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Primary care physician workforce in the United States and the global migration of health-workers
Primary care and Poor Countries
A More Then Meet The Eye Issue
Ethical implications: primary care physician workforce
Atonement for poaching of human resources for health from poor countries!
Poverty, emigration, government, development, and equity.
Market forces
foreign trained primary care physicians
Foreign-trained physicians and primary care
Primary Care IMG's
The Need for Self Sufficiency
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Onyebuchi A. Arah, Amsterdam, Netherlands Assistant Professor, Department of Social Medicine, Academic Medical Center, University of Amsterdam, Uzor C. Ogbu, and Karien Stronks
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We applaud Starfield and Fryer Jr. for their important contribution to the growing literature on the patterns and implications of physician migration to the United States. It is interesting to note that, while their paper shows that the poorest among source countries seemed to have contributed disproportionately more to the US primary care workforce, some recent work including ours show that the less poor or the richer among the poor source countries suffer relatively more physician emigration [1-4]. This makes sense as medicine is highly professional and technical requiring much economic and human capital investment. So, as the human development (standard of living, education, longevity) of source countries improve up to some yet-to-be-determined level, we can expect them to produce more and better physicians who then migrate to the US and other richer destinations in our increasingly global world [1, 3]. We can, nonetheless, infer from the current paper that if the poorest countries contributed relatively greater shares of primary care physicians (PCPs), then the richer and richest source countries who contribute less PCPs than the US average must contribute significantly higher percentages to the specialist workforce. In any case, global migration of health-workers is important for the low-to-middle-income countries especially given that migration is a knock- on phenomenon (that is, migration from the poorest to the poor, then to the rich and then on to the richest). Those countries at the bottom of the ladder will be trapped almost endlessly in poverty and disease. Those in the middle although perhaps not slipping into the despair of the poorest will never quite advance their health systems as far as they could sans migration. It is also becoming evident that physician loss mirrors nurse migration from the same source countries [5]. Add to this migration crisis the disastrous toll of HIV/AIDS on health-workers and the luring away of remaining health-workers from the local delivery systems to serve in vertical programs funded by the same western hosts of physician émigrés and the picture becomes very alarming [6, 7]. Therefore, although we agree with the authors that US health- workforce policies should be overhauled to reduce brain drain from poor countries, we strongly believe that the policy changes should be far more ambitious. The policies needed especially by the poorest source countries are those aimed at alleviating their overall poverty and low development. Health system improvement and hence physician retention will only work in an environment of widespread social and economic progress. Few people—and we suspect doctors are no different—want to leave their home countries behind if they can safely and meaningfully lead free lives with fair opportunities. References 1. Arah OA. The metrics and correlates of physician migration from Africa. BMC Public Health 2007;7:83 (1-7). 2. Arah OA. Physician migration and millennium development goals for maternal health: the untold story. Med J Australia 2007;186:659-660. 3. Arah OA, Ogbu UC, Okeke CE. Too poor to leave, too rich to stay: Developmental and global health correlates of physician migration to the United States, Canada, Australia and the United Kingdom. Am J Public Health 2008;98: doi 10.2105/AJPH.2006.095844 (advance access 22 October 2007). 4. Hussey PS. International migration patterns of physicians to the United States: A cross-national panel analysis. Health Policy 2007;84:298- 307. 5. Arah OA, Okeke CE, Ogbu UC. Metrics and Correlates of Health- worker Migration to the United States, United Kingdom and Seven Other Wealthy Destinations. In "AcademyHealth 2007 Annual Research Meeting: Abstracts." Orlando, FL: AcademyHealth, June 2007. Online: www.academyhealth.org/2006/612/arahoa.ppt. 6. Bärnighausen T, Bloom DE, Humair S. Human resources for treating HIV/AIDS: needs, capacities, and gaps. AIDS Patient Care STDS 2007;21:799- 812. 7. Samb B, Celleti F, Holloway J, Van Damme W, De Cock KM, Dybul M. Rapid expansion of the healthcare workforce in response to the HIV epidemic. New Engl J Med 2007;357:2510-2514. Competing interests: None declared |
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Barbara Starfield, Baltimore MD USA Professor, George Fryer
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Our study was designed to explore the extent to which foreign medical graduates helped the US to maintain its supply of primary care physicians and specialists. We found strong and statistically significant evidence that physicians from countries that were the poorest, had the poorest health levels, and had low physician to population ratios contributed disproportionately to the US primary care physician supply (but not the specialist supply). It seems likely that this is a result both of ‘push and pull’ factors, but we believe that an appropriate ethical response would be for the US to compensate these countries in a commensurate way to help the build health systems that are attractive enough to retain their own medical graduates. Instead of supporting a myriad of competing disease-oriented programs, assistance in building comprehensive and well funded primary health care systems could go a long way to reducing the ‘push’ factors. There is now enough evidence that a strong primary care infrastructure in health systems reduces costs, improves outcomes, and reduces social disparities in health. The US health system would be greatly improved by a stronger orientation towards primary care; giving more support to building such an infrastructure would benefit both our own country as well as others from which we currently derive benefit. Reference: Starfield, B, Shi L, Macinko J. Contribution of Primary Care th Health Systems and Health. Milbank Q 2005; 83: 457-502 Competing interests: None declared |
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Lawrence I Silverberg, Ellicott City, USA Family Physician-John Hopkins HCGH
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This manuscript provides content for thought. There are considerable worldwide tribulations awaiting health care recipients and health care providers in the future requiring a skilled approach. Drs. Starfield and Fryer start with the stated purpose to examine the characteristics of countries exporting physicians to the United States and their contribution to the primary care supply of the United States. Unfortunately, in my opinion, their conclusion misses and inserts a flawed political and ethical opinion into a very complex and multifaceted issue. These conclusions can only be considered after deeper inspection into the socio-economic and political intentions on both sides of the ocean. The etiologies of this migration phenomenon are not explored. Expatriates are attracted by work, needy American rural communities, economic opportunities, technology and remuneration, living style available in the United States as well as many other origins.1 The statistics offered are confounding, variable and hypothetical in some instances.2 Are tetanus rates an indication of significance to these issues? It appears Canada and other countries were excluded. In my opinion, research into the dynamics of these countries’ health-care migrants would add much greater dimension to this manuscript. Also, information is needed on the retention and return rate. How many returns take back valued educational experiences and help improve political, socioeconomic and health care in their countries of origin? Called for here is a discussion of the impact (positive and negative) of these mobile health care providers on medical practices and patient care in the United States.1 I find this document puzzling. It might be interesting to look at other fields, their trends and conclusions. It is also interesting that many in the technology-related fields who have migrated to the United States are now returning to their country of birth. Although an interesting read, I fail to see how the stated purpose of this article leads to the conclusions. When discussing a malady process it is essential to investigate the etiology and differential diagnosis. Unfortunately, I feel this is lacking with this text. An in-depth discussion of solutions (in view of causes) would add a tour de force to this study. I found this unclear and byzantine manuscript unfortunately provides no significant insight into this highly intricate and multifaceted issue. I almost get the impression that the authors are criticizing the American system for the shortcomings of the nations they've identified in their study. This paper takes on a highly significant issue but left me questioning its significance in primary care. This political and psychosocial issue certainly needs to be addressed but the conclusions reached here do very little to affect the practice of family medicine. References: 1. Jenna Johnson. Born in India, Transforming Rural Md. Washington Post. Friday, December 7, 2007; A01. http://www.washingtonpost.com/wp- dyn/content/article/2007/12/06/AR2007120602851.html 2. CONCEPTUALISATION, MEASUREMENT AND VALUATION OF HEALTH STATES. http://www.who.int/healthinfo/nationalburdenofdiseasemanual.pdf The Global Burden of Disease Study 1990 asked participants in weighting exercises to make a composite judgment on the severity distribution of the condition and the preference for time spent in each severity level. This was to a large extent necessitated by the lack of population information on the severity distribution of most conditions at the global and regional level. Following the GBD terminology, and consistent with the WHO International Classification of Functioning, Disability and Health (ICF), the term disability is used broadly in burden of disease analysis to refer to departures from optimal health in any of the important domains of health. These include mobility, self-care, participation in usual activities, pain and discomfort, anxiety and depression, and cognition and social participation. In some contexts, the word ‘healthy’ is understood to mean ‘absence of illness’. In the context of summary measures of population health, health is given a broader meaning. As well as implying absence of illness there are also no impairments or functional limitations due to previous illness or injury. We thus refer to disability weights and years lost due to disability (YLD) as shorthand terms for health state preferences and years of healthy life lost due to time lived in states other than the reference state of optimal health, respectively. A year of healthy life refers to a year lived in the reference state of optimal health. Note that disability (i.e. states other than ideal health) may be short-term or long-term. A day with a common cold is a day with disability. Competing interests: None declared |
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Barbara Starfield, Baltimore, MD, USA physician, The Johns Hopkins University
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Thanks to Joses Muthori Kirigia for providing more detail and more specificity to our recommendations. We would only add that the wealthy international donors need to re-direct their important contributions to building health systems instead of supporting diseases-oriented priorities that compete for scarce country health personnel. Some countries, especially in Latin America, have shown how primary care in poor countries can be made exciting enough not only to retain their workforce but also to provide an exciting challenge to their medical graduates. Competing interests: None declared |
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Joses Muthuri Kirigia, Brazzaville, Congo Health Economist, World Health Organization Regional Office for Africa
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Starfield and Fryer[1] found that “..the contribution of the [poor] countries to the US primary care physician workforce is highly correlated with measures of health deprivation in those countries: the greater the contribution, the poorer the health measures”. Approximately 18556 physicians trained in Angola (0.9%), Cameroon (0.6%), Ethiopia (1.8%), Ghana (5.0%), Mozambique (0.1), Nigeria (23.0%), South Africa (65.4%), Uganda (1.7%), Tanzania (0.2%) and Zimbabwe (1.3%) work in Australia, Canada, Finland, France, Germany, Portugal, United Kingdom, and United States of America.[2] The neonatal, infant, under-five, maternal and adult mortality rates in the ten African countries are very high.[2] Those high mortality rates are partially attributable to scarcity of skilled human resources for health (HRH) in the countries concerned. There is growing evidence that international migration of HRH has enormous health[1,2] and economic[3,4] negative effects on populations of middle-income (MI) and low- income (LI) source countries. The OECD countries that recruit scarce HRH from MI and LI countries are denying millions of poor people of their human rights to medical care and to life as stipulated in Articles 25 and 3 of the Universal Declaration of Human Rights.[5] The OECD countries should acknowledge that they have fundamental ethical obligation not only to stop “poaching” HRH from MI and LI countries but also to systematically cooperate with those countries to both counter the push and pull factors. The OECD countries that are recipients of HRH trained in middle- and low-income countries can take a number of ameliorative actions: (a) Compensate the source countries for the opportunity cost incurred as a result of loss of their skilled HRH, for use in addressing the push factors; (b) Allocate a percentage of overseas development aid (especially grants) for production and retention of HRH in source countries; (c) Insist that a percentage of debt relief funds and global health funds (e.g. GFATM and the GAVI) be allocated towards production and retention of HRH that provide primary health care; (d) Legislate against unethical recruitment of skilled HRH from MI and LI countries; and (e) Accelerate north-south collaboration between the institutions that produce HRH. References 1. Starfield B, Fryer GE: The primary care physician workforce: ethical and policy implications. Annals of family medicine. 2007; 5(6): 486-491. 2. World Health Organization. The world health report 2006: Working together for health. Geneva; 2006. 3. Kirigia JM, Gbary AR, Muthuri LK, Nyoni J, Seddoh A. The cost of health professionals’ brain drain in Kenya. BMC Health Services Research. 2006; 6:89. 4. Kirigia JM, Gbary AR, Nyoni J, Seddoh A, Muthuri LK: The cost of health -related brain drain to the WHO African Region. African Journal of Health Sciences. 2006; 13(3-4): 1-12. 5. United Nations: Universal Declaration of Human Rights. New York; 1948. Competing interests: None declared |
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Anonymous Cuban professional, Anon professional
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Dear AFM Journal Editors, Professors Starfield and Fryer, Jr, I studied your interesting editorials on ‘Equity --global theme’, ‘Recruiting PC physicians from abroad’, and research on ‘The PC physician workforce: ethical and policy implications’,[1-3] as well as the interesting e-responses. I understood well your fair ethical concern and humanitarian interest to improve your country and the poor countries healthcare systems. Nevertheless, I think that to have a more comprehensive discussion I shall contribute some balancing comments, facts and issues in relation to the other face of this very complex same coin. I would like to mention a reflection of Professor David Landes from Harvard: “The task of the rich countries with the poor countries, in their own interest as well as theirs, is to help the poor become (freer, wiser --my addition), healthier and wealthier. If the rich do not, the poor will seek to take what they cannot make; and if they cannot earn by exporting commodities, they will export people”,[4] (including their university professionals and physicians --my addition). Since the 1700s, the US has been developed as a first world power in liberties, education, science, medicine, health, wealth, working and living levels with increasing equality and quality of life by European, American, Asian, and African immigrants. In the 1900s, the US became the most competitive society accepting immigrants. These immigrants have been the architects and builders of the modern US.[4-7] The acceptance of them without their quota of doctors would have given the US healthcare system many more difficulties to face the sometimes millenarian lifestyles that some of them bring from abroad, and to decrease the US healthcare inequalities due to the consequent greater shortage of US PC physicians. However, if the US does not accept them, they will go to Europe, Canada, Australia, or other countries anyway. “Immigration over the past seven years was the highest in American history, bringing 10.3 million immigrants. One in eight people living in the US is an immigrant, for a total of 37.9 million people -- the highest level since the 1920s. The number of foreign-born people who settle here each year, legally and illegally, is about 1.2 million. The US immigration rate is about 4 x 1,000 residents yearly, less than half of the peak annual immigration rate of 10.4 x 1,000 in the decade from 1901 to 1910. Today about 12 % of the US population is foreign-born. That is still below the peak of 1910, when 14.7 % of people were foreign born”.[8] In my view, the US does not need to court people and physicians from poorest and unhealthiest countries. Our greatest tragedy is that our behind countries are unethically exporting them, because with mistaken policies our unable rulers are not accomplishing their socioeconomic, cultural, political, and civil responsibilities. Our incapable rulers are not allowing their people and physicians to have the modern working and living levels possibilities [9] that they deserve and could enjoy in their own fatherlands, if they had implemented the already known working policies. These are greater ethical and policy problems that the research academicians could face more in international forums and publications. I will be glad to cite a thought of our Cuban apostle of independence Jose Marti: “When the peoples emigrate, have more than enough rulers”. He lived his last 20 years as US immigrant fighting against the Spanish metropolis to liberate Cuba in the eve of the 1900s (Complete Works). The world could study the exceptional example of Cuba, once from 1902 to 1951 a democratic, educated, healthy, and middle-income capitalist developing nation of immigrants even from South Europe, having by US standards outstanding living and health levels with an excess of physicians.[10-22] {table} At that times, the emigration rates of people and physicians where very little.[12-13] The clandestine Soviet revolution imported from 1953 to 1959,[23] achieved the transformation of Cuba in a captive and low-income Soviet/Chinese satellite of semi-healthy people, but panicky, hungry, poorest, corrupted, overwhelmedly indoctrinated, psychopathic, and despaired to emigrate and emigrating to anywhere.[11,21-22] In Cuba more than 90% of medical graduates are forced since 1961 to do three years of civil rural service, and from 1984 to become PC family medicine specialists. Cuba’s capitalist and socialist --silently rationed-- multi-tier public-private healthcare systems deserve careful comparative research to help improve a deep understanding on human development and healthcare inequalities. In addition, it would be worthwhile to study the four Asian Tigers, China, {table} and Ireland in the eve of the 2000s, and the three Baltic Tigers, India, and Chile in the 2000s. I would like to bring a consideration of the Nobel Prize Amartya Sen: “Individuals should be free active agents of development (in their country --my addition), rather than passive recipients of dispensed benefits” [6] (and charities from abroad, and much less lance tip of unsuccessful socioeconomic and political systems in other countries --my addition). In Cuba, it could be studied since the 1990s, how a population covered with the double of physicians and of PC physicians needed, has been so abandoned. In the 2000s, the healthcare crisis has worsened, because one third of the Cuban doctors are abroad, doing ‘Trojan horse’ ideological agitation within the poverty class of Venezuelans and others peoples, to finance the Cuban socialist moribund tyranny.[10-11,21-22] Today Cuba’s human development index ranks in the world place 51. [18] It would be over the 100 place, if it was calculated including a individual civil freedoms/political rights variable.[10,24] In 1951, with relatively high life expectancy at birth, literacy/school enrollment, GNP per capita, and individual freedoms/rights observance, for those times, Cuba would have ranked very probably below the 25 world place.[10-22] If in Cuba, the people that would like to emigrate safely to anyplace could do it freely, the island would lose in short at least a fifth of its 11.3 million population and 71,500 physicians.[25] The working and living conditions of the Cuban doctors, are in average as those described for sub-Saharan Africa,[2] but worsened by the world lowest mean wages (less than one US$ daily), more unfreedoms and discrimination than even for the common Cuban natives, situation only worst in North Korea. {table} The IMF and the World Bank policies are very hard as has been the capitalist take off in the most advanced nations, to help develop the behind countries going out of the authoritarian primitive non capitalist or socialist socioeconomic, cultural, political, civil, legal, and moral chaos. These policies are not to reward their governing irresponsible, unscrupulous and corrupted bureaucracies, which do not let the aid arrive to their people and doctors. The UN agencies and other international agencies (mainly using US aid), could learn more from this approach to be able to enhance quicker many poor developing countries.[21-22] It is a great fortune that very few of the American people and physicians have had to emigrate abroad in 250 years. This is a good final indicator that the US living and healthcare system with all their problems have been improving and reducing the living and health inequalities. The world research academicians especially in developing countries, need to study and learn still very much of the so unfairly reviled US model. Thank you for reading me. IMF: International Monetary Fund References: Table
Competing interests: None declared |
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Dan J Schmidt, Moscow, ID, USA Family Physician
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In the 1980's when I was in medical school, the rural state that sponsored me in another states' medical school(WAMI) threatened to increase the cost passed on to the medical students to bear the full burden, ie, what the state of Idaho paid to the state of Washington, at that time $29K. In an attempt to dissuade the legislature, I tried to find evidence that indebtedness increased higher-paying specialty choice, driving students away from Family Medicine. At the time there were NO articles to support this theory. There are a few now. Why, as physicians do we believe physicians will behave (or think) differently than any other human being? I cite the title of a best selling book to support this. And, if we really expect those of us in the Guild to behave (or Think) differently, why don't we hold ourselves to this expectation? I understand the third world doctors who want to practice in this country, just like I understand fewer and fewer medical students chosing Family medicine. Last year I made $90k. Our hospital recruited a young radiologist at $350K. Until "the system"(could some one please give me the address of "the system"?) acknowledges that income disparity, above a certain level, is unhealthy we will continue to promote excess, and foster unhealthy practices. It is time for Family Physicians to take up this banner and proclaim the need for a more rational health care system. If we were to acknowledge that WE make enough money, and any physician making over twice what we made was, what, "greedy?", then maybe the forces that influence physician payment would change. Then, maybe the world might not want to come here for our offer of wealth, but for our atmosphere of peace. www.poemd.blogspot.com Competing interests: None declared |
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