Brief Submission from the People's Health Movement Australia Brain Drain Working Group in reply to Productivity Commission’s Health Workforce Position Paper

The People's Health Movement Australia was disappointed and concerned by the position taken by the Productivity Commission on the reliance on overseas trained health professionals in Australia and the ethical ramifications of brain drain from developing countries. This submission is limited to responding to those two issues.

The Commission has endorsed the National Health Workforce Strategic Framework with the caveat that Australia does not need to be self sufficient in health professionals. The willingness to overturn the principle of national self-sufficiency is very disappointing given that the Framework has been endorsed by a wide range of significant stakeholders including both state and Federal government and represents a well-considered, worthy aim. The principle of self sufficiency is a fundamental element of the Framework which was developed in the best interests of the nation (DoHA). The caveat that the reliance on overseas-trained workers should not be “unsustainable” is vague and likely to be ignored given the imperative to staff health systems. It certainly is not sustainable for poor countries to be losing trained health professionals at the current rate with the effect of brain drain on source countries being outlined in our initial submission. For most poor countries, the benefits of international aid given by developed countries and the contribution made to the source country by remittances is outweighed by the harm done to their health systems by brain drain (Hollingsworth 2004, Scott 2004). The net contribution of a skilled health professional such as a general practitioner to health and the overall economy will be much greater if they stay in a developing compared to the contribution made if they migrate to a developed country where they may spend much of their time reassuring the worried well or seeing people with minor illnesses (Hollingsworth 2005). 

As noted in our earlier submission, loss of health professionals to Australia and New Zealand is a particular concern for our neighbouring countries in the pacific (Baravilala 2004) The Age newspaper recently highlighted the issue after experts in international migration highlighted Australia as being particularly successful at attracting skilled migrants from poor countries (Colebatch 2005). Neighbouring countries such as Samoa and Tonga were noted in this report as losing the majority of their university graduates largely to New Zealand and Australia (Kapur D 2005). The issue of brain drain has been emphasised by the Word Health organization and other noted experts as a major impediment to achievement of the Millenium Goals particularly in the areas of HIV and tuberculosis (Figueroz-Munoz J Lee 2003). 

 Australia is receiving an increasing proportion of migrating doctors from poor countries. This is a fairly recent change with the majority of migrating doctors previously coming from the United Kingdom and Ireland (Birrell 2004). There is a trend for nurses to be increasingly migrating from poor countries with a lack of information on allied health professionals (Nurses Board of Victoria 2004, Nurses and Midwives Board of New South Wales 2004). This trend is likely to continue given the national and global nursing shortage, the maldistribution of general practitioners in Australia and the relative ease of obtaining accreditation as a general practitioner in Australia compared to other comparable English speaking developed countries (Buchan 2004, Birrell 2003). Ethical recruitment guidelines have not been shown to be effective in reducing brain drain. The United Kingdom has adopted widely-accepted ethical guidelines regarding recruitment but is still a major recipient country in studies of brain drain from poor countries (Willetts 2004). 

Overseas trained doctors are currently the major solution to the problem of maldistribution of doctors within Australia because of restricted provider numbers. However this is also unsustainable as the majority of these overseas trained doctors leave rural/remote areas when their provider number restriction is lifted (Hawthorne 2003, Kosmina 2004). Without solutions to maldistribution, reliance on overseas trained health professionals is likely to be long term. However the Commission has not made any recommendations which are likely to make a significant difference to maldistribution for medical practitioners. The issue of maldistribution is also a major problem in other health professionals such as nurses and allied health professionals. If the Commission believes that efficiency gains will be more effective than increasing workforce supply then increasing migration should not be a major part of the solution as most medical overseas trained doctors will eventually move to urban areas. Australia will also be in competition with other western countries and will be forced to offer lucrative conditions in order to compete. This could create upward pressure on wages.

There may be strong pressure on hospital systems and rural areas to accept professionals without ensuring that their training is suitable for the Australian system and that their orientation is adequate. The consequences of this pressure has recently been seen in Queensland. Work by Hawthorne et al found that many overseas trained general practitioners currently complain of a lack of support and training when working in Australian rural general practice (Hawthorne 2003).  Pass rates for the Fellowship exam for the College of General Practitioners has recently dropped significantly for overseas trained doctors to less than 50% and there have been recent concerns about discrimination (Sweeney C 2005). This is likely to be a reflection of the lack of support these doctors receive. Over 3000 doctors who migrated to Australia since 1990 have been unable to pass the Australian Medical Examinations and are consequently an example of brain waste (Birrell 2004).  

It needs to be acknowledged that overseas trained health professionals have played a vital role in Australian’s health system and will continue to do so. Health professionals will continue to migrate from developing countries to Australia and other developed countries. However, stronger policy responses need to be developed to reduce active recruitment from developing countries with a shortage of health care workers (which would include most developing countries) and to compensate those countries for the loss caused by migration. Developed countries also need to explore ways in which professionals from developing countries can continue to make a contribution to the health care system of their home country. The contribution of Sri Lankan health professionals to the health care problems caused by the tsunami is evidence of the strong ties and desire to contribute evident in many overseas trained professionals. 

We believe that the Australian population would support the principle of national self-sufficiency in health professionals. Competition for many health courses is intense and a significant proportion of suitably qualified candidates miss out on a place. The Commission has stated that increasing supply of health professionals will increase maldistribution and cause over supply in urban areas. Reliance on overseas trained health professionals does not solve this problem as most migrate to urban areas eventually (Kosmina 2003, Hawthorne 2004).  This needs to be addressed by strong government policy responses. Increasing training places for nurses is not likely to lead to an oversupply in urban areas given the significant and growing shortages in Australia (Nursing Education Review Secretariat). 

We do not support Professor Gibbons suggestion that Australia should export training expertise with the aim of providing a pool of labour from low wage countries as a source of health workers (Gibbon W 2005). Australia should be aiming to export training expertise in order to improve global health. Australia also has a self-interest in developing countries having a functioning and improved health system because of global public health threats such as avian influenza.  Our initial submission included some suggested actions to mitigate the effect of brain drain on poor countries. The policy solutions to this problem have not been expanded in this submission given the Position Paper did not acknowledge brain drain as a problem. 

In conclusion, Australia is a prosperous nation with a well educated population and so should be a net contributor the development of health care systems in developing countries. This is both an ethical imperative and in our national self-interest given the threats to global health and stability posed by avian influenza, SARS and other infectious diseases. The Productivity Commission is proposing that Australia be a net drain on global health care resources indefinitely. We believe that the Australian population would find this policy unacceptable on ethical grounds and also because it will mean that Australian young people will continue to miss out on places in health courses for which they are well qualified. 

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