Protest by healthcare workers amid the economic crisis outside General Hospital Colombo in September 2022. Photo: IMAGO / NurPhoto
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Sri Lanka’s exodus of healthcare workers
Following Sri Lanka’s economic crisis, the healthcare sector is experiencing a migration wave, which has led to a shortage of healthcare workers, impacting healthcare services, medical education, and health equity in the country.
Last November, Keheliya Rambukwella, Sri Lanka's minister of health, said in parliament that healthcare workers migrating for overseas jobs without proper approval would be blacklisted and have their medical licences cancelled. This statement received intense backlash from Sri Lankan trade unions in the health sector. The Association of Medical Specialists issued a statement: "AMS considers the Minister's statements as a serious breach of the professional dignity of Sri Lankan medical specialists and their fundamental rights." The Government Medical Officers' Association (GMOA) also identified the minister's statements as a gross violation of workers' rights. "We need to introduce regulations to allow foreign doctors to come and work in Sri Lanka", subsequent statements by the minister Ramesh Pathirana led to further outrage among healthcare workers. It was against this backdrop that the ministry of health recently appointed a committee to look into the grievances of healthcare workers who are migrating to other countries.
The economic crisis of 2022 had a severe impact on Sri Lanka's strained healthcare system, which had already been grappling with the challenges of the Covid-19 pandemic. Stock-out of essential medicines and consumables, power cuts, fuel shortages and political issues challenged the efficient delivery of health services. Healthcare workers had to endure the brunt of this as they had to manage the increased demand for health with ever-dwindling resources. The personal and family lives of healthcare workers were also affected by high inflation, salary cuts, tariff hikes and other austerity measures imposed during this period. They also had to face serious discrimination during the pandemic and the economic crisis. On top of this were preexisting service and administrative issues that have been eroding the job satisfaction of healthcare workers over the years. In this context, an increasing trend of outward migration among healthcare workers in Sri Lanka comes as no surprise.
The wave
According to the 2020 Annual Health Bulletin, Sri Lanka's health workforce comprises 150,273 healthcare workers, with 2730 medical specialists, 21,450 doctors, 1564 dentists, 46,385 nurses, 8525 midwives and other allied health workers including lab technicians, radiographers, therapists and medical attendants. The quality and commitment of these healthcare workers has been the main factor behind Sri Lanka's remarkable achievements in public health, recognised both in the region and in the world. For these same reasons, they are in high demand in the international healthcare market and their migration for overseas jobs has been happening slowly but steadily over the last few decades. A study conducted in 2012 found out that 11 percent of the country's medical specialists migrated between 1980 and 2009.
Healthcare workers are often criticised for deciding to serve in other countries after Sri Lanka has made significant investments in their education and training. However, healthcare workers who migrate to other countries have to vacate their stable jobs, leave their homes and extended families behind, and often become underemployed.
Asela Gunawardena, Sri Lanka's director general of health services, recently stated that about 700 medical officers, including consultants, migrated overseas in 2022. During an interview with the author, Chamil Wijesinghe, the spokesperson of the GMOA, affirmed that according to a survey conducted by the organisation, 477 doctors, including 125 consultants, had migrated for overseas jobs between January and August 2022, and that these numbers were high compared to previous years. Dileep de Silva, a specialist in healthcare management in Sri Lanka, concurred that the increase in migration by health professionals in 2022 was exponential compared to earlier times. According to De Silva, about 280 post-graduate trainees go abroad annually to complete their specialist training, out of which about 250 trainees return to be appointed as consultants in different parts of the country. This number drastically reduced to 105 in 2022, with the majority of those who went aborad remaining there. In a recent media briefing, Ashoka Gunarathne of the Association of Medical Specialists mentioned that, given the current trend, only 50 percent of the consultant vacancies in Sri Lanka estimated for the year 2024–25 will be filled.
Limited data on the outflow of the health workforce makes it difficult to quantify the exact magnitude of this problem. Though the ministry of health maintains records of the healthcare workers who apply for foreign leave, many take short-term leave, resign or vacate their posts with the intention of migrating, making it difficult to track actual numbers. There are also issues related to the sharing of available data at the ministry of health.
Several proxy indicators show the rising intention to migrate among Sri Lankan healthcare workers. Over the last two years, there has been a large spike in the number of Sri Lankan applicants for international medical-licensing exams like the Australian Medical Council (AMC) exam or the Professional and Linguistic Assessments Board exam. Based on data from the AMC's annual reports, the number of Sri Lankan applications for AMC international portfolios increased more than threefold in recent times, from 222 in 2020-21 period to 725 in 2021-22 period. In 2021-22 period, of all the countries in the world, Sri Lanka accounted for the second-highest number of applicants for AMC portfolios.
Increased migration is also prevalent among other professionals like nurses and therapists given the high demand for carers in the West. The governments of the United Kingdom and Sri Lanka signed a memorandum of understanding in 2022 for the recruitment of Sri Lankan nurses, midwives, therapists and radiographers to the United Kingdom's National Health Service (NHS).
Increased migration is also prevalent among other professionals like nurses and therapists given the high demand for carers in the West. The governments of the United Kingdom and Sri Lanka signed a memorandum of understanding in 2022 for the recruitment of Sri Lankan nurses, midwives, therapists and radiographers to the United Kingdom's National Health Service (NHS).
There is also a high demand for specialties like emergency medicine, critical care, anaesthesia and psychiatry in countries like the United Kingdom and Australia, which have become the most common destinations for migrating Sri Lankan healthcare workers. As a result, there is a comparatively larger migration of professionals from these specialties. Recent news reports identified many board-certified anaesthetists, emergency physicians and child psychiatrists in the country who have migrated overseas. A few weeks ago, the only paediatric radiologist in Sri Lanka left the country. These findings are warnings that Sri Lanka's healthcare system, and its citizens, may face dire consequences soon.
The migration of consultant physicians has challenged medical services in district general hospitals such as those in Kilinochchi, Mullaitivu and Avissawella, while the migration of consultant surgeons has affected services at the district general hospital in Hambantota among others. Photo: IMAGO / NurPhoto
Forces at play
Healthcare workers are often criticised for deciding to serve in other countries after Sri Lanka has made significant investments in their education and training. However, healthcare workers who migrate to other countries have to vacate their stable jobs, leave their homes and extended families behind, and often become underemployed. There is also abundant evidence in the literature that shows how migrant health workers suffer from increased depression, anxiety and stress due to job insecurity, culture shock and discrimination.
Limited data on the outflow of the health workforce makes it difficult to quantify the exact magnitude of this problem.
In a recent media report, the Sri Lankan minister of health was quick to attribute the current wave of migration by healthcare workers to last year's Aragalaya, or people's protest movement. Interviews I conducted indicate that the primary driving force behind the migration has been the country's ongoing economic crisis and its resulting hardships.
"Me and my husband never wanted to leave," a doctor who moved to West Asia in 2022 said. Like others I spoke to, the doctor did not want to be named due to the negative image that has been created of migrating health workers in the public without accounting their side of the story. "We have taken housing loans like any other healthcare worker and before the crisis we were able to manage with the salary that remained. But after the crisis, with the high cost of living including prices of fuel and food, we were not even able to take care of our children with the amount that remained. This was when we decided to move."
"Me and my husband never wanted to leave," a doctor who moved to West Asia in 2022 said. Like others I spoke to, the doctor did not want to be named due to the negative image that has been created of migrating health workers in the public without accounting their side of the story. "We have taken housing loans like any other healthcare worker and before the crisis we were able to manage with the salary that remained. But after the crisis, with the high cost of living including prices of fuel and food, we were not even able to take care of our children with the amount that remained. This was when we decided to move."
A nursing officer who is moving to Singapore on a two-year contract explained, "I had only a small interest in working overseas. Then we had to go through the economic crisis last year, which was what induced me to seriously consider that thought. Now there are serious shortages at the clinics where I work at. I might even consider permanent migration with my children, depending on my experience in Singapore."
Job satisfaction among healthcare workers in Sri Lanka has also been falling over the years due to a high patient burden, often-toxic work environments, accommodation and transportation issues, subpar salary scales, problems in transfer lists, red tape at the ministry of health and constant administrative pressures.
A nursing officer who migrated to the United Kingdom in October 2022 shared her story: "I had to travel between Kandy and Colombo to see my child who was with my parents. Last year, it came to a point where we couldn't continue to afford it. I never could get a transfer arranged. Had I received it, I may have stayed, but now I am together with my child and family here."
A nursing officer who migrated to the United Kingdom in October 2022 shared her story: "I had to travel between Kandy and Colombo to see my child who was with my parents. Last year, it came to a point where we couldn't continue to afford it. I never could get a transfer arranged. Had I received it, I may have stayed, but now I am together with my child and family here."
The stigma against healthcare workers during the pandemic and the economic crisis made things worse. "It was disgusting to watch, after all the commitments we made during Covid-19, how the government manipulated people against healthcare workers by creating haphazard fuel allocations during fuel shortages. This was intended to shift the blame away from them," a doctor who is leaving for the United Kingdom recalled. "There was a lot of discrimination towards healthcare workers during the crisis."
For numerous healthcare workers, the well-being and future prospects of their children emerged as a significant factor in contemplating migration. The doctor who moved to West Asia said, "I felt helpless as paediatric wards ran out of essential medicines. There were many problems in education as well. I felt a general lack of safety and security for children in the country." Similar sentiments were echoed by other healthcare workers who migrated with their children. A lack of trust in public institutions and disappointment in their trade-union representation were also common complaints.
For numerous healthcare workers, the well-being and future prospects of their children emerged as a significant factor in contemplating migration. The doctor who moved to West Asia said, "I felt helpless as paediatric wards ran out of essential medicines. There were many problems in education as well. I felt a general lack of safety and security for children in the country." Similar sentiments were echoed by other healthcare workers who migrated with their children. A lack of trust in public institutions and disappointment in their trade-union representation were also common complaints.
The personal and family lives of healthcare workers were also affected by high inflation, salary cuts, tariff hikes and other austerity measures imposed during this period.
Junior professionals cited challenges in establishing themselves financially and professionally in Sri Lanka – a problem that existed prior to the crisis as well – as part of their reasons for migration.
"Contrary to popular opinion, a doctor's salary in Sri Lanka does not ensure stability," a young doctor who recently migrated to Australia said. "The only way for a junior doctor to achieve such was to either spend all their free time on private practice or become a consultant by following post-graduate studies. Though I had the potential to do the latter, working with postgraduate trainees made me realise they had little personal or family life during their training. I did not want to make such a compromise."
During the height of the economic crisis, when the government desperately needed to raise foreign currency reserves, a new public-administration circular was issued allowing five years of leave without pay for public officers in Sri Lanka looking to go abroad for =foreign employment, with no prejudice to their seniority or pensions but with a mandatory condition for remitting money into a Sri Lankan bank account. Though this was aimed at increasing foreign remittances while regulating migration practices, De Silva believes it may have added a certain impetus to the wave of migration.
The increased demand for medical professionals in the United Kingdom following Brexit and the recent struggles of the NHS also directly contributed to the rise in migration. Though the World Health Organisation's "Code of Practice on the International Recruitment of Health Personnel" categorically discourages active international recruitment from countries already facing shortages of healthcare workers, such recruitment is still common in low- and middle-income countries. Furthermore, as Sri Lanka is not included under the 2023 "WHO Health Workforce Support and Safeguards List," which identifies countries with the most pressing health-workforce issues (Nepal and Bangladesh, for instance, are both on the list), there are no restrictions on international recruitments from Sri Lanka.
Health at risk
Losing significant numbers of the health workforce invariably affects both curative and preventive service delivery. In 2019, even prior to the economic crisis, Sri Lanka's healthcare-worker density, which is calculated by summating the density of doctors, dentists, nurses, midwives and pharmacists, was only 70 percent of the global threshold. When considering medical officers, though Sri Lanka has a national doctor-to-patient ratio of 1.2 per 1000, which is close to the WHO recommendation of 1 per 1000, the country has significant inequities in their domestic distribution. For example, the capital, Colombo, enjoys a consultant-to-patient ratio four times higher than that of districts like Nuwara Eliya, Ampara and Monaragala. The impact of migration will be felt hardest by the vulnerable healthcare sectors in these areas.
Increased migration is also prevalent among other professionals like nurses and therapists given the high demand for carers in the West.
There is current evidence of this disproportionate impact from many peripheries of the Sri Lankan health system. According to Wijesinghe, from the GMOA, the migration of consultant physicians has challenged medical services in district general hospitals such as those in Kilinochchi, Mullaitivu and Avissawella, while the migration of consultant surgeons has affected services at the district general hospital in Hambantota among others. In many peripheral units, the workload has increased, leading to stress and burnout among the remaining staff. Additionally, the migration of highly experienced consultants, doctors and nursing officers in large tertiary-care centres like National Hospital Colombo, National Hospital Kandy and Teaching Hospital Peradeniya has curtailed the service quality and the availability at these facilities of many important subspecialties, including cardiology, radiology and urology.
Patients are not the only stakeholders affected by the migration of healthcare workers. Medical education has also been jeopardised as a result. One timely example is the temporary closure of the professorial paediatric unit of the faculty of medicine at Rajarata University due to the migration of its academic staff. There is also considerable migration of experienced professors and senior lecturers from pre-clinical, para-clinical and clinical departments in different medical faculties. These losses will impact the standard of medical graduates produced in Sri Lanka and, ultimately, the quality of healthcare delivery.
"We have a major issue of health governance," Dr Vinya S Ariyaratne, the president of the Sri Lanka Medical Association, said. (Disclosure: Ariyaratne also serves on the board of directors of Himal Southasian.) "The government has not prioritised this issue of healthcare-worker migration and their response has been rather lethargic. At the moment, Sri Lanka needs comprehensive short- and long-term plans for human-resource management in health." The "Framework for Sri Lanka's health workers' mobility" recently published by the International Labour Organisation has identified a set of regulations that could be incorporated into the country's existing policy framework.
Healthcare workers, including postgraduate trainees, in Sri Lanka must enter into a bond with the Ministry of Health before leaving for any foreign training, where resigning while abroad or upon return will be considered a violation of the said bond, making them liable to pay. De Silva pointed out that increasing this bond value for healthcare workers may act as a deterrent in the short term. "While increasing investments in healthcare is crucial, we also need strategic changes like strengthening primary care, which has the potential to address many health workforce issues," Ariyaratne added. Both De Silva and Ariyaratne emphasised that the existing circular allowing five-year leave for healthcare workers going abroad needs revisiting. Wijesinghe mentioned that the government must also address existing drug shortages as well as problems of accommodation and other facilities at peripheral hospitals if the current brain-drain is to be stemmed.
Losing significant numbers of the health workforce invariably affects both curative and preventive service delivery.
Introducing fair taxation policies, streamlining the transfer process and providing financial and non-pecuniary incentives, especially to healthcare workers working in peripheral areas, will be crucial to keeping them in the country. Upgrading the salaries of healthcare workers must also be a strategic objective if Sri Lanka is to successfully discourage them from going abroad. This is where austerity measures to cut down on state services and spending conflict with safeguarding the country's health. Despite the country's health sector facing continuous budget cuts amid the economic crisis, the defence budget has seen notable growth – a reminder that investments in health and the health workforce are a political choice rather than just a matter of fiscal space.
On balance, many systemic reasons underpin a healthcare worker's decision to migrate, and it is not merely a search for greener pastures. Only by understanding these drivers can Sri Lanka balance healthcare workers' rights against the country's health security. If policymakers fail to address this critical issue, the damage to Sri Lanka's health system will be irreparable, compromising even the comparative stride in health that the country has achieved so far.
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