Article:Trade in Health Services:The case of Cross-Border Movement of Nurses and Midwives
Debashis Chakraborty[1]
1. Introduction
The growth of the global healthcare sector over the years has been phenomenal, aided by the domestic liberalizations, cross-border investments and movement of medical professionals as well as patients. In particular, the migration of nurses and midwives from developing countries has increased considerably in recent period. It is observed from Figure 1 that several developing countries in Asia and Africa are among the major exporters of nurses and midwives.
Figure 1: “Top Ten” Source Countries of International Nurse Registrants (2005-06)
Source: data obtained from Buchan (2007)
According to an Amnesty International report (2006), the main reasons behind the cross-border movement of nurses and midwives include higher remuneration opportunities, limited career prospects; feelings of lack of respect or value, concern over poor condition of governance and management, concern over poor retirement benefits and prospects etc. The similarity in cultural and linguistic factors also plays a crucial role in determination of the destination country. For instance, migration of the nurses in UK is generally happening from the Commonwealth countries or the Philippines, thanks to their fluency in English (Buchan et al, 2006).
2. The Entry Routes
The demand for nurses and midwives in the developed countries comes from various segments like hospitals, nursing homes and other long-term care facilities. With the growing demand in this category, the need to streamline the recruitment process or to introduce an ethical element in the system has been realized. Several countries and international bodies have formulated guidelines in order to achieve this goal over the last couple of years. For instance, United Kingdom Code of Practice for the International Recruitment of Health Care Professionals (2004), Ireland Guidance for Best Practice on the Recruitment of Overseas Nurses and Midwives (2001), Scotland Code of Practice (2006), Commonwealth Code of Practice for the International Recruitment of Health Workers (2003) etc. could be mentioned in this regard. The UK Code was adopted for introducing an ethical dimension in the recruitment of foreign health professionals (Government of UK, 2004).
On the other hand, the requirement of undertaking tests by the nurses before entry for ensuring quality is also witnessed. For instance, tests / review process by the US Council of Graduates of Foreign Nursing Schools (CGFNS), National Council Licensure Examination-Registered Nurse (NCLEX) etc. are worth mention here (Pitman et al, 2007).
(Buchan et al, 2006) notes that the entry of the nurses in UK market takes place through two major routes. First, the hospitals under National Health Service (NHS) can employ foreign nurses. Second, the independent sector can also recruit the nurses from the international sources. Players within both the sectors obtain helps from specialized recruitment agencies to find out suitable candidates.
According to Pitman et al (2007), the recruiting companies hold a critical role in the US market as well, though direct recruitment by several major hospitals are not uncommon. However, the recruiting firms contribute significantly for tackling the procedural hassles relating to credentialing, licensure, immigration processes etc. The recruitment of foreign nurses is undertaken by variants of three major routes: (1) direct recruitment by healthcare organizatioins, (2) placement, and (3) staffing.
3. North-South Migration: Demand Pattern
Figures 2 and 3 show the demand pattern for the foreign nurses, especially from the developing countries, in the UK and the US markets respectively. It is observed from Figure 2 that a major proportion of the foreign nurses in UK are coming from China, India and Philippines, understandably owing to the wage differential. Similarly from Figure 3, it is observed that several US hospitals are recruiting nurses from Canada, India and Philippines. Nurses coming from Africa, China and Korea are also being recruited by local players.
Figure 2: Percentage of entrants onto the UK nursing register, from non-EU countries, by source country, 2001-02 to 2004-05
Source: Quoted from Buchan and Seccombe (2006)
Source: Quoted from Pitman et al (2007)
4. Emerging Trends in Source and Destination Countries: A Review
Buchan et al (2006) have undertaken a comprehensive sample survey of the migrant nurses in UK, so as to understand the broad emerging features as well as their experience. One interesting finding is that a significant proportion of the nurses coming from sub-Saharan Africa, South Africa and South Asia were aged 40 and above, perhaps indicating an inclination towards greater experience in the destination country. The development rift between the home and the destination country became obvious from the fact that while nurses coming from Australia, New Zealand or US were willing to stay only for a shorter duration, the nurses coming from developing countries were willing to stay for a longer period, ranging over two to five years or more. Also understandably, majority of the surveyed nurses, notably from South Africa and Philippines, were found to be remitting back a significant part of their salary.
Though the overseas employment offers better pay package to the nurses coming from developing countries as compared to their respective home markets, wage differential at the destination markets may not be uncommon. For instance, Buchan et al (2006) reported the presence of an inter-regional variation in the remuneration structure received by the foreign nurses. It was observed in their survey that majority of the nurses from sub-Saharan Africa, South Asia and Southeast Asia were placed in a lower pay band, while the nurses from Australia and New Zealand were placed in a relatively higher category.
Entry in a foreign country is also associated with cost, including search, compliance and transaction costs. For instance, Buchan et al (2006) noted that almost 75 percent of the total number of nurses coming to UK, mostly from Philippines and South Asian subcontinent, had to pay an intermediate agency for various services procured, including adaptation fees to the Nurses and Midwives Council in the UK. A similar experience is observed in the US market as well from the analysis of Pitman et al (2007), which notes that several recruiting agencies collect fees from the nurses on the ground of costs associated with testing, visa and immigration processing, credentialing etc. in addition to the fees they obtain from the US employers.
Over the time, several developing countries have streamlined their procedural as well as institutional regime so as to facilitate the overseas employment of medical professionals from their territories. For instance, Yamagata (2007) noted that Philippines has created an agency called Philippine Overseas Employment Administration (POEA), which advertises foreign employment opportunities, supervises recruitment agencies and verifies contracts between foreign employers and local professionals before the migration etc. The condition of the professionals working abroad is also scrutinized through diplomatic missions in foreign countries. On the other hand, in response to the market forces, a number of new medical schools have been established in Philippines, who are adapting their course curricula in line with the requirement of the foreign markets (Arunanondchai and Fink, 2007). Understandably, the number of Filipino nurses working in Europe, US, West and Southeast Asia has crossed 85,000.
As mentioned earlier, wage disparity across countries is a major determinant of the cross-country flow of nurses and midwives, and Asian and African nurses are often working in the developed countries at a lower wage as compared to the same offered to the nurses coming from developed countries. This is a cost efficient way of managing healthcare sector in the developed countries. However, despite receiving the relatively lower wage in the developed country markets, the foreign nurses may not be willing to return to their home countries immediately, and may like to extend their stay abroad. For instance, Buchan and Seccombe (2006) noted that majority of the foreign nurses in UK, especially those from the Philippines and India, were appearing in the CGFNS screening examination there, with the ambition of moving to US next.
5. Implications for Developing Countries
What would be the impact of this large scale outflow of trained nurses and midwives from the developing countries on their public health systems? Efficiency could be a major concern, as the most qualified nurses will always be the first ones to migrate owing to the remuneration package offered abroad being more commensurate with their perceived self-ability. The consequent brain drain is particularly frustrating for the policymakers in a developing country (WHO, 2006), owing to its limited resource base. Another potential concern for a developing country is a drastic decline in the qualified nurses-population ratio in the country, which increase the work pressure of the remaining workforce and might provide a rationale to them for migration as well. A summary of the opportunities and challenges for various stakeholders from the cross-border movement of nurses, as created by Buchan et al (2005), is provided in Table 1.
Table 1: International Recruitment of Nurses - Possible Opportunities and Challenges
Category | Opportunities | Challenges |
Destination countries | Solve skills/ staff shortages. "Quick fix". | How to be efficient, and ethical in recruitment. |
Source countries | Remittances. Upskilled returners (if they return). Lower unemployment in certain cases. | Outflow may cause shortages; negative impact on delivery of care. Costs of "lost" education. Increased costs of recruitment of replacements. |
Internationally mobile nurses | Improved pay, career opportunities, education. | Achieving equal treatment in destination country. |
Static nurses | Improved job and career opportunities (if worker versupply). | Increased workload as other nurses leave. Lower morale. |
Source: Quoted from Buchan et al (2005)
The cross-country evidence on this front however shows that the resultant effect may not always be unidirectional. For instance, in populous countries like Philippines and India, the shortfall has not reached any alarming level. Rather the inflow of remittances by Filipino nurses has influenced the training pattern etc. in the country towards creating a more favourable framework towards outward migration. Similarly, thanks to the wage differentials while Malaysian hospitals are hiring Indian and Filipino nurses; Malaysian nurses are going to Singapore and Saudi Arabia, and this inflow from other countries is restricting the domestic shortfall (Arunanondchai and Fink, 2007). However, the situation is quite serious in many sub-Saharan African countries, where the outflow of nurses has seriously affected their Millennium Development Goal targets. Kinfu et al (2009) have noted that in several African countries the current annual rates at which newly qualified nurses and midwives are graduating are not sufficient to maintain their health security, especially to offset the huge volume of outflow. Only South Africa, owing to better regional remuneration opportunities can partly reduce the shortfall through inflow of medical personnel from lower income neighbours (Economist, 2005).
The outward movement of nurses and midwives from the developing countries to the developed countries is likely to continue, given the population density and perennial disadvantages of the former as well as the aging problem and the economic downturn in the latter. However, the developing countries on their part need to understand the extent of their health security challenge, and should attempt to provide suitable career development opportunities and working environment to the local nurses and the midwives so as to avoid any disastrous outcome.
Bibliography
Amnesty International (2006), “Caring for human rights: Challenges and opportunities for nurses and midwives”, London.
Arunanondchai, Jutamas and Carsten Fink (2007), “Trade in Health Services in the ASEAN Region”, World Bank Policy Research Working Paper No. 4147.
Buchan, James (2007), “The UK, Asia and International Recruitment of Nurses”, Asia Research Institute Working Paper Series No. 87, National University of Singapore, Singapore.
Buchan, James and Ian Seccombe (2006), “Worlds Apart? The UK and International Nurses”, Commissioned by the Royal College of Nursing, London.
Buchan, James, Mireille Kingma and F. Marilyn Lorenzo (2005), “International migration of nurses: trends and policy implications”, International Council of Nurses, Geneva.
Buchan, James, Renu Jobanputra, Pippa Gough and Ruth Hutt (2006), “Internationally recruited nurses in London: a survey of career paths and plans”, Human Resources for Health, 4 (14).
Economist (2005), “African migration: Home, sweet home - for some,” August 13, p. 37-38.
Government of United Kingdom, Department of Health (2004), “Code of Practice for the international recruitment of healthcare professionals”, available at: http://www.dh.gov.uk/assetRoot/04/09/77/34/04097734.pdf.”, London.
Kinfu, Yohannes, Mario R Dal Poz, Hugo Mercerb and David B Evans (2009), “The health worker shortage in Africa: are enough physicians and nurses being trained?”, Bull World Health Organ, 87, 225–230.
Pittman, Patricia, Amanda Folsom, Emily Bass, Kathryn Leonhardy (2007), “U.S.-Based International Nurse Recruitment: Structure and Practices of a Burgeoning Industry”, AcademyHealth, Washington DC.
World Health Organisation (2006), “Poverty, Trade and Health: An Emerging Health Development issue”, Genev.
Yamagata, Tatsufumi (2007), “Securing Medical Personnel: Cases of Two Source Countries and Two Destination Countries”, Institute of Developing Economies Discussion Paper 105, Japan External Trade Organization (JETRO), Tokyo.
[1] Assistant Professor, Indian Institute of Foreign Trade, New Delhi
