USOS EDUCATIVOS DE LAS TIC

This research set out to explore why Indian physiotherapists chose to be globally mobile. The findings suggest a clarity of focus underpinned the aims and aspirations of individual physiotherapists who undertook the journey. They also reflect a complexity in the factors that influenced the decision to seek professional development overseas. Significant challenges associated with successful return were identified. From this research a grounded theory has been constructed that suggests the Indian physiotherapists' global mobility is a journey of professional identity transformation moving through four stages; 'forming', 'storming', 'transforming' and 'transferring'. This chapter summarises the issues and outlines key messages / implications for Indian physiotherapy. The research limitations are identified and suggestions for further research are made.

7.1. Key Findings Underpinning the Theory

7.1.1. Motivations to Go

The findings suggest that physiotherapists who are globally mobile ultimately want a better life. This incorporates being respected for what they do professionally, and being remunerated accordingly. Underpinning this aspiration is the professional drive to be better physiotherapists and to treat patients more effectively; to do this they need to be able to practise autonomously. The participants reported being frustrated that they were only able to practise in a non-autonomous technician role due to the hierarchy in many Indian physiotherapy departments, and they also considered that the continuing professional development opportunities in India did not adequately meet their needs or enable them to achieve their aspirations. Therefore they travelled overseas to destination countries where physiotherapy is a more mature

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profession, with a level of practice and associated knowledge, research and skill base that underpins the identity of an autonomous profession. They sought something different in terms of experience, practice, knowledge, respect and pay. Most started their journey overseas with masters level study, but they aspired to clinical work, ideally in a paid capacity, to gain experience of autonomous physiotherapy practice, until they were comfortable and confident with their new professional identity and all that it encapsulated.

This study has constructed a theory of a journey of identity transformation for the physiotherapists. The study findings regarding the motivations to travel, are resonant with the published global mobility literature and theoretical frameworks. The physiotherapists' motivations align more closely with doctors', than nurses' mobility but there are some identified differences.

These findings align with the published literature around global mobility of students. This suggests that students travel overseas for education that is insufficiently provided for at home (Vincent-Lancrin 2008) and the suggestion that an overseas degree is a pre-cursor to employment in the destination country (Cobb-Clarke 2000).

Push factors are the issues that drive an individual to emigrate. The literature identifies that low pay, management and governance issues often drove migration (Buchan et al 2003; Oberoi and Lin 2006; El-Jardali et al 2008). This study suggested that these factors are relevant for Indian physiotherapists, however working conditions and exposure to HIV/Aids was a factor in health professionals' migration in Africa (Buchan and Dovolo 2004; Bach 2006), but was not identified as an issue for Indian physiotherapists. Working style in the context of autonomy and respect was important for Indian physiotherapists. Pull factors affect the selection of destination countries. Pay differential is commonly

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discussed in the literature and it was an area of debate amongst this study's participants regarding adjustments for purchasing power parity and whether they would receive more pay upon return. In line with Kingma (2001), and Ross et als' (2005) conclusions, it was not the most significant factor in selecting the destination country, as all paid significantly more than India and the pay was associated with increased respect (Vujicic et al 2004). Khadria's (2004) study identified that for Indian doctors moving overseas the emphasis was on a professional development focus including access to higher education opportunities; working with experts; better professional infrastructure and employment opportunities; better income and quality of life. However, for Indian nurses, whilst they did identify access to training opportunities and career progression there was a greater emphasis on socially focused drivers around income, quality of life and education for children. The findings from this study suggests that the Indian physiotherapists motivations more closely align with those of the Indian doctors than the nurses. Oberoi and Lin (2006) identified that push factors played a greater role than pull factors, the findings from this study do not indicate a balance of importance. However, the push management and governance factors were significant and complex, and seemed to impact upon the success of return migration, and are explored further in the next section.

Brain drain and its impact upon the health workforce has been an emotive issue particularly for nurse migration from Africa (McElmurry et al 2005; Buchan 2006). In this study it was identified that there was insufficient employment for all the physiotherapists that had recently graduated and so this perspective was not considered to be of major importance. Conversely, it was identified that India had a significant need for more allied health professionals to meet its extensive health needs and disease burden but lacked resource to meet the demand. This study's findings suggested that some aspects of brain circulation theory were resonant (Bach 2006; OECD 2008c); the drive for new and different

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knowledge would support the increased stock of global knowledge; professional networks and role models were identified as mechanisms for circulating knowledge; returning home was a long term aspiration for all and a short term reality for many. However, although there were challenges associated with return migration, there was evidence of ongoing professional development post return. There was no suggestion in the data that the possibility of migration attracted talent to the profession.

7.1.2. Governance, Medical Power and Social Amplification

Indian physiotherapists chose to migrate overseas within a context of an Indian nation with strong economic growth, and had observed peers in different professions benefit from that growth (OECD 2012). In parallel there was considerable poverty, significant healthcare needs and huge disparities in healthcare provision (WHO 2013), Yet the future direction of the development of India's healthcare provision, and the government's identified aspiration to harness the expertise of the allied health professions in order to address India's workforce requirements and so meet India's health needs (NIAHS 2012), seemed to be stalled by vacillating governance. The two decade chronology of wasted government legislature (appendix one) to provide a legal framework for recognition and regulation of the physiotherapy profession, illustrates the complex power struggles and emotive narrative that appeared to underpin the future of India's healthcare provision.

Given the size of the Indian healthcare market and its continued growth, it was not surprising that the physicians were determined to retain their position as the sole authorised autonomous practitioners in Indian healthcare. The quarrel regarding Indian physiotherapists using the 'Dr.' prefix illustrated their sensitivity to any contamination of their medical identity. This perceived threat of an empowered autonomous physiotherapy identity suggested ambiguity in their

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privileged position. The western literature is scattered with discourses that explore the demise of the medical professionals identity and hegemonic authority, through a gradual corrosion of their mechanisms of power, leading to increased autonomy of the allied health professions (Ovreteit 1985; Kenny and Adamson 1992), the emancipation of the patients, and the restructuring of healthcare funding streams (Friedson 1985; Sullivan 2000; Ritzer 2001; Watts 2009). It was therefore not surprising that, given the scale of pending changes and demand, the Indian medical stakeholders wished to ensure that their professional autonomy, identity, practice and livelihood, was not undermined by the autonomy of others.

Foucault considers that identity is a form of subjugation and a way of exercising power over others and preventing them from moving outside fixed boundaries (Turner 1997). The Indian medical dominance, that could be seen as subjugating physiotherapy practitioners only to offer treatments according to a doctor's prescription and adopt a paraprofessional identity, supports Foucault's contention. However, the paraprofessional physiotherapist was also suppressed by societal power relations. Their low status in the medical hierarchy perpetuated a perceived lack of respect and actual low pay. In Indian society the importance of such meagre cultural capital is amplified way beyond comparable significance in the west. Indian societal power plays a central role through symbolic domination and hierarchy and invades many aspects of social life, particularly for men where there are significant familial and societal expectations (Webb et al 2002). Therefore Indian physiotherapists, who travelled overseas to transform their paraprofessional identity into the identity of professional autonomous practitioners, were also seeking to transform their cultural capital. Through professional development and increased cultural capital they would gain respect and be empowered to make the career choices that inform their better life.