The Doctor Is In

kochoa_richardIt has been more than a decade since the world was upstaged by shifting sands beneath the feet of patients and health workers.

This despite the reputation of being most dedicated – altruism honed supposedly by years of Bioethics study and refined further by training in critical situations.

In the Philippines, many doctors, among them specialists like neurosurgeons, have been enrolling in nursing schools with the goal of joining the bandwagon to greener pastures. 1

The exodus, a worldwide trend, has become so remarkable that it has alarmed the World Health Organization (WHO). Imagine this: There are more Malawian doctors in Manchester than in Malawi and more Ethiopian doctors in Chicago than in Ethiopia! 2

The issue of doctor migration is quite complicated.

On the macro-level, some developing countries produce doctors for the specific purpose of exporting their services. On the other hand, developed countries like the United Kingdom and the United States are perennially short of health professionals to train.

The money factor

At a micro scale, a Sierra Leone doctor recently shared to The Guardian how she only earned £40 a month (P2,536) in her home country. On many instances, she said, she even has to spend her own money for patient-care.

This all changed when she moved to London, the British paper reported.

She recalled how things were less bureaucratic back home. Still, she can’t help but appreciate how her career has advanced since her migration. 3

Many doctors like her migrate for a variety of reasons – fleeing political instability, war, conflict and violence in their workplace. The kind of governance and the quality of management in the home country are factors too.

Often, it begins subtly; moving from public practice to the private sector. The bolder move of moving from a rural setting to the cities follows. It’s a move that exposes the doctor to classier standards of living, albeit at higher costs.

The final egress is to a developed country; necessary by then because the income disparity between here and abroad has become too obvious. 4

The migration of health workers, particularly of doctors, does have positive effects.

Dollar earners

In the Philippines, where more health workers graduate than can actually be employed, they are a factor in national economic stability.

So much so that they have been hailed “modern heroes” for generating dollars abroad, dollars that are then remitted here, the very dollars that help drive the local economy.

It has long been contended, in fact, that the Philippines withstood the many global financial crises if faced only because of the billion-dollar revenues generated by its overseas Filipino workforce.

The problem begins when developed countries start actively recruiting health workers, including doctors, from countries with a prevalent dearth of local physicians.

When the healthcare system is in a fragile state, migration of key members will disrupt the system until its collapse.

Consequently, the financial reward offered by migration will be dwarfed by the lives lost and the loss of the investment placed in the education of these healthcare workers.

Top and bottom

A research published in the Lancet revealed that all but one of the top seven developing source-countries for international medical doctors have less than one doctor per 1000 population. 5

Almost a quarter of the doctors population in Australia hail from developing countries like India, Malaysia, Sri Lanka, South Africa, Pakistan, Iran and the Philippines.

And while the WHO sets no “ideal” doctor-to-patient ratio, Australia has 30 doctors per 10,000 people, putting it as the WHO’s top 35th country in terms of doctor-to-patient ratio.

The Philippines has zero per 10,000 and ranks 145th. 6

In the report presented by Danette McKinley7, the primary push for migration among physicians in Africa is salary.

However, in spite of the problem of physician migration, some doctors do have second thoughts about leaving, hesitating out of a desire to improve medicine locally.

Still, the WHO’s Global Health Observatory noted that African countries needed almost half a million doctors in 2015. 8

Getting them back, keeping them in

The uneven distribution of health workers is tipped precariously against disadvantaged countries.

According to the WHO’s Latest Situation and Trends9, countries with the lowest relative need for doctors have the highest numbers while those with greatest burden of disease-risk have to contend with whatever is available.

To cope, governments have been prompted to improve their healthcare worker retention policies, particularly in rural areas.

In the Philippines, this is still difficult given how better-paying government positions like medical specialists have to be created by congress.

A get-around was for the Department of Health to hire nurses and doctors on six-month contracts that are then renewed.

Unwittingly, however, this has made the health department the primary violator of the law against hiring contractual workers.

Improvement of local training facilities and workplace is another come-on for workers to return4; so too is compensating, protecting and treating them fairly.

Coping with the lack of physician varies from country to country.

In some areas, local health centers have a system of monitoring that addresses diseases before it reaches a level of outbreak. In Negros Occidental, midwives get tasked to tend the sick in the absence of doctors.

Some turn to traditional remedies and kitchen ingredients. Others find accessible information to remedy their illness through the internet.10

The other side

Some developed countries, on the other hand, have begun addressing their dependency on foreign-trained health workers by improving their educational system and training their own health professionals.

In order to avoid wage disparity between local hires and outsourced labor, fair-treatment policies are also put in place.

The United States Department of Labor, for example, has in place a Labor Condition Application of fair labor recruitment and employment before visas for foreign workers are issued.11

Several developed countries have subscribed to the 2010 Global Code of Practice on the International Recruitment of Health Workers drafted by the WHO and the Global Health Workforce Alliance.

Although not legally binding, the Code aims to protect migrant health workers and at the same time minimize the negative impact of the out-migration of health professionals from source countries.12

Still, one has to ask: “how effective have interventions been?”

A research published in the Human Resources for Health showed that the United Kingdom was “ineffective” in preventing mass registration by doctors from developing countries between 2001 and 2004, due to “competing National Health Services policy priorities”.

But after changes in immigration laws and strengthening of agreements among affected countries, the United Kingdom was able to significantly reduced new registration of doctors.13

The issue on the migration of doctors and other healthcare workers will remain for years to come.

Although the exodus of doctors migrating and working as nurses has abated in recent years, this is temporary and stems only from the on-going retrogression of the United States’ nursing visa processing.

Although the bill to relieve this has been junked in 201114, the possibility remains that once the cap has been lifted and foreign health workers such as nurses are again considered priorities for visa issuance, the deluge of migration of doctors and health workers will resume.

A patient cannot keep the doctor from waiting nor can the doctor keep the patient waiting.

Producing more medical graduates is not an effective stop-gap mechanism and to effectively address the problems requires the involvement of the village, the country where the health worker lives, and the cooperation of potential destination countries.

In these dire times, we all want to see the clinic sign “The Doctor Is In” more often.

1. Kochoa, RPF. MD-RN: A Working Title. Pecojon Magazine Maiden Issue. 2005
2. Kinnock, G. Organisation for Economic Co-operation and Development Centre Policy Brief No. 28. 2006
3. George, Sue. Assessing the cause and effect of health worker migration. The Guardian. 2011.
4. WHO Fact Sheet. 2010
5. Kevat, Dev. Migration of doctors from developing countries to Australia: an estimate from surveys of doctors. The Lancet. 2012
6. World Health Statistics: A Snapshot of Global Health. 2012
7. McKinley, Danette. Factors Affecting Physician Migration From Africa. 2007 Annual International Conference on Global Health.
9. Scheffler, RM, et al. Forecasting the global shortage of physicians: an economic-and needs-based approach. Bulletin of the World Health Organization.
12.  International Migration of Health Workers: IMPROVING INTERNATIONAL CO-OPERATION TO ADDRESS THE GLOBAL HEALTH WORKFORCE CRISIS. Organisation for Economic Co-operation and Development Centre Policy Brief. 2010
13. Blacklock, Claire, et al. Effect of UK policy on medical migration: a time series analysis of physician registration data. Human Resources for Health 2012
15. Foundation for Advancement of International Medical Education and Research