Doctors' Association for Social Equality

Publication: Bulletin of the World Health Organization; Type: Research
Article ID: 07-041681; Article DOI: 10.2471/BLT.07.048681
Manas Kaushik et al.
High-end physician migration from India
High-end physician migration from India
Manas Kaushik,a Abhishek Jaiswal,b Naseem Shahb & Ajay Mahalc
a Departments of Nutrition and Epidemiology, Harvard School of Public Health, 677 Huntington Ave, Boston
02115 MA, United States of America. Correspondence to Manas Kaushik (e-mail:
mkaushik@hsph.harvard.edu).
b All India Institute of Medical Sciences, New Delhi, India.
c Department of Population and International Health, Harvard School of Public Health, Boston, MA, USA.
Bulletin of the World Health Organization 2007;85:XXX–XXX
Une traduction en français de ce résumé figure à la fin de l'article. Al final del artículo se facilita una
traducción al español. ة ل 􀑧􀑧􀑧 ة العربي 􀑧􀑧􀑧 ي ن ەذەالترجم 􀑧􀑧􀑧 ة ف 􀑧􀑧􀑧 صەالخلاص 􀑧􀑧 ة الن 􀑧􀑧 ل ل اي 􀑧􀑧 ة ەذەالكام 􀑧􀑧􀑧 .المقال
doi: 10.2471/BLT.07.041681
(Submitted: 23 February 2007 – Revised version received: 11 June 2007 – Accepted: 25 June 2007)
Objective To examine the relation between the quality of physicians and migration among
alumni of All India Institute of Medical Sciences (AIIMS), New Delhi, India over the period
1989–2000.
Methods In a retrospective cohort study, data on graduates of AIIMS were collected from
entrance exam qualifier lists, the AIIMS alumni directory, convocation records, the American
Medical Association and informal alumni networks. The data were analysed by use of 2x2
contingency tables and logistic regression models.
Findings Nearly 54% of AIIMS graduates during 1989–2000 now reside outside India.
Students admitted under the general category are twice as likely to reside abroad (95% confidence interval: 1.53–2.99) as students admitted under the affirmative-action category.
Recipients of multiple academic awards were 35% more likely to emigrate than non-recipients
of awards (95% confidence interval: 1.04–1.76). Multivariate analyses do not change these
basic conclusions.
Conclusion Graduates from higher quality institutions account for a disproportionately large
share of emigrating physicians. Even within high-end institutions, such as AIIMS, better
physicians are more likely to emigrate. Interventions should focus on the highly trained
individuals in the top institutions that contribute disproportionately to the loss of human
resources for health. Our findings suggest that affirmative-action programmes may have an unintended benefit in that they may help retain a subset of such personnel.
Introduction
The migration of skilled professionals from developing to developed countries has long attracted
attention from researchers and policy-makers.1,2 The literature on the subject encompasses a vast area, including assessments of the implications of skilled labour migration for equity and efficiency in economic outcomes, examinations of the links between growth in international trade and trends in international migration, and optimum strategies to address losses to sending countries due to
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Publication: Bulletin of the World Health Organization; Type: Research
Article ID: 07-041681; Article DOI: 10.2471/BLT.07.048681
emigration.3,4 Migration of medical professionals has attracted concern in light of their impact on
health policy goals.5–7 In a seminal 2004 report, the Joint Learning Initiative (JLI) devoted an entire
chapter to international flows of doctors and nurses, and their potentially harmful effects on the less
well off in developing countries. As the report points out, “while the absolute numbers may not be very
large, the outflows can be ‘fatal’ for disadvantaged people in source countries”.8 The world health
report: working together for health, also reached a similar conclusion.9
Considerable information exists on the “push and pull” factors operating in different countries
and the number of doctors migrating from India to other countries, particularly towards Europe and the
United States of America.10,11 However, much less is known about the quality of medical professionals
who migrate, compared with those who remain. The issue of the quality of professionals emigrating is
important both for destination countries where these physicians eventually practice,12,13 but also for
source countries. While the number of physicians emigrating is one dimension of the human capital
involved in migration,14 simple head counts are insufficient if the individuals who emigrate are
academic leaders or better-skilled physicians than those who remain. This set may include institution
builders who are trainers, professors in medical schools, or physician leaders who influence positively,
by example or collaboration, the quality of health services provided by others who remain in the
country. By adversely affecting the training, leadership, and possibly even managerial capacity, the
emigration of high-quality medical professionals adversely affects the health system in a way that
cannot be captured in statistics on the numbers of migrants among medical professionals.
Among developing countries, India is the biggest exporter of trained physicians with Indiatrained
physicians accounting for about 4.9% of American physicians and 10.9% of British
physicians.10 We assess the relation between physician quality and emigration with information on
graduates of the All India Institute of Medical Sciences (AIIMS), India’s top ranked medical school,
over the period 1989–2000. Because there are no readily available objective measures for assessing the
long-term academic or leadership potential of newly trained physicians, we used several indicators of
quality. First, we compared overall emigration rates among AIIMS graduates to those for medical
schools in India as a whole, on the assumption that acceptance into an exclusive institution on the basis
of their performance in medical admission tests is an indicator of both greater academic preparedness
for medical school and overall ability.15 Related to this point, we also inquired whether students
admitted under an affirmative-action quota, whose scores in the AIIMS entrance examination were
generally lower than those of other entrants, have a lower likelihood of emigrating. Finally, we
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Publication: Bulletin of the World Health Organization; Type: Research
Article ID: 07-041681; Article DOI: 10.2471/BLT.07.048681
considered whether individuals who received academic awards at the time of graduation from AIIMS
were more likely to emigrate.
Methods
AIIMS admits students through an objective exam, in which 45 students from a typical pool of 30 000
applicants (0.15%) are selected. We assembled a cohort of AIIMS graduates who entered AIIMS from
1989 through2000, and extracted information on their state of residence at the time of entry and
whether admission was made under the affirmative-action programme from entrance-exam
notifications and national newspapers where exam results are published.
We identified the country of residence, gender and year of graduation for AIIMS graduates
from published16 and online alumni directories,17 with follow-up contacts with individual graduates and
their classmates for whom information was not accessible in these directories. We ensured consistency
of this information with physician registration data in the United States of America, where many
AIIMS graduates migrate. With the exception of two inconsistencies (which we addressed), our
information on country of residence, gender and year of graduation matched exactly with information
on residence available from the American Medical Association data set. However, the American
Medical Association data set does not include information on physicians who are currently enrolled in
graduate programmes (e.g. masters and doctoral courses) and research positions, for instance, and
constitute an important avenue for migration of new graduates. Moreover, there is a lag of 1–2 years in
updating American Medical Association data sets even after physicians join residency programmes.
Thus, we believe that our data set is more up to date than the American Medical Association database.
Information on academic awards received by AIIMS graduates for the years 1989–2000 was collected
from convocation booklets (graduation records) published annually by the institution.
At least 11 of the 45 students are admitted to AIIMS each year under a distinct admission track
for two population subgroups: scheduled castes and scheduled tribes that are considered particularly
deprived under the Indian Constitution. Some 800 castes (of a total of 3000 in India) are categorized as
belonging to scheduled castes, with another 250 groups designated as scheduled tribes.18 The defining
criterion for these groups includes economic and social deprivation, more fully described in an Indian
government commission report.19 Students from these groups whose scores exceed this minimum
become part of the general pool, irrespective of their social background. While we were unable to
obtain admission scores for the entire group 1989–2000, we were able to do so for a group of 394 new
students from 1998 through 2006. Our data show that the affirmative-action group had a mean score of
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Publication: Bulletin of the World Health Organization; Type: Research
Article ID: 07-041681; Article DOI: 10.2471/BLT.07.048681
56.5 (standard deviation = 4.5), whereas the general group (excluding affirmative-action candidates)
had a mean score of 69.4 (standard deviation = 3.8), out of a maximum of 100. Thus, we used
admission under affirmative-action category as a proxy for lower academic preparedness and ultimately
lower quality.
The use of entrance examination marks, or admission under the quota, as an indicator of quality
is problematic as entrance examination scores might not truly reflect ability among socially
disadvantaged people and the decision to emigrate might be based on social networks and economic
ability that can vary across different admission categories. We also used the receipt of academic awards
as a distinct proxy for quality, and compared emigration rates among award recipients and nonrecipients.
In general, because physicians practicing at AIIMS and other public institutions are shielded
from medical malpractice suits by virtue of working in the public sector,19 malpractice suits are
probably not a good indicator of quality, since some AIIMS graduates end up at public institutions.
Furthermore, the onerous nature of the Indian legal system discourages such suits.20 The use of clinicalvignette-
based standardized examination, such as United States Medical Licensing exams, in assessing
physicians, even for residency positions, is discouraged. In the absence of available and accepted
indicators of physician quality, particularly of international medical graduates, most of whom emigrate
soon after graduation, we believe that academic achievement can be used as an indicator of quality.21
We compared emigration rates among groups for alternative indicators of quality, using
proportions and multivariate logistic models for assessing the relative likelihood of migrating. Because
some individuals might have better access to, desire for, and information about opportunities for
migration, confounding might occur. If this propensity to migrate is randomly distributed across
individuals, our results will be unaffected. However, if this propensity were positively correlated with
academic performance,4 it would bias the magnitude of the relationship between emigration and
graduate quality upwards. Other elements of heterogeneity (patriotism or closer family ties) may bias
the relationship in the opposite direction. We sought to partly address such concerns by using
information on the region of origin of AIIMS graduates and their gender in a multivariate regression
analysis to potentially control for such biases.
A total of 564 students graduated from AIIMS during 1989–2000. We could not obtain
information on either the affirmative-action status or province of origin for 136 graduates. This left us
with a sample of 428 individuals. Of this, 21.2% belonged to the affirmative-action category, very
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Publication: Bulletin of the World Health Organization; Type: Research
Article ID: 07-041681; Article DOI: 10.2471/BLT.07.048681
close to the proportion admitted under affirmative action (22.5%). We used this sample to assess the
proportion of graduates emigrating by gender, region of origin, and affirmative-action category
(Table 1) and used multivariate logistic regression to assess the likelihood of emigration (Table 2). The
dependent variable in all of the four regression specifications in Table 2 took the value 1 if the
individual resided abroad and was 0 otherwise. For explanatory variables in multivariate regressions,
we included sex, time since graduation, the square of time since graduation and indicator variables for
region of origin in all models. The main difference in the four regression models used in this paper is
the indicator of quality used: an indicator variable indicating whether admission was under the
affirmative-action category or not (model 1), the logarithm of entrance exam scores for students for the
years they were available (1998–2000; model 2), an indicator variable for any award received
(model 3), and indicators, respectively, for exactly one award and for receiving more than one award
(model 4).
Because the information we possess is on the current residence of physicians, some individuals
in our sample might have returned after a stay abroad, whereas others may have moved both back and
forth. If so, the correct interpretation of dependent variable is that it reflects the cumulative probability
of net emigration of graduates. In fact, the number of returning migrant doctors from AIIMS appears to
be miniscule. For AIIMS graduates during the years 1996–2000, for which we have more detailed
information, only one of the emigrating AIIMS graduates returned to India and that was for just 1 year.
Results
Nearly 54% of AIIMS students who graduated during 1989–2000 now reside outside India. Of the total
alumni emigrating in this group, 85.4% emigrated to the United States of America with no significant
gender differences in the proportion emigrating. This conclusion is in line with our preliminary
examination of AIIMS alumni records showing that roughly 730 out of a total of 1440 AIIMS
graduates, dating all the way back to the early 1960s, reside abroad, suggesting emigration of at least
51%. Of the 428 students in our sample, 52 received at least one award, with some receiving more than
one, amounting to a total of 116 awards. Only one student of 87 (or 1.2%) in the affirmative-action
category received an academic award at the time of graduation, compared to 15.2% in the general
category, supporting the argument that this category may reflect a lower level of academic skill.
Table 1 presents cumulative emigration rates of AIIMS students graduating during 1989–2000
by gender, admission and award category. Among graduates over this period, we find that students
from the general group are nearly two-times more likely to be residing abroad (95% confidence
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Publication: Bulletin of the World Health Organization; Type: Research
Article ID: 07-041681; Article DOI: 10.2471/BLT.07.048681
interval: 1.53–2.99, P < p =" 0.436).">1. Grubel H, Scott A. The brain drain: determinants, measurement and welfare effects.
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Publication: Bulletin of the World Health Organization; Type: Research
Article ID: 07-041681; Article DOI: 10.2471/BLT.07.048681
Table 1. Demographic, award and emigration information on AIIMS graduates, 1989–2000
Characteristic Category Total Emigrated
% (n)
P-valuea
(2-sided)
Gender Men 350 54.9 (192) 0.436
Women 78 50.0 (39) –
Region 1b 101 61.4 (62) 0.090
2c 30 63.3 (19) –
3d 132 46.2 (61) –
4e 165 53.9 (89) –
Affirmative action 87 28.7 (25) < 0.0001
No awards 375 53.6 (201) 0.096
One award 28 42.9 (12) –
Two or more awards 25 76.5 (18) –
a P-values based on χ2 test and assess whether the proportion of students migrating differs across groups.
b Region 1: Punjab, Haryana, Himachal Pradesh, Chandigarh.
c Region 2: Maharashtra, Andhra Pradesh.
d Region 3: Bihar, Madhya Pradesh, Uttar Pradesh, Rajasthan.
e Region 4: Karnataka, Tamil Nadu, Kerala, North Eastern States, Jammu & Kashmir, West Bengal, Delhi.
Table 2. Quality and emigration among AIIMS graduates 1989–2000: logistic regression
results
Dependent variable: indicator of emigration
(standard error of the logistic regression estimates)
Explanatory variable
model 1 model 2 model 3 model 4
N 428 113 428 428
Constant 0.06
(0.35)
−30.80a
(10.81)
−0.37
(0.34)
−0.40
(0.35)
Sex
(male = 1, 0 otherwise)
0.08
(0.27)
−0.71
(0.53)
0.15
(0.26)
0.16
(0.26)
Time (since graduation) 0.24a
(0.11)
−1.91b
(1.02)
0.25a
(0.11)
0.25a
(0.11)
Time squared −0.02a
(0.01)
0.87b
(0.48)
−0.02a
(0.01)
−0.02a
(0.01)
Affirmative action
(yes = 1, 0 otherwise)
−1.42a
(0.28)
– – –
Log (entrance marks) – 7.47a
(2.58)
– –
Indicator variable
(one or more awards)
– – 0.25
(0.30)
Indicator variable 1
(one award)
– – – −0.36
(0.41)
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Publication: Bulletin of the World Health Organization; Type: Research
Article ID: 07-041681; Article DOI: 10.2471/BLT.07.048681
Indicator variable 2
(two awards or more)
– – – 0.99a
(0.47)
Dummy for region 1c 0.20
(0.27)
0.43
(0.54)
0.35
(0.26)
0.38
(0.26)
Dummy for region 2d 0.76b
(0.45)
0.02
(1.58)
0.35
(0.42)
0.43
(0.42)
Dummy for region 3e −0.25
(0.25)
−0.28
(0.53)
−0.26
(0.24)
−0.24
(0.24)
χ2 43.21 15.41 14.68 20.03
AIIMS, All India Institute of Medical Sciences.
a P < 0.05; P-values based on logistic regression (Wald test).
b P < 0.10; P-values based on logistic regression (Wald test).
c Region 1: Punjab, Haryana, Himachal Pradesh, Chandigarh.
d Region 2: Maharashtra, Andhra Pradesh.
e Region 3: Bihar, Madhya Pradesh, Uttar Pradesh, Rajasthan.
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