Regularly, when I visit a low or middle income country, I meet talented young psychiatrists who express forward looking ideas about mental health services, and are keen to contribute to the reform of the traditional hospital centred services in their countries. Occasionally one is invited to take part in national working groups, showing their potential to become a future leader. Sadly predictable, when enquiring about them later on, the reply is that they have left the country to work in Germany, France or the UK.
This came to my mind recently when I participated in an EFPT workshop on migration. Several young psychiatrists extolled the experience of working in Western countries. Cultural challenges were raised and the value of experiencing new cultures and working in different service models were discussed. A fascinating EFPT survey confirmed the attraction of working in new countries. Less attention was given to the consequences of the exodus of talent from low resource countries.
Let me put up front that I am not blaming individual psychiatrists who look for greater career satisfaction and better quality of life for themselves and their families. I have made that choice myself, emigrating twice to take up posts in new countries. This is an issue that has at least 2 sides to it: push and pull.
Some of my most depressing experiences have been visits to mental hospitals in the same countries I refer to in my introduction. Although there are islands of local initiative, many hospitals are old and in poor structural conditions, and preserve institutional practices with little potential for innovation, demoralising both patients and staff. Career paths are limited and salary poor and research funding is not available. Psychiatrists express a mixture of embarrassment and quiet desperation when they show me around. Some impressive people stay out of loyalty to their country and its people, but many choose a different path.
A few weeks ago I visited a small city in a Nordic country, and it felt and looked like a different world. Mental health care was delivered in modern buildings. New buildings were replaced by newer ones. There was a large academic department with plenty of funding. Staff were given the opportunity to attend conferences around the globe. The place and its culture, helped by its resources inspired a search for excellence and innovation. Several psychiatrists had come from abroad and were evidently thriving, intent to stay.
The question is not why people are migrating from East to West, the case is self evident. My concern is that we may well be witnessing a spiral of decline, with the rich getting richer and the poor poorer. Psychiatrists are not simple to replace. It takes 10 years to train a medical student to become a specialist, half a generation, so incentives to stay are important. I am uncertain to what extent workforce planning of doctors takes account of accumulating losses due to emigration, so anyone departing leaves a gap.
Even if anyone wished, movement of labour in the European Union cannot be restricted. Solutions will have to be found that offer incentives for staying in one’s home country as compared to the attractions of moving permanently abroad. Leaving aside broader personal and political issues that were raised by some in the EFPT survey, this means that actions have to concentrate on salaries and working conditions.
Many countries have indeed increased medical salaries, but it is an unfair struggle. Typical earnings of psychiatrists in Western Europe are at least 4-5 fold higher than in Eastern Europe. Even a doubling of income, not realistically affordable within squeezed public sector budgets, would not make much difference. The answer must therefore be sought in working conditions, and quite bit could be offered here.
Which brings me back to the young psychiatrist taking part in a policy workshop. If countries want to keep hold of their young talent, they will have to listen to them and genuinely empower them. Mental health reform has to be taken seriously, people do not want to work in dilapidated and stigmatising settings. Career paths can be created offering exciting positions that carry responsibilities not at the end of careers, but early on. Work settings should be attractive, with opportunities for research. WHO could support reform. The EU could play a role by offering scholarships for local service initiatives and research, targeting young practitioners.
But EFPT also could play a role. It would be of interest to conduct a survey, not enquiring why people leave but what would make them stay. I suspect young psychiatrists will want to make a difference, driven by aspirations and not merely by a pay check. Offering governments evidence of how to keep hold of their talents, in whom so much has been invested, could be very persuasive to inspire reform.
Dr. Matt Muijen (in picture above at a visit to Kiev)
Programme Manager Mental Health, WHO Regional office for Europe.