Orvill Adams

Migration of health-care workers from developing countries: strategic approaches to its management

Of the 175 million people (2.9% of the worlds population) living outside their country of birth in 2000, 65 million were economically active. The rise in the number of people migrating is significant for many developing countries because they are losing their better-educated nationals to richer countries. Medical practitioners and nurses represent a small proportion of the highly skilled workers who migrate, but the loss for developing countries of human resources in the health sector may mean that the capacity of the health system to deliver health care equitably is significantly compromised. It is unlikely that migration will stop given the advances in global communications and the development of global labour markets in some fields, which now include nursing. The aim of this paper is to examine some key issues related to the international migration of health workers and to discuss strategic approaches to managing migration.

The role of wages in the migration of health care professionals from developing countries

Several countries are increasingly relying on immigration as a means of coping with domestic shortages of health care professionals. This trend has led to concerns that in many of the source countries – especially within Africa – the outflow of health care professionals is adversely affecting the health care system. This paper examines the role of wages in the migration decision and discusses the likely effect of wage increases in source countries in slowing migration flows.This paper uses data on wage differentials in the health care sector between source country and receiving country (adjusted for purchasing power parity) to test the hypothesis that larger wage differentials lead to a larger supply of health care migrants. Differences in other important factors affecting migration are discussed and, where available, data are presented.There is little correlation between the supply of health care migrants and the size of the wage differential between source and destination country. In cases where data are available on other factors affecting migration, controlling for these factors does not affect the result.At current levels, wage differentials between source and destination country are so large that small increases in health care wages in source countries are unlikely to affect significantly the supply of health care migrants. The results suggest that non-wage instruments might be more effective in altering migration flows.

Imbalance in the health workforce

Imbalance in the health workforce is a major concern in both developed and developing countries. It is a complex issue that encompasses a wide range of possible situations. This paper aims to contribute not only to a better understanding of the issues related to imbalance through a critical review of its definition and nature, but also to the development of an analytical framework. The framework emphasizes the number and types of factors affecting health workforce imbalances, and facilitates the development of policy tools and their assessment. Moreover, to facilitate comparisons between health workforce imbalances, a typology of imbalances is proposed that differentiates between profession/specialty imbalances, geographical imbalances, institutional and services imbalances and gender imbalances.

Developing evidence-based ethical policies on the migration of health workers: conceptual and practical challenges

It is estimated that in 2000 almost 175 million people, or 2.9% of the worlds population, were living outside their country of birth, compared to 100 million, or 1.8% of the total population, in 1995. As the global labour market strengthens, it is increasingly highly skilled professionals who are migrating. Medical practitioners and nurses represent a small proportion of highly skilled workers who migrate, but the loss of health human resources for developing countries can mean that the capacity of the health system to deliver health care equitably is compromised. However, data to support claims on both the extent and the impact of migration in developing countries is patchy and often anecdotal, based on limited databases with highly inconsistent categories of education and skills.The aim of this paper is to examine some key issues related to the international migration of health workers in order to better understand its impact and to find entry points to developing policy options with which migration can be managed.The paper is divided into six sections. In the first, the different types of migration are reviewed. Some global trends are depicted in the second section. Scarcity of data on health worker migration is one major challenge and this is addressed in section three, which reviews and discusses different data sources. The consequences of health worker migration and the financial flows associated with it are presented in section four and five, respectively. To illustrate the main issues addressed in the previous sections, a case study based mainly on the United Kingdom is presented in section six. This section includes a discussion on policies and ends by addressing the policy options from a broader perspective.

Health professionals and migration

Migrant health workers are faced with a set of options that are a combination of economic, social and psychological factors and family choices (1). They trade decisions related to their career oppor-tunities — and to financial security for their families — against the psychological and social costs of leaving their country, family and friends. The comments of health workers themselves reflect the “push and pull” nature of the choices underpinning these “journeys of hope” as, for example, those collected in Ghana by Dovlo (2). Demotivating working conditions, coupled with low salaries, are set against the likelihood of prosperity for themselves and their families (by remit-tances), work in well-equipped hospitals, and the opportunity for professional development. In this issue of the Bulletin, Saravia & Miranda (pp. 608–615) point out that young, well-educated individuals are most likely to migrate, especially in pursuit of higher education.Employers in the countries of origin have their own perspective. They are unable to fulfil their mandates to provide equitable access to health care because the necessary health workers are not available. In many cases, the country is losing its investment in the education of health professionals, as well as losing the contribution of these workers to health care. Governments have to compete for health workers by making their condi-tions of work more attractive; they may also highlight the imbalance in com-petition between themselves and the receiving employers. Arguments from this perspective will inevitably include ethical and moral dimensions.Employers in receiving countries take a different position, driven by their need to provide sufficient health workers to meet the demand for services within the constraints of budget planning and the imperfections of the labour market. Kupfer et al. (pp. 616–619) discuss