The Emigration of Doctors

Words By: Dr. Smriti Mathema

“The decision for a doctor to migrate is multi-layered and complex, woven with political, social, and economic considerations. Choosing to stay in one’s own country can wield a significant positive impact on the quality of healthcare services provided.”

Back then in 1999, the popular motto amongst my high school friends was “Anyhow US jaaun” – which translates to “Anyhow, let’s go to the US”. There were boys with towels bearing the US flag and there were girls who used to pray, complete with a gesture, whenever they passed by the US embassy. I was the black sheep you see. I somehow surprisingly was unaffected with the US fervor and instead wanted to study medicine. 

Fast forward two decades, I am now an Associate Professor of Pediatrics in one of the medical colleges here in Kathmandu and I find the same zeal of going abroad in my medical students. I write at least 15 Letter of Recommendation for my medical students aspiring to go to the US for further studies with the promise of a “brighter” future. This number is just that of the subject Pediatrics. Combine all the other major subjects and you easily get over 100 students applying every year. That is an entire batch! And this is just from one single college.

Let us see what attracts young doctors to the developed world – the pull factors? A chance of a full scholarship with decent stipend during their residency. A better pay once employed. A better education for their children. A better car, a better house, a better lifestyle. They see this big bright shiny future waiting for them.

 

“While the allure of opportunities abroad may promise a better life, those who leave may find themselves grappling with unexpected challenges – from cultural assimilation to concerns about healthcare costs and the longing for familiar comforts.”

 

Let us now see what makes these young doctors want to leave the country – the push factors? Do you know an early career doctor in Kathmandu earns less than an unskilled laborer? He has to run to multiple clinics during his ‘off’ hours giving the general impression than doctors are always busy or lobhi, that is greedy. He does this to make a decent living, or pay off the loan he and his parents had taken out for his medical school, which runs in lakhs. Many doctors in Nepal report not being happy or satisfied with their job. Along with difficult work conditions, there has been an increase in violence against doctors, with very low tolerance of public and easily blaming the doctor for negligence rather than trying to understand the situation. Unemployment, lack of skill development opportunities, inadequate remuneration, ineffective regulation and monitoring, and the political encroachment of the health sector are but just a few reasons why someone would want to leave.

Many developed countries rely heavily on a supply of foreign doctors, especially from developing countries like India, Nepal, Sri Lanka and Nigeria, to staff their health workforce. As their health system goes from strength to strength, what are we left with? A scarcity of healthcare workers and a dire need of qualified good doctors, especially to cater the rural areas. According to a report published by the International Labour Organization, 2017, Nepal experiences inequitable distribution of health workers leading to critical shortage in most part of the country. This leaves the health worker-to-population ratio at 0.67 doctors and nurses per 1,000 individuals, which is significantly lower than the World Health Organization’s recommendation of 2.3 doctors, nurses and midwives per 1,000 individuals.

Once you land in the system of a foreign country, it may not be all rosy and pink as you may have imagined. Of course you will have a lucrative salary and a better working and living condition but you will always be an outsider, you struggle to get the right accent and potentially even have to face racism. A local native will be your boss and you have to work extra hard just to prove your worth.

There sure are some perks of staying back in a lower middle income country. You have much higher chances of securing research and travel grants and scholarships. You remain in close proximity with your family with a tight social circle, especially convenient when you are unwell or have young children. And you are surrounded by your own people speaking your own native language and eating dal-bhaat twice a day.  

It is crucial for a country like ours to have a comprehensive policy framework, act or guidelines specifically to govern the migration of health care workers. We need to identify the gap that exists between institutions producing health workers and the institutions that utilize them.  And it is extremely important to have provisions that include financial and non-financial incentives to create a better working environment for health workers and laws to control the increasing violence towards doctors so that they stay back in Nepal.

“It is crucial for countries like ours to bridge the gap between healthcare institutions producing professionals and those utilizing their services. Implementing policies to retain healthcare workers through incentives and addressing violence towards doctors are imperative for the nation’s healthcare landscape.”

As a financially independent mother of 2 precious children, I sometimes find foolishly asking myself what if my younger self was influenced by the “anyhow US jaaun” slogan. One thing is for sure- I would definitely have chased my dream of being a physician but I would be a pediatrician doing my own laundry and dishes, leaving my toddler in day care, driving my daughter to a ballet recital and a thousand miles away from my beloved big crazy party loving Newari family.

The ones who leave the country may have a better quality of life, but they will have to keep their own dead parents in a freezer waiting for their final rights.

Their kids may get an excellent education, but they will constantly have to worry about random shootings at school, their mental health and drug abuse.

They may have made new friends with the migrant Nepali diaspora, but you might have to take appointments to meet them, 2 weeks in advance.

They may have the security of health insurance, but when unforeseen situations arise, like you give birth to a preterm baby who has to be in the NICU for a month, your bill after insurance coverage, will run at least 60-70 lakhs, and you will spend half of your life repaying the debt.

They may not have to worry about basics like water and electricity supply, but their heart will always long for a piping hot plate of momo or jeri swaari.

The decision for a doctor to migrate is multi-layered and is a complex push-pull at various levels – political, social or economic. I am here today, standing in front of you, not because I could not leave the country but because I chose not to. Like mine, a simple idea in a particular doctor’s mind wanting to stay in their own country can have make a huge positive impact in the quality of health service you and your family would receive in your next hospital visit. 

(Excerpts from The Emigration of Doctors, Dr. Smriti Mathema, Tedx Talk, DWIT College, Ideas to Impact, September 30, 2023. Available at: https://www.ted.com/watch/tedx-talks)

Dr. Smriti Mathema

Associate Professor 

Department of Pediatrics

Kathmandu Medical College