Policy Wise

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The emigration of health professionals from developing world to member countries of the Organization of Economic Cooperation and Development (OECD) remains a highly contentious issue. In America itself, according to the American Medical Association (AMA), International Medical Graduates (IMGs) constitute approximately 25% of the physician population. Indians are by far the largest group-nearly 20% of American physicians were trained in India. According to some calculations, of the nearly 24,000 medical graduates India produces every year, 1200 eventually emigrate.

A new paper by Kaushik et al has approached physician emigration from a slightly different angle. The researchers have looked at physicians trained at India’s premier medical school, All India Institute of Medical Sciences (AIIMS), and have concluded that nearly 54% of its graduates (1989-2004) currently reside abroad. Focusing on quality of physicians emigrating, they have shown that general category students (those who did not benefit from reservations) are more likely to leave India for greener pastures abroad.

The findings are easy enough to explain. Medical profession in the West remains highly competitive, and AIIMS graduates-with their superior training-are at a distinct advantage. Quite clearly, this emphasis on quality also means that students with the highest academic achievement would contribute disproportionately to the ranks of emigrating physicians. Indeed, it is surprising that the researchers have declared the lower proportion of emigrating physicians among the reserved category students as an “unintended benefit of affirmative action programs”. It is premature to reach such a finding without comparing the rates of emigration among affirmative action beneficiaries in AIIMS with students of other medical schools. It is reasonable to hypothesize that emigration rates would be higher among AIIMS graduates across all categories.

Such issues apart, the main question remains: Are the researchers justified in arguing that “intervention should focus on highly trained individuals in the top institutions that contribute disproportionately to the loss of human resources for health?” There are two ways to answer this question.

First is to ask whether the health profession-and highly skilled physicians–can be viewed separately from the larger pattern of migration. According to the United Nations, in 2000, 175 million people were living outside their country of origin. Around 65% of the migrants have been classified as highly skilled. According to some estimates, 20% of the Indian Institute of Technology (IIT) graduates have moved abroad. Therefore, focusing merely on physician immigration without appreciating the context of a rapidly globalizing world is patently misleading. In fact, physicians move abroad for similar rewards as other high skilled professionals: higher salaries, better technology and better standards of living. An approach which focuses on emigration of specific groups rather than the economic, political, and social contexts which make emigration desirable is staring through the wrong end of the telescope.

Second, is the Indian health system really affected adversely by the emigration of physicians and other health professionals? Currently, around 600,000 doctors are registered with the Medical Council of India. The physician-population ratio of 56 per 100,000 is inadequate and below the levels recommend by the World Health Organization. However, the distribution is heavily skewed and the physician-population ratio in urban areas has been estimated to approach 200 per 100,000 which approximates the physician concentration in developed countries. In other words, India faces a severe shortage of physicians in rural areas, a problem which is not amenable merely to increased number of physicians. How many of these AIIMS graduates would have practiced in remote rural areas? In fact, it is questionable if AIIMS and other centers of medical excellence have justified the public expenditure on them. The budget of AIIMS-500 Crores-may be smaller than the research budget of an average American university but still it consumes a large proportion of the health budget. While so much attention is focused on tertiary care centers, the latest round of National Family Health Survey (NHFS-3) has clearly demonstrated the abysmal state of Indian public health system. Infant mortality still remains high (57 per 1000) while less than 50% of India children are fully immunized. None of this requires the intervention of highly skilled health personnel-rather the opposite-a renewed focus on general health practitioners and other health personnel.

The entire issue of migration needs to be examined in a broader economic context. Migration, like globalization, need not be a zero-sum game. To view it merely as “loss” and “gain” is to miss the immense economic opportunities it affords. The movement of high-tech personnel between India and the developed world has benefited both the parties. India is among the leading recipients of foreign remittances. This apart, many highly skilled individuals have moved back to India and helped fuel the Indian IT and services boom. A similar trend is being witnessed in the medical field with non-resident Indian doctors investing in greenfield hospital projects. After all, almost every factor which allowed India to emerge as the world’s most competitive destination for IT and outsourcing is present in the case of medical education.

Over the next few decades, with the demographic shift, the developed world will face an increasing shortage of trained health personnel. In nursing alone, according to the American Nursing Association, a shortfall of 200,000 is expected by 2013. India is uniquely placed to take advantage of this emerging opportunity. By freeing the medical educational from suffocating governmental regulations, India can emerge as the medical education outsourcing destination of the world. It will not only improve the standards of medical education in India, but can also help fund a much-needed expansion of India’s public health system.

In conclusion, emigration of health professionals to the developed world should be addressed from a different paradigm. Instead of subsidizing higher education and then attempting to curb emigration, the emphasis and the resources must be directed where state invention is directly required: rural areas and primary health care. Similarly, by creating conditions conducive for operation of free markets in medical education, India can hope to exploit the immense arbitrage opportunities of migration and globalization.

(A slightly edited version appeared in the December issue of Pragati)

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