5 days ago
India is exporting doctors and nurses. The country needs them too
The demand and supply of health workforce across countries continues to be a daunting problem, with most countries lacking adequate numbers of doctors and nurses and a projected global shortfall of 18 million health workers by 2030. Health workers migrate across countries, with the flow typically being from countries in the Global South to those in the North. The countries from which health professionals migrate are also those that face internal supply constraints. Sri Lanka, for instance, witnesses extensive outmigration, which is (partially) addressed by getting professionals from other countries. An estimated 10-12 per cent of foreign-trained doctors and nurses come from countries that are known to have a shortage of local healthcare workers. OECD data estimates suggest that between 2009 and 2019, 25 per cent to 32 per cent of doctors in Australia, Canada, the UK, and the US were medical graduates from South Asia and Africa.
Indian doctors, nurses, and other healthcare professionals migrate to countries across the world — almost 75,000 Indian-trained doctors work in OECD countries, and an estimated 640,000 Indian nurses work abroad. The Philippines is another example – the country is renowned for its large-scale export of nurses and other health professionals. Over 193,000 Philippines-trained nurses work abroad, constituting about 85 per cent of all Filipino nurses worldwide.
Economics and geopolitics influence the extent and nature of such migration through a combination of push and pull factors. Limited career growth and lower wages are key economic push factors. Political instability and conflict in the source country are often political push factors. Trade agreements that encourage migration, health crises that pull health workers to some areas and international recruitment policies are all pull factors, which, in turn, contribute to shortages in source countries. Countries like the Philippines and India have formalised policies to encourage the export of health workers, viewing them as sources of remittances and economic benefit. Yet, both countries have an acute shortage of health professionals.
Despite potential gains in the form of remittances and skill development, the loss of workforce capacity in countries already facing shortages outweighs the gains. What is needed, therefore, is a balanced domestic and international policy response that focuses on the needs of the individual, the national health system and global equity.
Cross-country migration is often leveraged for diplomatic gains. India, already known as the pharmacy of the world, leverages such migration to foster international partnerships, promote economic gains through remittances and investments, enhance its global influence in health sectors, and manage the challenges of the brain drain through policies encouraging circular migration and bilateral cooperation. It enhanced medical diplomacy during the Covid pandemic by deploying medical professionals to neighbouring and African countries. What is needed now is a greater focus on negotiating more comprehensive — and enforceable — bilateral agreements between source and destination countries, which can potentially include compensation mechanisms, targeted investments in medical education, health infrastructure, or technology transfer, to offset the loss of skilled workers. The WHO code is a starting point in rebuilding such agreements.
Ageing populations alongside declining birth rates are leading to growing demands and acute shortages of healthcare professionals in developed countries. India and other countries hold the potential to supply healthcare professionals. India could maximise gains through improved institutional mechanisms, such as establishing a centralised agency to manage workforce mobility. Kerala's experience with setting up agencies to coordinate overseas employment, address grievances, and support returnees can inform national approaches. So can the experiences of the Philippines' Department of Migrant Workers.
Diplomacy or economic gains cannot override the workforce agenda of individual countries or take priority over the strength of their health system. Countries exporting health workforce could benefit from greater attention to building a cadre of health professionals, developing the health workforce industry and addressing the need for retaining professionals. This will require expanding the health education infrastructure and increasing its economic viability, improving working conditions and providing incentives to retain talent and encourage circular migration, rather than permanent outflow, leveraging digital tools to enable Indian health professionals to provide services globally, where possible, without physical migration, ensuring accountability of international agreements and exploring regional approaches towards enhancing production capacity such as jointly developed and owned mechanisms of workforce production. Amplifying regional voices could potentially increase the bargaining power of workers from developing countries.
By combining investment in workforce capacity, strategic international agreements and policies that maximise economic, knowledge, and social gains, India and other southern countries can transform the migration of healthcare workers from a challenge into a multifaceted opportunity for national development. The rise of agencies in the Global South can mean that countries like the Philippines, Sri Lanka and India are active architects of workforce strategies that balance domestic needs and global engagement. They should be seen as not just exporters of workers or victims of the brain drain.
Venkateswaran is commissioner, Lancet Citizens' Commission on Reimagining India's Health System and Monteiro is a researcher on Global Health
