Migration intentions of Asian and African medical students educated in China: a cross-sectional study

Many students from Asia and Africa choose to study medicine abroad for a variety of reasons, such as clinical training in a higher-income country [1], seeking education opportunities, and paying low tuition fees [2], facilitated by the international alignment of the medical curriculum and English language [3]. According to reports by the Medical Council of India, nearly 20% of the total Indian medical students choose to study medicine abroad annually [4, 5], and approximately 40% of all the Nepalese medical students studied overseas in 2015 [6]. In African countries, the medical education system is characterized by the small number of medical schools and low student intake [7]. Furthermore, some medical disciplines are not available in many African medical schools. For example, the only medical school in the Union of the Comoros enrolls nursing and obstetrics students, but not other medical disciplines [8]. As a result, many African students are forced to study overseas to pursue their medical career.

For students from lower-income countries, China is one of the most popular destination countries to study medicine [2]. According to the latest statistics, China is now hosting over 68 000 international medical students (IMSs), mostly from Asian and African countries [9]. Some medical schools in China provide a 6-year undergraduate program for IMSs taught in English, which consists of 5-year courses of theoretical and practical studies and 1 year of compulsory clinical rotation internship. At the end of the program, qualified students are awarded a bachelor’s degree in medicine. Study visa is required for IMSs to study in China. For those who intend to work in China after graduation, they are required to apply for a work visa.

China-educated IMSs contribute to the health workforce in their home countries or abroad. Retrospective surveys were conducted by Tianjin Medical University and Guangxi Medical University [10, 11]. The surveys revealed that the majority of international medical graduates returned to their home countries, and the rest stayed in China or migrated to other countries including the UK, the USA, Canada, Australia, and Saudi Arabia. However, these studies did not explore the graduates’ characteristics which influenced their migration choices. Moreover, these studies were conducted more than 7 years ago, and hence, the results may no longer be applicable to the current situation, since the society has been developing rapidly and the whole world has undergone dramatic changes.

Low- and middle-income countries (LMICs) [12] do not have adequate human resources for health [13]. Therefore, the return of China-educated IMSs to their home countries can help alleviate this shortage. On the other hand, high-income countries (HICs) [14] benefit from incoming foreign medical professionals, regarding them as an important source of medical workforce and indispensable primary care providers [15‐17]. As China-educated IMSs are potential healthcare workforce for both their home countries and their migrated countries, in the study, we explored their migration intentions after graduation and analyzed the factors associated with the migration intentions.

In the study, we found about half of the students intended to return to home countries after graduation. Students with characteristics of Asian citizenship, lower academic performance, or middle/lower family socioeconomic status were more likely to return to their home countries after graduation, and those with characteristics of female gender or higher academic rank were more likely to move to HICs. The majority of those students who intended to stay outside their home countries chose China as a destination for short-term stay and the USA as a destination for permanent stay.

Medical students educated abroad are potential healthcare professionals for the countries they migrate into after graduation. Therefore, their migration intentions are important for such countries to develop healthcare workforce policies [19]. However, few studies have investigated the migration patterns of IMSs educated in LMICs, although a number of such studies have already been conducted in HICs [20, 21].

In this study, among China-educated IMSs, 53.38% of the responders showed an interest in staying outside their home countries after graduation. This result is similar to the migration trends of domestically educated medical students in India [22], Bangladesh [23], Nepal [2], Ethiopia [24], and Malawi [25]. Furthermore, only 7% of IMSs educated in Australia intended to return to the home country, while 82% preferred to stay in Australia after graduation [21]. Despite the shortage of medical recruits, the continuous exodus of health workers from LMICs, due to factors such as low payment, poor working conditions, and few career development opportunities, exacerbates the shortage of physicians in these countries, further compromising the healthcare delivery and health outcomes [24, 26].

Our study showed that about 20% of the IMSs chose China as the short-term destination for postgraduate education or further training, but less than 5% chose it as a place for permanent stay. The popularity of China as a short-term destination may be related to IMSs’ undergraduate education experience, abundant postgraduate education opportunities, and low tuition fees [2, 27]. However, because of the insurmountable language barrier [28, 29], which hinders IMSs from effectively communicating in the hospital practice and obtaining the medical license in China [30, 31], many IMSs are reluctant to choose China as a country for practicing medicine.

The results from this study show that return intentions of IMSs did not differ significantly between genders. This finding is consistent with some of the previous studies, exemplified by one study investigating the career plans of Malawian medical students [25], and another looking at the career practice locations of Nepalese physicians [32]. However, there are also other reports presenting a different result. Some researchers found that female health workers from Asia and Africa were more likely to remain in home countries [19, 24], possibly due to factors related to social and family considerations [19, 33]. However, we have not found any previous literature that analyzed gender differences in medical migration intentions to an HIC. In this study, we found that more females chose an HIC than males. Two reasons may contribute to this result. Firstly, highly educated female students are motivated to make the choice due to their ambition and courage to compete for opportunities. Secondly, the conservative societal attitudes towards working women [34] and the inequality in training opportunities as well as other gender disparities in non-pecuniary benefits in some LMICs [35] may also play a role in pushing female IMSs to choose a higher income country to seek employment or training opportunities.

Our study has not only identified an association between better academic performance and the intention to emigrate [36, 37], but also demonstrated that better academic performance influenced the decision to migrate to an HIC. It is reasonable that medical students with stronger abilities aim higher, which is also the case with brighter physicians, who may leave their home countries for better training and more advanced technology [37]. In fact, the exodus of the highest quality medical talents is currently a serious challenge to many LMICs [3], although Khan [29] argued that the migration of the best physicians would not affect the homeland healthcare service quality as much as it did to medical research.

Our research provides insightful findings that may help policymakers in LMICs to develop strategies or programs which preferentially attract overseas-educated medical graduates to return to their home countries. In fact, Sweden has already developed some policies to attract its overseas-educated medical students, such as encouraging them to come back for clinical practice and offering employment programs tailored to this specific population, in order to promote the domestic physician workforce [38].

In the study, we have found about half of the IMSs intended to return home after graduation, whereas the other half showed interest in staying outside the home country. The results also show that Asian citizenship, lower academic rank, and lower/intermediate family socioeconomic status were factors associated with IMSs’ return intentions, while female gender and higher academic performance were factors that influenced IMSs’ choice for HICs. Governments of the relevant countries should be aware of the inflow of such graduates and consider the need of such graduates when making healthcare workforce plans.