Competing Interest : None

This article is written in the background of recent international recruitment of psychiatrists by the National Health Service of UK which ignited hot debate and arguments mainly against it. Of special mention is the hue and cry raised by a Pakistani psychiatrist who believed that the health system will collapse and damaging repercussions will occur if such a practice will continue. Numerous write ups followed in the British academic and lay press which jolted the NHS to some extent. An article by the first author was published recently in the Journal of College of Physicians and Surgeons (JCPSP) detailing the dynamics of this situation. The current article addresses this perspective with a human right angle.

International recruitment of doctors from developing countries to developed countries was forcefully condemned on the grounds that the millions of people in these countries would be deprived of health care which is the basic human right of these people. The UN general assembly in its fifty-seventh meeting noted with concern that highly trained and skilled health personnel from the developing countries continue to emigrate at an increasing rate to certain countries, which weakens the health systems in the countries of origin with a further note that many developing countries are not yet technically equipped to assess the magnitude and characteristics of the outflow of their health personnel. 1

We would like to argue that the freedom of movement is fundamental to the ability of individuals to seek a better life. There are significant individual benefits associated with such migration of a doctor to a developed country from many perspectives. However, one cannot deny that it has serious implications, which have been argued as a major impediment to attainment of health related goals and thus, escalates to a form of human right abuse.

The World Health Organization has intrinsically assumed the problem arguable within the context of human rights. 2 It has repeatedly emphasized its implications on the rounds of violation of right to health for the people within the developing countries who ultimately would be deprived of the services of such trained workforce once they emigrated. In doing so it has adopted a one-dimensional narrow understanding of human right perspective. It has raised all the sympathy for the under served population from their right to health perspective but have totally overlooked the basic individual human rights of the health professionals. In his submission, Chaturvedi 3 was concerned about the predicament of psychiatrists that they are being compelled morally to stay back in their home countries, not to venture or earn from somewhere else, and whether it was ethical to prevent them from getting better monetary incentives. He also noted that doctors emigrate because of poor remuneration, bad working conditions, academic politics, job insecurity, and threat to violence, low standards of living, a wish to provide good education to their children, discrimination, poor funding, limited career structures, poor intellectual stimulation and dissatisfaction. Until and unless a consolidated effort has not been in place at national and international level for addressing these issues, emigration will remain a humane route of securing one's individual rights within health professional community. Any effort for blocking emigration will be immoral and unethical besides the violation of individual rights of health professionals.

We would like to focus here on Pakistan as a case study. Pakistan has recently been debated by few as among the list of developing countries hard hit by emigration/recruitment of health professional, especially the psychiatrists. It has been said that Pakistan, a strategically important developing country, with a population of over 150 millions and a work force of qualified psychiatrists of less than 250, the recruitment of psychiatrists by the developed world especially focusing national Health Service (NHS) in United Kingdom would ignite the death of existing health system in Pakistan. 4 It is worth mentioning here that NHS global recruitment campaign has only led to the absence of six qualified psychiatrists from Pakistan since its inception in 2003. 5 In addition, it is also equally important to recognize that such debate has not incorporated the background reasons for such a big problem. recognize that such debate has not incorporated the background reasons for such a big problem.

The health care scenario in Pakistan is still in doldrums and despite the dearth of health workers, the picture is not rosy when it comes to internal recruitments and placement of these skilled people in the framework of health services. The magnitude of unemployment is quite high in Pakistan.

In Pakistan, mental health care is provided by practically every body, the alternate practitioners take care of a large chunk of population for the simple reasons of low literacy level, stigma with mental illnesses, high cost of psychotropics, side effects of medications etc. General practitioners see the majority of the patients, their referral rate is inhibited by the patients' disapproval about seeing a psychiatrist, and the other medical consultants also look after the mental health of their patient population, perhaps because of the similar reasons. Pakistan medical and Dental Council (PMDC) place low weightage to psychiatry and are happy with even as low in number as 5 beds in psychiatry with no pressure of recruiting more psychiatrists for a department, the concerned private schools does not prefer to appoint more than one or two psychiatrists, with some exceptions. Therefore, room for placement of psychiatrists in private sector has not been enough for a number of psychiatrists being produced locally and those who are returning back from UK and USA. As far as public sector medical schools are concerned, active recruitment despite available vacancies is not in evidence because of multiple reasons like: fear of loss of authority by the existing chiefs on the grounds of qualifications and skills, posts advertised only for rural areas, hidden agenda, political reasons and to gratify as well as ratify the feudal system in psychiatry. Even, the option of private practice is not less than a living nightmare as one has to have an institutional support to build a bank of patients. Some non-government organizations run their clinics where there is ample opportunity to see a large number of patients but the remuneration is meager. Private clinics are also easy prey for terrorists which were reported several times in the media under the caption of "doctors killing", this has lead to many doctors leaving the country and deterred the others from returning back to the country. Low pay scales leading to economic difficulties in the era of high inflation, escalating cost of living is another factor which is a source of great dissatisfaction among psychiatrists. Moreover, it is very strange that a psychiatrist working in one province cannot apply in another province as the public sector appointments are based on their domicile. This is in contrast to many countries both developing and developed where an individual has all rights and liberty to apply anywhere in the country. Psychiatrists are also subjected to mental torture by many colleagues in the form of personal and professional jealousy upto the extent of defamation and even physical damage. How can one stop a doctor who is going abroad for better life, most important is "security" which is non-existent totally which can we witnessed in media with rampant killings, suicide bombing and gross human right violation. The human rights declaration, article 3 states "Everyone has a right to life, liberty and security of person", article 13 states, " Everyone has the right to leave any country, including his own, and to return to his country", article: 23: "Everyone has the right to work, to free choice of employment, to just and favorable conditions of work and to protection against unemployment, article 25: "Everyone has the right to a standard of living adequate for health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services". 6 With these declarations, are the governments of such countries taking some steps to preserve the individual human rights? Among the fundamental rights, security has assumed tremendous importance. Personal communication by the writers indicated that majority of doctors were prepared to stay in the country provided they get assurance of personal safety. The UN makes policies for global implementation and through W.H.O. and other agencies makes sure to help the developing countries to strengthen their capacity in terms of health care and other machinery, large donations flow to these countries but where does the money go? Is it used for the prescribed purposes? The W.H.O. and UN should also measure and monitor the problems of growing insecurity in these countries which lead to loss of the heath work force instead of just monitoring the life expectancy, infant mortality, poverty line, and demographic indicators etc. The US-UN has tremendous impact on developing countries, then why they cannot force these nations to curb violence, avoid political upheavals, respect human rights, wipe corruption and promote all favorable factors that can contribute to conducive environment which would lead to global social well-being, retention of health workers and respect for human rights. Without these steps, no country has any right to prevent their health workers to migrate for the sake of their individual human rights. Any effort in doing this will account towards gross human rights violation by the concerned state in particular and United Nations Organization in general.

1- United Nations. International migration of health personnel: a challenge for health systems in developing countries. Fifty-Seventh World Health Assembly, 2004, agenda item 12.11.

2- W.H.O. World Health Report. Working together for health. 2006, Geneva, Switzerland. pp. 1-30.

3- Chaturvedi, SK. What is important for quality of life of psychiatrists? International Psychiatry 2006, 3: 46-7.

4- Khan. MM. The NHS International Fellowship Scheme in Psychiatry: robbing the poor to pay the rich? Psychiatric Bulletin, 2004, 28: 435-7.

5- Goldberg. D. The NHS International Fellowship Scheme in Psychiatry: Reply to Khan. Psychiatric Bulletin, 2004, 28: 433-4.

6- United Nations. Universal Declaration of Human Rights, 1948-1998-the fiftieth anniversary, adopted and proclaimed by General Assembly resolution 217 A (III) OF 10 December, 1948.