‘Luring’ Overseas Trained Doctors to Australia:

Ethical Issues in Training and Trading

Robyn Iredale, Adjunct Senior Research Fellow

Australian Demographic and Social Research Institute (ADSRI)

ANU

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Outline•Background•Ethical issues

(a) Non-recognition of some foreign medical qualifications (b) Meeting national shortages with overseas doctors(c) Impact of the loss of medical human resources (d) Escalating medical practitioner migration & ‘brain drain’

•Australia’s history of medical migration•Rates of medical migration and trade in medical services to Australia from 1996•Regulation, recognition and rewards from 2000•Conclusion

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Background

• supply of medical practitioners is the centrepiece in health service delivery

• many countries experiencing shortages• immigration of doctors, first or last resort?• doctors came in regular migration intake but now

more targeted (long and short term)• WTO GATS Mode 4 intended to increase trade in

medical services

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Ethical Issues

(a) Non-recognition of some foreign medical qualifications

• Ongoing issue in most countries of immigration• Justified in terms of maintenance of high standards• Often contaminated by labour market demand and

supply issues• GATS Mode 4 also has serious recognition issues

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Ethical issues (cont.)

(b) Meeting national shortages with medical practitioners from overseas

• heightened international demand and competition for medical professionals

• Figure 1 shows the proportion of foreign-born among practising doctors in selected OECD countries in 2000 — NZ had 46.9% and Australia had 42.9% of their MP workforces born overseas. Many other OECD countries had above 25%

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Figure 1: Proportion of foreign-born among practising doctors in selected OECD countries,

2000

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

50.0%

AUS AUT CAN CHE DNK FIN FRA GBR HUN IRL LUX MEX NZL POL TUR USA

Country

Percentage

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Figure 2: Proportion of foreign trained doctors in selected OECD countries in 2000

& 2005

• NZ with 35.6% in 2005 was again at the top, followed by the UK (33.1%) and England (32.7%)

• Big increase in Ireland from 11.1% in 2000 to 27.2% in 2005 was the most dramatic increase

• Australia, Canada and the USA were similar in 2005 with 25.0%, 22.3% and 25.0%

• Differences between Fig 1 and Fig 2 due to influx of medical students - important for Australia, NZ

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Figure 2: Immigrant doctors registered in selected OECD countries, 2000 & 2005

0

5

10

15

20

25

30

35

40

Australia AustriaCanada

DenmarkEnglandFinlandFrance (1)

Ireland

Netherlands (3)New Zealand

Poland

Sweden (1)Switzerland

United Kingdom (4)United States (1)

2000 2005

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Ethical issues (cont.)

(c) Impact of the loss of medical human resources• Numbers available for sources of immigrant doctors

in OECD countries in 2000• Figure 3 shows numbers of top 25 ‘losers’• Asia non-OECD (Asia excluding Japan and South

Korea) provided the most doctors• Latin America non-OECD (Latin America excluding

Mexico) was the second most important source region

• N. Africa important source for France

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Figure 3: No. of foreign-born doctors in OECD countries by 25 main countries of origin, 2000

Doctors

0 2000 4000 6000 8000 10000 12000 14000 16000 18000 20000

United States

Italy

Lebanon

Nigeria

Sri Lanka

Malaysia

Syria

Romania

Chinese Taipei

Poland

Cuba

Morocco

Egypt

South Africa

Vietnam

Iran

Canada

Pakistan

Algeria

Former USSR

China

Philippines

United Kingdom

Germany

India

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Ethical issues (cont.)

• Only two sub-Saharan African countries, Nigeria and South Africa, fall in top 25

• More significant indicator of ‘loss’ is % of trained doctors who have left the country — emigration rate, i.e. need to look at relative rather than absolute no’s

• Figure 4: Rate of emigration of doctors for the 23 most seriously affected countries, 2000 (only OECD data)

• Countries with high emigration rates and low doctor density ratios (number of doctors/1000 population) are particularly badly affected — Senegal and Malawi

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Figure 4: Rate of emigration of doctors for the 23 most seriously affected countries, 2000

0 10 20 30 40 50 60 70 80 90 100

UR of Tanzania

Trinidad and Tobago

Togo

St Vincent and the Grenadines

Sierra Leone

Senegal

Sao Tome and Principe

Mozambique

Liberia

Jamaica

Haiti

Guyana

Guinea-Bissau

Grenada

Fiji

Dominica

Cook Islands

Congo

Cape Verde

Benin

Barbados

Antigua and Barbuda

Angola

Emigration rate of doctors (%)

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Ethical issues (cont.)

• South Africa (17%) but effect is still serious:

‘the government needs to hire an extra 1 000 doctors, 3 000 professional nurses and 700 pharmacists by next year to successfully deliver antiretroviral treatment to millions of HIV-positive South Africans using public heathcare. But the sector is already grappling with a staggering vacancy rate of 4 222 doctors, 32 734 nurses and 52 597 professional posts …’

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Ethical issues (cont.)

(d) Escalating medical practitioner migration and ‘brain drain’

• Increasing levels of high skilled migration from 1985• Even greater increases in medical migration — seen in

(1) increasing % of foreign medical practitioners in most OECD countries from 1970 to 2005, except for Canada; and

(2) the rising proportion of foreign-trained amongst new registrations: 68% in the UK in 2005; 82% in New Zealand in 2005; 50% in Ireland in 2002 and about 35% in the United States in 2005

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Figure 5: Tertiary Educated Emigration Rate, Percent of All Source Nation Adults

QuickTime™ and aTIFF (LZW) decompressor

are needed to see this picture.

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Ethical issues (cont.)

Issue of international equity raised recently by OECD - many countries aiming for self- sufficiency because of this

Widely acknowledged now that ‘brain drain is negatively impacting on some countries

African nations’ subsidisation of developed country health worker training costs of US$500/year

But talk of compensation is unpopular with most receiving countries

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Australia’s History of Medical Migration

Most doctors trained overseas till 1868 when first medical school established

Registration problems of Jewish refugee doctors in 1930s Similar for Displaced Person arrivals after WWII —but

conditional registration for outback, PNG, Antarctica Attitudes of BMA (later AMA) — xenophobic and

protective of their positions (Kamien,2006) Liberalisation in handling of OTDs in1960s (supervised

hospital placement on conditional registration) and increased training led to fears of oversupply by 1970s

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Australia’s History of Medical Migration (cont.)

National exam for OTDs introduced in 1978 - became only pathway to registration after 1981

Blackett’s explanations of low pass rates (39% between 1979-89) different from OTDs’ explanations - standards and/or supply?

AMA and government fears of oversupply- led to 3 strategies for reducing supply in 1992:(1) Quota of 200 to pass AMC exam - dropped in 1995(2) Loss of points for doctors applying to migrate perm.(3) Proposed phasing out of temporary recruitment

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Rates of Medical Migration and Trade to Australia from 1996

Temp. recruit increased under the Coalition - highlighting the inequity in handling of temp and perm OTDs. Hunger strikes ensued in 3 cities

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OTD’s Hunger Strike, 1997 - Macquarie St, Sydney

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Rates of Medical Migration and Trade to Australia from 1996 (cont)

DIMA supplied data in Fig 6 to OECD for movement of doctors between 1996-2005

Steep rise in temporary medical inflow is evident — < 2,000 in 2001 to 3,500 in 2004

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Figure 6: Doctors (work and residence permits), Australia

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Rates of Medical Migration and Trade to Australia from 1996 (cont)

But permanent entrant numbers only part of the intake (245 PAs in the Independent Skill Stream) — 33% of the total in 2004-05;

Fig. 7 shows total intake (750) by category.

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Figure 7: Medical practitioner settler arrivals by migration stream, 2004-05

14%

38%

1%4%

33%

6%4%

NZ

Family

Humanitarian

Aust sponsored

Independent

State-specific/regional

Other skilled/business

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Rates of Medical Migration and Trade to Australia from 1996 (cont.)

Fig. 8 provides a better representation of what happened between 1995 & 2004-05

Total number of settler arrivals fluctuated between 400 and 800

Deduce significant permanent emigration Net gain of temporaries escalated markedly —200

in 1995-96 to >1,250 in 2004-05 Total net inflow of all doctors was almost 1,600 in

2004-05

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Fig. 8: Settler inflows, net temporary movement and net total movement of

medical practitioners, 1995-96 to 2004-05

0

200

400

600

800

1000

1200

1400

1600

1800

1995-96 1996-97 1997-98 1998-99 1999-00 2000-01 2001-02 2002-03 2003-04 2004-05

Number

Permanent settler arrivalsNet Temporary MovementNet inflow of settlers, residents and long-term residents

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Rates of Medical Migration and Trade to Australia from 1996 (cont.)

Escalating shortages in specific geographic locations and specialties

Introduction or expansion of temporary visa categories (422, 442 and 457) and new permanent visa categories since 1996

Differential assessment of temp and perm OTDs — temporary OTDs do not have to sit AMC exams prior to entry

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Regulation, Recognition and Rewards from 2000

Very variable rates of entry to medical workforce by country — high for UK (83%), S. Africa (81%), low for E. Europe (23%), China (5%)

Due to proportion of temporaries, differential outcomes on the AMC exams, language difficulties, lack of bridging courses, different training methods and modes of patient care, and financial circumstances of applicants which may prohibit efforts to get qualifications recognised

No GATS Mode 4 mobility of MPs

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Figure 9: Proportion of doctor birthplace groups in medical employment,

unemployed and not in the labour force, 2001

0

10

20

30

40

50

60

70

80

90

UK/IrelandUSA/CanadaSouth AfricaSE Europe E Europe

NW Europe

India China TaiwanPhilippines

Iraq

%

Medical Employment Unemployed NILF

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The new ‘lure’ worked!

OTDs

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Conclusion

Australia is alone in the OECD in its specific targeting of OTDs to come here — 3 main issues:

continuing inconsistent system of o/s qualifications recognition for permanent and temporary OTDs

ongoing inadequate workforce planning and over-reliance on OTDs (mainly temporary)

international equity concerns regarding recruiting, ‘mutuality of benefits’, and compensation to developing countries for some of the $700-800 million gift we receive each year from their training costs —Australia’s absence from discussions and from Global Forum.