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Doctors beyond borders: Reversing the brain drain

December 14, 2011

Unlike most Pakistanis, who lack access to adequate healthcare, President Zardari is fortunate to have access to the finest healthcare services available in Pakistan. If the physicians and the medical facilities in Pakistan do not measure up to the Presidential needs, he can be flown to the state-of- the-art facilities in the Middle East or beyond.

While the rich-and-famous in Pakistan enjoy almost the same quality of healthcare as one would receive in a developed economy, the overwhelming majority of Pakistanis are severely underserved in health and wellness services. The healthcare spending in Pakistan accounts for fewer than 3 per cent of the GDP.

Further compounding the problem is the migration of trained physicians from Pakistan to developed economies. While Pakistan graduates several hundred physicians each year from medical colleges and universities, a large number of these graduates leave Pakistan for specialization abroad. Many never return to serve in Pakistan. The physicians’ brain drain has resulted in only 0.74 doctors per 1,000 persons in Pakistan. Israel, on the other hand, boasts 3.8 doctors per 1,000 people. Even with a population base of over a billion, China reports 1.5 doctors per 1,000 people. By 2020, the doctors shortfall in Pakistan is estimated between 58,000 and 451,000.1 At the same time, World Health Organization estimates a global shortfall of 4 million doctors.

The total number of physicians in Pakistan is estimated at about 120,000. However, a large number of Pakistani doctors have emigrated from Pakistan. Saad Shafqat and Anita Zaidi in 2007 estimated that there were at least 10,000 Pakistan-trained physicians serving in the United States alone.2 Other estimates put the total number of Pakistani physicians serving in the US and Commonwealth countries at around 14,000.

Some elite medical schools in Pakistan are known for their graduates to leave Pakistan in large numbers. For instance, by 2004, 900 out of the 1,100 medical graduates from the Aga Khan University left Pakistan for specialization. Reports suggest that only 40 doctors returned after completing specialization abroad.

Australia, New Zealand, the United States, and UK are known for aggressively recruiting medical professionals from abroad to meet the demand for physicians. One in four of the 780,000 doctors in the United States holds foreign qualifications. Furthermore, 64 per cent of the foreign trained doctors in the United States emigrated from low-income countries to the US.3 Similarly in UK, 92,000 of the 245,000 physicians were foreign trained.4

The supply lines providing foreign trained medical professionals to the US and UK have their origins in the Philippines, India, and Pakistan. The US alone absorbs 15,000 nurses annually, half of which come from the Philippines.5 Similarly, half of the 12,000 nurses absorbed in the UK were either from India or the Philippines.

The poaching of highly trained medical professionals by the rich countries plays havoc with the healthcare systems of low-income countries. At one point, the Philippines had shipped off so many nurses abroad that it could not keep wards operating in certain facilities. For some specializations, the resulting shortage is acute in home countries. Rachel Jenkins and others report that compared to the 315 psychiatrists serving in Pakistan there are 1,473 Pakistani-trained psychiatrists who serve abroad.

The sustained demand for foreign-trained doctors in the US, UK, Australia and New Zealand is known to most medical students in Pakistan who start preparing for foreign licensing exams while they complete their medical diplomas in Pakistan. Surveys of final-year medical students at King Edward Medical University in Lahore, Aga Khan University and Baqai University in Karachi, reveal that most students would prefer to travel abroad for specialization. More specifically, 95 per cent of the graduating class in Aga Khan University, 65 per cent in Baqai University, and 60 per cent in King Edward revealed their plans to travel abroad for specialisation.

Many medical professionals/students who travel abroad for specialization believe that they would one day return to Pakistan. Most in fact never do. Saad Shafqat and Anita Zaidi reported that of the 10,000 Pakistan-trained physicians in the United States only 300 doctors are known to have returned to Pakistan. Again, only 40 of the 900 Aga Khan University alums, who had gone abroad for specialization, made their way back to their motherland.6,1 Only 14 per cent of the respondents at King Edward Medical University indicated that they would like to return soon after completing their specialization. The rest had plans to stay for longer periods abroad or for never to return.

Young physicians however have sound reasons for their lack of enthusiasm in serving within Pakistan. Saad Shafqat and Anita Zaidi report that young medical interns are paid approximately $150 per month, which is no longer a decent pay in the inflation-stricken Pakistan. Young doctors cited poor pay, poor quality of training during internship, and poor work environment as the primary reasons for their lack of enthusiasm for serving in Pakistan.

Violent protests by young doctors on the streets in Lahore in March and April of 2011 are signs of young doctors’ frustration with their work environments. Should the federal and provincial governments continue to ignore the plight of young doctors, the brain drain will continue unabated.

TELE-HEALTH: REVERSING BRAIN DRAIN THROUGH TECHNOLOGY

Given the worsening of law-and-order situation in Pakistan and the structural collapse of the economy where power and fuel shortages have imposed a state of paralysis on the society, it is unlikely that a large number of Pakistani physicians will return to Pakistan in the near future. The challenge therefore is to find ways to obtain service from Pakistani physicians in diaspora without having them to relocate. Fortunately, the advances in communication and information technology (CIT) make it possible for the willing physicians to extend their practice to Pakistan from their homes and offices in US, UK, and elsewhere.

Tele-health allows physicians in North America and elsewhere to deliver health-related services using the CIT. For instance, physicians are able to observe and treat patients in remote locations by using computerised sensors that deliver patients vitals to the physician using the CIT. Thus blood pressure, temperature, and other observations from a remotely located patient are made available in real time to the doctor located in a clinic or a hospital.

A much simpler version of a tele-health model can be established for Pakistani physicians who are settled in the West to treat low-income patients in rural areas and small towns in Pakistan. Take the example of the 10,000 practising Pakistani physicians in the US who can pool their resources to establish a not-for-profit (charitable) organization in the United States. The organization will generate resources in the US to fund the establishing of basic health units (BHU) in underserved areas in Pakistan. BHUs can be staffed by a nurse or a pharmacist whose primary responsibility will be to maintain a computerised link with the physicians in the US using free service, such as Skype.

Patients in underserved areas in Pakistan can visit BHUs to obtain medical advice from highly trained Pakistani physicians in the diaspora, who will donate their time to the cause.

The morbidity burden in Pakistan is exacerbated by complications resulting from untreated conditions related to diabetes, blood pressure, and cholesterol. Patients in underserved parts of Pakistan will be able to get sound advice from foreign-based doctors over Skype or other modes of communication. The early interventions from such interactions will help prevent treatable ailments from turning into chronic diseases that impose significant burden on the poorly-funded healthcare system in Pakistan.

Technology now exists that allows surgeons to remotely operate on their patients. I am proposing a very simple application of tele-health to improve access to basic healthcare in the underserved parts of Pakistan. I know that our doctors in diaspora are keen to serve their motherland and are desperately searching for opportunities to donate time and money. By creating not-for-profits to raise funds to establish BHUs, expatriates (doctors and others) can join hands to turn the brain drain into brain gain.

1. Nazish Imran and others. 2011. Brain drain: Post graduation migration intentions and the influencing factors among medical graduates from Lahore, Pakistan. BMC Research Notes. 2. Saad Shafqat and Anita Zaidi. 2007. Pakistani physicians and the repatriation equation. The New England Journal of Medicine. 442-443. 3. Nadir Ali Syed and others. 2007. Reason for migration among medical students from Karachi. Journal of Medical Education. 61-68. 4. Rachel Jenkins and others. Feb 2010. International migration of doctors, and its impact on availability of psychiatrists in low and middle income countries. PLoS ONE, Volume 5, Issue 2. Pp. 1-9. 5. ibid. 6. Nadir Ali Syed and others. 2007. Reason for migration among medical students from Karachi. Journal of Medical Education. 61-68.

 

Murtaza Haider, Ph.D. is the Associate Dean of research and graduate programs at the Ted Rogers School of Management at Ryerson University in Toronto.  He can be reached by email at murtaza.haider@ryerson.ca

The views expressed by this blogger and in the following reader comments do not necessarily reflect the views and policies of the Dawn Media Group.