Migration of Physicians and Nurses: Trends & Policies
WHEC Practice Bulletin and Clinical Management Guidelines for healthcare providers. Educational grant provided by Women's Health and Education Center (WHEC).
In 1972, about 6% of the world's physicians were located outside their country of origin, the majority of whom were in the USA, UK and Canada. The main donor (principally Asian) countries reflected colonial and linguistic ties. These historical ties are now weakening as recipient countries recruit primarily on the basis of economic requirements. In both the countries of origin and the receiving countries, consumers of health services have similar concerns. There are also other influential factors, such as the continuation of vital financial support from migrant family members. Governments represent the collective voices of consumers and employers, but their perspectives are often internally diverse. With many different voices raised in concern, the migration of health workers is newsworthy, and the difficulties of collecting accurate data mean that unsubstantiated claims may be made in the media. Because of its inherent complexities, the migration of health workers benefits from multidisciplinary research: solutions must be informed by a better understanding of the perspectives and underlying motivations of the many stakeholders (1).
The purpose of this document is to discuss the international mobility and migration of the healthcare providers. Policy options to manage migration and suggestions for the developing countries to reverse the "brain-drain" are also provided. Policy-makers should focus on why people migrate? On the basis that migration is unlikely to stop given the advances in global communications and the development of global labor markets, the strategic approaches to the health worker migration are needed. Well- managed migrants' health benefits all; however, economic revitalization may be the only truly effective intervention.
Migrant health workers are faced with a set of options that are a combination of economic, social and psychological factors and family choices. They trade decisions related to their career opportunities and to financial security for their families against the psychological and social costs of leaving their country, family and friends. Employers in the countries of origin have their own perspective. They are unable to fulfill their mandates to provide equitable access to health care because the necessary health workers are not available. In many cases, the country is losing its investment in the education of health professionals, as well as losing the contribution of these workers to health care. Employers in receiving countries take a different position, driven by their need to provide sufficient health workers to meet the demand for services within the constraints of budget planning and the imperfections of the labor market. In both the countries of origin and the receiving countries, consumers of health services have similar concerns.
In 2000 almost 175 million people, or 2.9% of the world's population, were living outside their country of birth for longer than one year. Of these, about 65 million are economically active. In absolute terms the number of people living outside their country at any one time has more than doubled since 1965. 65% of all economically active migrants who have moved to developed countries are classed as "highly skilled" (2). The migration of health workers is not new: nurses and physicians have sought employment abroad for many reasons, including high unemployment in the healthcare labor market in their home country. Certain sets of skills and competencies are so specialized or in such short supply that they are being sourced globally. Nurses are part of this global market, as many countries, both those that are high in resources and those that are low in resources, are reporting shortages of nurses. Physicians do not appear to fall into the same category; in some countries there is an oversupply of physicians. Both the United States and the United Kingdom anticipate large shortfall in the number of nurses they will need over the next 10-20 years, and overseas recruitment is an overt tactic to compensate for these shortages.
The last important piece of research undertaken by the World Health Organization (WHO) in this field was in the mid-1970s, when Meija et al found that 6% of physicians and 5 % of nurses were living outside their country of birth. They also admitted that it was difficult to ensure its reliability and it was equally difficult to obtain qualitative data on the effects of migration on people and health systems (3). Data from countries that recruit or accept health professionals (destination countries) appear to be more reliable than data from the home countries of the professionals who travel work abroad (the source countries). Destination countries may address work-force issues that affect migration. Ironically, some of their problems are the same as those of the source countries, though without the extreme adverse effects that results from the loss of health workers from already struggling healthcare systems.
Why do healthcare workers migrate?
The overall economic and social contexts in which healthcare workers make the decisions to migrate are: wars, deprivation, and social unrest may all provoke waves of migration. The migration of health workers is primarily demand led, with workforce shortages in some destination countries, such as USA and UK. The availability of employment, particularly in the developed world, has a significant impact on the decision to migrate. The factors affecting health professionals' decision to migrate are:
- Want better or more realistic remuneration
- Want a more conductive working environment
- Want to continue education or training
- Want to work in better managed health system
In general, migration is influenced by social networks, which offer support to new migrants and often connections to employment. Nurses have links with nursing organizations and networks that may foster further migration. These networks then assist new migrants with social and cultural assimilation. A similar picture emerges for countries with colonial and political ties, where there are already established cohorts of migrants.
Financial and non-financial incentives:
In many developing countries healthcare systems are suffering from years of under investment, and for healthcare workers this has resulted in low wages, poor working conditions, a lack of leadership, and few incentives of any kind. Low job satisfaction and motivation affect the performance of health workers as well as acting to push people to migrate. Nevertheless, the prospect of making substantially more money is thought to be a pivotal factor in the decision to migrate. If donor money can be used in some developing countries to support the wages of healthcare workers, such incentives may be the more realistic possibility to reduce "brain-drain". In some countries, educating a group of community-based health workers to offer health services, especially in rural areas, and such workers are far less likely to migrate internationally.
Agreements between countries:
Recognizing the inevitability of migration and building in opportunities for health workers to work overseas for limited periods of time is possible through bilaterally negotiated agreements, for which temporary visas are granted, or through institutional agreements to take (or even exchange) workers. This type of scheme is being tried between the United Kingdom and South Africa, apparently with some success (2). The Caribbean Community (CARICOM) has devised a scheme to encourage skilled professionals to work overseas on a rational basis, going for three years or so and then returning. CARICOM hopes at least to limit the effects of a loss of skilled labor on Caribbean countries (4). Agreement between countries specify that the destination country will invest in institutions in the source country so that, in effect, some source countries will act as providers of healthcare personnel for destination countries by training a surplus of health workers. This sort of system has traditionally been in place in the Philippines, where private nursing schools train nurses who intend to migrate, though some commentators now contend that the loss of nurses is becoming detrimental to the health system.
The General Agreement on Trade in Services (GATS) comprises a set of legally enforceable rules that govern the trade in goods and services. Mode 4 of GATS concerns the movement of people, and in relation to the trade in health services by individuals from another country on a temporary basis. The possible impact of GATS on health care is controversial. In terms of migration, some countries will benefit from agreements to send their health workers abroad, but all countries have the opportunity to negotiate agreements. Early indications are that countries are more likely to enter into agreements for the modes that govern the supply of services and commercial presence (modes 1-3), such as private hospitals and clinics and a range of other commercial health-related facilities, than they are to make commitments to mode- 4 (5). One other anticipated difficulty with GATS is that it does not define what "temporary movement" means. This might act as an advantage for source countries by restricting the amount of time for which health workers can get visas. However, GATS will reinforce the move towards the international harmonization of qualifications, which already has some momentum in nursing.
Magnitude and impact of the brain drain:
Countries that contribute human capital to the brain drain rarely record the characteristics of emigrants. In contrast, countries rarely record the characteristics of emigrants. In contrast, countries that receive the migrants, of which there are fewer (Australia, Canada, France, Germany and the United States account for >90% of migratory flow to countries in the Organization for Economic Co-operation and Development), maintain statistics on foreign-born national and immigrants through census data and national databases on education and scientific and technological capacity. Immigrants to the United States have a higher level of education than the average individual in their home country. Furthermore, the proportion of the population migrating from either developing or industrialized countries, with few exceptions, is greatest among the most highly educated. Incentives for migrants to return to developing countries have been insufficient to override the limitations at home, both real and perceived, and the attraction of opportunities found abroad. Thus, in 2000 an estimated 1500 highly qualified Indians returned from the United States but more than 30 times that number leave India each year. According to the 2002 World Economic Forum report, Chile and Brazil generally retain their scientists and engineers while Argentina and Colombia do not.
The impact of the loss of highly skilled and well-educated individuals differs for countries with different sized economies. Medium-sized economies in particular may be the most vulnerable since migration can subvert the possibility of achieving a critical mass of capacity to produce and innovate efficiently. Many of these countries have made significant investments in infrastructure and education but have not achieved the scientific development and technological and innovative capability either to retain or to recover the human capital that they have generated. This raises the question of whether it is justified to continue losing human capital or to make the additional investment in science and technology and bring about the innovations needed to stop the loss and convert it into wealth generation. Although, every country, irrespective of size, must be able to use knowledge to compete in international markets, smaller economies may lack the market or population size to make the acquisition of certain skills profitable; they may thus be less affected by emigration. On the other hand, large economies may have the diversity of human resources and educational infrastructure to overcome losses resulting from emigration.
Strategies to address brain drain:
The issues surrounding brain drain are complex. For developing countries, scientific trainees who fail to return are a drain on the economy and on capacity building. While abroad, they can contribute to scientific advances of importance to their home country and serve as mentors for other trainees. Continuing Medical Education (CME) initiatives are one example of such efforts, which can be of benefit to donor, and recipient countries both. Some factors cited by researchers from developing countries as reasons for not returning after training include: lack of research funding, poor facilities, limited career structures, poor intellectual stimulation, threats of violence and lack of good education for children in their home country. However, not all the factors involved in brain drain is due to scientific and research funding; some such as violence and civil war are major factors for not returning back to the home countries. Strategies to manage migration of health professionals to protect national health systems will be successful only if all stakeholders are involved in the process. Although the brain drain undeniably has serious negative effects, these may be turned around to benefit migrants' home countries if managed well. Some training and skills gained abroad may really be more appropriate and better applied in developed countries than at home (6).
Honoring the Human Rights to Health and Freedom of Movement:
There is a growing need to clarify which we believe to be ethical in global development. This is readily apparent with regard to the migration of health workers, as evidenced by the burgeoning of both international and transnational voluntary codes of practice related to the processes surrounding their international recruitment. Internationally agreed upon human rights help to identify the shared principles that we hope to provide clarity on the potential forms that recommended practices can take in order to mitigate the negative effects resulting from the migration of health workers. A number of voluntary codes of practice on the issue of health worker migration suggest policies around self-sufficiency, limitation on active recruitment, and placement of government trained health workers in rural areas, as a means to temper the adverse consequences of the migration of health workers. These proposed practices have brought forward the potential tension between the human right to health and the human right to freedom of movement, and the need to balance the two. The human right to freedom of movement, like the right to health, is fundamental and universal. In addition to being present in numerous national laws, it is protected through the Universal Declaration of Human Rights and the International Covenant on Civil and Political Rights ("ICCPR"). Article 12 of the ICCPR provides that "everyone lawfully within the territory of a State shall, within that territory, have the right to liberty of movement". It further states that "everyone shall be free to leave any country, including his own". Unlike the right to health, the full realization of the right to freedom of movement must be achieved immediately. The right to free movement, as contained in the ICCPR, has been authoritatively interpreted by the Human Rights Committee in General Comment 27 as placing a duty on the state of residence or nationality to not unduly restrict the internal movement of persons lawfully within the country, or to place barriers on their leaving the country (7). Critically, the right to freedom of movement does not in any significant way impose duties on the receiving states. Within the context of health worker migration, the human right to freedom of movement is often raised as an argument against policies that might place restrictions on the movement of labor.
The international movement of health professionals, unlike other aspects of globalization such as the movement of capital and goods, is indeed centrally linked to human rights. However, the right to freedom of movement is limited internationally as it does not place a duty on the receiving state to grant entry to those wishing to work and reside within the receiving state's territory. With specific regard to health worker migration, no duty is placed on destination countries to facilitate the movement of health workers. Indeed it would seem incongruous should human rights law require such a duty of receiving states with specific regard to health workers, but a duty that would not otherwise be extended for their fellow citizens. The human rights to health and freedom of movement are fundamental, universal, and both create immediate obligations on states. The existence of these two rights in the context of managing health worker migration, particularly recommendations which limit active recruitment or promote self-sufficiency policies as part of an ethical code of practice, does not compromise a state's ability to honor both rights. The receiving states do not bear any significant human rights related duty to enable or facilitate the movement of foreign health workers into its borders. Even where a conflict might arise in the fulfillment of these two human rights, as perhaps in the case of temporary domestic government bonding of health workers, restriction to the freedom of movement could be permitted under the exception provided for public health. In sum, the tension between the two internationally accepted human rights remains in large part that of perception rather than one strictly dictated by human rights law.
Summary and Areas for Future Research:
Interventions to improve retention need to consider the local situation and context. A baseline analysis of factors influencing workers choices and preferences for location should inform the development of retention strategies for rural and remote areas. Single interventions may not work, as the underlying factors are complex, so the interventions will need to address the complexity of these factors. Monitoring and evaluation measures should be built in the strategy from the very start of the program. Cost analysis should also be part of these regular evaluations. Intersectoral collaboration is the key in this area, where changes in practice and regulation would require interventions from other sectors, such as labor, finance, local development, education etc.
The initial rapid review of the literature has shown that some of the critical questions for which research has not yet provided clear answers are as follows (8):
- What is the role of different factors in influencing where health workers' choices of location and how best can they be identified?
- How do these factors vary by cadre of health worker and by gender?
- How effective are different interventions in influencing health worker location?
- How should effective retention interventions be designed and implemented to improve staffing of rural health facilities?
- What regulatory frameworks need to be in place for the design and implementation of retention packages, such as for example salary increases, producing different types of health workers, or compulsory service requirement?
- How can the impact of retention strategies be measured and evaluated?
Acute shortages and the uneven distribution of health workers within and between countries amount to a global health workforce crisis. To help address this crisis, World Health Organization (WHO) is leading efforts to manage international migration and motivate health workers to remain in their workplaces. Other priorities include support for education and training for health workers, the strengthening of governance capacities, and a special focus on nurses and midwives. The organization is also harnessing experience and expertise around the world through a Health Professions Network. The WHO resolutions on migration (WHA57.19) and rapid scaling up of health workers (WHA59.23) request Member States to put in place mechanisms which aim to improve the retention of health workers. Very recently, the Kampala Declaration, called on governments to "assure adequate incentives and an enabling and safe working environment for effective retention and equitable distribution of the health workforce". It is against this background that WHO has embarked upon a process to develop evidence-based recommendations which will advise countries on addressing the critical issues of retention and equitable distribution of health workers. The eventual WHO recommendations will be informed by research and analyses of evidence on existing interventions, by a series of country case studies and by consultations with experts and stakeholders regarding the effectiveness of strategies to improve retention.
Given the borderless nature of disease and the international and interdisciplinary nature of current scientific research, international collaborations are key to addressing global health issues. Trained scientists are needed in every part of the world. The issues surrounding brain drain are complex. Providing equipment, access to journals and the Internet, and small re-entry grants appear to be practical strategies that could facilitate continuing research in lower-income countries. Low-cost measures such as networking support with writing grant applications and mentoring strategies also are useful. How can research interest and funding in developing countries be sustained in order to attract the brain drains? Governance of local research institutions, perceptions of fairness of academic and career progression opportunities, general optimism regarding progress in the country as a whole and the outlook for ones family and children's future are significant factors in determining whether professionals stay at home.
- Orvill Adams & Barbara Stilwell. Health professionals and migration. Bull World Health Organ 2004:82;560
- United Nations Population Division. Populations Database 2002
- Meija A, Pizurki H, Royston E. Physician and nurse migration: analysis and policy implications. Geneva: World Health Organization; 1979
- Buch J, Parkin T, Sochalski J. International nurse mobility: trends and policy implications. Geneva: World Health Organization; 2003. WHO document WHO/EIP/OSD/2003
- Neilson J. Movement of People and the WTO. Available from: http://www.oecd.org/dataoecd/48/41/1960878.pdf (OECD working paper on migration). Accessed 30 November 2009
- Delanyo Dovlo. Managing the return and retention of national intellectual capacity. Bull World Health Organ 2004;82:620-621
- Backman G, Hunt P. Health Systems and the Right to Health: An Assessment of 194 Countries Lancet; 2008;372:2047-2085
- WHO. Increasing access to health workers in remote and rural areas through improved retention. Background paper for the first expert meeting to develop evidence-based recommendations to increase access to health workers in remote and rural areas through improved retention Geneva, 2-4 February, 2009. Accessed on 1 December 2009 http://www.who.int/hrh/migration/rural_retention_background_paper.pdf
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