Doctors within borders

India should try to keep its doctors home, rather than wooing those already abroad

India has continued to struggle with health disparities and a poorly funded public health sector in spite of its rapid rise as a global economic power. To add to that, it is the largest exporter of highly qualified physicians, a phenomenon often referred to as the Indian brain drain. At the Global Healthcare Summit in Kochi, the possibility that the country would allow physicians of Indian origin who have trained abroad to function as fully-practising physicians in India was discussed.

The goal of the summit was increasing the cooperation of overseas Indians in healthcare delivery back home. The Union health secretary, P.K. Pradhan, said the Centre would soon push legislation to permit overseas Indian doctors to practise in the country without any further tests or licences.

Unfortunately, this proposal is not likely to address the shortage of physicians within India or the country's pressing healthcare needs. For decades, the Indian government and members of civil society have lamented the physician brain drain, where Indians who completed medical school in the country sought greener pastures abroad to pursue advanced medical training.

Today, India is the largest exporter of trained physicians, accounting for about 4.9 per cent of American doctors and 10.9 per cent of British doctors. Over 60,000 Indian physicians practise in the US, UK, Canada, and Australia — a workforce equal to 10 per cent of the physicians in India and the largest emigre physician workforce in the world. Worse yet, surveys conducted among the alumni of Indian medical colleges show that the better students and institutions account for a disproportionately large share of emigrating physicians. For example, of the students graduating from the All India Institute of Medical Sciences between 1989 to 2000, over 50 per cent had left India and migrated abroad a decade later.

So why have India's medical graduates sought to leave? India has traditionally devoted about 5 per cent of its GDP to health, but the overwhelming majority has been spent in the private sector. The public health system in India remains underfunded, disorganised and unable to meet the public's needs. This means that even the poor use their limited financial means to seek healthcare in the private sector. The Indian healthcare system has traditionally lacked adequate malpractice regulation, rules pertaining to hospital certification, guidelines for medical care, and professional licensure. For freshly minted medical graduates, there has also been a dearth of available postgraduate training positions, with less than one in two graduates being able to secure one. India lacks a coherent system or designated practitioners of primary care in a culture that values specialisation among doctors.

From the perspective of recipient countries, Indian medical immigration has brought great talent to the medical workforce and helped buffer their own workforce shortages. From the Indian perspective, this is more complicated. Some have argued that India may benefit through remittances and technology transfer. However, for a nation trying to meet its most basic public health goals, physicians are a scarce commodity that cannot be squandered. The ability of Indian physicians to migrate to the US is likely to become more difficult within the next few years, as US medical schools have expanded their own enrolment to better meet domestic workforce needs. This means there will be fewer postgraduate positions for Indian medical graduates.

The growth of private hospitals in India certainly provides opportunities for highly trained specialists to return home. However, returning may not be easy, given the problems with resettling, changes in professional and family life, lack of regulation. Rather than attempting to recruit back physicians trained abroad, a higher priority for Indian medical institutions should be retain their best talent. Reducing incentives to migrate may include further investment and modernisation of the public health sector, investment in what remains a fragmented primary care system dominated by specialists, restraining the further expansion of private medical colleges that cater to graduates who will be seeking positions abroad, and regulatory reform that emphasises quality of care over profits.

India is home to a vibrant and diverse healthcare sector. With the continued rise of India's per capita GDP, its government will have more funds to spend on healthcare and the average Indian is likely to spend more on healthcare services. Concurrently, at least in the case of the US, postgraduate training positions for Indian graduates may decrease. These circumstances should persuade more Indian medical graduates to stay back.

The writer is a post-graduate research fellow in obstetrics and gynaecology at Women and Infant's Hospital, Brown University, US

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