Background

According to the World Health Organization (WHO), there is a global shortage of 10.3 million healthcare professionals, expected to rise to 12.9 million by 2035.¹ It is further estimated that there is a shortage of 2.8 million physicians worldwide,² with low- and middle-income countries (LMICs) suffering the brunt of this burden.³ Psychiatry is no exception to the growing workforce shortage. Indeed, over the past 20 years, psychiatrists’ numbers have risen by only one-third compared with population numbers, which grew by 4.3 million, or 6.9%.^{Reference Sederer4} Clearly, a highly skilled workforce is essential to deliver high-quality patient care. This generates global competition for the scarce workforce resource.^{Reference Mathur5} The consequent global migration has sparked a broad international debate about sustainability, distributive justice and global societal accountabilities, not to mention the well-being of the migrant workers.^{Reference Aluttis, Bishaw and Frank6} Hitherto, the medical and allied healthcare workforce has been regulated within national boundaries. The post-COVID-19 surge in virtual working in health systems offers an opportunity for low-cost economies to contribute workforce to higher-paying economies without the damaging impact of the current brain drain. However, given the wide variation in technological development and support infrastructures among healthcare providers across the world, along with a huge variation in economic strength across nations, the opportunities of globalising digital healthcare are counterbalanced by the challenges (Table 1).^{Reference Dave, Abraham, Ramkisson, Matheiken, Pillai and Reza7} This editorial offers a potentially different view, providing a way for matching international demand with virtual workforce supply.

Table 1 Challenges and opportunities associated with a virtual international healthcare workforce

Digital solutions and healthcare leadership

Technology has played a big part in medical care for a very long time, especially in remote and rural communities. Bashshur et al define telemedicine as the establishment of medical care minus physical patient–doctor presence.^{Reference Bashshur, Shannon, Krupinski and Grigsby8} Weinstein et al also suggest the term telehealth, with an extended scope, encompassing telemedicine and including telenursing, telepharmacy, public health and health education.^{Reference Weinstein, Lopez, Joseph, Erps, Holcomb and Barker9} Digitalisation, globalisation and environmental issues, as they converge, will have a significant impact on organisations in the future related to how and where the workforce will work. Although an interconnected healthcare system offers new hope of bringing equitable and effective healthcare for all, there remains mistrust of technology, particularly in an intensely personal matter such as healthcare. However, digital solutions have often been adopted at a faster pace in emerging economies, for example in mobile payment technology. Whether similar paced innovations can occur in a highly regulated service such as healthcare remains a moot question. Facing off the twin challenge of workforce scarcity and designing and delivering sustainable health systems will require us to hold our ‘global nerve’ in adopting new technological solutions while keeping ‘up to date with the evolving compliance landscapes’.^{Reference Guo, Ashrafian, Ghafur, Fontana, Gardner and Prime10}

Global workforce, migration and healthcare

Migration of healthcare workers is not a new phenomenon. HICs have relied on workers trained abroad for decades. One sophisticated attempt to map and quantify healthcare workforce flows was conducted in 2007 by the Organisation for Economic Co-operation and Development (OECD), which reviewed the in- and outflow of doctors and nurses in OECD countries based on the best available data.³³ The study showed that over the past 25 years, the number and the percentage of foreign-trained nurses and doctors increased significantly in European countries.³³ Thus far, India is the top source country and provided United States, United Kingdom, Canada, and Australia with 69 000 Indian-trained physicians, it is estimated anywhere from 20% to 50% of Indian health-care workers seek employment overseas.^{Reference Walton-Roberts and Rajan34}

There is a broad consensus in the scientific literature that health worker migration has negative effects on the native country and its people, while the receiving country and the migrating worker are chief beneficiaries.^{Reference Aluttis, Bishaw and Frank6} Saluja et al used the concept of the value of a statistical life and marginal mortality benefit provided by physicians to estimate the economic cost for LMICs of excess mortality associated with physician migration. They estimate that LMICs lose US$15.86 billion (95% CI US$3.4–38.2) annually due to physician migration to HICs. The greatest total costs were incurred by India, Nigeria, Pakistan and South Africa.^{Reference Saluja, Rudolfson, Massenburg, Meara, Shrime and Saurabh35} It is important to note that brain drain does not result in a one-time capital loss, but rather continues to affect LMICs each year that their physicians are out of the country.

More recently, evidence from an exploration of the disproportionate impact of COVID-19 on Black, Asian and minority ethnic (BAME) healthcare staff in the UK has intensified the discussion by shining a light on the determinants of migration and immigration of international healthcare workers. The report has revealed the stresses experienced by international healthcare workers, such as poorer career progression, increased bullying and harassment, higher referral rates to regulators and, sadly, higher death rates related to COVID-19.³⁶

Admittedly, migration may also be associated with beneficial effects, ranging from increased remittances to LMICs to transfer of technology and expertise. Whether migration strengthens or restricts transfer of technology and knowledge between countries remains debatable, but the pandemic has altered the scope of discussion linking technology and the migration process.

Modern electronic technologies have possibly transformed not simply the ‘spatial and temporal’ association between healthcare worker and patient,^{Reference Yellowlees, Richard Chan and Burke Parish37} but also increasingly the recruitment of healthcare workers themselves. Seventy-five per cent of patient–doctor consultations in the pandemic period took place remotely (defined as utilising telephone and video calls).^{Reference Richardson, Aissat, Williams and Fahy38} As medical tourism is set to become less possible between countries in the wake of the COVID-19 pandemic, participatory treatment and the accessibility of marketable technologies can provide patients with extra possibilities to view and track their health information and to connect with their providers. For some, medical care will be delivered in the palm of their hand, in the comfort of their own home. Recently, a healthcare provider in the UK advertised a ‘virtual’ consultant psychiatrist post with 100% remote working.³⁹

Novel mechanism for levelling up global healthcare workforce equity

Could the underlying principle of remote consultations be the attractive alternative for health systems that are facing a crisis in recruitment of healthcare personnel and costs?

Expanding, improving and supporting the health workforce – collectively part of human resources for health – is of fundamental importance. Extending health coverage to more people and offering more services has proved challenging for many of the worst affected parts of the world.^{Reference Guilbert40} Codes of practice on ethical international recruitment – or similar policies – have been introduced at both national and international levels to protect the health systems of vulnerable countries.^{Reference Willetts and Martineau41} We contend that what the WHO's Global Code of Practice on the International Recruitment of Health Personnel^{Reference Guilbert40} has done is to expose the polarisation in the availability of health (including human) resources between HICs and LMICs. The WHO Code of Practice was an ambitious step in the evolution of what has become known as global health diplomacy, seeking to redress the imbalances among health workers around the world by raising important issues of human rights, including access to healthcare, equity and social justice.^{Reference Poz and Siyam42} The adoption of the Code in 2010 by all 193 member states of the WHO has put in place a new global health architecture.^{Reference Cooper, Kirton, Lisk and Besada43} This Code established and promoted voluntary principles and practices for the ethical international recruitment of health personnel and the strengthening of health systems.^{Reference Poz and Siyam42} It is a multilateral framework for tackling shortages in the global health workforce and addressing challenges associated with the international mobility of health workers. For these reasons, the role and relevance of the Code may require a revaluation in the areas shown in Table 2.

Table 2 Key factors requiring revaluation