Recruiting doctors from poor countries: the great brain robbery?

BMJ 2003; 327 doi: http://dx.doi.org/10.1136/bmj.327.7420.926 (Published 16 October 2003)
Cite this as: BMJ 2003;327:926

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Displaying 1-10 out of 29 published

21 July 2008

India is one country which has used the brain drain to their advanatge. Most indians working abroad send the money to India which is making India rich now. The anual budget of India is actaully smaller the total amount of money thats send from abraod. So in a way its good for India.

What Britain did for many centuries in their cololnies Indian brains are doing now in Britain.

Competing interests: None declared

Competing interests: None declared

Sumithra Josepha, Doctor,Kundubella,Near Cheranmarey Colony,Bellala,India

Kuttikole 670541

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The article by Vikram Patel draws attention to an important and complex issue of International recruitment of overseas doctor, but fails to fully address it.

We are increasingly living in a world which is rapidly shrinking and people are migrating more than ever for all sort of reasons. The resulting globalisation is a double edged sword for both developing and developed countries, bringing its own benefits and problems. In such an environment not to allow doctors from developing countries opportunity to gain experience of working with in the NHS, will be akin to discrimination.

Responsibility to manage the migration of highly qualified profesionals like doctors lies at both ends. Blaming a developed country alone is unfair. A Developing country like India trains one of the largest numbers of doctors in the world. However, persistant lack of investment in health care in India and resulting poor working conditions and lack of job opportunities mean that these doctors have to look at countries like UK or US for further training and contribution to high caliber research.

The problem depicted in the picture in this article is very emotive. Unfortunately, this problem is related less to shortage of medical staff and more to lack of adequate hospitals for poor.

Doctors of Indian origin like doctors from any other developing countries, have benefited both their country of origin and the UK in sevral ways. Putting a stop to this kind of recruitment will not solve health problems of India and may actually harm advancement of medical science at both ends.

I welcome the suggestions like close partnership between institutions in developing and developed countries and collaboration in fields like teaching and research. However, often the stumbling block in initiating any such alliance in my experience is bureaucracy in developing countries.

Competing interests: I am a doctor of Indian origin who came to UK for training and decided to stay on.

Competing interests: None declared

Niruj Agrawal, Consultant Neuropsychiatrist

St George's Hospital Medical School, London, SW17 0QT, UK

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EDITOR- Vikram Patel's comments regarding brain drain warrant serious discussion1. Others have expressed similar sentiments and presented a desperate picture2. I wish to use Sri Lanka (SL) as an example to stimulate discussion.

A tax-based state system funds undergraduate and postgraduate education in SL, which is "free" to the student. Therefore, there is an obligation for its under- and postgraduates to pay back, and a duty of the government to develop mechanisms to receive some degree of compensation if graduates choose to leave.

Unsystematic migration results in economic drain to countries, which educate and train the graduates. It is estimated that India loses US 2 billion per year to the US, for software professional3. SL has "exported" more psychiatrists to London, than it has for the whole country (less than 40 for approximately 19 million). At and individual level, most authors focus on the financial expediency for migration while ignoring other reasons. Some left because of war like conflict. Others leave because of bitter personal experiences with politicians or a stifling baeuracracy. These are individual decisions and which have to be respected.

The problem with the existing situation is in the system, and less so with the individual. Currently, we have a rudimentary procedure to recoup costs of medical education from migrating skilled persons. Undergraduates are free to leave immediately after graduation. Postgraduates, educated at state expense sign an agreement with the government, obligating the latter to serve for a specified period after training or pay back an agreed amount of money. Most abide by these procedures, though some leave during their postgraduate training abroad, without paying back the required sum.

Governments and the World Trade Organization (WTO) can do much to improve the situation. The World Bank suggested that governments should offer well-trained expatriates job opportunities with financial and tax incentives to return home to work5. However, this is not feasible when considering the extent of disparities between countries: the state-sector consultant's monthly salary in SL is around 400 US$ tax-free vs. about 10,000 or more in the UK. Moreover, other factors such as social instability and administrative lethargy affecting work cannot be compensated by money or tax incentives.

Other options to be discussed include the following3.
a) Exit tax paid by employees or employing firms when visas are granted
b) Loan schemes for higher education, which can be recouped
c) A flat tax where overseas nationals pay a fraction of their income back to their country
d) A cooperative model, with automatic inter-government transfer of payroll taxes or income taxes (from adopted country to country of origin)

The last option is very attractive and requires inter-government agreements but probably the easiest to administer.

A rarely heard option is to liberalize access to service sector markets. Currently, richer countries offer employment to qualified personnel from abroad and restrict access to less skilled jobs. If they are to practice the liberal democracy they preach, these hitherto protected jobs should be open to all eligible and qualified human beings.

References

1. Patel V, Recruiting doctors from poor countries: the great brain robbery? BMJ 2003;327:926-928

2. Levy LF, The first world's role in the third world brain drain. BMJ 2003;327:170

3. United Nations Development Programme, Human Development Report 2001: Understanding human creativity, national strategies. New York, Oxford University Press. Inc. 2001

4. World Health Organisation, The World Health Report 2002: Reducing risks, promoting healthy life, Geneva, World Health Organisation, 2002. The World Bank. World Development Report`1998/99:Increasing our knowledge of the environment in knowledge for development. New York, Oxford University Press. Inc.1999

Competing interests: Submitted and published in Rapid Response an extended and slightly different version titled "The Great Brain Robbery and beyond: a new role for governments and WTO?"

Competing interests: None declared

Saroj Jayasinghe, Associate Professor

Faculty of Medicine, University of Colombo, Kynsey Road, Colombo 08, SRI LANKA

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26 October 2003

I read with amused interest the article on recruiting doctors from poor countries: the great brain robbery. Patel [BMJ 2003:327:926-8] has mentioned the public health aspects of this phenomenon of invitation from the NHS. India has retained few psychiatrists because there are NO jobs for them. Every year of all those qualify postgraduate degrees and diplomas, less then 10% find a temporary job as a senior resident for a period of 3 years, less than 2% find a longer term appointment, others have to fend for themselves. The majority are left in the lurch, and seek oppurtunities elsewhere. Many medical colleges either have no positions of psychiatrists, or if they have positions, they have not been filling those positions. Some institutions have kept their positions vacant on grounds of reservation policy or financial crunch. It is natural that qualified professionals will look for stability and employment where ever it is available. No wonder there are more Indian Psychiatrists in the USA, and the UK, than in India itself ! There is no robbery, there is only seeking of a place to work !

S.K. CHATURVEDI, Professor of Psychiatry

Competing interests: Selected for NHS Fellowship, waiting to join since 16 months.

Competing interests: None declared

Santosh K. Chaturvedi, Professor of Psychiatry

NIMHANS, Bangalore, India

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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 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 so that we earn a living that we worked hard for.

What attracts doctors from developing countries to developed ones is that they can concentrate on their job and not having to do everyone else's job. Societies have long abandoned the value once placed upon doctors,most now consider doctors like any other kind of workers.

It is therefore only fair that doctors move to a job that pays well. 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!

It is upto societies and policy makers to create attractive work conditions and advertise for quality work force from anywhere in the world. In the context of Indian Subcontinent, if India and Pakistan stop wasting huge resources fighting an artificial war and divert resources in the health care of their people then they will find many applicants returning to jobs that Vikram Patel is concerned about.

Competing interests: None declared

Competing interests: None declared

Nikhil C Kaushik, Consultant Ophthalmic Surgeon

North East Wales NHS Trust Hospital, Croesnewydd Road, Wrexham LL13 7TD

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Sir,

Levy (1) again raised the problem of medical graduates in developing countries going overseas for further training - and not returning. He suggested that it might be better to train to a lower standard, so that overseas employment was impossible. In Nigeria at least, this was considered at the time of the Chinese Cultural Revolution - with the suggestion that Nigeria might train just "bare-foot" doctors along the then fashionable Chinese pattern. Luckily the inherent difficulties of such an approach were soon appreciated - not least of which would be the fact that the vast majority of the population would receive only minimal health care, while the privileged few would fly overseas for treatment.

Patel (2) has now suggested that it is undesirable for the NHS to recruit experienced medical personnel from developing countries because of the risk that they too might not return home, even though, as pointed out by Mellor (3) they are generally offered only relatively short fixed-term appointments in the NHS at consultant level.

Although it is by no means easy, a small number of medical personnel from developing countries do obtain consultant appointments in the NHS and are indeed lost to their home countries. But is this something that one should feel guilty about? Probably very few of us leave home solely to earn a higher salary: in most cases their decision to work overseas is likely to be determined mainly by whether or not facilities exist in their home country for them to fully utilise their specialist training. Rather than being a matter for regret, it may, indeed, be a matter of considerable pride, both for the individual and their country, that they have been chosen for appointment in the NHS in open competition with all other applicants. These doctors are now treating patients and training students in the country from where, many years ago, doctors may have gone to provide such services to the developing countries.

Finally I’ll like to end by stating the well known fact that majority of health professionals who have emigrated, are using the opportunities here to set up and support a number of charities who are providing incredible amount of services to their countries. In this regard, like Patel (2) I believe the UK Govt can do a lot more to assist those involved in such work. For example they can be given study leave time to pursue such work, which can form part of CPD.

1. Levy LF. The first world's role in the third world brain drain. BMJ 2003;327:170.(19 july).

2.Patel V. Recruiting doctors from poor countries: the great brain robbery? BMJ 2003;327:926-8.(18 Oct).

3. Mellor D.Commentary: Recruitment is ethical. BMJ 2003;327:928.(18 Oct).

Competing interests: None declared

Competing interests: None declared

I. A. Hassan, Consultant Microbiologist

SMUTH Wythenshawe Hosp. Manchester M23

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Due to the EU directives for Junior doctor’s working hours there was a shortage of Junior doctors, so suddenly PLAB became very easy from 2000 onwards with centres opening up in other countries. So much so that this year it is expected that more than 10,000 people will appear for PLAB. PLAB unlike the USMLE is an exam where there is no percentile or fixed pass mark so the GMC can keep a tab on the numbers it wants to pass. So as long as there are people to fill up the unwanted posts and GMC’s bank account it really doesn’t matter to GMC what conditions overseas doctors have to face in UK. To make matters worse overseas doctors have to pay £250 for every visa extension. Funnily enough when I called up consultants for SHO posts they said they’ll prefer people with UK experience and when I called for PRHO posts they said I was too qualified for the post. I would also like to add that I showed my CV to many consultants and they said it was good except that I did not have UK experience [4 publications of which one in US and other in UK journals, extra curricular activities, university ranks, distinctions]. Last year 3500 doctors registered for limited registration so extrapolating that data this year thousands won’t get jobs.

To add to this misery coaching classes are advertising that everyone gets a job. One may argue that people take PLAB at their own risk, but doesn’t GMC has a moral duty to inform people about the job scenario in UK, so people like me who would have otherwise started their own practice in their own countries would not have taken PLAB. Or does the GMC doesn’t care how many overseas doctors have to face economic and mental hardships as long as UK hospitals are getting junior doctors to do the jobs no one would have done otherwise?

Competing interests: GMC

Competing interests: None declared

Ashutosh Pandey, Qualified but unemployed in UK

B75 7RR

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EDITOR- Vikram Patel's comments regarding the Great Brain Robbery warrant serious discussion and reflection1. I have attempted to present several issues that need to be considered before reaching an ethically sound decision. As with many dilemmas, the decision would be coloured by the values and beliefs of the individual, community or society.

If one was to take the extremely hypothetical (neo-liberal) utopia, each of us would have studied using "our" funds, qualified from where-ever we wanted to and selected the best place to work based on the market opportunities. The different populations would have equitable access to services and "our" moving across borders would be irrelevant.

However, we live in a totally different world. A tax-based state system funds undergraduate and postgraduate education in a country such as Sri Lanka (SL) and each citizen has paid for it directly or indirectly. SL has fewer psychiatrists for the whole country (less than 40 for approximately 19 million), than Sri Lankan psychiatrists working in and around London. Our population is poorer and can afford less investment in health (59 vs. 1437 per capita in international dollars) though sicker than the UK (58.9 vs. 69.6 healthy life expectancy at birth in years). Thus the needs of the country and then obligations or duties of its graduates towards their country is proportionately more than in the UK.

On the contrary, the pay a consultant receives in SL is about 400 dollars per month. Many work away from urban centers, with few facilities. The private practice can easily double or treble the earnings, but at a huge personal cost of not seeing your family till late at night and blocking a few coronaries. The quality of education and material comforts one can offer to their children and family is limited.

The above factors have resulted in a range of situations in Sri Lanka. Some doctors have left their mother country because of war like conflict and bitter personal experiences at the hands of political goons or a stifling beuracracy. Others have justifiable family commitments. Some have simply vacated posts without informing (and not paid back the legally required bond for doing so). A few have chosen to stay overseas and paid back the sum in full or continue to come and work whenever a suitable opportunity arises. A significant proportion has returned home and worked amidst the chaos, happily or unhappily, but have to work till late at night. All of the above are individual decisions and we need to respect them for what they are. The problem, as implied by Patel lies in the system and less so with the individual. It is estimated that India loses US 2 billion per year to the US for software professional alone (in contrast to its total chare for higher education is US$ 2.7 billion in 1999)3 .

What can governments do about the worsening of inequities as a result of the brain drain of qualified personnel?

The World Bank has suggested that governments should offer well- trained expatriates good job opportunities and strong financial and tax incentives to return home to teach or work4. However, it is not only money that is the attraction of the developed countries. Factors such as quality of education available to children, quality of life in a remote setting, social stability are some factors, which cannot be compensated by money or tax incentives. Secondly, the developing countries have no funds to match the incentives available in the developed world (e.g. ability to apply for permanent residency with all its concessions). Other suggested methods to tax lost skills include, a) an exit tax paid by the employee or the firm at the time the visa is granted, b) introduction of a loan scheme for higher education, c) a flat tax where overseas national pay a small fraction of their income back to their country d) a cooperative model where a multilateral regime which would allow automatic inter-government transfer of payroll taxes or income taxes (from adopted country to country of origin) 3

For implementation, it is necessary for governments to develop systems where individuals have no bars to migrate, but a mechanism to enable the migrant or the host government to pay back an agreed proportion of the social costs to the migrant's country of origin.

Another option often ignored by international and national organizations is for the so-called liberal democracies to really practice what they preach and open hitherto protected service sector markets to all eligible and qualified human beings. Right now, they open their markets to qualified personnel (e.g. specialist doctors) from (developing and other) countries and restrict access to less skilled jobs (e.g. street cleaners). For the developed countries, option 1 would mean unemployment as result of severe competition for jobs and a fall in wages. This would be political suicide for any government, even though we in the developing world have known such misery for centuries.

References

1. Patel V, Recruiting doctors from poor countries: the great brain robbery? BMJ 2003;327:926-928

2. World Health Organisation, The World Health Report 2002: Reducing risks, promoting healthy life, Geneva, World Health Organisation, 2002.

3. United Nations Development Programme, Human Development Report 2001: Understanding human creativity, national strategies. New York, Oxford University Press. Inc. 2001

4. The World Bank. World Development Report`1998/99:Increasing our knowledge of the environment in knowledge for development. New York, Oxford University Press. Inc.1999

Competing interests: None declared

Competing interests: None declared

Saroj Jayasinghe, Associate Professor

Kynsey Road, Colombo 8, SRI LANKA

Faculty of Medicine, University of Colombo

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22 October 2003

I have read your artice with great interest.As an overseas doctor,I can understand the situation in India and other developing countries.

On the other side of the coin;I would like to highlight these points:

1. I think getting trained in a developed country can work to our advantage,if a person is just interested in the training aspect and willing to compete at highest level enriching the experience.

2. The reverse brain drain is possible if enough qualified doctors want to go back to their country of origin.This can change the existing medical system as mentioned in the article and brings more competition at local level with respect to level of patient care.

3.I think the private sector is already making a very good progress in the developing country as a result of involvement of returning doctors.

4.One cannot blame the recruiting body,given present communication technology (especially in India)it is not very difficult to know the situation here and purpose of recritment.

5. The rural area needs much more health attention than urban area in a developing country.It is difficult to say how many doctors are willing to go back to these underserved areas!

6.The imbalence in the health system is not just because of flow of doctors overseas but it is mainly because of improper use of our own resources effectively.

I think it is unreal to say a real 'Brain robbery'.

Competing interests: None declared

Competing interests: None declared

VIJAY HEGDE, SHENIOR HOUSE OFFICER

COVENTRY,CV1 4FH

UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE

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I always secretly wondered exactly what I paid my WMA Membership dues for ; but now I hereby publicly retract such obstinate thoughts . . . and warmly encourage all other doctors out there to unanimously join in the WMA's noble fight against 'Medical Inequalities'.

Well Done , Dr Human . . . Well Done.

Competing interests: Dr Joseph Chikelue Obi MBBS MD MPH DSc FRIPH FACAM is also the Chairman of the General Wellness Assembly (GWA); an International Professional Body for Independent Wellness Consultants.

Competing interests: None declared

Joseph . C . Obi, Chief Consultant

WellnessClinics.co.uk

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