Stealing Doctors from the Poor

The health workforce in Australia is made up of over 420,000 professionals employed across many categories of health provider. From the late 1980s to the late 1990s the Australian government capped the number of medical training places due to what was regarded as an over-supply of doctors, which has resulted in a serious shortage in the current health workforce. This shortage has been addressed by increased recruitment of international medical graduates (IMGs) and it is now estimated that over 26 per cent of the Australian health workforce were trained overseas. In rural Australia, this increases to 35 per cent of general practitioners trained overseas, 40 per cent of whom are from lower-income countries.

The legislation surrounding this mass immigration of health professionals is complex and rapidly evolving, with new procedures for assessment and medical registration of IMGs being announced last year by the Australian Medical Council (AMC). Increasing international pressure from academics, the World Health Organisation (WHO), the Commonwealth Secretariat and the United Nations is driving some of these procedures. They are calling for an end to the unethical “brain drain” to Western nations from developing countries, which is “seriously affecting the sustainability of health systems” in these already struggling countries.

The WHO report in 2006 identified a global deficit of 2.4 million doctors, nurses and midwives, with critical shortages in fifty-seven countries, most of which are in sub-Saharan Africa. Although considerable efforts have been made in many of these countries to train their own doctors, “the rate of migration often outstrips production”. Developing countries are failing to benefit from their investment in human medical resources, as the cost of training is borne by poor countries and the benefit reaped by wealthy countries. This has resulted in the greatest burden of disease being borne by countries with the smallest, least stable health workforces, and countries with the least need enjoying the highest rates of doctors per population, a situation which is unethical and unjust.

This instability in the health workforces of lower-income countries is a major impediment to disease reduction initiatives such as those attempting to address the HIV/AIDS epidemic in Africa. It is estimated that at the end of 2005, 27.2 million people were infected with the HIV virus in sub-Saharan Africa. With more than one million of the African health workforce working overseas, it is estimated that the number of health-care workers in sub-Saharan Africa will have to triple each year for ten years if every person with HIV or AIDS is to get antiretroviral treatment. Ghana has 30 per cent of its doctors working elsewhere. Further south in Africa the picture is little better, with Malawi’s 16 million population having fewer than 1000 doctors and Uganda’s 23 million having only 2000 doctors, compared to one primary care practitioner for every ninety-one people in Australia. The continued brain drain from developing countries is severely limiting the ability of the health workers that remain at home to combat the HIV/AIDS epidemic and provide basic health services. This situation is becoming more urgent each year as populations grow, the HIV epidemic spreads, and workers continue to migrate to developed countries.

The urgency and unacceptability of the gap between developed and developing countries’ health outcomes were recognised last November by 235 journals from thirty-seven countries simultaneously publishing more than 750 articles on poverty and human development. The facts are now undisputable and widely published that the recruitment and voluntary migration of health professionals to developed countries provides a “great financial benefit” to the recipient country but is badly “damaging to the already inadequate health systems” of the source country. There is some argument that the dubious ethics behind the recruitment of health professionals are offset by the remittances sent back to their home countries, although it appears that very little of this ever makes it back into the health system that educated them. Australia, although not as great a recruiter as the USA, relies heavily on IMGs to bolster its insufficient medical workforce, many of whom emigrate from countries that need them more.

Although it is unethical for Australia to recruit these IMGs from developing countries on the principles of greatest beneficence and justice, it can hardly be argued that health professionals from developing countries should not be allowed to leave. Many emigrate due to dissatisfaction with services in their country as well as better salaries, training opportunities, working conditions and resources in the destination country. To refuse emigration would be a violation of the individual’s autonomy; the Universal Declaration of Human Rights of 1948 tells us that the right to emigrate is itself a human right. The Declaration also states that “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family”. As each recruitment of a health worker from a developing country results in a “large number of people having their access to health care withdrawn”, how is it decided if one person’s autonomy to make a choice that affects them is a greater or lesser right than a much larger number of people’s right to health care? What is socially justifiable in today’s globalised world is currently a topic of much debate and controversy.

It is generally agreed to be socially justifiable for the training country to require a certain period of public service after graduation before allowing emigration, especially for developing countries where most doctors are trained in publicly funded medical schools. This has been called for in much current literature, and South Africa has a scheme whereby new graduates must do service in rural areas after graduation, much as teachers must do in Queensland. Schemes such as these reduce the “push” factors for graduates in developing countries but it is the responsibility of the developed recruiting country to reduce the “pull” factors. Wealthy destination countries like Australia have an ethical obligation not to seek recruits from developing countries; to facilitate the return of health professionals to developing countries; to provide training and development in developing countries, and to compensate developing countries for their loss of health personnel.

Unfortunately the Commonwealth Code of Practice for the International Recruitment of Health Workers is not a legal document and does not have to be followed, although some of its recommendations, which are also promoted by the WHO and the UN, have been subscribed to by Australia in the National Health Workforce Strategic Framework from the Australian Health Ministers’ Conference. It was recognised in the framework that Australia should “focus on achieving at a minimum, national self sufficiency in health workforce supply”. Certainly huge amounts of funding have been poured into increasing training places and building eight new medical schools to address the workforce shortages, however it is estimated that there will be up to a “ten year time-lag before any real effect will be seen in the workforce”. The failure to plan for the future a decade ago and current funding limitations are severely hampering Australia’s effort to achieve the principles set out in the framework in 2004.

IMGs are an “extremely important component of the medical workforce” in Australia and will continue to be recruited despite “serious ethical and global implications”. Aboriginal and Torres Strait Islander health services are heavily dependent on IMGs and it has been suggested that medical services in rural Australia would collapse without them. Certainly given that 35 per cent of primary practitioners in rural and remote Australia are IMGs and there is still great inequity in health service availability between rural and urban Australia, losing these valuable doctors would only further widen the gap. This would particularly affect the already disadvantaged Indigenous populations in remote areas, whose life expectancy is already twenty years less than for white Australians.

There could be one advantage that a higher percentage of Australian graduates in remote areas would bring, although there are many unanswered questions on the issue. Australian-trained doctors are required to undertake basic Indigenous cultural awareness training and all speak English fluently. IMGs are required to pass an English proficiency test before practising but are not provided with any cultural awareness training. It is unclear if IMGs experience greater cultural difficulties and barriers in remote Indigenous medical services but concerns for both preventive programs and continuity of care have been raised and more study is required.

These remote areas are highly dependent not only on IMGs but also on primary care practitioners, who comprise 70.6 per cent of all doctors in rural areas compared to the national average of only 40.8 per cent. Many IMGs have temporary registrations as primary care practitioners in designated areas of need, where they can work immediately without having passed the AMC exam. Further impact on remote areas would occur if IMGs weren’t recruited, as the supply of primary care practitioners is in high demand already, falling by 29.4 per cent nationally from 2000 to 2004. In the last five years in Australia, more graduates have chosen to specialise than stay in general practice, resulting in a 47 per cent increase in specialist doctors over that time, which usually requires further training in metropolitan rather than rural centres.

Although the worst workforce shortfalls would be in primary care in remote areas affecting particularly Indigenous Australians, repercussions of not recruiting IMGs would be felt throughout the Australian health system. Each year between 4000 and 5000 nurses and nearly 5000 doctors enter the Australian health workforce from overseas. Although many are lost again to positions in other developed countries, this is a significant number and in 2006 the WHO estimated that Australia had 11,112 overseas-trained doctors in the workforce. Specialists may be less affected than the other two largest professions, nursing and primary care, due to the recent increase in graduates specialising. There is little information about IMGs working as physiotherapists, managers, administrators and other allied health professionals but the nursing workforce in Australia has been a source of controversy for many years and has been well studied.

In 2004, 27,700 of the nearly 200,000 employed nurses had trained overseas. Although this is a much smaller percentage of IMGs employed as nurses than primary care practitioners, the Australian nursing workforce is already renowned for its working conditions disputes, and losing IMGs could only exacerbate the situation. Only a few months ago, the Australian Nursing Federation took on the Victorian state government demanding better pay and extra nurses. The dispute was bitter, drawn out and involved strike action but achieved a better deal for nurses in the end. It is not surprising given the international reputation such disputes give Australian nursing that the IMG proportion of nurses is smaller than for doctors.

Australia has an ethical responsibility to meet the needs of its own disadvantaged populations, however if until the increased training places turn into practising graduates we are depending on IMGs to do this, Australia needs to take some positive steps towards minimising the affect on disadvantaged populations here and overseas. Officially recognising and paying for the contribution not only of these emigrants but of their country of training as well by initiating bilateral agreements with all other countries from which IMGs are recruited is essential. Turkey, for example, is compensated by the German government for every Turkish worker in Germany, and India and the Philippines have collaborative health worker migration schemes. Other developed countries with complex health systems like Australia’s rely far less on IMGs; only 5 per cent of the French workforce and 1 per cent of the Japanese workforce are trained overseas. It is time Australia viewed the global health workforce as a finite resource, with the greatest need for health professionals being in developing countries, and pays for the valuable human resources it has failed to provide for itself.

Besides increasing training places, much can be done in Australia to rapidly minimise the need for IMGs and promote self-sufficiency in the health workforce. The National Health Workforce Strategic Framework, which the 2006 Productivity Commission called for “stronger national endorsement of”, not only promotes self-sufficiency in health workforce supply but also “recognised that a complementary realignment of existing workforce roles or the creation of new roles may be necessary”. Certainly there has been a lot of discussion in the past few years about role substitution and prescribing nurses as a method of providing better access to health services in remote areas and reducing doctors’ workloads. This involves nurses substituting for doctors in performing certain tasks and remote area nurses being allowed to prescribe common medicines. The new but rapidly expanding nurse practitioner role is widely claimed to fill a gap in access to health care in Australia, and initial trials on the feasibility of the role are promising. A medical professional retraining into more-needed specialties is another example of realignment of existing roles and is more efficient than training a specialist from scratch.

New roles in electronic and remote diagnostics will also be created in the Australian medical system of the future, with a multi-million-dollar project announced for a videoconferencing network to be established for small remote hospitals in New South Wales. A similar system to the successful rural IT support and diagnosis program running in remote Alaska for many years already could dramatically reduce the urgent need for IMGs to take up remote positions. Retention of trained staff is also a key factor in maintaining stability in the health workforce, and with about 20,000 Australian-trained nurses not working in the health sector there is definitely scope for improvement. Retention rates will improve if working conditions improve, including better remuneration for nurses in remote positions and family-friendly policies that acknowledge the needs of the nearly 60 per cent of new medical graduates who are women. An additional issue with staff retention that has arisen due to the workforce shortages is that many of the doctors in rural Australia are due to retire within the next five years. It has been suggested that attractive part-time packages to retain ageing doctors may still allow the generational transfer of knowledge to occur despite the large gap in the workforce.

In the longer term, there is much more that Australia and other wealthy countries can do to reduce the unacceptable inequity in global health outcomes made worse by the migration of health workers. With globalisation, all resources including human capital are now purchasable across the world; however, there is no international body such as the World Trade Organisation that oversees migration of professionals. It is up to wealthy countries like Australia to recognise how actions taken here can affect a small child in Africa, and to promote a more equitable global community through just and sustainable policy. Global dialogue is required to form a body whose role would be to ensure protection of the world’s most vulnerable people from exploitation by developed nations. A worldwide agreement to assist—instead of hindering—developing countries’ efforts to improve health care is required, although negotiating this without impinging upon countries’ national sovereignty will be difficult. Australia’s booming economy and low unemployment put it in a perfect position to address unacceptable inequities in health, both at home and in the developing world.

Health having been a hot election topic, the new Labor government will be assessed on its ability to address health workforce shortages ethically. Long-term investments that may not pay off during the government’s first term are required. Strong leadership, forward thinking and co-operation between professions and the government would reveal many feasible options for the Australian system to rapidly reduce its dependence on IMGs and therefore its impact on the health systems of developing countries. Ideally, the increased numbers of students will move into the health workforce in Australia, e-health technology will expand, nurses will be recognised for their potential, bilateral agreements will be made between countries for human resources and the urgent worldwide health workforce shortages of the start of the twenty-first century will abate.

Then—but preferably now—wealthy countries like Australia can repay the debt to developing countries that trained a large proportion of the workforce needed by countries like Australia and the USA due to a major failure to predict future needs in health. Repayment could take the form of a trade agreement: for each medical professional Australia recruits from a developing country, a senior specialist medical professional could be sent back at Australia’s expense for a six-month locum to provide quality care and training to doctors. Another method would be that IMGs from developing countries sent to areas of need in Australia who then later fail their AMC exams be removed from the substandard practice they would have been providing to those Australians most in need of quality care. These IMGs could receive further training here in Australia then be sent home to assist in the training of doctors. This would provide higher quality health care in areas of need in both Australia and developing countries.

Globalisation comes with the benefits of free trade but also with responsibilities to the global community. As Peter Singer states: “In societies such as America and Australia, we should raise our children to know that others are in much greater need, and to be aware of the possibility of helping them, if unnecessary spending is reduced.” Much can and should be done immediately to reduce the vast gap in health status between the developing and the Western world that our unethical recruitment of their health workforce has widened. As the Lancet has said, “Richer countries can no longer be allowed to exploit and plunder the future of resource-poor nations”, and Australia is now in a position to set an example on this urgent humanitarian issue.

Clare Stride currently works in community health on the Sunshine Coast, having spent many years working for non-profit welfare organisations. She recently completed postgraduate studies in public health. A footnoted version of this article is available from the Quadrant office.