Exodus of Lebanese doctors in times of crisis: a qualitative study

Introduction Since 2019, Lebanon is experiencing an unprecedented exodus of doctors, seriously threatening the national health system, which is expected to continue without quick and effective solutions. Therefore, this study aimed to understand the factors that push Lebanese doctors to migrate and the factors that retain others in the country. Additionally, this study aims to propose solutions to preserve an adequate supply of medical care amidst the crisis. Methods Qualitative semi-structured interviews and focus group discussions were conducted using pre-developed guides. Purposive and snowball sampling was adopted to recruit physicians who emigrated and physicians staying in Lebanon. Transcripts of interviews and focus groups were coded using Dedoose software and analyzed through a combination of inductive and deductive approaches. Results Emigration was found to be the result of numerous interconnected factors. The main drivers for emigration were declining income, career problems, reduced quality of care, unhealthy work environment, and the deteriorated political and socio-economic contexts leading to instability and insecurity. As for the retention factors, they included affective attachment and sense of belonging to the professional environment and the country, followed by recognition and valorization at work. Several recommendations were developed to maintain quality of care delivery, including reforms of the health system, development of focused human resource retention strategies based on resource mapping evidence, negotiations with recruiting institutions to endorse the code ethics ending unethical practices draining countries' human resources, provision of financial incentives to doctors, and the recognition and valorization of physicians. Other rapid interventions were suggested, such as short-term medical missions to mitigate shortages in certain specialties, telemedicine, adaptation of recruitment processes to compensate for resources shortages in certain specialties, and adoption of task-shifting approaches to alleviate the workload on overburdened specialists. Discussion The findings of this study shed the light on the different factors influencing migration while framing them in the Lebanese context. These findings and recommendations should inform stakeholders and policy makers about the interventions needed to restore the quality of care. The feasibility and sustainability of most formulated recommendations depend on several factors, with political and socio-economic security and stability being the most crucial ones.


Topic guide: Doctors abroad / who decided to leave
Thank you for agreeing to participate in this study aiming to understand the factors that pushed some physicians to migrate or consider migrating, as well as the factors that make other physicians stay in Lebanon.As part of my thesis in "Master in Health Management", I opted to study the exodus of Lebanese doctors with 3 objectives -Identify the factors that push some physicians to migrate or consider migrating.
-Identify the factors that lead some physicians to stay.
-Identify measures to maintain an adequate supply of care.
Sharing results: Twenty-eight interviews were carried out, involving 19 physicians who had emigrated and 9 physicians who chose to remain in Lebanon.The interview findings unveiled the following: [EN presented the interview findings following the same structure as the results presented in the manuscript, discussing the factors influencing physicians' emigration, starting with the "Push factors" and then addressing the "Stay and Stick factors ".] Then open question: Today, we will focus together on identifying measures to maintain an adequate supply of care.So, based on those results, what, in your opinion, can be done to maintain this supply of care?
If concordance, work out together.

Tips:
-Never interrupt the participants.
-Do not insist.
-Do not suggest.

I
'd like to start by introducing myself: ……….THEMES QUESTIONS PARTICIPANT PROFILE Could you please introduce yourself, your educational background, your current position, the number of years of experience you have?

are the main factors that affected your decision? Macro-level or national factors
Meso-level / Professional factors1.Did the work conditions affect your decision to leave the country? 2. Was your decision affected by the educational environment in Lebanon (if applicable)?

are your recommendations for a continuum of quality care service provision in Lebanon in the light of the current crisis? Would you like to add anything? Thank you for your time Topic guide: Doctors who decided to stay in Lebanon Thank
you for agreeing to participate in this study aiming to understand the factors that pushed some physicians to migrate or consider migrating, as well as the factors that make other physicians stay in Lebanon.

are the main factors that affected your decision? Macro-level or national factors
1. Why didn't you think about migration despite the multiple crises Lebanon is facing?2. What factors or characteristics of the Lebanese health sector pushed you to decide to stay, if any?What health sectors' factors or characteristics in other countries pushed you to choose to stay in Lebanon, if any? 3. Did any of the social factors that I will cite affect your decision and in case it did, how did it affect your decision?Gender inequalities, ethnic and racial discriminations, low quality of social services, culture of migration and social pressure, poor social rights, and religious conflicts.

your opinion, what are the factors that would make those who migrate consider returning to Lebanon? What are your recommendations for a continuum of quality care service provision in Lebanon in the light of the current socio- economic crisis? Would you like to add anything? Thank you for your time Topic guide for the Focus Group Welcome
and thank you for agreeing to participate in this study.