CASE STUDY | INDIA FROM BRAIN DRAIN TO BRAIN GAIN MIGRATION OF MEDICAL DOCTORS FROM KERALA Acknowledgements This report was prepared by researchers from Oxford Policy Management (Krishna D. Rao, Aarushi Bhatnagar, Udit Ranjan, Sarthak Joshi, Pooja Singh), the Health Systems Research India Initiative, Kerala (Arun Nair, Ashwani Singh, Aravind L.R., Jintu Mathew, Jenyc Ali) and the WHO Country Office for India (Pascal Zurn, Nilesh Buddh). Please address all correspondence to Krishna D. Rao ([email protected]) and Aarushi Bhatnagar ([email protected]). February 2017 Contents Acknowledgements . 2 Figures Abbreviations . 2 Figure 1 . Location of Kerala state, India . 5 Figure 2 . Registration of doctors at medical councils: 1. Background ....................................3 Kerala and India . 11 1 1. Kerala state . 4 Figure 3 . Density (per 10 000 population) of qualified 1 .2 Migration of health workers . 5 doctors, nurses and midwives, and all health workers, 2. Objectives .....................................5 India and states (2012) . 12 3. Methods . 7 Figure 4 . Percentage of vacancies in medical specialties 3 1. Production . 7 in government hospitals . 13 3 .2 Stock . 7. Figure 5 . Percentage of vacancies in surgical specialties 3 .3 Migration . 8 in government hospitals . 13 3 .3 1. Kerala Migration Survey . 9 Figure 6 . Registration of Indian doctors in United States 3 .3 .2 Other secondary data sources . 9. by year of graduation . 15 3 .3 .3 Retrospective study of medical graduate cohorts . 9 Figure 7 . Location and occupation of medical graduates . 16 4. Results .......................................10 Figure 8 . Current occupation and location of male and 4 1. Production . 10 female MBBS graduates . 16 4 1. 1. India . 10 Figure 9 . Distribution of Selected MBBS graduates currently 4 1. .2 Kerala . 10 located in Kerala by sex . 17 4 .2 Stock . 11. Figure 10 . Requests for certificates of good standing 4 .2 1. Doctors in India . 11 by year of MBBS registration . 18. 4 .2 .2 Doctors in Kerala . 11 4 .3 Migration . 13 Tables 4 .3 1. Migration from India . 13. Table 1 . Key development indicators: Kerala and India . 5 4 .3 .2 Migration from Kerala: Table 2 . Primary data collection: MBBS colleges in Kerala . .10 . Kerala Migration Survey, 2014 . 15 4 .3 .3 Migration from Kerala: Table 3 . Number of MBBS colleges: Kerala and India . 11 Retrospective study of medical graduates . 15 Table 4 . Number of doctors in primary health centres in Kerala and India . 13 4 .3 .4 Certificates of good standing . 18 Table 5 . Characteristics of Indian-born doctors currently 4 .4 Foreign-trained medical graduates . .18 . registered with the American Medical Association 5. Discussion ....................................18 (n = 43 290) . 14 5 1. Production and stock of dcotors . 18 Table 6 . Distribution of doctors currently working in 5 .2 Migration of doctors . 19 India/Kerala, by graduation college, public/private sector, 5 .2 1. Migration policies . 21 and urban/rural location . 15 5 .2 .2 Information on migration . .21 . 6. Conclusion ....................................21 Box Box 1 . Migration: Policies and departments . 21 References . .23 Annex 1 . Detailed information on current occupation and location of MBBS graduates from selected colleges in Kerala . 24 Annex 2 . List of medical colleges (MBBS), Kerala . 25 Annex 3 . Overview of select data sources . 26 MIGRATION OF MEDICAL DOCTORS FROM KERALA 1 Acknowledgements We would like to thank Mr Rajeev Sadanandan, Additional Chief Secretary, Department of Health and Family Welfare, along with the department, for their support towards undertaking this study in Kerala. We would like to acknowledge the support of Dr. Remla Beevi, Director of Medical Education, and Dr. Srikumari, Joint Director of Medical Education at the Department of Medical Education, for helping us get in touch with government medical colleges in the state and providing us with relevant data. Further, we would like to extend our gratitude to Dr. Thomas Mathew, Principal, and Dr. Sarah Varghese, Head of Department – Community Medicine, Government Medical College, Thiruvananthapuram; Dr. Ajay Mohan, Principal, Government Medical College, Thrissur; Dr. Jose Joseph, Principal, Government Medical College, Kottayam; and Dr. Joseph John, Amala Institute of Medical Sciences, for their assistance in providing access to data for medical graduates. We would also like to thank Dr. R. Ramesh, Director of Health Services, Government of Kerala, and Dr. Thankappan K.R., Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, for their helpful insights. We would also like to thank the Centre for Development Studies, Dr. I. Rajan and Dr. Sunitha Syam for their cooperation and for sharing data on the work undertaken by them in the area of health worker migration from Kerala. We would like to acknowledge the assistance provided to us by Dr. Muhammed Shaffi and the staff at the Trivandrum Chapter of the Indian Medical Association. We would also like to thank the following medical colleges for their engagement in the second phase of this study: Government Medical College, Thiruvananthapuram; Government Medical College, Thrissur; Government Medical College, Kottayam; and Amala Institute of Medical Sciences, Thrissur. Funding for the development of this report was provided through the project Brain Drain to Brain Gain: Supporting the WHO Code of Practice on International Recruitment of Health Personnel for Better Management of Health Worker Migration, co-funded by the European Union (DCI-MIGR/2013/282-931). The contents of this document are the sole responsibility of the authors and can under no circumstances be regarded as reflecting the position of the World Health Organization and the European Union. Abbreviations AMA American Medical Association AYUSH ayurveda, yoga and naturopathy, unani, siddha and homeopathy ECR emigration check required GDP gross domestic product KMS Kerala Migration Survey MBBS Bachelor of Medicine, Bachelor of Surgery (Latin: Medicinae Baccalaureus, Baccalaureus Chirurgiae) NORI no obligation to return to India NORKA Non-Resident Keralites’ Affairs Department NSSO National Sample Statistics Organization ODEPC Overseas Development and Employment Promotion Consultants OECD Organisation for Economic Co-operation and Development TCCMM Travancore-Cochin Council of Modern Medicine WHO World Health Organization Key words: India, Kerala, migration, doctors, MBBS, WHO Global Code of Practice 2 FROM BRAIN DRAIN TO BRAIN GAIN MIGRATION OF MEDICAL DOCTORS FROM KERALA 1. Background the public contribution to overall health care expenditure in India has remained around 1.3% of gross domestic India’s health care system is complex. Health services are product (GDP) (3). A combination of low health delivered by both the public and private sectors. In the insurance coverage and a dominant fee-for-service country’s federal structure, individual states are respon- private sector in the delivery of curative care services sible for the delivery of public sector services. The public has resulted in a situation where the vast majority (71%) sector provides curative and preventive health services of health spending is financed out of pocket (3). Such through a vast multi-tiered network of health facilities high levels of out-of-pocket payments cause catastrophic comprising health subcentres, primary health centres, health spending and impoverishment, particularly community health centres, and, at the top of the pyramid among the poor and near-poor. Studies have estimated in each district, the district hospital. In addition, there that 3.5% of the population fall below the poverty are public sector tertiary and teaching hospitals. This line and 5% of households suffer catastrophic health structure is common to all states in the country, though expenditures (4). The public health system in India is staffing norms can vary. Services in both allopathic financed by the central, state and local governments, and Indian systems of medicine are offered, though the though the first two are the most important. The main thrust of the public sector system is on allopathic majority of government spending on health is on medicine. Despite a large public sector network, India’s health worker salaries. health system is highly privatized. Approximately 80% of outpatient visits and 60% of hospitalization episodes Human resources for health in India are characterized by were provided by the private sector (1). The private a diversity of health workers, including practitioners of sector is a heterogeneous group encompassing a diversity allopathic medicine and Indian systems of medicine. The of health care providers. The scale of operations ranges workforce also includes many informal medical practi- from general practitioners operating their own clinics, tioners, generally called registered medical practitioners to small to medium-sized hospitals, to large corporate (5). One study estimated that around 56.4% of all health hospitals. Importantly, a sizeable portion of the private workers in India did not have any formal qualification providers, particularly in rural areas, operate without a (2). In recent decades, India has undergone a remark- recognized medical qualification (2). able growth in the capacity to produce medical doctors and nurses, largely driven by the growth in the number Health care in India is overwhelmingly financed by out- of private sector institutions. The number of medical of-pocket payments from