In recent years, Nepal has also joined the list of the small, poor countries with insufficient human health resource, losing medical professionals to the developed world. The important factors pushing them out of the country are personal insecurity, corruption, limited opportunity for professional growth, political instability, politicization of work environment, poor hospital infrastructure, insufficient employment capacity and peer pressure. The biggest factor that lures the health workers to the developed world is the high demand for their professional skills along with a much higher salary. A medical career in industrialized countries ensures economic prosperity, personal security, professional growth, job satisfaction and improved standard of living for their families.
A medical student in the United States owes an average amount of $150,000 in loans by the time he/she graduates. Naturally, most of these doctors will opt for the high-paying specialties for their residency training. In the US, each year 27 percent more residency positions are made available than the number of US medical graduates that are filled by the International Medical Graduates (IMGs). The IMGs mostly work in areas that are less sought after by the citizens, in America’s large hospital emergency departments to provide primary care to the uninsured American population. Furthermore, they are allowed to stay in the US if they agree to practice in the rural underserved areas after completion of their training. Such policies have made it possible for countries like US to save a large amount of money otherwise required to train medical professionals and ensure access to care for their people.
US President Barack Obama’s new healthcare plan seeks to provide care for millions of currently uninsured Americans. This implies that US will need thousands of more primary care physicians as well as other specialists in the near future. In an interview to the National Public Radio on Dec 6 last year, Dr Atul Grover of the American Association of Medical Colleges predicted that “even without significant expansion in insurance coverage, (there would be) a shortage of somewhere between 125 and 150 thousand physicians by the year 2025.” Even if the US finally starts increasing its own production of physicians, it will still be attracting even more IMGs in the coming years.
In Nepal, the cost for medical education ranges between $25,000 to $55,000 but for the students studying in government-funded institutions and/or under government scholarships, the amount is miniscule in comparison. The heavily subsidized rate of medical education in most developing countries is meant to produce human health resource for their citizens. However, simply the production of medical graduates yields little unless it is complemented by a health system that is able to retain the products. This is a key factor contributing to the migration of medical professionals within and across countries. As migration patterns tend to follow demand rather than need, resource poor countries and weak health systems fail miserably to attract these migrating professionals. It is indeed sheer injustice to the taxpayers, who contributed to the medical education of their countrymen, to face shortage of physicians when they need them.
Nepal could take some tips from the education funding system in the US. Instead of the subsidized cost and scholarships, the government might yield better returns by introducing education loans to students (medical and non-medical) after high school. The interest of the loan can vary according to the workplace and the pay scale of the graduates. When such a policy is adopted, the exported professionals will be required to pay a higher interest. The terms of the bond can be made more lucrative to those staying at home. A certain percent of loan repayment of physicians choosing to work in public hospitals and rural areas may be exempted depending upon the duration and type of service provided.
Therefore, for some medical graduates, the cost of medical education may not be very different from what it is at present. Creation of a favorable atmosphere and incentives for those working in resource limited settings has been long overdue. The cost recovered can be used to improve hospital infrastructure and staff facilities in public hospitals. Needless to mention, a strong mechanism to keep track of the medical graduates and their loans along with financial transparency would be vital and this would require international cooperation and agreement.
The urgency for a political commitment to revise policies to strengthen the health system cannot be overstated. A major global shortage of doctors and nurses over the next decades has been predicted. If the present trend of brain drain is any indicator of the future, the effect in poor countries will be catastrophic at best. It is estimated that in the cases of some African countries, there are more native doctors working outside their country than within. Without a change in the current policy, Nepal is very likely to find itself in a similar situation in the near future. Unfortunately, the noble means to keep the professionals home are limited.
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