The Commonwealth as a custodian of dental migratory ethics: views of senior oral health leaders from India and Australia

Abstract

Objective: The Commonwealth of Nations is a unique congregation of 53 countries providing a platform for realistic collaboration on several social and health care issues. Ethical migration of health professionals from developing to developed countries is a key priority of the Commonwealth and several ethical codes have been put into practice. However, these codes have been mainly developed in regard to the medical workforce (physicians and nurses), and can have some limitations when applied to the dental profession. The aim of this study was to understand the role of the Commonwealth in influencing ethical migration of dentists from developing to developed countries, by examining the case of Indian-trained dentists migrating to Australia. Methods: The research design involved interviewing key health care or oral health leaders in India and Australia. A semi-structured interview process was designed. Grounded theory techniques were used in data collection and analysis. Findings: Both the Indian and Australian participants expressed serious doubts on the Commonwealth or any of its Associations in influencing ethical migration of Indian trained dentists to Australia. Three reasons emerged: indifferent priorities, lack of funds and the rise of other international organisations. Bilateral cooperation between concerned countries was considered as a feasible alternative. Conclusion: The role of the Commonwealth as a custodian of dental migratory ethics is limited. Further research is required as to how bilateral cooperation between India and Australia could be improved. There is also an urgent need for targeted funding allocations in oral health, especially in the form of international aid for research and development both in India and Australia.

INTRODUCTION

“The Empire is a Commonwealth of Nations.”

Lord Rosebury, 1884

The Commonwealth is an association of 53 countries brought together by ties of history, language and institutions. It is a unique partnership between free and equal countries united through five principles: democracy, freedom, peace, the rule of law and opportunity for all¹. Member countries extend over six continents, and comprise 30% of the world’s population (around two billion people). Members include both developing and developed countries, with vast differences in economic status (Table 1).

Table 1.

The Commonwealth nations by income status and continent

	High income	Middle income	Low income
Africa		Botswana Cameroon Lesotho Mauritius Namibia Nigeria Seychelles South Africa Swaziland	Gambia, The Ghana Kenya Malawi Mozambique Rwanda Sierra Leone Tanzania Uganda Zambia
Americas	Bahamas, The Barbados Canada Trinidad and Tobago	Antigua and Barbuda Belize Dominica Guyana Grenada Jamaica St. Kitts and Nevis St. Lucia St. Vincent and the Grenadines
Asia	Singapore Brunei Darussalam	India Malaysia Maldives Pakistan Sri lanka	Bangladesh
Europe	Cyprus Malta United Kingdom
Oceania	Australia New Zealand	Kiribati Nauru Papua New Guinea Samoa Tonga Tuvalu Vanuatu	Solomon Islands

Source: The Commonwealth Secretariat.

Notes: Income status is based on the World Bank classification system. Upper and lower middle income countries have been together classified as middle income countries.

Commonwealth Heads of Government (CHOG), made up of the representative heads of member nations, meet once every 2 years in order to develop collective policies and initiatives for collaboration². There are three intergovernmental organisations in the Commonwealth: the Commonwealth Secretariat, the Commonwealth Foundation and the Commonwealth of Learning (COL). The Secretariat is the bureaucratic structure, which executes plans as agreed by the CHOG. The Foundation is the civic structure, which provides direct funding to community organisations. These organisations are mainly professional associations, which work independently on granting aid received from the Foundation³. The COL promotes educational activities and encourages sharing of knowledge and resources between the Commonwealth countries. In addition, the Commonwealth Ministerial Action Group (CMAG), a rotating group of nine Foreign Ministers, exercise ‘quiet diplomacy’ and work towards resolving conflicts and enhancing democratic structures¹. The Queen is the Head of the Commonwealth, and the Secretary-General is the chief executive of the Secretariat.

This unique congregation of developing and developed countries and well-defined organisational structure provides a pathway for realistic collaboration on several social issues. Health care is a key agenda of the Commonwealth. Top health priorities include maternal and child health, HIV/AIDS and the health workforce⁴. The Commonwealth was one of the first international organisations to deliberate on ethical problems caused due to migration of health personnel from developing to developed countries⁵. A detailed code of practice for international recruitment of health workers was adopted by the Commonwealth Health Ministers (a part of CHOG) meeting in 2003⁶. These codes have been mainly developed in regard to the medical workforce (physicians and nurses). The oral health agenda of the Commonwealth arises through political action from the Commonwealth Health Ministers and/or influenced by the Commonwealth Dental Association (CDA). The CDA is a voluntary professional association comprising National Dental Association members from Commonwealth countries, and established through a grant from the Commonwealth Foundation⁷. It has an observer status in the Commonwealth Health Ministers meetings, and provides advisory services if and when required⁸.

The application of the Commonwealth’s code for ethical recruitment has some limitations in relation to the dental profession. This is mainly due to the reason that the concept of active recruitment is redundant in the dental profession. Dentists from developing countries are not usually actively recruited through participation of government or private organisations of developed countries, as they are for physicians and nurses. Nevertheless, the migration of dentists is substantial⁹. Further, the Commonwealth codes have a ‘developing country bias’, focussing mainly on loss of health personnel from developing countries and very little on loss of potential opportunities for local personnel (dentists and students) in host countries. This is more relevant in a highly privatised dental profession, where an open market and competition can cause severe repercussions the local personnel in developed countries. Due to these reasons, the Commonwealths ethical codes on migration might not be relevant to the dental profession. Therefore, the aim of this study was to examine the role of the Commonwealth in influencing ethical migration of dentists from developing to developed countries. This study was based on a case of Indian-trained dentists migrating to Australia.

QUALITATIVE RESEARCH METHOD

The research design involved interviewing key health care or oral health leaders in India and Australia. Selection of participants was based on an expert sample of 35 oral health academics/researchers and oral/health care administrators. Fifteen leaders, who gave consent to participate in the study were interviewed (five from India and ten from Australia). All participants were provided with an information sheet including details on the study (rationale, objectives, researcher’s details and ethical obligations) and an informed consent sheet including details on participants’ willingness to record the interview, and mode of participation (in person or telephone). Ethical approval for this study was obtained from the University of Queensland (No: MB05112008).

The majority of the interviews lasted between 45 and 60 minutes. All interviews were recorded, except for one where detailed notes were taken. Transcripts were prepared for all conversations, and analysis was made through qualitative analysis software NVIVO8.

Data collection and analysis were based on techniques specified by Strauss and Strauss & Corbin10., 11.. A semi-structured interview process was designed, which was primarily used to understand the participant’s visualisation on migratory ethics of Indian-trained dentists to Australia. The latter part of the interviews involved a transformative aspect, where participants were asked to comment on the role of the Commonwealth in influencing ethical migration of Indian dentists to Australia. The findings presented here include only the transformative component.

FINDINGS

The findings are first organised in the form of raw data according to selected participant characteristics. Later, the dimensions within the data are ordered into categories that help us in understanding the role of the Commonwealth as a custodian of dental migratory ethics. Finally, alternative thoughts proposing other solutions towards the problem are discussed.

Table 2 illustrates the data extracts from the interviews. These extracts correspond to the dominant thought as it emerged from each of the fifteen participants. Participants are classified based on their nationality and primary occupation.

Table 2.

Data extract from the interviews

Data extract	Nationality	Occupation
“I don’t think that the commonwealth connection is a good enough one because the Commonwealth is pretty broad churched”	Australia	Policy maker
“...administrative and financial implications – anything on those lines is very difficult.”	Australia	Academic
“I don’t think the Commonwealth will have any head in any country at all. The heterogeneity across the ex commonwealth countries – this could be a problem.”	Australia	Academic
“It’s such a loose confederation and I am not sure and in such diverse countries.”	Australia	Academic
“The common recognition between Britain and Australia fell as largely as a need for the developing Europe – so Britain become Euro Centric and not Commonwealth centric.”	Australia	Academic
“It’s not top priority for the Commonwealth. I think it’s something for other global organisations to think about – say the WHO”	Australia	Academic
“One should start at the local level – working with things that can be achieved first.”	Australia	Academic
“I don’t think you will find a situation where every Indian institution for example will be able to meet standards – because the reality is that they have access to fewer resources”	Australia	Academic
“How you do it will be the hard part... I just see it as a difficult process as it’s always hard to get people on agrees to things.”	Australia	Academic
“You know the conservative nature of the profession of dentistry – I would not be bold enough to say – 10 times larger than the medical profession – makes innovation very slow”	Australia	Academic
“I don’t think they have or could play a role in that. They have very poor resources.”	India	Policy maker
“I don’t know if any Commonwealth body have the power to call the presidents of the 53 dental councils to come for the interview. Do they have the finances and the resources to do that?”	India	Policy maker
“I am not sure of this. Same to what I already answered. They (Commonwealth Dental Association) can be taken into picture and they can be taken to help”	India	Policy maker
“Funding should come from places where the funds come from.. if multi country involvement is then there should be some funding in it multilaterally.” “Commonwealth Dental Association! But it is just like any dental association. Indians have served as President of the organisation. They do not have any role in regulating the profession.”	India	Academic
“The Commonwealth Dental Association have not been very active – as other associations (commonwealth) – for only conference and not involved in regulatory issues. In 9 years I do not know – most of the times the agenda is related to dental education, hosting conference and do not talk of the regulations.”	India	Academic

Both the Indian and Australian participants expressed serious doubts on the role of the Commonwealth or any of its Associations in influencing ethical migration of Indian trained dentists to Australia. While most of them expressed their concerns directly (six Australian and four Indian; seven academics and three policy makers), others provided suggestive evidence on the extent of problems involving the Commonwealth argument.

Indifferent priorities

A major finding that emerged from the interviews is the indifferent priorities of the Commonwealth. This was expressed in two concepts: ‘heterogeneity’ and ‘euro-centricity’. Heterogeneity speaks about the diverse political cultures of the Commonwealth countries. To some extent all the participants felt that this diversity made the organisational structure a loose federation; contributing to focus on a very minimal agenda of mutual interest. Further, their functionality in oral health issues was limited to dental education and organising conferences, having no role in the regulation of the workforce. Euro-centricity indicates the changing priorities of the lead Commonwealth nation: Britain. Participants recognised the view that the change in Britain’s priorities from being Commonwealth-centric to Euro-centric, has affected leadership within the Commonwealth.

Lack of funds

‘Funding’ emerged as a distinct concept to the Commonwealth argument. Participants were amenable to the view that very few resources were being diverted to assist ethical migration or to dental workforce or even to other oral health issues. Further, participants indicated that the availability of financial assistance was dependent on the contribution of all Commonwealth nations, reflecting that either the funds were not available or were not being prioritised for dental workforce issues.

Rise of other international organisations

The rise of other international health care organisations has also contributed towards the declining role of the Commonwealth in health care issues. This was expressed in the ‘competition’ concept. Participants believed that the Commonwealth lacked power and had lost to other international organisations like the World Health Organisation, especially on health workforce issues.

In addition, the majority of the participants were synonymous with the view that ethical migration is best handled by bilateral cooperation within concerned countries. All Indian participants expressed similar concerns on improving institutional ties, research funding and governmental collaboration in oral health activities between both countries. It was suggested the ideal pathway should begin at a local level, aptly summed up by an Australian academic, “We should work on a bottom up approach and in a longer way out.”

DISCUSSION

The study used a revelatory case of Indian-trained dentists migrating to Australia to examine the role of the Commonwealth in influencing ethical migration of dentists from a developing to developed country. The sample size of this qualitative study was small (15 participants). None of the participants were associated with the Commonwealth. A large majority were academics. Thus, there is some scope to suggest that the study might have overlooked intricacies involved in the political decision making, best known to the ministerial and bureaucratic members of the Commonwealth. Further, the Commonwealth argument was only a part (transformative aspect) of the research design. This limited the depth in questioning, and dialogue with the participant. Therefore, the findings from this study are only suggestive, and by no means are conclusive.

The Commonwealth is made up of 53 countries. The majority of them are either middle or low income countries, and are made up of varying political circumstances. There is considerable research that supports the argument that priority setting in international organisations (like the Commonwealth) is heavily influenced by the diversity and permeability of the involved nations12., 13., 14.. It is more likely that the dominant health concerns of mutual interest reflect communicable disease intervention, life threatening situations, or key contributing factors like physician and nurse workforce, but not necessarily oral health or migration of dentists. According to Bexell et al.¹⁵ structuring and functioning of international organisations are also key elements in understanding factors that influence priority setting. Oral health takes a backseat in the organisational set up of the Commonwealth. The CDA, functioning under the auspices of the Foundation, has no direct role in influencing the oral health policy of the Commonwealth. Further, being a congregation of national professional associations (non-government) they have participation bias to the Commonwealth.

The Commonwealth is “shaped by British experience and the experience other nations have had of the British”¹⁶. All Commonwealth countries of different social and cultural background are brought together only due to their association with Britain17., 18.. Thus, the role of Britain is central to leadership. The post cold war era had witnessed a dramatic shift in Britain’s foreign policy from being Commonwealth-centric to more focus on European and transatlantic relations¹⁹. This change in focus seems to have some repercussions on the future direction of the Commonwealth.

The overall budget of the Commonwealth Secretariat²⁰ is around £40 million. Health care in general receives only around 2% of the overall budget. The Commonwealth Foundation²¹ functions with an annual budget of nearly £4 million. Funding for the Foundation is both based from the Secretariat, through the allocation determined by the CHOG and from direct contribution by philanthropists or focussed allocation by participating organisations/governments. Grants-in-aid from the Foundation occupy only one-fifth of the overall budget expenditure. The CDA receives around £25,000 as a grant from the Foundation, and the majority of this income is spent in organising an annual conference/workshop²². None of the expenditure accounts of the Commonwealth (other than the CDA) illustrate funding allocation in particular to oral health. In this scenario of limited funding and ambiguous allocation of health funds it is likely that oral health or dental workforce issues are underfunded.

The health care programme of the Commonwealth is limited in scope and funding, when compared to other specialised public health organisations like the World Health Organisation (WHO). The WHO is a highly focussed public health arm of the United Nations, providing leadership on international health issues, and having an extensive reach in developing countries²³. The budget of the WHO alone far exceeds the overall expenditure of all three Commonwealth organisations combined²⁴. The prominence of the WHO is also compounded by the fact that international dental organisations like the Federation Dental Internationale (FDI) have far reaching influence in the dental profession and are well placed to intervene in ethical issues of dentist migration. Over the past decade bilateral relations between India and Australia have improved in education and research activities. Endowment has been through the Australia-India Strategic Research Fund, with both governments contributing to research and development activities²⁵. The Australian government also contributes funding through the AusAID²⁶ program, mainly for Australian researchers. However, oral health issues have been neglected and funds are rarely allocated through these competitive funding streams. In addition, philanthropy in both countries is not very active, when compared to other regions. The current scenario does not seem encouraging for research/institutional collaborations in both countries. Focussed action for oral health is inadequate, and this follows suit in the dental workforce and for that matter in ethical migration of Indian-trained dentists to Australia.

CONCLUSION

This study concludes that the role of the Commonwealth as a custodian of dental migratory ethics is constrained due to three reasons: indifferent priorities, lack of funds, and the rise of other international organisations. Oral health issues are not prioritised by the Commonwealth due to the diversity in organisational structure and focus on other health care issues. Funding for oral health is extremely limited within a grossly underfunded Commonwealth health care budget. Further, the WHO and FDI are better organised, and funded, and they are in a more strategic position to influence dental workforce issues.

It is also suggested that the issue of ethical migration of dentists from India to Australia is best tackled by bilateral cooperation. Further research is required as to how bilateral cooperation could be improved. With a growing focus on Australia-India relations, there is a need for targeted funding allocations in oral health, especially in key international funding aid such as the AusAID in Australia.

We conclude with the words of Krishnan Srinivasan¹⁶, former Deputy Secretary-General of the Commonwealth: “What the Commonwealth can actually do in the real world seems to make little difference”.

Acknowledgements

The first author was supported by an Australia-India Council Junior Australian Studies Fellowship funded by the Australian Government Department of Foreign Affairs and Trade. The work was conducted in the School of Population Health, The University of Queensland. Further assistance was received in the form of administrative support from all the other Australia-India Council Consortium Universities.