Out-Migration of Health Care Workers and its Impact on Domestic Health Care in Kerala, India

Abstract

Background: In the post-colonial period, many developing countries including India started to expand their health services and to train their nationals to staff them. Initially the prospects looked good. However, from the 1960s there were already concerns that some of these professionals were being lost to richer countries, which were expanding their own health services and lacked sufficient home-grown professionals - thus widening the divide between developed and developing countries. 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. In the 1970s, it was estimated that about 135,000 nurses (or 4.0% of the world total) were outside their country of birth or training, 92% of these were in Europe, North America and the developed countries of the west pacific. India was a significant contributor to this. Over 14.0% of nurses newly registered in USA in 1972 were from India, Korea, Thailand, and West Indies. Similarly, 35.0% of hospital physicians in UK in the 1970s were trained overseas, 60% in developing countries. In 1996, India - the world's highest earner of remittance - received $US 7.6 billion. Kerala was the leading 'exporter' from India. Studies have shown that India has lost up to US $5 billion in investment in training of doctors since 1951 because of the out-migration. Objective: This analyzes the factors influencing the out-migration of health care workers from Kerala and its implications for the state health care system in terms of unavailability of human resources.Methodology: A cross-sectional survey among doctors (N=225 who are preparing to migrate was conducted using a prestructured questionnaire in three major cities having international airports in Kerala. Five FGDs were conducted among doctors and medical students. Secondary data from state health services and the medical education department regarding vacancies of doctors and the effect of the recruitment drives was analyzed. Qualitative study of the various stakeholders' views in this issue was done by in-depth interviews of key informants among stake holders. Results: 98% of the respondents were unsatisfied with the salary in the government sector here. Higher salary was the primary reason for their decision to go abroad in case of 62% doctors in the study. Other reasons for going abroad (primary reason) included options for higher studies/training (21%), better working atmosphere (8%), better living condition (5%) better job prospects in the Middle East nations after training in UK or US (4%).Data from state health services show that many doctors and nurses in the state service are on long leave or are absent without notification as they out-migrated. Repeated recruitment drives by the government in January, February, April and June 2005 and throughout 2006 were all failures as only less than 300 joined when 1000 odd doctors were given appointment orders. In addition, almost 30% of the specialty posts in the service are also vacant despite repeated efforts to fill the posts. The recent drive to attract doctors to work in two additional shifts in secondary level hospitals at extra pay was received well by the doctors, which again points to the fact that salary is the single most important factor which attracts the doctors to the health services. This is more evident from the fact that out of the 700 odd doctors who opted for this scheme, more than 250 were specialists. In the medical education department, almost 400 plus vacancies are remaining vacant, which is seriously compromising the quality of medical education in the state. The salary offered in the private medical colleges are almost three times that in the government medical colleges.Conclusion: The most frequently reported loss to source countries is that of health personal and the impact of under staffing of health systems. In the case of longer-term migrant the gain of the country receiving the trained personal is at the same time the lost educational investment to the sending country.Government should understand that long-term neglect of these responsibilities by successive governments has been the cause of the migration. All organizations including government should recognize the value of their staff and will have to develop some kind of attraction and retention strategies, which revolve around pay, conditions of service, working conditions and above all job satisfaction.