The international mobility of health workers is not a new phenomenon. However, recently the number of health care workers from developing countries migrating to wealthier countries has been increasing.¹ These migrant health workers include physicians, and notable source regions are Africa, the Caribbean, southern and South-east Asia. The Organization for Economic Cooperation and Development (OECD) reported the primary destinations as the Anglophone countries of Canada, the US, the UK, Australia and New Zealand.¹

Family physicians/general practitioners are now in the mainstream of migrant health workers. Within the Asia-Pacific region, foreign medical graduates are now seen in Singapore’s polyclinics and emergency rooms and in Australia serving in rural and remote areas and answering house calls.

As health resources are depleted in developing countries, global health crises loom; thus, the World Health Organization has given emphasis to health-based human resources.² To draw attention to the global workforce crisis and to celebrate the dignity and value of working for health, the 2006 World Health Day’s theme is ‘working together for health’. The period from 2006 to 2016 was launched as Decade for Health Human Resources, hoping to arrive at concrete solutions to this complex health workforce problem.

Stopping medical migration would prove to be difficult, if not impossible because of the universal declaration of human rights which guarantees freedom of movement for all people. We also cannot stop physicians from searching for more fulfilling careers in medicine and better lives for their families. Further, the deregulation of trade and its implications for retaining health professionals have been particularly costly to developing countries.

Definitely, intervention is necessary because of the overlying issue of equity in health for all citizens of the world. The World Organization of Family Doctors during the WONCA Rural Health Conference in Durban in 1997, called for action urging developed countries to examine their policies on recruiting physicians from developing nations.³ This was reiterated in October 2001 during the same conference in Melbourne, resolving that an intervention is necessary to address health worker migration. Some developed nations fail to oversee the strain in the health care systems in developing nations. As the British Medical Association (BMA) chairman James Johnson once said: ‘The failure of countries to train enough doctors has had devastating consequences for the developing world.’ Dr Edwin Borman, also of BMA, further adds that ‘at the moment, richer countries simply are not doing enough to prevent this catastrophe.’³

Previous studies as to causes of migration of physicians identified the following: decades of under-investment in their education;⁴ demoralization of personnel and a dramatic deterioration of health services due to lack of even basic equipment and drugs;⁵ political and economic instability and poor governance; lower salaries and benefits; poor work environments characterized by heavy workloads, lack of supervision, and limited organizational capacity; environmental considerations with potentially dangerous workplaces due to lack of sanitation and supplies to protect workers from diseases such as HIV/AIDS and tuberculosis.⁶

Economics is only part of the reason why physicians leave their home country, and outflow of physicians is not necessarily a sign of health system malfunction. Other countries, particularly the Philippines, has made out-migration of physicians a part of an overall strategic labor plan.

In addition, certain factors on recruiting countries make migration of health workers very appealing and these are: growing demand for health care workers, especially those who can provide assistance to the elderly; and change in policies concerning migration that includes the opportunity for migrating doctors to bring their families with them

IMPACT OF MIGRATION ON SOURCE COUNTRIES

Although it has been argued that the home countries of these health workers benefit from remittances, such transfer of financial resources do not necessarily go to the health system or to public funds. Health is a very important resource for national development and compromising it would mean compromising productivity and development of these nations. The worst affected in this out-migration would be people in rural and remote areas as physicians serving these areas migrate to urban areas, filling up vacancies created by this phenomenon.¹

The shortage of health workers leads to unqualified individuals performing critical skills in order to augment delivery of health care services, overburdened staff, and lack of popular confidence in the health care sector. Some of those who leave are involved in managerial and training roles, thus, there is also loss of institutional knowledge, thereby weakening the source country’s health care system.¹

The financial loss to the source country can be significant as well. Because it is the source country that invests in the training of these health care professionals through subsidies in public education, the return of investment is lost when students eventually graduate and work abroad.¹

WHAT CAN BE DONE

There is no single solution to this complex problem. Host and source countries need to collaborate on how to address the issue. It would be prudent to focus the following recommendations toward the host countries, since they benefit more from this phenomenon.

I agree with the comments and recommendations of Bundred and Levitt, some of which have been discussed also in WHO meetings:⁶

1 Host countries should be prepared to reimburse the source country’s financial investment in training health care professionals.¹

2 More developed countries should train sufficient doctors to meet their projected human resource needs, without reliance on graduates from other countries.

3 Support less developed countries in the modernization of their medical education systems so that they produce doctors who are trained to work in health systems that rely on clinical skills, rather than advanced technology.

4 Establish an international code on ethical guidelines for recruiting physicians from less developed countries. This code would be endorsed by member countries and would guide them in the ethical recruitment of health professionals. Regulating recruitment from countries facing critical shortage for health workers may be necessary.⁷

5 Create bilateral agreements or other mechanisms for promoting health worker flows that are more beneficial to source countries. The protection of health care workers from abuse should be a component of any discussion on health care provider mobility, especially for those who do choose a career abroad in less desirable positions or locations.¹

In order to create a more effective solution to the problem, this must be worked out at local, national and international levels, and must involve governments, the United Nations, health professionals, non-governmental organizations and community leaders.³

Source countries should also play an active role in addressing this problem. Financial gains received from out-migration should be channelled directly to the development of their health care systems. In this manner, it is expected that this can address the poor work environment in the source country, upgrading the health infrastructure and improving remunerations and benefit packages as well.

In the light of ongoing migration of family physicians and general practitioners in the Asia-Pacific region, the World Organization of Family Doctors is challenged to help address issues and concerns. Resolutions have been passed in the Durban and Melbourne conferences acknowledging the impact of migration of health care workers from developing countries. Perhaps it is time for the 19-member organizations in Asia Pacific to review the extent of migration and come up with resolution on ethical recruitment and compensation. In addition, reviews of core curricula for residency/vocational training, studies on the possibility of international accreditation of training programs and conjoint examination, and consensus on the status and role of family medicine in the health care system, would be beneficial in helping integrate migrant physicians with their host countries.

References

1 Hamilton K, Yau J. Migration Information Source Feature Stories. The Global Tug-of-War for Health Care Workers. Migration. Policy Institute, December 1, 2004.
2 World Health Organization. Draft Outline. World Health Report 2006, 1. Available at:
Http//Www.Who.International/Hrh/Whr06_Consultation/En/Print.Html (Accessed 11 March 2006).
3 World Organization of Family Doctors. Health for all rural people – the Durban declaration. The Second World Rural Health Congress Conference. Durban, South Africa, September 1997.
4 British Broadcasting Corporation. Warning over healthcare migration. BBC News item. Available at:
http://news.bbc.co.uk/go/pr/fr/-/2/hi/health/4535805.stm Published: 2005/05/11 09:38:44 GMT.
5 Alkire S, Chen L. Medical exceptionalism in international migration. Should doctors and nurses be treated differently?” In: Joint Learning Initiative. Human Resources for Health and the Global Equity Initiative. Boston: Harvard University Asia Center, 25 October 2004: p. 7.
6 Bundred PE, Levitt CB Medical migration: who are the real losers? Lancet 2000; 356: 245–6.
7 Scott ML, Whelam A, Dewdney J, Zwi AB. Solving health workforce shortages and professionals from developing countries. MJA 2004; 180: 174–6.


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