The international migration of skilled health workers (SHWs) has grown rapidly since the 1970s, become more complex, more global, and of concern to countries that lose workers from fragile health systems. As health care has become more commercialized, so too has migration, as part of a wider globalization of health services. Few parts of the world, either as sources, destinations, or both, within a now global healthcare chain, are unaffected by the consequences. Most migration is to developed Organization for Economic Cooperation and Development (OECD) countries, in Europe, North America, and also the Gulf. Countries most affected by emigration are relatively poorly performing economies in sub-Saharan Africa, alongside some small island states in the Caribbean and Pacific, though absolute numbers are greatest from such Asian countries as India and the Philippines.
The international migration of SHWs parallels somewhat similar international migration of other professionals. The emergence of regional trading blocs and agreements, notably the European Union (EU), has expanded opportunities for international migration. International migration is linked to the General Agreement on Trade in Services, established in 1995, to liberalize international trade in services, including the movement of the so-called ‘natural persons.’ Many countries have eased their legislation on the entry of highly skilled workers, introduced points systems where skills facilitate entry, and actively recruited overseas. Such professional services as health care are part of the new internationalization of labor, and migration has largely been demand driven (or at least facilitated) by the growing global integration of healthcare markets. Forty years ago doctors – mostly men – were the main migrant group, but nurses – mostly women – have increasingly become dominant.
Demographic, economic, political, social, and, of course, health transformations have had significant impacts on international migration. Restructuring, often externally imposed, has affected health systems of developing countries, contributing to concerns over wages, working conditions, training, and other issues, all of which have stimulated migration. The health sector is different from other skilled sectors because most employment remains in the public sector. More dramatically, migration literally involves matters of life and death. Technology cannot easily replace workers, while the rise of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) and non-communicable diseases and the aging of populations have placed new demands on health workforces. There is now a greater range of jobs for women, other than in a sector that is seen by some as dirty and dangerous (and unrewarding), sometimes difficult and demanding, and perhaps degrading. SHWs are in global demand.
Migrants move primarily for economic reasons, and increasingly choose health careers because they offer migration prospects. Migration has been at some economic cost, has depleted workforces, diminished the effectiveness of healthcare delivery, and reduced the morale of the remaining workforce. Countries have sought to implement national policies on wage rates, incentives, and working conditions, but these have usually been canceled out by global uneven development and national economic development problems. Recipient countries have been reluctant to establish effective ethical codes of recruitment practice, or other forms of compensation, or technology transfer, hence migration may increase further in future, despite the development of a Global Code.
Around the turn of the century, accelerated recruitment from developing countries, where populations are aging, expectations of health care are increasing, recruitment of health workers (especially nurses) is poor, and attrition considerable, contributed to a labor force crisis in source countries, raising complex ethical, financial, and health questions. The costs of training healthcare workers in developing countries are considerable, hence migration has been perceived as a subsidy from the poor to the rich. Migration issues are not only linked to financial issues, serious though these are, but are critical for the delivery of health care.
A Geography Of Need
Human resources are central to healthcare systems, and have long been unevenly distributed. The need for health care is at least as uneven. Though definition and measurement of needs and shortages is complex, and the competence and effectiveness of workers hard to assess, demand for health care is greatest in the least-developed countries and regions, most of which are tropical, and, in a perfect example of the ‘inverse health care law,’ these needs are less well served than those in developed countries. The link between ‘health workforce density’ and health outcomes has been clearly demonstrated: Lack of health workers contributes to poor health status, and provision of such basic functions as adequate coverage of immunization or attendance at births. The disease burden is especially great in sub-Saharan Africa. World Health Organization (WHO) has shown that North and South America contain only 10% of the global burden of diseases, yet almost 37% of the world’s health workers live in this region, whereas Africa has 24% of the global burden of diseases, but just 3% of the health workforce and less than 1% of global financial resources. At a national scale, the sub-Saharan countries of Uganda and Niger have 6 or 7 nurses for 100 000 people, whereas the US has 773, yet migratory flows – a perverse flow – are invariably from the former to the latter.
The WHO estimated that in 2005 some 57 countries had critical shortages of SHWs, equal to a global deficit of 2.4 million doctors, nurses, and midwives, let alone pharmacists, dentists, radiologists, and others. Some 36 of 47 sub-Saharan African countries fell short of the minimum. Moreover, most SHWs are concentrated in urban areas and usually in the often primate city: A consequence of economies of scale, urban bias, and the social preference of SHWs.
A Brief History Of Migration
In the nineteenth century, migration of SHWs from more developed countries to their colonies was part of a colonial endeavor and missionary practice that remained in place until quite recently. In the 1940s and 1950s the direction reversed, from south to north, and the first flow of health workers began to migrate from developing countries, mainly to the UK and the USA, and mainly of doctors from larger countries such as India, Iran, and Pakistan. Nurses also migrated and were later recruited for emerging Gulf states. Britain, Australia, and Canada were experiencing both the immigration of doctors, mainly from the Philippines, India, Pakistan, Iran, and Colombia, and their emigration, usually to the USA. The Philippines had already contributed the largest number of overseas doctors in the USA, with training increasingly oriented to overseas needs. By then the ethnic distinctiveness of this skilled migration into Britain was evident, and a geographical pattern had emerged that scarcely changed substantially in later years. Over time what were then relatively simple migration flows, reflecting linguistic, colonial, and postcolonial ties, became steadily more complex. This new phase of migration was the start of what became widely recognized as a ‘brain drain,’ a term first applied by Oscar Gish at the end of the 1960s to the movement of doctors and scientists.
Such early flows were also characterized by active recruitment (notably of nurses from the Caribbean), and the employment of the migrants in the lower echelons of the health service. By the 1960s, the less-developed countries were experiencing the greatest costs from emigration, as SHWs left emphasizing the disparity in the number of medical workers per capita alongside the heavier burden of disease. In the 1970s, because of growing concerns over uneven flows and development, the WHO mounted a path-breaking study by Alfonso Mejia and others of migration from some 40 countries. Then, as now, the migration of SHWs was of greater concern than other skilled international migration flows, and the idea of a brain drain largely emerged from analysis of migratory health workers.
After a period of quiescence demand for SHWs in developed countries again increased in the 1990s, resulting from aging populations, growing demand and ability to pay, inadequate training programs, and high attrition rates (for reasons ranging from patient violence to discontent with working conditions, etc.), as jobs in the health sector were seen in many developed countries as too demanding, poorly paid, and lowly regarded (in line with reduced public sector funding, and disregard for the public sector). Reduced recruitment of health workers also followed declining birth rates in developed countries: There were fewer young people and more diverse employment opportunities for women, many with superior wages and working conditions, and greater prestige and respect. Significantly, these influences are similar to the reasons for attrition and migration in source countries.
Contemporary international recruitment of health workers is increasingly global. Where, a quarter of a century ago, it was mainly a movement from a few developing countries to a small number of developed countries, most countries are now involved. New movements of nurses occur between relatively developed countries, notably within the EU. Ireland, once an exporter of SHWs, has become an active recruiter. The new complexity of international migration is evident in Poland, as much a sending country as a recipient, where its source countries are eastern European countries (Ukraine, Belarus, Russia, and Lithuania) and the Middle East (Syria, Yemen, and Iraq), although Polish nurses migrate westwards. China has entered the market as a supplier of nurses, and its considerable interest in becoming more involved has the potential to profoundly influence the future system.
Over the past 30 years, the key receiving countries have remained remarkably similar, dominated by the UK and the USA. Whereas demand in the Gulf has stabilized, other European and global destinations (including Canada and Australasia) have grown in importance. Despite policies of localization, the Gulf states still employ 20 000 migrant doctors, and many more nurses, mostly from south Asia, but also from neighboring and poorer Middle Eastern states such as Egypt and Palestine.
In most developed countries, the proportion of foreign trained medical workers in the health workforce has usually risen slowly: for example, in the USA and the UK, foreign doctors now represent approximately 27% and 33%, respectively, of their medical workforces; similar percentages occur in Australia and New Zealand, whereas comparable estimates are approximately 7% for Germany and France. Other OECD countries have become significant recipients. Hitherto Japan, virtually only one of the countries that have experienced substantial postwar economic growth and aging populations, has largely managed its health services without resorting to overseas workers, but has recently entered into agreements with the Philippines.
Throughout this time the Philippines has remained the main global source of SHWs for almost every part of the world, alongside India. Sub-Saharan Africa has emerged as a major supplier, and a major source of concern. Relatively recently other Asian states have become sources of SHWs, whereas much smaller Caribbean and Pacific states have become sources. Eastern Europe supplies Western Europe, whereas Latin America has tended to experience proportionately less emigration, though Latin America nurses have moved north to the USA and Europe, especially Spain.
Patterns of health worker migration from sources of supply such as sub-Saharan Africa have also changed. In the 1970s, SHWs were from a relatively small number of African countries (the larger states of South Africa, Nigeria, and Ghana) and predominantly went to a few developed countries outside Africa. Subsequently migration has become much more complex, involving almost all sub-Saharan countries, including intraregional and stepwise movement (e.g., from the Democratic Republic of Congo to Kenya, and from Kenya to South Africa, Namibia, and Botswana), because of targeted recruitment, by both agencies and governments, as much as individual volition. Globally, the 20 countries with the greatest emigration factors in the mid-2000s (the ratio of emigrant to resident doctors) included 6 in Africa (Ghana, South Africa, Ethiopia, Uganda, Nigeria, and Sudan), 3 in the Caribbean (Jamaica, Haiti, and the Dominican Republic), the Philippines, India, and Pakistan, a cluster of countries perhaps best characterized by crisis (Sri Lanka, Myanmar, Lebanon, Iraq, and Syria), and also New Zealand, Ireland, Malta, and Canada. Migration is now shaped by both market forces and cultural ties, and deeply embedded in uneven global development.
The greater complexity of migration is evident in the interlocking chains of recruitment and supply, some of which were in place 30 years ago. Canada recruits from South Africa (which recruits from Cuba), as it supplies the USA. Kenyan nurses first went to southern African countries such as Botswana, Zimbabwe, and South Africa, and then moved on as ‘step migration’ to Britain. Something of a hierarchy of global migration – the global care chain – links the poorest sub-Saharan, Asian, and island microstates, to the developed world, culminating in the USA. New transport technology and reduced costs have produced variants of ‘commuter migration’ with SHWs taking on brief assignments elsewhere.
Migration is constantly in flux depending on labor markets, domestic pressures, evolving global legislation and codes of practice, and individual perceptions of amenable destinations. Migration links languages, training institutions, educational regimes, often in the context of other migration flows, sometimes characterized as chain migration in the context of a ‘transnational corporation of kin.’ Language proficiency is more crucial in the health sector than in any other arena of migration, skilled or unskilled. Although recruitment has crossed new borders, as trade barriers have disappeared and the Internet become accessible, potential migrants are also more likely to be informed about global job opportunities and be in some position to choose more widely than hitherto. Migration ranges from fixed-term contract migration (typified by that from the Philippines to the Middle East), usually negotiated between governments, and more personal, individual migration that may last a lifetime.
Rationales For Migration
Migration is primarily a response to global uneven development, usually explained in terms of such factors as low wages, few incentives, or poor social and working conditions. Poor promotion possibilities, inadequate management support, heavy workloads, and limited access to good technology including medicines have been widely recognized as ‘push factors.’ Such pressures are intensified in rural areas, where health workers feel they and their institutions are too often ignored, victims of institutionalized urban bias in development. Cultural factors have emphasized some migration flows. Tamil doctors have been more likely than majority Sinhalese to migrate from Sri Lanka for more than 30 years. Recruitment, by both agencies and governments, has played a critical facilitating role. However, all these various, specific factors are embedded in the broader context of social and economic life, family structures, and histories and broader cultural and political contexts.
Consequently, migration of SHWs occurs for many reasons, despite remarkable uniformity across quite different regions and contexts. Reasons include incomes, job satisfaction, and career opportunities, alongside social, political, and family reasons. The last of these factors, though often neglected, is particularly important since few migrants make decisions as individuals, but are linked to extended families and wider kinship groups. The migration of SHWs is rarely unique but exists within the context of wider migration flows. This is evidently so in India, the Philippines, and most small island states, like those of the Caribbean and Pacific, where there have been steady and diverse migration streams for several decades. In such circumstances, there is effectively a ‘culture of migration’ where most individuals at least contemplate migration at some time in their lives.
Yet migration is usually constrained in certain ways. Even for those with skills it is rarely easy to cross political boundaries. Where political circumstances have changed, as in the expansion of the EU, migration from poorer eastern states to those in western Europe quickly became substantial. Violence, coups, crime, warfare, and persistent social unrest have predictably hastened migration from countries such as Zimbabwe, Fiji, and Lebanon.
Intention to migrate may occur even before entry into the health system. In the Philippines, at least some people sought to become nurses, partly and sometimes primarily, because that provided an obvious means of international migration. By the end of the 1980s, a medical degree at the Fiji School of Medicine was widely seen as a ‘passport to prosperity’ and in Kerala (India) a nursing diploma is considered an ‘actual passport for emigration’ thereby raising the status of nursing. Specific careers may be chosen that optimize migration opportunities; in the Philippines and Pakistan, male doctors have retrained as nurses, and fewer people choose a medical career, as nurses have superior migration opportunities. The initial overseas destination may not be the intended final destination, especially for health workers in the Gulf, who seek to move on to the USA. Migration is not solely of SHWs; for some SHWs a career in health is seen as a way to move the whole family. This step migration points to the challenges in source countries of trying to develop an effective national workforce, when substantial proportions of those being trained may migrate.
Health workers have not usually entered the profession solely for income benefits, but also out of some desire to serve and be of value in the community. However, such feelings do not sustain a career, as workers become frustrated by low pay and poor (or biased) promotion prospects, especially in remote areas. As, increasingly, people do join the health sector for economic reasons, migration becomes even more likely. Income differentials are therefore invariably key factors in migration, as they are in decisions to join or later leave the health profession. Many decisions are simply rationalized in this way, since income differences between countries are often increasingly evident. Income differences are often such that even significant wage increases have had little effect on reducing the extent of migration. Econometric studies, at least for the Pacific island states, have shown that migration demonstrates considerable sensitivity to income differences, but complicated by the structure of household incomes. In countries where there have not been specific surveys of migration, anecdotal evidence and, in some cases, the rationale for strikes by health workers, emphasize the significance of wage and salary issues. Similarly, the general movement of doctors, dentists, and others from the public to the private sector marks the quest for better incomes and conditions.
Income is firmly linked to the structure of careers and promotion, which many health workers see as being more about ‘who you know than what you know’ – nepotism and favoritism – and longevity in the system, rather than ability. SHWs have been critical of the lack of a transparent career structure, preferring to move to a meritocracy where skills and accomplishments will be rewarded. Where health workers are stationed outside the main national urban center, the perception that they are being ignored for promotion is even stronger as many consider themselves to be ‘out of sight and out of mind.’ Inadequate opportunities for promotion constitute not only an incentive to migration, but a constraint to productivity and innovation in the health system.
After income, the actual conditions of employment are influential for migration. Migrants, and potential migrants, frequently complain about the work environment in terms of insufficient support, through inadequate management (lack of team work, poor leadership and motivation, limited autonomy and support, and little recognition and access to promotion and training opportunities) or through the outcome of poor ‘housekeeping’ (limited access to functioning equipment and supplies). A desire to acquire further training and gain extra experience is a key factor influencing migration. Long hours of overtime, double shifts, working on the early morning ‘graveyard’ shift or on weekends, especially when these do not receive proper income supplementation, further influence migration. Shift work is a universal source of complaint, and particularly so in more remote places, where fewer staff are available and pressures on those remaining are greater. Inadequate working conditions may also entail the risk of contracting disease. The rise of HIV/AIDS made the nursing profession especially much less attractive than hitherto and, notably in Africa, created a more difficult working climate as the workload increased.
In several developing countries economic restructuring, sometimes externally imposed by international agencies, has led to reductions in the size of the public sector workforce and restrictions on the hiring of new workers. Changes in the health sector take place in a wider context where negative balances of payments and high levels of debt servicing place huge resource constraints on many developing countries. This has sometimes meant the deterioration of working conditions rather than the greater efficiency it was intended to encourage. Ironically, in the mid-2000s, in Kenya, for example, though half of all nursing positions were unfilled, a third of all Kenyan nurses are unemployed, as International Monetary Fund pressure encouraged national wage restraint. In several countries lack of resources, or alternative priorities, has resulted in low wages and poor conditions, with simultaneous vacancies, unemployment, and migration.
Many migrants have left rural areas to take advantage of superior urban and international educational, social, and employment opportunities. These factors reinforce each other, especially in the health sector. The widespread education bias enables young and skilled migrants, with fewer local ties, to migrate more easily. Most nurses, and many other SHWs, are women and may face particular constraints related to partners’ careers and family obligations, which may make remote postings and overseas migration difficult. Consequently, the most likely migrants are young single workers followed by married workers without children. In contrast, Indian nurses from Kerala have migrated because their ability to earn and retain significant incomes gave them high status and the consequent ability to find high-status partners in the ‘matrimonial market.’ In many contexts, gender relations have been restructured following migration. Social ties may result in pressure to migrate, to support the extended family, but may sometimes make migration more difficult to achieve.
Developed destination countries offer real alternatives to political and economic insecurity in many source countries. A high standard of living with higher wages, better career prospects, good education, and a future for children are offered in recruitment campaigns, and often verified by those migrants established overseas. The structure of migration has become increasingly privatized through the expansion of recruitment agencies, and their regular use by recipient countries and by particular hospitals. Recruitment has existed since the 1940s but grew rapidly around the turn of the century. Irrespective of any existing intent to migrate, active recruitment has put growing pressure on, and impressive opportunities in front of, potential migrants. Recruitment agencies smooth the way in attending to bureaucratic issues, satisfying concerns over distant and different countries and cultures, and sometimes providing their own induction training in destinations.
Little information exists on the operations of recruitment agencies, and therefore there is no evidence on whether they exaggerate the potential of overseas employment, although they increase its probability. Recruitment has been particularly significant in sub-Saharan Africa, though there, as elsewhere, it would not have been successful unless other reasons for migration existed. In the early 2000s, half of all overseas nurses in Britain were there because they had been recruited. Recruitment has significantly extended migration beyond its postcolonial routes, for example, taking Chinese nurses to the Gulf and Fijian nurses to the Bahamas and the United Arab Emirates.
Recruitment is competitive, resulting in ‘selective depletion’ of the more qualified workers from several countries. In recruiting health workers for the UK many agencies engaged in some forms of exploitation. Both in source and recipient countries agencies operate beyond the extent of effective regulation. Such issues resulted in regional attempts to construct and use codes of practice for ethical recruitment, spearheaded by the Commonwealth Secretariat for former British colonies, thus covering significant parts of the Caribbean, Pacific, and sub-Saharan Africa.
The finalization by WHO of a Global Code in 2010 emphasized continued migration concerns and universal agreement to mitigate its harmful effects, notably that migration did not disrupt health services in source countries. However, migration is a human right and occurs in contexts that do not necessarily involve health issues; there are no incentives for recipient countries and agencies to be involved in ethical international recruitment and all codes are voluntary which limits their impact. Recruitment and migration are both likely to continue.
Consequences Of Migration
The trade in, and migration of, SHWs has diverse impacts, from more obvious effects on the delivery of health services and the economic consequences of the loss of locally trained skilled workers, to more subtle social, political, and cultural impacts. Migrants tend to be relatively young and recently trained, compared with those who stay. Many leave after relatively short periods of work, but long enough to gain important practical experience. They often include the best and the brightest. Because migrants move to improve their own and their families’ livelihoods, they are usually the key beneficiaries of migration. Recipient countries benefit from having workers who fill shortages in the healthcare system. Conversely, sending countries and their populations, especially in remote areas, lose valuable skills unless those skills are an ‘overflow’ or are otherwise compensated for.
Migration affects the provision of health care both in quality and quantity. Links exist between migration and the reduced performance of healthcare systems, though actual correlations between emigration and malfunctioning healthcare systems are difficult to make, because it is impossible to quantify what is not there. However, India and the Philippines, both long-term providers of migratory health workers, in circumstances initially described as an overflow, now appear to have become negatively affected, whereas sub-Saharan Africa and many small states experience critical problems, but not simply or even primarily because of migration.
In some circumstances, the quantitative outcome of migration is obvious. In Malawi, the loss of many nurses to the UK in early 2000s brought the near collapse of maternity services even in Malawi’s central hospitals, with 65% of nursing positions being vacant. Maternal health care has been similarly affected in Gambia and Malawi with increased workloads, waiting and consultation times, and poorer infection control. In Jamaica, wards have been closed, male and female units have been merged raising cultural issues, and immunization coverage and in situ training have both been declined. Although such data are fragmentary, and often depict worst-case scenarios reported in the media, and are not solely the outcome of international migration, they point to difficult circumstances.
Reduced staff numbers mean that workloads of those remaining become higher, and less likely to be accomplished successfully. Many anecdotal reports emphasize longer waiting times with the implication that this raises opportunity costs of medical care, and may also result in medical attention coming too late. In Zimbabwe, in the 2000s, over a quarter of health workers believed that longer waiting times, and shorter opening times, had resulted in unnecessary deaths that prompt attention could have prevented. Foreign aid programs expanded in sub-Saharan Africa in the mid-2000s, to provide drugs to millions affected by tuberculosis and AIDS, yet were hard to implement because too few nurses existed to administer them effectively.
A further consequence of health worker migration is that of some patients traveling overseas for health care, as part of the growing phenomenon of medical tourism. Where such referrals are paid by the state, the cost is considerable. Even where they are not, as is usually the case, resources are nevertheless transferred overseas. In several African countries, referrals have increased at the same time as health worker migration, resulting in an unprecedented increase in the expense of care to fewer people and in the use of foreign currency, which could have been used for other development programs or for the motivation and retention of the country’s health workers. The lack of health personnel may not always be the primary motivation for traveling overseas for treatment, but it nonetheless represents a substantial loss of scarce resources, especially because some of the source countries of medical tourist are impoverished nations such as Yemen. Even in countries that are relatively well supplied with health personnel, the cost of referrals is considerable, making the task of financing local health systems and organizing more labor-intensive preventive health care more difficult.
Rural And Regional Issues
The impact of emigration is usually most evident in remote regions, where losses tend to be greater (and where resources were initially least adequate), and has therefore fallen particularly on the rural poor (and sometimes therefore on cultural minorities) who are most dependent on public health systems, and where health needs are often greater, further emphasizing urban bias and the ‘inverse care law.’ The impact of emigration is complicated and compounded by ubiquitous internal migration, and a parallel movement from the public to the private sector. The movement of SHWs to the private sector has disadvantaged the poor, most of whom cannot afford higher private sector costs, alongside growing evidence of less adequate public sector services. This is poorly documented and it is primarily the evidence of inadequate stocks of health workers in the regions, and very different staff: patient ratios, which suggests the extent of adequate provision and migration (and attrition) in remote areas. The WHO has developed distinct strategies for developing and stabilizing regional workforces. Internal migration exhibits a similar rationale to international migration, but poses distinct problems where the internal migration is of those with particular skills, such as radiologists or pharmacists, and where few are required; hence the loss of even a small number may be crucial.
The Economics Of Migration
Training SHWs is costly because of the long duration and high costs and is a burden on relatively poor states, whether directly or through overseas scholarship provision. When trained workers migrate and the process is repeated, costs mount further. However, there have been few estimates of the costs of the ensuing brain drain, or the possible gain in skills through return migration, and a variety of methodologies and conclusions. The impact on healthcare provision of the emigration of doctors may be remarkably slight, compared with that of nurses, who provide the bulk of health care in many places, and especially in regional areas, where needs are considerable, but not necessarily complex.
A series of estimates of training costs suggest that low-income African countries subsidize high-income countries by as much as $500 million a year through the migration of SHWs, whereas equally fragmentary data from developed countries indicate considerable cost savings involved in hiring overseas trained SHWs rather than training locally. This has been described as a perverse and unjust subsidy from relatively poor countries to relatively rich ones. These estimates are based solely on the costs of training rather than additional costs based on foregone health care, lost productivity, the under use of medical facilities, etc. However, they usually ignore possible remittances and their consequences. Where the remittances of health workers have been calculated, as in the Pacific island states, they are substantially above training costs, though they flow into the private sector rather than the public sector where most training takes place, and make no contribution to equitable human development.
Where return migration of SHWs occurs, the relationship between income losses, return, and the acquisition of human capital becomes more complex. Return migration of SHWs is relatively limited in many countries; however, if migrants return from overseas, with enhanced skills, knowledge, experience, and enthusiasm (and perhaps also some capital), there can be major gains from migration, including a positive transfer of technical knowledge. However, significant return migration fails to occur for the same reason that migration occurs: Migrants are less likely to be tempted back by a system they left because of its perceived failings. The overall number of return migrant nurses and doctors is modest, and many return because of perceived benefits, such as business opportunities, outside the healthcare system.
A further outcome of migration can be a skill loss when migrants with specific skills do not use them, which may result from failure to recognize qualifications, discrimination, or a preference for jobs with better wages and conditions. The most significant skill loss comes where nurses are employed as caregivers in nursing homes rather than working in hospitals. Expensive training is largely wasted and neither health systems, the migrants, nor their kin at home, who wait for remittances, make real gains.
The social costs attached to the migration of SHWs are complex but often considerable, especially where women move as individuals, leaving families at home. Many migrant workers, especially women within and outside the health sector, experience deprivation and discrimination. Recruitment agencies may impose unforeseen costs, and SHWs experience difficult circumstances, especially where cultures differ from those at home. Numerous examples exist of their experiencing racism in developed countries, and being ignored or experiencing reprisals when complaining of such problems, alongside being denied parity with local workers, promotion, or wage gains.
Health workers are often recruited for, and directed into, positions and locations that are unattractive to local health workers, and peripheral geographical placement is common. Consequently, new migrants are unlikely to be involved in specialist activities despite previous experience, and are most likely, at least initially, to be in the least attractive fields of health care and in outlying parts of the country, and with limited autonomy and authority. Stresses may occur for the families of migrants. Children may have to make complex adjustments to parental absences, and experience what has been called a ‘care deficit.’ However, migrants and their families usually gain in status through the material benefits of migration.
Migration of SHWs has made it necessary for less or nonqualified people, such as nurses’ aides, to perform tasks that are normally beyond their training. This poses risks of incorrect diagnoses and inappropriate treatment. Patients have also reverted to the informal sector with sometimes costly, uncertain, and ineffective outcomes. In many countries, migrant nationals have been replaced by other international migrants, as part of the cascading global care chain, though the direct economic costs may be considerable (in both recruitment and salaries) and they may be less effective because of language and cultural differences, which restrict their ability to provide health services, contribute to training, and enable sustainability.
The Future Global Healthcare Chain
Shortages of SHWs exist in most countries in the world, and have been remedied mainly by migration from poorer countries rather than by strategies for improved retention and recruitment, hence the development of a Global Code of recruitment by WHO to encourage a more regulated migration, bilateral reciprocity, and greater international cooperation. Countries such as India and the Philippines, that previously exported an ‘overspill,’ have experienced some adverse effects from their ‘export policies.’ Migration has been problematic for relatively poor countries as the costs of mobility are unevenly shared, and the care chain becomes more global and hierarchical. Greater complexity increases the challenge of achieving more equitable outcomes.
An open international market is said to offer efficiency and economic gains. However, gains in economic efficiency tend to be localized in receiving countries and, as the evidence of costs to national health, economic, and social systems has mounted, there has been somewhat greater interest in developing policies to diminish and mitigate the impacts of migration. Nonetheless, international migration is not the main cause of healthcare shortages in developing countries, nor would a significant reduction in emigration remove human resource problems.
The onus for a more equitable global distribution of SHWs has gradually shifted toward recipient countries, where demand occurs. Few recipient countries have taken effective measures to increase recruitment and reduce attrition of SHWs, at a time of greater demand, either by increasing the number of training places or improving wages and working conditions. Continued migration has thus led to be renewed calls for ethical recruitment guidelines, adequate codes of practice binding countries, and/or compensation for countries experiencing losses; yet compensation is inherently implausible and impractical, although ethical arguments confront political realities. Better regulation, and more ethical recruitment, alongside bilateral relationships suggest some partial solutions, in terms of more effective managed migration.
The principal occupational flows of SHWs are primarily of nurses, where the evidence of losses in developing countries is substantial; however, there are more poorly documented flows of all cadres of health workers, such as radiologists and pharmacists. Failures of governance, broadly the inadequate delivery of services, whether health or education, and weak or nonexistent political will, constrain the development and retention of national workforces. Various possibilities exist for more effective production and retention of SHWs, ranging from diverse financial incentives (inside and outside the health system), strengthening work autonomy, and improving the status of health workers, increasing recruitment capacity, introducing intermediate categories of workers, such as nurse practitioners, and ensuring an effective ‘fiscal space’ for health services, but only rarely have these been effectively implemented in a concerted manner.
The international migration of SHWs has increased because perceptions of inadequate local conditions have grown, diaspora ‘host’ populations are generally increasing in destination states, demand has increased and recruitment intensified, and because health skills are valuable commodities in international migration. Yet paradoxically almost everywhere fewer people are being attracted to health careers. Wages and conditions are increasingly seen as deterrents to entry as other sectors become more attractive. Potential employees witness the frustrations of health workers and there is a wider range of job options. In both developed and developing countries, careers in health are now less attractive, other than as a means to migration.
Sending countries have not always been able to discourage migration, which is widely perceived as a human right. Indeed, several remittance-dependent countries, such as Cape Verde, the Philippines, and Kiribati, have not challenged migration but nurtured it because of its economic role. Unions have supported the rights of members to better their circumstances by migration, while also pressing governments to act locally to improve working conditions. Migration is increasingly embedded in national and international political economies. It is more resilient to cyclical downturns than other sectors. Few recipient countries have taken realistic and effective steps to increase national market supply, and any solution requires multilateral consensus rather than a national or bilateral approach. Migration of SHWs, and its complex consequences, will probably continue.
- Bach, S. (2008). International mobility of health professionals: Brain drain or brain exchange? In Solimano, A. (ed.) The international mobility of talent, pp 202–235. Oxford: Oxford University Press.
- Brown, R. and Connell, J. (2004). The migration of doctors and nurses from South Pacific island nations. Social Science and Medicine 58(11), 2193–2210.
- Clark, P., Stewart, J. and Clark, D. (2006). The globalization of the labour market for health-care professionals. International Labour Review 145, 37–64.
- Connell, J. (2008). The global health care chain: From the Pacific to the World. New York: Routledge.
- Connell, J. (2010). Migration and the Globalisation of Health Care. Cheltenham: Edward Elgar.
- Connell, J. and Buchan, J. (2011). The impossible dream? Codes of practice and the international migration of skilled health workers. World Medical and Health Policy 3(3), 1–17.
- Connell, J., Zurn, P., Stilwell, B., Awases, M. and Braichet, J-M. (2007). SubSaharan Africa: Beyond the health worker migration crisis? Social Science and Medicine 64, 1876–1891.
- Gish, O. (1971). Doctor Migration and World Health. London: Bell.
- Ho, C. (2008). Chinese nurses in Australia: Migration, work and identity. In Connell, J. (ed.) The International Migration of Health Workers, pp 147–162. London: Routledge.
- Kingma, M. (2006). Nurses on the move. Migration and the global health care economy. Ithaca: Cornell University Press.
- Mackintosh, M., Mensah, K., Henry, L. and Rowson, M. (2006). Aid, restitution and international fiscal redistribution in health care: Implications of health professionals’ migration. Journal of International Development 18, 757–770.
- Mejia, A., Pizurski, H. and Royston, E. (1979). Physician and Nurse Migration: Analysis and Policy Implications. Geneva: WHO.
- Percot, M. and Rajan, S. (2007). Female emigration from India. Case study of nurses. Economic and Political Weekly 42, 318–325.
- Vujicic, M. and Zurn, P. (2006). The dynamics of the health labour market. International Journal of Health Planning and Management 21, 101–115.
- World Health Organization (2006). Working together for health. Geneva: WHO.