Is India's brain drain the other way around

Brain drain in the healthcare market

IN all countries of the world, the training of doctors and medical staff takes place in uncoordinated phases, so that there is a drastic shortage of skilled workers in one country and in another. With its standard of living and the equipment of clinics and research facilities, the West is still attractive enough to meet its need for qualified doctors and nurses, if necessary in distant countries: every fifth general practitioner in Great Britain comes from Asia, almost every fourth medical professional in the USA completed his training abroad. This has fatal consequences for the health system in the countries of origin.


In December 2001 the UK Government stated that the public health system would need 8,000-10,000 additional general practitioners to continue functioning through 2004. As a result, a campaign to recruit foreign medical professionals began. In January 2001, South Africa urged Canada to stop poaching South African general practitioners because of the shortage of doctors in rural Canada. After all, South Africa had only recently hired 350 Cuban doctors,1 to compensate for the emigration of skilled workers trained in the country. In October 2000 Ireland hired 55 anesthesiologists from India and Pakistan. Even Sweden, the model country of social welfare, recently started poaching on foreign territory and, among other things, employed 30 Polish doctors. 23 percent of medical professionals in the United States have trained overseas. Almost 20 percent of general practitioners in Great Britain come from Asia.

There are around 8,000 doctors in France who have trained abroad. 4,400 of them studied outside Europe. They are employed in public hospitals and provide a substantial part of the care in the fields of paediatrics, obstetrics and radiology. As far as status and salary are concerned, they are of course much worse off than their French colleagues. A little more than 20,000 doctors work in the Arab Gulf States, most of them from the Indian subcontinent. Such migrations between countries in the south are usually limited in time.2

For the affected countries, the migration of doctors is a very painful bloodletting. For example, Zimbabwe trained 1,200 doctors in the 1990s, of which only 360 were still working in the country in 2000. Half of all doctors trained in Ethiopia, Ghana and Zambia have emigrated. Many of these emigrants no longer practice their profession in the host country. In any case, the available statistics do not give a precise picture of migration, because they are assigned differently to “voluntary emigrants” and “refugees”, sometimes also their own citizens born abroad.3

The lack of nursing staff is even greater. In 2000 the UK Ministry of Health recruited more than 8,000 nurses and midwives from outside the European Union - in addition to the 30,000 foreign colleagues who already work in the UK's public and private hospitals. It can already be foreseen that by 2010 the United States, Great Britain and France will have a shortage of tens of thousands of qualified workers.

The doctor as a voyager of discovery

Since time immemorial, science has developed further, not least because people move from one place to another and pass on their knowledge. Medicine is no exception. In the Middle Ages, doctors went to study at the famous universities of Alexandria, Córdoba, Bologna or Montpellier. Later they went on the explorers' ships. Since Louis Pasteur revolutionized medicine with his bacteriological discoveries in the 1860s and 1870s, doctors have traveled the world from the far north to the deepest south and founded tropical medicine.

There are now far fewer nurses in Christian missions around the world. The western experts have not taken their place; they have other tasks to perform. Since the independence of many former colonies, medical practitioners have migrated in the other direction. This is due on the one hand to the demand in the industrialized countries and on the other hand to the drastic tightening of health budgets, which was imposed on the developing countries by the donors of international funds in the name of structural adjustments at the beginning of the 1980s.

The emigration of doctors is not only due to poverty in their countries of origin, survival strategies or changed behavior. For many migrants, the decisive factor is the impression that the countries of the north offer qualified doctors a way of life and professional opportunities that correspond to their knowledge and skills. In addition, there are politically unstable conditions in the home country, ethnic discrimination, frustration at work (due to cumbersome bureaucracies, late salary payments, elite clique or professional isolation), the mismatch between course content and its implementation in practice or even family problems. All of these factors contribute to the decision to emigrate, so it is usually about more than the mere material incentive.4

The reasons that lead practicing physicians to lose the desire to practice their profession in their own country are indeed complex. One of them is often suppressed and affects the north as well as the south: it lies in the ongoing crisis of medical thought. Consciously or unconsciously, doctors still see themselves as those who embody "the triumph of medicine" and who can therefore demonstrate healing successes that are just as natural as they are reliable. In many cases, this idea has shaped the choice of career. But when the material prerequisites are lacking to be able to exercise this profession appropriately, the ideal becomes an illusion. Disappointment and anger are the result. Not being able to make a diagnosis because you cannot do laboratory tests; Not being able to administer a suitable drug or not being able to comply with the elementary rules of hygiene - a large number of medical professionals in developing countries have to come to terms with all of this. As soon as one of them has the opportunity to emigrate, they face the dilemma of remaining loyal to their country or their profession.

The World Health Organization (WHO) once set high goals for the countries of the southern hemisphere. In the year 2000 every country should have at least one doctor for every 5,000 inhabitants and one trained nurse for every 1,000 inhabitants, even in rural regions. But the laws of the labor market, the lack of realism of international donors and the indifference of the authorities in the affected countries have turned these goals into a farce. The world average today there is one doctor for every 4,000 people: one for every 500 people in western countries, one for every 2,500 people in India, and in the world's 25 poorest countries there is one doctor for every 25,000 people. The mobility of doctors, nurses and medical-technical specialists has led to apartheid in health policy for the countries of the south.

In the face of such contradictions, the international organizations that issue health policy guidelines and fight against social inequality have shown a remarkable degree of silence. Since 1979, neither the WHO nor the United Nations Devolopment Program (UNDP) has published any studies on the consequences that the transfer of skilled workers will have on the health of the disadvantaged people.5 The World Bank does a lot of research on the merits of market opening, but strangely enough, it has never assessed the flows of money created by exchanging human capital. Without a doubt, it simply ignores UN resolution 2417 “On the emigration of managers and technical personnel from developing countries”. This namely condemns the "poaching" for specialists in all professions.6 But after all, the health care system does not contribute directly to the gross national product ...

At the beginning of 1995 the guidelines "Shaping a WHO for the 21st Century" were adopted. They deal primarily with the prerequisites for a global health policy, but ignore the question of how the migration of qualified health care workers could be regulated.7 In addition, the WHO does not take medical flight into account in its “Index of lost healthy years of life”. However, this factor is also crucial in calculating the premature deaths and incapacity for work in the respective countries. Nor is the outflow of doctors and nurses taken into account when compiling the UNDP's Human Development Index. Mind you: The suffering of people who are cut off from health care cannot of course be expressed in numbers. Yet these figures make it all too clear that the maternal and newborn mortality rate is no longer falling as it was a few years ago.

In response to voices critical of globalization, the WHO Director General has commissioned a committee called “Macroeconomics and Health” to draft a new investment plan.8 In their report, the Commissioners reject the old argument that public health automatically improves as the economy grows. Rather, they emphasize that, conversely, better health is critical to economic recovery and social progress in low-income countries. With their “health pact” they are trying to create a new basis for relations between donor and recipient countries. However, the proposals remain surprisingly vague as to the medical staff that will be required for these new approaches.

In order to achieve its goals, the World Fund to Fight AIDS, Malaria and Tuberculosis will have to build or maintain medical infrastructures, because this is the only way to carry out the planned projects efficiently. This applies in particular to the treatment of HIV patients with antiretroviral drugs.

How the south subsidizes the north

THE costs for training skilled workers are difficult to estimate - not least because they vary considerably from one region to another. It is also difficult to determine the respective effects of training on the health system and the level of development in the countries. If one assumes, however, that general medicine training costs about $ 60,000 per person for general medicine training and training of other medical personnel costs about $ 12,000 per person, one comes to the conclusion that North America, Western Europe and Australia are roughly calculated are "subsidized" by developing countries annually with 500 million dollars.9 The WTO, which aggressively advocates the prerogatives of the multinational pharmaceutical companies, has to wear blinkers in this regard. Because it does not recognize the importance of the medical professionals, although only they can prescribe prescriptions and distribute medication. Or should the WTO possibly rely on the current black market to boost drug sales?10

Can it be prevented at all that the rich countries acquire the scientifically trained specialists of the low-income countries, where, moreover, it is already clear that the international migratory movements of scientists will continue to increase?11 ?

There are various possible solutions. The first version is not new and has been revisited on occasion lately12 : The host country of the migrant pays compensation to the state that provided the training. This option has so far been used rather arbitrarily because international law does not have any relevant provisions. The countries of origin can also make emigration more difficult or delayed by only issuing diplomas after a minimum number of years of service. The host countries can help by increasing their training requirements. However, such measures cannot do anything against the dismantling of the health system in the affected countries. Various attempts to regulate migration by the state have proven to be largely ineffective.

The second possible solution is of greater significance because it starts with a cultural and social upgrading of the health professions. The traditionally trained doctor can hardly meet the needs of the people in the southern countries because he is trained on the universalist model of healing and scientific medicine - and for them public preventive medicine was considered a minor matter. Doctors need new intellectual and practical tools in order to be able to identify with the goal of progress in their own country, and here an ideological break with the Western study canon proves necessary.13

In such a reform, maintaining health must be given higher priority than treating diseases. It needs to draw attention to the community rather than the individual. It must insist on interdisciplinary work in order to bring the approaches of healing and prevention closer together. Finally, the hospital - which is only accessible to a minority - must no longer be the only possible place for quality medical care. Such a reform would force the state authorities and all medical staff to justify their actions publicly - and no longer just to international donors.

The transition from a universalistic to an acculturated medicine upgrades the resources of the southern countries and takes their regional characteristics into account. Of course, it harbors the risk of two-tier medicine. The emigration of doctors would certainly be made more difficult if their training no longer met the requirements in the West. But could this really prevent the flight of the best experts - such as the graduates of the All India Institute of Medical Sciences, 75 percent of whom are continuing their doctoral studies in the West?14 And wouldn't doctors who stayed in their own country risk that their Western colleagues no longer take them seriously and ignore their scientific work?

Since the countries of the South do not form a homogeneous whole, the strategies and working methods of cooperation with the industrialized countries must take into account their different conditions and short- or long-term goals. In addition, some countries (such as Cuba, Egypt, Spain, Italy, Israel and the Philippines) train more medical staff than they can employ. Others, such as the United States, Canada or Great Britain, cannot keep their population supplied at the desired level without immigrants. The solution to the problem of professional migration cannot therefore be to restrict the mobility of individuals.

A third approach seems more appropriate in this context: Healthcare professionals should be encouraged to stay in Heimtaland or to return later. In addition, unequal access to medical care should be reduced and investments in education and health should be given higher priority. The new communication technologies with the establishment of centers for distance learning or interactive networking open up interesting possibilities for this.

A virtual campus would be conceivable that links a university in the south with one in Europe or North America and ensures that the study programs are updated and access to specialist literature is ensured. Interactive networks connect the emigrants both with one another and with their colleagues in their home country. This creates new forms of the intellectual and scientific diaspora. The aim is closer cooperation between North and South, the upgrading of the work of colleagues in the South on an international level and the search for possibilities of a temporary, better still permanent return to the home country.

There are already more than 40 such diaspora networks in over 30 countries. Some number a few dozen, others several hundred members.15 Since the emigrants stay in contact with their homeland, they can work abroad at the same time and contribute to progress in their own country. This policy of encouraging people to return is the aim of the project “Tokten” (“Transfer of Knowledge through Expatriate Nationals”). It is funded by UNDP and the International Society for Migration.However, the results in the health care sector are still rather modest.

It is difficult to make predictions about the need for doctors and health workers - not least because the expected economic and population growth can hardly be determined. In addition, the emigration of highly qualified people is neither a general phenomenon nor the result of a uniform policy. Anyone who wants to tackle it must take into account the human, cultural and social characteristics of the emigration and immigration countries. It is also clear that the human capital of the health system cannot be steered in one direction or the other by directives of rich countries and the WTO or by laws that poor countries enact on their own.

It is high time that the WHO reconsidered its task and drafted a worldwide regulation of the health system based on solidarity-based ethics. Last but not least, it would have to open a debate on the future of “trade in public services”, in which the UN, world trade organizations and the international financial institutions would have to participate as well as experts in international law. The aim of this debate would be to develop a convention on the international recruitment of skilled workers. This treaty should lay down the conditions under which developed countries can recruit medical personnel from countries that themselves have a shortage of skilled workers.16 It would complement relevant international agreements on vocational training and define more specifically the right to health as set out in the Charter of Human Rights.

German Herwig Engelmann

* Doctor and former lecturer at the Universities of Minnesota, Paris V, Addis Ababa and Calcutta.

Footnotes: 1 Cuba is training many more doctors than it needs itself. 2 See Joaquín Arango, “Expliquer les migrations: un regard critique”, Revue internationale des Sciences Sociales, Unesco, Paris, September 2000. 3 Sabine Cessou, “Fuite des cerveaux: L'Afrique part en croisade”, Marchés tropicaux, Paris , February 23, 2001, No. 2889. 4 Cf. Marc-Eric Gruénais and Roland Pourtier (eds.), “La santé en Afrique”, Afrique Contemporaine, Paris, No. 195, July – September 2000. 5 Alfonso Mejìa, Helena Pizurki and Erica Royston, “Physician and Nurse Migration: Analysis and Policy Implications”, WHO, Geneva 1979. 6 General Assembly, 23rd session, Resolution 2417, 1745. Plenary session, 17 December 1968. 7 WHO, “Regional Office for Europe , Health 21 - Health For All in the 21st Century ", Copenhagen 1999. 8 Report of the Commission" Macroeconomics and Health "(Jeffrey S. Sachs, ed.)," Investing in Health for Economic Development ", WHO, Geneva, 20. 12. 2001, 9 In “Diplômés aux enchères”, Courrier de l‘Unesco, Paris, September 1998, Sophie Boukhari arrives at a total of 10 billion dollars for the flight of university graduates. 10 See Jeanne Maritoux, Carinne Bruneton and Philippe Bouscharin, “Le secteur pharmaceutique dans les États africains francophones,” Afrique Contemporaine, July – September 2000, no. 195. 11 The American Labor Office assumes that the domestic market for health and Nursing services will grow by 30 percent between 1996 and 2006 and will then have 3.1 million employees. See “Occupational Statistics outlook”, Statistics Handbook 1998–1999. 12 Peter E. Bundred and Cheryl Levitt, “Medical Migration: Who Are the Real Losers?”, The Lancet, London, Vol. 356, July 15, 2000. 13 In the developed world, curricula and funding of medical training are under discussion: Arnold S. Relman, "The Crisis of Medical Training in America," The New Republic, Washington DC, Feb. 10, 2000. 14 Sanjoy Kumar Nayak, "International Migration of Physicians: Need for New Policy Directions," European Association of Development, Research and Training Institutes (EADI), Eighth General Conference, Vienna, September 11-14, 1996. 15 Jacques Gaillard and Anne Marie Gaillard, “Fuite des cerveaux, retours et diasporas,” Futuribles, no. 228, February 1998. 16 Tikki Pang , Mary Ann Lansang and Andy Haines make a similar suggestion in Brain Drain and Health Professionals, British Medical Journal, London, Vol. 324, March 2, 2002.

Le Monde diplomatique of May 17th, 2002, by DOMINIQUE FROMMEL