What does the continued movement of health professionals from poorer countries to the wealthy nations signify for the health of nations and for that ideal “Health For All” advocated by the United Nations?
Health experts agree that this hemorrhage of health professionals from the developing world is a most serious human resource problem and that it calls into question wealthy countries' rhetoric of support for poorer countries struggling to reach the health targets of the Millennium Development Goals.
They agree too that these problems are rooted in the under development of public health systems in poorer countries, and that they are aggravated by the global brain drain, creating a vicious downwards spiral in health human resources (if you happen to be poor in a poor country) or a virtuous upward spiral (if you happen to be rich in a rich country).
But as one cynic put it, “Nobody ever put a gun to an overseas doctor’s or nurse’s head and forced them to enter the developed countries to work and live!” While that may be literally true, the medical world is once again debating the pros and cons of that clichéd phrase, ‘medical brain drain.’
In a recent study, the Regional Network for Equity in Health notes that this pattern is part of an overall "global conveyor belt of health personnel moving from the bottom to the top" of distributions of wealth. The result is increased inequality of access to health care among countries.
Consider this. The World Health Organization target for the doctor to population ratio is 1 per 1,000. The doctor-patient ratio is currently 1 per 500 in wealthy countries, and only 1 per 25,000 in the 25 poorest countries, a 50-fold difference made all the more unacceptable when one considers the greater health gain such care affords the poor in poorer countries.
Debate Initiated By Dr Vikram Patel
The most recent debate began with an Indian physician, attached to the London School of Hygiene and Tropical Medicine, who claimed that the people in the developing countries are paying for the health care of those who live in some of the developed countries, and, unless immediate steps are taken, the brain drain of health professionals will result in huge inequities in global health.
In an article entitled ‘Recruiting doctors from poor countries: the great brain robbery?’ in the British Medical Journal, Dr Vikram Patel, a senior lecturer, went on to accuse the developed countries of reaping the benefits derived from educating and training health professionals in public funded medical schools in the developing countries.
Referring to the new scheme promoted by Britain’s NHS to recruit doctors and nurses from India, he says it merely perpetuates global health inequalities. The new NHS scheme invites psychiatrists, clinical oncologists, radiologists, histopathologists, cardiac anesthetists, and thoracic surgeons from India to work in the United Kingdom for up to two years at a consultant’s salary of up to £46 000 with assistance in relocation and housing.
Though these overseas recruitment schemes are marketed primarily as an opportunity for doctors to experience one of the world's best healthcare systems, Dr Patel notes that in fact few of the doctors return to their home countries. He warns that unless such schemes are linked with measures to enable the flow of doctors back to developing countries, it will worsen the brain drain and inequities in global health. Furthermore, Patel observes that the recruitment is being promoted in defiance of an existing code of practice for international recruitment.
Thus, while acknowledging that the opportunity to work in different societies is a rich experience with benefits that go beyond financial gains, Patel says that what is needed is an acknowledgment that institutions in developed countries have an ethical obligation to facilitate the return of health professionals to developing countries.
Patel buttresses his arguments by making the following points:
1. The developing world has fewer doctors per population than developed countries 2. Schemes to recruit doctors from developing countries risk damaging their fragile health systems 3. Partnerships between institutions in developed and developing countries are needed to encourage doctors to return
It is the kind of partnership envisaged by Dr. Patel that Drs. Madhukar Pai and Nitika Pai, Division of Epidemiology, University of California at Berkeley, say they are experiencing through a program sponsored by the Fogarty International Center and the NIH, known as the Fogarty AIDS International Training and Research Program. These two Indian physicians, who moved to the US for higher education, agree that “individuals who leave their countries for higher education must find ways to share their expertise and resources with their countries.”
According to the two physicians, FIC recently launched the Global Health Research Initiative (GRIP) program to combat the “brain drain” problem by setting aside $1 million per year for the next 5 years to pay partial salaries for researchers from developing countries who return home. As they explain: “With these re-entry grants, researchers can continue projects begun in the US while working in their home country institutions. Overall, because of these efforts, we have managed to maintain strong academic ties with our country. In our opinion, two factors have enabled this process: the encouragement we receive from our program in the US; and the exceptional support of collaborators in India.”
View Of The World Medical Association
Delon Human, Secretary General of the World Medical Association (WMA) based in France, acknowledges that the ‘great brain robbery’ article of Dr Vikram Patel raises some crucial issues that are currently being debated by the WMA.
While some countries are solving their need for physicians by recruiting medical graduates from other countries, there is an important ethical dimension to these issues, since the flow of international migration of physicians is generally from poorer to wealthier countries, admits Delon. “As a result the poorer countries bear the expense of educating the migrating physicians and receive no recompense when they enter other countries. The receiving countries gain a valuable resource without paying for it, and in the process they save the cost of educating their own physicians.”
Therefore, at its General Assembly meeting in Helsinki in September 2003, the WMA adopted a Statement declaring that every country should do its utmost to educate an adequate number of physicians, taking into account its needs and resources. It said that no country should rely on immigration from other countries to meet its need for physicians. The WMA is now pursuing the idea that countries wishing to recruit physicians from another country should only do so through a Memorandum of Understanding entered into between the countries.
Responses To Vikram Patel
Dr Patel’s article, which appeared in a recent issue of the British Medical Journal, has resulted in much soul searching among Indian physicians in India as well as abroad.
A letter from Dr Amrit Kejriwal, who claims to be “unemployed (courtesy British Government),” cites his own case as an example of the injustice done towards physicians from overseas. “I was working in a cardiac hospital in India. While I was working I contacted the British Council. On the basis of my past experience the British Council agreed to sponsor me for further training in General Medicine in the United Kingdom. Accordingly I came to the United on the 2 May 2003. Since then I have applied to over four hundred places and faced disappointment. My application has been rejected on the grounds that I do not have sufficient United Kingdom experience. Is it not ironical that for my first job in UK I am expected to have UK experience. If I am being sponsored and this is a criteria then I should have been told this when I was in my country. ..This is not only my story but of many doctors who come to this country…It seems as if this country is trying to deprive people of other countries of adequate medical facilities. As it keeps many unemployed overseas doctors, the people of their own country are affected by the shortage of doctors. “
In a globalized world the physical location of a person may or may not have any relation to the ability to make an impact on human health, comments Dr. Adnan Hyder assistant professor Department of International Health, Bloomberg School of Public Health, Johns Hopkins University. He explains: “Countries need to recognize that they compete with the best institutions in the world for quality manpower. A study in Pakistan shows a small proportion of people funded for a doctorate returning, and on return, facing major non-financial disincentives for good performance. Thus the financial component of such flows is only part of the picture and in some cases not the major push or pull factor.”
Dr Hyder’s suggestion: “It is time to understand and accept that health professionals' mobility is part of life in the 21st century. It is time to bury the archaic concept of brain drain and turn to assessing the performance of health professionals and systems, wherever they are in the world.”
Dr Rajeev Kak, an Opthalmologist in New Castle upon Tyne counters with the following view: The fact of the matter is that there is no shortage of doctors in India (where I come from). ..Most doctors leave India to find a better life for themselves, for financial reasons and for a better quality of life. There are no jobs going abegging in India. The number of Medical schools that have been sprouted with little or no regard to meeting regulatory standards in the last 20 years is hard to believe. This has resulted in a large pool of poorly trained unemployed doctors. The government in India doesn't spend its money to open new medical schools anymore. This has been left to 'private enterprise'. Called donation medical colleges, it means if your parents have the money you can have a place to train to become a 'doctor'. Successive governments in India have been reluctant to spend money on health care infrastructure and that is the real problem. What you have today is too many doctors clustered in the cities being exploited by private enterprise in private mini-hospitals that you find everywhere in our cities.
While acknowledging that India has not reached a stage where it can afford to produce professionals for other nations, Dr Varatharajan Durairaj Associate Professor (Health economics & policy) Sree Chitra Tirunal Institute for Medical Sciences & Technology in Kerala, says that if the demand for the professionals simply does not exist here due to faulty decisions on the production of manpower, there is nothing wrong if the professionals migrated out to find a 'market' for themselves.
“There is no point in sulking in a job in Lahore, Bombay or Dakka while a nice one is available in London, Bonn or Dallas!” observes Nikhil C Kaushik, Consultant Ophthalmic Surgeon North East Wales NHS Trust Hospital. Kaushik explains: “The whole purpose of education and hard work required in qualifying as a doctor is to improve one's lot and when we move from India to UK, or from UK to Saudi, USA or Australia we simply do so that we earn a living that we worked hard for. It is therefore only fair that doctors move to a job that pays well.”
Kaushik adds: “It must be flattering to anyone being described as 'BRAINS'. I think doctors are under some kind of delusion that they are more brainy than other sections of any society. The fact of the matter is that a doctor is no more 'BRAINS' than let us say a Plumber or a Teacher. So why single out the departure of a doctor from relatively poor countries to a rich one as Brain Drain or Robbery.”
The final word may have to go to Dr J.S.Nagabhushan of Crosshouse Hospital, who says: “The discussion about the brain drain from developing countries is a hot issue which has no end in sight. From a trainees point of view, who has graduated from India and worked in the NHS for over four years, I believe that there are three main factors which is very important for practicing medicine in India. Professional satisfaction, financial gain, and the ability to sustain in adverse political situations.
“It is very difficult to achieve all the three if you are at home and the fact that the presence of vacancies in the UK make this a possible safe option, albeit with an element of risk. Professional satisfaction can be achieved with hard work, but financial gain and the ability to sustain in harsh political red-tapism, corruption and resistance to change make us think twice about continuing our practice further at home.
“I agree with Mr Patel, that mechanisms should be in place to exchange personnel and training material in order to train and educate third world doctors in improving the current medical standards in India. In the current political situation it would take a lot of hard work to achieve the above goals but it is moving slowly in the right direction.
“With regards to many doctors migrating to developed countries especially UK and the USA has much to do with personal expectations and financial gain. Although few of them genuinely are interested in getting back to homeland they encounter difficulties in every step due to political redtape, widespread corruption, and resistance to change. Ultimately I do believe that our services are best utilized at home and we need to realize that we do have some responsibility towards our country and improve the existing health standards. So its important to return back after your training goals are achieved.”