning Director of Planning √

Human Resources √

Resource CentrePrincipal Biostatistician

√

National authorities charged with reporting on the Global Code

Permanent Secretary Permanent Secretary √

Director-General √

Line ministries in the country

Ministry of Education √

Ministry of Internal Affairs (Immigration)

√

Ministry of Foreign Affairs √

Ministry of Gender, Labour and Social Development

√

Note: The designated national authority for Uganda and the national authority charged with the responsibility for reporting on the Global Code to WHO and globally are at different levels in the Ministry of Health.


subcommittee identified in stage 2. At verification, it was established that the registers were regularly updated by the councils, which employ data managers for this purpose. It was established that cleaning of the registers was undertaken continually to ensure validity, complete-ness and accuracy. Table 3 shows the data sources for both the general and the surgical workforce pertaining to entry, exist or exit for which verification and analysis were carried out.

2.4 Protocol stage 4: data gap identification

Gaps. Regarding general gaps identified in health work-force exits, current sources that are dependent on letters of good standing are largely proxy indicators and not actual exits. Indeed, some of those who seek these letters sometimes end up not leaving the country. This is one area that will require strengthening.

Mitigation measures. The project will support the coun-cils to set up a functional exit register that will in future facilitate the tracking and disaggregation of medical health workers leaving the health workforce.

2.5 Protocol stage 5: minimum data source identification

The Medical and Dental Practitioners Council and Nurses and Midwives Council capture comprehensive data on all applicants, which cover all fields in the minimum data set (Table 4).

Data source

Data available that have potential

for health worker migration tracking?

(Yes/No/Don’t know)

If yes, are data for:

Entry?Exist?Exit?

Key stakeholder sources

(list contact details)

Designated national authority To be determined Permanent Secretary

Professional registers YesEntry; Exist;

Exit

Registrar of Uganda Medical and Dental

Practitioners Council, Registrar of Uganda Nurses and Midwives

Council

Professional licensure/ examination data Yes Entry; Exist

Migration visas Yes ExitCommissioner,

Migration

Work permits Yes Entry

Population censuses Yes ExistUganda Bureau of

Statistics, Population Secretariat

Administrative/population registers No

Employer surveys No

Labour force surveys No

Public Service Commission, Health Service Commission No

TABLE 2. TEMPLATE B: CURRENT RECORD OF RELEVANT DATA SOURCES AND DATA PROVIDERS IDENTIFIED

Entry Exist Exit

Register √ √

Licensure/exam √

Census √

Employer census/surveys √

Labour force surveys √

Migration permits/visa √ √

Work permits √

Other

TABLE 3. SURGICAL WORKFORCE DATA VERIFICATION AND ANALYSIS


3. Results3.1 Minimum data setAs mentioned in section 2.5, both the Medical and Dental Practitioners Council and the Nurses and Midwives Council capture comprehensive data on all applicants, covering all fields in the minimum data set.

Medical and Dental Practitioners CouncilThere is a full register as of June 2015 available online on the Uganda Medical and Dental Practitioners Council website. This register contains the following information:

registration number, name, sex, telephone number, email address, year of first qualification, and date of first regis-tration. Currently, 4811 practitioners are registered (3442 males, 1369 females). The annual practising licence register had 1362 practitioners as of 30 April 2015, and the same information as on the full register was included. The operating licence register contained 963 practition-ers as of June 2015.

A total of 119 had sought a certificate of good standing to seek jobs or study abroad, as reported in 2014. Their destinations include southern Africa, East Africa and

Nurses and midwives Medical and dental practitioners Foreign health workers

ID/registration number √ √ √

Name √ √ √

Date of birth √ √ √

Citizen/country/nationality √ √ √

Address √ √ √

Contact details √ √ √

Telephone contact √ √ √

Licence number √ √ √

Employment status √ √ √

Employment address √ √ √

TABLE 4. MINIMUM DATA SET

2010 2011 2012 2013 2014 2015

Male Female Male Female Male Female Male Female Male Female Male Female

Anaesthesiologists 20 9 14 8 20 9 21 10 21 11 15 9

Dental surgeons 2 2 2 2 4 3 3 1 2 2 2 2

ENT surgeons 15 5 16 4 15 4 18 4 17 4 12 4

General practitioners 815 350 821 302 1016 345 1172 434 1289 459 1258 487

Neurosurgeons 0 4 3 0 1 0 4 0 5 0 6 0

Obstetricians 98 30 110 32 107 30 93 25 98 25 103 27

Ophthalmologists 20 6 18 8 24 9 22 7 21 8 18 7

Orthopaedic surgeons

30 2 30 0 30 1 29 4 1 1 32 1

Physicians 82 25 76 20 82 25 82 31 85 34 72 31

Urologists 6 1 6 1 5 0 5 1 6 1 5 1

Total 1088 434 1096 377 1304 426 1449 517 1545 545 1523 569

TABLE 5. UGANDA DOCTORS BY SPECIALTY


Europe. There is a notable number of practitioners who work in South Sudan and Somalia, but these were not re-corded, as those countries do not require the certificate. However, it is known that a good number of Ugandans work there. Foreign health workers in the temporary licence register numbered 415 as of 31 October 2014. The specialist register listed 2092 as of 31 August 2015. Table 5 shows the stocks by specialty over the period 2010–2015. More information about specialties is included in Annex 1.

Migrating surgical workforce by cadreTaking requests for letters of good standing as a proxy, the cadre most subject to emigration is general prac-titioners, who accounted for 76% of health worker requests during the period 2010–2015. Other cadres of migrating health workers seeking letters of good stand-ing were anaesthesiologists (5%), obstetricians (4%), ear, nose and throat surgeons (2%), and neurosurgeons (2%). General practitioners are included in this analysis because in the Uganda setting they perform routine sur-geries such as caesarian sections, safe medical circumci-sions, management of simple fractures and hernia repair.

A migration trend analysis reflects a peak in migration between 2013 and 2014, when the highest number of surgical workforce cadres indicated intention to migrate (Figure 1). Before and after the peak years, migration was relatively lower. This trend in migration could be attributed to the dynamics of health workforce labour markets in Africa4 and in the world in general. A higher than usual influx of surgical personnel from Uganda into South Africa was recorded during that period.

Migrating surgical workforce by destinationAgain taking letters of good standing as a proxy, most of the migrating surgical workforce (68%) were destined for African countries, especially Botswana and South Africa. North America accounted for 17% of the destinations, with Canada alone accounting for 13.6%. This was notably greater than intended migrations to all European destinations combined, which accounted for 11% of the letters of good conduct sought (Figure 2).

4 Brain Drain–Brain Gain case study, South Africa: management of health worker migration and surgical workforce in South African health system, presented during the second year project coordination meeting.

FIGURE 1. DISTRIBUTION OF MIGRATING SURGICAL WORKFORCE BY CADRE, 2010–2015

Migrating surgical workforce by sexThe data further indicate that the majority of the migrating surgical workforce are males (70%) (Figure 3). Women account for 29.7% of all new registrations of medical doctors in Uganda. The numbers of women among the migrating surgical workforce is therefore pro-portional to the sex distribution of the health workforce stock. This provides an interesting insight into the migra-tion dynamics of health workers—sex has no significant impact on the rate of migration, and women are as likely to migrate as males.

Need excel file

North America

Europe

Africa

Middle East

Asia

Australia/ New Zealand

1%2%

68%

11%

17%

1%

FIGURE 2. DISTRIBUTION OF MIGRATING CADRE BY DESTINATION


3.2 Additional dataThe information captured at registration by both the Uganda Nurses and Midwives Council and the Uganda Medical and Dental Practitioners Council is quite com-prehensive, and meets the WHO minimum data set standard.

3.3 Qualitative informationEmployment conditions determine labour outcomes. Health workers prefer working in environments with good infrastructure. They also prefer to work within a supportive management system, under leaders who have vision and know what to do under challenging circumstances. Health workers prefer to go to places with opportunities for capacity-building and career progression. Most health workers fear that they will be forgotten when they go up-country. Health workers need to be determined and focused, but such attributes require nurturing, and there needs to be linkage between human resources for health and the health outcomes they are expected to achieve.

Health workers have migrated even when their salaries have been increased, which implies that studies need to be undertaken to identify the factors that contribute to retention of the health workforce. Health workers need to be fully engaged and satisfied with their employment conditions, and health standards and health education need to be aligned with the desired health outcomes.

Male

Female

70%30%

FIGURE 3. DISTRIBUTION OF MIGRATING CADRE BY SEX 4. Discussion and recommendations

The Annual health sector performance report for financial year 2014–2015 shows the staffing level in the public sector and the distribution of the 42 530 health workers employed in the public sector by type of institution. This number represents the health workers who were in post. They consist of health workers already on payroll (40 938), new recruits who had reported on duty but were not yet on payroll (1092) and health workers hired on contracts by various implementing partners (500). These human resource for health data were aggregated to form the national staffing levels for public institutions, comprising the Ministry of Health headquarters, national referral hospitals, 3 central specialized institutions, 14 regional referral hospitals, 47 general hospitals, 166 level IV health centres, 962 level III health centres and 1321 level II health centres. Staffing levels are presented for each of these levels. The overall staffing level at central-level institutions has declined slightly to 77% from 79% in financial year 2014–2015. Regional referral hospitals are generally better staffed. The performance report however does not mention numbers working in the private sector. Furthermore, it does not disaggregate by cadres, which would give some insight as to how many comprised the surgical workforce.5

The European Commission-funded case study in Uganda, in its first year, provided useful information on the dynamics of the health workforce in the country for entry, exist and exit. Furthermore, the main data sources – the Uganda Nurses and Midwives Council and the Uganda Medical and Dental Practitioners Council – gave adequate information on the minimum data sets as stipulated in the research protocol. These data showed gaps in some elements, especially in the areas related to the migration of the medical surgical

5 Source: Ministry of Health and USAID/SHRH project reports, 2015.


BOX 2. RECOMMENDATIONS ARISING FROM THE CASE STUDY

• Information about the private sector health workforce should be collected and included in national health workforce statistics.

• The maldistribution challenges that hinder attraction and retention of the health workforce in some locations need to be addressed through more attractive working conditions and remuneration packages, in order to reduce the high turnover of staff.

• Efforts should be made to ensure that project activities act as a catalyst for the reinforcement of the capacities of councils to incorporate in their routine data management systems additional information that can track, on a regular basis, exit from the workforce.

• The existing national policies on human resources for health should be applied more effectively to human resource management, for example to address shortages by developing human resources for health staffing projections in keeping with health system priorities.

• Surveys should be conducted on the cohorts of health workers that requested letters of good standing to determine what proportion of them actually did migrate.

workforce, such as identifying and registering those exiting the health workforce. Exits through death and retirement could easily be captured, though exits through migration are less easily captured. Letters of good standing provide a proxy measure, as they are usually required by those seeking to leave the country for job-related interests or for studies. Unfortunately this method also has its shortcomings, as some of those who receive these letters do not actually leave the country.

These findings indicate that there is a need for the Ministry of Health human resources for health unit to work closely with the councils regarding the manage-ment of the professional workforce. Advantage should be taken of the practices introduced by councils for encouraging continuing professional development. The outcome of these activities should be made available at workplaces to monitor the quality of performance. Clear policy implications and recommendations can be derived from the findings of this case study (Box 2).


Bibliography1. HRH Action Framework, http://www.capacityproject.org/framework/uganda/.

2. World Health Report 2006.

3. Improving HRH evidence for decision-making: human resources for health biannual report. Ministry of Health, Republic of Uganda, 2015.

4. Ouagadougou Declaration on Primary Health Care and Health Systems: a reiteration of the principles of the PHC approach, within the context of an overall health system strengthening approach.

5. International Health Partnerships (IHP+) on Aid Effectiveness.

6. The post-MDG 2015 agenda: a focus of global efforts in improving health impacts through implementing the universal health coverage (UHC) agenda in health.

7. Uganda Vision 2040.

8. National Development Plan 2015/16–2019/20, Republic of Uganda. NPA; 2015.

9. National Development Plan 2010/11–2014/15, Republic of Uganda. NPA; 2010.

10. Second National Health Policy, Republic of Uganda, 2010/11–2019/20.

11. Health Sector Strategic and Investment Plan, Republic of Uganda, 2010/11–2014/15.

12. Uganda National Health Research Organization Strategic Plan 2010/11–2014/15.

13. Draft Health Financing Strategy, Ministry of Health, Republic of Uganda

14. Roadmap for Accelerating Reduction of Maternal and Neonatal Mortality. Ministry of Health, Republic of Uganda, 2007.

15. Reproductive Maternal, Newborn and Child Health Sharpened Plan for Uganda. Ministry of Health, Republic of Uganda, 2013.

16. Uganda Cancer Institute Strategic Plan 2015.

17. East African Community Health Sector Strategic Plan 2015–2020.

18. Country Cooperation Strategy, Uganda, World Health Organization; 2015.

19. Family Planning 20/20 Initiative, Geneva: World Health Organization.

20. District development plans (DDPs), Republic of Uganda, 2014/15–2018/19.

21. Health Sector Strategic Investment Plan: Mid-term review report, Ministry of Health, Republic of Uganda,2013.

22. Annual health sector performance reports 2010/11, 2011/12, 2012/13, 2013/2014, Republic of Uganda.

23. National Health Accounts report 2010/11–2011/12, Ministry of Health, Republic of Uganda.

24. World health statistics report. Geneva: World Health Organization; 2014.

25. Statistical abstract 2014, Uganda Bureau of Statistics.

26. Uganda Demographic and Health Survey, Uganda Bureau of Statistics; 2011.

27. Draft hospital and HC IV census report.,Ministry of Health, Republic of Uganda,; 2015.

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29. Uganda Millennium Development Goal report 2013.

30. Global Health 2035, http://globalhealth2035.org/.

31. The common African position of the African Union 2014.


Annex 1. Tables on migration flowsTABLE A1.1 NEW REGISTRATIONS: UGANDANS

Year M F Total

2010 153 73 226

2011 198 71 269

2012 180 89 269

2013 204 98 302

2014 234 97 331

2015 259 91 350

TABLE A1.2 INCOMING FOREIGN PRACTITIONERS

Country

2010 2011 2012 2013 2014 2015

M F M F M F M F M F M F

Algeria 0 0 0 0 0 1 0 0 0 0 0 0

Angola 0 0 0 1 1 0 0 0 0 0 0 0

Argentina 0 0 0 0 0 1 0 0 0 0 0 0

Australia 3 1 6 1 1 1 0 1 1 1 0 0

Austria 0 0 0 0 1 0 0 1 0 0 0 0

Bangladesh 0 0 0 1 0 0 0 0 0 0 0 0

Belgium 0 0 2 0 0 0 0 0 0 1 0 0

Burundi 0 0 0 0 1 0 0 0 1 1 0 0

Canada 11 12 13 15 7 12 18 9 21 25 8 5

China 0 0 2 1 0 1 4 1 1 0 0 0

Colombia 0 0 0 0 0 0 0 0 0 0 0 0

Cuba 0 0 2 2 0 0 0 0 3 2 2 0

Czech Republic 5 6 1 4 2 2 0 0 0 0 0 0

Democratic Republic of Congo 5 0 2 1 3 0 2 0 5 3 2 0

Denmark 0 0 0 0 0 0 0 1 0 0 0 0

Dominican Republic 0 0 0 0 0 0 0 0 0 0 0 0

Ecuador 0 0 0 0 0 0 0 0 1 0 0 1

Egypt 4 0 20 0 8 1 0 0 4 0 0 0

Eritrea 1 0 0 0 2 1 0 0 1 0 0 0

Ethiopia 1 0 2 0 0 0 0 0 0 0 0 0

France 0 0 0 1 1 0 0 1 0 0 0 0

Germany 6 2 1 1 2 1 1 3 5 7 1 1

Ghana 0 0 0 0 0 0 0 1 0 2 4 1

Greece 0 0 1 0 0 0 0 0 0 0 0 0

Guatemala 0 1 0 0 0 0 0 0 0 0 0 0

Guinea 0 0 0 0 1 0 0 0 0 0 0 0


(continued)

Country

2010 2011 2012 2013 2014 2015


Guyana 0 0 0 0 0 0 1 0 0 1 0 0

Honduras 0 0 0 0 1 0 0 0 0 0 0 0

Hungary 1 0 0 0 0 0 0 0 0 0 0 0

Iceland 0 0 0 0 0 0 1 0 0 0 0 0

India 9 5 12 7 11 2 21 5 13 7 0 0

Iran (Islamic Republic of) 0 1 0 0 0 0 1 0 0 0 0 0

Ireland 1 0 3 5 0 4 0 1 2 1 0 0

Israel 1 1 0 0 0 0 0 0 1 1 1 0

Italy 13 5 14 9 15 12 4 6 12 10 3 2

Japan 3 1 3 1 2 0 1 0 2 0 0 0

Kazakhstan 0 1 0 0 0 1 4 2 0 1 0 0

Kenya 1 0 3 2 5 1 0 0 2 1 0 0

Malawi 0 0 0 0 1 1 0 0 0 0 0 0

Malaysia 0 1 0 0 0 1 1 0 0 0 0 0

Mali 0 0 0 0 1 0 0 0 0 0 0 0

Mexico 2 0 0 0 0 0 0 0 1 0 0 0

Moldova 1 0 0 0 0 0 0 0 0 0 0 0

Montenegro 0 0 0 0 0 0 0 0 0 0 1 1

Mozambique 0 0 0 0 0 1 0 1 0 0 0 0

Nepal 0 0 1 0 0 1 0 0 0 0 0 0

Netherlands 5 3 5 1 0 1 1 3 1 3 1 1

New Zealand 0 0 0 1 0 0 2 0 0 0 0 1

Nigeria 2 0 6 0 1 0 0 0 1 0 0 0

Norway 0 0 0 0 0 1 0 0 0 0 1 1

Pakistan 1 0 6 3 2 1 3 0 1 1 0 0

Palestine 0 0 0 0 0 0 1 0 0 0 0 0

Panama 0 2 0 0 0 0 0 0 0 0 0 0

Philippines 1 2 0 0 0 0 0 1 0 1 0 0

Poland 0 0 0 0 2 0 1 1 0 2 3 0

Republic of Korea 7 2 6 1 3 0 4 0 12 0 0 0

Russian Federation 2 0 1 2 1 1 0 2 1 3 1 1

Rwanda 2 0 5 2 4 2 1 0 0 0 0 0

Saudi Arabia 0 0 5 0 0 0 0 0 0 0 0 0

Serbia 0 0 0 0 1 1 1 0 1 0 1 0

Sierra Leone 0 0 0 0 1 0 0 0 0 1 0 0

Singapore 0 0 0 0 0 1 0 0


Country

2010 2011 2012 2013 2014 2015


Slovenia 0 0 0 2 0 0 0 1 0 2 0 1

Somalia 2 0 1 1 1 0 9 0 2 0 0 1

South Africa 2 0 1 1 1 0 0 0 0 0 0 0

South Korea 2 0 1 0 3 0 1 0 0 0 0 0

South Sudan 0 0 0 0 0 0 1 0 0 0 0 0

Spain 0 1 0 1 2 0 1 0 0 0 0 0

Sudan 0 0 1 0 1 0 1 0 1 0 0 0

Swaziland 0 0 0 0 0 1 0 0 0 0 0 0

Sweden 1 0 1 0 2 0 2 5 0 2 0 0

Switzerland 0 0 0 0 0 0 1 0 0 0 0 0

Syria 0 0 0 0 0 0 0 0 0 0 1 0

Thailand 0 0 0 0 0 0 0 1 0 0 0 0

Turkey 13 3 2 0 10 0 0 0 4 0 0 0

United Arab Emirates 0 0 0 2 0 0 0 0 0 0 0 0

United Kingdom 12 17 9 16 18 16 12 21 16 33 6 9

United Republic of Tanzania 1 0 2 1 0 0 0 1 1 0 0 0

United States of America 54 42 58 44 47 42 33 30 59 41 20 24

Uzbekistan 0 0 0 0 0 0 0 0 0 0 0 0

Venezuela 0 0 0 0 0 0 0 0 0 0 1 0

Viet Nam 0 0 0 0 0 1 0 0 0 0 0 0

Zimbabwe 0 1 0 0 0 0 0 0 0 1 0 0

Total 175 110 198 130 166 112 134 99 176 155 57 50

TABLE A1.3 INCOMING BY CADRE

2010 2011 2012 2013 2014 2015

TotalM F M F M F M F M F M F

Anaesthesiologists 4 5 4 3 5 5 1 0 5 1 0 0 33

Dental surgeons 0 0 0 0 0 0 0 0 1 0 0 0 1

ENT surgeons 3 1 2 1 1 0 2 0 3 2 0 0 15

General practitioners 111 79 140 108 126 96 91 86 109 134 44 46 1170

Neurosurgeons 1 0 1 0 2 0 2 0 5 0 0 0 11

Obstetricians 4 1 2 4 3 1 1 2 3 1 3 2 27

Ophthalmologists 4 2 3 0 0 0 4 0 2 0 0 0 15

Orthopaedic surgeons 6 1 3 0 2 0 5 0 8 0 3 0 28

Physicians 5 4 4 1 2 3 1 2 7 3 3 0 35

Urologists 4 0 2 0 3 0 3 1 1 0 0 0 14

TABLE A1.2 INCOMING FOREIGN PRACTITIONERS (CONTINUED)


TABLE A1.4 OUTGOING BY CADRE

2010 2011 2012 2013 2014 2015

Total F M F M F M F M F M F

Anaesthesiologists 1 0 0 1 1 0 2 1 0 0 2 3 11

Dental surgeons 0 1 0 0 0 0 0 0 0 0 0 0 1

ENT surgeons 0 1 1 0 1 0 0 1 0 0 1 0 5

General practitioners 8 5 7 3 8 4 19 5 46 17 42 19 183

Neurosurgeons 0 0 1 0 0 0 1 1 0 0 2 0 5

Obstetricians 0 0 1 0 2 0 1 1 0 0 4 1 10

Ophthalmologists 1 1 0 0 2 0 1 0 0 0 0 0 5

Orthopaedic surgeons 0 0 0 0 0 0 1 0 0 0 0 0 1

Physicians 1 0 0 0 2 1 3 2 1 4 0 3 17

Urologists 0 0 0 0 0 0 1 1 0 0 0 0 2

TABLE A1.5 OUTGOING BY DESTINATION COUNTRY

Country

2010 2011 2012 2013 2014 2015


Australia 1 1 0 0 4 0 0 1 0 1 2 1

Belgium 0 1 0 0 0 0 0 0 0 0 0 0

Botswana 5 0 4 0 4 5 5 0 15 3 13 3

Canada 1 1 2 0 4 0 8 6 2 1 5 4

Egypt 0 0 0 0 0 0 1 0 0 0 0 0

Gambia 0 0 0 0 0 0 1 0 0 0 0 0

Germany 0 0 0 0 0 0 3 1 1 0 0 0

India 0 0 0 0 0 0 0 0 0 0 2 0

Ireland 0 0 0 1 0 0 0 0 0 0 0 0

Kenya 2 1 1 0 2 2 2 0 6 3 1 1

Lesotho 0 0 0 0 0 0 2 0 1 0 1 0

Liberia 0 0 0 0 0 0 0 0 2 0 0 0

Malawi 0 0 0 0 0 0 0 0 1 0 0 0

Mozambique 0 0 1 0 0 0 0 0 0 0 0 0

New Zealand 0 0 0 0 0 0 0 0 0 0 0 1

Nigeria 0 0 0 0 0 0 1 0 0 0 0 0

Rwanda 0 1 0 0 0 0 2 0 0 1 1 0

Singapore 0 0 0 0 1 0 0 0 0 0 0 0

South Africa 1 1 4 3 6 1 4 2 6 2 4 1

Spain 0 0 0 0 0 0 0 0 1 0 0 0

Sudan 0 0 0 0 0 0 0 0 1 1 0 0

(continued)


Country

2010 2011 2012 2013 2014 2015


Swaziland 0 0 1 1 0 0 2 2 1 0 2 1

Sweden 0 0 0 0 0 0 1 0 0 0 1 0

Trinidad and Tobago 0 0 0 0 0 0 0 0 2 0 0 0

United Arab Emirates 0 0 0 0 0 1 0 0 1 0 0 2

United Kingdom 1 1 0 0 0 0 3 3 5 3 1 1

United Republic of Tanzania 1 1 0 0 3 0 2 1 1 0 4 2

United States of America 0 0 0 0 0 0 1 0 0 2 1 0

Zambia 0 1 0 0 0 0 0 0 0 0 3 1

Zimbabwe 0 0 0 0 0 0 0 0 0 0 2 0

Total 12 9 13 5 24 9 38 16 46 17 43 18

TABLE A1.5 OUTGOING BY DESTINATION COUNTRY (CONTINUED)

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