Abstract:

The goal of this policy brief is to understand why there is a drive for professionals to come to first-world nations after getting an education in their developing home countries, such as India. Developed countries need more physicians and health workers, but it impacts developing nations in which workers are coming from. When viewing this through a biomedical perspective, it seems reasonable to recruit foreign-trained healthcare workers, but the social justice perspective sees this approach as morally wrong because developed nations are draining valuable resources from developing nations that also need a strong health workforce. The most reasonable response to this issue is to make a global effort to address the care-workers shortage.

Keywords: Healthcare, Migration, India, Medicine, Physicians, Development

Challenge:

India faces a health workforce crisis. According to the WHO, the doctor to patient ratio is 1:10000. In a recent Public Health study, it was recorded that on average, the government hired doctors within the country to attend to more than 10,000 people, which is almost 10 times more than the recommended amount for physicians. This leads to burn-out for current healthcare professionals. With the increase of population size, India requires a stronger healthcare foundation, and with their already inadequate infrastructure and human resources, they struggle to serve many people in need. Even with an increase in medical colleges, India is not able to sustain itself due to the massive size of the population, and migration of doctors to developed countries, such as the US, does not help their current state either.

India is the biggest exporter of trained physicians as India-trained physicians account for approximately 4.9% of American physicians. At the same time, the US is facing problems with shortages of health workers, especially in times of a global pandemic, which causes them to need foreign doctors and nurses. The issue arises when we compare the biomedical/technological advances in the US with those in India. There is a clear disparity between the two nations, as India is still considered a developing country. Both countries need more doctors in general, but the mass migration of trained professionals leaves India at a loss. While around 600,000 physicians are registered to practice within India, the actual number is much less due to emigration. In addition, the number of physicians in rural versus urban areas is very skewed towards urban areas (there are almost 6 times more doctors in urban areas). In the book What’s up Doc?, Saranya Nandakumar writes that it is a challenge to keep doctors in the country especially if emigration can benefit these individuals when they are provided more income, acknowledged for their merit, and have the change to escape the “chaotic” government structure in India.

Proposal:

Access to high-quality healthcare services is crucial to improve health outcomes that are outlined in the Sustainable Development Goals. Without the healthcare workforce developing countries, like India, are not able to provide proper services for all of their citizens. This is mainly due to globalization, which has led to a “brain drain” or “care drain.” This is a term used to describe the “migration of health personnel in search of the better standard of living and quality of life, higher salaries, access to advanced technology and more stable political conditions in different places worldwide”. Some even argue that this is “brain robbery” or “free-riding” on the resources of developing countries by richer nations. Lawrence Gostin of Georgetown University Law Center writes, “Perhaps the most extreme injustices arise in the global allocation of health resources. Developing countries suffer the multiple, compounding burdens of destitution (lack of medical equipment, health professionals, and hospitals), impoverished environments (drought, famine, and contaminated drinking water), and extremely poor health (tuberculosis, malaria, and HIV)”. When viewing this through a social justice/public health perspective, one possible solution for this problem is creating policies that look at the public good and the shared responsibility for health improvement rather than giving importance to national power. This could mean investing in a trust fund for public health efforts and devoting resources that would meet global needs for essential health services.

Indian healthcare systems have been impacted since a lot of investment has been put into education and training of youth health professionals. When these workers qualify as professionals and leave the country, India loses a valuable resource: intellectuals who can help with the current healthcare crisis. This becomes a complicated problem because restricting immigration into the US is not helpful for people who want to have a future here, but when viewing this through a global health issue, we can see that it is not helpful when health workers leave their developing countries for personal economic benefits. “Healthcare expenditure in India is 3% of GDP compared to 13% of GDP in the USA and the ratio of doctor to patients in India is 1:2083 compared to the USA where the ratio is 1:500”. Developing healthcare systems are suffering from years of underinvestment, which has resulted in low pay and poor working conditions. The first solution could be to improve working conditions within India. This might incentivize physicians and workers to stay and serve their communities. Better working conditions could mitigate the stress levels physicians face, which can also increase their efficiency. To create these conditions, it is imperative to understand the lifestyles of physicians. In a study, doctors noted that a lot of their stress comes from how they don’t have adequate time with their loved ones. They experience work burn out. This could be solved if policies were restricting the number of hours one doctor can work per week. Another solution is to require more than 1 doctor per area that contains more than 1,500 citizens to reduce the workload per physician. As of July 2019, India has one doctor for every 1,457 citizens.

To increase the number of doctors in India, education needs to be more accessible. India has already taken steps on increasing seats for medical schools, but it still might not be as easy to reach that point. The root of the problem is the privatization of primary and secondary schooling. Nowadays, government schools in India are not given adequate attention/funding, and this results in poor quality facilities and resources for children who cannot afford to attend private schools. This creates a socio-economic gap in education, that affects the future of many children and families in India. When there is a lack of care given to government schools, teachers less inclined to attend, which leaves many schools underemployed. In addition, most of these schools serve underprivileged children, who are not given the same opportunities as their richer neighbors. Retention rates drop, and the drive to pursue higher education is diminished due to these structural problems in India’s society. In order to solve this, India needs to distribute a better amount of the nation’s wealth into the educational sector. This will allow government schools to access better facilities, develop teacher training programs, and increase morale within students. A current issue many states face is that government schools in some areas do not go past primary education. To go to secondary school (high school), students have to travel far from home, or they are forced to join private schools, which is simply not feasible for a lot of families living in poverty. With more development in the education sector, India should try to find ways to fund the implementation of secondary schools, which in turn will encourage more students to go onto further schooling (medical college). When we tackle the problem at its roots, it can help with the long-term results of creating more doctors within the country.

India’s education system needs improvement, but the US can also make some changes. The US is known for having low acceptance rates into medical school, which contrasts the given the need for more physicians within the US. The competition is never going to cease, and neither should the standard of applicants, but given our current situation, it might be worth reconsidering how strict those standards should be. Or, the American Medical Association can reevaluate other methods of assessing qualified students that are not so heavily based on test results and numbers. If the US trained and retained more healthcare workers, we would not need to recruit professionals from abroad. Medical schools are not opening up fast enough to account for the rise in demand for medical education. Also, newer schools are not located in places with severe doctor shortages, such as rural areas. If Medical schools were less competitive, there might be more of a drive among young Americans to pursue this field. This would be difficult to achieve if the US government does not provide any aid for health education. If medical schools were built in more rural areas, this would be beneficial to the shortage of physicians in those areas as people will be training there and will have opportunities to do a residency as well, which was also a problem because residency spots are at a low. A proper re-distribution of America’s wealth is necessary for developing more medical schools.

A global effort is required when trying to solve the migration issue. On India’s end, if the government was concerned about shortages and/or migration of health workers, policy to suppress recruitment and uptake of migration opportunities might be a sensible place to start. But this needs to be paired with better working conditions. On the US’s end, medical education should be having an equitable distribution in rural areas. The collaboration of the two nations can be done by creating a policy that encourages migration as long as physicians serve in India for a required amount of years. This way, it allows people to practice in India after becoming a certified doctor and does not immediately push them towards moving to more developed countries. There could be policies that encourage return migration or bilateral agreements between countries. There are already some policy responses to health worker migration, “which are embedded in wider processes aimed at health workforce management,” but there are no clear plans to manage health care professional migration at a state or central level of government.