1

Migration and the Global Healthcare Workforce: Balancing Competing

Demands

Peter Scherer: Counsellor,

Directorate for Employment, and Social Affairs

Organisation for Economic Cooperation and Development

2

The Sources of Demand

The reasons some countries are net recruiters of health professionals lies in their domestic markets.

One of the main drivers seems to be the extent to which countries have restricted the number of places in tertiary institutions

Those which have held down training places are turning to foreign suppliers to compensate for their under-investment

3

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

1960 1970 1980 1990 2000

Prac

tisin

g ph

ysic

ians

per

1 m

illion

pop

ulat

ion

Austria Belgium Greece Switzerland

Canada Japan New Zealand United Kingdom

Countries that don’t or recently started to regulate medical school intake

Countries that regulate medical school intake

Impact of planning and market regimes on physician density

4

Graduation Rates

It is clear that many OECD countries are not training enough nurses or physicians to compensate for the outflow into other occupations and into retirement.

5

Graduated nurses as a percentage of practising nurses, 2000

7.2

7.2

6.2

5.8

4.8

4.6

4.3

3.9

3.9

3.5

3.2

3.1

2.7

2.5

2

0 1 2 3 4 5 6 7 8

Korea

Slovak Republic

Japan

Austria

Germany

Portugal

United States

Denmark

Norway

France

Mexico

Switzerland

United Kingdom

Australia

Canada

Proportion of nurses who graduated in 2000

6

Graduated physicians as a percentage of practising physicians, 2000

9.6

6.2

4.5

4

3.8

3.6

3.4

2.9

2.8

2.8

2.7

2.6

2.5

2.4

1.9

1.9

0 2 4 6 8 10 12

Korea

Ireland

Austria

Australia

United States

Spain

Switzerland

Slovak Republic

Germany

Netherlands

Belgium

Canada

Mexico

Denmark

France

Portugal

Proportion of practising physicians who graduated in 2000

7

The variation in domestic supply

Although he data are only indicative (given definitional problems) the difference between the densities of doctors and nurses (as a percentage of the population) across member countries are striking.

Spain constitutes a notable paradox: there is high unemployment amongst Spanish nurses, and official policy is that there is a “surplus” and foreign recruitment is welcome.

Yet the density of nurses in that country is one of the lowest in the OECD

8

Nurse density, 2000

13,963

11,726

10,735

9,928

9,620

9,582

9,533

9,130

8,835

8,782

7,476

6,750

5,885

3,694

3,663

3,007

1,897

0 2,000 4,000 6,000 8,000 10,000 12,000 14,000 16,000

Ireland

Australia

Switzerland

Canada

Germany

New Zealand

Denmark

United States

Sweden

United Kingdom

Slovak Republic

France

Austria

Spain

Portugal

Korea

Mexico

Practising nurses per 1 million population

9

Physician density, 2000

4,482

4,051

3,855

3,829

3,683

3,510

3,419

3,294

3,263

3,259

3,176

3,041

2,642

2,443

2,232

2,220

2,095

2,005

1,933

1,295

1,102

0 500 1,000 1,500 2,000 2,500 3,000 3,500 4,000 4,500 5,000

Greece

Italy

Belgium

Austria

Slovak Republic

Switzerland

Denmark

France

Spain

Germany

Portugal

Sweden

United States

Australia

New Zealand

Ireland

Canada

United Kingdom

Japan

Korea

Mexico

Practising physicians per 1 million population

10

Changes in Density

There is no apparent evidence that countries with higher density are reducing their nursing workforce (Canada is the exception)

Hence the sources of demand for foreign nurses need to be sought in areas other than “overall” shortages,

11

Change in nurse density from 1990 to 2000

11268

11103

11054

9294

9172

8986

8581

7775

5481

4131

2857

2793

1547

13963

9928 1

1726

9582

8835

9130

9533

8782

6750

5885

3694

3663

1897

0

4000

8000

12000

16000

Pra

ctis

ing

nu

rse

s p

er

1 m

illio

n p

op

ula

tion

1990

2000

12

Outflows from the profession

It is the tendency of nurses to leave the nursing workforce which is the perhaps the main driver of the perceived “shortages” to which employers respond,

In the slide which follows, the net inflow/outflow rate relates the absolute number of nurses in a particular age band in a specific year to that of the previous age group five years earlier.

13

Net inflow/outflow rates of nurses, 1996-2001

Age band

30-34 35-39 40-44 45-49 50-54 55-59 60-64

Austria 122 106 88 102 80 34 39

Belgium 92 89 87 89 86 67

Denmark 266 131 101 91 62 55 55

France 104 91 99 107 92 62 28

Germany 84 94 101 106 72 94 26

Italy 145 114 109 92 90 53 50

Netherlands 81 80 85 106 120 113 26

New Zealand 139 102 99 90 81 72 80

Spain 776 90 100 79 72 121 52

14

South African Case Study

Practitoners (Doctors, dentists,

pharmacists)Nurses and midwives

Registered in South Africa 1996 38,119 177,5202001 46,130 172,338

New graduates 2001 1,420 8,167

Proportion intending to practice abroad 2001 42%

Unfilled Vacancies 2001 4,222 32,734

South African Born Practising in Australia, Canada, US, NZ, UK 2001 8,921 6,884

UK recruitment, South African nurses 1998-1999 599

1999-2000 1,4602000-2001 1,0862001-2002 2,114

15

Flow chart of the production of health care

New graduatesImmigrantsRe-entrants

LeaversEmigrants

Retirees

Stock andproductivity

of physicians

Volume andVolume andquality of health carequality of health care

DerivedDemand

Supply

PatientsPatients

OutflowOutflow

InflowInflow

Stock andStock andproductivity productivity

of other health of other health care resourcescare resources

Supply

DerivedDemand

Policies on:• Education• Pay• Work conditions• Migration• Retirement

Stock andproductivity

of nurses

SKILL MIX

16

Principal axes of international mobility of health professionals (by country of birth)

17

Main message

Cross-border migration is just one aspect of normal movements in labour markets

The same issues of policies to improve retention which apply domestically apply to national policies

Excessive rates of movement indicate a malaise in employment conditions

In South African case, re-orienting training to address South African needs may help to reduce the role of the profession as a conduit for immediate migration

But the aim should be to encourage retention for a reasonable number of years, not prevent movement.