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Doctors For The World: Indian Physician Emigration
PROLOGUE: One of the great geopolitical stories of the past few years has been India’s explosion onto the world stage as an "other" Asian economic powerhouse viewed by many in the West as the natural democratic counter to the increasingly muscular Chinese juggernaut. With gross domestic product (GDP) growth rates the envy of the old industrialized economies, India has enormous potential as both a consumer market and a center of production, along with an even more rapidly metamorphosing China. This represents a key factor motivating many strategic analysts to dub the twenty-first century as "the Asian century." Yet for all its advances, India remains a developing country struggling with problems that confound even the most prosperous developed countries, including health and economic disparities between urban and rural spheres; and a poorly funded public health sector, ill-equipped to confront an oncoming AIDS epidemic. India’s distinction as being the largest exporter of highly qualified physicians figures into this complex mix as well. Many who study global workforce migration through a public health lens tend to view this trend as a negative, draining needed native brains from meeting the health needs of India’s massive population. Others in the economist community point to recent research documenting the economic value that donor nations, such as India, might accrue as a result of physician, among other workforce, emigration. Indeed, many Indian policymakers themselves openly view India’s capacity to produce physicians for export as an asset for the mother country, and they consider shortfalls in domestic health care access as a function more of resource maldistribution than of actual shortages. This paper delves into the issue by offering a compelling, journalistic exposé descriptive of India’s medical education system and the drivers of the emigration phenomenon. The author comes down squarely on the side of curtailment and concludes by offering policy guidance intended to discourage emigration from both the supply and demand ends of the equation. Fitzhugh Mullan (fmullan{at}gwu.edu) is the Murdock Head Professor of Medicine and Health Policy and a professor of pediatrics at the George Washington University, in Washington, D.C., and a contributing editor of Health Affairs.
Almost 60,000 Indian physicians practice in the United States, United Kingdom, Canada, and Australia—a workforce equal to 10 percent of the physicians in India and the largest émigré physician workforce in the world. I traveled to India to interview leaders in medical education, health policy, and public health, to better characterize and understand Indian physician emigration. A changing political and policy environment in India is raising new questions about what might be done to keep more of India’s physicians at home.
IT IS AN UNDERSTATEMENT TO SAY THAT India is a country of contrasts and complexities. Occupying 2.4 percent of the world’s land mass, it is home to one billion people—more than 15 percent of the world’s population. Twenty-two languages (not including English) are recognized in the Indian Constitution. Although 80 percent of the people are Hindu, India is the home of more than 120 million Muslims (making it the third-largest Muslim nation in the world) and 100 million Christians, Sikhs, Jains, Buddhists, and Parsis. Bombay has been long known for its urbanity, Bangalore for high-tech prowess, and Calcutta for sheer population density, yet three-quarters of India’s people live in rural areas, where conditions resemble the nineteenth century more than the twenty-first. Information technology (IT), business outsourcing, and "medical tourism" are hallmarks of a country with a 6.2 percent gross domestic product (GDP) growth rate (compared with 4.4 percent for the United States and 2.4 percent for the European Union) and a burgeoning middle class. At the same time, India’s life expectancy of sixty-two years and its infant mortality rate of sixty per 1,000 births place the country well down the list of developing countries, and its annual per capita income of $470 is 161st in the world. There are many Indias within India. Medicine and the "brain drain." The British brought European medicine to India in the nineteenth century; today allopathic medicine is a popular and revered profession. During the latter half of the twentieth century, large numbers of Indian physicians traveled to the United States, the United Kingdom, Canada, and Australia in pursuit of residency training and practice positions. The total number of graduates of Indian medical colleges now practicing in these four countries is 59,095—a workforce equivalent to 10.1 percent of the 592,215 physicians registered by the Medical Council of India.1 From the perspective of the recipient countries, Indian medical immigration has brought enormous talent to the medical workplace and helped buffer physician shortages in these countries. From the Indian perspective, the benefit/loss analysis is more complicated. The expatriation of so many Indian physicians is a straightforward loss and a preeminent example of "brain drain." Mitigating factors. However, some elements of emigration mitigate this loss. The most frequently cited is the hard currency returned as remittances to family members by Indian physicians working in the United States and elsewhere. Also cited are the benefits of the technology transfer provided by Indian physicians returning home and the professional opportunities afforded physicians who feel that their financial or technological expectations would not be met in India.2 Outlook for the near future. Although Indian physicians are the world’s most frequent medical expatriates, the emigration of physicians from developing countries to the West is a global phenomenon, and emerging shortages in many developed countries promise to increase the lure of emigration in the immediate future.3 At the same time, growing global concern with the adequacy of national physician workforces to combat HIV/AIDS and assist in meeting development goals has raised questions that give new importance to understanding emigration.4 To gain a better understanding of physician emigration, I spent July 2004 in India exploring Indian perspectives on these questions. I visited four major cities noted for medical innovation and medical education (Bangalore, Chennai [Madras], Delhi, and Mumbai [Bombay]), and I interviewed more than forty practitioners, medical educators, economists, and public officials about the health care sector and medical migration. Despite its well-established history and certain obvious motivators, physician emigration is a complicated event influenced by educational experiences and practice prospects. To assess the impact of emigration on India, one must understand the medical culture in which the émigré trains and from which he or she departs. In this essay I describe current medical practice and education in India before discussing my observations on emigration. I conclude with a set of policy recommendations based on those observations.
India devotes 5.1 percent of its GDP to health, ahead of Pakistan (4.0 percent) and Sri Lanka (3.7 percent) but behind China (5.4 percent), Brazil (7.6 percent), and the United States (15.6 percent). The striking fact about Indian health expenditures is that they are heavily in the private sector. Only 0.9 percent of the country’s GDP is spent on public-sector health programs, whereas 4.2 percent is private. India ranks 171st out of 175 countries in percentage of GDP spent in the public sector on health and 17th in private-sector spending.5 Interviewees reported time and again that the system of publicly administered health care dating back to the time of independence was "brilliant" on paper but was poorly funded and, as a result, dysfunctional in many aspects. The government system supports a series of tertiary and secondary hospitals in cities and larger towns and a nationwide network of primary health centers staffed, in theory, by a physician and four paramedics for every 35,000 people. With exceptions, the former are crowded, unattractive, and stressed, and the latter are disastrously short of funds, equipment, medications, and personnel. Physician supply. About 600,000 physicians are registered to practice in India, although the actual number is probably lower because of emigration and retirements.6 With a population just above one billion people, the physician-to-population ratio in India is 50–60 per 100,000. The distribution of practitioners is heavily skewed toward urban areas. The Center for Enquiry into Health and Allied Themes estimates the urban physician-to-population ratio at almost six times the rural concentration of physicians.7 India’s allopathic physicians practice largely as private fee-for-service (FFS) practitioners among the urban middle class—some 250,000,000 people—meaning that the effective physician-to-population ratio among India’s better-off citizens is about 200 per 100,000, approximately the physician concentration in the United Kingdom. This analytic perspective explains why some observers report that "India has enough physicians," while many Indians, in fact, never receive the services of allopathic physicians at all. Physician services for poor or rural people. The vacuum in service provision for poor and rural people is filled by nonallopathic FFS practitioners from a variety of indigenous systems of medicine (ISM), whose educations are also government-sponsored at the university level.8 These are practitioners of Ayurvedic medicine (Hindu), Unani (Muslim), homeopathy, and Siddha (Tamil). In addition, there are numbers of "nonqualified" doctors in practice—people with no medical training of any sort. An allopathic physician reported to me that when he began a practice in a rural village, he discovered twenty-eight private "competitors" in the area—all practitioners of ISM. In the Mumbai slum of Jari Mari, I was told that the most popular practitioner was, in fact, a "nonqualified" doctor. In most cases, ISM practitioners use allopathic diagnoses and prescribe or sell allopathic medicines. Allopathic medicine predominates, even if its practitioners do not. The presence and influence of such a large overall number of doctors (allopathic and ISM) as well as a relative shortage of nurses has led to a generally nonreceptive environment to the development of new clinicians such as nurse practitioners and physician assistants. Private-sector medicine. The private sector enjoys high levels of investment, enterprise, and energy. Private hospitals, many with national brand names such as Apollo, Escort, and Manipal, have opened in most large cities, providing excellent facilities and cutting-edge technical care to those who can pay. In addition, these hospitals have begun to draw patients for high-cost elective procedures, such as transplants and bypass surgery, from the Persian Gulf states and countries in Asia, Africa, and Europe—a development referred to as "medical tourism." Many of these hospitals are specialty institutions, and many have recruited Indian specialists back to India from the United States and the United Kingdom, contributing to their technical capabilities and market prowess. Specialization and "super" specialization are predominant values among doctors and knowledgeable patients. There is no formal system or designated practitioners of primary care. Small, private hospitals called "nursing homes" are ubiquitous in large cities. Mumbai has 1,150 hospitals, 90 percent of which are private and 70 percent of which have fewer than thirty beds.9 "Nursing homes" all have operating theatres and diagnostic equipment, which, if used regularly, make them extremely profitable institutions. Diagnostic and imaging centers are commonplace, and all respondents reported active commercial competition for patients and procedures. In Chennai, for instance, twenty hospitals offer renal transplants.10 Fee splitting (often called "follow-up payments") from laboratories and imaging centers is frequent, and multiple observers reported many instances of unwarranted surgical interventions. Numerous reports and a number of my respondents described an active, illegal trade in purchased organs (kidneys, in particular) that has developed in tandem with the growth in transplantation centers.11 "Interventionist" medical environment. The concentration of physicians in urban areas along with aggressive pharmaceutical and medical equipment sales strategies and physician-ownership of hospitals have created a highly commercialized and actively interventionist medical environment. Government regulations pertinent to areas such as hospital certification, prescriptive practices, and proscribed behavior are either not in place or rarely enforced.12 The result is a culture in which supplier-induced demand is commonplace and ethical improprieties and unwarranted surgeries are widely acknowledged.
Within India there are two dramatically different patient populations—the poor and the nonpoor. The health status of these two groups is strikingly different.13 An infant born in the poorest quintile of the population is two and half times more likely to die in infancy than an infant in the top quintile and four times more likely to die in childhood. An adult from the poorest quintile is six times less likely to access hospitalization, and a pregnant woman, more than six times less likely to be attended by a medically trained person than their counterparts from the richest quintile.14 Rural-versus-urban data show similar health disparities in percentages of births attended by skilled personnel, infant mortality, and immunization.15 The pronounced disparities in health between the well-to-do and the poor are dramatic even by developing-country standards and a huge challenge to rhetoric of the ruling Congress Party and Indian public health leadership. Poverty reduction and improvements in sanitation and education will certainly provide the basis for better population health. But the presence (or absence) of physicians also has a bearing on the health of populations, which reasonably raises questions about what the expatriation of large numbers of Indian physicians means for national health improvement.
Medicine is a popular profession in India. It is widely respected, seen as a remunerative career, and, for some, presumed to be a ticket to emigration. More than 100,000 students in the final year of secondary school take examinations, administered by government, for entrance into medical studies each year. This system, as originally conceived, allots the tuition-free seats in government medical colleges based on the examination results. Growth of medical education. Medical education has grown rapidly in India, from 11,800 admissions per year in 1990 to 24,000 in 2005. Much of this growth has been attributable to the opening of private, for-profit medical schools, which now account for 42 percent of medical student seats.16 The new private schools are expensive, charging "capitation fees" (also called "donations") of $40,000–$50,000 at the time of admission followed by tuition payments in the range of $3,000–$6,000 per year. Admission to private schools is determined by the ability to meet cost requirements as well as academic achievement. This picture is complicated by a government requirement that private schools award a designated number of seats to merit candidates from the government list at low tuition rates. Additionally, some government medical colleges have initiated sharp tuition increases of their own. The 242 medical schools currently listed by the Ministry of Health and Family Welfare are mostly urban and are located in twenty-seven of India’s thirty-five states and territories.17 The continued growth of medical colleges is testimony to the popularity of medicine and the belief by large numbers of students and families that the combination of growth in the Indian economy and opportunities abroad will guarantee future medical employment. Although private colleges do not explicitly educate for emigration, multiple observers told me that the rationale for the development of more private schools was continued high interest in emigration. The quality of education at these institutions was also a subject of concern—in particular, the shortages of trained faculty and clinical learning opportunities. Community service requirement. The requirement of a period of community service in return for receipt of medical education has been attempted at some schools. Government medical colleges in certain states have instituted mandatory two-year rural service following graduation to be eligible for postgraduate training. Reportedly, service requirements are frequently ignored by physicians and have effectively been abandoned by a system that lacks enforcement ability. Medical colleges with a religious base, such as St. John’s Medical College in Bangalore and Christian Medical College in Vellore, ask their graduates for two years of clinical service in village clinics or mission hospitals. More of their graduates do fulfill these stipulations, but large numbers are reported to go abroad or find other training or work opportunities without fulfilling the obligation. Postgraduate specialization. Although the medical school exiting degree (bachelor of medicine/bachelor of surgery, or MBBS) is sufficient to obtain registration and to practice in India, most medical graduates desire postgraduate training. Specialization is uniformly seen as desirable for reasons of competence, stature, and income. The total number of residency positions is uncertain but appears to be in the range of 10,000 annually for the 24,000 students now graduating each year.18 This means that postgraduate training in India is available to fewer than half of all graduates. Many postgraduate programs (especially those in private institutions) require a capitation fee of as much as $50,000 for entrance into postgraduate studies. The dearth of positions as well as cost are factors that contribute to travel abroad for medical specialization. Status of primary care. In contrast to this emphasis on specialization, multiple national committees and commissions since the time of independence have promoted the concept of the primary care physician as the basis of health care in India.19 Despite such pronouncements, curative medicine, interventionism, and specialism are strong cultural values in medical education in India, and postgraduate positions are entirely specialty oriented. Family medicine as a discipline is virtually nonexistent, and preventive and community medicine are considered second-class specialties. One commentator characterized the position of general practice in Indian medical education as "devalued, degraded, and distorted."20
Rate of return. "Going abroad" for postgraduate work has long been perceived as a prestigious step for young physicians. Most leave with at least an open mind on the subject of return to India, but growing familiarity and acceptance as well as clinical opportunities and income make return less likely. Most respondents volunteered that virtually all physicians going to the United States for training ended up staying permanently; return rates from the United Kingdom were higher. "If you work hard, everything is possible in the U.S.," one U.S.-trained, returned Indian nephrologist told me. Current data indicate that 59,095 Indian-educated physicians are working in the United States, the United Kingdom, Canada, and Australia. They constitute 4.9 percent of the U.S. physician workforce and 10.9 percent of the U.K. physician workforce.21 Analysis of U.S. residency data indicates that there are about 5,000 graduates of Indian medical schools in U.S. training programs today, meaning that approximately 1,200 enter into the U.S. residency system each year. Reasons for emigration. The psychology of emigration is captured in a recent book about medical practice in India titled What’s Up, Doc?22 Author Saranaya Nandakumar summarizes the "ideology of the brain drain" as follows: (1) "The West Is Best Epidemic"—the long-standing belief of young doctors and their parents that training outside of India is superior and a mark of achievement; (2) "The Materialism Bug"—the expectation of bigger incomes and more material acquisition associated with life in the West; (3) "Specialization in Extremis"—the lure of high-tech training and "super" subspecialization perceived as prevalent in the West; (4) "Governmentitis"—reaction to the strictures and barriers of Indian governmental management of the education system and the corruption often associated with it; and (5) "Chaosphobia"—escaping the chaotic government and commercial systems in India in favor of what are perceived to be the more regularized and merit-based medical systems of the West. Multiple respondents described rationales similar to these for the continued high interest in going abroad in the current epoch in spite of improvements in the Indian economy. This very growth in private medical education seems likely, in the eyes of many, to result in even higher levels of emigration in the future. The cost of private medical education is high ($75,000–$100,000), and students who make this kind of investment are likely to expect a financially productive career—something predictably found in the West. This expectation, combined with the increasingly crowded ranks of doctors in the Indian fee-for-service sector, will likely result in more graduates intending to emigrate. Attitudes toward emigration. Prasad Rao, then secretary of the Ministry of Health and Family Welfare, addressed emigration without ambivalence. "India is a big country," he told me. "We have a billion people. We graduate 20,000 doctors every year. If 600 leave us, that is not a problem."23 These comments are important for two reasons beyond the data they convey. First, Rao’s estimate of 600 annual physician emigrants is a sizable underestimate: At least 1,200 come to the United States each year, and hundreds more leave for other countries. Likewise, his complacency in regard to the departure of physicians from India is indicative of the level of acceptance that exists among current Indian policymakers. Although attitudes about the benefits and advisability of emigration vary, most people accept the ongoing reality of physician emigration and the right of human beings to try to better their positions. Nevertheless, the "brain drain" (a term that was frequently used) is an emotional topic, with many people expressing concerns about the departure from India by doctors educated at public expense in publicly financed hospitals. This vexation was not much diminished in regard to graduates of private medical schools, since, many people observed, those schools receive many government benefits, and their students often learn medicine in public hospitals. Many stated with resignation that a major exodus of physicians is inevitable until the Indian economy is greatly improved and should not be opposed by public policies in India or the recipient countries. Notable comments about emigration included the following: (1) A professor at a private medical college described the college’s strategy as being one of training physicians who are "globally competitive but locally responsive." (2) With a mixture of pride and frustration, an academic nephrologist told me that "there were more Indian nephrologists in the U.S. than in India." (3) The director of a department of surgery talked about "the paradox of saturation," where Indian cities had too many doctors, and the countryside, almost none. (4) The dean of a medical college declared that with the spate of new private medical colleges, he was worried about "the growing danger of a large number of new doctors who have no commitment to this country or to ethical standards of practice. At least if they go abroad we are rid of them." (5) A community organizer in a Mumbai slum that has virtually no allopathic physician practitioners commented, "I just cannot believe the government spends all that money [estimated to be about $40,000 per medical student] on a medical education for a doctor who turns around and leaves the country. We could make amazing progress here [in the slum] if we had the tuition of just one medical student."
Some numbers of expatriated Indian physicians do return to India. "No one ever really wants to abandon their country," an oncologist trained in Texas who returned to Chennai told me. "You always leave a little of your heart behind." The number of nonresident Indian (NRI, a term frequently used to characterize Indians who have moved abroad regardless of their precise emigration status) physicians returning is increasing. New proprietary hospitals and high-tech medical centers catering to "medical tourism" have recruited many NRI physicians because the quality and prestige of their international credentials are an important element in the institutions’ marketing strategy. Problems of resettling. Returning is often not easy, even for those with a strong sense of motivation. "The logistics of resettling are daunting," was the way one recent returnee put it. Although the income of returned physicians might be substantial, adjustment to life in India can be difficult for families. Professional life requires readjustment as well. "Everybody with a laparoscope wants to take out every appendix and gall bladder they see," a successful, British-trained transplant surgeon told me. "You have to compete and market yourself." He also cited omnipresent "civil corruption," the absence of good regulation of hospitals, the lack of credentialing, and the generally "uncontrolled and uncoordinated health care system" as problems for him and others who trained in the West. Attracting capital. It is widely believed that NRI physicians, as other NRIs, send considerable amounts of money home, helping India with hard-currency accumulation. Although estimates are available on overall remittances to India, no specific data exist on physicians’ remittances. Several observers told me that they did not believe that physicians emigrating to the West, coming as they did from generally wealthier families, sent a great deal of money home. A new area of financial engagement for NRI physicians, however, is investment in commercial medical enterprises such as hospitals, medical colleges, and medical equipment firms. A variety of economic and immigration policies are being modified explicitly to attract NRI capital back to India.24 Additionally, the children of Indian expatriate families are returning to India to study medicine, drawn, in part, by private medical colleges whose sizable (by Indian standards) tuitions are nonetheless attractive by U.S. standards. These students then compete for U.S. residency training positions as international medical graduates (IMGs). The Manipal Medical College system, for instance, reserves 30 percent of its seats for NRIs. The SRI Ramachandra Medical College in Chennai has established a relationship with Harvard Medical International, bringing a global educational brand to the school, which presumably helps its competitive position.
Acceptance. The emigration of large numbers of Indian physicians to the West has been taking place for more than a half-century, and acceptance of it (sometimes enthusiastic, often grudging) is the norm. "Building for export" has its proponents, who argue for the brilliance of this strategy, pointing out that India has vast human resources, ambitious people, and excellent professional training capabilities. The export of physicians provides opportunities to the individuals, financial remittances to the country, and the augmentation of NRI communities abroad. The public’s acceptance of doctors going abroad is bolstered by a perception in some quarters that "India has enough doctors," or, occasionally, "India has too many doctors." Concerns. Concerns about health equity, poverty reduction, and the wise use of public resources have led many to skepticism about migration. The use of medical education to leave India and, particularly, the training of health personnel for export at the public expense has evoked consternation in many. A second concern expressed was that the growth of tuition-based private education linked to practice abroad was further skewing the economic profile of physicians toward the wealthy. A third objection to building for export is that it attracts motivated young people who seek careers as health professionals and effectively provides them an immediate passport out of India. This means that their clinical and political energies will never address the improvement of health care in India. In this view, the brain drain serves as a pressure release valve that permits both skills and political energy to escape the task of reform of Indian health care. Moreover, any pronouncements about the "sufficiency" of the Indian health workforce speak to the private sector, which caters primarily to wealthier and urban populations and not the poorly funded, under-staffed public sector—or the poor themselves. What if? I repeatedly sought opinions on what the several thousand Indian graduates who emigrate every year would do if opportunities abroad diminished and they had to remain in India. Would this create a diffusion of physicians into areas that because of geography or economy had been previously unattended by allopathic physicians, or would this create a competitive glut of physicians in the cities? Respondents were divided on the question. All agreed that urban-trained, specialty-oriented physicians would not fare well in the poor and rural areas in which physicians are in shortest supply. Nonetheless, many felt that the pressure of competition combined with an improving Indian economy and rural development would make diffusion an important element of future health improvement. Those who felt more strongly about this potentiality agreed that the diminution of emigration and the greater availability of physicians in India would move this process along more quickly.
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 well-being of all Indians.
The research and travel for this study were supported by a grant from the Department of Human Resources for Health of the World Health Organization, Geneva, Switzerland.
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The Market Rules
Disparate Outcomes
