Consider the following headlines—“Ontario continues to open more doors for internationally trained doctors,” “Recruiting African health workers: A crime”, “4 million Canadians lack access to a family doctors,” “International medical graduates complain of inability to use skills.” These headlines encapsulate complex issues that are part of current public discourse. They reflect a world in which health care providers are in critical short supply. They also underscore the importance of an open dialogue and full consideration of the role developed countries like Canada play in the global economy of health care providers.
I think it is essential that I situate myself with respect to these issues. I bring three related but independent perspectives to this situation. First, I am an academic physician and part of my professional responsibilities entail the clinical training of medical students and postgraduate trainees in family medicine. Our training site has been home to and has successfully trained several international medical graduates. Secondly, I am the director of a bioethics centre at a Canadian university. One of our major activities over the past decade has been to build capacity for bioethics, particularly research ethics in developing world contexts. To this end we have received funding from the National Institutes of Health in the United States to train mid-career professionals in research ethics and bioethics in order to return to their home environment and create strong, robust local programmes. Thirdly, I am a founding Board Member of Dignitas International, the humanitarian medical organization pledged to address issues with respect to the HIV/AIDS pandemic. Here I have witnessed first hand how a critical shortage of health care professionals hampers the ability of impoverished nations to respond to a devastating epidemic.
With respect to the first consideration, it has been a great privilege participating in the training of many international medical graduates. Like graduates from Canadian medical schools, they are a heterogeneous group—some possessing impeccable judgment and medical skills with whom I would be more than happy to have myself and my family cared for, while others are comparatively weak and perhaps irredeemable.
The need to fast track international medical graduates stems from the need to provide opportunities for internationally trained physicians to help offset shortages created by changes in policies in the recent past for training domestic physicians, which have resulted in the current supply/ demand mismatch, particularly for primary care providers. One way of managing the shortfall of human resources in the Canadian context is to provide opportunities or put policies in place to ensure physicians who have had medical training or have been practising in another comparable system are eligible for registration and licensure. The other component of the recently released report on international medical graduates in the province of Ontario indicates the need to help internationally trained physicians enter medical practice with transitional licenses and to provide more efficient assessment of clinical skills to allow integration into the system. Attention will be paid to provide support to international graduates that is culturally and linguistically appropriate and to develop “individualized assistance for those who need to transfer their international medical skills and knowledge into another area of the health profession or a related career.” While much of this seems to be sensible and be an acknowledgement of the skills and practices of health care professionals trained elsewhere, it is important that the global health situation be considered.
The Global Crisis of Health Care Workers
Removing barriers to practice and increasing the number of international medical graduates available to provide care to Canadians without physicians seems like an ideal solution to a recurring problem. However, such solutions need to be considered in terms of the current state of global health. In terms of global health, there is a set of interdependent considerations that have resulted in some of the world’s poorest countries showing regression in terms of life expectancy and worsening of health indicators. Increasingly, in the developing world, health systems are faltering and failing to provide a minimal standard of health care. Much of this has to do with the ravages of HIV/AIDS, particularly in the sub-Saharan African context. HIV/AIDS is devastating health workers and health systems and increasing workloads for health workers and reducing morale. Current data from the World Health Organization indicates that many states lack the capacity to provide a workforce trained to shore up these faltering health systems. For example, there is an estimated shortage of more than 4,000,000 health care workers globally. There is a large skill imbalance with a too heavy reliance in many sectors on physicians and specialists. More to the point, though, is the global maldistribution which is noted to have been worsened by unplanned migration.
The Global Distribution of Physicians
Globally, there are within individual countries issues involving urban/rural maldistribution, similar to what occurs in Canada. Highly qualified professionals concentrate in urban areas leading to difficulties in service provision for rural communities. This type of maldistribution is even more pointed when we look at comparisons between countries. This issue is recognized as a significant threat to global health equity. For example, in a recent commentary in the journal The Lancet,Francis Omaswa notes, “Over several decades a global health workforce crisis has developed before our eyes. The crisis is characterized by widespread global shortages, maldistribution of personnel within and between countries, migration of local health workers, and poor working conditions.” He notes factors such as increasing demand for care in developed countries where the demographic transition results in aging populations with complex health needs and the inability to provide sustainable health resources within their own system.
It is interesting to reflect on the dynamics of the problem. In 2005, Fitzhugh Mullan published an article in the New England Journal of Medicine called “The Metrics of Physician Brain Drain.” In this article, he meticulously presented data on the countries of origin and migration and emigration factors of the global physician workforce. His results demonstrate that in developed countries—such as the United States, United Kingdom, Canada, and Australia—23-28 per cent of physicians are international medical graduates and that lower-income countries supply between 40 and 75 per cent of these international medical graduates. There is variability in terms of which lowincome countries are supplying developed world contexts. For example, the United Kingdom, Canada, and Australia rely heavily on physicians from South Africa. Furthermore, he found that nine of the 20 countries that have the highest outflow of physicians are in sub-Saharan Africa and the Caribbean.
In the Canadian context, in terms of country of origin, the United Kingdom, South Africa, India, and Ireland are the four most common source countries for international medical graduates. According to Mullan’s data, in 2002 there were 15,701 international medical graduates practising in Canada, representing 23 per cent of the physician workforce of which 43.4 per cent arise from lower-income countries. The great net beneficiary of the international flow of the physician workforce is the United States, which is the only country with a total net inflow of physician workforce.
What Mullan’s data shows is an extensive cycling of physicians amongst the four largest recipient countries. Interestingly enough, Canada still has a net outflow of physician workforce relative to its inflow. According to the 2002 data presented in this article, there were 68,906 physicians practising in Canada with an inflow of 3,501 and an outflow of 9,105, 8,990 of whom left for the United States. In terms of the US physician workforce, there are 836,036 physicians estimated to be working with a net inflow of 13,573 and an an outflow of only 671,519 of whom returned to Canada. Thus, we have strange dynamic of forces. The developed world is increasingly reliant on attracting health care workers trained elsewhere, and the United States is the greatest global magnet for highly qualified health care professionals.
Is it a crime?
The response to this situation has been varied and perhaps the most strongly worded response is a viewpoint article published in The Lancet in February of 2008. Ed Mills, a scientist with the British Columbia Centre for Excellence in HIV/AIDS at the University of British Columbia, along with other colleagues from Canada, Ireland, and South African, published an article entitled “Should Active Recruitment of Health Workers from sub-Saharan Africa be Viewed as a Crime?” The polemical title was intentional. The authors argue that shortages of health care providers, particularly in sub-Saharan Africa, have reached such critically low levels that it may rise to the level of a crime to continue to advertise and recruit health care professionals from the developing world. They point out dramatic reductions in numbers of nurses, physicians, and pharmacists and also document the marked global disparities within and between nations. For example, in Malawi, the country where the NGO I am associated with is operating, it was estimated in 2004 that there were 0.02 physicians per 1,000 population and 0.59 nurses for 1,000 population as opposed to Canada, where there were 2.14 physicians per 1,000 population and 9.95 nurses per 1,000 population. The Malawi rates are amongst the lowest in the world, in a nation with a high prevalence of HIV/AIDS, tuberculosis and infant mortality.
Mills and colleagues take issue with the efforts of recruitment agencies establishing offices in South Africa to facilitate recruitment, as well as castigating the behaviour of corporations that directly and actively recruit from South Africa by using the method of touring recruitment workshops. They write[a]lthough the active recruitment of health workers from developing countries may lack the heinous intent of other crimes covered under international law, the resulting dilapidation of health infrastructure contributes to a measureable and foreseeable public health crisis. There is now substantial evidence of state and organizational involvement in active recruitment of health workers from the developing to developed nations.
They further go on to argue that this is an important violation of human rights of the people in Africa and that using the mechanism of international crime would strengthen accountability of health systems to international standards.
What to do?
These are no doubt difficult issues and many Canadians who are supportive of the fast tracking and integration of internationally-trained health providers, such as physicians and nurses, are no doubt more concerned with ensuring accessibility of care for themselves and their families. However, it must be recognized that current policies are indeed contributing to worsening health crisis globally. Serving our own needs contributes to further disadvantaging some of the worst off countries and populations in the world.
The issues also speak to the clash between universal human rights and the need for certain sectors and health systems to be functional. In terms of international rights statutes, there is a right to health, but, similarly, health workers also have rights to mobility and the right to freely choose where they wish to live and work. As well, many physicians seeking licensure in Canada come from areas experiencing significant political instability and civil strife and are rightly seeking a place of refuge where they can practise without threat to themselves or their family.
Are there progressive ways of thinking through these dilemmas whereby the policy choices made by health systems in Canada are not responsible for worsening health inequities? It must be recognized that every physician that leaves South Africa to work in Canada provides an opportunity for physicians in other African countries such as Malawi, Botswana, and Zimbabwe to seek employment in South Africa’s a better health system and with higher remuneration.
Certain countries in sub-Saharan Africa, such as Malawi, are the final ground of evacuation. That is, when physicians leave these contexts, there is no feeder country that is providing them with the necessary health professionals to provide care in replacement for those lost.
Mills and his colleagues have some suggestions for an appropriate way forward. They argue that governments, nation states and policy makers should provide incentives to address some of the core reasons for migration, including inadequate remuneration, insufficient resources, heavy workloads, and lack of career paths, as well as risks to the individuals health from providing care. They also point out the need for finding ways to compensate nation states that have lost or contributed health workers to other systems. For example, they quote a report showing that Ghana lost £35,000,000 of its training investment in health care professionals who went to the United Kingdom, whereas the United Kingdom saved £65,000,000 in training costs and was granted £39,000,000 in service provision by virtue of this asymmetrical relationship
Shortages of health care providers, particularly in sub-Saharan Africa, may make it a crime to recruit healthcare professionals from the developing world.
Larry Gostin, a leading expert in global health law at Georgetown University, in a recent commentary in the Journal of the American Medical Association, points out that there is a need to discuss responsible recruiting that would address equity in national and global circumstances. He suggests there needs to be much closer surveillance of migration patterns of health care professionals and, furthermore, there should be documentation of the impact of these immigration patterns on health systems. He argues for increasing attention to human resource investment and planning. Destination countries need to build a supply of skilled workers through education and training leading to national self-sustainability and limiting the need for active recruitment from developing world.
The issue of incentives is an important one. Gostin argues that a basic principle should be to take no more than a fair share. Wealthy states should restrict active recruitment in low-income countries that have severe nurse and physician shortages. He also states, and this is a compelling point, that there should be an element of giving back. That is, wealthy developed nations such as Canada should be helping to build capacity in countries from which they recruit. There is a variety of means by which this could be facilitated. Academic institutions such as universities with professional training programmes in medicine, nursing, dentistry, pharmacy, and occupation and physical therapy, could play a much greater and proactive role in clinical training, health care worker exchanges. Policy makers should consider bilateral aid such as cash payments and support for retention programmes, thus ensuring mutual benefits for both countries.
The issues raised by the global shortage of health care workers are important and require public reflection and discussion on our role and responsibility in global health. Are we content to be contributing to worsening health inequities in countries from which we have helped decimate the health system? It is imperative that we invest in our own academic institutions to ensure an adequate workforce. What about fast tracking and paying for health care workers to work in underserviced areas?
It is clear that this is an issue that will not soon be resolved. It also provides us with a time to reflect upon our investments in health systems and how best to secure the conditions of health. It is interesting to note that the country that receives the most highly qualified professionals in the international global economy is one that does not have the best health outcomes. This illustrates the point that the health care system is only one dimension of securing healthy populations. It seems adequate human resources cannot be secured in even the most developed nations. Investments in other determinants of health such as ensuring potable water and a safe food supply; providing adequate educational opportunity and a secure, stable and peaceful environment and more equitable distribution of economic resources may do as much to ensure a healthy population as a functional and well-staffed health care system. AM
Ross Upshur is a physician, Director of the University of Toronto’s Joint Centre for Bioethics and Canada Research Chair in Primary Care Research. At the University of Toronto, he is also an Associate Professor in the Departments of Family and Community Medicine and Public Health Sciences.