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.
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
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.
* 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.
(Source: BMJ 2003;327:926-928 (18 October)
Correspondence to: V Patel, Sangath Centre, 841/1 Alto Porvorim, Goa 403521, India email@example.com
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).
letters in response to this article yielded some very valid points on both sides of the argument:
Various discussions and opinions have followed to this article from all over the world on the email discussion list Afro-Nets, See 'Recruiting doctors from poor countries'
Information and archives: http://www.afronets.org
Other relevant articles:
Brain drain and health professionals. Tikki Pang, Mary Ann Lansang, Andy Haines. BMJ vol 324, 2 March 2002.
Medical migration: who are the real losers? Peter Bundred, Cheryl Levitt. The Lancet, vol 356, July 15, 2000
Trade in health services. Rupa Chanda. Bulletin of the WHO, 2002,80 (2).