Doctors For The World: Indian Physician Emigration

Fitzhugh Mullan

Health Affairs. 2006;25(2):380-393. 

In This Article

Strategic Options

Momentum favors emigration. Economic ambition, educational opportunity, and a long history of "going West," coupled with the chronic physician shortage in Anglophone nations, makes continued large-scale emigration a likelihood. Those concerned with the inequities of the current system and the possibilities of capturing the financial and human resources now lost to emigration for India will need to be creative in countering the emigration momentum. They are challenged with crafting policies that will both attenuate emigration and make better use of the physician services thereby made available to India. On their side, however, are growing concerns about poverty reduction and health inequity within India and elsewhere in the world. These concerns are making the brain drain a more topical issue and raise again the link between educational investment and national service. The World Bank's Millennium Development Goals are a prime example of such international policy concern, and the Indian Ministry of Health's intention to dramatically boost the budget for public health services suggests increased national political concern.

There are a number of strategic options available to policymakers in India that could moderate physician emigration and put more of India's medical talent to work in India. To be fully effective, though, any such strategies would need to be complemented by policy and program changes in recipient countries such as the United States. The following is a listing of strategic options for both India and recipient countries based on my observations and counsel received from many of those whom I interviewed. Most observers felt that travel restrictions to stem emigration were neither fair nor effective, but many felt, as the proposals reflect, that major changes are necessary in the Indian medical sector if emigration diminishes and the growing numbers of Indian physicians are to fully benefit the country.

Policy Options for India

Public-Sector Investment. The marked underinvestment of the Indian government at the national and state levels contributes to poor staffing and morale at government hospitals and clinics. Increased investment and modernization initiatives would create opportunities and momentum toward re-balancing the system and offering more career options for allopathic physicians to remain in India and engage in public-sector work.

Investment in Primary Care. Reengineering a physician primary care role for India and investing in it would be important for both the public and private sectors. In the public sector, it would improve career opportunities and medical practice for an upgraded primary care system. In the private sector, it would provide some balance to the current fragmented and specialty-dominated system. This will not be an easy task. Primary care concepts have been tried and have failed before, and an Indian solution will need to be developed. The government will have to play a leading role in both definitional and reimbursement issues to make this concept work. Medical educators and specialty leaders will need to contribute as well.

Moratorium on New Medical Colleges. Restraint in the further growth of private medical education would be advised for the immediate future. Uncertainties about both the numbers of graduates and the quality of education voiced by many observers suggest that this would be a prudent course. Given the dramatic expansion in recent years, a moratorium on new medical colleges until graduation patterns and quality standards stabilize would improve future practice standards and diminish potential problems with emigration.

Hold the Line on Tuition. To avoid the further "privatization" of medical education, the government needs to keep tuitions low at government medical colleges and continue to require that a substantial percentage of seats at private colleges be awarded to students from the government list (merit candidates) at government tuitions. Additionally, the creation of scholarship and loan programs for students willing to commit to service in rural and poor inner-city settings would help improve services to underserved areas.

Legal and Regulatory Reform. Corruption and the perception of corruption are problems in the medical sector. Building a professional environment in medicine that emphasizes high-quality practices and discourages profiteering would do a great deal to improve medical care in India and would appeal to many physicians. Laws covering hospital accreditation, practice standards, the credentialing of health professionals, and prescriptive practices need to be regularized and enforced. Professional ethics and professional discipline need higher profiles.

Support the Rising Tide. An improving economy promotes better business and professional life in all sectors. Certainly, an improving GDP and per capita income improve both the government's ability to fund public-sector health care and Indian patients' ability to purchase private health care. Both of these developments would do a great deal to promote the retention of physicians in India.

Policy Options for Recipient Nations

Self-Sufficiency. The substantial percentages of the medical workforces of the United States, United Kingdom, Australia, and Canada that come from abroad suggest long-standing patterns of underinvestment in medical education in those countries. The United Kingdom, Australia, and Canada are all increasing their numbers of medical graduates, and the United States is considering doing the same. The discussions in all of these countries need to include the concept of "self-sufficiency," meaning an education policy aimed at training a physician workforce close to the size of the demand for physicians in practice. Although greater self-sufficiency in recipient nations would take time to accomplish, it would decrease the demand for physicians from abroad and thereby allow India and other countries to focus their medical education strategies on domestic health care needs and minimize investments in training physicians who are destined for other medical economies.

Special Competitive Study Programs. Consideration should be given to the sponsorship of special study opportunities for Indian physicians in recipient nations that feature leadership training focused on transferring medical leadership skills for the purpose of return to India. This initiative, modeled perhaps on the Rhodes Scholars program, would be funded by the recipient nations as part of a program of recognition of Indian physicians' past contributions to recipient nations. The program would be developed with bilateral input, be for a specified period, and be offered on a competitive basis to people who already are associated with clinical or academic institutions in India. Study subject areas might include health policy, public health, health ethics, medical education, and medical informatics.

Bilateral Short-Term Training. A separate and parallel program of exchange consultations, with a similar rationale and funding, might be developed in areas deemed important by India and the recipient countries. Areas that might be appropriate for consideration for Indian physicians coming to the West might include hospital administration, quality improvement strategies, research administration, and primary care. Areas for Western physicians going to India might include infectious diseases, complementary and alternative medicine, health and development, and IT and health.

Indian physicians, long-standing ambassadors of talent and ambition, are major players in many countries' medical sectors. The vigor of India's medical marketplace holds great promise for the nation and raises the possibility of keeping more new Indian graduates at home, to better the health of all of India's people. But the market will not do this by itself. This opportunity will require conscious leadership, a battle plan, and a long-term perspective. One would hope that policymakers, medical educators, and public health officials in India and elsewhere would collaborate to harness more of India's medical capacity for the wellbeing of all Indians.