Contextualizing migration and mental health in the post-COVID era

Background: The population of migrants all over the world is progressively rising. The major reasons for migration include the desire for self-actualization, moving to a place with more opportunities, tourism, and education, and escaping hardship and political unrest in the home country. In recent times climate change, insecurity, and economic hardship are top of the list. The global economy has suffered a major blow from the multiple waves of the lingering COVID-19 pandemic. To lessen the scourge of inflation and to restore economic stability, several countries are being forced to liberalize their immigration policies and therefore immigrants are welcomed in these nations. This review attempts to investigate how migration in the post-pandemic era affects migrants' mental health. Main Text: Migration and the COVID-19 epidemic both have beneficial and durable effects on the mental health of migrants and immigration laws have a direct impact on several health-related issues. Mental health disorders may develop at any point from the pre-migration phase to the post-migration settlement in the host nations. Factors such as host community, racism, marginalization, political climate, poor support, loss of social status, language barriers, undocumented status, climate change, mode of dressing in the host country, and several others may lead to mental health disorders among migrants. Unfortunately, there is limited access to care, and the services provided may not be culturally sensitive. Conclusion: Despite the benefits gotten from migration like financial benefits and economic development of the native country and the left behind family members, migration has enormous psychological complications which have to be attended to. Access to specialists who are trained to provide culturally sensitive interventions and implement outreach programs to introduce the services to the migrants' community should be encouraged.

Pentazocine versus tramadol-paracetamol combination as analgesia in labor: A randomized controlled trial

Objectives: Labor should be a satisfactory experience and effective pain management should be employed as recommended by the American Congress of Obstetricians and Gynaecologists. In developing countries, pain management in labor is still a big challenge and the search for the ultimate labor analgesia is still ongoing. The objectives of the study were to determine whether the synergistic analgesic effect of the combination of tramadol and paracetamol will produce analgesia comparable to pentazocine with a better side effect profile. Material and Methods: This was a randomized controlled, double-blinded trial of tramadol-paracetamol combination versus pentazocine as labor analgesia and was carried out at the University of Abuja Teaching Hospital, Abuja, between June 2018 and March 2019. A total of 218 eligible parturients recruited at term, were counseled on labor analgesia, its benefits, and the options made available to them and educated on the pain scoring system. Parturients were allocated into two groups using computer-generated numbers with the WINPEPI software. Group A was given tramadol-paracetamol combination, while Group B received pentazocine, both at standard doses. Hourly pain scores, APGAR scores, labor duration, patients' satisfaction, and side effects were collated. The level of significance was set at <0.05. Results: Tramadol-paracetamol was administered to 109 (50.9%) while pentazocine was administered to105 (49.1%) of the study participants. The mean age in the tramadol-paracetamol group was 29.6 ± 4.8 years, and in the pentazocine group, it was 28.8 ± 4.5 years. The difference in pain scores on the visual analog scale was statistically significant at the 3rd and 4th h (P = 0.02 and 0.004), but not significant in the 1st and 2nd h (P = 0.05 and 0.22) in the two groups. Overall, the average pain score in the tramadol-paracetamol group was significantly higher compared to the pentazocine group (5.27 ± 1.86 vs. 4.72 ± 1.54; P = 0.02). The 1st and 5th min APGAR scores (P = 0.44 and 0.67, respectively) of neonates in the tramadol-paracetamol and pentazocine groups were comparable. Nausea and drowsiness occurred more frequently in the pentazocine group at P-values of 0.047 and 0.0015, respectively. There was no statistically significant difference in the duration of labor between the tramadol-paracetamol and pentazocine groups. not statistically significant, a higher proportion of parturients in the pentazocine group was satisfied compared with the tramadol-paracetamol group (71.4% vs. 63.3%; P = 0.13).Conclusion: This study showed that intravenous pentazocine provides better pain relief in labor, but the tramadol-paracetamol combination has fewer side effects

Physician Brain Drain in Sub-Saharan Africa: The Career Plans of Rwanda's Future Doctors

Introduction: Brain drain is defied as the migration of health personnel in search of the better standard of living and quality of life; higher salaries; access to advanced technology and more stable political conditions. Methods: A novel survey was created and distributed to 97 sixth year medical students in Rwanda. The survey queried respondents regarding their likelihood to work abroad or to seek opportunities within NGO's to evaluate the impact of internal and external brain drain. The data were tabulated and analyzed using Microsoft Excel. Results: More than half of students reported a strong desire to study or work abroad. When asked about employment and training after medical school; 29% answered that they will seek opportunities outside Rwanda. When asked on the will to work for NGOs/Public health oriented organization; 64.9% responded that they would do it collaboratively but still practice medicine. Respondents reported financial opportunity as the fifth motivations for their potential desire to depart from clinical care of patients if such opportunities emerged. Conclusion: Our findings suggest that internal brain drain (work for NGO's) may potentially coexist alongside and external or international brain drain as an important contributing factor in the shortage of medical doctors in Rwanda and Sub-Saharan Africa

Cross border mobility of nurse educators: Case studies from Botswana and South Africa

Migration of nurses across the borders is an ongoing phenomenon that stimulated debates nationally and internationally. The debates were mostly concerned with the nurses working with patients and in the communities. Very little was a concern for nurse educators especially in the two countries studied. Currently, there is acute shortage of nurse educators in these countries with an average age of 50 years for those currently employed. The purpose of the study was to raise awareness on cross border mobility of nurse educators and draw on Foucault's analysis to conceptualise the means by which cross border migration of nurse educators could be revisited. A case study design of seven nurse educators who had migrated and came back to their countries of origin was explored. Data were generated in three phases using telephonic qualitative interviews. All data were analyzed by constant comparison. The study concluded that the quality of nurse education is undermined by shortage of nurse educators and high student ratios partly as a result of issues concerning cross border migration. Three main themes emerged from the study: family disintegration, lack of recognition and shortage of nurse educators. The study findings have implications for health care policy regarding nurse educators and a change of mindset on cross border mobility of nurse educators

Migration and Sexual Behaviour among Youth in Nairobi's Slum Areas

Migration remains an important event in the urbanization process. However; research evidence indicates that migration is associated with negative outcomes. For migrant youth; migration often coincides with leaving home and divesting of parental authority and controls. This study investigates migration as a determinant of risky sexual behaviours and the factors influencing the timing of first sex among migrant youth. We used data collected between 2006 and 2008 from youth aged 12-22 years living in two slums in Nairobi. We use Cox proportional hazards model for timing of first sex among migrants and logistic regression for determinants of risky sexual behaviour. Migration is important for number of sexual partners but not for sexual debut. The risk of initiating first sex soon after in-migration is higher for youth with problem behaviour. Among adolescents in Nairobi's slums; migration is not associated with a higher risk of engaging in risky sexual behaviour. However; youth with problem behaviour face a higher risk of initiating sex soon after migration

Commitment and the Emigration Intentions of South African Professional Nurses

The emigration of skilled nurses from South Africa exacerbates the crisis in the provision of public health services. A descriptive; quantitative design was applied to investigate the relationship between intention to emigrate and employee commitment. Over 400 registered nurses (N = 419); working within public sector tertiary hospitals in the Western Cape; responded to a cross-sectional survey questionnaire. Three foci of employee commitment (organisational; professional and national) were examined but only national commitment significantly helped predict intention to emigrate from South Africa in the regression model (beta = -0.0525; p 0.0001). The implications of the results obtained in this study are discussed

Factors Influencing the Retention of Registered Nurses in the Gauteng Province of South Africa

Background: South Africa is a source country for many destination countries that recruit registered nurses who emigrate for personal and/or professional reasons. A large number of South African nurses belong to the baby boomer generation (born between 1943 and 1964) who will retire within the foreseeable future. Statistics from the South African Nursing Council show a decline of 42.0in the number of nurses who completed their training in South Africa from 1996 to 2005. These aspects combine to predict a potential dire shortage of nurses in South Africa within the foreseeable future. Objectives: Retention of registered nurses should be the focus of health-care planners to avoid crises in South Africa's health-care services. This study attempted to identify factorsthat would influence registered nurses' decisions to stay with their current employers in the Gauteng Province of South Africa. Methods: An exploratory descriptive quantitative design was adopted and questionnaires were sent to a sample of nurses; registered with the South African Nursing Council (SANC); with addresses in the Gauteng Province. A total of 108 nurses completed and returnedquestionnaires; of whom 77 (73.1) had considered leaving their current employers. Results: The most important factors that would influence more than 90.0of these nurses' decisions to stay with their current employers related to finances; safety and security; equipment and/or supplies; management; staff and patients. Conclusions: In terms of Maslow's Hierarchy of Needs Theory; deficiency needs (physiological; safety and social needs) should be met by improved salaries revised on an annual basis; paying long-service and outstanding-service bonuses; and improving the safety and security; as well the available equipment and supplies; at institutions. Sufficient numbers of nurses should be employed and vacancies should be filled rapidly. However; not all changes required to enhance nurses' retention rates involve increased costs. Managers should lead by example and respect nurses; and encourage doctors as well as patients to do so; to meet nurses' self-esteem needs. Recognising and rewarding outstanding service would meet nurses' self-actualisation needs; as well as opportunities to further their education

The Costs and Benefits of Nurse Migration on Families: A Lesotho experience

The present day migration of nurses from developing countries; to more developed countries;depletes these countries of this vital human resource; which is necessary to provide optimum quality nursing care to their populations. If nurse migration persists; the health systems of these countries face collapse. It is important that a nurse understands the costs and benefits of migration to their families; whom they leave behind. This is not only to curb the problems that may occur; but to help the migrant nurses to realise how migration affects their families; especially their children and spouses; before they decide to leave their home countries to work in foreign lands. The purpose of this study; which was exploratory; descriptive and qualitative; was to investigate and describe the experiences of family members; of migrant nurses; from the Maseru district of Lesotho; about the costs and benefits of nurse migration. The objectives were to explore and describe the disadvantageous costs and the benefits gained by the families of migrant nurses. These were explored through the research question 'What are the experiences of family members of migrating nurses with regard to the costs and benefits of nurse migration?' The target population of the study was families of migrant nurses from Lesotho. Using purposive sampling the families of two migrant nurses; who were colleagues of the researcher; were identified and approached to participate in the study. Snowball sampling was next utilised to recruit the remainder of the participants. In total; six families were identified and included in the study. The semi-structured interviews and field notes were the two data collection methods that were implemented. The Giorgi's (1970) steps for data analysis; as outlined in (Burns et Grove 2001:610); were followed and seven themes were discovered as findings. The themes that relate to the costs of nurse migration are: emotional instability; weaker family connections and increased responsibility. The themes that relate to the benefits of nurse migration for their families are: better household income; improved quality of life; essential skills development and travelling opportunities. The use of communication technology is recommended to increase contact across borders in order to reduce the emotional costs of nurse migration on the families of migrant nurses. The article provides a balanced view of the costs and benefits of nurse migration on their families

A study of factors influencing brain drain among medical personnel in Nigeria

The economic depression of the late 80's has made work force groups particularly in the medical industry to look beyond their nose and seek for greener pasture somewhere outside their environ at all cost. This economic situation deeply affected the medical groups that migration became the chorus of the medical personnel. This perennial situation made the study to examine the factors influencing brain drain among the medical personnel in Nigeria; using a selected University Teaching Hospital Complex as a case study. A protested 5-point Likert scale questionnaire was administered to 85 randomly and purposively selected medical personnel; to ferret the causes of immigration and the corresponding effect on the provision of medical services and development of future medical personnel in the country. The survey made use of both historical and descriptive research methods. The survey was based on the light of high skilled personnel popularly referred to as brain drain. The data gathered through the questionnaire were subjected to simple descriptive statistical analysis. The results were ranked in the order of importance. The result showed that migration decision is mainly caused by the conditions within the organization rather than the pull factors. The motivation of workers is at very low level; with ability to meet the physiological needs rated first with 30.6 percent of the respondents strongly agreed to this concept. The effect of brain drain was also significant on the provision of medical services; training and development of future medical personnel. The result depicted that the push factors are the most important influences in the decision to migrate than the pull factors. The survey revealed that desire for better life could be counted as the most important factor for searching for greener pasture (75.0 percent) considering pull factors; better working condition was considered as the very important reason for migration (87.0 percent) migration. The migration of medical personnel would endanger the development of future medical personnel. It was concluded that desire for better life is the most important factor as the basis for the migration decisions; and certainly brain drain is the fall-out of economic depression. If this syndrome is not addressed promptly it will continue to hinder the development and delivery of medical services in this country

Reasons for Doctor Migration from South Africa

Background: The migration of doctors from their home countries is not a new phenomenon. Apart from voluntary migration due to various reasons; medical professionals; often from sub-Saharan Africa; are actively recruited by developed countries. Doctors in South Africa are esteemed for the high standard of training they receive locally; a quality which renders them prime candidates for employment. Various factors are involved in the push-pull theory of migration. It has; however; been reported extensively that push factors usually play a much greater role in doctors' decision to leave their countries of origin; than the pull factors in the host or recipient country. Push factors motivating migration most frequently include dissatisfaction with remuneration packages and working conditions; high levels of crime and violence; political instability; lack of future prospects; HIV/AIDS; and a decline in education systems. In addition to a depletion of intellectual resources through losing highly qualified and skilled individuals; source countries also face substantial monetary implications caused by the migration of doctors. The cost of training medical students is subsidised by the government; and could be regarded as a lost investment when young graduates seek permanent employment abroad. The aim of the study was to investigate the profile of South African qualified physicians who emigrated from South Africa. Methods: The investigation was conducted in 2005 as a descriptive study where the participants were primarily found by the snowball sampling method. The initial group of participants were known to the researcher. Participants had to be graduates from South African medical schools/faculties; living abroad and in possession of a permanent work permit in the countries where they were employed. Short-term locum doctors were not included. Information; consent letters and questionnaires were either hand-delivered or e-mailed; and completed forms and questionnaires were returned via these routes. Participation was voluntary. Results: Twenty nine of 43 potential participants responded; of which 79.3were male and 20.7female between the ages of 28 and 64 years (median 47 years). The year of graduation ranged from 1964 to 2000 (median 1985); and the year of leaving the country ranged from 1993 to 2005 (median 2002). The majority (72.4) were in private practice before they left; 27.5had public service appointments and 17.3were employed by private hospitals. Seventy nine percent of respondents had postgraduate qualifications. Countries to which migration occurred included New Zealand; United Arab Emirates; Bahrain; United Kingdom; Canada; Yemen; and Australia. Forty one percent of respondents indicated that they would encourage South African young people to study medicine; although 75would recommend newly graduate doctors to leave the country. Financial factors were indicated as a reason for leaving by 86.2of the respondents; better job opportunities by 79.3; and the high crime rate in South Africa by 75.9. Only 50of the respondents said that better schooling opportunities for their children played a role in their decision to leave the country. Approximately one-fifth (17.9) of the respondents indicated that they already had family abroad by the time they decided to emigrate. Conclusions: Financial reasons were the most important motivating factor in this particular group of doctors who relocated to overseas destinations; followed by working conditions and the rate of crime and violence in the country. In comparison to other investigations published previously; the results presented here clearly indicate a tendency that more doctors offer financial and crime-related reasons for migration from South Africa than before. In order to prevent the loss of medical expertise from a society already in need of quality healthcare; issues compelling doctors to look for greener pastures should be addressed urgently and aggressively by stakeholders

Migration; Access to ART; and Survivalist Livelihood Strategies in Johannesburg

Since the end of apartheid; patterns of migration into South Africa have shifted; and South Africa has become a destination for people from across the African continent and beyond - a small but important number of whom are refugees and asylum seekers. While South Africa has a protective; integrative; urban refugee policy; many of these individuals struggle to access the rights to which they are entitled; including healthcare. In addition; many lower-skilled international migrants are unable to legalise their stay in South Africa. As a result; international migrants often become part of the group of 'urban poor;' falling within the periphery of health and social welfare provision and relying on a survivalist livelihood within the informal economy. The health and wellbeing of an individual impact greatly on their ability to maintain a secure livelihood; and this becomes more difficult in the context of an HIV epidemic. This paper presents findings from a case study situated in the City of Johannesburg. The research made use of 1) 2006 survey data on migrant livelihood strategies in Johannesburg; 2) a study investigating non-citizens' access to antiretroviral treatment (ART) in the inner city; which included 3) a set of interviews conducted with migrant ART clients who were working in the city's informal economy. The findings indicate (a) the importance of the informal economy for migrants to Johannesburg; (b) the challenges that non-citizens face in accessing ART in the public sector in South Africa; and (c) the linkages between urban migrants' access to ART and their ability to maintain a survivalist livelihood. The paper argues that upholding people's right to ART for all who need it within South Africa will enable international migrants (including refugees and asylum seekers) to maintain an otherwise fragile survivalist livelihood; and this in turn will assist their self-reliance and integration into urban life. Recommendations are made to ensure that the right to healthcare is upheld for all in South Africa

Globalization; Migration and Brain Drain: a Reality Check

"Migration is an old phenomenon in human history. It takes place for various reasons; which have been roughly grouped into ""push"" and ""pull"" factors. Migrants have always faced harsh conditions either in transit or on arrival; from the environment and the citizens of their destinations. Of recent; migration has increased due to globalization; which has increased the access of people in sending countries to ""pull"" factors through the media. However; more recently; stiff regulations have been put in place by the receiving countries to curb immigration; partly as part of the global ""war on terror""""; but partly as a political measure to contain intolerance of foreigners in their societies. In a special way; international migration of skilled labour has come under increased scrutiny over the recent years. It has been argued that for the sending/losing countries; it leads to a brain drain and depletes national resources spent on training. It also denies the remaining population the opportunity to benefit from their highly skilled compatriots usually educated at the public's cost. Proponents argue that it is the right of individuals to look for the working conditions acceptable to them; in order to earn acceptable income for themselves and their families. They argue that; moreover; migrant workers send back remittances to their relatives. In fact; in some countries like Uganda; remittances are the leading source of foreign exchange. Such countries have therefore started policies to export skilled labour or to support the return of remittance with a view tap into the wide base of remittances for public use. This paper discusses the pros and cons of migration and concludes that international migration is inevitable but should be managed in a way that is beneficial for both the sending and receiving countries. It ends on a prophetic note that current intolerance to foreigners will end spontaneously in the course of a generation."

Factors that May Influence South African Nurses' Decisions to Emigrate

Although no accurate statistics about the number of South African nurses working in other countries are available; the Organisation of Economic Cooperation and Development estimated that 35 000 South African nurses were working outside South Africa and/or outside the health care system (Horning; 2005:58). The global shortage of nurses; creating opportunities for South African nurses to work in foreign countries; as well as a variety of factors related to nursing; health care and the general living conditions in South Africa influence nurses' decisions to emigrate. The purpose of this study was to explore and describe the factors that influence nurses' decisions to emigrate. Maslow's Hierarchy of Needs Theory was used as a point of departure to establish what motivates the behaviour of nurses to emigrate from South Africa. A quantitative approach was used. The target population comprised all the nurses (n=3 331) on the registers of the South African Nursing Council (SANC) who completed their basic training during 2002. A random sample of 15 (n=501) of the total population of nurses who completed their basic training during 2002 was selected. Data were collected by structured questionnaires. The analysis of the data indicated that nurses' inadequate remuneration; poor working conditions; excessive workloads; lack of personal growth and career advancement possibilities and inability to meet their safety and security needs were major factors that influenced nurses' decisions to emigrate. The recommendations include improved remuneration for nurses; enhanced working conditions with adequate supplies and equipment; reduced workloads by employing more nurses; expanded career prospects and improved safety

Lost investment returns from the migration of medical doctors from Malawi

Migration of medical doctors from African countries to developed nations compromises the delivery of health care on the continent. The full cost of producing a medical doctor was estimated in Malawi by adding the costs of education from primary school through undergraduate medical education. The cost in fees for one medical doctor produced was US$ 56;946.79. The amount of lost investment returns for a doctor who migrated out and served for 30 years in the receiving country ranged from about US$ 433;493 to US$46 million at interest rates 7and 25; respectively. Quantitative assessments of the estimated loss in investment allows for informed policy discussions and decisions

The cost of health-related brain drain to the WHO African Region

The African Region continues to experience loss of a sizeable number of highly skilled health professionals (physicians, nurses, dentists and pharmacists) to Australia, North America and European Union. Past attempts to estimate cost of migration were limited to education cost only and did not include the lost returns from investment. The objective of this study was to estimate the social cost of emigration of doctors and nurses from the African Region to the developed countries. The cost information used in this study was obtained from one nonprofit primary and secondary school and one public university in Kenya. The cost estimates represent unsubsidized cost. The loss incurred by African countries through emigration is obtained by compounding the cost of educating a medical doctor and a nurse over the period between the age of emigration and the retirement age in recipient countries. The main findings were as follows: total cost of educating a single medical doctor from primary school to university is US$65,997; for every doctor that emigrates, a country loses about US$1,854,677 returns from investment; total cost of educating one nurse from primary school to college of health sciences is US$43,180; for every nurse that emigrates, a country loses about US$1,213,463 returns from investment. Developed countries continue to deprive African countries of billions of dollars worth of invaluable investments embodied in their human resources. If the current trend of poaching of scarce human resources for health (and other professionals) from African countries is not curtailed, the chances of achieving the Millennium Development Goals would remain dismal. Such continued plunder of investments embodied in human resources contributes to further underdevelopment of Africa and to keeping majority of her people in the vicious circle of poverty. Therefore, both developed and developing countries need to urgently develop and implement strategies for addressing this issue.

The migration of physicians from sub-Saharan Africa to the United States of America: measures of the African brain drain

Background: The objective of this paper is to describe the numbers; characteristics; and trends in the migration to the United States of physicians trained in sub-Saharan Africa. Methods: We used the American Medical Association 2002 Masterfile to identify and describe physicians who received their medical training in sub-Saharan Africa and are currently practicing in the USA. Results :More than 23of America's 771 491 physicians received their medical training outside the USA; the majority (64) in low-income or lower middle-income countries. A total of 5334 physicians from sub-Saharan Africa are in that group; a number that represents more than 6of the physicians practicing in sub-Saharan Africa now. Nearly 86of these Africans practicing in the USA originate from only three countries: Nigeria; South Africa and Ghana. Furthermore; 79were trained at only 10 medical schools. Conclusions: Physician migration from poor countries to rich ones contributes to worldwide health workforce imbalances that may be detrimental to the health systems of source countries. The migration of over 5000 doctors from sub-Saharan Africa to the USA has had a significantly negative effect on the doctor-to-population ratio of Africa. The finding that the bulk of migration occurs from only a few countries and medical schools suggests policy interventions in only a few locations could be effective in stemming the brain drain

The role of wages in the migration of health care professionals from developing countries

Several countries are increasingly relying on immigration as a means of coping with domestic shortages of health care professionals. This trend has led to concerns that in many of the source countries - especially within Africa - the outflow of health care professionals is adversely affecting the health care system. This paper examines the role of wages in the migration decision and discusses the likely effect of wage increases in source countries in slowing migration flows. This paper uses data on wage differentials in the health care sector between source country and receiving country (adjusted for purchasing power parity) to test the hypothesis that larger wage differentials lead to a larger supply of health care migrants. Differences in other important factors affecting migration are discussed and; where available; data are presented. There is little correlation between the supply of health care migrants and the size of the wage differential between source and destination country. In cases where data are available on other factors affecting migration; controlling for these factors does not affect the result. At current levels; wage differentials between source and destination country are so large that small increases in health care wages in source countries are unlikely to affect significantly the supply of health care migrants. The results suggest that non-wage instruments might be more effective in altering migration flows

Managing health professional migration from sub-Saharan Africa to Canada: a stakeholder inquiry into policy options

"Background: Canada is a major recipient of foreign-trained health professionals; notably physicians from South Africa and other sub-Saharan African countries. Nurse migration from these countries; while comparatively small; is rising. African countries; meanwhile; have a critical shortage of professionals and a disproportionate burden of disease. What policy options could Canada pursue that balanced the right to health of Africans losing their health workers with the right of these workers to seek migration to countries such as Canada? Methods: We interviewed a small sample of emigre South African physicians (n = 7) and a larger purposive sample of representatives of Canadian federal; provincial; regional and health professional departments/organizations (n = 25); conducted a policy colloquium with stakeholder organizations (n = 21); and undertook new analyses of secondary data to determine recent trends in health human resource flows between sub-Saharan Africa and Canada. Results: Flows from sub-Saharan Africa to Canada have increased since the early 1990s; although they may now have peaked for physicians from South Africa. Reasons given for this flow are consistent with other studies of push/pull factors. Of 8 different policy options presented to study participants; only one received unanimous strong support (increasing domestic self-sufficiency); one other received strong support (increased health system strengthening in source country); two others mixed support (voluntary codes on ethical recruitment; bilateral or multilateral agreements to manage flows) and four others little support or complete rejection (increased training of auxiliary health workers in Africa ineligible for licensing in Canada; bonding; reparation payments for training-cost losses and restrictions on immigration of health professionals from critically underserved countries). Conclusion: Reducing pull factors by improving domestic supply and reducing push factors by strengthening source country health systems have the greatest policy traction in Canada. The latter; however; is not perceived as presently high on Canadian stakeholder organizations' policy agendas; although support for it could grow if it is promoted. Canada is not seen as ""actively' recruiting"" (""poaching"") health workers from developing countries. Recent changes in immigration policy; ongoing advertising in southern African journals and promotion of migration by private agencies; however; blurs the distinction between active and passive recruitment."