Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Not just a migration issue
- David J Brookman (28 January 2005)
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The Economic Costs to Donor Countries
- Jyothis T George (31 January 2005)
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Re: Not just a migration issue
- James V Conway (31 January 2005)
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International recruitment- inter-national bias may hamper the quality of health care.
- Riddhi Prakash (1 February 2005)
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Migration of health professionals: Concerns for Developing Countries like India
- Anant Bhan (1 February 2005)
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Migration of health professionals: Not just a problem for developing countries
- Catherine Jacqueline Yang (2 February 2005)
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Calculating realistic costs and benefits for ‘brain drain’ of doctors from developing countries to wealthy nations.
- Niyi Awofeso (2 February 2005)
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Health Tourism
- Stevie M Gamble (3 February 2005)
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Re: Migration of health professionals: Concerns for Developing Countries like India
- Keith Masnick (4 February 2005)
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International Recruitmaent of Health Professionals: Musings from Sociological Perspective
- ritu mathur (4 February 2005)
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Reverse brain drain
- Dr Amit Kapoor (4 February 2005)
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Re: Re: Migration of health professionals: Concerns for Developing Countries like India
- Jayaprakash Gosalakkal (5 February 2005)
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Re: Re: Re: Migration of health professionals: Concerns for Developing Countries like India
- Keith Masnick (7 February 2005)
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Re: Re: Re: Re: Migration of health professionals: Concerns for Developing Countries like India
- Jayaprakash Gosalakkal (8 February 2005)
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Disjointed thinking, disjointed policy responses
- Shefaly (Ms.) Yogendra (10 February 2005)
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International Recruitment of Health Professionals
- Vincent C. O. Okafor (21 February 2005)
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Migration of healthcare professionals. Is there a solution ?
- Avinash P Joshi, Ashwini Joshi, Umesh Nagare (14 March 2005)
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David J Brookman, Senior Lecturer University of Newcastle, Australia, 2308
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The recruitment of health manpower is not just an issue of migration and depletion of manpower in countries whose health needs may be greater. The cost of training the professionals is borne by the country of origin and their migration represents a net wealth transfer from the underdeveloped world to the developed world. 24% of the US medical workforce was trained free of charge to the USA, and for Australia this has risen to approximately 20% by active recruitment to fill positions in rural areas. These political decisions mean that politicians can fill the demands for manpower in areas that are poorly served because domestric training fails to equip people to work in those area, or because they are insufficiently remunerated for the work stresses involved. From a domestic economic aspect it is a clever policy but in world economic terms it is a tax on poor nations imposed by the west. It is a policy of absolute selfishness. The only solution that maintains the right of individual choice by a potential migrant is for the receiving country to reimburse the entire NPV cost of the education to the country of origin. Competing interests: None declared |
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Jyothis T George, SHO - Medicine Monklands Hospital, Airdrie, Scotland, ML6 0JS
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Sir, Economic costs to countries where doctors emmigrate from is a debatable area. The article assumes that doctors who train in developing countries are trained at the expense of the public purse, akin to doctors in the UK. However, this is not entirely true. In South East Asian countries, India in particular, all doctors are not trained using public funds. There are two types of places available at medical schools: self-financing and tax-funded. The proportional intake of these two types of medical students vary from one institution to another, with some institutions having only one type. Therefore, it might be wrong to deny graduates from developing countries, especially those who have financed their course, an opportunity to train further or work in the UK. What developing countries need is more investment into healthcare, and having more doctors ( Bangalore has five medical schools!) may not be the 'cure-all' solution. Competing interests: I am an immigrant doctor! |
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James V Conway, Consultant Psychjatrist Sheffield S10 3LE
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Agree with Dr Brookman Should we reimburse cost locally or cost if trained in developed country fee ? Most of the Fellowships were filled by psychiatrists ?50% Indian doctors say there is no work in India Competing interests: None declared |
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Riddhi Prakash, doctor(intern) Lokmanya Tilak Municipal Hospital,Mumbai. zip code-400022
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For any nation who trains medical personnel on public funds is like sowing wheat and reaping gold grains... Each medical professional is worth much more than what is invested in his education.Even if he saves just one life in his whole career will anyone be able to price that life?And when the Great Britian gets that without that much investment by just importing health professionals is really a double benifit. I agree completely with the Author when he shows concern towards the problem of developing countries that has resulted from the remedy to UK's shortage of health professionals.I feel the remedy to this problem would be just tightening the net by raising the standard of the professional and linguistic board examinations. The point I want to stress here is that if the recruitments were to be based on inter-national agreements it is not in keeping with the right of an international citizen.The right of each inhabitant of earth to be treated alike irrespective of his race,religion,ethnic group or nationality. Competing interests: None declared |
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Anant Bhan, Fogarty International Fellow University of Toronto Joint Centre for Bioethics, 88 College Street, Toronto, ON M5S 3L1, Canada
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The editorial by James Buchan[1] rekindles the debate on the migration of health professionals from developing countries like India. Patel [2] equated this phenomenon with a brain robbery , drawing a lot of defensive responses from immigrant doctors. I graduated with an M.B.B.S. degree from an Indian government medical college in 2002. More than half of my class of around 150 students has migrated to other countries, chiefly the UK to work in the NHS. We all had our educations subsidized by the money of Indian tax-payers. Even students in self-financed seats or in private colleges indirectly benefit from government subsidies to the institutions they study in. I hear accounts of living in crowded conditions, and attending interviews for one post with hundreds of contenders, from my friends in the UK. Many of them seem depressed and dejected by the failure of their “British Dream” at least until they land a job. Those who do, get salaries which are 50-60 times what they would be earning for equivalent posts in India. The happy endings of the cross- continental voyages of these few doctors encourage more to travel to UK to write their PLAB exams, and apply for jobs. With limited jobs (in urban areas) and residency opportunities available in India, most of the thousands of doctors who graduate every year keep attempting entrance exams to post graduate courses for years, or decide to try their luck abroad. Unsatisfactory working conditions, low pay, and a kind of “sheep mentality” (blindly following their friends and seniors who migrated earlier) also contributes. Most of those who take up residency positions in the UK prefer to stay back, or to shift to work in other western countries like the US, or West Asia where salaries are comparable to the UK. Few choose to return to India. References 1) Buchan J. International recruitment of health professionals. BMJ 2005;330:210 2) Patel V. Recruiting doctors from developing countries: the great brain robbery? BMJ 2003;327:926-928 Competing interests: I am currently pursuing graduate studies in Canada on a Fogarty International Fellowship. I will be returning to work in India in June 2005 in the field of bioethics. |
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Catherine Jacqueline Yang, Medical Student, Auckland representative for the New Zealand Medical Students’ Association. University of Auckland, Private Bag 92019, Auckland 1020, New Zealand
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Editor- Buchan writes that ‘Push factors of low pay… continue to have an impact in many developing countries1’. I wish to point out the ensuing problem of newly graduated doctors migrating away from small, developed countries like New Zealand to work in the United Kingdom. Medical education in New Zealand is subsidised by tax-payers’ money. However, the remaining portion weighs a significant burden to individual students. With the ever increasing burden of student debt, accruing interest at 7% per annum, medical graduates are migrating to countries that pay higher salaries, to pay back their loans. In 2001, the median debt upon graduation was NZ$70 0002; nearly three times the mean annual income3. The predicted size of debt at graduation was positively correlated with plans to practice medicine overseas4, and research showed that 82% of graduating medical students planned on leaving New Zealand within two years3. With such large debt bearing on their credit profiles, many students find themselves ineligible for mortgages for housing, and other means to support their family and children. Students wishing to pursue research pathways or interest in lower paid specialties are now being forced to leave with the obligation of paying their debt. Furthermore, with the media and the public regarding medical students as a group with significant earning potential, medical students have little say in influencing government budgets. Instead, medical graduates are voicing their dissent through migrating to other countries. 1. Buchan, J. International recruitment of health professionals. BMJ. 2005; 330:210 (29 January) 2. Statistics New Zealand. New Zealand Income Survey: June 2001 quarter. 3. Gill, D., Palmer, C., Mulder, R., Wilkinson, T. (2001) Medical student debt at the Christchurch School of Medicine. The New Zealand Well -being, Intentions, Debt and Experiences (WIDE) survey of medical students pilot study. Results Part I. NZMJ: 114: 1142. pp 461 4. O'Grady, G., Fitzjohn, J. (2001) Debt on graduation, expected place of practice, and career aspirations of Auckland medical students. NZMJ: 114: 1142. pp468 Competing interests: I plan to work in the NHS for a brief period after graduation, in order to pay back my student debt. |
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Niyi Awofeso, Conjoint Associate Professor of Public Health. University of New South Wales, Sydney, Australia.
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Sir, Buchan’s editorial[1] touches on the need to identify interventions with potentials for mutually beneficial impact vis-à-vis optimising the costs and benefits of international migration of health workers. Literature on this subject is rich on the costs to developing countries, but silent on the benefits, especially with regards to doctors. For instance, each of the 21,000 Nigerian trained doctors currently practicing in the US is estimated to cost Nigeria $US184,000 in training costs and cost of potential contributions to Nigeria’s healthcare system (http://web.idrc.ca/en/ev-67849-201-1-DO_TOPIC.html). Some of the assumptions implicit in such calculations are invalid as they, for example, exaggerate migrant doctors’ taxpayer funded training costs, inflate doctors’ potential contributions relative to their salaries in developing countries, and take for granted the availability of suitable placements for qualified doctors in developing countries. Even if the above cost estimate is assumed to be representative, what about the benefits to migration to developing nations AND the migrating doctors? For a typical migrant doctor to the US, after the four years of subsistence living and passing qualifying examinations, she or he is capable of earning an after-tax income of $40,000/year annually for the subsequent six years. Thus, within a decade, the migrant doctor would have earned more than his country is supposed to have ‘lost’. Remittances to migrant doctors’ relatives in developing countries are usually at least 20 times as much as would have been affordable if the doctor had been practising locally. More importantly, the migrant doctor has gained unique professional skills that some, including myself, would be willing to share in developing countries provided the universities and medical councils in our fatherland provide us with real opportunities to deploy our skills (http://www.who.int/bulletin/bulletin_board/82/stilwell1/en/print.html). It is not enough to lament at a global shortage of health workers[2], if migrating doctors keen to return to contribute to healthcare delivery in developing countries are finding it very difficult to secure employment in the countries from where they initially migrated. When more realistic costs and benefits of ‘brain drain’ are provided, we would be closer to finding feasible and effective solutions to address most of its various facets. References Buchan J. International recruitment of health professionals. BMJ, 2005; 330: 210. Chen L. et al. Human resources for health: overcoming the crisis. The Lancet 2004; 364(9449): 1984. Competing interests: The author migrated from Nigeria to Australia in 1997, following basic medical training and eight years of clinical practice in Nigeria. |
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Stevie M Gamble, retired EC2Y 8BL
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There have been a number of responses to James Buchan's observations on 'International recruitment of health professionals'. Your readers may be interested in the story of a UK resident who flew to Bangalore for a heart bypass operation, which provides a further twist to these ethical conundrums... http://www.guardian.co.uk/uk_news/story/0,3604,1402771,00.html Stevie M Gamble Competing interests: None declared |
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Keith Masnick, PhD Student University of New South Wales
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In a further response to Buchan's editorial[1], is it churlish to suggest that either governments such as India (see other responses)are responsible for the overproduction (or misallocation) of doctors or that such governments are actively exporting doctors for their remittance capacity or potential return as more skillful doctors? 1. Buchan J. International recruitment of health professionals. BMJ, 2005; 330: 210 Competing interests: None declared |
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ritu mathur, programe coordinator in a field based NGO India 302004
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After reading the editorial and responses from various readers from different parts of the world, I too wish to pen down my views and concerns about the issue. First of all I would like to say that I do not belong to the medical community and have not experienced any kind of “fair or foul” experiences regarding career prospects, salary aspirations and all other kind of push or pull factors but since I am working in the development sector, the issue holds a reasonable relevance to my personal and professional interests. My response entirely emerges from my field based experiences in the rural parts of India which have often made me to think (upon my return visits while sitting in the rail or bus coaches)how to make doctors stay back and work in the villages. I think the preliminary need is to understand WHY migration? The possible answers are – limited career opportunities, low salary packages, less scope to grow due to inadequate state of the art tools and technologies, less recognition of work and few other political dynamics. But at the bottom of all this I understand is the desire to lead a ‘posh’ life, confirming to the highest standards of urban life style. If replied honestly and after analyzing reasons behind reasons many doctors would agree to my contention. Otherwise they would find ample opportunities to work in the remote rural areas of India and other developing nations. Once, only if once the aspiring doctors could go and see the plight of people in the rural areas they would get to know how much scope of a good career is there, waiting for them. This career is of course not in terms of money but in terms of doing a worthwhile job of a Doctor, who in Indian tradition is being seen as an incarnation of God. I do not mean to say that the entire blame is on the shoulders of the aspiring doctors. There is a valid reason for every one to earn money as they have to probably pay back their debts and fulfill other duties towards their families and other social roles which demand money. In this context I agree with the writer that it would be too late (and probably would bear too high costs) to opt for a wait and watch style and see the dynamics of demand and supply in the market, therefore there is a need for proactive action. It has a lot to do with the policy level interventions also. It is indeed laudable that England has tried to devise few strategies to recruit people from appropriate places (despite the operational lacunas in the system).In the same way there is a need to devise such strategies in the out migrating countries as well. For example, the students in the classes need to be given orientation towards the social problems and understand the meaning of career and other kinds of growth within this framework. It may sensitize them towards their roles and responsibilities. One possible example is to make it mandatory for every medical graduate to serve at least for 2 years in the villages of the native country and then aspire for higher studies or migration or whatever. But the need is to address this problem with a holistic approach giving spaces to every ones personal desires but at the same time maintaining a balance between rights and responsibilities. Competing interests: None declared |
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Dr Amit Kapoor, Consultant Surgeon-Director Broadview Health Center- Juhu Tara Road- Mumbai-400049 India
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According to a study by Charities Aid Foundation of India,many Indian doctors and scientists who have studied and practised abroad are returning to their home country to find professional fulfilment. Some of these doctors are giving up lucrative jobs in USA and other Western countries to join the medical force in India. Some Indian corporate groups are hiring doctors with packages ranging from $250,000 to 400,000 a year. It has been observed that doctors who have returned to India can afford luxuries that could not be imagined in England.The working conditions are more flexible and 50 times less stressful. In these changing times 'brain drain' is giving way to 'brain circulation'as these doctors are returning home with valuable working experience to serve as role models, teachers and mentors for the local doctors. Competing interests: None declared |
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Jayaprakash Gosalakkal, Consultant Paediatric neurology UHL Leicester
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Masnick thinks migration of Indian doctors to the west is some sort of plot by the Indian government.I guess migration of British doctors to Australia,white South african doctors to the UK etc are for more moral reasons!.Could it simply not be a case of demand and supply.There seems to be less objection to Indian computer specialists contribuiting to the wealth of silicon valley.Of course doctors are supposed to be ascetics with no material ambitions.Economic migration has been a fact of life over the ages,one such migrant was vasco de gama looking for new trade routes to India who landed fifteen miles away from my village! Competing interests: An Indian Nomad |
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Keith Masnick, PhD student University of New South Wales
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Gosalakkal, in reply to my response, seems to overlook my use of the word “churlish”. The point I sought to make was that maybe India and other countries are wrongly educating too many doctors to cover their own demands. Targetting medical training to local needs might reduce the export value of medical graduates. Thailand [1], for example, has encouraged the use of the Thai language in medical education, making it marginally more difficult for Thai doctors in English speaking countries. As well, Addison [2] has pointed out that remittances make up more than 10% of Ghana’s GDP and Alkire and Chen[3] have said that numerous countries do actively export their medical personnel. I understand and respect an individual’s capacity to seek the best for themselves, but I also recognise the fact that governments have the right to protect their investments and their population. 1. Wibulpolprasert, S., & Pengpaibon, P. (2003). Integrated strategies to tackle the inequitable distribution of doctors in Thailand: four decades of experience. Human Resources for Health, 1(12), 1-17. 2. Addison, E.K.Y. (2004). The macroeconomic impact of remittances, Conference on migration and development in Ghana pp. 1-33). Accra: UNDP. 3. Alkire, S., & Chen, L. (2004). "Medical Exceptionism" in Internation migration:should doctors and nurses be treated differently?, JLI Working Paper 7-3 pp. 1-27): Joint Learning Initiative. Competing interests: None declared |
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Jayaprakash Gosalakkal, Consultant Paediatric neurology UHL Leicester
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The Indian Government does not actively promote migration of doctors nor is it dependant on thier earnings to maintain reserves.One could also make the argument that the British tax payers also subsidize medical education and loose out when a doctor decides to migrate.Everyone is aware of the shortage of doctors in the NHS.Education in other languages would deprive the trainee of significant literature until there is significant local research input.Fortunaetly for countries like India the government has been wise enough not to listen to such half baked advise .A lot of non English speakers from the EU currently migrate and work in the UK.Such artifical controls are bound to fail. Competing interests: None declared |
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Shefaly (Ms.) Yogendra, Doctoral Candidate, University of Cambridge Cambridge CB2 1AG
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I may be in a minority of readers of the BMJ, who remember that a few weeks ago, we were discussing the merits of training a doctor in a developing nation, as the experience was wider and richer. Many doctors from outside developing nations also contributed to the responses. However that article and this one should be read in conjunction to address the problem of skill development and retention in the medical profession. Those readers, who are familiar with international trade and economics, may know that global public health and its geopolitics transcend several ordinary negotiations (for which please refer to the Doha Round of TRIPS and compulsory licensing as an illustration). In the ideal world, policy makers will negotiate and agree a framework of training, skill development, professional practice and compensation that sees health professionals as a global resource addressing a global issue, that of health. Disjointed discussion of problems can only lead to disjointed and inefficient policy responses. Competing interests: None declared |
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Vincent C. O. Okafor, Geriatrician Moseley Hall Hospital, Birmingham. B13 8JL
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Re: International Recruitment of Health Professionals Implementation requires sincerity from recipient countries Editor – Your recent editorial1 on the impact of recruitment of doctors from abroad, especially from sub-Saharan Africa, did much to highlight the problems but little towards suggesting solutions. As the Secretary General of the Medical Association of Nigerian Specialists and General Practitioners (MANSAG) in the British Isles, and someone who is in regular contact with the Association of Nigerian Physicians in the Americas (ANPA), I am fully aware of the staggering degree of brain drain afflicting Nigeria. As your editorial highlighted there is a growing consciousness to control this brain drain by various local and international bodies. The problem is that in practice, decisions reached during the summits of these bodies take years to cascade downstream if at all. The young final year medical student sees the PLAB or the USMLE as his only impediment to jetting off the moment he is handed his medical diploma. He has probably never heard of all the summits and subsequent volumes of memos and circulars relating to his ambition to emigrate. Professor Buchan rightly pointed out that the debate on migration of health workers must shift from an obsession with numbers (how many?) to identifying effective approaches to managing and moderating the process (how?). The “how” is an area that MANSAG has given a lot of thought. We are consulting with all appropriate arms of the government in Nigeria to see how we can implement the checks in Nigeria. Two things have emerged from our efforts. The first is that for the plans to be successful, they must be embraced by all donor countries and not Nigeria alone. The second is that the recipient countries must stand firm to implement the agreement. It may mean a reduction in the supply of junior medical manpower but only for the first 3 to 5 years of the implementation. The suggestions MANSAG is putting forward to the Nigerian authorities are: • A vigorously sustained campaign to discourage immediate post-MB,BS emigration throughout the final year of medical training. The notion of easy life abroad that seduces the new graduates must be deemphasized. • The establishment of a National Service period lasting about 3 – 5 years after housemanship. In the latter suggestion, it will be mandatory for the doctors to practise in their country for the 3 – 5 years at the end of which they will receive a National Service Certificate (NSC). It will then be incumbent on the recipient countries to insist on the NSC before the doctor is registered. To avoid the accusation of singling out only the medical graduates for “punishment” we have suggested that this same principle could be applied to all new graduates in all professional disciplines. The anticipation here is that by the time the graduate has spent 3 to 5 years in his country, he may have developed other interests or commitments that will keep him in his country. The more ambitious ones would have gone up a rung or two towards the ladder of specialisation. Emigration, if it occurs, will be as a specialist. Vincent C. O. Okafor
Secretary General,
MANSAG.
1 James Buchan. International recruitment of health professionals. BMJ 2005; 330:210. (29 January). Competing interests: None declared |
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Avinash P Joshi, Orthopaedic Surgeon Gloucester Royal Hospital, Great Western road, Gloucester, GL1 3NN, Ashwini Joshi, Umesh Nagare
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The above article by Prof. J. Buchan highlights the present trend of filling up of 'service vacancies' in the NHS and private sector. This now is a international disease(1) and is a part of a deeper malaise relating to planning failures, lack of pay and career prospects in the developing countries. There is a large scale targetted international recruitment(2) by developed nations, 'often cherry picking' the talented professionals. This always gives an advantage to the recruiting nations, effectively shredding to pieces the bilateral agreement between the two countries. This creates 'pockets of vaccum' in the local healthcare system. In all the push, pull, stick and at times grab factors contribute to migration. The whole process involves 'hard' and 'soft' elements of brain drain(3). The policy implementation of which is difficult due to GATS, fundamental economic disparities and domestic potential priorities(4). Finally each individual has a right to economic prosperity, right to personal professional development. It seems a concerted international effort is necessary by the recruiting nations to manage the whole process of modernising and managing the process. I am afraid however that the targetted recruitment by countries like the UK may just not be good enough, as with the hard realities and experience of working in the NHS,the migrant is sure to look at greener pastures beyond the horizons of UK, making 'retention' of the recruited a major hurdle to overcome. References - 1) J.Buchan. International recruitment of health professional.BMJ 2005;330:210. 2) J Hutton. Code of practise for the international recruitment of healthcare professional. Department of health. Dec 2004. 3) Muula AS. Is there any solution to brain drain of health professionals and knowledge from Africa. Croat Med J.2005 Feb;46(1):21-9. 4)Schrecker T. Taming the brain drain. Int J Occup Environ Health. 2004 Oct-Dec;10(4):409-15. Competing interests: None declared |
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