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Migrant health workers: Is one country’s gain another’s pain?

Severe staff and skill shortages in the health systems of many countries have fostered the active recruitment of health workers from abroad, and this migration poses a potential threat to the health systems of developing countries, says a new ILO report which focuses on the situation of migrant nurses. Monica Evans from the ILO London Office spoke with the author, Dr. Stephen Bach.

Article | 19 December 2003

LONDON (ILO Online) – Visiting a hospital or attending a doctor’s appointment often provides an example of how globalization touches almost all of us. Health workers, particularly nurses, are an increasingly mobile workforce: South Africa has become a major source for medical staff, while up to 80 per cent of its rural doctors are drawn from other nations.

“Many developing countries find it increasingly difficult to compete for skilled human resources in the existing global market” says Dr Bach whose paper examines health worker migration not only from an employment relations and health policy perspective, but also as a global economic trend.
Initially, migration followed mainly colonial and linguistic links – e.g. North Africa to France, the Caribbean to the UK, but now the lure of richer destination countries has altered traditional routes. Also, ethical recruitment practices as applied by governments (recruitment agencies fall outside their remit) have played a role in changing the migration patterns.

In 1999 after Nelson Mandela had criticised the United Kingdom for recruiting nurses from South Africa, the Department of Health stated in its guidelines to employers “It is essential that all NHS employers do not actively recruit from developing countries which are experiencing nursing shortages of their own.” Subsequently this was amended to allow for bilateral agreements, but in any case the provisions do not exclude the acceptance of unsolicited applicants from overseas.

The United Kingdom has historically been a major destination country for doctors and nurses. In 2002, more than half of the country’s fully registered doctors were trained abroad, and two thirds of those were from outside the European Economic Area. Between January 2002 and March 2003, there were almost 13,000 overseas-trained nurses registered in comparison to around 18,000 trained in the UK. However, as Dr Bach points out, this is not a one-way flow – many UK trained doctors and nurses work abroad seeking better lifestyles and working conditions in countries such as Australia and the United States.

The ILO estimates that 77 million people are living and working away from their country of origin, accompanied by a similar number of dependents. The Philippines plays a central role in the political economy of migration with an estimated 7 million Filipinos working, or living abroad. It is the largest source of registered nurses working overseas. In the 1970s there were 63 schools of nursing in the Philippines and some 40 thousand registered nurses. By 1998 the schools had increased to 198, and the total of registered nurses to more than 300,000. Seventy per cent of the 7,000 nurses who graduate in the Philippines every year leave the country and yet an estimated 30,000 nursing positions remain unfilled as people seek a better life abroad, or at least an opportunity to improve opportunities for their relatives through remittances.

Recently, Kunzang Chungyalpa, regional chief of the UN Development Fund for Women (UNIFEM), said remittances from all migrants to Asia's developing countries totalled 80 billion dollars last year - surpassing foreign direct investment for the first time.

While the Philippines may see their migrant workers almost as an industry, for other countries the exodus of health workers has more serious implications. In some African nations high rates of migration contribute to high vacancy rates – in 1999 Ghana had unfilled positions for 42.6 per cent of its medical posts and 25.5 per cent of its nursing posts. Meanwhile many South African doctors are recruited by Canada, and the number of nurses leaving the country has increased eightfold since 1991 – half of them to the United Kingdom. “All this while the continent is fighting the devastating effects of HIV/AIDS, which exacerbates staffing problems as health workers die, contributing to increased workloads and low morale”, says Dr Bach.

But what faces the migrant nurses when they reach their destination? The belief that as skilled professionals health workers will maintain their status can prove unfounded. “The evidence suggests that overseas trained staff don’t get the recognition of their training and experience that they merit and may be confined to lower level tasks. Paradoxically, in their own country they may have had to take on extended roles because of staff shortages” reports Dr Bach. “Migrant health workers often feel constrained in making complaints about their employment conditions because of their sense of vulnerability.”

The migrant nurse also faces possible additional hazards if they have obtained work through a recruitment agency, and the difference between expectation and reality can be harsh. Unfortunate examples exist of trained nurses being used as care workers and made to work in less favourable conditions than locally hired staff.

This is where trade unions are seen as performing a crucial role in safeguarding the interests of overseas workers, since in most countries they have shifted their focus from a protectionist and exclusionary stance to a greater acceptance of immigration as an inevitable component of a more globalized economy, and a potential source of union members. Dr Bach argues that government- to- government recruiting, since more tightly regulated and containing greater scope for mutuality of benefit, is preferable to codes of practice for recruiters and subcontractors of health workers.

According to the study, governments and employers should do more to safeguard and improve the working conditions of migrant health workers by ensuring the ratification and enforcement of ILO Conventions, and of the UN International Convention on the Protection of the Rights of all Migrant workers and Members of their Families, as well as ensuring monitored and ethical recruitment, adding “ When state authorities use policies of international recruitment, the detrimental impact on source countries should be minimised by focusing on regulated, managed migration.”

The issue of 'Migrant workers' will be the main topic for the general discussion on the agenda of the 92nd Session of the International Labour Conference to be held in June 2004. The main focus areas for this discussion are migration and globalization, migration policies and practices, and improving migrant workers protection.

For further information on (health) migrant workers and the ILO, please check the following websites: (health workers) (migrant workers)

1 ILO Working Paper "International migration of health workers: Labour and Social issues", by Dr Stephen Bach.