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The phenomenon of brain drain – defined as the migration of health care professionals from low- and middle-income countries (LMICs), which have a gross national income (GNI) per capita of less than $14 005, to high-income countries (HICs), where the GNI per capita exceeds $14 005 – in pursuit of improved working conditions, better opportunities, advanced training, and stronger health care systems, poses a critical challenge to LMICs, particularly in specialties like gastroenterology[1]. This migration exacerbates existing shortages of gastroenterologists in LMICs, underscoring stark disparities in specialist density between regions. For instance, while the United States boasts 3.9 gastroenterologists per 100 000 population, Nigeria has only 60 gastroenterologists to serve a population exceeding 150 million, with the vast majority of physicians reporting concrete plans for migration[2]. The ethical implications of this trend are profound, especially for HICs that benefit from recruiting physicians trained in countries facing severe shortages. For example, between 1998 and 2002, the United Kingdom saved approximately £65 million in training costs by recruiting medical professionals from Ghana, whereas Ghana incurred a loss of £35 million in training investments[3]. Notably, the rates and drivers of physician brain drain differ significantly across regions and specialties. OECD data show India has the highest absolute number of expatriate doctors (74 455), but this represents just 7.3% of its domestic workforce. In contrast, Romania, with 21 800 doctors abroad, faces a staggering 37.2% migration rate, reflecting severe proportional workforce loss. Egypt loses 16.8%, Pakistan 10.6%, and the UK and Poland around 8%, while Germany and Russia experience lower proportional losses (5% and 3.1%, respectively). Importantly, this pattern is not unique to gastroenterology; specialties like anesthesiology, oncology, and cardiology also face significant losses. For instance, Sub-Saharan Africa has only 0.1 anesthesiologists per 100 000 compared to over 20 per 100 000 in HICs, and many African nations report fewer than one oncologist per million people. These cross-specialty patterns underscore the systemic nature of brain drain and the need for coordinated, multisectoral interventions[4]. The economic costs associated with physician brain drain are equally substantial. A modeling estimate of the added cost of excess mortality due to physician migration across all disciplines to HICs reported an annual loss of $15.86 billion to LMICs, with India, Nigeria, Pakistan, and South Africa bearing the highest total costs[2–4]. These economic burdens, compounded by the continuous outflow of skilled professionals, severely restrict access to essential gastroenterological services in LMICs. In Eastern Africa, the number of gastroenterologists remains critically low, with fewer than five specialists per 100 000 population in many countries. Access to gastroenterological procedures is similarly constrained; in Sub-Saharan Africa, the availability of endoscopists is as low as 0.12 per 100 000 population. A survey conducted across Ethiopia, Kenya, Malawi, and Zambia revealed that only 63 doctors performed endoscopy, six conducted endoscopic retrograde cholangiopancreatography (ERCP), and just two carried out endoscopic ultrasound, with the majority of these procedures occurring in private health care facilities. Nigeria exemplifies the disparity in access to gastroenterological services. With just 200 centers providing endoscopic services for a population of 200 million, the country faces an acute shortage of gastroenterologists. This shortage reflects the broader challenges posed by physician migration, highlighting the urgent need for targeted strategies to mitigate the economic and health care impacts of brain drain within gastroenterology in LMICs[5]. Comparing GI disease burdens across income settings further illustrates the impact. LMICs are witnessing a sharp rise in colorectal cancer, projected to increase by 64% by 2040, compared to a 28% rise in HIC[6]. Peptic ulcer complications like perforation and bleeding carry mortality rates exceeding 15% in LMICs, versus <5% in HICs, largely due to delayed presentation and lack of surgical and endoscopic capacity[7]. Access to advanced GI interventions remains limited, worsening patient outcomes and amplifying the negative effects of physician shortages. Hepatitis B and C infections, leading causes of hepatocellular carcinoma (HCC), remain far more prevalent in LMICs, where vaccination and antiviral treatment coverage are lower, resulting in disproportionately high HCC mortality rates. Inflammatory bowel disease (IBD), while more prevalent in HICs, is rising rapidly in LMICs, where limited access to biologics and advanced immunosuppressive therapies hampers effective management. Access to pediatric GI care is particularly limited in LMICs, with many regions lacking even a single trained pediatric gastroenterologist, increasing childhood morbidity and mortality from treatable conditions like biliary atresia and congenital anomalies[8]. Consequently, addressing the issue is of grave importance. At the international policy level, various agreements have been established to oversee the movement and recruitment of health care professionals, such as the World Health Organization’s Global Code of Practice, the Health Worker Migration Policy Initiative, and the Global Health Workforce Alliance[9]. However, despite these policies and frameworks, physician migration continues to hinder gastroenterology services in LMICs. Several factors contribute to the migration of gastroenterologists from LMICs to HICs, with financial incentives being a primary driver. For instance, a junior doctor in Malawi earns approximately £1900 per year, compared to £36 000 annually for a foundation doctor in the UK[10]. The vast income disparity not only provides financial motivation but also highlights the economic challenges of retaining specialists in LMICs. Beyond financial disparities, the limited focus on in-service training and professional development in LMICs significantly impacts career satisfaction. Many LMICs prioritize pre-service training, resulting in fewer postgraduate opportunities for specialization, career advancement, and academic progression in fields like interventional endoscopy, motility, and nutrition[10,11]. The lack of mentorship and access to cutting-edge technologies further alienates potential trainees. Additionally, LMICs often face systemic challenges, including a scarcity of resources, poor infrastructure, and inadequate working conditions, which impede effective practice and career growth. In Africa, the higher risk of exposure to communicable diseases, such as HIV, during interventional endoscopic procedures also increases the physical and emotional toll on gastroenterologists, further deterring new entrants into the field[5]. Other contributing factors include limited access to opportunities to engage in gastroenterology research for aspiring academic physicians, and minimal opportunities for continuing medical education[2,4,8]. Physician migration is also influenced by a complex interplay of non-financial factors that extend beyond economic incentives. A study focusing on expatriate physicians in the United Arab Emirates found that long-term residency visas and settlement in affluent nations influenced physicians to move out of the country[11]. In Ethiopia, qualitative research revealed that professional dissatisfaction, political instability, and inadequate governance were key non-financial push factors influencing physicians’ decisions to emigrate[12]. To address the ongoing migration of gastroenterologists from LMICs, a dual-pronged strategy is essential – one that both enhances self-sufficiency in HICs and improves the retention of locally trained physicians within LMICs. For example, the 2003 UK–South Africa bilateral agreement aimed to reduce the long-term outflow of health care workers by offering time-limited placements in the UK as an alternative to permanent migration[9,13,14]. Similarly, Norway has pursued self-sufficiency by expanding training opportunities and prioritizing locally trained candidates for specialty positions, including those in gastroenterology[14]. A cornerstone of physician retention in LMICs is the development of robust training infrastructure. The World Gastroenterology Organisation (WGO) has significantly contributed to this through the establishment of 24 global training centers, including in Addis Ababa (Ethiopia) and Suva (Fiji). These centers deliver comprehensive education and practical training, thereby strengthening local expertise and reducing dependence on international migration for career advancement[11,14]. Complementing this, the Australia and New Zealand Gastroenterology International Training Association has implemented tailored in-country training programs in nations such as Fiji, Nepal, and Myanmar. These involve volunteer gastroenterologists and nurses from HICs who provide pro bono training in endoscopy and hepatology, specifically designed to meet local clinical needs[13,14]. Digital education has emerged as another impactful strategy. The ARCADE projects, for example, have demonstrated the effectiveness of open-source platforms in delivering health research training across Africa and Asia, addressing limitations in infrastructure and access. In Pacific nations, the integration of emerging technologies such as telehealth and artificial intelligence – highlighted during the Pacific Gastroenterology Telehealth Seminar – offers medium-term solutions to address workforce shortages in the specialty[8]. In addition, the WGO’s global “cascade” guidelines provide adaptable frameworks based on available resources, enabling LMICs to implement best practices in gastroenterology appropriate to their specific contexts[9,11]. Nevertheless, the implementation of these digital innovations is not without challenges. Many LMICs face obstacles including poor internet connectivity, limited access to digital infrastructure, and a shortage of trained personnel capable of managing these technologies. Additional barriers such as language differences, resistance to technological change, and insufficient institutional support or funding further hinder scalability. These realities underscore the need for long-term investment, capacity-building, and context-sensitive planning to ensure digital interventions are effectively integrated[13,14]. Diaspora health professionals represent an underused engine for capacity-building across clinical services, education, and research. Evidence syntheses document recurring, scalable models – structured mentorship networks, short-term return programs, telemedicine clinics, and co-authored research/quality-improvement projects – that strengthen skills locally while avoiding permanent loss of talent. Scoping reviews and case reports show that diaspora-led initiatives can improve specialist training, guideline uptake, and service re-organization when they are embedded within national priorities and linked to accredited training centers; they also emphasize the need for coordination, monitoring, and host-institution ownership to sustain gains. Formalizing these pathways (e.g., protected leave schemes, bilateral MoUs, and recognition of visiting faculty roles) could convert one-off missions into durable “brain circulation[15]. Unchecked health-worker migration exacerbates inequities in service coverage and undermines progress toward SDG 3 (health and well-being) and SDG 10 (reduced inequalities). WHO projects a shortfall of ~ 10–11 million health workers by 2030 – concentrated in low- and lower-middle-income countries – while countries with the lowest densities shoulder the highest burden of avoidable morbidity and mortality. The resulting capacity gaps also weaken compliance with the International Health Regulations (2005) core capacities for detection and response, with implications for global health security. Aligning retention and ethical recruitment policies with SDG target 3.c (invest in, train, and retain health workers) and SDG target 10.7 (well-managed, safe migration policies) is therefore a shared international responsibility, not just a domestic workforce issue[13,15]. At the national level, LMICs can adopt a range of retention strategies to reduce brain drain. Expanding gastroenterology training programs in underserved regions and offering scholarships or bonded service agreements can encourage graduates to serve domestically. National policies also play a pivotal role. For example, Nepal’s Rural Staff Support Programme has improved physician retention by offering rural doctors triple the standard government salary. Similarly, India’s Chhattisgarh Rural Medical Corps Scheme provides financial incentives and preferential postgraduate admissions to medical officers working in remote locations – both of which have proven effective in bolstering workforce stability[8,9,13,14]. Economic modeling estimates annual losses to LMICs in the tens of billions of US dollars from physician migration alone, reflecting training subsidies and excess mortality costs; these losses are proportionally greatest in low-income countries and the WHO African Region. Such outflows compound already stark workforce density gaps and divert scarce fiscal space away from strengthening services and training pipelines. Research development also contributes significantly to physician retention. The Special Programme for Research and Training in Tropical Diseases supports regional training hubs in LMICs, enabling locally driven research on context-specific health challenges. In Sri Lanka, targeted efforts to address the gap in mental health research have successfully mobilized local researchers and resulted in sustained improvements in service delivery[13]. Governments and institutions should invest in dedicated gastroenterology research units and foster international collaborations to support academic growth. Providing funding for locally relevant research not only enhances professional fulfillment but also serves as a deterrent to migration by offering meaningful career opportunities at home[14,15]. Local incentives remain a key pillar of retention efforts. These include competitive remuneration, rural housing allowances, access to continuing medical education, structured mentorship, and formal recognition of outstanding service – all of which have been shown to improve job satisfaction and reduce attrition[15]. Economic modeling estimates annual losses to LMICs in the tens of billions of US dollars from physician migration alone, reflecting training subsidies and excess mortality costs; these losses are proportionally greatest in low-income countries and the WHO African Region. Such outflows compound already stark workforce density gaps and divert scarce fiscal space away from strengthening services and training pipelines[3]. Consequently, we call on WHO to reinforce implementation of the Global Code of Practice on the International Recruitment of Health Personnel through (1) stronger Member-State reporting (including on private recruitment agencies), (2) independent periodic reviews with public scorecards, and (3) technical support for ethically framed bilateral agreements that include compensation and co-investment in training capacity[13,15]. In gastroenterology, we urge the WGO – in partnership with regional societies – to convene a time-bound global taskforce to map specialist gaps, expand accredited Training Centers in underserved regions, and publish a roadmap that links “cascade” guideline implementation to funded fellowships, twinning, and diaspora-led mentorship. High-income countries should align recruitment with the WHO Code (e.g., avoid active recruitment from “red list” countries, prioritize bilateral agreements with training investments, and publish transparent workforce impact assessments). LMICs can improve retention by financing training posts tied to rural/underserved placements, recognizing advanced practice roles, and enabling regulated “circular migration” with guaranteed re-entry to posts. Both should co-fund data systems to track movements and outcomes and report regularly under the Code[8,13]. On the side of HICs, reducing reliance on internationally trained gastroenterologists requires proactive efforts to strengthen domestic training pipelines. As noted by Bharadwaj et al (2024), strategies such as promoting early interest in gastroenterology at the undergraduate level, increasing funding for gastroenterology-specific research, incorporating advanced technologies like artificial intelligence into training, and fostering diversity and inclusion within the specialty are essential. These measures are not only vital to addressing projected workforce needs but also serve to mitigate the ethical challenges associated with health care worker migration from LMICs[5]. In conclusion, the specialist workforce crisis is a shared global challenge with clear consequences for equity, health security, and progress toward the SDGs. Ethical recruitment frameworks exist, yet implementation gaps persist; the result is continued extraction of expertise from countries with the lowest workforce densities and highest disease burdens. We argue for a dual strategy: retain and develop talent in LMICs through financed training pipelines, fair career structures, and digitally enabled mentorship; and reshape international recruitment into transparent, compensatory partnerships that expand capacity where it is scarcest. The WHO should accelerate the current review of the Global Code with stronger monitoring and accountability, while GI societies – led by the WGO – can demonstrate sector-specific leadership through a taskforce and funded expansion of Training Centers and cascade guideline adoption. Harnessing the medical diaspora as co-educators, visiting faculty, and research partners can convert one-way “brain drain” into equitable brain circulation. These actions are feasible now and would place global gastroenterology on a credible path toward SDG 3 and SDG 10.