Recruiting doctors from poor countries: the great brain robbery?

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.

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.

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

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