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  • br We appreciate the response by Sharath Nagaraja and


    We appreciate the response by Sharath Nagaraja and Ritesh Menezes to our Comment, in which we had argued that patients with tuberculosis deserve a complete and patient-centric solution, irrespective of whether they seek care in the public or private health sector. Nagaraja and Menezes seem to have missed this key point and instead reframe the argument as public sector strengthening versus private sector engagement. They also make the erroneous claim that most of India\'s population is served by the public health system, when data suggest the converse.
    The adoption of the WHO Global Code of Practice on the International Recruitment of Health Personnel in May, 2010, ostensibly heralded a new era of accountability in the migration of health-care workers. Global health advocates lauded its unanimous adoption by all 193 WHO member states convening at the 63rd World Health Assembly as a sign of changing social expectations for human health resources, foreshadowing an imminent end to the GS-9973 drain of skilled health professionals from resource-constrained countries. The effectiveness of the WHO Code to stem the brain drain from poor to rich countries is predicated on its voluntary implementation. However, the only study to evaluate the comprehensive implementation of the Code by all WHO member states has found disappointing results. WHO has often stressed that shortages and out-migrations of health-care workers are global in nature and will need global solidarity for a solution. Nonetheless, there are justifiable expectations that high-income countries whose primary care systems draw heavily from the health workforce of low-income and middle-income countries should do more to limit such dependency. The USA is the leading destination of physicians from the developing world and has a disproportionate stock of international medical graduates in its physician workforce. Many international medical graduates recruited into the US physician workforce are immigrants from countries with critical shortages of skilled health workers. Ongoing data monitoring for such migrants can help to build the evidence base recommended by the WHO Code as necessary to evaluate its implementation, effectiveness, and relevance. About a year after adoption of the WHO Code, we collected data for immigrant physicians educated in sub-Saharan Africa and recruited into the US physician workforce. We found the records of 7370 graduates from medical schools in sub-Saharan Africa in the 2011 American Medical Association Physician Masterfile (AMAPM). After excluding all potential retirees, we estimated the number of potentially active graduates from sub-Saharan African medical schools in the 2011 AMAPM to be 7130. Although two-thirds of these doctors graduated from Nigerian and South African medical schools, the highest national proportion of national-to-USA physician émigrés were seen in Liberia (52%), Ghana (26%), and Ethiopia (20%). Because nearly all these migrant doctors were admitted into the US physician workforce before the inception of the Code, their numbers can serve as baseline metrics for future comparisons of physician migration from sub-Saharan Africa to the USA before and after the WHO Code. 3 years after adoption of the WHO Code, we revisited the AMAPM to ascertain whether the aggregate data for physicians from sub-Saharan Africa that we previously observed had changed. In the May, 2013, AMAPM, we found the records of 8260 graduates from sub-Saharan African medical schools, of whom 7900 (96%) were in active practice or were active but semiretired (working <20 h/week). These updated figures reflect a 10·8% (770) increase from the 2011 data, and an annual growth of 5·4% among graduates from sub-Saharan African medical schools appearing in the US physician workforce between mid-2011 and mid-2013. Our previous analysis suggested that migration of medical graduates from sub-Saharan Africa to the USA had increased by 38% between December, 2002, and mid-2011, reflecting an annual percentage growth of 4·5%.