Ahmad Zaheer Qureshi  ( Department of Physical Medicine and Rehabilitation, King Fahad Medical City, Riyadh Saudi Arabia. )
Farooq Azam Rathore  ( Department of Rehabilitation Medicine, CMH Lahore Medical College, Lahore Cantt, University of Health Sciences , Lahore. )

There are around 175,600 registered doctors in Pakistan, but limited data is available about Pakistani physicians pursuing medical careers abroad. Additionally, no data is reported about Pakistani physicians who leave the country to pursue medical career overseas, but end up in non-medical professions. We identified two groups of physicians leaving the country: those going abroad for postgraduate training and residency; and those doing so for better career incentives and monetary benefits and to avoid the deteriorating law and order situation and rising hostilities towards doctors in the last few years. Other factors contributing towards physician\'s migration include poor service structure and career prospects, lack of research funding, increased workload and stressful work environment. Optimal measures need to be taken so that the locally trained doctors can deliver their services where they are needed the most, instead of seeking overseas opportunities. Similarly, volume of expertise may be enhanced by promoting social accountability among Pakistani physicians working abroad and by creating comparable opportunities within the country.
Keywords: Pakistan, Physicians, Job Satisfaction, Training Programs, International Perspectives, Globalization.


Introduction

Global health relates to the ailing humanity in every part of the world. Since illness cannot be confined within borders, therefore healthcare provision is not a restricted privilege. Hence clinicians are obliged to provide their services beyond borders, wherever they are needed the most and where they can provide their services to the best of their capabilities. Pakistani doctors moving around the world are no exception. There is evidence that medical students and physicians in Pakistan plan to go abroad to study or settle permanently because of various reasons.^1,2 As of March 2013, total number of physicians registered with Pakistan Medical and Dental Council (PMDC) was 175,600.³ There were 161,674 registered medical practitioners and 12,839 registered dental practitioners. No definite data is available as to how many Pakistani physicians who have graduated from Pakistani medical schools are continuing with their professional careers abroad. One study estimated in 2005 that Pakistan had contributed about 13,000 medical graduates to USA, UK, Canada, and Australia.⁴ The impact of brain drain was reflected in a study which reported that, compared to the 315 psychiatrists serving in Pakistan, there are 1,473 Pakistani psychiatrists serving abroad.⁵ The objective of the current study was to briefly review the trend of Pakistani physicians pursuing their professional careers outside the country and to identify the factors that lead to this massive efflux of physicians from a country having an underdeveloped healthcare delivery structure.


Methods and Results

Data was extracted from an electronic literature search (1950-2013) on Pubmed, Google Scholar, Sciencedirect, Ovid, and Sagepub, with key words \'Pakistan\'; \'physicians\'; \'residents\'; \'trainees\'; \'expatriates\'; \'medical education\'; \'residency programme\'; \'training\'; \'medical graduates\'; and \'foreign medical graduates\'. Since this was a narrative review so no qualitative analysis was done to exclude articles. All pertinent manuscripts (original research articles; news; brief reports and commentaries) were read and relevant data (number of physicians; reasons for migration and dissatisfaction etc.) were extracted.
In addition, the websites of the Ministry of Health, Government of Pakistan; PMDC; College of Physicians and surgeons Pakistan (CPSP); General Medical Council (GMC), UK; Foundation for Advancement of International Medical Education and Research (FAIMER) were explored for additional data and insight.
We identified two groups of physicians leaving the country: those going abroad for postgraduate training and residency; and those doing it for better career incentives and monetary benefits as well as to avoid the deteriorating law and order situation and rising hostilities towards doctors that have become common in the last few years.
The annual net emigration of Pakistani physicians ranges from 1,000 to 1,500, of whom only10-15% return, resulting in a net migration of 900 to 1,275 physicians every year.⁶ The factors contributing towards this trend are several.
The first factor is international recognition of PMDC and MBBS from Pakistan. Out of the 89 PMDC-recognised medical colleges, 88(99%) are listed on FAIMER International Medical Education Directory,⁷ which makes Pakistani medical graduates eligible to pursue their careers abroad by taking foreign licensing examinations. Graduates of top medical schools in Pakistan are also leaving in large numbers for postgraduate training abroad. For example, by 2004, 900 out of the 1,100 medical graduates from the Aga Khan University (AKU) had gone to USA for specialisation.⁸ In addition, Pakistan is the second biggest contributor of International Medical Graduate doctors in the UK⁹ and despite the 9/11 aftermath, it ranks number three in total number of J1 visas (non-immigrant visa category for individuals approved to participate in work-and study-based exchange visitor programmes) issued for the year 2010-11.¹⁰
The second factor is shortage of junior physicians abroad. In 2011, there was a crisis in Ireland requiring 4,600 junior physicians on an urgent basis. In one trip to Pakistan and India, 420 doctors were recruited by Health Service Executive (HSE) Ireland.¹¹ It is interesting to note that even formal requirements for medical registration were exempted, like licensing exams and International English Language Testing System (IELTS), during this hiring.
The third factor is better monetary incentives abroad. It is observed that Middle East and Gulf remain the destination of choice for Pakistani doctors. Saudi Arabia alone hired 2,500 doctors in 2010.¹² The monetary incentives being offered to physicians at all stages of career are much more lucrative than what is being offered in Pakistan (pay package 5 to 10 times better than the Pakistani pay scale along with free return tickets, accommodation and allowances etc. for each category).¹²
The fourth factor is deteriorating law and order situation in Pakistan and increased hostilities towards doctors. As many as 32 doctors have been killed in acts of terrorism in the last one decade.¹³ In addition, kidnapping of doctors, particularly in the Balochistan province, is also on the rise.
Another factor worth mentioning and praising is the role of CPSP, which has made a substantial contribution in international recognition of its postgraduate medical qualifications. This has resulted in various international collaborations, especially with Saudi Arabia, United Kingdom and Ireland. CPSP training network has spread to 139 accredited institutions within the country and 96 overseas hospitals, with 2,500 supervisors and over 13,000 trainees within Pakistan and abroad.¹⁴ Consequently, there has been an increase in overseas job opportunities for locally-trained Pakistani doctors. Besides, the pathway for seeking foreign training in United States, United Kingdom and Australia continues traditionally.
Other factors contributing towards physician\'s migration include poor service structure and career prospects,¹⁵ lack of research culture and funding, increased workload and stressful work environment.¹⁶
Also, within Pakistan some physicians are pursuing non-medical careers (business, Pakistan Civil Services etc.), and no data is available for them either. This also results in loss of trained physicians. It is pertinent to consider that medical education in all public-sector medical colleges in the country is heavily subsidised. A developing country like Pakistan uses taxpayer\'s money to educate and train future physicians at negligible cost to them. Hence, there is a need to pay back the country by serving its people for at least some time.
Perhaps measures like the Pakistan Overseas Employment Foundation\'s mandatory Protectorate Certificate for those individuals having employment offers from overseas employers can help streamline the physician emigration abroad.


Conclusions

Only limited data is available about Pakistani physicians who are pursuing their medical career abroad. No data is reported about Pakistani physicians who leave the country and end up in non-medical professions. Similarly, statistics regarding return of physicians to Pakistan need to be well documented. It will help evaluate the dynamics of this oscillation and its impact on healthcare in the country. Consolidating locally-trained manpower remains a challenge in the medical field. The seriousness of the matter is often under-rated both by the stakeholders and medical professionals. Optimal measures need to be taken so that locally-trained doctors can deliver their services where they are needed the most instead of seeking opportunities overseas. Similarly, volume of expertise may be enhanced by promoting social accountability among physicians working abroad and by creating comparable opportunities within the country.

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