Muhammad Arif1, Mary Cruickshank2, John Fraser3 To migrate abroad or remain: A study of Pakistani physicians’ decision-making Muhammad Arif1, Mary Cruickshank2, John Fraser3 1. School of Health , University of New England, Australia 2. School of Health Sciences, Charles Darwin University, Australia 3. School of Rural Medicine, University of New England, Australia

Background Recruitment, retention & migration of health care professionals is a global problem According to WHR (2006) estimates, globally there is 59 million health workforce There is a global shortage of 4.3 million HRH There are 57 countries with critical shortages of 2.4 million physicians, nurses and midwives Majority of these countries are in sub-Saharan Africa and South-East Asia

Study significance Pakistan is among the leading sources of physicians working in USA, UK, Canada & Australia It falls in the category of 57 countries having low density of health workers and high under 5 mortality rate Causes of physician migration and retention are not being evaluated in depth Better inform future health human resource policy and planning in Pakistan

Study aim Explore Pakistani physicians’ decision-making concerning their decisions to stay, migrate abroad or re-settle back into their country following a period of working abroad

Study design Methodology: Hermeneutic phenomenology Study methods: Semi-structured in-depth interviews conducted via telephone Study settings: Pakistan & Australia Study population: Pakistani physicians who obtained their primary medical qualification from Pakistan and were working as physicians either in Pakistan or Australia at the time of the study Sample size: 13 ( Leavers 5; Re-settlers 4 & Stayers 4) Analysis technique: thematic analysis

Preliminary findings A. Differences Reasons for leaving – leavers & re-settlers Lack of good post-graduate training ‘There [Pakistan], when you start medicine then you look for a brighter future. Then you look for training. So, there was no training. So keeping this in mind, we came out and then a cascade has started.’ (PL3) Lack of career progression ‘The second problem was that professionally I was stagnant. I was not moving forward. At some stage I was stopped and I could not see how I could move forward or not.’ (PL2)

Preliminary findings (Cont.) Societal degradation ‘….I had never ever liked societies not merit based and my biggest problem in Pakistan as a doctor or as an individual was that there was no merit, no remission of merit. There was no justice and things are going from bad to worse rather improving, they are deteriorating.’ (PL1) Lower Salaries ‘The salaries are very less here and in this salary you can’t afford living. The education of children has become very expensive especially professional education.’ (PR4)

Preliminary findings (Cont.) Reasons for re-settlement Permanent job in Pakistan Quality of life vs. standard of life Difference between locals and non-locals Problems in re-settlement Difficulty in finding suitable jobs Underpaid jobs

Preliminary findings (Cont.) Lack of welcoming attitude ‘There was no welcoming attitude in government hospitals that a person has returned after so much leaning. There were no such opportunities that you apply somewhere…. that you should take such people in your system so that they teach something more to our future students.’ (PR3) Resistance to innovation (by seniors) ‘In Pakistan, the biggest problem is that if you want to do something new, then people will resist you badly, the seniors of your own department. So, this is a big flaw in medicine here.’ (PR2)

Preliminary findings (Cont.) Reasons for staying - stayers Permanent jobs Less difference b/w local & overseas earnings (specialists) Desire to serve own people Family & cultural attachment Difference between natives & non-natives abroad

Preliminary findings (Cont.) Similarities Identity & belonging If all of us were running out for economic reasons then there will be no improvement in this country. This is our identity. (PR3) Health not being a priority in Pakistan Lack of health human resource policy & planning Value of overseas training & work ‘There [UK] it was real business, real training. They used to take work from you. There it was proper training. They teach you how you will communicate with your patients, GPs communications and community communication, how to prepare for your exam. You know it was a proper training in every respect.’ (PR1)

Preliminary findings (Cont.) Feminization of medicine Trend of specialisation ‘I mean if someone say that someone is doing specialization because of interest, they are very rare. The main reason is that their aim is to specialize and then join a teaching position and get rid of transfer and postings and secondly establish a good clinic.’ (PS3) Lack of doctors in rural areas due to lack of facilities (especially children education)

Discussion Recruitment, retention and migration of physicians is a complex issue Social, political and economic factors that affect their decisions Need to place health on the policy agenda Greater budget allocation Package of incentives (in rural areas) Abolishment of contract employment policy

Discussion (Cont.) A viable health human resource strategy Need for reliable data on health workforce Needs of future feminised medical workforce Family friendly work environments Part-time trainings and jobs Quality & salaries of postgraduate medical education programs Repatriation of overseas Pakistani doctors or at least involving them in the development of the local health system

Conclusion Although there may be individual factors contributing to Pakistani physicians’ decisions to stay, migrate or re-settle back, there are certain systemic causes that are only amenable to strategic policy actions. To develop a sustainable heath care system, Pakistan needs to develop an effective health human resource strategy that provides for the right opportunities and support of its medical workforce especially in rural areas and those wishing to return back to their country.

Thank you very much!