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date: 06 May 2021

Global Healthcare Worker Migrationfree

  • Heidi BludauHeidi BludauMonmouth University

Summary

The global migration of healthcare workers is one of the most widely studied issues in healthcare worldwide. Fueled by a global shortage of healthcare workers, this movement is considered a crisis in health sector human resources. Over the past half century, the need for skilled healthcare workers has increased in wealthy countries, which have not been able to keep up training and retaining a sufficient labor force to fill their demands and, thus, have increasingly relied on foreign-trained healthcare workers. Migrants are motivated by push factors in their home countries and pull factors in receiving countries. While some countries are capitalizing on the global market demand to facilitate export of their workers, some poor countries who lose their skilled workers to more developed countries are concerned about “brain drain.” Private, for-profit recruitment firms are increasingly entering this market and shaping migration patterns. The general consensus of research in this field is that more work needs to be done globally to build the capacity for training healthcare workers, increase recruitment and retention of healthcare workers in their local regions, and manage the global movement of healthcare workers of their own accord.

Historical Patterns of Healthcare Migration

Since the 1960s, international migration has been on a steady rise, with fewer than 2.5 million migrants moving in the decade of the 1960s to over five million between 2010 and 2015 (United Nations 2015). A large part of that migration has been healthcare workers, making their migration one of the definitive global health issues of the early 21st century. A global shortage of medical workers fuels this movement. The estimated thirty-nine million healthcare workers worldwide cannot meet the global demand for health services (Finlay, Crutcher, and Drummond 2011, 188). The World Health Organization stated in its World Health Report (2006) that as many as 2.4 million doctors, nurses, and midwives and two million pharmacists were needed worldwide. An estimated additional 12.9 million workers will be needed by 2035 (Cabanda 2017, 216).

The main factors contributing to the global shortage include issues around training, retention, increased demand for services, and an increasingly aging population. For example, professionals in the workforces of wealthy countries are retiring at higher rates than they are being replaced, and many countries are not training enough medical professionals to meet their own needs. Shortages of physicians and nurses are exacerbated by the increased need for general and long-term care, especially in industrialized nations. As people are living longer but not necessarily healthier lives, they need more sustained care. In addition, shortages in nursing also can be attributed to more attractive career opportunities for women outside carework, a poor image of nursing, and job dissatisfaction (Dywili, Bonner, and O’Brien 2013). In wealthy nations, a dramatic increase in the need for healthcare workers has taken place since the latter part of the 20th century such that demand has been outpacing training (Aluwihare 2005, 16). Consequently, recruiting foreign-trained healthcare workers has become an ongoing strategy for countries like the United States, United Kingdom, Canada, Australia, New Zealand, Japan, and Saudi Arabia. For my purposes, I will identify countries that rely on the strategy of recruiting foreign-trained healthcare workers as “healthcare migration destination countries.” These countries are typically, but not exclusively, members of the Organisation for Economic Co-operation and Development, with highly developed healthcare systems.1

This topic does not come without controversy. James Buchan (2006), a leading researcher in health sector human resources, states that migration can have “positive aspects” such as solving staff shortages, relieving oversupply of staff, and helping individual health workers to improve their skills, career options, and standards of living. Conversely, healthcare worker migration can create problems of shortages for the home countries of emigrating healthcare workers, as an increase in emigration has the “potential to undermine attempts to achieve health system improvement in some developing countries” (Buchan 2006, 3). Healthcare migration destination countries are painted as “poaching” workers from countries in need (Bradby 2013, 25). This blame is arguably misplaced, because the assumption that more doctors and nurses will produce a healthier population lacks evidence (Bradby 2013; Mejia 1978). While it is clear that a severe shortage of healthcare providers will have detrimental effects on the delivery of health services, researchers find that the “push” factors—the conditions of the local social, political, economic, and healthcare environment—drive emigration more than the “pull” factors of the receiving countries (Aluttis, Bishaw, and Frank 2014, 3).

Until the mid-20th century, the scale of healthcare worker migration was relatively confined to specific circumstances, like colonial projects. After World War II, the demand for h ealth workers swelled with the expansion of health services across the globe and the postwar baby boom. Wealthy countries like the United States and the United Kingdom found themselves turning to migrant doctors, nurses, and midwives to fill their needs. By the early 1970s, it was obvious that the foreign-trained medical professionals moving from developing to developed countries were being regarded as a “reserve army” to supplement the needs of the host countries (Gish 1971). Consequently, the need to fill staff shortages prompted the recruitment of doctors and nurses to wealthy countries. Focus also turned to the consequences of “brain drain,” the loss of highly trained professionals, from the source countries. In the early decades of the 21st century, research and policy (e.g., Aluttis, Bishaw, and Frank 2014; Hagopian et al. 2005; Mills et al. 2011) turned to examining how the investment cost of training medical professionals affects the sending country and benefits the receiving countries.

By the turn of the 21st century, only a few countries were not involved in some way with the flow of healthcare migrants. The movement of healthcare workers can be “understood as a global crisis in human resources” (Bradby 2013, 7) and has become “one of the most widely addressed international health issues” (Joudrey and Robson 2010, 528). It is almost impossible to examine healthcare today without including the dimension of migration. In fact, the opportunity to migrate incentivizes career choices in health professions in many places (Johnson, Green, and Maben 2014).

Intersections of state and private entities influence the direction of migration routes and abilities of health professionals to work internationally. In the case of healthcare migration, decisions regarding national healthcare systems—their funding, organization, and staffing—influence migration patterns. Healthcare migration is a political concern and has implications for economic development and social equity (Mejia 1978). States are not passive but at times highly active in the migration process, as well. Some countries, notably the Philippines, have capitalized on the global market and educate nurses for export (Choy 2003; Guevarra 2010). Other countries strive to maintain an adequate health workforce at home by creating bilateral or other trade agreements with countries to supply workers (e.g., South Africa, Cuba) (Hammett 2014) or policies to delay mobility after completion of degree requirements (e.g., Ghana, India) (Cabanda 2017). In addition, political and economic conditions in the broader society affect decisions to migrate, and global flows of medical professionals have emerged that simplify movement. To understand the scope of global healthcare migration, we must look at the micro-, meso-, and macrolevel elements that frame, influence, facilitate, and affect individual decisions.

Healthcare Migrants Defined

Most medical migrants are physicians, nurses, or midwives; these are my focus. Other types of workers, such as dentists, pharmacists, and opticians, tend not to migrate in large numbers because their qualifications are not recognized in many destinations (Connell 2010, 46). The range of terms used to refer to these migrants includes a number of combinations using the terms skilled, medical or health(care); worker or professional; and migrant or foreign-educated/trained. The term “migrant” is problematic but is being used here to indicate permanent and temporary movement from one country to another, whether multistaged, direct, or return. I also focus on foreign-trained (e.g., a Filipino nurse trained in the Philippines and working in Saudi Arabia) rather than foreign-born (e.g., an Indian physician born in India but trained in the United Kingdom and working in the United Kingdom) individuals, as they are more relevant to the issue.2

Up until the mid-20th century, most migrants were physicians and male. However, in this area, along with other areas of feminized migration, the numbers of women, usually in the roles of nurse or midwife, have increased dramatically, and the “gendered nature” of healthcare worker migration emerged in the 1990s (Bradby 2013). Most healthcare migrants are generally part of the “mobile middle class” and highly educated (Wojczewski et al. 2015b, 2) and are from low- or middle-income developing countries. Healthcare worker migration is typically voluntary (Martineau, Decker, and Bundred 2004) but can be “forced” by political instability or dire economic conditions.

The Scale of Healthcare Migration

It is almost impossible to measure the scale of healthcare workers on the move. Statistical data tracking physicians, nurses, midwives, and other health professionals are often deficient (Aluttis, Bishaw, and Frank 2014; Bradby 2013; Mejia 1978). Lack of international standards in migration-related documentation, lack of data on specific health professions, and lack of correlation between applying for a license to practice in a foreign country and actually using the license all add to the dearth in useful data (Bach 2003; Bradby 2013; Buchan 2006).3 New migration policies that operate on point systems may help delineate the data on healthcare professions better (Iredale 2009, 32). In addition, licensure and registration data measure the intent to move and work abroad but not the actual employment. While all types of healthcare workers can migrate, they do not always find work in the health field and are not present in data on health professionals. For instance, physicians working as taxi drivers or nurses working as care assistants in a foreign country often do not appear in data on healthcare migration (Buchan 2006, 4). Work permit information varies from country to country and often does not include occupation (Bach 2003, 3). Despite these weaknesses in available data, the trends indicate that the number of skilled migrants is increasing (Skeldon 2009, 4). For example, one study (OECD 2019) found that in 2016 the number of foreign-trained physicians working in Organisation for Economic Co-operation and Development countries had risen to nearly five hundred thousand, an increase of 50 percent from 2006. Similarly, the number of foreign-trained nurses working in these countries had risen 20 percent between 2011 and 2016, reaching almost 550,000 (OECD 2019, 11). Because of the paucity of useful data, researchers draw on more qualitative methods to illustrate the effects of migration in the local context. Regardless of the type of data, doctors and nurses are the two most numerous groups of mobile healthcare professionals, have been the subjects of the most studies (Grignon, Owusu, and Sweetman 2013), and therefore will be my focus.4

Healthcare migration demonstrates both common global themes and specific reactions to local conditions. It generally follows many of the trends found in global migration today, in which healthcare workers’ motivations “resemble the broader sets of motivations that encourage other migrants” to move (Cabanda 2017). However, doctors and nurses deserve separate attention in the study of migration due to their “occupational characteristics, labour market position and political profile” (Bach 2003, 1). Medical migration is unpredictable and largely uncontrolled (Mejia 1978) but is becoming increasingly managed. As government-licensed professionals, healthcare workers must meet local standards of education and other competencies, such as language. Healthcare recruitment companies have multiplied in the early 21st century, serving as the brokers between migrants and employers. Due to the importance of healthcare workers to the public good, the consequences of this arena of migration have distinctive implications in policy and public discourse, and are often seen as different from other types of migration (Skeldon 2009, 7).

Theoretical Approaches to Global Healthcare Migration

Push and Pull Factors

Despite the limitations of push-pull analysis, when used in context, it is still a useful lens through which to understand migrants’ motivations (Prescott and Nichter 2014). Pull factors are the conditions and opportunities that will draw people to a country; push factors are the conditions that compel people to leave their present locations. Push factors are usually seen as “negative and involuntary,” whereas pull factors are positive factors associated with the destination country (Finlay, Crutcher, and Drummond 2011) and create spaces for individual agency. Most people do not want to leave their homes, so high levels of migration do not take place without strong push factors in the home country (Freeman, Beaulieu, and Crawley 2015).

Often, push and pull factors offset each other; the same person is typically “pushed” from one country and “pulled” to a specific country by opposing factors. Focusing only on the “pull” factors often associated with recruitment ignores the “push” factors that affect the personal safety or well-being of migrants or their families and diverts attention from potential policy interventions that can mitigate the rationale for emigrating (Bach 2003). Simply juxtaposing push and pull factors fails to explain not only medical migration but also why some individuals choose to stay in areas with high levels of emigration (Tankwanchi 2018), which is a grossly understudied phenomenon. Some factors carry more weight than others in an individual’s decision. Primary factors include economic, professional development, and work environment conditions. Each of these encompasses a variety of more specific features.5 For example, a survey of twenty-seven doctors and nurses from Sub-Saharan Africa revealed three primary push factors: educational purposes, political instability and insecurity, and family reunification (Poppe et al. 2014). However, social status, public perception of healthcare workers, and lack of government investment “push” physicians and nurses out of Eastern Europe (Bludau 2012; Suciu et al. 2017).

As with other forms of migration, a recurrent theoretical framework for the study of migration of healthcare workers is a neoclassical economic approach, or the idea that wage differentials regulated by supply and demand drive healthcare migration; consequently, a push-pull analysis is the most commonly found framework (Bach 2007; Kingma 2006; Kline 2003; Mejia 1978). However, medical migration is too complicated to be analyzed as a straightforward market demand. Push-pull models do not explain the role geopolitical factors play in migrant choices. Prescott and Nichter (2014) argue for more comprehensive approaches that take the range of social, political, and economic factors into account. Kingma (2006, 13) states that despite the evolution of migration theory, especially in regard to nurses, “no one theory has yet captured all the forces that influence an individual’s decision to move.”

Economic Factors

Economic push-pull factors are by far the most widely considered motivation for all decisions regarding migration options and opportunities (e.g., Chikanda 2005; Dywili, Bonner, and O’Brien 2013; Kingma 2006; Koch-Weser 1978; Li, Nie, and Li 2014). Adzei and Sakyi (2014, 106) state that African healthcare workers are “often said to be moving mainly for economic benefits” that come with each subsequent move. Czech nurses migrating to Saudi Arabia at times fail to list money as a motivation because it is an implied motivation to migrate, stating “of course” when then asked if money is a factor (Bludau 2012). Individuals in low- and middle-income countries are increasingly choosing medical professions to enhance their social and economic mobility (Connell 2010, 7; Walton-Roberts 2015). Often, in these countries the training outpaces the jobs available to graduates and they must migrate to find jobs (Monnais and Wright 2016; Prescott and Nichter 2014).

The influence of finances on decision-making varies. Expectations of better salaries than at home is a key dynamic. A case study on doctors and nurses in Estonia reports that “nearly 60% feel that fair pay for their work would be 1 to 2 times higher than it is now, and one fifth believes that the pay should be 2 to 2.5 times higher,” with some requiring a salary four to six times higher to justify emigration (Buchan 2006, 11). In addition to salary, economic pull factors include better benefits and compensation and the ability to save money for building projects, dowries, and children’s education. In contrast, Poppe et al. (2014) state that while financial factors did play a role for their respondents, it was not listed as a “main driver.” In fact, studies have shown that as the wage or income gap between sending and receiving countries decreases, workers are disincentivized to migrate (Adzei and Sakyi 2014).

Women have different variables acting on their economic factors. When the migrant is a woman, financial motivations are a “double burden” or a choice between money and family. The discourse in nursing gets more complicated because women’s gendered and professional identities are intertwined with their profession of caring. When emphasis is placed on women leaving their families, it downplays the reality that they must do so in order to support their families (Hull 2010, 865). Gender discrimination is linked to economics through obstruction of access to career paths or the subordination of the gendered nursing profession, as well as broader gender politics in the home country. There is also a body of research that focuses on nurse migration as a form of female empowerment and independence through which women either gain independence from matrimonial and maternal obligations or increase their value in seeking a spouse (Cabanda 2017). Nurses from Kerala become lead migrants supporting their husbands (George 2005). Polish women use the nursing profession as a way to escape “conservative policies and social values in relation to gender roles” (Dussault, Buchan, and Craveiro 2016, 113).

The Context of Globalization

Early 21st-century research has drawn from network analysis, policy, and globalization studies. Bach (2007) notes that healthcare migration analysis focuses more on immigration policy than the policies of the countries involved in transnational migration and suggests a more well-rounded approach. Twenty-first-century healthcare migration research examines not only globalization but also current concerns around neoliberalism (the ideology and policy that values competition in a free market with limited government intervention) and the ways nation-states are managing care (England 2015). Bradby (2014, 581) examines migration of healthcare workers as part of the medicalization of global public health problems, challenging the assumption that “trained professionals rather than socioeconomic conditions” are the key to improving public health. As the overly simplistic and politically charged focus on “brain drain” has lost saliency, some scholars are turning to network theory as a way to examine knowledge exchange in skilled healthcare migration, leading to a preference for the term “brain circulation” (Ackers 2012), or the flow of healthcare workers in and out of healthcare systems (Kirk 2007, 28). Other types of network analysis of migration examine the interpersonal relations and links that facilitate migration (e.g., Tankwanchi 2018), although the role of overseas nursing associations as a network has not received as much attention as it deserves (Bach 2003, 10). Research on recruitment firms falls under different areas of job placement and work visa services as well as cultural orientation to destination counties, often involving subordination of the migrant-self (e.g., Barber 2013; Guevarra 2010). Following recruiter guidelines, migrants transform themselves into candidates who are marketable in the destination country, where, as immigrants, they are often systematically under- or devalued.

“Healthcare-worker migration represents the longest and best-documented female transnational labour migration” (Wojczewski et al. 2015a, 2), yet gender is often overlooked in the research. When gender is considered, the analyses tend to focus on nurses as part of the broader work on global care chains and concentrate on the gendered nature of the nursing profession and not the broader ways that gender influences migration decision-making and experiences abroad. Yeates (2009) has been instrumental in bringing the profession of nursing into the broader analysis of the feminization of transnational migration, supporting exploration of the global nurse care chain. Gendered analyses of physicians look more to the way gender influences migrants’ decisions and experiences (e.g., Dussault, Buchan, and Craveiro 2016; Wojczewski et al. 2015a).

Emerging Patterns in Healthcare Migration

Types

In the 19th and early 20th centuries, physicians and nurses moved in relation to colonial endeavors, both servicing colonial administration centers and creating local healthcare systems, usually with the intention of returning to their countries of origin after a specific amount of time. After World War II, physicians and nurses from newly independent countries started to seek specialized training abroad, and many stayed in those locations due to better working conditions or unstable environments at home (Dussault, Buchan, and Craveiro 2016). As many countries expanded welfare and health services, they started relying on foreign-trained workers (Bach 2003).

Since the 1970s, processes of globalization have facilitated global migration through reduced barriers to trade and mobility and increased forms of communication. In 1972, at least 140,000 (6 percent) of the world’s doctors were in countries other than those where they had been born and/or trained, equal to “the world medical school output in 1970,” outside of China (Mejia 1978, 208).6 The United States, the United Kingdom, and Canada hosted more than 75 percent; Australia and Germany were also prominent recipient countries. Nurses reflected a similar pattern: 5 percent of their global population is found across the United States, the United Kingdom, Canada, and Germany (Bach 2003, 3).

By the 1980s, the flow of medical professionals from the Global South (term used by the World Bank to indicate low- and middle-income countries in Africa, Asia, Latin America, Oceania, and the Caribbean) to the Global North was identified as a concern and claimed as a cause of origin countries not meeting health-related Millennium Development Goals.7 Since the late 1990s, the international recruitment and migration of healthcare workers have increasingly played a role in global health (Buchan 2006). Over the past few decades, the patterns of migration have changed, with new “source” countries emerging, including Cuba and countries in Sub-Saharan Africa, the Caribbean, and the former Soviet Union (Martineau, Decker, and Bundred 2004, 2). The Middle East emerged as a receiving area after the oil boom in the 1970s led to rapid economic development. Saudi Arabia has become one of the largest importers of medical migrants, especially nurses (Jordan 2011). In 2001, the number of non-Saudi nurses working in Saudi Arabia was fifty-five thousand, or approximately 80 percent of those in the country (Yamagata 2007). In the future, we can expect the number of foreign-trained medical professionals in healthcare migration destination countries to increase unless they start to train enough workers to meet their needs (Bach 2003).

Studies in medical migration must recognize the differences between occupational groups and geographical regions, as well as the positions different countries hold in migration flows (Bach 2003). Three general types of countries exist in medical migration: sending/source countries; receiving/destination countries; and countries that both send and receive. The global flow of healthcare migrants is overwhelmingly characterized by migration from poorer to wealthier nations (Finlay, Crutcher, and Drummond 2011). Most of the literature focuses on the receiving countries the United States, the United Kingdom, and Canada, which have active recruitment policies (Poppe et al. 2014). The directions of migratory flows are often determined by language and historical links, as well as compatible education and training. Regulatory frameworks regarding training and recognition of medical licensure also shape patterns. For instance, a Czech nurse is more likely to migrate to Saudi Arabia, where her license is recognized, than the United Kingdom, where she must apply for licensure with no guarantee of approval (Bludau 2012). Medical migration is one realm of migration where postcolonial ties are ever-present. Otherwise, proximity is important, and migration flows between neighboring countries are high (Bradby 2013, 15). Migration flows are not unidirectional and are often referred to as “carousel” or “step” types; in “step” migration, people work temporarily in one place to gain experience before moving to a more developed country (see figs. 1 and 2) (Connell 2010; Kingma 2006). In “cascade” migration, one county’s healthcare workers fill gaps left by another country’s emigrants (see fig. 3) (Bradby 2013). “Chains” of migration are created to facilitate movement along well-known paths and are often managed through recruitment activities more easily (see fig. 4).

Figure 1. Carousel migration: migrants move from one country to another in their own cycles, or carousels. As skilled healthcare workers (SHWs) leave one country, their positions will be filled by other SHWs on their own “carousel of migration.”

Diagram by author.

Figure 2. Step migration: skilled healthcare workers (SHWs) follow a series of steps, filling positions in lower income and then to higher income countries, learning and improving the skills necessary to be marketable at the next destination. The migrant may or may not eventually return home.

Diagram by author.

Figure 3. Cascade migration: one country’s healthcare workers fill gaps left by another country’s emigrants. In this example, Slovak skilled healthcare workers (SHWs) fill gaps in the Czech Republic, while Czechs go to Germany and Germans go to the UK, a healthcare migration destination country (HDMC) (Connell 2010, 60). Although the Organisation for Economic Co-operation and Development and the World Bank designate Slovakia and the Czech Republic “high-income,” there are still marked differences in income between the four countries in this example.

Diagram by author.

Figure 4. Chain migration: skilled healthcare workers (SHWs) choose a destination because a large number of their compatriots are already there, in essence following others out of their country of origin and creating a “chain” between the origin and destination countries. Personal relationships do not necessarily exist but are often a factor. In the diagram, SHW 1 has migrated to a healthcare migration destination country (HMDC); following her, SHWs 2 and 3 migrate there; SHW 4 follows SHW 3, and then SHW 5 follows her; SHWs 6 and 7 simultaneously follow SHW 3. Recruitment firms often facilitate chain migration. Migrants in a chain are supported by those who have migrated previously, and the chain is perpetual.

Diagram by author.

Export Programs

Some countries have developed state-managed export processes for healthcare migration. States promote emigration, even designing and enlarging medical and nursing education systems with the goal of graduates being employable abroad (Cabanda 2017). The Philippines is a leader in this area in regard to nurses (Bach 2003; Guevarra 2010), with India, China, and some former Soviet states trying to follow their model (Aiken et al. 2004). China has a surplus of nurses due to underinvestment in their healthcare system leading to a lack of budgeted positions for graduates (Fang 2007) and has become a major supplier for the United States, Singapore, and Saudi Arabia (Bradby 2013). In 2007, India, the Philippines, and China were among the top five exporters of physicians to Organisation for Economic Co-operation and Development countries (Iredale 2009, 38). Remittances become a source of income for exporting countries. By 1993, Filipino nurses had sent home an estimated $800 million from their various jobs around the world (Aiken et al. 2004). The Chinese government gets 10–15 percent of Chinese foreign workers’ annual salary in exchange for managing their employment (Fang 2007, 1419–1428).

The Philippines, known for taking advantage of the global nurse demand, is the classic case. It has been producing a surplus of nurses since the 1950s (Choy 2003) and adjusts nursing coursework and training to meet employer needs (Cabanda 2017, 222). An estimated 85 percent of working Filipino nurses are working abroad (Aiken et al. 2004; Lorenzo et al. 2007). Over half a million Filipino nurses moved abroad between 1975 and 1989 (Hawthorne 2001, 215); an estimated 250,000 were employed globally in 2004 (Ball 2004, 119). They are recognized worldwide as well-educated, hardworking, and well-prepared for the global market (Choy 2003; Guevarra 2010). Facilitated by postcolonial relationships (Choy 2003), the largest concentration of the global Filipino nurse population is in the United States (Lorenzo et al. 2007). Filipinos enter the nursing profession not to improve their potential earning capacity not at home, where nursing is low-paying, but abroad (Amrith 2010, 413). India claims to facilitate healthcare migration (Walton-Roberts 2015, 376), preparing nurses to take foreign board exams (Khadria 2007), rather than promoting it.

An active healthcare export system can be detrimental to the delivery of local health services. Training standards in the Philippines are inconsistent, and local board exam pass rates are decreasing with the rapid increase in nursing schools (Barber 2013; Hancock 2008). Training emphasis can shift from nursing theory and practice to language training or global health trends not found at home (Hancock 2008, 260). For example, some schools will employ foreign nationals to teach in a market-friendly language such as English or focus on Western diseases like heart disease rather than those that have high rates of mortality or morbidity locally. In countries like the Philippines and Bangladesh, nursing graduates work for little or no pay in their home countries so that they can gain the experience to qualify for jobs overseas (Iredale 2001); these practices make it difficult to pay back student loans and/or save for migration, adding to chronic mass unemployment due to overproduction for local needs (Prescott and Nichter 2014).

Motivations, Ways, and Means

Decisions to migrate are personal choices but are influenced by intersections of the cultural, economic, educational, historical, legal, political, and social factors that are intertwining through, and acting on, migrants’ lives (Mejia 1978). For instance, decisions to emigrate for Indian nurses are individual but embedded in working conditions and family issues, as well as desires for personal and professional development (Garner, Conroy, and Bader 2015). Understanding of why healthcare professionals migrate can inform policy and can aid in retaining workers in source countries. Typologies created by leading scholars on nurse migration reflect broader medical migration motivations across professions (Buchan, Parkin, and Sochaiski 2003; Kingma 2006).8 While doctors and nurses exhibit similar motivations for migration (Dussault, Buchan, and Craveiro 2016), their experiences abroad often differ due to training recognition and licensure.

Permanent emigration is motivated by better standards of living, career opportunities, and partner migration, as well as improved quality of life, survival, or adventure, and can result in changed citizenship status. Medical migration differs from general migration when a woman is a skilled healthcare worker. Sheba Miriam George (2005) is one of the few researchers who discusses husbands as the partner migrants of their wives who leave India to work as nurses in the United States. Temporary migration includes holiday work, study tours, student exchange, and contract work, has a planned end period, and lasts from weeks to years, depending on the type of migration and/or changed plans. For instance, a one-year contract could be extended multiple times. Often third-party recruitment plays a role in contract and more permanent healthcare worker migration.

Professional Development

Professional development through enhanced education or specialized training can be critical for skilled healthcare workers. Chances to learn technologies or acquire specialties not available in the home country (Bach 2003) or to use knowledge and skills not required at home (Kingma 2006) serve as incentives to seek foreign workplaces. Lack of continuing education or opportunities for career advancement demoralizes professionals who seek professional development (Bludau 2012; Dywili, Bonner, and O’Brien 2013). In Nigeria and Ghana, physicians are part of a culture of migration that expects them to go abroad to further develop their skills and training (Hagopian et al. 2005). Ghanaian physicians see the opportunity to bring knowledge back to their country on return as a motivator (Adzei and Sakyi 2014). Seeking more rewarding careers, physicians from India often emigrate as young professionals to acquire advanced medical degrees with the intent of remaining in the destination country (Cabanda 2017). Nurses in India leave looking for higher status in their profession (Walton-Roberts 2012). Nursing in some Central European countries is an apprentice-style profession, with limited career advancement or responsibilities (Dussault, Buchan, and Craveiro 2016). Professional development can also be a way for migrants to mitigate financial incentives as the sole purpose for leaving home (Bludau 2012; Schühle 2018).

Work Environment

Work environment is dependent on and includes many factors such as funding, organizational culture and structure, safety of the workplace, and public context. The lack of medicine, supplies, and equipment, as well as adequate staffing levels, creates unsatisfactory working conditions and pushes medical workers into better sourced healthcare systems (Aluttis, Bishaw, and Frank 2014). Job dissatisfaction may also push healthcare workers away from the healthcare sector, exacerbating personnel shortages for those who remain. Globally, because the brunt of patient care falls on nurses, they feel the effect of personnel shortages in their day-to-day duties of care more acutely than physicians, often carrying higher workloads than is advised for quality care. Organizational structure can correlate with shortages and burnout. A lower nurse-to-patient ratio is an often-listed pull factor encouraging healthcare immigration (e.g., Bludau 2012; Kingma 2006; Lorenzo et al. 2007; Zhou, Roscigno, and Sun 2016).

The HIV/AIDS epidemic in Sub-Saharan Africa threatened the safety of many medical workers and worked as a push factor in the region. High infection rates combined with inadequate funding for equipment put healthcare workers at risk of infection, causing an estimated “19 to 53 percent of all deaths of health employees in the public sector” (Kingma 2006, 44). Nurses are more at-risk for infection of communicable diseases due to the role they play in the care of patients. Chikanda (2005, 169) reports that in Zimbabwe, 60 percent of the nurses in his study felt their employers (e.g., hospitals, clinics) were not taking “adequate precautions against HIV infection.”

Work environment is affected by the local political and economic context. Political instability or conflict drives all forms of emigration. Healthcare workers may have more means to emigrate due to their professional mobility and class in their home countries. Fleeing a conflict region intersects with economic factors because conflict affects all aspects of daily life, including the delivery of healthcare (Finlay, Crutcher, and Drummond 2011; Poppe et al. 2014). Forced migration of medical workers is often overlooked by policymakers and researchers because these workers are not categorized as asylum seekers but as medical professionals (Ray, Lowell, and Spencer 2006). In Zimbabwe, those who were unable to use recruitment firms to obtain positions abroad used their status as “political refugees” to emigrate, drawing on a different form of cultural capital (Chikanda 2005, 171).

Social and Cultural Capital

Social and cultural capital are key elements of a migrant’s success. Capital may come in the form of “familiarity with the language, knowing colleagues who have already migrated or a social network in the destination country, having qualifications that meet the requirements for recognition and previous knowledge of the destination country” (Dussault, Buchan, and Craveiro 2016, 114). The amount of capital a migrant has or can accrue influences migration decisions. Individuals who plan to migrate postgraduation may even take “concrete steps” toward those goals while still students (Suciu et al. 2017).

Social networks in destination countries are an important form of social capital. Bach (2003) notes the role nursing associations have played in establishing networks in various receiving countries, often acting as both incentives and support systems. Filipino nursing associations are well known across healthcare migration destination countries and serve as a known support system (Choy 2003). For physicians, “kinship, family, and professional ties” in destination countries are dominant factors that influence decisions (Cabanda 2017, 219).

Recruitment Firms

The practice of recruiting foreign workers to solve shortages of healthcare workers looms large but is not new. The US health market has relied on foreign nurses since it started educational exchanges with the Philippines in the 1930s (Choy 2003). What is new is the “marked expansion of organized international nurse recruitment; the growth of private, for-profit agencies to do this work; and an increasing number of countries sending nurses” (Brush, Sochalski, and Berger 2004). Many wealthy countries view recruiting foreign workers as integral to meeting workforce needs (Aluttis, Bishaw, and Frank 2014; Bach 2003). To facilitate foreign worker recruitment, countries may relax immigration regulations or provide special avenues for specifically needed skills. For example, the United States created the H-1A and C visas to recruit nurses, while Japan has trade agreements with the Philippines and Indonesia (Iredale 2001). Aggressive recruitment of foreign-trained healthcare workers indicates a large-scale failure to manage local recruitment and retention challenges and poor human resource planning (Bach 2003). Overall, healthcare migration destination countries put more effort into recruiting than retention strategies.

While some healthcare professionals find work by themselves, most medical migrants are recruited directly by employers or, increasingly, through private firms. Using recruitment firms to mediate job placement is the preferred route for many health institutions because it is cost-effective and allows both the migrant and the employer to avoid complicated or tedious paperwork and vetting processes. Recruitment firms serve as sales representatives for hospitals, which offer a variety of benefits to entice foreign workers, including free travel tickets, subsidized or free accommodations, tax-free salaries, and opportunities to improve medical training and/or be exposed to unusual medical cases (Bludau 2012; Brush, Sochalski, and Berger 2004; Kingma 2006). Recruitment firms typically cannot charge fees for recruitment but do so for a variety of services from processing paperwork to specialized training, often earning additional money through finder’s fees (Guevarra 2010; Zhou, Roscigno, and Sun 2016). Private firms are not regulated, and at times recruiters will exploit migrants by promising fictitious jobs (Martineau, Decker, and Bundred 2004), charging high fees, or deceiving them about salaries (Garner, Conroy, and Bader 2015). In general, recruiters shape migration through their choice of clients and where migrants will be offered employment. In China, recruiters select those who are “healthier, better educated, and more affluent,” drawing on existing privileges for further advancement (Zhou, Roscigno, and Sun 2016, 170). At the end of the day, recruitment firms’ job is to fill vacancies through mobilizing healthcare workers to meet shifting market demands (Bradby 2014).

The World Health Organization (2010) and other organizations have long advocated against active recruiting from low-income countries. The International Council of Nurses denounces unethical recruitment but supports an individual’s right to migrate (Dywili, Bonner, and O’Brien 2013). The European Commission has publicly questioned the sustainability of relying on migrant health workers (Dussault, Buchan, and Craveiro 2016). Consequently, source and destination countries are shifting to managed migration approaches through which countries work together to regulate migration flows in ways that are beneficial to both source and receiving countries, as well as migrants (Bach 2003).

Experiences Abroad

The experiences migrants have abroad not only influence their own movements but also, when shared, can influence the movements of others. Unsurprisingly, migrants often find employment in the lower ranks of healthcare service, for example in marginalized regions and less popular areas of medicine or care, or find themselves underemployed. Transition can be difficult, especially for those who have left family behind and those who move to systems and cultures that differ vastly from those of their homes. Level of fluency in the local language is also a socialization factor. Hospitals that employ large numbers of foreign-trained workers typically offer transitional programs.

Accreditation

Although some migrants will have accreditation and licensure approved before moving, it is part of the overall experience with the new country. Accreditation ensures that migrants will not threaten standards of health services and, at times, functions as an immigration barrier. Nursing qualifications have become known as a “ticket to emigrate,” but accreditation influences destination. Although there are more nurse than physician migrants numerically, it is more difficult for nurses to get their qualifications recognized, due to the lack of global standardization in the nursing profession (Dussault, Buchan, and Craveiro 2016). Various programs exist to facilitate nurse accreditation but are not without criticism. The United States created the Commission on Graduates of Foreign Nursing Schools in 1977 to ensure that foreign-trained nurses would meet US licensing requirements and to ease licensure. The exam can be taken abroad but is in an often unfamiliar multiple-choice format and requires high fees (Bach 2003). Nurses still must pass the National Council Licensure Examination to be licensed in the United States. Since 2010, nurses with bachelor’s degrees and EU diplomas in nursing should meet European Higher Education Area criteria for professional recognition in other EU member states. However, nurses still find it difficult to gain acceptance as qualified workers because each country has the right to grant (or deny) professional licenses. In the United Kingdom, the national competent authorities still assess each migrant’s qualifications. Nurses from Eastern Europe find that their degrees are not accepted or adaptation periods (up to six months with no pay) are prohibitive; they often immigrate as care assistants instead (Bludau 2012). Finally, foreign licensing exams test not only medical knowledge but also cultural knowledge or competence that is difficult to acquire at home (Masako, Yoshinori, and Kiyoshi 2010).

Physician qualifications do not easily transfer from one country to another unless educational and training standards are considered equal or superior; degrees earned in countries such as the United States or United Kingdom are more internationally recognized. Doctors should be assessed on universal standards of biomedicine, but there is no international governing body. Foreign-trained physicians may be unfairly treated and denied access or confined to practice in marginalized areas of work (Iredale 2009). Physicians moving to the United States may have their education accepted by passing the United States Medical Licensing Examination but must still complete a multiyear residency (Schühle 2018). Canada requires foreign-trained physicians to pass additional exams to become licensed (Joudrey and Robson 2010). Both physicians and nurses are often required to take “bridging” courses to demonstrate competency (Skeldon 2009, 12) or gain full registration (Bach 2003), allowing them to work at the level their home training allows. Competency in the required language is also part of accreditation and is discussed in the cultural competence section.

Work Experiences

Biomedicine may be founded on evidence, but it is practiced globally in different ways; migrants must adapt to be successful. One of the most troublesome elements for migrants in their new work environments is the need to master new levels of technology. For instance, migrants often arrive with limited knowledge of the technology and drugs used in better-funded hospitals (Edwards and Davis 2006, 269). However, Nigerian physicians feel American doctors rely on technology too much (Schühle 2018); Czech midwives in Saudi Arabia are offended at the strong technocracy there (Bludau 2017).

Different approaches to healthcare practices populate migrant narratives (e.g., Bludau 2017; Magnusdottir 2005; Schühle 2018). Systems of documentation and of policies and procedures challenge medical migrants, who are not used to such systems. The policies themselves offer forms of autonomy to nurses that they may not have experienced before but also highlight the litigious nature of Western societies, all of which can be overwhelming (Moyce, Lash, and de Leon Siantz 2016). The scope of nursing practices is a common theme as well. Variations among national healthcare systems in nursing education and responsibilities have created a global assortment of these systems. The level of autonomy, the physician-nurse dynamic, and the role of the nurse in diagnostics are the most common differences noted (Moyce, Lash, and de Leon Siantz 2016; Sherman and Eggenberger 2008).

Cultural Competence

Cultural competence is not merely the possession of knowledge about various cultures from which the nurse and patient come but a process that uses multiple senses to integrate one’s own cultural awareness, knowledge, skill, encounters, and desires (Kleinman and Benson 2006). Despite the universal nature of biomedicine, it is still practiced in different locales in which local cultures are reflected. Local organizational structures and clinical procedures require professional and cultural adaptation (Buchan 2006). Individual countries may have “distinctive” forms of training and practice that migrants have not found abroad (Schühle 2018, 300). Migrants may need to abandon any assumption that medicine is viewed the same way globally, especially when patient and provider come from societies with different worldviews (Aboul-Enein 2002). Some cultural assumptions have the potential to endanger the patient. Different understandings of treatment goals and of regimes or issues surrounding family, end-of-life decisions, patient autonomy, or consent often challenge migrants and can impact patient care (Slowther et al. 2012, 158) at times when providing culturally congruent care is essential to patient survival. Cultural orientation is common in countries that rely on medical migrants, like Saudi Arabia and the United States (Aboul-Enein 2002). Individuals who have trained and worked in similar systems will find it easier to adapt, whereas those who have not done so experience culture shock in their professional settings. At any rate, migrants may experience a form of culture shock when overwhelmed with extensive learning resources and opportunities (Hancock 2008).

The ability to communicate effectively is a particular form of cultural competence and a necessary skill for patient safety. Certification processes often include language assessment, both language knowledge and communication skills (Bach 2003). English is known as the global language of science and technology and is often used in places that rely on medical migrants (Bradby 2013). The language in which one is trained also factors into migration destination decisions and opportunities (Mejia 1978; Skeldon 2009). Attaining language proficiency can be a challenge for migrants and a barrier to finding and keeping employment abroad. Different roles in healthcare require different levels of language proficiency; poor communication skills may marginalize the migrant both professionally and socially, as well as blocking promotion. Body language and facial expressions reportedly cause medical migrants problems; both acquiring and assessing nonverbal communication skills are difficult endeavors and are not part of required language exams (Slowther et al. 2012). Migrants who have high levels of cultural competence may be invisible as “foreign,” but a notable accent can trigger discrimination.

Discrimination

Gendered and ethnic hierarchies shape migrant experiences and are reflected in discrimination in different forms, like marginalization of foreign-trained migrants, salary differences, or subtle harms that undermine individual confidence. For example, failure to recognize skills and qualifications can lead migrants to feel that their competence is inferior (de Vries, Steinmetz, and Tijdens 2016, 41). Medical migrants experience bullying, racism, and lack of professionalism in their personal lives, as well as from coworkers, supervisors, and even patients at work. Inadequate salaries and benefits are the most common instances of discrimination. For example, in 1999, a nursing home in the US state of Missouri was found to be paying nurse’s aide wages to sixty-five Filipino nurses registered in the United States (Bach 2003, 18). Saudi Arabia is known to calculate salary as a base rate relative to the expected rate in the migrant’s home market, with Americans making thrice the base (Bludau 2012, 203). Less explicitly, foreign workers may be directed into medical specialties that pay less and lead to fewer promotions (Bach 2003, 19). Migrants of non-European heritage repeatedly note feelings of not being welcomed in their workplaces as foreigners (Wojczewski et al. 2015a).

“Brain Waste,” Deskilling, and Underemployment

Medical migrants often experience “brain waste,” the deskilling or underemployment of highly skilled professionals in the host country. Deskilling can be by choice, though. For example, there is a growing trend of Filipino physicians retraining as nurses, called “nurse medics,” in order to augment their marketability (Bach 2003; Barber 2013; Lorenzo et al. 2007). Structural barriers like unrecognized training and experience, discrimination, or language fluency impede full employment. When nurses cannot obtain a license to practice, they often work as aides or assistants, though often assigned the work of registered nurses (Barber 2013; Bludau 2012; Iredale 2001). At times the type of visa or work permit a migrant obtains will limit job options (Bach 2003; de Vries, Steinmetz, and Tijdens 2016). Migrants who need time in the destination country for added training or accreditation review may experience temporary deskilling or unemployment. Even licensed professionals may be denied the opportunity to practice particular procedures. Wealthier countries that have more specialists take procedures away from the role of the generalist (Joudrey and Robson 2010). Inability to work at one’s level of training, and decreased levels of authority and responsibility, can affect a migrant’s perceived social status and morale.

Return Migration

Much less is known about return migration, which can be defined as any movement to one’s home country for an extended amount of time and may entail an ongoing process of departure and return and then going abroad again. Like any migration, return migration is a complex intersection of social, familial, economic, political, and personal factors. Economic downturns in receiving countries may diminish pull factors or result in unemployment. Economic development in home countries may give them their own pull factors for return. Social factors include discrimination or homesickness. Migrants may have met their personal goals of money saved, skills learned, or education achieved. Life-cycle factors—finding a spouse, starting a family, caring for ailing relatives—at times bring individuals home. Changes in immigration laws or other policies may push someone home, possibly earlier than planned. Whereas push factors weigh more heavily in original decisions, pull factors more strongly influence decisions to return (Gmelch 1980) and are often noneconomic (Haour-Knipe and Davies 2008). Individuals who have emigrated due to crisis often seek to reunite with family (Finlay, Crutcher, and Drummond 2011). Gender and family obligations are more relevant factors for return migration than for emigration, especially for female nurses (Haour-Knipe and Davies 2008). Family decisions often depend on one’s partner’s goals or the age and educational level of one’s children. Families may want younger children to be acculturated to the home country, whereas grown children who are established in the destination country may encourage parents to stay.

There is an underlying assumption that return migrants will bring back enhanced knowledge and skills to benefit their home countries; this assumption is often used by migrants as a motivating factor in the original migration (Labonté et al. 2015; Suciu et al. 2017). Those planning to return home before retiring often pay to maintain their licenses in the home country. Evidence has shown that such migrants’ new skills may not match the local conditions they find at home (Bach 2003; Haour-Knipe and Davies 2008; Mejia 1978). Return migrants may also become disenchanted with the local system and seek work in related or nonhealthcare arenas. Local responses to return migrants vary. Those who can successfully reintegrate into their home healthcare system may have increased cultural capital built on their experiences abroad (Garner, Conroy, and Bader 2015; Hull 2010). Others may be demoted or reluctantly accepted but have lost opportunities for promotion (Kingma 2006).

Effects of Work Emigration on Sending Countries and Their Responses

The effect on sending countries depends on a number of factors including population size, the ratio of healthcare workers to the population, and overall well-being of the healthcare system. Other than remittances, there are few positive effects for the sending country.

Shortages and “Brain Drain”

The global healthcare worker shortage is not evenly distributed, reflecting global inequalities, with a resulting “brain drain.” Sending countries are often those that are poorer on the global scale. Many countries in Sub-Saharan Africa have a vacancy rate of over 50 percent in the public health sector (Wojczewski et al. 2015b, 1). By the year 2000, “more than a quarter of all African countries had at least 50 percent of the stock of doctors born in those countries living in a developed country” (Okeke 2013, 169). The World Health Organization estimates that Sub-Saharan Africa will need one million additional workers to meet the Millennium Development Goals (Bradby 2013, 18). Due to aggressive recruitment by the United States, the United Kingdom, Canada, and other countries, over 50 percent of nurses from several Caribbean countries were working abroad in 2000 (Haour-Knipe and Davies 2008, 18).

It is difficult to measure the effect of emigration on direct health outcomes because it is difficult to establish a causal relationship (Aluttis, Bishaw, and Frank 2014; Okeke 2013). Access to care and treatment is not possible without adequate healthcare providers (Eyal and Hurst 2008). However, many of the push factors for migration also contribute to other indicators of a population’s health and well-being. When specialists practicing a particular kind of medicine are limited, the effects can be measured more easily. As facilities experience staff shortages, the remaining staff feel the increased workload burden, which leads to burnout and a lower standard of care and morale (Aluttis, Bishaw, and Frank 2014; Bach 2003; Chikanda 2005). Consequently, when emigrant numbers are high enough, they may lead to an “implosion” of the health sector (Chikanda 2005; Hagopian et al. 2005). One way to manage shortages of skilled healthcare workers is to adjust competencies in healthcare roles. For example, nurses and physician assistants can be trained to take on some physician duties (Eyal and Hurst 2008).

Healthcare education will also feel the burden of shortages. Fewer professionals means fewer people free to move into higher education positions or to serve as clinical supervisors, creating an interference in “academic reproduction” (Martineau, Decker, and Bundred 2004, 4). In addition, clinical supervisors, when providing necessary care to too many patients, have less time to teach nursing students. Often, the best candidates for migration—the most experienced and educated—are the ones who are best suited to positions in education and leadership in their home countries (Hancock 2008). Inexperienced practitioners will be promoted to fill teaching positions, with less experience on which to draw for the application of theory in teaching, which leads to a weakening in the quality of training.

Investment and Remittances

Countries where the state funds the education and training of healthcare workers lose the investment in that training. Aluttis, Bishaw, and Frank (2014) examine the collective investment loss from educating physicians who trained in Sub-Saharan countries but worked abroad. Their assessment is that as of July 2011, close to $2.17 billion had been lost from the region, while the United Kingdom and the United States had financial savings of $2.7 billion and $846 million, respectively. Even if funding is private, states lose the tax revenue that would have accumulated through earning streams (Bach 2003). Countries that want to replace lost staff need to draw on additional funds. African countries spend an estimated $4 billion each year in this endeavor (Chikanda 2005, 162). Taxing emigrants would be one way to recoup some of the loss, but poorer countries rarely do so (Hagopian et al. 2005).

Remittances, funds migrants send to their home countries, are one way that source countries benefit. Few studies account for health sector remittances, but it is apparent that they can contribute to national incomes and surpass development assistance (Dovlo 2007). Remittances are a motivator for the government of the Philippines to train nurses, as well as other foreign workers, for export (Guevarra 2010). Unfortunately, healthcare workers’ remittances are not reinvested into the healthcare system (Bradby 2013) but typically are invested in other sectors of the country’s economy and do not offset the capital lost in education and training (Aluttis, Bishaw, and Frank 2014).

How Source Countries Respond

States can address outmigration in a number of ways, including forming barriers to emigration, creating bilateral agreements, encouraging return migration, and decreasing push factors. Bonding schemes, one barrier to emigration, require graduates to work for the government for a specific amount of time or buy back the bond before they can work overseas (Bach 2003). This barrier implies a “moral obligation to stay” (Hagopian et al. 2005, 1757) but comes with the ethical argument of the human right to unrestricted movement (Okeke 2013). Ghana, Zimbabwe, and India, among others, require healthcare professionals to perform community service or repay their educational fees (Cabanda 2017, 220; Hagopian et al. 2005, 1757).

Bilateral agreements, suggested by the World Health Organization Global Code of Practice, reduce the need for commercial recruitment firms and their potential abuses. These agreements shift the cost of migration from the migrant to the employer and allow a source country to negotiate for trade terms that benefit it (Bach 2003). South Africa employs both practices requiring a “compulsory Community Service year” for new medical graduates and an agreement through which Cuba sends doctors and lecturers to South Africa and South Africa sends students to Cuba’s Latin American Medical School (Hammett 2014). The Caribbean as a region has developed its Managed Migration Program to direct training and movement across the region and to manage and moderate nurse migration (Salmon et al. 2007). Overall, policies that do not address the underlying push factors will have limited long-term effects.

One way for countries to increase their numbers of healthcare workers, retain them, and encourage return migration is to “scale up” health education and training, for example by establishing in-country and specialist training (Oman, Moulds, and Usher 2009). Task-shifting—having less qualified individuals take on responsibilities of more highly trained professionals and making the provision of healthcare not solely dependent on doctors and nurses—is another way national systems can meet health demands (Bradby 2013).

Effects of Work Immigration on Receiving Countries

Receiving countries benefit in a variety of ways but must manage a diverse workforce. The primary benefit is filling staff shortages, but healthcare migration destination countries also save on training and education of health staff (Aluttis, Bishaw, and Frank 2014; Martineau, Decker, and Bundred 2004). Concerned about shortages, many Organisation for Economic Co-operation and Development countries (e.g., France, Japan, the UK, the US) have made “deliberate policy decisions” to increase the numbers of matriculants to medical and nursing schools (OECD 2019, 27), but the increase has yet to meet growing labor demands. Migrants are often more willing to take less desirable posts (e.g., medical specialty, shift, geographic region) (Martineau, Decker, and Bundred 2004; Schühle 2018). Due to an underinvestment in nursing, the United States suffers from chronic nursing shortages (Aiken et al. 2004). The US education system currently does not have the capacity to train enough nurses for the country’s own needs and turns away interested applicants by the thousands. Consequently, it has long relied on foreign-educated nurses, who made up approximately 15 percent of its workforce of registered nurses in 2015. In 2005, foreign-educated healthcare workers made up almost one-third of the physicians admitted to the General Medical Council’s medical register in the United Kingdom (Heath 2007, 981) and approximately 13.42 percent of the Australian healthcare system (Rumsey et al. 2016, 96). High percentages of foreign-trained healthcare workers indicate that the standard of medical care provided depends on primary caregivers who have trained in other countries. Healthcare teams may not work as well, due to different cultural backgrounds, although a diverse medical team can be beneficial in multicultural settings (Li, Nie, and Li 2014).

The Ethics of Global Healthcare Migration

The migration of healthcare professionals involves a range of ethical issues and controversies, including financial losses and other impacts on the delivery of health services in sending countries, global inequalities between richer and poorer countries, and migrants’ ability to make decisions and act on them. The primary issues relate to healthcare migration destination countries exploiting poor countries. It has been noted that a skilled health sector is essential for the basic welfare of a population and that the loss of medical professionals will prove detrimental to achieving development goals (Skeldon 2009). The International Council of Nurses stated that the shortage of nurses and other healthcare workers is one of the “biggest obstacles” to achieving Millennium Development Goals (Hancock 2008, 258).

The ethical dimension of “brain drain” has been one of the most public issues regarding global healthcare migration. Recruitment specifically has been demonized, as healthcare migration destination countries rarely consider the impact of their policies on source countries (Skeldon 2009). Poor source countries accuse wealthy countries of “robbing,” “poaching,” or “raiding” their health services (Bradby 2013, 25). Another perspective is to question whether using the human resources produced in poorer nations without due compensation is ethical. What is often left out of these analyses are the effects on the individual migrants themselves. One can argue not only that their lives and the lives of their families are improved but also that the potential for migration provides “incentive to acquire the human capital necessary for migration” (Okeke 2013, 169). However, some critics of healthcare worker migration “presume” that healthcare workers belong to the country where they trained and have a moral obligation to stay (Bradby 2013, 34). Several countries have enacted policies to limit active recruitment in countries that are suffering as a result of their own shortages. Globally, the ethical issues of healthcare migration were first recognized in 2010 when the World Health Organization instituted a framework for ethical global healthcare recruitment known as the Code of Practice (Glinos 2015).9 It recognizes the right to migrate and urges source countries to address push factors (Aluttis, Bishaw, and Frank 2014). Unfortunately, it is not monitored or enforced.

“Brain drain” is often blamed on the migrants or the recruiting countries when, in reality, it is a symptom of larger systemic problems. Skeldon (2009, 12) explains that as health professionals from developing countries typically come from urban areas, their emigration rarely affects “services in the areas of greatest need.” Consequently, “migration as ‘brain drain’ is being blamed for wider failure of policy” (Skeldon 2009, 12). While an adequate supply of healthcare staff is necessary in the delivery of health-related services, sufficient funding for supplies, equipment, training, and infrastructure is also necessary. The lack of proper funding for health systems often serves as a push factor in emigration. In addition to healthcare systems, outside factors often influencing emigration include poor socioeconomic conditions and political instability (Adzei and Sakyi 2014). “Thus, the migration of health workers can act as both an expression and a perpetuation of structural deficiencies in health systems globally” (Walton-Roberts 2012, 176).

Across the globe, more attention on human resource management in healthcare would alleviate the shortages that drive much of healthcare worker migration. The Code of Practice asks destination countries to focus on building appropriate capacity for their needs so they will not need to rely on migrants (Aluttis, Bishaw, and Frank 2014). If healthcare migration destination countries put more efforts into not only increasing their own capacity for training healthcare professionals but also improving working conditions and pay and increasing retention efforts, they would no longer need to rely on international recruitment to meet their needs (Bach 2003).

Roles forAnthropology

The roles for applied anthropologists in global healthcare migration are in two primary areas: policy and organizational culture. While both source and destination countries try to alleviate their medical shortages through various policies, it is evident that the structures of their healthcare organizations, and at times more public institutions, exacerbate the global shortage. Policy needs a more interdisciplinary, multicultural and multilevel approach rather than the current siloed approach (Bradby 2013). Policies aimed at improving retention need a local-level approach. There is little research on how sending states actually manage migration practices (Cabanda 2017) or how different countries address the problem of healthcare worker shortages in policy, for example by lessening push factors. The experiences of migrants themselves, including a gendered lens, inform policy and healthcare planning and provide a comparative perspective. While it is important to understand why individuals choose to migrate, it is equally important that policymakers understand what makes people stay—either in source countries with high levels of emigration or in their countries of destination.

There is no panacea for the problematic areas of global healthcare migration. In fact, some systems are quite successful (e.g., the South Africa–Cuba bilateral agreement [Hammet 2014] and the Managed Migration Program in the Caribbean [Salmon et al. 2007]). One can argue that migration is a human right. However, to solve the problems, there needs to be widespread culture change in the ways healthcare organizations approach meeting their needs. Healthcare migration destination countries need to shift the ways they train and retain healthcare workers instead of relying so heavily on immigrant labor. At the same time, sending countries need to shift more of their focus to their healthcare infrastructures to ensure that they can meet their own medical needs. In addition, healthcare organizations do not operate in vacuums but intersect with other types of organizations. Anthropologists study complex organizations not only through change factors internal to an organization or within its immediate external environment but also in the context of globalization processes, recognizing that nation-states are integral to organizational change, even when acting as external to an organization (Jordan 2012). Anthropologists bring these approaches to all facets of healthcare migration management, including research and planning, training, and program management and evaluation.

More work needs to be done in finding ways to apply solutions that work in different arenas, like task-shifting. Organizations in which migrants work need to be understood, as well as the practices of recruitment firms, as they are increasingly important in this arena. Our critical understanding of global healthcare would improve by knowing more about how migrants culturally and professionally adapt in new settings, the effectiveness of transition or orientation programs, the extent to which foreign-trained practitioners affect quality of care, and successful reintegration into home healthcare systems. These areas of research all would enable anthropologists to help design managed migration systems that integrate the training and retaining of medical workers, as well as the deploying and returning of medical migrants. Since anthropologists work across employment arenas, those working on healthcare worker migration could find roles in both the public and private sectors. Individual healthcare systems, as well as government health ministries or departments and international organizations—the World Health Organization, the International Organization for Migration, the International Labour Organization—could utilize anthropologists in addressing both policy and organizational culture concerns.

Further Reading

  • Aiken, Linda H., James Buchan, Julie Sochalski, Barbara Nichols, and Mary Powell. 2004. “Trends in International Nurse Migration.” Health Affairs 23 (3): 69–78.
  • Aluttis, Christoph, Tewabech Bishaw, and Martina W. Frank. 2014. “The Workforce for Health in a Globalized Context—Global Shortages and International Migration.” Global Health Action 7 (1): 1–7.
  • Bach, Stephen. 2003. International Migration of Health Workers: Labour and Social Issues. Working Paper 209. Geneva, Switzerland: Sectoral Activities Programme, International Labour Office.
  • Buchan, James, Tina Parkin, and Julie Sochalski. 2003. International Nurse Mobility: Trends and Policy Implications. Geneva, Switzerland: World Health Organization.
  • Connell, John. 2010. Migration and the Globalisation of Health Care. Cheltenham, UK: Edward Elgar.
  • Grignon, Michel, Yaw Owusu, and Arthur Sweetman. 2013. “The International Migration of Health Professionals.” In International Handbook on the Economics of Migration, edited by Amelie F. Constant and Klaus F. Zimmermann, 75–97. Cheltenham, UK: Edward Elgar.
  • Kingma, Mireille. 2006. Nurses on the Move: Migration and the Global Health Care Economy. Ithaca, NY: Cornell University Press.
  • Martineau, Tim, Karola Decker, and Peter Bundred. 2004. “‘Brain Drain’ of Health Professionals: From Rhetoric to Responsible Action.” Health Policy 70 (1): 1–10.
  • Mejia, Alfonso. 1978. “Migration of Physicians and Nurses: A World Wide Picture.” International Journal of Epidemiology 7 (3): 207–215.
  • Monnais, Laurence, and David Wright. 2016. Doctors beyond Borders: The Transnational Migration of Physicians in the Twentieth Century. Toronto: University of Toronto Press.
  • Organisation for Economic Co-operation and Development. 2019. Recent Trends in International Migration of Doctors, Nurses and Medical Students. Paris: OECD Publishing.
  • World Health Organization. 2010. WHO Global Code of Practice on the International Recruitment of Health Personnel. Edited by World Health Organization. Geneva, Switzerland: World Health Organization.

References

Notes

  • 1. The Organisation for Economic Co-operation and Development is an international economic organization that promotes economic development and world trade. Member countries are developed, high-income countries.

  • 2. An OECD (2019) report does indicate that foreign-born but locally trained physicians and nurses are increasingly filling shortages in healthcare migration destination countries but not at the same rate as foreign-trained ones, due to lack of medical training facilities.

  • 3. It should also be noted that a decrease in practitioners in a country may not correlate to emigration but merely leaving the medical field.

  • 4. Migration of other professionals (pharmacists, dentists, physical therapists, etc.) has increased, but little research has been done on these populations to date. See Labonté et al. (2015) as one example.

  • 5. Opportunity to travel or assist in aid work are also pull factors but are smaller in number and usually more temporary. Relatively little research has been done on these motivators.

  • 6. The World Health Organization, in its 1979 seminal study on healthcare worker migration, defined “migrant” as “one who enters or is in a country other than that of which he or she is a national or in which he or she was either born or trained or both” (Mejia, Pizurki, and Royston 1979, 15); that definition differs from the one used in this article: one who is trained in the country of his or her birth.

  • 7. The United Nation’s Millennium Development Goals form a framework to meet the needs of the world’s poorest (United Nations 2015).

  • 8. James Buchan has create a typology of nurses recruited to the United Kingdom (Buchan, Parkin, and Sochalski 2003), while Mirelle Kingma’s taxonomy relates to global nurse migration in general (Kingma 2006).

  • 9. The United Kingdom instituted a code of practice for the National Health Service in 1999.