Global Physician Supply

Global Physician Supply

Human capital in regards to health workers is an essential component to any health system. Physicians, not to discredit other valuable health professionals, are putatively the authoritative professionals in the diagnosis and treatment of disease and injuries. However, the distribution of physicians worldwide is not based upon need, but rather health-related expenditures. This is illustrated by a WHO report detailing the relative distribution of physicians by the proportion of the world’s total health expenditure by region. For instance, the Americas region accounts for 50% of the world’s total health spending, 20% of the world’s supply of physicians, and 10% of the global burden of disease.¹ A stark contrast can be seen when comparing these figures to that of the WHO South-East Asia region which suffers the highest proportion of the global burden of disease. The people in this area experience 29% of the global burden of disease and yet only have access to 11% of the world’s supply of physicians and 1% of the world’s total health expenditures.¹ These figures present three readily apparent implications: 1) physicians tend to practice in areas with more health spending rather than in areas with need, 2) due to the vast disparity in physician supply and health expenditure, many physicians may be heavily influenced to migrate to more wealthy areas of the world, and lastly 3) global health expenditures do not match the burden of disease experienced by people worldwide. This leaves us with the pointed questions of whether physicians are the best answer for lower-income countries. Could nurses provide the same level of care? Who is best suited to meet the basic health needs of the impoverished and misfortunate? My initial thoughts immediately favor a model with physicians playing the lead role in the global effort. The sheer number of potential medical diagnoses and treatments, the presentation of clinical sequelae to detract from the underling health issue, and the inherent difficulty in treating multiple co-morbidities all speak of the need for highly trained individuals to provide effective care. The quality of care may be especially important in areas that may currently rely on more traditional (and ineffective) medicine. This is not to discredit traditional remedies under the assumption that all traditional remedies are ineffective, but rather to build national confidence in the fledging health systems –thus increasing needful utilization.

Perhaps the largest contributor to the disparities observed in the global physician distribution is the famed “brain drain.” This is so called because many well-trained and bright individuals leave their home in search of better living conditions or more pay. This benefits both the immigrant and the receiving country as the immigrant (upon successful completion of a US residency) may enjoy a higher standard of living (monetarily at least) and the receiving country gains a physician without contributing to the expensive medical education process. The US in 2004 had a working international medical graduate (IMG) workforce of 208,733 (25% of the total physician workforce) with 60.2% of them coming from lower-income countries.² IMG’s have played a huge part in shaping our physician workforce in the past 30 years. Medical school enrollment in the US has remained constant since 1980 with the increasing number of physicians to accompany population growth and demand largely coming from India, the Philippines, and Pakistan.³ Thus, not only are the countries of origin loosing human capital, but also their investment in the training of the individual. This behavior is not to be unexpected. Perhaps these individuals are frustrated about the widespread need for health care and yet lack the tools and infrastructure to make a meaningful impact. Perhaps rampant disease and illness (such as illustrated by AIDS) in the area frightens the physician as he/she must work in conditions that dramatically increase the chance of transmission. It would be interesting to know whether practicing in a wealthy country is a major expectation among foreign, low-income country medical students.

The need for “locally grown” physicians (I believe) is of paramount importance for building health systems that are: cognizant of local culture and values, aware of local health-related knowledge/perceptions, knowledgeable about local traditional healing, able to garnish local respect and trust from patients of the same nationality, and establish a sense of responsibility and local ownership of population health. However, much work is needed to build a world where this is the norm rather than the exception.

Sources

1.       Scheffler R, X Liu J, Kinfu Y, and R Dal Poz M. Forecasting the global shortage of physicians: an economic and needs-based approach. Bulletin of the World Health Organization. July 2008;86:516-525

2.       Mullan F. The Metrics of the Physician Brain Drain. The New England Journal of Medicine. Oct. 2005;353:1810-1818

3.       Anderson G, Reinhardt U, Hussey P, and Petrosyan V. It’s The Prices, Stupid: Why The United States Is So Different From Other Countries. Health Affairs. 2003.22:89-105