Objectives: The study aimed to determine the proportion of nursing and medical students who were intending to emigrate, their attitudes and beliefs about, and the factors influencing their decision to emigrate.

Method: This study was conducted at three medical schools and one nursing school in South Africa (n = 298) amongst 260 medical and 38 nursing students. One hundred and twenty-five students were in the final year of their studies and 143 were in their prefinal year. Thirty students did not indicate the year of their studies. Every student present on the day of data collection completed a questionnaire comprising psychometric and survey-based questions. Descriptive and inferential statistics were used to analyse the data.

Results: More than a third (37%) of the respondents intended to work or specialise abroad. The majority of medical (58.9%) and nursing (66.6%) students intended to leave SA within five years of completing their medical or nursing studies. The perception of poor working conditions within the health sector, such as long work hours, high patient loads, inadequate resources and occupational hazards, influenced medical students to consider emigrating from South Africa.

Conclusion: The high number of medical and nursing students intending to emigrate requires a reassessment of effectiveness of retention strategies for doctors and nurses in the South African healthcare system and actions to improve working conditions in the public healthcare sector.

Contexte: La migration des professionnels de la santé peuvent avoir des répercussions profondes sur les systèmes de santé partout dans le monde. La mobilité des professionnels de la santé la recherche (projet MoHProf) visant à améliorer la connaissance de la migration des professionnels de la santé et de comprendre la migration intentions et les facteurs influant sur la migration des médecins et des étudiants en sciences infirmières.

Objectifs: L’étude visait à déterminer la proportion des soins infirmiers et étudiants en médecine qui ont l’intention d’émigrer à l’étranger, leurs attitudes et leurs croyances, et les facteurs qui influent sur les élèves» décisions à émigrer.

Méthodes: Cette étude a été menée dans trois écoles de médecine et une école d’infirmières en Afrique du Sud (SA) (n = 298). Les élèves ont rempli un questionnaire composé de qualités psychométriques et basé sur les données d’enquête et aux questions. Descriptif et inférence statistique ont été utilisés pour analyser les données.

Résultats: Un tiers des personnes interrogées ont l’intention de travailler ou se spécialiser à l’étranger. La majorité destiné à laisser SA dans les cinq premières années de leur carrière médicale. Les résultats suggèrent que ces répondants étaient probablement l’intention d’attendre quelques années après l’obtention de leur diplôme, peut-être, afin de se spécialiser dans SA, enregistrer de l’argent pour les frais de l’émigration, ou pour terminer leur travail obligatoire engagements.

Conclusions: Le montant substantiel des soins médicaux et infirmiers les étudiants désireux d’émigrer à l’étranger exige une réévaluation de l’efficacité des efforts de conservation pour les travailleurs de la santé dans la SA système de soins de santé et des mesures décisives pour améliorer les conditions de travail dans le secteur de la santé publique.

In terms of actual migration flows, work permit data and registration data for 2001 and 2002 show there has been significant growth in the inflow of doctors to the United Kingdom. In 2002, nearly half of all the new full registrants on the UK General Medical Council (GMC) register were foreign,² and of those, 3509 were South African trained doctors. In the same year 1950 South African doctors were reportedly living in the USA.¹ In 2002, 2884 South African nurses were documented to have emigrated from South Africa (SA) to the UK,³ the number had decreased to 1418 in 2003.⁴ By 2004, 7% of the total nursing workforce in SA had left SA to work in seven Economic Co-operation and Development (OECD) countries (Denmark, Canada, Finland, Portugal, USA, UK and Ireland), whilst slightly over a third of the South African doctors (37%, n = 12 136) who had been trained in SA were living in eight OECD member countries (Australia, Canada, Finland, France, Germany, Portugal, USA and UK).³ Moreover, by 2006 the proportion of South African doctors who had left the country rose to 40%.¹ Statistics from the South African Department of Health indicate that in 2006 almost 9000 SA doctors (n = 8921) and 6844 nurses and midwives were working in Australia, Canada, New Zealand, UK and USA.⁵

Research has found^6,7 a high degree of emigration intention amongst health science students in southern Africa, with 65% indicating that they would like to emigrate within five years of graduating. Health science students in the study by Crush, Pendleton and Tevera⁶ were noted to have given more thought to moving to another country and to be inclined to stay in their destination country for a longer period of time than non-health science students. Although lower than the proportion found by Crush et al.,⁶ a study amongst 194 medical students in the province of KwaZulu-Natal showed that roughly one in five students intended to practise abroad after graduation, whilst fewer wished to pursue postgraduate training abroad (n = 10, 7.6%)⁷. Emigration considerations were also prevalent amongst a sample of 9743 students from sub-Saharan Africa which included 4532 SA students. Approximately four in five students (79%) had thought about moving to another country, and 35% said that they would consider the possibility during the next six months. The proportion of final year students in the study, however, who had actually taken active steps to leave the country was much lower; only 19% had applied or were in the process of applying for work permits abroad, whilst 11% were applying for permanent residence or citizenship elsewhere.⁶

Factors influencing individuals’ decisions to migrate to other countries are commonly grouped into push and pull factors depending on whether the factor is located in the source or destination country. Prominent push factors for HPs in sub-Saharan Africa include resource-limited health care systems, deteriorating work environments, human resource shortages, low salaries, political tensions and upheaval, gender discrimination, lack of personal security, HIV and AIDS, and deteriorating quality of life and social systems such as education and welfare.^1,9,10 Salient pull factors attracting HPs to developed countries abroad often relate to the availability of jobs in the destination country, more manageable workloads, higher remuneration, better working conditions, safer living environments, higher quality of life and a more economically and politically stable country.^1,9,10 Although few studies have explicitly set out to determine the variation of push and pull factors across age groups, it is interesting to note that Maslin¹¹found that HPs between the ages of 20 and 29 were more likely to cite deteriorating working conditions as a reason for leaving SA than their older counterparts.

Research amongst South African HPs revealed that financial factors, better job opportunities for themselves and better schooling opportunities for their children abroad as well as the high crime rate in SA were significant factors encouraging these health workers to emigrate.¹² Further, the opportunity to gain international experience is an important pull factor attracting South African HPs, particularly doctors, to overseas countries.¹¹ According to Oberoi and Lin,¹⁰ however, push factors motivating HPs to leave SA can exert a more powerful influence on their emigration decisions than the factors attracting them to their destination country. The major push factors that emerged most frequently in their interviews with South African doctors who had emigrated to Australia were poor remuneration, lack of job satisfaction, lack of future prospects for further education and career development, poor working conditions, HIV and AIDS and poor quality of life.¹⁰

Hence, this study aimed to achieve three objectives:

1. To determine the proportion of nursing and medical student respondents who intend to emigrate within five years of graduation.

2. To assess the attitudes and beliefs of respondents intending to emigrate.

3. To examine the factors associated with respondents’ intentions to emigrate from SA.

Apart from three questions drawn from three studies, the demographic questions were mostly developed by the researchers.^6,7,8 Several of the items regarding Section 4 (Sources of information about emigration) were taken from Crush, Pendleton and Tevera.⁶The push factors listed in Section 5 are a compilation of factors drawn from several authors.^6,7,8,13,14Question items from previous studies^6,8,13 as well as items developed by the authors were used to develop 13 Belief statements. Thirteen question items enquiring about respondents’ attitudes to emigration were also developed by the researchers for the study. The alpha reliability for the Beliefs scale was originally .74. Two items were omitted because they were correlating negatively with other Belief items (‘The increase in salaries due to the OSD [Occupational Specific Dispensation] will ensure that more doctors and nurses stay in SA’ and ‘I will be exposed to fewer occupational risks abroad). After dropping these items the alpha coefficient increased slightly to 0.77. Initially the alpha reliability for the Attitudes scale was 0.58. The inter-item correlation matrix and item total statistics tables were inspected to see which items could be dropped to improve the internal consistency of the scale. Three items were dropped (‘Pursuing work opportunities abroad will give doctors and nurses valuable experience and skills they will not acquire in SA’, ‘The emigration decisions of doctors and nurses should be based entirely on what is best for them and their families rather than for SA’ and ‘Governments have no right to implement policies that restrict the migration of HPs to and from countries’), which increased the alpha reliability for the Attitudes scale to 0.66.

Table 1 illustrates the frequencies and percentages of medical and nursing students and the likelihood of their moving abroad within two and five years after graduating. The results showed a significant difference in the proportion of medical respondents and nurses who would like to move abroad within two years of graduating, X² (6, n = 213) =29.47, p < 0.01. A larger proportion of nursing students (21%, n = 5) compared to medical students (18%, n = 33) reported being ‘likely’ to leave SA within two years of graduating, whilst 29% (n = 7) of nursing students compared to 9% (n = 17) of medical students indicated they were ‘very likely’ to leave the country within two years of graduating. Approximately two thirds of the sample (63%, n = 145) indicated that they were not likely to leave the country for at least two years after graduating, whilst 28% (n = 64) thought they would probably have left SA by that time. This increases dramatically, however, when respondents were asked whether they were likely to leave SA within five years. Almost half of the respondents (46%, n = 137) indicated that they were ‘likely’ or ‘very likely’ to leave SA within five years of graduation. Only 55 respondents (19%) were certain that they would remain in the country for at least five years after graduating.

Respondents tended to hold negative attitudes about emigration, tending to be in favour of HPs remaining in SA to work (Table 3). The majority of respondents did not feel that the South African government was to blame for the emigration of HPs based on poor working conditions (79%, n = 193) or low salaries (83%, n = 203) and believed that the government has a right and responsibility to introduce measures to reduce the emigration of South African health workers (79%, n = 193). Attitudes towards emigration were not found to be significantly associated with intentions to work abroad (p = .82), intentions to train abroad (p = .07), or respondents’ most likely destination country (p = .29).

The strongest pull factors attracting respondents to emigrate abroad included the opportunity to earn higher salaries (48%. n = 110), the quality and variety of specialist training offered (47.3%. n = 107), prospects for professional advancement (44%. n = 99), the availability of good jobs (40%, n = 90) as well as greater personal safety abroad (40%, n = 90).

Table 5 provides the frequency counts and percentages of respondents that identified certain obstacles as either ‘somewhat of a barrier’ or a ‘great barrier’. The costs associated with emigrating (e.g. for visas, examination fees and plane tickets) (40%, n = 107), having dependents in SA (40%, n = 105), obligatory work commitments respondents would be involved in after their community service (38%, n = 101) and ease of adjustment to the healthcare system in their destination countries (34%, n = 90) were the most important barriers to emigration. A smaller proportion of respondents indicated that government policies in SA (24%, n = 64) and in their destination country (25%, n = 67) and qualifying for visas in their destination country (6%, n = 23) were substantial barriers deterring them from moving abroad.

The results also showed that there were significant differences in the proportion of medical respondents and nursing respondents who would like to move abroad after two years of graduating. Although far fewer nursing students participated in the study compared to medical students, the findings suggest that a higher proportion of nursing respondents than medical respondents would like to emigrate within two years after graduating. Other researchers have also noted the high emigration potential amongst young nurses in SA, arguing that young people are increasingly more likely to choose the nursing field as a career, even if it is not their preferred choice, because of the emigration opportunities and better career prospects it offers them.¹⁵

In terms of the respondents’ attitudes to emigration, the findings showed that in general most of the respondents were supportive of HPs remaining in SA for the duration of their careers and government actions and strategies to curb the emigration of HPs. These negative attitudes towards emigration may be influenced by the stance of their educational institutions on the emigration of HPs, given that the majority of the sample reported that their educational institution was not encouraging them to work or train abroad. The general attitude against emigration does contradict the high prevalence of emigration intentions reported by the sample. Moreover, the lack of association between respondents’ attitudes and beliefs about emigration suggests that some respondents could hold these relatively strong attitudes against emigration alongside positive beliefs about the working conditions and job prospects of working abroad. It seems that holding onto values and ideals that disapprove of HPs leaving SA is not a guarantee that they will not want to work abroad.

Regarding the barriers that may hinder respondents from leaving the country to work or train abroad, the foremost barriers identified by respondents were the costs associated with emigrating such as the air fares, examination fees to acquire professional registration abroad and applications for visas and work permits. Furthermore, the high cost of emigrating may partially explain why most respondents intended to emigrate within two to five years of graduating, giving them time to save money to pay for the costs associated with moving abroad. Secondly, having dependents might deter some respondents from leaving the country, whether these be children or older family members. Adjustment to the culture of the healthcare system in the respondents’ destination countries was another prevalent barrier that emerged from the findings. This potential barrier may contribute to explaining why HPs prefer to emigrate to English speaking countries such as Canada, North America, Australia, New Zealand and the UK and also to other EU countries, as the results of this study show and other studies confirm.^1,3

Having to fulfil obligatory work commitments after their community service was another salient barrier deterring many of the respondents from moving abroad and it was surprising to find that more than a third of the sample had obligatory work commitments to fulfil. Our results show that working abroad to earn money to repay financial commitments sooner than would be possible if they remained in SA, played an important role in approximately a third of the respondents’ emigration plans. Given that 42.9% (n = 118) of the respondents indicated that they had received government bursaries and scholarships, this may culminate in huge losses for the SA government.

The findings also showed that qualifying for visas and government policies in SA and their most likely destination were least likely to be perceived as barriers hindering respondents from working abroad, compared with the other identified barriers. This suggests that respondents may be unaware of some countries’ stringent immigration policies, also regarding the recruitment and employment of foreign HPs. Respondents were in the early stages of planning and preparing for moving abroad and therefore they may not have been familiar with their destination countries’ policies regarding immigration and the employment of foreign doctors and nurses, or they may merely have started the process of applying for visas and work permits.

The predominance of work-related factors over lifestyle-related factors in the students’ emigration decisions may relate to the time period they find themselves in, where few have families and/or dependents and work-related concerns are therefore a higher priority. To this end, it would be important for longitudinal research studies to be conducted in order to contribute towards an understanding of dominant push and pull factors across health professionals in different age groups and career trajectories in order to develop retention strategies and incentives tailored to health professionals’ needs and circumstances.

Furthermore, the findings revealed that intentions to emigrate were relatively common amongst both the medical and nursing students in our samples. The fact that countries within the EU and the UK in particular remain a popular destination for student respondents indicates that inflows of South African HPs into the EU will probably continue into the future even with the introduction of the Professional and Linguistics Assessments Board (PLAB) exams and stricter policies regarding the recruitment and employment of foreign HPs. It appeared that many student respondents would wait for an initial period after graduating or completing their community service before deciding whether to leave the country, during which time most of them would either specialise, work as junior doctors and nurses, or fulfil obligatory work commitments associated with their financial assistance. This highlights a critical early period in the careers of junior doctors and nurses during which many are prone to want to emigrate. Given the large investment by the government into the training of nurses and doctors in the country, the fact that a majority of doctors and nurses would emigrate early in their careers is of concern and represents a potential major loss of investment for the country.

There is much concern about the loss on investment incurred by host countries when medical students move abroad after completion of their studies, particularly those whose studies have been subsidised by governments in developing nations.^18,19 The importance of selecting the right candidates for financial assistance to protect the return of an investment spent on training health workers is underscored by the fact that over half the sample receiving financial assistance did so in the form of government bursaries and scholarships. Furthermore, the opportunity to repay financial commitments was a strong motivator influencing more than a third of the sample to emigrate. As the findings show, there is a small contingent of medical and nursing students who are resolved to remain in the country, and who should be the target of government bursaries and scholarships to ensure a better return on investment in the training of HPs in the future. In addition, it is of utmost importance that doctors and nurses feel adequately engaged by the South African government with regard to their complaints about working conditions, low salaries and heavy workloads during the critical early period in their careers. This carries with it implications for efforts to improve the community service experience of nurses and doctors to ensure they come through their year of community service with a desire to remain in the country.

1. Buchan J. International recruitment of nurses: policy and practice in the United Kingdom. HRET. 2007;10(1111):1475–6773.

3. Breier M, Wildshut A, Mgqolozana T. Nursing in a new era: The profession and education of nurses in South Africa. Cape Town: HSRC Press; 2009.

4. Buchan J. Dovlo D. International recruitment of health workers to the UK: A report for DFID. DFID Health Systems Resource Centre; 2004;1–44.

5. South African Department of Health. Human resources for health South Africa: HRH Strategy for the Health Sector: 2012/13 – 2016/17. Pretoria: Department of Health; 2011.

6. Crush J, Pendleton W, Tevera DS. Degrees of uncertainty: Students and the brain drain in southern Africa. SAMP. 2005;1–24.

7. Van Wyk JM, Naidoo SS, Esterhuizen TM. Will graduating medical students prefer to practice in rural communities? SA Fam Pract. 2010;52(2):149–153.

8. Pendleton W, Crush J, Lefko-Everett K. The haemorrhage of health professionals from South Africa: Medical opinions. SAMP. 2007;47:1–38.

9.Hamilton K, Yau J. The global tug-of-war for health care workers. Migration Policy Institute; 2010.

10. Oberoi SS, Lin V. Brain drain of doctors from southern Africa: Brain gain for Australia. Aust Health Rev. 2006;30(1):25–33. PMid:16448375

11. Maslin A. Databank of bilateral agreements. The Aspen Institute: Global Health and Development; 2003.

12. Bezuidenhout MM, Joubert G, Hiemstra LA, Struwig MC. Reasons for doctor migration from South Africa. SA. Fam Prat. 2009;51(3),211–215.

13. Crush, J. Losing our minds and the South African brain drain. Cape Town and Queen’s University, Canada: Idasa; 2000.

14. Packer C, Labonte R, Spitzer D. Globalisation and health worker crisis. WHO Commission on Social Determinants on Health; 2007.

15. Troy PH, Wyness LA, McAuliffe E. Nurses’ experiences of recruitment and migration from developing countries: A phenomenological approach. Hum Resour Health 2007;5(15):1478–4491.

16. George G, Rhodes B. Is there really a pot of gold at the end of the rainbow? Has the Occupational Specific Dispensation, as a mechanism to attract and retain health workers in South Africa, levelled the playing field? BMC Public Health 2012;12:613. http://dx.doi.org/10.1186/1471-2458-12-613, PMid:22867099, PMCid:3444331

17. Awases M, Gbary A, Nyoni J, Chatora R. Migration of health professionals in six countries: A synthesis report. World Health Organisation Document; 2004.

18. Mills EJ, Katers S, Hagopian A, et al. The financial cost of doctors emigrating from sub-Saharan Africa: Human capital analysis. BMJ. 2011; 343:d7031. http://dx.doi.org/10.1136/bmj.d7031

19. Dovlo, D. The brain drain in Africa: An emerging challenge to health professionals’ education. JHEA/RESA. 2004;2(3):1–18.