Brain drain of healthcare professionals from Pakistan from 1971 to 2022: Evidence-based analysis

Since the creation of Pakistan in August 1947, political instability has been a persistent issue in the country, causing a migration of highly qualified, skilled people, and healthcare professionals. From 1971 to 2022 the total number of highly qualified and skilled people including healthcare professionals who migrated from the country is 60,19,888. Among them, 251677 (4.18%), were highly qualified, 455097 (7.55%) were highly skilled, and 5313114 (88.27%) were skilled professionals. Moreover, 50110 (0.83%) were healthcare professionals including doctors 31418 (62.69%), nurses 12853 (25.64%), and pharmacists 5839 (11.65%). The unsustainable political environment, lack of advanced technology-based institutes, poor healthcare infrastructure, low job opportunities and salary benefits in Pakistan caused the brain drain of highly qualified people including healthcare professionals. It adversely affected the academic institutes, the healthcare system, socio-economic growth, research productivity, and the development of the nation. The government of Pakistan must establish sustainable policies to minimize the brain drain of highly qualified people, and healthcare professionals, and recuperate the prosperity of their academic institutes and healthcare system for better healthcare services, and the advancement and sustainable development of the nation.

INTRODUCTION 455097 (7.55%) were highly skilled, and 5314004 (88.27%) were skilled professionals (Table-I Fig.1). While analyzing the profession of these highly qualified people, it was found that 50110 (0.83%) were healthcare professionals including doctors 31418 (62.69%), nurses 12853 (25.64%), and pharmacists 5839 (11.65%) ( Table-II While analyzing the data for the year 2022, about 832,339, skilled professionals headed abroad. Among them, 17976 (2.15%) were highly qualified and 20865 (2.50%) were highly skilled professionals. It shows that 2312 people left their homeland per day during the recent year. Among them, 2,464 (0.29%) were doctors, 1768 (0.21%) were nurses and paramedics (Table-I & II and Fig.1   In the year 2022, people who migrated from Pakistan are from Islamabad 83169 (9.99%), Lahore 66708 (8.01%), Karachi 44341 (5.32%), Faisalabad 28385 (3.41%), Peshawar 20519 (2.46%), Rawalpindi 12437 (1.49%), Multan 7563 (0.90%), Abbottabad 6737 (0.80%), Jamshoro 5924 (0.71%), Bahawalpur 4788 (0.57%), Quetta 4328 (0.51%). These are the major cities of Pakistan from where most people migrated abroad. 8 Brain drain factors: The brain drain or the human capital flight, occur in their pursuit of better living situations, high wages, advanced technology base environment, and better political conditions in various places worldwide. People pursue their careers because of the freedom of independence, and intellectual satisfaction of creativity. 9 Although these characteristics are inspiring, society always needs minds of creative thinking. There are multiple factors including political instability influence the migration of skilled people from Pakistan. The most concerning factor is that young people are not the only ones who are rushing for the exit, people in their middle age are also trying to move out of the country due to unemployment, inflation, poverty, security, and economic issues. 9,10 The people get disheartened because of low incentives for their academic credentials and experience causing them to migrate to developed countries. The common reasons why the brain drain takes place are fewer career options, low salary packages, lack of benefits, low quality of life, political instability, and crime conditions. 10,11 Moreover, long term war in Afghanistan also effected the state and caused brain drain. The brain drain of highly qualified people including physicians, researchers and academicians adversely affected the

Impact of brain drain on academia and research:
In Pakistan, political instability, lack of job opportunities and limited resources negatively affect the progress and prospects of universities and academic institutions and cause the university faculty to flee from their universities and homeland. 11 The science faculty not only migrate but also carry inventions and scientific prints. The migration of university faculty members developed a gap in the global standing of universities. This may be one of the reasons that Pakistani universities did not achieve a place among the topranked universities in the world. 13,14 Although, Higher Education Commission (HEC) was established in year 2002, and a lot of efforts were made, opportunities were provided to enhance the quality of research by foreign collaborations, but the important aspect of brain drain was not amply addressed. More recently, Nadir et al 2023 15 reported that one in three medical students intends to migrate abroad after graduation due to a lack of resources and mismanagement in Pakistan. This has been adversely affecting Pakistan's health system. Saluja and colleagues, 2020 16 estimate the cost due to mortality linked with physician migration. The authors reported an annual loss of about $15·86 billion with the greatest costs incurred by India, Nigeria, Pakistan, and South Africa. The economic, social, and political instability in low-middle-income countries has induced further migration waves of healthcare workers compounding the pressure on already overstretched health systems. 16 The recent wave of political instability in Pakistan in the year 2022 caused the migration of about 832,339 highly qualified and skilled people including healthcare professionals to head abroad. The migration of such a large number of professionals is likely to negatively impact research productivity and visibility. From January 2000 to December 2022, the number of articles published in the web of science-indexed journals worldwide was 248457. As per the Web of Science 2022 report, the rising trend decreased in the year 2022. 17 The most potential reason for decreasing research productivity may be the political instability and brain drain from Pakistan.
In Pakistan, there are a total of 380 Higher Education Commission (HEC) indexed journals in various academic disciplines. 18 Out of 380 HEC-indexed academic journals only 11 (2.89%) academic journals achieved a place in the Web of Science and quartile ranking. Among these journals only one journal, the Pakistan Journal of Medical Sciences (Impact Factor 2.340) crossed the IF of more than 2.0; the remaining journals have an impact factor of between 0.57-1.80. 17 The highly qualified and skilled people are sending regular remittances, but it cannot compensate the loss of country in terms of qualified people that are much needed to participate in the universities, research institutes, and healthcare sector for the overall prosperity of the nation. It must be analyzed deep down whether this compensation is good enough or whether it is a great loss for the country to lose the highly qualified and skilled professionals who could help the country in a better way rather than just sending the remittances earned. The higher number of highly qualified and skilled professionals who departed the country is a cause of concern and it decreases academic and research productivity.
Science itself is one of the more migrant professions, and many scientists' cross borders in search of better options and opportunities. Today, more people live outside the country of their birth than ever before. 19 Knowledge and research productivity is a borderless enterprise, but some states such as Pakistan are worried that they are losing their top researchers. The worldwide highly cited scientists, one in eight scientists were born in developing countries, and 80% of those had since moved to developed states. 20 A large number of Pakistan intellectuals try to return to their placental place after staying a long period in developed nations but once they return too late, they feel misfits in the system and their career structure. Moreover, the system is not easily accepting these intellectuals, hence the brain drain is a highly challenging issue for the state.

CONCLUSIONS
Over the last fifty years, about six million highly qualified and skilled professionals migrated from the country. The unsustainable political environment, poor healthcare infrastructure, low job opportunities and salary benefits in Pakistan caused the brain drain of highly qualified people including healthcare professionals. Moreover, Afghanistan war and war on terror also had a compounding adverse affect on Pakistan's state, society and brain drain. It adversely affected the academic institutes, healthcare system, socio-economic growth, research productivity, and the development of the nation. The government of Pakistan must establish sustainable policies to minimize the brain drain and recuperate the prosperity of their academic institutes and healthcare system for better healthcare services, and the advancement and sustainable development of the nation.