Indian psychiatrists in the Australian workforce – From brain drain to brain exchange

Abstract

Worldwide doctors have been migrating from low- and middle-income countries to high-income countries for decades. This contributes to dearth of doctors, especially psychiatrists, in low- and middle-income countries – often referred to as ‘brain drain’. Australia has a fair share of psychiatrists of Indian origin in its workforce. This article endeavours to re-formulate the migration phenomenon as ‘brain exchange’ through the experiential insight of the authors along with published literature and discusses the contribution of substantial number of psychiatrists of Indian origin to the Australian society. Furthermore, the article highlights the potential for the Royal Australian and New Zealand College of Psychiatrists to be a leader in this area by facilitating globally responsible practice by giving back to countries from which psychiatrists originate. The key observations and recommendations are transferrable to other similar countries and equally to other medical specialities.

Introduction

There is significant movement and migration of skilled and unskilled workforce in today’s globalised world, driven by market economy. Doctors, including psychiatrists, have moved across the globe for decades, with the trend being migration from low- and middle-income countries (LMICs) to the high-income countries (HICs). While better living and working conditions are common reason for doctors to migrate, factors like advanced training, qualifications and research opportunities also influence the decision for many. This phenomenon is sometimes described as ‘brain drain’ (Jenkins, 2016).

This has contributed towards significant global inequalities in the distribution of the health workers worldwide, e.g., North America has 10% of the world’s burden of disease and 42% of the world’s health workforce while Africa has 25% of the world’s burden of disease and 3% of the world’s health workforce (Oladeji and Gureje, 2016). This movement of health workers also has substantial effects on patient safety, with nurses who make up the majority of the health workforce also being impacted by both push and pull factors to migrate to HICs (Peters et al., 2020). Furthermore, this is occurring within the context of a global shortage of health care workers (Scheffler and Arnold, 2019; Tankwanchi et al., 2019). Hence, the movement of health workers to HICs has provoked ethical debates focusing on the right of the individual health workers to seek better career opportunities and working conditions versus the rights of the citizens of the LMICs who subsidised the health worker training to access health care (Oladeji and Gureje, 2016).

Australia is one of the preferred destinations for overseas-trained doctors in particular the Psychiatrists of Indian Origin (PIOs). This article explores the contribution PIOs make to Australian workforce and henceforth to Australian society. These contributions are equally transferrable to other HICs. This discussion would not be complete without recognising the cost to LMICs from where psychiatrists are recruited; thus, the phenomenon of ‘brain drain’ is discussed through a more positively focused discussion of ‘brain exchange’, with actionable recommendations espoused. The opportunity for Royal Australian and New Zealand College of Psychiatrists (RANZCP) to take a leadership role and be central to this process is highlighted.

The challenges of migration

The newly arrived PIOs face the usual challenges of migration, such as finding their feet in a foreign country, professional recognition, establishing new social connections, financial challenges and family considerations. Language – the famed ‘Aussie accent’, use of colloquialisms along with differences in work culture and professional hierarchies come up as the initial hurdles for most PIOs which further stands out in the context of professional practice of psychiatry.

Many PIOs find their first placement in under-resourced regional, rural or remote areas, with limited professional support and supervision at a time when they require professional guidance and assistance with acculturation. The supervision requirements have been made more explicit over the years by the Australian Health Practitioners Regulatory Authority (AHPRA), but in reality, the under-resourced area of need positions struggle to adequately meet the needs of PIOs. RANZCP too has made a number of changes over the years to better support overseas doctors including an undertaking from the employers to provide supervision and other supports for progression on the recognition pathway.

Contribution to Australian Society – clinical, leadership and academic

We found it difficult to quantify the exact number of PIOs in Australia. The data are dispersed between different professional/regulatory bodies, does not readily identify PIOs or account for the myriad of pathways adopted by migrating doctors. The latest available Department of Health report on psychiatric workforce expresses concerns on high reliance on international medical graduates (IMGs) entering psychiatric workforce (especially in rural areas) and forecasts the trend to continue at current migration levels (Department of Health, 2016). The data reported by RANZCP on IMGs to the Medical Board 2014–2019 reveals that out of 374 applications for specialist recognition, applicants from India (30%) were second only to those from the United Kingdom (42%) (Medical Board of Australia, 2021). It is highly likely that many applicants in the ‘UK cohort’ would have their primary medical qualification from India. Hence, we can say with reasonable confidence that PIOs are among the largest cohort of overseas-trained psychiatrists in Australia and perhaps the largest nationality entering psychiatric workforce in recent years – a trend likely to continue.

Despite the initial challenges, most PIOs successfully navigate the professional and registration requirements and integrate well with the medical workforce. In addition to providing clinical services in public as well as private sector in Australia, a number of PIOs provide clinical leadership as clinical/medical directors of Australian mental health services. PIOs also contribute significantly to academic psychiatry through university academic positions and undertaking internationally recognised research in the field of psychiatry.

Concept of brain exchange: lessons learnt from global mental health

Jenkins et al. (2010) used the respective professional databases in the United Kingdom, the United States, New Zealand and Australia and documented that there were 4687 psychiatrists from India in these 4 countries in 2009. This number is likely to have grown significantly in the last decade. This is despite a huge disparity between an average of 10 psychiatrists per 100,000 population in these HICs, compared to 0.3 psychiatrist per 100,000 in India (Patel et al., 2016). Chaturvedi (2021) highlighted that there are more PIOs employed outside of India, than within India. Patel (2003) criticised the National Health Services (NHS) UK for their recruitment drives in poor countries, calling it ‘the great brain robbery’. Furthermore, it is recognised that there are a number of factors that ‘push’ PIOs to leave India such as limitations within the mental health care system in India (Mishra and Galhotra, 2018).

While individual clinicians have a right to migrate in a free-market globalised world, population in the donor countries have a right to health. Jenkins et al. (2010) recommended creative international policy approaches and agreements to mitigate harm to donor countries for example through collaborative partnerships to strengthen health services in the LMICs. Jenkins (2016) called for ethical recruitment practices and went as far as recommending that the rich countries must reimburse the LMICs for every health professional migrating after receiving training in their country.

While brain drain is a well-recognised phenomenon, professionals returning to their home country either permanently or to serve temporarily may be called ‘brain gain’, thereby completing the loop of ‘brain circulation’ or ‘brain exchange’ as mentioned in a report by the World Psychiatric Association (WPA) on brain drain. It further goes to recommend that the HICs which benefit from brain drain (e.g. USA, UK, Canada and Australia) commit to contribute towards capacity building in the LMICs from which they imported psychiatrists (Gureje et al., 2009).

Brain exchange – the potential contribution of PIOs to health care in India

A significant proportion of PIOs in Australia is keen to give back and contribute to mental health care in India but require support from various professional organisations or government agencies.

The following six points are offered as actions that could be followed through by interested PIOs, speciality colleges, government and regulatory agencies to close the brain drain and brain gain loop, resulting in a symbiotic brain circulation/brain exchange loop:

1. Teaching: A large proportion of PIOs have expressed willingness to make regular visits to the Indian medical colleges and/or contribute through video-conference for teaching assignments pro bono. In addition to the regular medical/clinical teaching, PIOs can particularly contribute in areas of medical/psychiatric ethics (Ravindran, 2008), communication and collaboration skills, clinical governance and public mental health.

2. Psychiatric Curriculum: Psychiatric training in India has come a long way in recent times including establishment of sub-speciality training. However, many areas can benefit with collaboration with PIOs in areas of mental health law and human rights, clinical governance (quality and safety), public mental health and particularly research. Other areas include emphasis on continuity of care, community care and collaborative care inclusive of family, carers and other stakeholders.

3. Clinical Service: Several PIOs are keen to provide clinical input by rotation at primary care level by holding medical camps in rural areas as well as at a tertiary level at the Indian medical colleges with limited or no psychiatry presence. This requires formal collaboration and agreements between health services, universities and regulatory agencies in both countries. Specifically, this would need to be approved by the Central as well as State Government(s) in India and will need to be delivered in close collaboration with medical colleges’ principals/heads of the departments and district health services. Practical aspects like expatriate psychiatrists’ medical registration in India and credentialing would need to be streamlined.

4. Clinical Governance: The structure and delivery of mental health services in LMICs can be highly variable. Clinical governance involves ensuring that the health service delivery is safe and of high quality, by incorporating evidence-based medicine, clinical guidelines, clinical audits, risk management, regular review mechanisms and quality assurance/improvement activities. Currently, innumerable PIOs are working in senior management positions in the Australian mental health system and have significant health management/administration experience with many PIOs gaining specific qualifications e.g. Fellowship of Australasian College of Medical Administrators (FRACMA). They can play a pivotal role in ensuring robust clinical governance framework, at all levels of mental health care in their country of origin.

5. Public Health: The answer to health care challenges in Indian context will come, to a large extent, from public health principles of health promotion, prevention and early interventions. It is critical to address the social determinants of health and to ensure that there is a whole of government approach to the health of the nation. Public policy in every sector of the government has to be socially responsible to improve a variety of health and human indices. PIOs can play a key role, in collaboration with the Indian public health experts, in providing input into public mental health policy. This could be undertaken in conjunction with the Ministry of Health, the state/district public health and community medicine experts. Furthermore, the initiation and development of collaborative relationships and resource sharing between clinicians and researchers in India and Australia will assist with developing local evidence that can further inform the development of public policy. Moreover, the local evidence garnered could be made accessible through the online portal mentioned below.

6. Technology: There is the potential to utilise technology to facilitate and enhance all of the aforementioned actions to enable brain exchange between HICs and LMICs (Chaturvedi, 2021). Due to the COVID-19 pandemic, the world, including the field of psychiatry, has gained significant expertise and experience with tele-health (Looi & Pring, 2020); this rapid uptake and expansion of tele-health can be a blessing in disguise to facilitate global brain exchange.

Role of RANZCP in facilitating brain exchange/brain circulation

The RANZCP has an opportunity to be a leader in this field through commitment to capacity building efforts in countries from where migration of psychiatrists occurs. It has already taken some steps in this direction e.g. in Asia Pacific Region where meaningful collaborations with not only the local professional organisations but also service delivery has helped raise its profile in the region. RANZCP has been hosting an annual Asia Pacific Mental Health Forum since 2013. One of the key themes in these forums is the psychiatric workforce and challenges in delivery of services in the region. As a result of that initiative, it established a Portal on its website that aims to host relevant information specific to this region (RANZCP, 2016). RANZCP has also initiated an International Corresponding Membership for overseas psychiatrists in 2016 as part of this work. RANZCP could enhance these initiatives further, and this model would be easily transferable to other countries of the Indian subcontinent and indeed any LMICs from where psychiatrists are recruited. Endeavours such as this could be overseen and directed collaboratively by RANZCP and the WPA by facilitating exchange of information between various professional bodies including universities. A number of recommendations are suggested as below:

1. RANZCP and/or AHPRA must maintain readily accessible and structured data on IMGs from different countries to better recognise this important component of health workforce.

2. Develop a formal partnership with member societies such as Indian Psychiatric Society (IPS) to support various initiatives.

3. Facilitate engagement with various professional organisations including universities as part of the IPS and RANZCP partnership to

4. Support psychiatrists in LMICs through developing international networking opportunities.

5. Create a network of RANZCP fellows who have relocated to their countries of origin, to support them in their efforts to local workforce capacity.

6. Targeted opportunities and financial support (e.g. reduced or free registration) for psychiatrists from LMICs to attend College annual conference or other conferences.

7. Allowing free or reasonable cost access to RANZCP journals or Continuing Professional Development platforms.

8. Work with Australian governments to enhance local recruitment in psychiatry rather than relying on psychiatrists from overseas.

Conclusion

PIOs are a significant component of the Australian Mental Health System and the psychiatric workforce will continue to rely on IMGs for foreseeable future. Almost all PIOs have had to navigate initial migratory challenges in professional and cultural assimilation. PIOs make significant contribution to Australian psychiatry through key clinical, administration, teaching and research roles. Their diverse origins and experience parallels the diversity in multicultural Australia.

Psychiatrists migrate for many reasons, but they also stir up ethical debate involving HICs they migrate to. A range of actions are proposed to close the brain drain and brain gain loop leading to brain exchange. This requires active collaboration between several stakeholders. Specifically, HICs could assist LMICs from which they draw health staff by contributing expertise in areas of teaching, medical curriculum development, clinical services, public health and medical administration. These collaborative relationships and undertakings could be facilitated by technology. Thus, the Australian Government and key regulatory bodies such as RANZCP and their counterparts in LMICs are in the position to lead and facilitate globally responsible practices in the migration of health workers. Such an endeavour could begin with psychiatry, but the model utilised would be readily transferrable to other specialities and countries.