For more than a century, doctors who received training at the Fiji School of Medicine (FSM),1 the University of Papua New Guinea,2 or, more recently, the Pacific Basin Medical Officers Training Program3 in Pohnpei have been the mainstay of the medical workforce in Fiji and the Pacific island nations. Recently, an attempt has been made to make Fiji and its neighbours self-sufficient in medical personnel by enlarging the undergraduate student intake into the MB BS course from 50 to 70 and by establishing postgraduate specialist training programs at the FSM. However, these plans have largely been thwarted by the shortage of doctors in countries such as Australia and New Zealand, creating a vacuum that has resulted in an enormous “brain drain” of FSM graduates into those countries. Two political coups in Fiji, in 1987 and 2000, have only exacerbated the problem.

Fiji has a population of about 850 000 people, and the other main Pacific island nations (excluding Papua New Guinea) have a total population of about the same size. Hence, a medical workforce is required for about 1.7 million people. The current intake into the MB BS course at the FSM is 70 students per year — or about one student per 25 000 people. By comparison, Australia, with a population of about 20 million people, has a total intake into medical courses of over 1200 per year — or at least one student per 17 000 people.

The exact number of Fijian graduates from the FSM who end up working in Australia, New Zealand, the United Kingdom or the United States is unknown. However, between 1987 and 2002, a total of 510 doctors left the Fijian government health service (Fiji Ministry of Health, September 2004, unpublished data). During this time, the FSM produced 284 graduates for Fiji. Most of the doctor “drain” is to the abovementioned developed countries — so much so that a cynic might conclude that those countries are simply using Fiji and the other Pacific islands as a cheap training ground.

To fill government vacancies, the Pacific island nations rely on expatriate doctors from Australia or similar Western countries, or from Asian countries such as China and India. Expatriate doctors have given excellent service to the people of the Pacific islands. However, there are problems with relying on expatriates for a medical workforce, including difficulty and cost of recruitment, language and cultural differences, and frequent mismatches in expectations between the doctors and the employing country. The morality of recruiting doctors from other developing countries whose needs are just as great as, if not greater than, those of the Pacific island nations is also obviously an issue.

A lot more can be done within countries to develop incentives (and remove disincentives) for our graduates to remain in their home country rather than seek “greener pastures” abroad. For instance, the employment conditions of doctors should allow more flexible and attractive career paths for young graduates. However, the economies of the Pacific island nations will never be able to afford salaries competitive with those offered in developed countries. Appeals to national pride also tend to fall on deaf ears when the political elite are seldom good models of personal sacrifice for the good of the country.

It has been suggested that any country that employs a medical graduate trained in a developing country should reimburse that country the cost of his or her training.4 This seems a good idea, but it is hard to see where the political drive will come from to force a country like Australia to reimburse Fiji the full cost of training, for instance, a specialist surgeon.

Another suggestion is that the FSM should deliberately alter its curriculum to make its graduates less competent to practise medicine in a developed country. However, this would be absolutely counter to the philosophy of excellence in teaching that is at present a fundamental mission of FSM — as it should be. And the practice of medicine in the Pacific is not so different from that in a developed country as to really make this a feasible proposition.

The first step must be for Australia and similar countries to admit there is a problem that must be addressed, and that it is morally unacceptable to actively recruit medical graduates from countries such as Fiji to make up shortfalls in their medical workforce resulting from their own poor forward planning. Once this is agreed, all the stakeholders should devise appropriate responses to assist the requirements of the developed countries for more health professionals, while not overly depleting Pacific countries of their doctors. A suggestion is to genuinely try to reduce the requirement for more doctors in Australia by utilising other health professionals in roles traditionally filled by doctors.

Market forces cannot, and should not, be entirely removed when it comes to employing doctors. However, an unfettered market will usually lead to one party going out of business, and no one wants healthcare in the Pacific islands to go out of business.