Critical Factors Favoring Outward Physician Migration | RMHP


Plain Language Summary

The migration of physicians from low and middle income to high-income countries has become a global health concern. Health worker migration decisions are influenced by many personal, professional, financial, and political reasons. Our results show that salaries and career-related opportunities contribute to the short-term retention of physicians in the UAE; but lifestyle related factors play a more important role in long-term retention.


The shortage of skilled health practitioners is a global concern. Studies show that the density of physicians and nurses correlates significantly with important population health outcomes, including life expectancy and infant and child mortality rates.1 [REF] However, approximately half of countries worldwide do not currently train adequate numbers of healthcare professionals to meet population needs, and rely on the importation of an expatriate health workforce.2 Globalization has enabled the increased mobility of health practitioners, primarily from low and middle-income countries to high-income nations, but the recruitment and retention of quality physicians have not been without challenges. The coronavirus 2019 (COVID 19) pandemic has exacerbated the consequences of these physician migration patterns.3 The source countries suffer from medical “brain drain” by educating and training practitioners without benefitting from their clinical practice, leading to shortages and weakening of the healthcare systems, leaving them ill-equipped to respond to crises.4 It is estimated that the financial costs associated with excess mortality due to physician migration in low income countries are approximately 15 billion US dollars annually. Studies also suggest that many immigrant clinicians face discrimination, wage disparities, underemployment and deskilling.5 For the destination countries, expatriate healthcare practitioners can impose their own cultural values, which may be incongruent with the customs and norms of the society they are serving, resulting in decreased patient satisfaction and low adherence to treatment regimens.6 High attrition also leads to the loss of expertise and increased recruitment costs.7

The United Arab Emirates (UAE), a high-income Gulf country, offers a unique opportunity to examine health professional migration trends. In recent decades, the UAE has invested substantially in the development of healthcare and education infrastructure. Yet, despite improvements in the quality of medical education and increases in the quantity of medical trainees,8 the country has not achieved medical workforce self-sufficiency, primarily due to an aging population and high prevalence of cancer and chronic diseases.9–11 Moreover, health systems in the UAE have high turnover rates and retention issues.12 A 2012 study, for example, revealed that 12% of nurses and 15% of physicians left the UAE workforce in a single year.13 Although published national statistics are lacking, in Abu Dhabi, expatriates comprise 87% of the physician workforce.9 The majority of expatriate healthcare workers in the UAE are recruited from neighboring Arab countries, South Asia and Southeast Asia.9 Residence visas for physicians are linked to the healthcare facility of employment and require renewal every 3 years. In 2019, 10-year visas were made available to eligible physicians in the country.14 This study is part of a larger project evaluating expatriate physician retention in the UAE. We have previously reported that expatriate physicians in the UAE primarily cited lifestyle related factors in their decision to remain in the country, specifically quality of life, proximity to extended family and personal and family safety.15 In this study, we look specifically at outward migration intentions of expatriate physicians who have resided and worked in the UAE for at least 5 years, as compared with newly emigrated physicians. This physician population has likely adapted to the local environment and actively contributed to the advancement of medical care in the country; their attrition is a significant loss to the UAE healthcare system.


Survey Participants

Participants included expatriate physicians working and living in the UAE. Inclusion criteria included expatriate (immigrant) physicians, between the ages of 21 and 65, who were engaged in active medical and dental practice, as verified by their active professional license and national identification card. UAE nationals and participants unwilling to consent were excluded from the study. The expatriate physicians were categorized as: a) actively practicing medicine and living in the UAE for less than 5 years (early immigrants), and b) actively practicing medicine and living in the UAE for 5 or more years (late immigrants).

Survey Administration

Development and validation of the survey questionnaire has been previously described.15 The instrument consists of 23 items, organized into 4 domains, namely work and career, cost and quality of life, family and social life, and health system and regulation. A cross sectional survey was administered between November 2018 and September 2019 to physicians working in public and private hospitals and clinics in 4 emirates in the UAE- Abu Dhabi, Ajman, Ras Al Khaimah and Umm Al Quwain. Physician researchers approached potential respondents during routinely scheduled meetings, conferences and training workshops. Respondents completed self-administered electronic surveys. Written informed consent to participate in the survey was obtained. No incentives were offered for participation.

Data Analysis

Responses were tabulated into two categories: (1) very likely and likely to leave UAE and (2) unlikely and very unlikely to leave UAE, and represented as a percentage of the cumulative response.16 Chi-square test was used to analyze the differences between early and late immigrant physicians. Statistical significance was determined and p-value of ≤ 0.05 was considered statistically significant. The study was reviewed and approved by the Tawam Hospital research ethics committee. The study was conducted in accordance with the Declaration of Helsinki.


A total of 374 physicians from across the UAE successfully completed the questionnaire. Approximately 52% (199/374) of the participants lived in the UAE less than 5 years, and were categorized as early immigrants. The remaining 47% (175/374) of respondents lived in the UAE for 5 or more years, and were categorized as late immigrants. The median duration of UAE employment for the early immigrants and the late immigrants were 3 and 9 years, respectively.

Factors Promoting Outward Migration of Physicians

Six factors promoted the outward migration of practicing physicians from the UAE, with half from the “Work and Career” category. The factors most frequently reported to encourage physicians to leave their destination country included work hours, job security, job satisfaction, and career advancement, irrespective of duration of employment. Job satisfaction (125/175, 71.4%, p<0.05), job security (103/175, 58.9%, p<0.05), extended work hours (102/175, 58.3%, P<0.001), and lack of career advancement opportunities (115/175, 65.7%, p<0.05) were more likely to contribute to the migration of the late immigrant physicians, as compared with early immigrant physicians (Table 1). In the “Cost and Quality of Life” domain, cost of living affected both groups of physicians, but only 11.4% of the late immigrant physicians, compared to 18.1% of the early immigrant physicians (p<0.002), considered it to be a factor in remaining in the UAE (Table 1). Interestingly, none of the factors from the “Family and Social Life” domain contributed to the outward migration of either group of physicians from the UAE.

Table 1 Assessment of the Pull Factors Promoting the Outward Migration of Late Immigrant Physicians from the UAE

Factors Promoting Retention of Late Immigrant Physicians

Work-life balance was a decisive factor for the late immigrant physicians to remain in the country (62.9%), when compared to the early immigrant physicians (52.3%, p<0.01) (Table 2). In fact, work-life balance is the only factor from the “Work & Career” domain that prevented the exodus. The social environment (64.6% vs 47.7%, p<0.01), spouse’s employment opportunity (58.7% vs 42.7%, p<0.005), and proximity to extended family (49.1% vs 34.2%, p<0.01), were also reported to significantly contribute to late immigrant physicians’ decisions to remain in the UAE, when compared with their early immigrant counterparts (Table 2). Approximately 70.3% of the late immigrant physicians considered the multicultural environment to be a positive factor influencing their decision to remain in the UAE (Table 2). Family safety (67.4%) and political stability (76%) also promoted retention of the late immigrant physicians. Quality of life was another significant factor promoting retention of the late immigrant physicians (Table 2). Almost 70.2% of the late immigrant physicians reported quality of life as a factor to remain in the UAE, as compared with…


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