Special Feature

Dentist migration in Asia Pacific: Problems, priorities and policy recommendations

[Nature India Special Issue: Oral Health Inequalities and Health Systems in Asia-Pacific]

Madhan Balasubramanian1, Jennifer E Gallagher2, Stephanie D Short3 & David S Brennan4

doi:10.1038/nindia.2017.24 Published online 17 March 2017

Policy Recommendations

• Dentist migration is an emerging policy issue in the Asia-Pacific region.

• There is an urgent need to improve workforce surveillance and political advocacy about dentist migration.

• A regional hub to address dentist migration issues is recommended.

(Clockwise from top left)  Madhan Balasubramanian, Jennifer Gallagher, Stephanie Short & David Brennan
Dentist migration is an emerging policy issue in the Asia-Pacific Region (the region includes the WHO South-East Asian Region and Western Pacific Region). While migration is a human right1, and considered essential for global development, it can also lead to brain drain in developing and poorer countries2. To date, there is very little understanding of the dentist migration issue and analysis of its impact on oral health systems and dental workforce development in this region3. This commentary aims to provide an overview of the dentist migration issue in the Asia-Pacific Region.

Why do dentists migrate?

Oral health is integral to general health and dentists aim to maintain and improve it in accordance with the ethics of the profession and within the scope of their education, training, and experience. The choice of dentistry is an at­tractive career option for school leavers4, requiring at least five years of dental education and training before they can practise. The high educational invest­ment and technical skill-sets possibly makes dentists an obvious candidate group for migration.

The reasons for dentist migration are complex5, and include the lure of better remuneration, professional development, career growth, better working and living conditions. Political and economic forces also influence the decision to migrate.

Dental workforce in the Asia-Pacific

It is estimated there are about 1.5 million dentists globally6. The Asia-Pacif­ic region is home to a quarter of these. India, Japan, China, and the Philip­pines contribute to about 80 percent of the dentist workforce in the region. Overall, there are about 10 dentists for every 100,000 people in the region.  Some middle-income countries in the region have for many years deliberately trained more healthcare providers that can be absorbed into the domestic healthcare system. For example, the number of private dental col­leges in India increased from 55 in 1990 to 259 in 20137. Nevertheless, with more than 20,000 dentists graduating every year, India still faces a scarcity of dentists in the villages. Whilst similar issues exist for doctors and nurses, the disparity is more marked for dentistry8.

High-income countries such as Japan, Australia, New Zealand, Singapore and Republic of Korea have more than 30 dentists for every 100,000 people. However, many low- and middle-income countries in the region have less than five dentists per 100,000 people. Pacific Island countries such as Papua New Guinea, Kiribati and Vanuatu have some of the lowest dentists-to-population ratios in the world. Geographic inequalities and maldistribution of dentists (between urban and rural areas) is common in almost all countries in the re­gion.

Migration patterns

The predominant migration pattern in the region is the movement of dentists from middle- to high-income countries. Countries with shared historical and cultural ties, such as being part of the Commonwealth of Nations, can influ­ence migration9. Dentists from India, Malaysia, Sri Lanka and Bangladesh are more likely to migrate to high-income countries in the region also hav­ing a Commonwealth connection (Australia, New Zealand, Singapore and Brunei).

The existence of several bilateral agreements between countries (and dental councils) influences the free movement of dental personnel. For ex­ample, Australia and New Zealand have mutual recognition of dental quali­fications; and an Indian dental degree is accepted for registration to practice in Malaysia. Also trade liberalisation agreements may be agreed regionally, possibly leading to improved migration flows among health professionals. A good example is the Association of South East Asian Nations (ASEAN), fol­lowing the creation of the ASEAN skills recognition framework10. However, many of these regional agreements are at the very early stages, and national dental councils maintain strict protocols on the recognition and assessment of overseas qualifications. 

The case for a regional hub

A major gap in understanding the dentist migration issue is the lack of relia­ble data to support policy decisions, highlighting the importance of workforce surveillance, research evidence and political advocacy on the migration of dentists11. Many poorer and developing countries in the region lack suitable health/dental workforce surveillance systems, such as workforce censuses or surveys. There exists very little reliable information on key issues such as numbers, geographic distribution, and practice activity patterns. Most organi­zations involved in understanding migration issues focus on doctors and nurs­es, and dentistry is relatively neglected in research and development.

Migration data are key to support policy analysis of health personnel migra­tion12. A minimum requirement is data on inflow, outflow and stock of dentists, reasons for migration, career plans, career history, job satisfaction and cultural adaptation issues are essential to better understand the influences on migra­tion and for policy development.

A regional logistics record could improve research and data on dentist migration issues and broadly other dental workforce issues, so as to provide ideas and evidence to underpin policy decisions13. Such a hub could possibly be a part of an international dental workforce and/or oral health inequalities agenda. Research intensive university/academic structures that can provide a sustainable long-term solution to dental workforce research and capacity building in the Asia-Pacific Region offer a logical avenue to build the platform. There also exists a strong case for global organizations (such as FDI World Dental Federation, International Association for Dental Research and the World Health Organization) to incorporate dentist migration and dental work­force strengthening agenda as part of a broader vision of oral health inequali­ties and to enable them to play a more proactive role in the Asia-Pacific region. 

1Research Associate, Australian Research Centre for Population Oral Health (ARCPOH), School of Dentistry, University of Adelaide, Australia; Honorary Associate, Discipline of Behavioural and Social Sciences in Health, Faculty of Health Sciences, University of Sydney (madhan.balasubramanian@adelaide.edu.au); 2Professor, Kings College London Dental Institute, Population and Patient Health  Division, United Kingdom (jenny.gallagher@kcl.ac.uk); 3Professor, Discipline of Behavioural and Social Sciences in Health, Faculty of Health Sciences, University of Sydney, Australia (Stephanie.short@sydney.edu.au); 4Professor, ARCPOH, School of Dentistry, University of Adelaide, Australia (david.brennan@adelaide.edu.au).

References

1. World Health Organization. WHO Global Code of Practice on the International Re­cruitment of Health Personnel. WHA 63. ed. Geneva. 16, 1–12 (2010)

2. The World Health Report. WHO 2006 Report: Chapter 5. Managing exits from the workforce. Geneva (2006)

3. Chen, L. et al. Human resources for health: Overcoming the crisis. Lancet. 364, 1984–1990 (2004)

4. Gallagher, J. E. et al. Understanding the motivation: a qualitative study of dental stu­dents’ choice of professional career. Eur. J. Dent. Educ.12, 89–98 (2008)

5. Balasubramanian, M. et al. The “global interconnectedness” of dentist migration: a qualitative study of the life-stories of international dental graduates in Australia. Health Policy Plan. Oxford University Press 30, 432–441 (2015)

6. World Health Organisation. Global Health Observatory Data Repository. WHO (2013)

7. Dental Council of India: Colleges and Institutions, New Delhi (2012)

8. Anand, S. & Fan, V. World Health Organization. The health workforce in India. Human Resources for Health Observer Series No.16. Geneva (2016)

9. Balasubramanian, M. & Short, S. D. The Commonwealth as a custodian of dental mi­gratory ethics: views of senior oral health leaders from India and Australia. Int. Dent. J. 61, 281–286 (2011)

10. ASEAN Economic Community (2015)

11. Balasubramanian, M. et al. The importance of workforce surveillance, research evi­dence and political advocacy in the context of international migration of dentists. Brit. Dent. J. 218, 329–331 (2015)

12. Balasubramanian, M. et al. The international migration of dentists: directions for re­search and policy. Community Dent. Oral Epidemiol. (2015) 

13. Short, S. & Mcdonald, F. Health workforce governance: Improved access, good regula­tory practice, safer patients. Ashgate (2013)