Managing medical migration from poor countries
BMJ 2005; 331 doi: https://doi.org/10.1136/bmj.331.7507.43 (Published 30 June 2005) Cite this as: BMJ 2005;331:43
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Editor,
In his thoughtful article Ahmad (1) has explored many of the issues
and dilemmas raised by medical migration, the need for "ethical
recruitment" and freedom of movement.
The goal is arguably not "to meet the legitimate labour needs of the
developed countries", but to enable the development of the healthcare
systems of the developing countries without their being damaged by the
labour needs (legitimate or otherwise) of developed nations.
At present the developing nation loses not only intellectual capital
but also social capital in addition to the finance spent in training a
health care professional (HCP). In any financial system this is not
sustainable…
The compensation strategy that Ahmad places last in his suggested
list of solutions is the most important to tackle. One mechanism is to
develop a clear and strong global framework whereby the receiving country
replaces the lost capital of the developing country when a trained HCP
moves to a developed country to train or work in a service-providing post
in health care. Such a system could be administered by an international
Trust and linked to professional registration in the receiving country.
The receiving country would pay into the Trust as long as the HCP was
professionally registered and the developing nation would receive a
payment from the Trust to be channelled into health education.
This system would be more just for all. It does not restrict the
worker's rights to move freely, it enhances the value of the worker in the
receiving nation, it makes the receing nation think more clearly about its
personnel needs, and it gives the developing country an opportunity to
retain its capital.
There are a number of side issues that need further discussion but it
provides a starting point for negotiation.
John Dorward
General Practitioner
Eyemouth Medical Practice
Berwickshire
dorwards@fish.co.uk
1. Omar B Ahmad Managing medical migration from poor countries
BMJ 2005; 331: 43-45
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None declared
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Sir,
There may be nearly as many Ghanaian doctors in New York state as there
are in Ghana [1] but these doctors are not the cause of poor health in
their country of origin. Ahmad's article [2], although learned, fails to
acknowledge the primary cause of ill health in developing nations:
poverty. Public health initiatives would have a greater impact than any
formal health care provision. I would argue that limiting recruitment from
developing countries is well meaning but ultimately misguided.
Migrant remittances to developing countries in 2002 have been
estimated to be up to $200 billion. [3] This massive sum, representing a
considerable proportion of poorer nation's GDP, exceeds the total amount
of aid given to Africa in the past 40 years. It is my humble opinion that
these talented men and women contribute more to the alleviation of poverty
and hence improved health in developing nations than any national strategy
for the migration of health workers. Richer countries should allow
unfettered access to employment in their health care systems if they want
to help imrove the lives of those in poorer countries.
Yours etc.,
Anand Sharma
[1]CBFC.org IRIN interview with the President of the Ghana Medical
Association, Dr. Jacob Plange-Rhule,October 6, 2003.
[2]Omar B Ahmad, Managing medical migration from poor countries BMJ 2005;
331: 43-45
[3]'Migrant remittances to developing countries', UK Department of
International Development, by Cerston, Bannock Consulting, June 2003.
Competing interests:
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One of the main reasons for migration from the 'developing' world to
'developed' world is the super strong currencies here. Compare India and
the UK for example where 1 pound buys 80 or so rupees:
The purchasing power of 80 rupees is however much greater than 1
pound by about 4 to 1 i.e. 1 pound buys as much as 20 rupees. Therefore
any prospective doctor from India should divide any UK salary by about 4
to get a realistic idea of the true worth of his UK salary when comparing
it to his Indian salary.
If the aim is to save money and return home it makes sense. if
staying in the UK is the goal the massive costs of living here should be
taken into consideration.
Competing interests:
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Dear Sir,
I read this article by A. Omar.It was a very good article. The points
highlighted reflected a great depth of thought in the matter. I
personally feel that intellectual assets are going to developed countries
not because the life there is very attractive but because they do not get
enough support in their own country and they have to struggle through the
beurocractic system for career development.
It is very easy to blame developed countries for the brain drain but actually
many talented people leave their homes even if it means staying away from
their childhood friends, local pub and relatives but as things for them
are made so difficult in their own country that they are not left with any
option but to go to places where their talent would be recognised.
Most of the scientist and research workers that migrate to developed
countries say that the main reason for their desicion was perhaps because
they were not able to have opportunites they wished in their own work
practice. Some of them are very keen to come back but when they come they
find there is no place for them in the system in their original birth
place.
In Summary I feel the main reason for the brain drain is that developing
countries do not recognise the talent of their people and do not give
opportunities that they deserve.
Kind Regards
Girish Chawla
Competing interests:
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Editor – the article about the medical migration by Omar B Ahmad
describes “why”, “what” and “how” aspects of migration of medics to the
developed countries. As far as India is concerned, it is not only the
medical drain but we must say that it is the “intellectual drain”. The
main reason for migration is the policies of the country, the demand in
the developed countries and attractive salaries offered in the developed
countries. Actually, many of the youngsters in India, dream about visiting
a developed country, working for there for a few years, make money and
come back. For an Indian, if he works in USA or England, the money he will
get is five to ten times more that he will get in India. So they like to
go and work for a few years and come back to the motherland. Some of them
settle there if they get a permanent residence ship. In India, first of
all, it is difficult to get a good pay with a basic degree. It is very
difficult to get a job in the first place. Here, most of the software
engineers, doctors and PhD holders will be waiting to get a job in a
developed country. They feel it is a shame on their part to work in India.
Countries like India have to realize that “Only monkeys will stay if you
give peanuts to eat”. They have to change the government policies and
create job opportunities to the intelligent deserving people in order to
stop the brain drain.
Competing interests:
None declared
Competing interests: No competing interests
Omar B Ahmad, while discussing the migration of skilled health
professionals from poorer to richer countries, omitted to mention the
existence of a counter-flow.
Recognizing its existence and its reasons, together with whit the
obstacles that make it more difficult, is of paramount importance.
The migratory flow described by Ahmad is not simply a flow from poorer to
richer countries, but, more precisely and correctly, from poor and reach
countries to reach English speaking countries with a rather well developed
recruitment system (Canada, US, UK, Australia, NZ).
Language, by all means, mechanisms in place to make possible the
achievement of equivalent professional titles, and recruitment systems
appear to be key factors.
Ahmad also mentions Italy among the Countries producing more health
professionals than they can absorb. A recent bibliographic reference is
missing.
In fact, this statement deserves, at the least, a more accurate review.
If it is true that in 2002 Italy, with 583 physicians per 100,000
population, had probably the highest level of medical staffing in the
world, it must be emphasized that the overproduction of doctors occurred
mainly in the decade 1974-84 (98 % more than in 1964). In the following
decade this has been of the 41 % and, in the last decade, of the 5,4 %
only (1). From the Academic Year 1988-89, the number of enrolments to the
Italian Faculties of Medicine in is regulated according to the demand of
doctors on the territory. However, this new regulation, is clearly likely
to cause a shortage of doctors within the next 2 decades due to the
retirement of those graduated in the ’70s.
OOH services are already struggling in obtaining appropriate cover,
especially by doctors with postgraduate qualification in Primary Care.
Surprisingly, the physician/population ratio is lower in the Northern
Italy, where the pro-capita GDP is much higher than in the Southern Italy.
The feature evidences the importance of non-economic factors in shaping
the geographic distribution of health workforce.
1 Calcopietro M. [Medical doctors in Italy: a situation analysis].
[French] [Journal Article] Cahiers de Sociologie et de Demographie
Medicales. 42(1):113-48, 2002 Jan-Mar.
Competing interests:
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Rich country, poor country, poor doctor
The article on managing medical migration barely avoids the trap of
laying more blame for Third World problems at the door of developed
nations rather than the afflicted countries themselves – a way of
thinking that is at the heart of the wider debate about where the
solutions to Africa’s problems lie. If America needs doctors and nurses it
will, for we live in a free world, recruit from wherever it finds them.
Awkward, artificial barriers to the movement of healthcare workers are as
much an infringement of individuals’ rights as they are, in the long run,
unfeasible. The most effective answer to a mass exodus of Poor Country’s
doctors is to make Poor Country and its hospitals enjoyable to work in.
Besides, the suggestion that the retention of doctors in their
developing countries of origin would mean better healthcare in those
places is a fallacy. Many of my colleagues back home are unemployed,
underemployed or unable to undertake postgraduate training because of
stagnant infrastructure and rudimentary healthcare delivery systems. And
where they do begin hospital practice, they soon face the despondency of
incessant strikes and an appallingly equipped workplace.
This problem has moved from fresh young graduates to involve doctors
at every level of specialist training. As a medical student and then house
officer at the largest teaching hospital in Nigeria, I saw – among other
departures – a professor of medicine leave for the UK to take the PLAB
exam, while the chief resident in medicine and a consultant paediatrician
set off to begin residency anew in America. It all served to rather
extinguish what little hope I had of staying put to further my training in
my own country. I came to realise that possibly the single most important
factor driving the emigration of healthcare professionals is a lack of
job satisfaction. It goes that bit beyond salaries, housing allowances and
cars.
As your editorial rightly pointed out, rich countries awash with
vacancies will always pull professionals from the developing world. It
really isn’t about right or wrong. If the developed world became
self–sufficient in training people for its own manpower needs, all well
and good. The outflow of expertise from developing countries would
consequently halt, leaving them with trapped doctors who in turn would be
left with little choice but to hope for the day when their patient won’t
die for want of an urgent blood electrolyte investigation.
Anthony Bella
sesanbella@yahoo.com
Competing interests:
None declared
Competing interests: No competing interests