understanding and influencing the international migration of health workers barbara stilwell world...

Understanding and Understanding and influencing the international influencing the international migration of health workersmigration of health workers

Barbara StilwellBarbara Stilwell

World Health OrganizationWorld Health Organization

AcademyHealth Scientific Session AcademyHealth Scientific Session

International Migration of Health WorkersInternational Migration of Health Workers

San Diego June 6-8 2004San Diego June 6-8 2004

World Health Organization GenevWorld Health Organization Genevaa

Outline Outline • The health care workforce in the global contextThe health care workforce in the global context

• Why is the migration of health care professionals a Why is the migration of health care professionals a concern? concern?

• Factors Driving MigrationFactors Driving Migration

• Policy Options to Manage MigrationPolicy Options to Manage Migration

• Moving ForwardMoving Forward


The health care workforce in the The health care workforce in the global contextglobal context• Migration flows are likely to increase in the futureMigration flows are likely to increase in the future

• Labour markets are becoming globalizedLabour markets are becoming globalized

• Free-trade agreements and GATS, for example, are Free-trade agreements and GATS, for example, are removing barriers to labour flows between removing barriers to labour flows between countriescountries

• Training programs in many developing countries Training programs in many developing countries are of high quality and are similar to those in are of high quality and are similar to those in developed countriesdeveloped countries

• In the global labour market, some countries are In the global labour market, some countries are large importers, others are large exporterslarge importers, others are large exporters


Proportion of professionalsProportion of professionalsUKUK

Total migration compared to physicians, nurses and all professionals

1

10

100

1000

Years

Nu

mb

er

(th

ou

sa

nd

s)

Total

Physician

All prof.

Nurses


Proportion of professionalsProportion of professionalsUSUS Immigrants to the United States 1992 to 2000

1000

10000

100000

1000000

1992 1993 1994 1995 1996 1997 1998 1999 2000

Year

Nu

mb

er

All Immigrants

All HealthProfessionalsPhysicians

Nurses

All Occupations

Source: Statistical Yearbook of the Immigration and Naturalization Service 2001; Bureau of Citizenship and Immigration Services


Migration Flows 1 Migration Flows 1

Annual Migration of Nurses out of the Philippines to Various Countries

Country 1992 1997 2002

(to October)

Saudi Arabia 3,279 3,794 5,083

UK 0 63 3,633

UAE 271 209 367

Libya 269 175 349

USA 1,796 11 295

Kuwait 320 25 104

TOTAL 6,078 5,245 10,627

• Changing patterns – Changing patterns – less to US, more to less to US, more to Saudi Arabia and UKSaudi Arabia and UK

• Only 22 nurses Only 22 nurses migrated from Saudi migrated from Saudi Arabia to the UK in Arabia to the UK in 2002 – 'carousel'?2002 – 'carousel'?

Source: Department of Labour and Employment, Manila, Philippines


Migration Flows 2Migration Flows 2

• However, most of the Angola-born and Cape Verde-born However, most of the Angola-born and Cape Verde-born physicians in Portugal completed medical school in Portugalphysicians in Portugal completed medical school in Portugal

Source Source CountryCountry

Number Number PhysiciansPhysicians

Number Number NursesNurses

In PortugalIn Portugal In In source source countrycountry

In PortugalIn Portugal In source In source countrycountry

AngolaAngola 820820 961961 383383 1428814288

Guinea Guinea BissauBissau

358358 197197 253253 12991299

Sao ToméSao Tomé 238238 6767 8484 183183

Cap VerdéCap Verdé 231231 7171 4040 232232


Why is the migration of health Why is the migration of health care professionals of concern?care professionals of concern?

• Developed countries are increasingly relying on Developed countries are increasingly relying on migrant health care professionals to cope with migrant health care professionals to cope with domestic shortages domestic shortages

• Less developed countries are now the main source Less developed countries are now the main source of migrant health care professionalsof migrant health care professionals

• Outflow of health care professionals is believed to Outflow of health care professionals is believed to affect adversely the health care system in several affect adversely the health care system in several of these developing countriesof these developing countries

• Member countries are seeking solutions from WHOMember countries are seeking solutions from WHO


Impact in source countriesImpact in source countries• Though actual numbers of migrants are Though actual numbers of migrants are

small, the problem is exacerbated by other small, the problem is exacerbated by other factors in developing countriesfactors in developing countries: : – stocks and flows into the workforce are smallstocks and flows into the workforce are small– weak health systems, with poor capacity to weak health systems, with poor capacity to

expandexpand– the rising death toll among health professionalsthe rising death toll among health professionals– weak economies, so that the decision to weak economies, so that the decision to

migrate comes sooner migrate comes sooner


Factors Driving MigrationFactors Driving Migration

• How many health care professionals are How many health care professionals are governments willing to accept into their country? governments willing to accept into their country?

desire to accept migrants desire to accept migrants

• How many health care professionals are willing to How many health care professionals are willing to leave their home country and to move abroad?leave their home country and to move abroad?

desire to migrate desire to migrate


Factors Driving Migration Factors Driving Migration • Desire to Accept MigrantsDesire to Accept Migrants

– Domestic shortages of health care professionalsDomestic shortages of health care professionals– Insufficient training capacity to produce enough health care Insufficient training capacity to produce enough health care

professionals domestically professionals domestically – High quality training programs in developed countries High quality training programs in developed countries

• Desire to MigrateDesire to Migrate– Wages and working conditions better abroadWages and working conditions better abroad– Opportunities for career advancement Opportunities for career advancement – Improved living conditionsImproved living conditions– Send remittances back home - Send remittances back home - 'transnational corporations 'transnational corporations

of kin' of kin'


Factors affecting the motivation of Factors affecting the motivation of health workers in five African health workers in five African countriescountries

0 10 20 30 40 50 60 70 80 90

Better/realisticremuneration

Conducive w orkingenvironment

Continuing education,training

Better management ofhealth services

Percentage

Zimbabwe

Uganda

South africa

Ghana

Cameroun

Source: Awases M, Gbary A, Nyoni J. and Chatora R, Migration of health professionals in six countries: Report, Brazzaville, WHO Regional Office For Africa, 2002.


Remittances Remittances

0 10 20 30

East Asia and Pacific

Central Asia

Latin America and theCaribbean

Middle East and NorthAfrica

South Asia

Sub-Saharan Africa

Remittances (billions of dollars)

2002

2001

2000

1999

Workers’ remittances received by developing countries by region 1999 - 2002


Policy Options to Manage Policy Options to Manage MigrationMigration

• Migration can not be stoppedMigration can not be stopped

• It is often a symptom of much wider labour It is often a symptom of much wider labour market conditions that need to be taken into market conditions that need to be taken into consideration:consideration:

•working conditions may be poor in the health working conditions may be poor in the health sectorsector

•there may be unemployment and therefore it is there may be unemployment and therefore it is difficult to find a jobdifficult to find a job

•part time work may not be availablepart time work may not be available

•there may be a mismatch of skillsthere may be a mismatch of skills


Policy Options to Manage Policy Options to Manage MigrationMigration• To manage migration, countries might:To manage migration, countries might:

– Encourage temporary staysEncourage temporary stays– Restrict immigration from at-risk countriesRestrict immigration from at-risk countries

•e.g.. Commonwealth Agreement on Ethical e.g.. Commonwealth Agreement on Ethical RecruitmentRecruitment

– Facilitate return migration, harness the diasporaFacilitate return migration, harness the diaspora– Use bilateral agreements to manage migrationUse bilateral agreements to manage migration– Encourage ethical recruitment practicesEncourage ethical recruitment practices– Train new types of providers that meet local Train new types of providers that meet local

needsneeds– Bond new graduatesBond new graduates


Moving ForwardMoving Forward

• Migration resolution requests WHO to: Migration resolution requests WHO to: • Monitor movement of health workforce through improved Monitor movement of health workforce through improved

information systemsinformation systems

• Research impact of trade agreementsResearch impact of trade agreements

• Support Member States in improving planning mechanismsSupport Member States in improving planning mechanisms

• Develop a Code of PracticeDevelop a Code of Practice

• Facilitate dialogue between countries to explore modalities Facilitate dialogue between countries to explore modalities for source countries to offset lost investmentfor source countries to offset lost investment

• Ensure that all programmes pay attention to HR Ensure that all programmes pay attention to HR strengtheningstrengthening

• Declare World Health Day 2006 as Human Resources for Declare World Health Day 2006 as Human Resources for Health DevelopmentHealth Development

• Include human resources as a top priority area in the POWInclude human resources as a top priority area in the POW

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