Canada contributed 3.6 billion dollars in assistance to developing countries in 2005-2006. But we and other rich countries practice what has been called by some “foreign aid in reverse”: The recruitment of foreign health professionals from the developing world, a potential obstacle to the deployment of our initiatives in poorer countries. The WHO estimates that 57 nations are now facing a critical shortage of health professionals, 36 being located in sub-Saharan Africa, a region facing huge challenges with HIV/AIDS, as well as drug resistant tuberculosis and malaria. The total need for these countries is estimated at 2.4 million physicians, nurses and midwives.
At the same time, there are more Malawian physicians in Manchester than in Malawi, and more Ethiopian doctors in Chicago than Ethiopia. Canada is among the most active recruiters of healthcare professionals in the developing world. Data from CIHI (2011) shows that across Canada, 24% of practicing physicians are international medical graduates (IMGs). At the same time, the proportion of Canada’s IMGs trained in developing nations has increased steadily, from 52% in 1981-1990 to 76% in the last decade – so we are poaching doctors from developing nations at an ever-increasing rate. The same CIHI report shows that in Saskatchewan, fully 47% of the medical workforce is composed of IMGs, and 96% of its new IMGs graduated from medical schools in the developing world.
It is difficult to define what constitutes a fair balance between the principle of free movement of individuals and a collective responsibility to support (or at least not hinder) the sustainable improvement of public health and living conditions in the developing world. The good news is that during the last decade this issue has been exposed, debated and some action is being taken. In Canada, however, we are still putting much more emphasis on our own needs for health care professionals than on the unintended consequences of our appetite for foreign trained physicians and nurses.
In 2003, the Commonwealth countries adopted a Code of Practice for the International Recruitment of Health Workers. Unfortunately, not all member states ratified the document: Canada and a few others expressed only general support. In 2010, the WHO published a global code of practice for healthcare worker migration and similar initiatives have taken place in the Pacific region and the Caribbean countries. The UK, initially singled out as one of the main culprits, signed a bilateral agreement with South Africa in 2003, which focuses on reciprocal educational exchange of personnel. Under this agreement, South African doctors and nurses will have the opportunity to work in the UK National Health Service on various projects, while National Health Service staff will be encouraged to take on assignments in South Africa. The UK has also introduced a code of conduct for ethical cross-border recruitment and retention of healthcare workers.
The principles contained in these documents revolve around the concepts of transparency, fairness and mutual benefits. Their aim is not to build obstacles to the recruitment of foreign health professionals or limit the free movement of individuals. Rather, they seek to combine recruitment efforts with a sustained commitment to support training in the affected countries and fair treatment of these workers once they integrate into our health care systems.
Our federal, provincial and territorial ministers should take a step back from their disputes over financing and jurisdiction to address this important issue. It would have a profound positive impact both and home and abroad. In global health, we must stop being part of the problem.
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The major issue here is the huge inequality in terms of physician salary in high-income countries and low-income countries, but beyond that, people move for many reasons, including (often) hope for a ‘better life’ for their children with better education and employment opportunities. Reimbursement rates are generally lower in a low-income country in comparison to a high-income one for all health personnel, not just physicians. However, we aren’t discussing migration of allied health professionals because they’re usually not of the same socioeconomic status as physicians and have less financial resources to even consider a move. In order to prevent this massive brain drain, instead of focusing on setting up barriers for migration of people who are looking for a better life for themselves and their families, we should support higher compensation for the physicians and other healthcare workers in their home countries allowing them to live in their land and serve their own people with dignity. This means low-income countries have to better enforce taxation which is often evaded by the local upper class and use this revenue to have a more robust system that not only encourages equity in access of care but also appropriate reimbursement.
See Bhagwati’s “Diaspora Economics” for a solid academic refutation of much of what Dr. Couillard is saying here. For a specific current health example look at Nursing supply in the Philipines. The Philipines now graduates as much as 8x the number of nurses required for domestic supply. They send tens of thousands to Canada and similar numbers to other countries. In addition the oversupply has created a call center industry in and around Manila that serves U.S. HMOs.
The point is that labour mobility is the solution in the longer term and so shutting it down should be viewed with deep scepticism
I do recognize that seeing the application of Bhagwati’s views to the least developed parts of the world (as opposed to Developing nations like the Philipines) can be hard to do in the medium term.
But labour mobility really is an important value to pursue.
For sure Canada is becoming a big part of the problem as much as other western countries. However, Canada is attracting foreign physicians to Canada and not making any concesssions to absorb the all the foreign health professionals that migrated to this country based on the requirements of Canada immigration. Actually Canada do not have a clear policy how to integrated foreign physicians. On one hand Canada immigration is posting the need for foreign health professionals, on the other hand the Royal College of Surgeons and Physicians struggling to keep foreign physicians from entering the Canadian health care system to prevent the wide distribution of patients to wide spectrum of physicians that will lead to decrease in the number patients and in return will lead to decrease in the gross income for each physician. But the story it is not true because there are many places that lack physicians espcially in the rural areas not even in the suburburn areas of medium to large cities..
As UK citizen who has recently benefitted from NHS care I have to say three things, two of them (points 2 and 3) related:
1. The care which I received was superb. I could not praise it highly enough
2. Two-thirds of the staff who looked after me (surgeons, physicians, nurses, pharmacists, even meal orderlies) were not UK-born
3. Over the past 20 years, education in the UK has been dumbed-down so that we are getting too few youngsters studying Maths, Physics, Chemistry, Biology, etc to school-leaving level, let alone beyond.
That situation should be changed (a) for our own benefit and (b) for the benefit of the countries from whom we poach people. A placement of a few years for learning purposes is one thing; a lifetime’s work overseas is quite another