A wasteful mockery / by Zbigniew Bankowski

"A wastelul mockery" A glut of medical graduates and an unprecedented level of unemployment among medical and dental graduates is causmg deep concern in many parts of the world today by Zbigniew Bankowski conference on "Health Man- power Out of Balance: Con- flicts and Prospects," held last autumn in Acapulco, Mexico, brought together about 120 health policymakers, physicians, dentists, nurses, medical students and educators of health personnel from 40 countries. It was prepared in close collaboration with WHO, the Pan American Health Organiza- tion, the World Federation for Medical Education, and the Sec- retariat of Health of Mexico. This meeting was convened in response to a deep concern ex- pressed by health leaders from both industrialised and developing coun- tries about a glut of medical gradu- ates in their countries, and conse- quently an unprecedented level of unemployment among medical and dental graduates . The number of unemployed phy- sicians is poorly documented, but some data are available which illus- trate this frightening phenomenon. For example , 45,000 physicians are unemployed in Italy, 40,000 in In- dia, 23,000 in Spain and 2,500 in the Netherlands. The United States forecasts an excess of 70,000 physi- cians in 1990 and 150,000 in the year 2000. In Mexico in 1984 there were about 40,000 unemployed physicians and in Bangladesh more than 5,000. Pakistan reports 6,000, Egypt 4,000, and the Republic of Korea estimates about 26,000 un- employed physicians in the year 2000. Already, associations of un- employed physicians have been founded in Argentina, Bolivia, Chile, Mexico and the Netherlands. Final examination for aspiring physi- cians. Will their skills match the needs of the population? Photo WHO/P. Boucas W oRLD HEALTH, April1987 With the present trends, the world faces the prospect of a sur- plus of 250,000 physicians or more by the year 2000. This would be a wasteful mockery in the year targeted to celebrate Health for all, as was stated by one of the partici- pants at the Acapulco Conference. It should be underlined, however, that the shortage of certain categories of health worker is still a major problem in many developing A debating-point for the World ,. Health Assembly A resolution passed by WHO's Executive Board at its session in January in Geneva expressed concern that "while shortage of certain categories of health man- •.·.· power is still a problem in mahy cmmtries, an increasing number of member states have an over- supply of certain categories· of health professional, such as phy- sicians and dentists, leading to their under-utilisation, unemploy-1 ment and migration to other countries.'' lt urged member countries of wHo "to reorient education and training of health manpower to respond fully to local needs," and "to employ measures urgently, when actual imbalances exist or occur, to adjust the production of health manpower, in order to bring the supply and distribution into line with expected future demand for services, bearing in mind the country's ability to sup- port such services." The 40th World Health Assem- bly, to be held in Geneva next month, was to discuss this resol- ution in the context of "promo- tion of balanced health man- power development''. countries, and will probably remain so for a long time to come. There is frequently a discrepancy between the training health workers receive and the skills they need to provide health care for' the needs of the population. Moreover, few countries have a manpower dis- tribution pattern that conforms to community needs, whether such a distribution is by geographical area, by occupation, by speciality or by type of health care. In some coun- tries, even those facing an acute shortage, the so-called "brain drain" of highly-trained health workers to more prosperous sur- roundings has traditionally been a well-recognised phenomenon. The overall goal of the Acapulco conference was to analyse the qual- itative and quantitative balances in the production and use of health care providers, in terms of rele- vance to national policies and strategies for achieving Health for all by the year 2000, and also to estimate present and foresee- able imbalances in health man- power-especially those result- ing from an over-production of physicians. The participants also tried to as- sess the social and economic conse- quences , to weigh up alternative policies for preventing and reducing imbalances and alleviating their consequences, and to consider the educational factors involved and their implications. From the outset it was realised that a dearth of information severe- ly limited the definition of health manpower imbalances in most countries. But 16 countries , repre- senting a variety of economic, cul- tural and socio-political conditions, prepared studies illustrating their 3 "A wasteful mockery" respective health manpower imba- lances and identifying the overall trends. They ranged from Argen- tina, Cuba and Egypt to Canada and the United States. A main working paper presented a composite picture of health man- power imbalances worldwide, sug- gested a conceptual framework, provided a common terminology and information base, and served as a focus for discussion. It also sug- gested steps which national and in- ternational agencies might take to deal with the problem. In addition a number of papers on selected issues were prepared, covering such gen- eral aspects as the nature, scale, natural history, demography and economics of the imbalances, and dealing not only with physicians but also with other categories of health professional such as dentists, nurses and pharmacists. After five days of deliberation, the conference concluded that the problem of imbalance of health manpower is far more severe than had previously been thought. Very few countries, if any, are exempt from imbalance, and hence the need for action, both preventive and curative, is worldwide. While the medical profession is by far the most severely affected, with unem- ployment and under-employment of practitioners as the most obvious manifestation of imbalance, other ,, " l health occupations are also affect- ed, in an increasing number of countries. The participants discus- sed particularly the over-produc- tion of medical graduates, its main causes, complications and conse- quences, and suggested alternative interventions. The conference recommended a number of preventive actions and other measures which would help to solve acute manpower imbalances. The aim should be to bring the supply of health professionals into line with the foreseeable demand of the population and the economic ability of a country to make ad- . V "" ,, Present supply. of physicial'lS · .~ Country Reference Population Number of Doctors/1 00,000 Evaluation year (1000) doctors population (1985) Argentina 1980 27,947 46,353 165.8 Surplus Brazil 1980 119,099 101.793 85.5 Adequate Canada 1983 25,000 41.440 165.7 Surplus Colombia 1985 28,100 18,158 64.6 Surplus Cuba 1985 10,048 22,910 228.0 Adequate Egypt 1985 47,000 71.739 152.6 Surplus India 1981 685,185 250,000 36.5 Surplus Mexico 1985 77,777 95,000 123.4 Surplus Pakistan 1985 94,700 25,650 27.1 Surplus Philippines 1982 50,000 30,000 60.0 Surplus Rep . of Korea 1984 40,559 28,015 69.1 Adequate Sri Lanka 1983 15,400 1,243 8.1 Shortage USA 1982 235,700 465,026 197.3 Surplus Only one out of 13 countries which evaluated their supply of physicians felt there was a shortage. l 4 Imbalances can be corrected: but action is needed now. Photo lnterfoto MTI Hungary© equate use of them. Urgent re- search is needed into this fast-grow- ing problem, and a regular ex- change of information between countries. Among radical actions that might be taken to reduce the surplus of doctors, the conference . suggested the following: - limiting the intake into medical schools or restricting the number of graduates; - postponing the opening of new medical schools or even closing existing ones ; - imposing a compulsory retire- ment age for physicians. Above all, the conference con- cluded that it was essential to alert not only health professionals and health policy-makers but also politicans and the public at large to the present alarming trends in im- balance and the negative conse- quences they are bound to have for many societies in the future. The recommendations were sum- m.ed up in a statement made by Professor A. Gellhorn, Chairman of the conference. "Concerted action is now imperative," he said. "Both quantitatively, and qualitatively, health manpower imbalance has serious implications for the attain- ment of Health for all. We all agree that imbalances may be predicted and prevented: therefore, the necessary interventions have to be initiated now". • WoRLD HEALTH, April 1987