PHA-Exchange> Brain Drain : NHS to blame?

[Anant Bhan]

hi,
TIME FOR INTROSPECTION: I present both sides of the coin !!!!
 
Courtesy: BMJ recent issues
 
Warmth,
Anant.
 
 
Recruiting doctors from poor countries: the great brain robbery? Vikram Patel, senior lecturer1 
1 London School of Hygiene and Tropical Medicine, London WC1E 7HT 

Correspondence to: V Patel, Sangath Centre, 841/1 Alto Porvorim, Goa 403521, India vikpat_goa at sancharnet.in 

An important impediment to achieving health for all in developing countries is the shortage of doctors and nurses. Can the NHS justify schemes to recruit staff from these countries? 

An enormous gap in health staffing exists between the United Kingdom and India. India has fewer than 3000 psychiatrists for its one billion population compared with one psychiatrist for every 9000 people in the United Kingdom, a 27-fold difference.1 Despite this inequality, the NHS has launched a scheme to recruit senior psychiatrists and other specialists from India and other developing countries. This scheme will worsen the brain drain and inequities in global health unless it is explicitly linked with measures to enable the flow of doctors back to developing countries. 

 Waiting for treatment: shortage of medical staff is an important barrier to health in India 
Credit: MARK HENLEY/PANOS PICTURES 


Opportunities or opportunism? 
Overseas recruitment schemes are marketed primarily as an opportunity for doctors to experience one of the world's best healthcare systems. Yet it is obvious that the NHS is trying to fill jobs in specialties where there is a shortage of staff. Although shortages are acknowledged in the promotional material for the new NHS international fellowship scheme, the difficulties that doctors will face when they attempt to return home are ignored. Experience with previous schemes, such as the overseas doctors' training scheme, suggests that few doctors returned to their home countries. Indeed, when I finished my training in psychiatry in the United Kingdom in 1992, I found that few routes were available to facilitate my return to India.2 My work in developing countries over the past decade has been entirely funded by research grants, mainly from the Wellcome Trust. 
NHS international fellowship scheme 
Whereas earlier schemes recruited junior doctors, the new NHS scheme is taking highly experienced specialists, reflecting the changing requirements of the NHS. The international fellowship scheme invites psychiatrists, clinical oncologists, radiologists, histopathologists, cardiac anaesthetists, and thoracic surgeons to work in the United Kingdom for up to two years. Doctors will be paid a consultant salary and given up to £46 000 to assist with relocation and housing.3 Although the available materials do not specify how many specialists will be appointed, there have been over 400 applications in the first round, with psychiatrists accounting for the largest proportion of recruitments.3 The promotional material includes a letter from the British prime minister inviting doctors to take up the new opportunities that are being created as a result of a "dynamic expansion programme" in the NHS.4 
Recruitment is being promoted using the obvious advantages the NHS has over employers in developing countries. The code of practice for international recruitment explicitly states that "there should be no NHS advertising in developing countries unless that country has specifically invited the UK to undertake a recruitment programme" and that recruitment "should only be undertaken as part of an inter-governmental cooperation agreement... encouraging the exchange of healthcare personnel, healthcare information, and guidelines."5 The promotional material for the scheme does not indicate that either condition has been met.4 
Apart from the immediate effects of the scheme on human resources in developing countries, the scheme could perpetuate global health inequalities for generations. Consider, for example, a country that must import expatriate doctors using scarce foreign exchange. Most doctors in developing countries have been trained in public funded medical schools. The cost of training is borne by the poor country and the rich country reaps the benefits. In effect, the people of poor countries are paying for the health care of those who live in one of the richest. 
Stemming the brain drain 
The opportunity to work in different societies is a rich experience with benefits that go beyond financial gains. There is no place for creating new barriers to the movement of peoples between countries. What is needed is an acknowledgment that institutions in developed countries have an ethical obligation to facilitate the return of health professionals to developing countries (box). 

Requirements for ethical recruitment from overseas 

   Flexible training schemes that permit doctors from developed countries to work in developing countries

   Long term partnerships, including funding and training, to strengthen the research, clinical, and teaching infrastructure of institutions in developing countries

   Grants to enable returning doctors to establish personal and professional lives

   Audit of the outcome of overseas doctor training schemes in terms of proportion of doctors who return home





Institutions in developed countries must engage with those in developing countries to facilitate an attractive environment for returning doctors to work in. Doctors from developing countries who go abroad to train and work have a key role in this process. The opportunity to choose the country we live and work in is the result of the opportunities that were available to us in the country of our birth. Doctors going to work overseas must search for ways to share their expertise and resources—for example, by partnering their new institutions with the ones in which they trained. 

Summary points 
The developing world has fewer doctors per population than developed countries 
Schemes to recruit doctors from developing countries risk damaging their fragile health systems 
Working and training in another country provides valuable experience 
Partnerships between institutions in developed and developing countries are needed to encourage doctors to return 
Institutions in developed countries need to reform to provide more rewarding professional environments 



Institutions in developing countries must acknowledge that doctors leave not only for monetary gain but also to escape from stifling hierarchies and bureaucracies. In India, for example, doctors who want to attend scientific meetings often have to obtain a "no objection certificate" from the head of their institution. Promotions are more likely to be determined by the number of years of service than academic skills and achievements. Institutions must reform to allow professional environments to flourish by rewarding achievements—for example, by reducing routine clinical load and by providing alternative paths for career progression, honorariums, and training opportunities. 
Ultimately, all concerned parties need to define the obligations and responsibilities of institutions in rich and developing countries. Unless these steps are taken urgently, the brain drain will continue to fuel the huge inequities in global health. 



---------------------------------
I thank Gauri Divan for the title of this article. 
Contributors and sources: VP is a psychiatrist, originally from India, who is presently working on public health aspects of psychiatry in India as a full time researcher from a UK institution, funded entirely by a UK agency. 
Competing interests: None declared. 
References 

   World Health Organization. Atlas country profiles of mental health resources. Geneva: WHO, 2001. 
   Patel V, Araya R. Trained overseas, unable to return home: plight of doctors from developing countries. Lancet 1992;339: 110-1.[CrossRef][ISI][Medline] 
   Goldberg D. The NHS international fellowship scheme for consultant psychiatrists. Newsletter of the Faculty of General and Community Psychiatry 2003;6: 5-6. 
   National Health Service Careers. Opportunities for doctors in England: NHS international fellowship scheme, 2002. www.nhs.uk/fellowships (accessed 22 Aug 2003). 
   Department of Health. Code of practice for NHS employers involved in the international recruitment of health care professionals. London: DoH, 2001. www.doh.gov.uk/international-recruitment/codeofpract.pdf (accessed 22 Aug 2003). 
(Accepted August 7, 2003) Recruitment is ethical 
Debbie Mellor, head of NHS employment policy1 

1 Department of Health, Leeds LS7 2EU international.recruitment at doh.gsi.gov.uk 

NHS international fellowships were launched by the Department of Health in February 2002 to give experienced consultants the opportunity to come and work in the NHS in England for two years. This is in addition to the campaign we launched in August 2001 to recruit consultants and general practitioners from around the world into substantive posts. So far, 304 doctors have been recruited through the campaigns, 82 of whom come from India. 
Most doctors have been recruited as international fellows and are using the opportunity to sample living and working in England for a relatively short period. The feedback we have received shows that they value the opportunity to work in a different health system, acquire new skills, get wider work experience, pursue research interests, and develop their teaching skills. 
We operate an ethical recruitment policy, with all NHS trusts working to a code of practice approved by the Department of Health. We are committed not to recruit from a country if its government has any concerns about the effect on its workforce and work only with recruitment agencies that comply with the code of practice. This list can be obtained from the international recruitment website.1 
It is wrong to suggest that the health service is targeting health staff from struggling countries. Most of the staff we are recruiting come from Europe, with others from the United States and Australia. 
Working with developing countries 
We have worked closely with the Indian Ministry of Health in the development of the campaign in India, and it has been supportive of the opportunities we are offering doctors. The Indian minister of health and family welfare responded to a parliamentary question in July 2003 by saying that the overall availability of doctors in India is sufficient. 
We are working with India and other developing countries to support them in developing programmes to retain their staff. In some cases, we are assisting them in offering fixed term placements in the NHS as part of career planning for healthcare professionals. 
In addition, individual NHS trusts are putting a great deal back into developing countries. Much of this work is voluntary and receives little publicity. Many NHS volunteers spend considerable time and resources developing and providing diverse services in countries such as India, Ghana, Russia, Iran, and China. In India, for example, volunteers are providing services in mental health, leprosy prevention, neonatal resuscitation, women's health, sexually transmitted infections, and HIV.2 



---------------------------------

Competing interests: None declared. 

References 

   Department of Health. International recruitment agencies. www.doh.gov.uk/international-recruitment/agencylist-nhs-ref-htm (accessed 22 Sep 2003). 
   Department of Health. Compendium of the NHS's contribution to developing nations. www.doh.gov.uk/internationalhumanitarianandhealthwork (accessed 22 Sep 2003). 

The brain drain debate: Is it too simplified?17 October 2003   Godwin S.K, 
Researcher 
sree chitra tirunal institute for medical sciences and technology, Trivandrum, Kerala, India 695011 
Send response to journal: 
Re: The brain drain debate: Is it too simplified?

Email Godwin S.K 



Dear sir, 
The article of Vikram Patel highlights the concerns of a sincere citizen of a third world whose country government spends a handsome amount of its already thin medical budget on training of medical professionals. But the argument that availability of doctors and health professionals itself will make health care accessible to all the population is another day light robbery. If it is so, why the city called Mumbai has 60 per cent of the doctors in the State, but only 12 percent of the State's population, because the nature of private practitioners is that they will be concentrating mostly on "islands of purchasing power". The reply by the Indian Minister about the "self-sufficiency" of doctors is also hiding the most unpalatable truth that large number of primary health centres and rural areas are starved of doctors as revealed by the government data. 
Let's go back to the brain drain issue, whether this outgoing professionals are going forever or coming back to their country and also how much monetary resources they are sending back to compensate for their "loss" to the mother country is a moot question? To find an answer to bring brain drain to halt is as difficult as making the "market" work for the poor. The controversy of "brain drain" in the articles is still standing at the periphery by saying that this can be cured by steps like intergovernmental agreements or conventions. The most important reason for forcing the third world professionals to fly out is, I feel, is the amasing difference in the nominal and actual purchasing power of the different currencies of the world in different countries. If we take an example by Vikram Patel, an amount of £46000 in U.K which a specialist can earn in one year is worth about Rs.3450000 in India,(£1=Rs.75 at current exchange rates)which is beyond the imagination of the same doctor, had
 he/she practiced in the country of origin within, say, 5 years. That is also the reason why professionals are not migrating to those countries whose nominal purchasing power is low compared to the mother country, and unfortunately majority are third worlds. The theoretical reasons for jumping out of the counrty are not far to seek, as individuals are utility maximisers he/she will be looking forward to maximise his/her utility subject to the consraints of thier material and spirirtual relations or conceptions and the society's rules and regulations. From the point of view of an individual who had been on the boiling point of exams and frowning teachers, he/she wants to compensate the "loss" by earning and enjoying the maximum, which opportunity may not be available in third world countries, for which the third world heirarchical system is to be blamed for. It is also obvious that the professionals attach special weightage to other aspects of the work culture in developed countries. 
The reason why the relative wages are high in developed countries is that their input prices like rent, cost of living etc are also high and that gets reflected ultimately in the compensation package through DA hike etc, which often does not take place in the third world where majority of the occupation is unorganised and non monetised. My point is that unless policies which do not take into account the difference in the real and nominal purchasing power of the currency, there is possiblity of further worsening the inequality. Intergovernmnetal agreements should take into account this factor while formulation of policies and there should be close monitoring by the authorities of the mother country over the migration of such highly qualified personnel and atleast the training cost plus some minimum costs of loss is to be recovered from the individual migrating abroad. 
Competing interests: None declared

Ethical Recruitment18 October 2003   Andrew D Lawson, 
Hon Clinical Teacher, Medical Ethics Unit, ICSM 
London W6 
Send response to journal: 
Re: Ethical Recruitment

Email Andrew D Lawson 



Editor- Am I alone in finding it laughable that the head of the NHS employment policy writes an article on the ethical nature of recruiting from developing countries and then declares "no conflict of interest?' This piece should be on the DoH website not in a peer reviewed journal. 
Competing interests: None declared

Is the NHS recruitment policy really ethical?18 October 2003   Sindhu Ashim, 
Specialist Registrar in Psychiatry 
Royal Oldham hospital, Oldham, OL1 2JH, 
Bettadapura Ashim 
Send response to journal: 
Re: Is the NHS recruitment policy really ethical?

Email Sindhu Ashim, et al. 



Ms. Mellor states that the international fellowship scheme was launched for the purpose of providing experienced overseas consultants the opportunity to work in the NHS. (1) Surely then all specialties should be represented? It is very clear that the scheme exists to recruit to vacancies in the NHS for shortage specialities (like Psychiatry) so that trusts do not have to spend huge amounts on Locum cover. 
I do not think anybody, let alone the Indian Minister for Health, would believe that the British need 27 times more psychiatrists than the Indians do. Isn’t it clear to the head of the NHS employment policy that the Indian government’s position is farcical? The Indian Government’s position definitely does not provide moral justification for the scheme. 
It is ironic that the UK government invites doctors on one hand to manage shortages and on the other hand should support programmes to retain doctors in the developing countries. Any number of such programmes will not help a country that is deprived of thousands of doctors and nurses every year (over a thousand junior doctors enter the NHS each year through the PLAB exam alone). 
Ms Mellor speaks about the voluntary sector putting a 'great deal back into developing countries'. Can voluntary work alone make up for the amount of skill that is imported? Is this a fair exchange? Will the voluntary sector be able to provide healthcare for millions of people that these overseas doctors would have provided otherwise? 
I am shocked that the head of the NHS employment policy would put forth such futile arguments. It would be worthy of her to acknowledge the moral dilemmas and engage in developing solutions as suggested by Dr Patel in his article.(2) Dr. Patel presents a valid and balanced view of the current state of recruitment of overseas doctors. I also agree with Dr. Godwin’s view that health care policies which do not take into account the difference in the real and nominal purchasing power of the currency in the third world leads to a worsening the inequality.(3) 
References 
1.Debbie Mellor. Recruitment is ethical BMJ 2003;327:928 
2.Vikram Patel. Recruiting doctors from poor countries: the great brain robbery? BMJ 2003; 327: 926-928 
3.Godwin S.K. The brain drain debate: Is it too simplified? http://bmj.bmjjournals.com/cgi/eletters/327/7420/928#38026 
Competing interests: None declared



 


Dr. Anant Bhan, Flat No. 405,
Building No A-11, Planet Millennium,
Aundh Camp, Pune-411 027.
Phone: 020-7404110
Email: dranantbhan at yahoo.com

---------------------------------
Do you Yahoo!?
The New Yahoo! Shopping - with improved product search
-------------- next part --------------
An HTML attachment was scrubbed...
URL: <http://phm.phmovement.org/pipermail/phm-exchange-phmovement.org/attachments/20031020/aaddd862/attachment-0001.html>