World Migration Report which is entitled the âFuture of Migration: Building Capacities for. Changeâ. ..... http://ap
BACKGROUND PAPER
WMR 2010
The Future of Health Worker Migration
The opinions expressed in the report are those of the authors and do not necessarily reflect the views of the International Organization for Migration (IOM). The designations employed and the presentation of material throughout the report do not imply the expression of any opinion whatsoever on the part of IOM concerning the legal status of any country, territory, city or area, or of its authorities, or concerning its frontiers or boundaries. IOM is committed to the principle that humane and orderly migration benefits migrants and society. As an intergovernmental organization, IOM acts with its partners in the international community to: assist in meeting the operational challenges of migration; advance understanding of migration issues; encourage social and economic development through migration; and uphold the human dignity and well-being of migrants.
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BACKGROUND PAPER WMR 2010
The Future of Health Worker Migration *
BINOD KHADRIA JAWAHARLAL NEHRU UNIVERSITY, NEW DELHI
[email protected]
* I thank my graduate student Narender Thakur for valuable research assistance and anal cal discussion in the wri ng of this paper. Perveen, Lopa, Shantanu, Rashmi and Umesh provided cri cal assistance in upd ng and The responsibility for errors and omissions, however, remains with me alone. correc ng an earlier d
FOREWORD
This paper is one of 19 background papers which have been prepared for the IOM, 2010 World Migration Report which is entitled the “Future of Migration: Building Capacities for Change”. The 2010 report focuses on likely future trends in migration and the capacities that will be required by States, regional and international organizations, civil society and the private sector to manage migration successfully over the coming decades. Over the next few decades, international migration is likely to transform in scale, reach and complexity, due to growing demographic disparities, the effects of environmental change, new global political and economic dynamics, technological revolutions and social networks. The 2010 World Migration Report focuses on capacity‐building, first because it is good governance to plan for the future, especially during a period of economic downturn when the tendency is to focus on immediate impacts and the short‐term period of recovery. Second, capacity‐building is widely acknowledged to be an essential component of effective migration management, helping to ensure the orderly and humane management of migration. Part A of the World Migration Report 2010 focuses on identifying core capacities in key areas of migration management. The aim is not to recommend “one size fits all” policies and practices, but to suggest objectives of migration management policies in each area, to stimulate thinking and provide examples of what States and other actors can do. Part B of the World Migration Report 2010, provides an overview of the latest global and regional trends in migration. In recognition of the importance of the largest global economic recession since the 1930s, this section has a particular focus on the effects of this crisis on migrants, migration and remittances. Frank Laczko Head of the Research and Publications Division IOM Headquarters Geneva, Switzerland Email:
[email protected]
INTRODUCTION The concern about international migration of health workers – leading to shortages of skilled personnel and/or a drain of resources spent on their training in countries of origin – is not a new issue. An international disquiet about this brain drain of health workers (following the recognition of the phenomenon at the Commonwealth Medical Conference in Edinburgh back in 1965) led to the setting‐ up of the World Health Organization (WHO) Multinational Study of International Migration of Physicians and Nurses, which resulted in a study in 1979 that has been a celebrated classic citation on the subject for the past three decades (Mejia et al., 1979). The objective of this paper is not to review the related literature that might have evolved since, but to look at the future of health worker migration, with a view to taking stock of the range of capacities that are already available, and speculating on those that need to be created to mitigate the continuing and emerging adverse effects of the phenomenon – not only in the countries of origin (which have been focused upon traditionally) but also in the countries of destination. Migration‐related policies in origin countries, such as India, that initially targeted more the push factors at the micro level – (i) educational conditionalities,1 (ii) promotion of employment and wages in countries of origin aimed at reducing the gaps in wages and working conditions that prompted individual workers to migrate abroad and iii) the boosting of supply to meet global demand of health workers – are no longer relevant or effective in isolation. In future, with ageing of populations in most destination countries pushing up aggregate demand for health workers, perhaps the policies ought to be more focused on moderating and stabilizing the pull factors at the macro level in destination countries and coordinating them with long‐term supply of health workers through the expansion of education facilities in the origin countries. Policies should, in other words, be demand‐focused rather than supply‐centric. The underlying basic question, however, is whether these traditional supply–demand approaches will be sufficient in terms of analysing and addressing the issue of health worker migration in the future, or whether new paradigms are necessary to supplement or even replace the old ones. For example, should they still address the issue largely from a welfare‐maximizing, cost‐benefit approach or should the future construct be an efficiency‐based strategic approach? This paper includes examples of the various dimensions of global migration among health workers, existing capacities for addressing the health worker migration issue, the various approaches advocated by different international and multilateral agencies, and future directions for capacity‐building in addressing the developments in health worker migration, as well as conclusions and recommendations.
DEVELOPMENTS IN HEALTH WORKER MIGRATION Health workers comprise a range of people who provide health‐care services, such as doctors, nurses, dentists, pharmacists, laboratory technicians, management staff and support staff. The health worker migration discourse is, however, largely focused on the migration of doctors and nurses. There are 1
India generally does not have a restrictive policy for emigration of highly educated, trained and experienced personnel. From time to time, various measures to contain the problem have been conceived, but there has never been a consensus regarding the best approach. The Ministry of Health has, for example, introduced fees of INR 50,000 (USD 1,120) for a No‐Objection Certificate (NOC) and INR 100,000 (USD 2,240) for a No Obligation to Return to India (NORI) certificate as monetary compensation for the removal of restrictions on all specializations, and the participation at the program of certification by the Educational Commission for Foreign Medical Graduates (ECFMG) or its equivalent in India. The issue of compulsory rural service for a few years by doctors going abroad has also been mooted time and again (Khadria, 2002). 5
immigration data on some health worker categories, including doctors and nurses in the OECD countries, but practically no data on emigration from developing countries, and no specific data on health worker emigration in sending countries. What is important is that not only have the developing countries exported their doctors and nurses to developed countries (see table 1), but developed countries have also experienced health worker emigration to other developed countries – as in the case of German and British doctors migrating to other OECD countries (see table 2). In a sense, the brain drain seems to have come full circle, since it started with the exodus of British doctors to the United States in the early 1960s. Table 1: Top 20 nations providing doctors to Australia, Canada, the United Kingdom and the United States, various years Destination country Source country
Percentage of US physician workforce
Percentage of UK physician workforce
Percentage of Canadian physician workforce
Percentage of Australian physician workforce
Total number from source country
India
4.9
4.9
2.1
4.0
59,523
Philippines
2.1
0
0.4
0.3
18,291
Pakistan
1.2
2.1
0.5
0.2
12,713
United Kingdom
0.4
‐
4.0
8.6
10,838
Canada
1.1
0
‐
0
8,990
China/Hong Kong
0.8
0
0.3
0.8
7,335
Egypt
0.5
1.1
0.8
1.0
7,278
0
1.2
2.0
2.3
4,987
Germany
0.4
0.6
0
0.2
4,695
Mexico
0.5
0
0
0
4,578
Ireland Nigeria
0 0.3
3.0 0.8
1.7 0
0.8 0
4,433 3,921
Poland
0.3
0
0.6
0.3
2,995
Lebanon
0.3
0
0.2
0
2,717
Sri Lanka
0
0.5
0.2
1.2
2,212
New Zealand
0
0.3
0
3.2
2,047
Australia
0
0.5
0.4
‐
1,119
Jamaica
0
0.4
0.3
0
651
United States
‐
0
0.8
0
519
Viet Nam
0
0
0.3
0.2
331
South Africa
Sources: Mullan, 2005; US data based on the Educational Commission for Foreign Medical Graduates (ECFMG)/American Medical Association (AMA), 2004; UK data based on the National Health Service (NHS) (adjusted); Canadian data based on the Canadian Institute for Health Information/the Canadian Post‐MD Education Registry (CAPER), 2002; Australian data based on Australian Institute of Health and Welfare, 1999 (adjusted); all cited in Report of the High Level Group on Services Sector, Government of India, Planning Commission, New Delhi, March 2008.
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Table 2: Foreign‐born doctors and nurses in OECD countries by main countries of origin (top 24), 2000 Country of origin of doctors India Germany United Kingdom Philippines China Former USSR Algeria Pakistan Canada Iran Viet Nam South Africa Egypt Morocco Cuba Poland Romania Syria Malaysia Sri Lanka Nigeria Lebanon Italy United States
Number of doctors in OECD Expatriation Country of origin countries rate (%) of nurses 55,794 8.0 Philippines 17,214 5.8 United Kingdom 17,006 11.3 Germany 15,859 26.4 Jamaica 13,391 1.0 Canada 11,360 ‐ India 10,793 23.4 Ireland 10,505 8.3 Nigeria 9,946 13.0 Haiti 8,991 12.9 Fmr Yugoslavia 7591 7,355 7,243 6,221 5,911 5,821 5,182 4,721 4,679 4,668 4,611 4,552 4,386 4,354
15.2 17.4 15.8 28.0 8.2 5.8 10.9 16.6 22.5 30.8 11.7 28.3 1.8 0.6
Mexico China Former USSR Tri&Tob. Poland Algeria France Malaysia New Zealand Guyana Italy Netherlands United States South Africa
Number of nurses in OECD countries 110,774 45,638 31,623 31,186 24,620 22,786 20,166 13,398 13,001 12,948
Expatriation rate (%) 46.5 6.1 3.8 87.7 7.4 2.6 24.9 9.5 94.0 NA
12,357 12,249 10,034 9,808 9,153 8,796 8,589 7,569 7,564 7,450 6,945 6,798 6,022 6,016
12.2 0.9 NA 72.9 4.6 12.4 1.9 19.6 19.5 81.1 2.2 3.0 0.2 3.2
Sources: OECD (2007) International Migration Outlook: SOPEMI 2007 Edition, and Khadria (2009b) (ed.) India Migration Report 2009: Past, Present and the Future Outlook, p.99.
Sources such as WHO (2008), OECD (2008), and IOM (2008) conclude that health workers are migrating globally and will do so increasingly in the future. However, speculation on future scenarios will depend on available data and how such data are analysed. Most available data are based on the last rounds of national censuses, most of which are a decade old. New data will only be available after the next rounds of censuses are completed this year (2010) or in 2011. Until then, the analysis of migration trends can only be based on either stock data (such as those presented in tables 1 and 2) or on the expatriation rate of health workers (as presented in table 2). In both tables, India is at the top of the list of countries of origin in terms of absolute numbers of doctors in major developed countries. However, in terms of the expatriation rate of doctors (table 2), the Philippines (24%) ranks higher than India (8%), Germany (6%) or the United Kingdom (11%).2 Similarly, the expatriation rates of nurses (table 2) from Caribbean countries are higher than that of the Philippines, which has sent the highest number of nurses abroad. 2
Filipino‐born nurses and Indian‐born doctors each represent about 15 per cent of all immigrant nurses and doctors in the OECD. The United Kingdom and Germany are the second and third most important origin countries (OECD, 2007). 7
Along with analysis of these kinds of data, it is also important to address the issue of how the countries of origin and destination are likely to be impacted by emigration and immigration of health workers. In the United States, the number of overseas‐educated doctors passing Step 3 of the United States Medical Licensing Examination (USMLE) – the stepping stone to working as a fully registered medical doctor in the United States – increased by 70 per cent between 2001 and 2008. Over the same period, temporary migration of doctors increased twofold in Australia and by 40 per cent in Canada. In these two countries, regulations on permanent migration for doctors have been relaxed and flows have been increasing rapidly. Inflows of foreign doctors with long‐term permits have also increased markedly in Switzerland (by 70% between 2001 and 2008), mainly from Germany. The significance of such data can be appreciated by looking at the picture from the side of the destination country (see figure 1). Figure 1: Share of foreign‐trained or foreign doctors in selected OECD countries in 2008 (or latest year for which data are available) (%)
Source: www.oecd.org/health/workforce Note: Data for Poland and France are for 2005; data for the Netherlands are for 2006; data for Australia, Canada, Sweden and the United States are for 2006; data for Portugal and the Slovak Republic are for 2004.
Changes in the share of foreign‐trained health workers reflect the cumulative impact of past migration flows, sometimes with a lag because of the time taken for full registration. In many OECD countries, the share of foreign‐trained doctors has been visibly high in recent years. Figure 1 shows that the percentage of foreign‐trained doctors ranged from below 1 per cent in Poland to 39 per cent in New Zealand around 2008. High percentages were also recorded in the United Kingdom and Ireland, where about a third of all doctors were trained abroad. In Australia and the United States, the percentage of foreign‐trained doctors was 23 per cent and 26 per cent, respectively, in 2007. Interestingly, the share of foreign‐trained nurses tends to be lower than that of doctors (see figure 2). In Sweden, for example, less than 3 per cent of nurses were foreign‐trained in 2008, compared with over 18 per cent for doctors. Similar findings apply to most OECD countries, but not in Ireland, which has the second highest nurse‐to‐doctor ratio in the OECD (5:1) with 47 per cent of the nurses being foreign‐ trained compared with 35 per cent of doctors.
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Figure 2: Share of foreign‐trained or foreign nurses in selected OECD countries in 2008 (or latest year for which data are available) (%)
Source: www.oecd.org/health/workforce Note: Data for Denmark and the Netherlands are for 2005; data for Australia, Canada and Sweden are for 2007; data for the United States are for 2004; data for the United Kingdom are for 2001.
The recent economic crisis does not seem to have drastically affected the international migration of health workers. Employment in the health sector is more resilient during a cyclical downturn than employment in most other sectors, and the demand for health care is certainly not decreasing in the short term, due to the crisis. In the medium term, however, the economic crisis is putting severe strain on public finances, which could affect the number of health workers being trained or recruited in the future. So far, however, there is little evidence of any significant impact.
CURRENT CAPACITIES FOR ADDRESSING HEALTH WORKER MIGRATION Changing patterns in health worker migration initially impact the supply and demand gaps in the labour markets of origin and destination countries, as reflected in the worker–population ratios (physicians and nurses per 1,000 persons) and, ultimately, by the conditions in health‐care facilities and the health status of their population, which is measured by the mortality rates (infant mortality rate and maternal mortality ratio). The WHO threshold for a ‘health workforce crisis’ is 23 health workers for every 10,000 persons in a country. Table 3 presents these ratios for doctors and nurses in selected countries. For example, India, an origin country, with only 19 health workers per 10,000 persons, is in a crisis state. India has also had a low nurse–population ratio (Khadria, 2004; 2007). As destination countries, the United Kingdom and the United States have ratios of 75 and 125 health workers per 10,000 persons respectively, which are far above the benchmark. However, there is still a demand for doctors and nurses in these countries. 9
Table 3: Health conditions and health worker ratios in selected sending and destination countries
Country
Infant mortality rate (IMR) (per 1,000 live births)
Maternal mortality ratio (MMR) (per 100,000 live births) 2000–09* 254 13 7 8 15 162
Physicians (per 10,000 persons)
Nursing and midwifery personnel (per 10,000 persons)
Total health workers (per 10,000 persons)
2008 2000–09* 2000–09* 2000–09* India 52 6 13 19 United States 7 27 98 125 United Kingdom 5 21 54** 75 Australia 4 10 109 119 Saudi Arabia 18 16 36 52 Philippines 26 12 61 73 Source: WHO, 2010b * For indicators with a reference period expressed as a range, figures refer to the latest available year in the range. ** This figure comes from the Global Health Atlas for reference year 2003 http://apps.who.int/globalatlas/dataQuery/reportData.asp?rptType=1, as the figure given in the World Health Statistics 2010 (for the latest available year between 2000 and 2009) is 6, which seems to be too low compared to the figure 128 given in World Health Statistics 2009 (for latest year prior to year 2000).
Table 3 also shows the infant and maternal mortality ratio as indices of health status of the population. In the year 2008, the IMR and MMR in India and the Philippines were 52 and 254, and 26 and 162, respectively. In the United Kingdom, the IMR was 5 and the MMR was 7; in the United States, the figures were 7 and 13, respectively. The reduction in infant mortality rate and maternal mortality rate, as part of the Millennium Development Goals (MDGs), is crucial for countries such as India and the Philippines to achieve health equity. To achieve the MDG targets, the provision of health‐care services and workers must be handled in a way that facilitates a sustainable supply of such services and workers in both sending and destination countries. In OECD countries, there is an increasing demand for health workers because of rising incomes, new medical technology, increased specialization in health‐care services, and population ageing. The higher demand for health workers in OECD countries resulted in an increased supply of physicians and nurses in those countries in the 1970s and 1980s, but the growth rates have slowed sharply since the early 1990s (OECD, 2010). The average growth in the numbers of physicians and nurses in OECD countries slowed sharply between 1990 and 2005, compared with the previous 15 years (1975–1990) (OECD, 2008). Cost‐ minimization policies adopted by OECD countries, such as control of entry into medical school and closure of hospital beds (in the case of nurses), explain much of the slowdown. Furthermore, trends such as the growing number of female physicians, higher rates of part‐time work and early retirement are also likely to have reduced hours worked by the average health worker. By 2000, several OECD countries were reporting shortages of doctors and nurses in some areas (OECD, 2010). In response, OECD countries recruited health‐care professionals from abroad – an attractive option for cost‐ minimization and to increase supply of health‐care professionals, at least in the short term. In other words, they opted for a “quick fix” rather than training extra doctors and nurses, which takes much longer to have an effect. Subsequently, following the shortages of health workers, OECD countries adopted policy initiatives to increase the supply of such workers, and many also increased their investment in the education and training of doctors and nurses. As a result, since 2000, the number of nursing graduates has increased by at least 50 per cent in Australia, Canada, France and the United Kingdom. The number of places in medical schools has also been raised. However, as it can take more
10
than 10 years to fully train doctors, and from 3 to 5 years to train a nurse, the effects of these policies will, in most cases, only be visible in the next few years (OECD, 2010). From the perspective of potential migrant health worker, the push and pull factors driving the migration of personnel broadly coincide with those that apply to highly skilled workers in general. Despite the lack of doctors and nurses in many developing countries, the first motivation for migration is often linked to more and better employment opportunities abroad (encompassing higher salaries, better working conditions, prospects of career advancement, etc.) (Khadria, 2004). Wage differentials across countries play an important role, but other factors, such as the possibility of a better and safer future for health workers’ children, may also be a major determinant. Often, migration of health workers is a symptom of the difficulties faced by the health‐care system and, more generally, the society of the country of origin rather than its direct cause. In the past decade, there have been rapid increases in the numbers of health‐care personnel migrating, notably to OECD countries (OECD, 2007). Despite recent trends showing signs of stabilization or decline in a few countries, overall migration of health‐care personnel to OECD countries is still on the rise.3 To promote concrete solutions to this complex health workforce problem, the period from 2006 to 2015 was dubbed the Decade of Health Human Resources by the Observatory of Human Resources in Health Sector Reforms. In July 2009, the G8 countries4 at the L’Aquila Summit (Italy, 8–10 July 2009) encouraged WHO to develop a code of practice on the international recruitment of health‐care personnel by 2010, and the ministerial declaration of the 2009 high‐level segment of the United Nations Economic and Social Council called for the finalization of that code. Accordingly, in January 2010, WHO framed a draft code of recruitment.5 The code sets out the principles applicable to the international recruitment of health‐care personnel in a manner that promotes an equitable balance of interests among health workers, source countries and destination countries. One of the guiding principles of the draft code is that current and anticipated shortages in the health workforce must be addressed, as this is of critical importance to global health. Another important principle relates to the mutuality of benefits. As stated in Article 3 of the code, the health‐care systems of both source and destination countries should derive benefits from the international migration of health workers. In developing and implementing international recruitment policies, Member States should strive to ensure that the balance of gains and losses of health worker migration should have a net positive impact on the health‐ care systems of developing countries and countries with their economies in transition. WHO highlights what needs to be done by importing countries in terms of “ethical recruitment policies” for tackling the adverse consequences of health workforce migration, as follows:6 •
Reduced dependency on migrant health workers in industrialized countries. The main solution is to train more health workers at home. The United States, for example, trains 30 per cent too few physicians to meet its own needs. • Bilateral agreements with exporting countries, aimed at softening the financial impact of health worker migration. 3
For updated statistics, see www.oecd.org/health/Workforce and OECD, 2009. The Group of Eight comprises Canada, France, Germany, Italy, Japan, the Russian Federation, the United Kingdom and the United States. In addition, the European Union is represented within the G8, but cannot host or chair. 5 The WHO Executive Board on January 2010 decided to submit the draft code of practice to the World Health Assembly of May 2010 for deliberation and possible adoption by Member States. This code would be voluntary, global in scope and applied to all health personnel (OECD, 2010). See www.hsu.net.au/publications/discussethicalrecruit.html for Ethical Recruitment and Employment of Overseas Trained Health Workers. 4
6
See http://www.who.int/mediacentre/factsheets/fs301/en/index.html (accessed March 2010) 11
• • •
Responsible recruitment policies by industrialized countries and fair treatment of migrant health workers. Agreements on ethical recruitment of, and working conditions for, migrant health workers, and international planning of the health workforce for humanitarian emergencies and global health threats. Commitment from donor countries to assist crisis countries in their efforts to improve and support the health workforce. Of all new donor funds for health, 50 per cent should be dedicated to strengthening health‐care systems and 50 per cent specifically to the health workforce.
The Commonwealth, experiencing increasing emigration of its health workforce in high‐needs countries, in the face of shortages and health crises, is one of the leading advocates for improved arrangements for health worker recruitment internationally.7 The shortages, which tend to be more severe in small island States (such as in the South Pacific) and some remote and rural areas in African countries, reduce the countries' capacity to provide good‐quality health‐care services to their populations. In May 2007, the Commonwealth Health Ministers acknowledged the existence of critical shortages in 17 Commonwealth countries and agreed that a consensus approach to dealing with the problem of international recruitment of health workers should be adopted. Accordingly, the Commonwealth put forward the following principles for consideration and adoption by the First Global Forum on Migration and Development in Belgium in July 2007: •
• •
•
Wealthier countries wishing to recruit health workers from poorer countries should help strengthen the capacity of the latter to increase their output of skilled professionals, through institutional capacity‐building – for example, sponsoring relevant education and training institutions. Qualified migrants should not be disadvantaged or relegated to a lower status simply because their qualifications and experience are not recognized in their country of destination. Regulating bodies must facilitate recognition of qualifications, through the use of professional development, if necessary. While standards must be maintained in the accreditation and recognition of qualifications, governments must be encouraged to facilitate mutual recognition of qualifications The International Labour Organization (ILO) and WHO must be supported in their efforts to ensure that migrants to other countries have access to ethical recruitment procedures and are properly treated, and that migrants’ rights are respected.
The OECD is currently undertaking a Health Workforce and Migration Project, which aims to provide an overview of migration flows of health workers across OECD countries in tandem with OECD policies and planning.8 Their objective is to formulate recommendations and policy options to facilitate a coherent approach to health workforce policies and migration among OECD countries. These recommendations are to take into account the impact on the health‐care system for sending countries, health workforce policies in sending countries, and the aid development policy of receiving countries.
7
See http://www.thecommonwealth.org/Templates/Internal.asp?NodeID=34042 (accessed August 2010)
8
See www.oecd.org/health/workforce (accessed August 2010) 12
CAPACITY REQUIREMENTS FOR ADDRESSING THE FUTURE MIGRATION OF HEALTH WORKERS Capacity requirement in the context of future migration by health workers could be addressed in two ways: (i) capacity to enhance the status of national populations’ health‐care systems by balancing supply and demand for health workers between nationals and migrants; or (ii) capacity to achieve optimal levels of emigration or immigration of health workers in a more globalized, open‐economy scenario. Strategies and policy options for addressing the former are focused on enhanced capacity‐building to formally educate and train adequate numbers of health workers, whether or not migration is involved. On the other hand, the strategies and policy options in the latter are focused on addressing the issue of emigration and immigration of health workers as variables rather than absolutes, and their impacts on decisions made by individuals and society – for example, whether to invest in medical education with a view to sending health‐care professionals out into the global labour market or to keep the global labour market as a fall‐back option if there is not enough employment at home for nationals. The problem with the first generation of policies, aimed at stemming the migration of health workers, was that the policies were invariably based on national capacity‐building – for example, focusing on the domestic labour market and discouraging emigration by offering compensation or imposing immigration restrictions relating to profession‐specific qualifying examinations and non‐recognition of foreign degrees and certificates. Inevitably, the principles of these policies were not strictly adhered to by aspiring migrant health workers (Khadria, 2002, cited in Lucas, 2005:139–40). The second generation of policies (which include the ineffective “ethical recruitment policy”) treated the migration of health workers as an aberration and tried to solve it through moral suasion of the employer and the employee. None of the policies so far have considered migration for employment abroad to be the basic human right of every health worker – or any skilled worker. The right of the employer to choose the best employees for the cost‐effective production of goods and services has, likewise, been neglected. Identifying key areas for further capacity‐building involves addressing these two issues. However, mobilizing public and State support can be daunting; curtailing the free movement of health workers at the micro level (through exit/entry restrictions, non‐recognition of educational qualifications, charging of monetary compensation for exit permits such as NOC, NORI, etc.),9 and preventing employers from recruiting and deploying the best and the most economical human resources in providing health‐care services, is extremely costly and difficult to implement. This is because none of the strategies mooted under these policies have been based on incentives. The problem of health worker migration has promoted the development of health‐care tourism, whereby high‐income developed‐country patients travel to developing countries to receive treatment and care for a fraction of the price it would cost in their home countries. However, this approach is limited to one‐time or limited‐period treatments, such as surgery or limb replacement, and it does not resolve the ongoing supply‐demand mismatch on location, where continuous health‐care services are required. Innovations such as e‐medicine and e‐health are being considered as possible, partial solutions, but the fact remains that most migration by health workers is driven by decisions that are sometimes jointly taken by various members of a health worker’s family – often for reasons that have nothing to do with health, medicine, patients or the availability of health workers. While it is clear that migrant health workers could play a significant global role in uplifting the health status of various populations in and across countries, it is also clear that such a possibility has never 9
See footnote 2. 13
been put on an agenda relating to a proposed framework of migration and health policies. Now, at the global level, the capabilities of international migrants need to be ascertained, and the capacities of States and private players to positively and efficiently enhance these capabilities must also be improved. For the efficient use of human resources, including international migrants, coordination of global health workers with other stakeholders in migration and in health policies could be promoted. The instrumental roles of different stakeholders have been repeatedly identified and stressed and there is a need for more novel, innovative approaches. The governments of both source and destination countries and their private sectors could, for example, build a model of “third‐country development” through migrant health workers, to specifically look after the health status of populations in countries with a “health workforce crisis”. It is common knowledge that almost all migrant health‐care professionals with roots in their home countries routinely or occasionally return home for work, pleasure or vacation. It might be worth floating a scheme whereby they could be mobilized to spend one or more of their vacations providing health care to the marginalized sections of global migrants in a third country – not the home country or the host country – where they could devote quality time to the mission without the distraction of family or friends. Health‐care professionals may be open to the idea of doing some humanitarian work while visiting and working in another country. However, this would only satisfy the “necessary condition”. To satisfy the “sufficient condition”, infrastructure and medicines would have to be provided by the State and the private sector – not just for the welfare of the population, but to enhance productivity and help stimulate demand for that country’s products. If such a scheme were introduced, it could help to build capacity through temporary migration between two or more countries. The participating migrant health workers could be considered an “international health‐keeping corps”, like the highly successful Doctors Without Borders or the UN’s peace‐keeping forces. In order to streamline the global supply of, and demand for, migrant health workers (whether in an institutionalized third‐country development model or a spontaneous free‐market model of mobility), the uncertainty due to unpredictable immigration policy changes and volatile visa restrictions need to be minimized. This uncertainty is prompted by destination‐country considerations of strategic self‐interest, relating to the “trilogy of advantages – age, wage and vintage” (Khadria, 2009a; 2009b). Such considerations are based on strategic self‐interest rather than standard cost‐benefit analysis, because the gains and losses, in terms of productivity and finance, are not only indeterminate and undefined, the accounting cycles do not necessarily keep pace with those of the origin countries, which usually operate on very short time horizons. The trilogy of advantages is significant: immigration policies have increasingly been geared towards replacing older generations of workers (including health workers) with younger ones, through temporary and circular migration, keeping the age profile of the immigrant worker population young to look after the old, as well as neutralizing the aging profile of the population in host countries. Younger immigrant health workers are admitted also because they can be paid a lower wage, with fewer perks and pensions, thereby keeping the labour costs in health‐care services depressed and more globally competitive for the host countries. However, they also reduce migrants’ remittances, as savings abroad are lower when immigrant workers’ wages are lower. Finally, countries selectively accumulate the latest “vintage” of knowledge in health sciences and technology embodied in the most recent generations of medical graduates and nurses. Keeping their policies flexible also enables host countries to fill short‐term labour market shortages at short notice.10 In origin countries, however, this unpredictability creates what is called “diverging cobweb disequilibrium” in the decision‐making processes relating to education and career choices made by individuals and their families – choices that 10
An example of this is the introduction and subsequent withdrawal of the controversial Highly Skilled Migrant Programme (HSMP) by the British Government, which attracted expatriate doctors from India and later put them in an undefined status, leading to court cases against the Home Department in the British judiciary. 14
are seriously considered and, in most cases, are irreversible. To curtail the uncertainties in the global labour market, the following steps are required: • •
Stabilize policies by making it mandatory to put a ‘transparent expiry date’ on any change in immigration policy, to be honoured by the enacting States unless abnormal circumstances warrant otherwise; Develop ‘bad‐practice guidelines’ that identify bad practices11 for the purpose of reforming immigration and visa regimes.
The questions of who would take the initiative and what could be the ideal strategy for introducing and operationalizing these instruments would still need to be addressed.
CONCLUSIONS AND RECOMMENDATIONS Globally allocating health workers in the presence of scarcity could be reduced to lobbying countries to work together to optimize the global interests of all three stakeholders – the actual or potential migrant health worker, his or her country of origin and its population, and the country of destinations and its population – rather than leaving each of the stakeholders to maximize their own gains in isolation. In introducing an expiry date for immigration policy changes and in phasing out the bad practices mentioned earlier, the developed destination countries and the developing origin countries must have a proper and empathetic understanding of each other’s interests. This could entail what I call a North– South “equitable adversary analysis”, whereby the contending parties step into each other’s shoes in order to analyse and argue the case of the other. This could be attempted at the level of the United Nations, at the multilateral level, or bilaterally between two countries. To operationalize the “third‐country development” model, migrant health workers based in a developed country reside, temporarily, in a developing country other than their country of origin to provide health‐ care services, as mentioned earlier. Southern countries can leverage the emerging trend of dual citizenship being acquired by their citizens residing in developed countries to initiate developmental participation in third countries. The informal or formal acceptance of dual nationality can increase the availability of migrant health workers’ services transnationally. Such measures can help to foster South– South cooperation among the low‐income “crisis” countries, and contribute to intra‐South development‐related transnationalism in the health‐care sector.12 The granting of dual citizenship to an individual by one nation involves transnational recognition of the sovereignty of the other nation upon its members and, therefore, of the mutual benefits at the global level. As an extrapolation of this latent relationship between countries, dual citizenship could be seen as a possible route to South–South cooperation for global sharing of a common human‐capital pool of migrant health workers. For example, an Indian‐American health worker (a doctor), with dual citizenship in the United States could become the medium of arbitration and cooperation between the two governments of India and Kenya when his or her colleague is a Kenyan–American citizen through whom he/she could lobby the Kenyan 11
This was formally proposed at the Third GFMD in Athens and was adopted as one of the objectives.
12
For example, the Indian Spinal Injuries Centre (ISIC), which also houses returning Indian doctors, is setting up the Kenya Spinal Injuries Centre (KSIC) in Nairobi. According to the ISIC Chairperson, “Africa lacks facilities for spinal injury management. By helping KSIC set up a facility ... ISIC hopes to reach out not only to spinal injury patients in Kenya but also to people from other neighbouring countries who routinely come there for treatment. If this initiative is successful, it will set the trend for many such centres to come up in different parts of Africa and around the world.” See: Medical centre in Kenya to be set up with Indian assistance, The Hindu, New Delhi edition, 7 July 2009, p.4. 15
Government. Such scenarios could also be simulated multilaterally when “club members”, comprising naturalized American citizens, hold two citizenships – one in the United States and the other in their Southern country of origin. When dual citizenship is leveraged, the members would have both the legitimacy and the strong social capital of an emotional bond to get involved in such endeavours. For voluntary NGO activities, the scope of such cooperation would be even greater. This can also be fostered through existing regional blocks, such as the ASEAN or the SAARC,13 or emerging ones, such as the BRICs14 and the BASIC.15 To operationalize such cooperation between the Member States of such regional blocks in the South, one possibility could be to create regional or subcontinental umbrella networks of the health worker diasporas across countries.
13
South Asian Association for Regional Cooperation Brazil, Russia, India and China 15 Brazil, South Africa, India and China 14
16
REFERENCES Government of India 2008 Report of the High Level Group on Services Sector, Government of India: Planning Commission, New Delhi. IOM 2008 World Migration Report 2008, International Organization for Migration (IOM), Geneva. Khadria, B. 2009a Adversary analysis and the quest for global development: Optimizing the dynamic conflict of interest in transnational migration. Social Analysis, 53(3):106–122. 2009b India Migration Report 2009: Past, Present, and the Future Outlook. International Migration and Diaspora Studies (IMDS) Project, Jawaharlal Nehru University, New Delhi. 2007 International nurse recruitment in India. Health Services Research Journal, 42:1429–1436. 2004 Migration of Highly Skilled Indians: Case Studies of IT and the Health Professionals. OECD Science, Technology and Industry Working Papers, 2004/6, Organisation for Economic Co‐ operation and Development (OECD), Paris. 2002 Skilled Labour Migration from Developing Countries: Study on India, International Labour Organization (ILO), Geneva. Lucas, R. 2005 International Migration and Economic Development: Lessons from low‐income countries. Edward Elgar, Cheltenham. Mejia, A. et al. 1979 Physician and Nurse Migration: Analysis and Policy Implications. World Health Organization (WHO), Geneva. Mullan, F. 2005 The Metrics of the Physician Brain Drain, The New England Journal of Medicine, 353(17):1810– 1818. OECD 2010 International Migration of Health Workers: Improving international co‐operation to address the global health workforce crisis. Policy Brief, Organisation for Economic Co‐operation and Development (OECD), Paris. 2008 The Looming Crisis in the Health Workforce: How can OECD countries respond? OECD Health Policy Studies, Organisation for Economic Co‐operation and Development (OECD), Paris. 2007 International Migration Outlook, SOPEMI, Organisation for Economic Co‐operation and Development (OECD), Paris. WHO 2010a Global Health Atlas. World Health Organization (WHO), Geneva. http://apps.who.int/globalatlas/ (accessed 27 September 2010) 2010b World Health Statistics 2010. World Health Organization (WHO), Geneva. 2008 World Health Report 2008. World Health Organization (WHO), Geneva. 2006 World Health Report 2006. World Health Organization (WHO), Geneva. 17
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