The Global Tug-of-War for Health Care Workers
In the not too distant past, discussions involving "health" and "migration" would likely have focused on the physical and mental condition of immigrants, or, perhaps, the incidence of communicable diseases in a refugee camp. Today, however, the connection between health and migration can just as readily be illustrated by a hospital in AIDS-stricken Malawi, which has only 30 nurses, 26 of whom have plans to leave the country.
The international mobility of health workers is nothing new. In recent years, however, migration of health workers — from highly skilled physicians to those in lesser skilled positions, from the developing world to wealthier destinations — has increased. Moreover, the countries with the most alarming outflows include those sub-Saharan African nations suffering acutely from the HIV/AIDS epidemic and dwindling numbers of health workers.
Controversy surrounds the proper role of policy interventions in the global labor market of health care professionals. Emigration of health care workers weakens already failing health systems in the developing world. Yet this movement may more accurately be described as a symptom or an aggravating factor, and not the root cause of health care system failures in the developing world.
At the same time, the graying of the industrialized world has placed pressures on industrialized countries to find a solution for scarce or poorly distributed health care labor to support their aging populations.
Both scenarios shed light on this new global tug-of-war for health care workers. It is still unclear what the new rules of engagement will be to retain and train health care workers where they are most needed and to mitigate the grave imbalance between the rich and the poor with regard to health care. In light of these factors, experts are weighing a series of policy options that have important implications for the migration of the world's health care workers.
Ethical considerations that pit the right of individuals to move against a greater public good are at stake as well. Policymakers find themselves struggling with two complex sets of issues: how can health care workers with needed skills maintain their freedom of movement and the opportunity to respond to more favorable employment offers outside their country or region of origin without damaging the fundamental right of others in a population to a basic standard of health care?
The Care Drain: A Global Phenomenon with Local Implications
While the flight of health care workers from sub-Saharan Africa to the United Kingdom, Australia, and North America captures the spotlight in current discussions on "health care brain drain," mapping out medical migration as a global phenomenon highlights the interconnections of flows across regions.
Notable source regions for health care-related migration are Africa, the Caribbean, South Asia, and Southeast Asia. According to the Organization for Economic Cooperation and Development (OECD), the primary destinations are the Anglophone countries of Canada, the U.S., the UK, Australia, and New Zealand. Across these countries, an average of 23 to 24 percent of physicians are trained abroad. Other recipients of significant numbers of medical migrants include Western Europe and the oil-exporting Gulf States.
Nurses, in particular, are leaving their home countries in greater numbers. The number of nurses in the UK from non-EU countries grew from approximately 2,000 in 1994-1995 to more than 15,000 in 2001-2002.
In the U.S., the percentage of nurses trained abroad increased from six percent in 1998 to 14 percent in 2002. Even the Philippines, a traditional sending country, sent more than three times the number of nurses abroad in 2001 than in 1996, primarily to the UK, Ireland, and Saudi Arabia. Such trends persist despite severe or emerging shortages in home countries. In fact, long-time source countries like India and the Philippines face health worker shortages themselves in rural and underserved areas.
Some developing countries, too, are becoming both destinations and sources of skilled workers. While an estimated 5,000 doctors have moved from South Africa to the U.S., UK, Canada, and Australia, South Africa has become a destination for health professionals in its own right, as indicated in a 2002 study by the Southern Africa Migration Project (SAMP). Neighboring Botswana shares a similar position in the Southern Africa region.
Among industrialized countries, too, there is an ever-shifting pattern of movement. The United Kingdom has replaced its health professionals who have gone to North America with entrants from Germany. Germany, in turn, hosts a significant and growing number of physicians from the Czech Republic. In anticipation of a mass exodus after EU expansion in May 2004, Czech health systems identified recruitment from neighboring Slovakia as a coping strategy. The downstream effects of such recruitment strategies have a profound effect on source countries.
Impact of Health Care Migration on Source Countries
Outflows of health care workers are not necessarily a sign of health system malfunction. In fact, in some countries, such flows have been part of an overall strategic labor export plan. The Philippines, India, and Cuba have intentionally invested in the training of health workers for export. In return, some migrants contribute to their home countries with remittances and enhanced skills when they return.
However, for some countries, even limited migration can have a big impact. Indeed, a study by the Joint Learning Initiative at Harvard University notes that "while the absolute numbers may not be large, the outflows can be 'fatal' for disadvantaged people in source countries."
Health care migration from countries that are involuntary or reluctant sources tends to have more wide-spread negative reverberations. This is especially true in the case of sub-Saharan African countries, whose health systems are already compromised by an HIV/AIDS epidemic that claimed 77 percent of the disease's deaths worldwide in 2003.
Approximately 37 of 47 sub-Saharan African countries do not have 20 doctors per 100,000 people, as recommended by the World Health Organization (WHO) minimum standards (see Table 1). In contrast, the average among OECD countries was approximately 222 physicians per 100,000 people in 2000. Malawi filled only 28 percent of vacant nursing positions in 2003. South Africa had up to 4,000 doctor vacancies and 32,000 nurse vacancies in 2003.
Table 1: Physicians per 100,000 people in Sub-Saharan African Countries
Migration is not solely responsible for the shortages but it is an active factor. For instance, the main cause of attrition among health workers in Malawi is not migration but death, mainly from HIV/AIDS. South Africa has 35,000 registered nurses documented as being in the country who are inactive or unemployed, despite 32,000 vacancies in the public sector.
At the same time, however, a 2003 WHO report found that 60 percent of South African institutions had trouble replacing nurses who had emigrated; a significant number of pharmacies in Zimbabwe have closed due to the outflow of pharmacists.
International migration flows have also exacerbated rural health shortages, as vacancies in urban areas left by migrating workers are filled by those leaving rural tracts. For example, in South Africa, rural areas account for 46 percent of the population, but only 12 percent of doctors and 19 percent of nurses. These internal disparities have also been noted in countries whose governments support the emigration of health care personnel.
The dearth of health care workers has hampered not only the expansion of AIDS treatment programs in Botswana and South Africa, but also routine services for tuberculosis and immunizations throughout sub-Saharan Africa. On the ground, such shortages lead to unqualified employees performing critical services, overburdened staff, lack of popular confidence in the health care sector, and loss of institutional knowledge. International migration also tends to disproportionately involve those most likely to contribute in managerial and training roles, further weakening a country's health system.
The financial loss figures are significant as well. Because many developing countries pay for health training through public medical schools, they lose a substantial amount in training investments when health workers migrate. Estimates range from $500 million per year on average for a developing country to $1 billion per year for South Africa.
Although the home country may gain from remittances, such transfers do not necessarily go to the health system or to public coffers. Furthermore, as a nation's economic productivity is linked to the health of its citizens, the economic impact of poor health systems may become significant.
Contributing Factors to Health Care Migration: Salaries, Training, Distribution
Beyond the fundamental challenges facing many source countries of health care migrants, such as political and economic instability and poor governance, there are other starting points for appropriate policy responses.
Salaries and benefits are an obvious factor, given extreme wage differentials across countries. A 2002 survey led by human resource management and development expert Tim Martineau listed monthly salaries for physicians that range from US$50 in Sierra Leone to US$1,242 in South Africa. Wages in Canada and Australia are approximately four times those in South Africa.
However, many experts emphasize that pay is not the sole motive for leaving the country. Other factors include poor work environments characterized by heavy workloads, lack of supervision, and limited organizational capacity. There are also environmental considerations; workplaces may be dangerous due to lack of sanitation and supplies to protect workers from diseases like HIV/AIDS and tuberculosis.
This is occurring when much of the current international funding is narrowly focused on disease-specific programs rather than capacity-building to improve salaries, human resource management, and the procurement of basic medical supplies and much-needed in-country training.
In many developing countries, health care needs require a broad grounding in public health. Training, however, in some source countries for medical professionals — especially for physicians — has tended to focus on advanced medical techniques. Graduates are unlikely to use such training or to make professional advances in these areas without moving to countries where medical technology is more readily accessible and used.
Other factors in destination countries act as magnets for health workers in the developing world. With fewer people having children and individuals living longer, there has been a profound change in the industrialized world's age distribution, from Japan to Italy. As a result, there is a growing demand for health care workers, especially those who can provide assistance to the elderly. The U.S. Department of Health and Human Services projects a possible lack of 275,000 nurses by 2010 in the U.S., and the UK's National Health Service has a goal of adding 20,000 more nurses by 2004.
In some instances, inappropriate or poor distribution of health care professionals and not a shortage is at the root of increased demand. Although some estimates suggest that the U.S. produces more medical doctors than it needs, there is a shortage of general practitioners. Furthermore, 20 percent of Americans live in rural areas, but fewer than nine percent of physicians live in these areas.
All of these factors have contributed to the emergence of a robust, international recruitment industry. Recruitment drives by actors as diverse as the provincial governments in Canada to Wal-Mart pharmacies in America have been important facilitators of the medical migration process. Recruitment practices include retaining third-party recruitment agencies, aggressive advertising in professional medical publications, and relocation services for migrants.
Proposed Policy Responses
As outlined above, several players and conditions have conspired to deplete developing countries of their important health care providers. At issue is not only the availability of healthcare workers but also the long-term viability of health care systems. Shoring-up crumbling systems has emerged as a critical policy challenge.
As might be imagined, policy responses are controversial and not easy to implement. A major study in 2004 by the nongovernmental organization Physicians for Human Rights (PHR) sets forth some guidelines for rich countries in search of additional health care labor. (To view the PHR report, click here.)
A similar report by the Joint Learning Initiative at Harvard University carefully documents the spectrum of challenges, including migration, that developing countries face. (To view the Joint Learning Initiative report, click here.)
The recommendations focus on changing the conditions for native health care workers, including increasing wages and opportunities for training and improving working conditions. In addition, they suggest that developed countries should work to minimize their reliance on foreign health professionals by placing native health professionals in underserved areas (e.g., through programs focused on loan repayment and recruitment from rural areas).
Several actors — ranging from sending and destination countries to advocacy groups in Africa and around the world — have promoted recommendations to deal explicitly with managing the migration of health workers.
Rather than restricting the movement of health professionals, such schemes emphasize minimizing the factors that foster migration. In light of the disparities between sending and receiving countries and the critical need for health workers in poor countries, the WHO and other global actors are giving high-level consideration to such actions.
Regulating Active Recruitment
Host countries as well as representatives from organizations such as Physicians for Human Rights and the International Council of Nurses have called for regulated recruitment from developing countries facing a critical shortage of health care workers. South Africa, for example, did just that through a government mandate issued in 1995 that prohibited South Africa from recruiting doctors from the 14 member countries of the Southern African Development Community. The effort has reportedly been successful, with implementation carried out through professional registration controls.
Similarly, the UK has implemented a "code of practice" — renewed in 2001 to reflect concerns about Africa — that prohibits its National Health Service organizations from recruiting health workers from certain countries. While the code has been well respected in the public sector, it is not binding on the private sector. As a result, the number of nurses from abroad increased in 2002.
Consequently, the focus has centered on the accountability of private actors. It is unclear, however, how to manage such private recruitment. Several ideas have been floated. These include requiring recruitment agencies to report their practices publicly; creating an independent watch-dog type agency to oversee the process and to monitor and promote compliance with a code, and taxing employers and recruitment agencies that import medical workers without following codes of conduct.
Bilateral agreements are another mechanism for promoting health worker flows that are more beneficial to source countries. For instance, Norway's public health sector limits recruitment from most developing countries. However, it has signed agreements allowing nationals from Poland and the Philippines to work there.
Likewise, China has initiated agreements to send medical professionals to England for training purposes. Such arrangements have also been initiated by countries with health worker shortages. South Africa has proposed bilateral agreements which aim to stop active recruitment of its health workers with several countries. Similar to mandates and codes of practice, bilateral agreements face challenges of private sector enforcement.
In light of the difficulty in enforcing such agreements, as well as the resulting shift in migration that would likely occur to and from countries that do not have such practices in place, some groups have called for an international standard to be set forth by the WHO or an international treaty. Some analysts believe that such a standard could be an important advocacy tool for those within a country pushing their government to codify ethical recruitment policies.
Promoting Training Through Short-Term Visas
Other recommendations under consideration include changing the visa policies of wealthy countries to promote skills development through short-term visas. The hope is that such training could improve health care treatment and retention in the health care profession within origin countries.
Others are dubious of such efforts, pointing to the importance of understanding more clearly the kinds of skills shortages and the distribution of current health care workers. They argue that increased numbers are unlikely to solve these mismatches.
Furthermore, many believe it will be difficult to enforce the departure of those on temporary training visas. Such new visa programs will also have to ensure that training is appropriate for the needs in the origin country.
Compensating Countries for Losses Associated with Health Care Worker Migration
One of the most controversial issues within the health care field as well as the international migration management field as a whole is the idea of compensation. In 2004, the World Health Assembly — the decision-making body of the World Health Organization — recommended that its director general examine reimbursement by destination to source countries for the investments lost when health professionals migrate.
Critics of such a plan counter that individuals search out opportunities outside their country of origin because of poor in-country opportunities for professional growth and remuneration. Governments, therefore, should not be rewarded for their failure to provide meaningful employment for their own citizens and for domestic economic mismanagement.
Others have suggested that any compensation should be invested directly in the health care system, potentially through foreign aid streams. One possible source of reimbursement under consideration is taxing employers of foreign health care workers. Noting the traditional resistance of importing countries towards compensation measures, some observers have alternatively proposed large-scale reinvestment efforts funded by rich countries to develop human resources in sending countries.
Proceeding Carefully with Trade in Health Services According to the GATS
Other policymakers have focused on the General Agreement on Trade in Services (GATS) regime. They believe that source countries should move cautiously to liberalize trade in health services. While the GATS — a framework supported by the World Trade Organization (WTO) — will allow for a freer flow of service workers with a goal to improve the efficiency and global allocation of labor, health care workers may constitute a notable exception.
Some have suggested that the GATS may constrain sending governments' flexibility in human resource planning in the health sector. In reality, the section of the GATS dealing with professionals has been little used by developing countries, and the World Health Assembly has requested that the director general cooperate with the WTO to address the possible effect of trade agreements on international health workers.
Facilitating the Migration of Health Care Professionals to Countries with Health Worker Shortages
Many of the tens of thousands of health professionals living outside of their country of origin are willing to contribute their skills to their home countries. There are a range of tools available to countries to promote such transfers, including allowing dual citizenship to foster more circular migration.
Developed countries can also allow health care workers to go home under special arrangements that will not penalize them upon their return to the developed country. Many health professionals abroad are unaware of opportunities at home, a weakness that organizations such as the International Organization of Migration are working to strengthen.
Similarly, several countries suffering from health worker shortages, such as Botswana, Kenya, South Africa, and Zimbabwe, have utilized foreign volunteers and recruited doctors from India, Pakistan, Cuba, and elsewhere to work in the most rural and disadvantaged areas. Under the right conditions, foreign health workers may be able to enhance local capacity and provide training, supervision, and technical skills.
There is a tremendous need for more research on health care migration. The scale and nature of skills shortages in the health care sectors, especially in rich countries, is poorly understood, as is the relationship between recruitment and retention. Sorting out challenges of geographical distribution versus those posed by scarce supply will continue to be important.
Furthermore, there has been relatively little discussion about the protection of health care workers who do choose a career abroad in less desirable positions or locations. As a factor in retention, such protections from abuse should be a component of any discussion on health care provider mobility.
A resolution passed at the May 2004 World Health Assembly calls on WHO's 192 Member States to work towards mitigating the negative effects of health care migration (click here to view the text of the WHO resolution). The challenges in the next decade of responding to the growing inequities of medical migration are surmountable, but they will require political will, collaboration, and commitment from international agencies, governments, and public and private agencies.
Governments and donors who aspire to ambitious United Nations Millennium Development Goals, such as reversing the spread of AIDS, tuberculosis, and malaria by 2015, must be serious and consistent about investing in sustainable health systems. Concurrently, sending and destination countries of health workers must adopt migration regimes that seek to secure within source countries an adequate number of health professionals.
Although the end goals are clear, the tactics that all players must support are still hotly contested. The next decade will be an important one as advances in the management of global health challenges and in our understanding of international migration and its role in development begin to coalesce.
There may, indeed, emerge policies that support the idea of medical migration exceptionalism, including policies that exact a tax or some kind of compensation for the recruitment of scarce labor with special health care skills. If so, it is possible these policies will serve as templates for other kinds of skilled emigration. This is all the more reason to move cautiously and thoughtfully, but ahead nonetheless.
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