An important impediment to achieving health for all in developing countries is the shortage of doctors and nurses. Can the NHS justify schemes to recruit staff from these countries

Patel, Vikram

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Recruiting Doctors From Poor Countries: The Great Brain Robbery?

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Patel, V (2003) Recruiting doctors from poor countries: the greatbrain robbery? BMJ, 327 (7420). pp. 926-928. ISSN 1468-5833Downloaded from: http://researchonline.lshtm.ac.uk/15975/Usage GuidelinesPlease refer to usage guidelines at http://researchonline.lshtm.ac.uk/policies.html or alterna-tively contact researchonline@lshtm.ac.uk.Available under license: Creative Commons Attribution Non-commercial No Derivativeshttp://creativecommons.org/licenses/by-nc-nd/2.5/will propose a prohibition on industry sponsoredreviews when he speaks at the Barcelona meeting.One important group, until now silent in thisdebate, are the public agencies who currently provide alarge part of the collaboration’s core funding. InEngland, the Department of Health’s funding is signedoff by the director of research and development, JohnPattison. “It seems perfectly legitimate for Cochrane toconsider industry funding, and it’s healthy to have thisopen debate,” he said before adding that theproposition did raise some worrying issues. “The worrywould be that he who pays the piper calls the tune, andwe ended up with a situation where it was industry whowere determining the nature of the work done, orworst of all, the possibility that it might have someinfluence on outcomes.”Pattison reserved judgment about whether industryfunding would damage public support for the collabora-tion. “If the perception is that by taking industry moneythis would deter public funders from funding becausethey thought there was a loss of independence—that’s alegitimate point of view, but I want to see the strength ofthat argument.” Although declining to advocate aparticular path, Pattison did say that mechanisms tominimise influence would be highly desirable ifCochrane decides to accept industry funding. “It’s verymuch better for any monies to come through a general-ist association rather than a specific company—becausethen you would worry about a hidden agenda. To put itinto some activity independent of specific reviews wouldalso be another legitimate way to ensure separation.”Alongside the debate about industry funding, sitsthe even more difficult question of the individual finan-cial ties of researchers who produce Cochrane reviews.Where does disclosure end as a management strategyand disqualification begin? In both debates, no matterhow deep the complexity or the conflict, the delegatesin Barcelona can take some small comfort from know-ing they are by no means alone. Indeed, they will gener-ate considerable global interest if they can design afoolproof mechanism for accepting sponsorship andensuring independence. Perhaps they might evenpatent it.Contributors and sources: RM has been reporting on medicineand health care for seven years and is a visiting editor with theBMJ. This article is based on interviews with those quoted plusIain Chalmers, Mike Clarke, Phil Wiffin, Mark Gibson, andothers who spoke on condition of anonymity.Competing interests: None declared.1 Mallett S, Clarke M, How many Cochrane reviews are needed to coverexisting evidence on the effects of healthcare interventions? Evidence-Based Medicine 2003 Jul-Aug:100-1.2 Bekelman JE, Li Y, Gross CP, Scope and impact of financial conflicts ofinterest in biomedical research: a systematic review. JAMA 2003;289:454-65.3 Lexchin J, Bero L, Djulbegovic, Clark O, Pharmaceutical industrysponsorship and research outcome and quality: systematic review. BMJ2003;326:1167-70.4 Cochrane Collaboration. Cochrane Reviewers’ Handbook. Section 2.2.1. www.cochrane.dk/cochrane/handbook/hbook.htm (accessed 15 Sep 2003).5 Smith LA, Oldman AD, McQuay HJ, Moore RA. Eletriptan for acutemigraine. Cochrane Database Syst Rev 2001;(3):CD003224.6 Oldman AD, Smith LA, McQuay HJ, Moore RA. Rizatriptan for acutemigraine. Cochrane Database Syst Rev 2001;(3):CD003221.7 Cochrane Collaboration Consumer Network. Consumer Network Newslet-ter, Issue 11, October 2001. www.cochraneconsumer.com/index.asp?SHOW=News (accessed 15 Sep 2003).8 Time to untangle doctors from drug companies [theme issue]. BMJ2003:326 (31 May).Recruiting doctors from poor countries:the great brain robbery?Vikram PatelAn important impediment to achieving health for all in developing countries is the shortage ofdoctors and nurses. Can the NHS justify schemes to recruit staff from these countries?An enormous gap in health staffing exists between theUnited Kingdom and India. India has fewer than 3000psychiatrists for its one billion population comparedwith one psychiatrist for every 9000 people in theUnited Kingdom, a 27-fold difference.1 Despite thisinequality, the NHS has launched a scheme to recruitsenior psychiatrists and other specialists from Indiaand other developing countries. This scheme willworsen the brain drain and inequities in global healthunless it is explicitly linked with measures to enable theflow of doctors back to developing countries.Opportunities or opportunism?Overseas recruitment schemes are marketed primarilyas an opportunity for doctors to experience one of theworld’s best healthcare systems. Yet it is obvious thatthe NHS is trying to fill jobs in specialties where thereis a shortage of staff. Although shortages are acknowl-edged in the promotional material for the new NHSinternational fellowship scheme, the difficulties thatdoctors will face when they attempt to return home areignored. Experience with previous schemes, such asSummary pointsThe Cochrane Collaboration is divided over drugcompany sponsorship of systematic reviewsSupporters say Cochrane needs commercialsupport and could benefit from companyperspectivesOpponents say sponsorship will influenceresearch agendas and damage independence andintegrityMechanisms are being floated for industry tocollectively sponsor Cochrane activities and avoidperceptions of influenceEducation and debateLondon School ofHygiene andTropical Medicine,LondonWC1E 7HTVikram Patelsenior lecturerCorrespondence to:V Patel, SangathCentre, 841/1 AltoPorvorim, Goa403521, Indiavikpat_goa@sancharnet.inBMJ 2003;327:926–8926 BMJ VOLUME 327 18 OCTOBER 2003 bmj.comthe overseas doctors’ training scheme, suggests that fewdoctors returned to their home countries. Indeed,when I finished my training in psychiatry in the UnitedKingdom in 1992, I found that few routes wereavailable to facilitate my return to India.2 My work indeveloping countries over the past decade has beenentirely funded by research grants, mainly from theWellcome Trust.NHS international fellowship schemeWhereas earlier schemes recruited junior doctors, thenew NHS scheme is taking highly experiencedspecialists, reflecting the changing requirements of theNHS. The international fellowship scheme invites psy-chiatrists, clinical oncologists, radiologists, his-topathologists, cardiac anaesthetists, and thoracicsurgeons to work in the United Kingdom for up to twoyears. Doctors will be paid a consultant salary andgiven up to £46 000 to assist with relocation andhousing.3 Although the available materials do notspecify how many specialists will be appointed, therehave been over 400 applications in the first round,with psychiatrists accounting for the largest pro-portion of recruitments.3 The promotional materialincludes a letter from the British prime minister invit-ing doctors to take up the new opportunities that arebeing created as a result of a “dynamic expansionprogramme” in the NHS.4Recruitment is being promoted using the obviousadvantages the NHS has over employers in develop-ing countries. The code of practice for internationalrecruitment explicitly states that “there should be noNHS advertising in developing countries unless thatcountry has specifically invited the UK to undertake arecruitment programme” and that recruitment“should only be undertaken as part of an inter-governmental cooperation agreement . . . encourag-ing the exchange of healthcare personnel, healthcareinformation, and guidelines.”5 The promotionalmaterial for the scheme does not indicate that eithercondition has been met.4Apart from the immediate effects of the scheme onhuman resources in developing countries, the schemecould perpetuate global health inequalities for genera-tions. Consider, for example, a country that mustimport expatriate doctors using scarce foreignexchange. Most doctors in developing countries havebeen trained in public funded medical schools. Thecost of training is borne by the poor country and therich country reaps the benefits. In effect, the people ofpoor countries are paying for the health care of thosewho live in one of the richest.Stemming the brain drainThe opportunity to work in different societies is a richexperience with benefits that go beyond financialgains. There is no place for creating new barriers to themovement of peoples between countries. What isneeded is an acknowledgment that institutions indeveloped countries have an ethical obligation tofacilitate the return of health professionals to develop-ing countries (box).Institutions in developed countries must engagewith those in developing countries to facilitate anattractive environment for returning doctors to workin. Doctors from developing countries who go abroadto train and work have a key role in this process. Theopportunity to choose the country we live and work inis the result of the opportunities that were available tous in the country of our birth. Doctors going to workoverseas must search for ways to share their expertiseand resources—for example, by partnering their newinstitutions with the ones in which they trained.Waiting for treatment: shortage of medical staff is an importantbarrier to health in IndiaMARKHENLEY/PANOSPICTURESSummary pointsThe developing world has fewer doctors perpopulation than developed countriesSchemes to recruit doctors from developingcountries risk damaging their fragile healthsystemsWorking and training in another country providesvaluable experiencePartnerships between institutions in developedand developing countries are needed toencourage doctors to returnInstitutions in developed countries need toreform to provide more rewarding professionalenvironmentsRequirements for ethical recruitment fromoverseas• Flexible training schemes that permit doctors fromdeveloped countries to work in developing countries• Long term partnerships, including funding andtraining, to strengthen the research, clinical, andteaching infrastructure of institutions in developingcountries• Grants to enable returning doctors to establishpersonal and professional lives• Audit of the outcome of overseas doctor trainingschemes in terms of proportion of doctors who returnhomeEducation and debate927BMJ VOLUME 327 18 OCTOBER 2003 bmj.comInstitutions in developing countries must acknowl-edge that doctors leave not only for monetary gain butalso to escape from stifling hierarchies and bureaucra-cies. In India, for example, doctors who want to attendscientific meetings often have to obtain a “no objectioncertificate” from the head of their institution. Promo-tions are more likely to be determined by the number ofyears of service than academic skills and achievements.Institutions must reform to allow professional environ-ments to flourish by rewarding achievements—forexample, by reducing routine clinical load and byproviding alternative paths for career progression,honorariums, and training opportunities.Ultimately, all concerned parties need to define theobligations and responsibilities of institutions in richand developing countries. Unless these steps are takenurgently, the brain drain will continue to fuel the hugeinequities in global health.I thank Gauri Divan for the title of this article.Contributors and sources: VP is a psychiatrist, originally fromIndia, who is presently working on public health aspects of psy-chiatry in India as a full time researcher from a UK institution,funded entirely by a UK agency.Competing interests: None declared.1 World Health Organization. Atlas country profiles of mental health resources.Geneva: WHO, 2001.2 Patel V, Araya R. Trained overseas, unable to return home: plight of doc-tors from developing countries. Lancet 1992;339:110-1.3 Goldberg D. The NHS international fellowship scheme for consultantpsychiatrists. Newsletter of the Faculty of General and Community Psychiatry2003;6:5-6.4 National Health Service Careers. Opportunities for doctors in England:NHS international fellowship scheme, 2002. www.nhs.uk/fellowships(accessed 22 Aug 2003).5 Department of Health. Code of practice for NHS employers involved in theinternational recruitment of health care professionals. London: DoH, 2001.www.doh.gov.uk/international-recruitment/codeofpract.pdf (accessed 22Aug 2003).(Accepted 7 August 2003)Commentary: Recruitment is ethicalDebbie MellorNHS international fellowships were launched by theDepartment of Health in February 2002 to give expe-rienced consultants the opportunity to come and workin the NHS in England for two years. This is in additionto the campaign we launched in August 2001 to recruitconsultants and general practitioners from around theworld into substantive posts. So far, 304 doctors havebeen recruited through the campaigns, 82 of whomcome from India.Most doctors have been recruited as internationalfellows and are using the opportunity to sample livingand working in England for a relatively short period.The feedback we have received shows that they valuethe opportunity to work in a different health system,acquire new skills, get wider work experience, pursueresearch interests, and develop their teaching skills.We operate an ethical recruitment policy, with allNHS trusts working to a code of practice approved bythe Department of Health. We are committed not torecruit from a country if its government has anyconcerns about the effect on its workforce and workonly with recruitment agencies that comply with thecode of practice. This list can be obtained from theinternational recruitment website.1It is wrong to suggest that the health service is tar-geting health staff from struggling countries. Most ofthe staff we are recruiting come from Europe, with oth-ers from the United States and Australia.Working with developing countriesWe have worked closely with the Indian Ministry ofHealth in the development of the campaign in India,and it has been supportive of the opportunities we areoffering doctors. The Indian minister of health andfamily welfare responded to a parliamentary questionin July 2003 by saying that the overall availability ofdoctors in India is sufficient.We are working with India and other developingcountries to support them in developing programmesto retain their staff. In some cases, we are assisting themin offering fixed term placements in the NHS as part ofcareer planning for healthcare professionals.In addition, individual NHS trusts are putting agreat deal back into developing countries. Much of thiswork is voluntary and receives little publicity. ManyNHS volunteers spend considerable time andresources developing and providing diverse services incountries such as India, Ghana, Russia, Iran, andChina. In India, for example, volunteers are providingservices in mental health, leprosy prevention, neonatalresuscitation, women’s health, sexually transmittedinfections, and HIV.2Competing interests: None declared.1 Department of Health. International recruitment agencies.www.doh.gov.uk/international-recruitment/agencylist-nhs-ref-htm(accessed 22 Sep 2003).2 Department of Health. Compendium of the NHS’s contributionto developing nations. www.doh.gov.uk/internationalhumanitarianandhealthwork (accessed 22 Sep 2003).EndpieceA prayerFrom inability to let well alone; from too much zealfor the new and contempt for what is old; fromputting knowledge before wisdom, science beforeart, and cleverness before common sense, fromtreating patients as cases, and from making thecure of the disease more grievous than theendurance of the same, Good Lord, deliver us.Sir Robert Hutchison (1871-1960),BMJ 1953;1:671Fred Charatan,retired geriatric physician, FloridaEducation and debateDepartment ofHealth, LeedsLS7 2EUDebbie Mellorhead of NHSemployment policyinternational.recruitment@doh.gsi.gov.uk928 BMJ VOLUME 327 18 OCTOBER 2003 bmj.com

Recruiting doctors from poor countries: the great brain robbery?

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Recruiting doctors from poor countries: the great brain robbery?

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