Physicians' Migration: Perceptions of Pakistani Medical Students

SURVEY REPORT

Physicians' Migration: Perceptions of Pakistani Medical Students ABSTRACT

Nazli Hossain, Nusrat Shah, Tahira Shah and Sidra Binte Lateef

Objective: To study the perceptions of medical students about factors responsible for physicians’ migration. Study Design: Cross-sectional survey. Place and Duration of Study: Dow Medical College and Civil Hospital, Karachi, from April to May 2015. Methodology: A self-administered structured questionnaire was used including demographic details, attitudes about push and pull factors of migration, and reasons for migrating or not migrating abroad. Final year students and interns were included. Likert scale from 1 to 4 (1=strongly disagree to 4=strongly agree) was used to assess attitudes. Data was analyzed by SPSS version 16. Results: A total of 240 medical students, mostly females (n=181, 75%) (60% final year and 40% interns), participated in the study. Majority wished to go abroad (n=127; 54%) with United States being the favourite destination (n=80; 66.1%) and internal medicine fields being the preferred choice for specialization (n=126; 54%). The major pull factors were better quality of postgraduate education abroad (n=110; 48.2%) and economic prospects (80; 35.2%); while the push factors were a weak healthcare system (n=219; 94.3%), inadequate salary structure (n=205; 88.3%), insecurity (n=219; 93.9%) and increasing religious intolerance in Pakistan (n=183; 78.5%). Conclusion: This survey highlights the continuing trend of physician migration from Pakistan owing to an interplay of various push and pull factors. Majority of our medical students wish to migrate, mainly due to low salaries, poor job structure, and insecurity. Urgent interventions are required to reverse this trend of medical brain-drain. Key Words: Attitudes. Medical students. Physician migration.

INTRODUCTION

Migration of health professionals to higher seats of learning is not a new phenomenon as for centuries physicians have been known to migrate to designated Centers of Excellence to improve their knowledge and skills.1 However, the phenomenon of international physician migration or “brain-drain” has increasingly led to worsening of a global imbalance between the availability of healthcare providers and the burden of disease, particularly in the source countries.2 According to WHO, around 56% of all internationally migrating physicians (IMGs) were moving from developing countries to four high income countries (HICs) of the world, i.e. United States, the United Kingdom, Canada, and Australia, and 45% of all IMGs originate from just three countries: India, Pakistan and Philippines.3

Physician migration may have some advantages in the form of remittances being sent home and the educational and research collaborations, which can be established as evidence of “brain-gain.” However, migration may be partly responsible for the poor health infrastructure in developing countries as most of these Department of Obstetrics & Gynaecology Unit II, Dow Medical College, Civil Hospital, Karachi. Correspondence: Dr. Nusrat Shah, Associate Professor, Department of Obstetrics & Gynaecology Unit II, Dow Medical College, Civil Hospital, Karachi. E-mail: [email protected] Received: August 07, 2015; Accepted: July 25, 2016. 696

countries have been unable to control epidemics of common diseases due to lack of qualified and efficient manpower.4

Pakistan is the sixth most populous country in the world with a population of approximately 190 million5 and a physician per thousand people ratio of 0.8.6 A study by Talati and Pappas estimated the total pool of registered practitioners in Pakistan as 101,090; out of this, only 73,890 might be actually practising in Pakistan as 12,813 physicians were working in the four high income countries (HICs) and around 3000 in Arabic-speaking nations (ASNs) with Saudi Arabia asking for 20,000 more or as many physicians as possible. They calculated the emigration ratio to be 17.6%. The Bureau of Emigration and Overseas Employment shows that about 1000 - 1500 physicians migrate every year of whom 10 - 15% return, giving a net migration of 900 - 1,275 physicians. The migrating physicians are usually the most brilliant academically and socially, who have the ability to reform and organize the weak healthcare system of Pakistan.7,8 There are many important “push factors” which lead to the brain-drain of physicians from Pakistan, such as high rate of unemployment, quality of postgraduate education and training, work overload and stressful environment in public sector universities, poor job prospects with low salary structures, limited career opportunities, lack of research culture, terrorism and bad law and order situation, harassment and sectarian killings of doctors, prevalent culture of favouritism and unethical environment, and overall a poor quality of life. On the

Journal of the College of Physicians and Surgeons Pakistan 2016, Vol. 26 (8): 696-701

Physician migration from Pakistan

other hand, the factors which pull our physicians away include the opposite of push factors as well as acute shortage of healthcare workers in the affluent countries and the favourable recruitment policies with ease of getting visa and work permit.9-11 This medical brain-drain also raises several ethical issues including global injustice, human rights, and individual versus societal gains. Here arises the question of moral responsibility of wealthy nations towards poor countries in improving the situation.12,13

Currently, Pakistan is suffering from the menace of population overload, extreme poverty, and a very high burden of infectious (tuberculosis, malaria, typhoid) and non-infectious diseases (anemia, hypertension, diabetes, heart attacks and stroke), in addition to having one of the highest maternal and perinatal mortality ratios in the world.7 Hence, the principle of social justice demands that as Pakistan spends huge amounts of public funds to provide medical education to our physicians, it is fair to expect the graduates to “pay back” to their country by playing their role for the larger purpose of social good in contrast to the smaller goal of personal benefit.14 The aim of this research was to study the medical students' perception to migrate and to analyse their attitudes to factors responsible for medical migration. This was done in the hope that remedies be suggested to reduce the trend of medical migration from Pakistan.

METHODOLOGY

This cross-sectional survey was conducted among the final year medical students and interns of Dow Medical College (DMC) and Civil Hospital Karachi (CHK), from April to May 2015. The sample size was calculated through Check Market online sample size calculator.15 The total size of population was approximately 600 which included all final year students (300) and all interns (300). For a 5% margin of error and 95% confidence level, our sample size came out to be 235. Three hundred questionnaires were distributed, expecting a response rate of nearly 80%.

All medical students posted in clinical wards were approached by one of the investigators. A structured questionnaire was used which had 3 parts: first was about demographic details, including age, gender, intention to migrate, choice of country for migration, choice of specialty and preparation for postgraduation exams; second part assessed attitudes about various push and pull factors, identified from literature search, and third part included reasons for migrating or not migrating. Only final year medical students and interns were targeted, as at this stage they might have decided whether they would like to migrate abroad or not. The second part of questionnaire was rated according to Likert scale from 1 to 4 (1=strongly agree, 2=agree, 3=disagree and 4=strongly disagree).

Ethical approval was taken from institutional review board. A pilot study was conducted among a group of 12 final year students to assess whether the questions contained clearity or needed modification, before administering them to the study sample.

The data was entered in SPSS version 16 and analysed. Continuous data was reported as mean and standard deviation; whereas, categorical data as frequencies and percentages. Gender differences were reported for intention to migrate, choice of country for migration, preparation for postgraduate exams, chosen specialty for postgraduation and reasons for migration or nonmigration (Table I). Attitudes regarding various “push” and “pull” factors were reported as frequencies and percentages. Chi-square test was used to find the differences in attitudes between students who wish to Table I: Intentions about migration, choice of specialty and reasons for migration by gender. Gender

Intention to migrate Yes No

Total

Choice of country: USA UK

Canada

Middle East Europe Others

Female, n (%)

Male, n (%)

Total, n (%)

90 (51.7)

37 (62.7)

127 (52.9)

59

234

181 (75.4)

85 (48.8)

175

51 (60.7) 18 (21.4) 7 (8.3) 7 (8.3)

1 (1.1) 0

59 (24.5)

22 (37.2)

29 (78.3) 02 (5.4) 0 0

4 (10.8) 2 (5.4)

Total

84

37

USMLE

35 (19.8)

25 (43.1)

Preparing for postgraduate exam: FCPS PLAB

Others None

Total

Choice of specialty:

8 (4.5) 2 (1.1)

3 (1.7)

128 (72.7) 176

Medical and allied

98 (55.3)

Undecided

17 (9.6)

Surgical and allied Total

Reasons for migration:

Better postgraduate education

62 (35) 177

n = 90

76 (50)

Economic reasons

54 (35.5)

Parents settled abroad

10 (6.5)

Better prospects for children Total

Reasons for non-migration

12 (7.8)

152

n = 85

0 0

0

33 (56.8)

1 (1.7)

5(4.1)

2(1.6)

121

60 (25.6) 8 (3.4) 2 (0.8)

3 (1.2)

161 (68.8)

89 (38.1) 18 (7.7)

233

34 (45.3)

110 (48.4)

n = 37

26 (34.6) 12 (16) 3 (4)

75

n = 22

14 (31.8)

128

7(5.7)

56

23 (17.9)

Total

7(5.7)

126 (54)

27 (48.2)

Parents and family

10 (7.8)

20 (16.5)

28 (50)

18 (40.9)

Visa issues

80 (66.1)

234

63 (49.2)

32 (49.2)

107 (44.5)

58

To serve country

Economic reasons

240 (100)

8 (18.1) 4 (9)

44

n = 127

80 (35.2)

24 (10.5)

13 (5.7)

227*

n = 107

81 (147)

40 (23.2)

37 (21.5)

14 (8.1)

172*

* Total number of reasons for migration and non-migration are more than total number of students who wished to migrate or non to migrate because students choose more than one reasons for migration or non-migration.


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migrate and those who want to stay in the country. A p-value of ≤ 0.05 was taken as significant (Table II). Means and standard deviations for attitude items were also reported (Table III).

RESULTS

The total number of respondents were 240 (final year students: 144; 60%), interns: 96; 40%). The overall mean age of respondents was 23.61 ±0.92 years (final year = 23.35 ±1.01 years, interns = 23.99 ±0.59 years). The majority of respondents was female (n=181; 75.4%) with only 59 male respondents (24.58%, Table I). More than half the respondents wished to go abroad (n=127/240, 52.9%). More males wanted to migrate Table II: Attitudes of medical students by intention to migrate. Salary for physicians is poor in Pakistan: Agree

Disagree

Total

I'm satisfied with PGME in Pakistan: Agree

Disagree

Total

Healthcare system is poor in Pakistan: Agree

Disagree

Total

Physicians face insecurity in Pakistan: Agree

Disagree

Total

Physicians have a duty to serve their country: Agree

Disagree

Total

Standard of PGME is poor in Pakistan: Agree

Disagree

Total

Religious intolerance is increasing in Pakistan: Agree

Disagree

Total

I can't afford to go abroad: Agree

Disagree

Total

Job prospects for physicians are poor in Pakistan: Agree

Disagree

Total

I want to take care of my parents: Agree

Disagree

Total

698

compared to females (Table I). The most favourite place for migration was USA (n=80/121; 66%), followed by UK (n=20; 16.5%). Nearly 70% of students were not preparing for any local postgraduate examinations. More males were preparing for further exams compared to females. (43.1% versus 27.2%), and mostly for USMLE (Table I). Total number of females preparing for next examinations were 35 (USMLE), 8 (FCPS), 2 (PLAB), 3 (others) constituting 48 (27.2%). The most popular fields for postgraduate studies were medical and allied (54%), followed by surgical and allied (38.1%). More boys opted for surgical fields compared to girls (48.2% versus 35%). Significantly more girls were undecided about their field of specialization compared to boys (9.6% versus 1.7%, Table I). Intention to migrate

Yes, n (%) 112 (54.6)

13 (48.1)

42 (37.5)

No, n (%)

93 (45.3)

14 (51.8)

70 (62.5)

83 (69.1)

37 (30.8)

118 (53.8)

101 (46.1)

7 (53.8)

119 (54.3) 7 (50)

105 (50.4)

19 (82.6)

80 (62.5)

45 (43.6)

105 (57.3) 21 (42)

27 (36)

97 (62.1)

39 (44.3) 87 (60)

117 (54.6) 6 (50)

6 (46.1)

100 (45.6) 7 (50)

103 (49.5)

4 (17.3)

48 (37.5)

58 (56.3)

78 (42.6)

29 (58)

48 (64)

59 (37.8)

49 (55.6)

58 (40)

97 (45.3) 6 (50)

Total n (%)

p-value

205 (88.3)

0.212

27 (11.6)

232

112 (48.2)

120 (51.7)

0.000

232

219 (94.3) 13 (5.6)

0.998

232

219 (94) 14 (6)

0.011

233

208 (90)

23 (9.9)

0.006

231

128 (55.4)

103 (44.5)

0.172

231

183 (78.4)

50 (21.4)

0.642

233

75 (32.4)

156 (67.5)

0.064

231

88 (37.7)

145 (62.2)

0.000

233

214 (94.6) 12 (5.3)

0.367

226



Table III: Means and standard deviations for Likert scale 1 to 4 (where 1 = Strongly agree, 2 = Agree, 3 = Disagree, and 4 = Strongly disagree). Item

Means (± 1 SD)

Salary for physicians is poor in Pakistan

1.69 (± 0.6)

Standard of postgraduate medical education is low in Pakistan

2.35 (± 0.7)

Standard of life for physicians is poor in Pakistan

1.96 (± 0.7)

Healthcare system is poor in Pakistan

1.58 (± 0.6)

Religious intolerance is increasing in Pakistan

1.89 (± 0.7)

Physicians have a duty to serve country after graduation

1.78 (± 0.7)

Physicians face insecurity in Pakistan

1.49 (± 0.6)

I want to take care of my parents

1.52 (± 0.6)

I can't afford to go abroad

I'm satisfied with job prospects for physicians in Pakistan

The most common reason given for migration was for better postgraduate education, followed by better financial prospects. The most important reason for nonmigration was to serve the country, followed by economic reasons and for parents and family (Table I). Majority of the respondents who wished to migrate said they would like to come back after their postgraduation (76/127, 59.8%). Table II shows the attitudes of medical graduates towards the various “push” and “pull” factors that may be responsible for migration.

The vast majority of respondents agreed that salary structure is poor (88.3%) in Pakistan. In addition, nearly 95% of respondents agreed that healthcare system is weak. However, only a small majority thought postgraduate education is not up to the mark (55.4%).

Most students agreed that physicians face physical insecurity in Pakistan (94%). This perception was common among both who wanted to migrate (119/126; 94.4%) as well as who wished to stay in Pakistan (100/107; 93.4%). Moreover, nearly 80% of respondents felt that religious intolerance is increasing in Pakistan (183/233; 78.5%). Only a few students said they would migrate because their parents or families were settled abroad (6.3%). Almost 95% of students said they would like to look after their parents, irrespective of whether they stay in Pakistan or migrate abroad. Similarly, nearly 90% of the respondents felt it was their duty to serve the country after graduation. Students, who disagreed that it was a duty to serve the country, were significantly more likely to migrate compared to those who agreed (p=0.006) (Table II).

Only a small majority said they were not satisfied with postgraduate medical education (n=120; 51.7%). However, over 60% thought that job prospects for physicians were good in Pakistan (n=145; 62.2%, Table III).

DISCUSSION

This study showed that 54% of respondents wanted to migrate abroad, which is comparatively less than that

2.80 (± 0.7)

2.70 (± 0.7)

reported in a study from Lahore16 and also from a study conducted at the same university a few years ago (60.4%).10 This may be attributed to the higher proportion of females in this study (over 75%), who generally prefer to stay back for social reasons. This number is also markedly less compared to that of a study reported from the Aga Khan University, (AKU) Karachi, where more than 95% of medical students wanted to move abroad after graduation.17 This may be because of having a negative image of Pakistan, peer pressure, and role modelling as a large number of faculty members serving there are foreign trained.7

The most favoured country for migration was United States of America (USA), particularly for boys, followed by UK, Canada and Middle East. Although majority of students preferred medical and allied subjects for specialisation, the most favourite single subject was general surgery (15%), followed by internal medicine (14.2%), pediatrics (9%), and obstetrics and gynaecology (8.6%). This distribution is similar to that of a study by Shaikh et al. from the same institution.10 Better postgraduate medical education (PGME) was the main reason for migration abroad (110/127; 86.6%), followed by desire to improve economic condition (80/127; 62.9%%). In the present era of internet and communication boom, students are very well aware of medical advancement. Although some improvements have been observed in the last decade, a lot more needs to be done for improving the standard of PGME in Pakistan. In a survey of postgraduate residents, 54% reported lack of supervised training, 55% thought supervisors were not competent for the given role, and 50% thought faculty was not a good source of learning.18

The institution which is responsible for PGME in Pakistan is the College of Physicians and Surgeons, Pakistan (CPSP) which offers postgraduate diplomas in 85 disciplines. Though it has been declared “WHO Collaborating Centre for Research and Training in Educational Development of Health Personnel”, reforms in medical education are still needed.19 Medical students were dissatisfied with the health infrastructure of the country as well as the salary of the doctors. This lack of infrastructure is also responsible for


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internal brain-drain or migration from rural areas to urban areas where most of the training programmes are located along with better provision of all basic necessities of life. One solution to counter this rural/urban imbalance is to build new medical colleges and teaching hospitals in rural areas and provide incentives to the doctors working there. Moreover, the salary structure for doctors is not attractive in Pakistan, considering the amount of hard work, and the long period of study and training that work for the making of physicians. The monthly salary equivalent to around 400 to 500 US dollars during postgraduate training period is hardly sufficient for their own expenses, how could they be expected to look after their families.16 Improving the job structure and salary package and offering other financial incentives in the form of timely promotions, overseas training allowances, study leaves, better pension plans, and child care plans will go a long way in retaining the doctors in the country.9 The vast majority of students agreed that physicians face insecurity and religious intolerance, as it is on the rise in Pakistan. Doctors have been kidnapped for ransom and as many as 32 have been killed in sectarian killings in the last decade.20 The recent wave of targeted killings of doctors belonging to different minority sects also resulted in forced migration of those doctors who were well settled in the country. Unless the Government improves law and order and security situation in the country, doctors will continue to fly to safer zones of the world.

The net effect of this brain-drain leaves the country with loss of public money spent on medical education as well as loss of manpower meant for controlling the epidemics or killer diseases. Pakistan is spending as much as 35,000 US dollars on the education of a doctor and yet it has not been able to fight the avoidable health problems like malaria, tuberculosis, diarrheal diseases and an unacceptable level of maternal and perinatal mortality ratios. Though, migration of medical graduates to foreign countries has been justified on the basis of right of the individual, but this disturbs the principle of societal justice, where poor people of source country are spending a large amount of public money on producing healthcare providers and are deprived of those very healthcare providers. Physician migration has critically affected our health system and it is high time we introduce certain policy changes and reforms. These may include improving the healthcare system, raising the salaries for doctors, improving the security situation, binding doctors to serve their own community for a period of 3 years before moving abroad, and asking high income countries to issue only temporary work visa, and pay compensation for the cost of education of the migrating doctor. Currently, mushrooming of medical colleges is taking place all over the country, in both public and private sectors, as a huge profit-making

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business. This is going to increase the quantity of doctors at the cost of quality and will lead to further deterioration in the PGME. The regulatory authorities should put a ban on opening of new medical colleges, and should strictly evaluate and monitor the standard of medical education in the country.3,11

CONCLUSION

This study highlights the continuing high trend of physician migration from Pakistan owing to an interplay of various push and pull factors. Majority of Pakistani medical graduates wish to leave the country for postgraduate qualification abroad, mainly due to low salaries, poor job structure, insecurity and religious intolerance. Certain urgent interventions are required, if we want to reverse this trend of medical brain-drain.

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