Brain Drain of Doctors

Currently, there is a tendency that doctors migrate from developing to developed countries. This phenomenon is known as "brain drain". Australia, for instance, has benefited from the migration of doctors from southern African and South Asian countries. This post tries to present the key factors that push and pull migration and some policy analysis related to how to stem the migration.

What is the relevance to the Indonesian Health Systems?

Indonesia is experiencing distribution problem in health workforce. Shortages of medical professionals are more significant in outer metropolitan, rural and remote areas, especially in eastern Indonesia such as Sulawesi, Kalimantan, Maluku and West Papua. There are many factors contribute to the unequal distribution of health workers in Indonesia. Geographical difficulties with lack of transportation and infrastructure in eastern Indonesia cause refusal of health workers to be placed in those areas. Other factors to consider are low salary, lack of facilities, uncertainty of future carrier, and uncertainty due to decentralisation policy in health and other sectors since 2001.

Some of the problem characteristics in southern African and south Asian countries are similar to Indonesia such as low wages and poor working conditions. Therefore, recognising major reasons of migration as well as appropriate health policy implications is relevant for informing the health workforce planning in Indonesia, in the central government and in the local governments where decentralisation process of policy has been happening. By understanding the pull and push factors that form migration, it is possible to examine the measures that might contribute to improved health services.

Some Important Factors

Working environment is a major issue. Majority the decision to migrate is because of family consideration. It is influenced by poor working conditions, lack quality of life, high levels of crime, political instability and social pressure. Higher risk in home countries play a role in the decision to leave and work overseas. Similarly, conflict, civil war and violence are factors that push health professionals and their family to move and seek employment abroad. It follows that the combination of poor working environment in source countries with stay and stick factors (better conditions in destination countries) potentially maintains the brain drain phenomenon.

Personal development and training is another important perspective. It is recognised that almost a half of doctors migrate due to seeking further education. Some doctors have believed that a period of specialists training abroad would increase their future career when they return to their home country. This is an important factor that motivates external migration.  However, the differences in curriculum in training institutions can lead to frustration of health professionals when they return to their home country, because the knowledge gained cannot be applied in the local circumstances.  This is therefore reasonable that they seek places in developed countries where they can apply their new knowledge and skills.

Remuneration and wages are mentioned as one of endogenous factors causing migration. It was estimated that the difference of wages between destination and source countries is between 3-25 times. This remains a key push factor of migration. 

Some Policy Responses Analysis

It is often argued that retention of health workers can be achieved by increasing payment. Some people still contend this method is somewhat questionable. Increasing salary levels does not necessarily reduce the out-migration. Giving incentives to health workers who work overtime often failed to decrease migration if the governance is still poor. Therefore, it seems that increasing salary levels is necessary but not a sufficient condition in the absence of other enhancements in working conditions. Rather, retention would be more achievable by improving non-wages instrument such as the involvement of workers in decision making, open communication, and assisting adjustment process for new entrants. This can increase level of satisfaction and motivation, create conducive working condition and is important for the retention strategy.

Capacity building is needed due to employers' requirement, enhancement of patients' expectation and advancement in health technology. Providing financial assistance to gain further qualifications followed by promoting temporary migration as a working holiday or study tour to obtain qualifications will be beneficial to reduce permanent migration.

Another strategy to reduce the migration is ‘brain drain migration tax', imposing a tax to the citizens abroad. The fact is that such scheme has not proven to be successful. It will also need involvement of destination countries to monitor the refund. Therefore, it seems impossible whether employers or authorities in recipient countries would be willing to perform this role.

The last approach to consider is the role of international bodies. The creation of code of practice and policy direction will be able to regulate the streams of health workers to benefit both donor and recipient countries. The scope and effectiveness of the international bodies' role are still debatable. However, this is a broader perspective of policy responses that leads to changing from a reactive strategy that focuses on reducing migration towards more active agenda of managed migration.

For my colleagues in developing countries: let's build the community who need us the most. Stop brain drain... increase brain gain!!

Articles reviewed for this post:

• Oberoi SS & Lin V. Brain drain of doctors from Southern Africa: brain gain for Australia. Australian Health Review 2006 30: 25-33
• Forcier MB, Simoens S, Giuffrida A. Impact, regulation and health policy implications of physician migration in OECD countries. Human Resources for Health 2004; 2 (12)
• Vujicic M, Zurn P, Diallo K, et al. The role of wages in the migration of health care professionals from developing countries. Human Resources for Health 2004; 2 (3)