The Causes of International Migration of Nurses Essay
International migration of nurses is on the rise in the recent decades due to rapid globalization. Nursing profession is considered to be a mobile profession as thousands of nurses every year move from one country to other for better future career, social security, and professional development (Kingma, 2007). So, in 21st century nurse migration is a national as well as a global issue. Studies show that most of the developed and industrialized countries are confronting a critical shortage of health care workers in general and nurses in particular in these days (Walani, 2015). Those countries, including Canada, are recruiting Internationally Educated Nurses (IENs) to meet the health care needs for their population.
Current trend of nurse migration is from the developing and under developed countries of Asia and Africa to the industrialized and developed countries like U.S.A., Canada, Australia, and United Kingdom. However, nurses also migrate from one developed country to other developed country. For example, in 2011, 15.3% nurses in Canada were from the United Kingdom (CIHI). Similarly, a different survey says 19,699 (11.9%) nurses educated in Canada emigrated to the U.S. (HRSA, 2010).
When nurses complete professional education and training outside of Canada and immigrate to Canada for professional employment, obviously they come along with their social and cultural values, education and language, which are different from the host country, Canada, in many respects. The differences in socio-cultural background, professional scope, language, educational training and practices
‘Brain drain’ can be discussed as a global trend that is caused by social and economic factors, and its potential impact on the global health is negative because of significant reductions in the quality of health care in many world regions.The Causes of International Migration of Nurses Essay
Thus, ‘brain drain’ is a notion used to describe the global trend of the health workers’ migration. It is possible to speak about ‘brain drain’ when competent health workers from developing countries move to the developed countries in search of a better life. The obvious result of such migrations is the disproportionate distribution of health workers in developing and developed countries (Kill or Cure: Doctors and Nurses, 2010).
The current impact of this trend on the global health is the acute shortage of the workforce in heath care facilities in many Asian, Middle Eastern, and African countries.
The potential negative impact on the global population’s health is more dramatic because of the impossibility of doctors in developing countries to control epidemics (Kasper & Bajunirwe, 2012, p. 974). Furthermore, ‘brain drain’ affects the health status of developing nations during decades, and it is a significant barrier to the development of global health goals and to the implementation of relevant health care policies.
While referring to the factors that can contribute to the progress of ‘brain drain’, it is necessary to focus on such economic factors as low wages and economic statuses in developing countries and such social factors as the lack of educational opportunities, the stable growth of population in developing countries, and the limited access to health care services.The Causes of International Migration of Nurses Essay
African countries suffer from the crisis in the health care industry because physicians and nurses affected by problematic economic and social situations choose to study and work in Europe (Kill or Cure: Doctors and Nurses, 2010).
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As a result, trying to escape difficult economic conditions, health workers from developing countries support the development of the ‘brain drain’ tendency and the worsening on the social situation in their native countries while referring to the health care provision.
In order to address the crisis in the global health and respond to the problem of health workers’ migration, it is necessary to recommend an effective strategy to follow in such developing countries as Malawi and India. The active ‘brain drain’ results in reducing the number of health workers for every 10,000 people in developing countries (Kasper & Bajunirwe, 2012, p. 974).The Causes of International Migration of Nurses Essay
To address the problem, it is necessary to propose the combination of economic and social strategies. Thus, in order to attract health workers to developing regions, it is necessary to improve funding and support in health care industries of developing countries. The effective strategy should respond to the health workers’ expectations regarding their wages and working conditions.
Investments into health care, additional funding, support of the research, and increases in health workers’ salaries are important to attract nurses and doctors (Kasper & Bajunirwe, 2012, p. 976).
The next step is the improvement of the occupational safety, working conditions, and competence with the help of international workforce policies and training programs provided by the world health organizations and other global public organizations.The Causes of International Migration of Nurses Essay
It is possible to state that the lack of the competent health personnel is a problem typical for developing countries that is caused by ‘brain drain’ effects.
Inadequate working conditions make health workers migrate to developed countries in search of a better life in spite of the fact that their skills and knowledge are necessary in developing countries of Africa and Asia. The results of this trend are workforce shortages and unequal distribution of health services in regions.
‘Brain drain’ is a complex process which should be discussed from two perspectives. On the one hand, ‘brain drain’ can be described as a loss of health workers in developing countries because of the active migration. On the other hand, ‘brain drain’ is a lack of the access to the research results observed in developing countries.
Following the statistical data, it is possible to state that high-income countries provide jobs for more than 30% of all international medical graduates (Muula, 2005, p. 24). From this perspective, only 10% of health care workers return to their native developing countries because low-income countries cannot provide them with all the necessary conditions for the effective work (Muula, 2005, p. 25).The Causes of International Migration of Nurses Essay
Health care workers seek for respect and prestige while working in developed countries. Moreover, contributing to the research in the health care sphere, medical professionals have no adequate opportunities to influence the development of health care in their native countries.
As a result, ‘brain drain’ as a global tendency can be discussed as having a negative effect on the distribution of the human capital in the health care industry and on the reduction of health care issues in low-income countries. The potential impact of ‘brain drain’ on the health in developing countries can be considered as dramatic because of the necessity to overcome workforce shortages.
Responding to the question about factors which influence ‘brain drain’, it is important to refer to such aspects as poor resources and significant income differences between developed and developing countries. Being provided with superior job opportunities in high-income countries, health workers intend to improve the socioeconomic conditions.The Causes of International Migration of Nurses Essay
Thus, the social and political instability observed in developing countries is one more contributing factor to the development of the ‘brain drain’ tendency. The problem is in the fact that medical students undertaking feel safe protected while studying and working in developed countries.
Returning to their native countries, the medical workers focus on the poor availability of resources and facilities (Blacklock, Ward, & Heneghan, 2014, p. 100). Thus, a lack of resources and adequate health care facilities is a leading cause of death in developing countries. In this regard, health workers prefer working in countries where research is funded and health care reforms are effectively implemented.
The factor of comfortable working environments and opportunities for the career growth and development also influence health workers’ decisions.The Causes of International Migration of Nurses Essay
The structure of the health care industry in developing countries is one more factor that contributes to ‘brain drain’ because of the extreme workflow and inadequate investment in the healthcare service delivery (Blacklock et al., 2014, p. 100). Having no job satisfaction and prospects for further education, health workers choose to migrate in order to receive effective training and opportunities for the career progress.
I would like to acknowledge the support of people who made the completion of
this dissertation possible. First and foremost, I thank my committee members. I
am especially grateful to Dean Yang whose guidance at all stages of my research was
invaluable; he knew when to impart encouragement when it was needed. I thank Jeff
Smith. No one reads drafts as meticulously as Jeff and his comments substantially
improved the final product. Ach Adhvaryu and Brian Jacob often made themselves
available to help me think through details, which was crucial to moving forward. I
could not have formed a better team to support my research.
It was the friendship of fellow graduate students that sustained me throughout
graduate school. I am grateful to Chris Boehm and Nitya Pandalai-Nayar. Second
year was a particularly tough time for me, but they kept me sane through their dinner
parties and the “love shack”. Prachi Jain had weekly coffee with me, allowing me
to share day-to-day joys and frustrations, plus the occasional gossip. These were
cathartic and kept me calm. Minjoon Lee was always a good neighbor to me. I thank
him for helping me work through microeconomic theory, and for being key to my
meeting my wife.The Causes of International Migration of Nurses Essay
I received excellent research assistance for my first chapter from Carlo Robert
Mercado, Katherine Peralta, Donald Bertulfo, Jan Fredrick Cruz, Samantha Coronado, Louise Oblena, Christopher Ordonez, and Ricky Guzman. My third chapter is
joint work with Caroline Theoharides, who was quick to respond, despite her busy
schedule. The Department of Economics and the Rackham Graduate School at the
University of Michigan provided generous funding and support for my research.
My interest in studying international migration comes from my own experience as
an immigrant, but also owes to Michael Clemens, who convinced me that it is a topic
worth studying. Back when I was a new immigrant to the U.S., Michael opened doors
for me by hiring me as his research assistant at the Center for Global Development.
His passion for the topic was what led me to graduate school.
My deepest thanks go to my wife, Hyejin, and my parents, Carol and Edgar. No
words can fully express how their love and encouragement has meant to me. Both my
parents sacrificed careers in the Philippines to move to the U.S. so that my siblings
and I can have better opportunities. The completion of this dissertation, in a way, is
In 2006, the World Health Organization estimated that there was a shortage
of more than 4.3 million health personnel across the world. Low-income
countries were particularly hard-hit by shortages: of the 57 countries with a
critical shortage, 36 were sub-Saharan African countries.
Because the international migration of doctors and nurses has become
increasingly visible, it is often seen as the main culprit behind these
shortages. This has led to a polarized debate between the negative aspects of
migration and the individual rights of health personnel to leave any country
including their own. In this context, policy discussions often occurred
around the issue of compensation. The work jointly carried out by the OECD
and WHO provides a detailed picture of the magnitude of health workers
migration and shows that the global health workforce crisis goes beyond the
The global economic crisis and events such as the A/H1N1 pandemic have
recently increased the pressure on health systems and health personnel, and
as a result are adding to the urgency to address the global health personnel
To tackle the health workforce crisis, there is a need to increase training
capacity, to improve retention and management of the health workforce,
to address concerns related to international migration of health workers
and better monitor these flows. Recent G8 summits in Toyako (Japan, 2008)
and L’Aquila (Italy, 2009) reiterated the need for progress in these areas
and encouraged WHO to develop a code of practice on the international
recruitment of health personnel.
This Policy Brief provides new insights on recent migration trends for doctors
and nurses up to 2008, and discusses the main causes and consequences
for destination and origin countries. It presents possible policy responses
stressing the importance of international co-operation to address the
worldwide scarcity of health workers. n
What are the
in the international
migration of health
What are the
mobility of doctors
What is the impact
of migration on less
How can countries
How to strengthen
international migration of health workers
The past decade has witnessed rapid increases in migration of health
personnel, notably in most OECD countries (OECD, 2007). Despite recent
trends showing signs of stabilisation or decline in a few countries, overall
migration of health personnel to OECD countries is still on the rise (for
updated statistics see www.oecd.org/health/workforce and OECD, 2009).
For example, in the United States, the number of overseas-educated doctors
passing Step 3 of the USMLE exam (the stepping stone to full registration to
work as a medical doctor in the United States) has increased by 70% between
2001 and 2008.The Causes of International Migration of Nurses Essay Over the same period, temporary migration of doctors has
increased two-fold in Australia and by 40% in Canada. In these two countries,
regulations on permanent migration for doctors have been relaxed and
flows have been increasing rapidly. Inflows of foreign doctors with long-term
permits have also increased markedly in Switzerland (+70% between 2001
and 2008), mainly from Germany. On the contrary, the number of new full
registrations of foreign-trained doctors has been declining in the United
Kingdom since 2003, when it peaked at about 14 000. In 2008, only just over
5 000 new registrations were recorded. This still leaves, however, the United
Kingdom as the second largest destination country for foreign-trained doctors
after the United States.
Changes in the share of foreign-trained health workers reflect the cumulative
impact of past migration flows, sometimes with a delay because of the time
taken for full registration. In most OECD countries, the share of foreigntrained doctors has been increasing in recent years. In 2008 (or the latest year
available), the percentage of foreign-trained doctors ranged from below 1% in
Poland to 39% in New Zealand (Graph 1). High percentages are also recorded
in the United Kingdom and Ireland where around a third of all doctors were
trained abroad. In Australia and the United States, this percentage was
international migration of health workers
The share of foreign-trained nurses tends to be lower than for doctors
(Graph 2). In Sweden, for example, less than 3% of nurses were foreigntrained in 2008 compared with over 18% for doctors. Similar findings apply to
most OECD countries but not in Ireland which has the second highest nursesto-doctor ratio in the OECD (5 to 1) and where about 47% of the nurses were
foreign-trained in 2008 compared with almost 36% for doctors.
That being said, migration of nurses has increased in many OECD countries
since 2000. However, in the United Kingdom and Ireland, between 2001 and
2008, new registrations of foreign-trained nurses decreased by a factor of
4 and 2.7, respectively. In the meantime, permanent migration of foreign
registered nurses to Australia increased six-fold, while it was multiplied by
three in Canada. In the United States, the number of foreign-trained nurses
passing the licensing examination has quadrupled between 2001 and 2007,
before decreasing significantly in the last two years. In Sweden, Denmark
and Switzerland, inflows of foreign-trained nurses peaked around 2003 before
decreasing significantly until 2006. Since then, growth in migration flows
seems to have resumed.
It is unlikely that the recent economic crisis will affect drastically the
international migration of health personnel. Employment in the health
sector is more resilient to a cyclical downturn than is employment in most
other sectors of activity and the demand for healthcare is certainly not
decreasing in the short-term due to the crisis. Push (i.e. reasons why people
might want to emigrate) and pull (reasons why a country might seek to
attract immigrants) factors for migration could nonetheless be affected.The Causes of International Migration of Nurses Essay
On the one hand, the deterioration of the economic conditions in countries
of origin could provide further incentives to look actively for employment
opportunities abroad. On the other hand, people who have recently left
the health workforce in OECD countries to take up other types of jobs, may
Share of foreigntrained or foreign
nurses in selected
OECD countries in 2008
(or latest year
international migration of health workers
consider returning to the health sector because of the greater job security.
In the medium-term, however, the economic crisis is putting severe strain
on public finances, which could affect the number of health workers being
trained or recruited in the future. There is little evidence that any of these
effects have been significant, at least so far.
These short- or medium-term effects should not distract attention from some
of the more structural reasons why some OECD countries rely on migration of
healthcare professionals. In particular, the ageing of the health workforce will
continue, depriving countries of cohorts of educated and experienced staff.
Demand for health services shows no sign of slackening and indeed may well
increase in line with population ageing. OECD countries will need to continue
their recent efforts to improve training and retention of staff. Migration
might help them cope with shortages in the short-term, but is not a credible
response to the longer-term trends. n
The work recently undertaken by the OECD and WHO provides some new
insights into the causes and consequences of the international mobility of
doctors and nurses (OECD, 2007; OECD, 2008). In particular, countries that
have more migration in general, and notably those which have more highly
skilled migration, tend to have more migrant health workers. In other words,
while international migration flows in recent years tend to be selective
towards the highly skilled, they are not specifically oriented towards health
Rising incomes, new medical technology, increased specialisation of health
services, and population ageing are pushing up demand for healthcare
workers in OECD countries. In response, there was a prolonged growth in
physician and nurse density in OECD countries in the 1970s and 1980s, but
the growth rates have slowed sharply since the early 1990s. Cost-containment
policies, such as control of entry into medical school, and closure of hospital
beds in the case of nurses, may explain much of the slowdown. In addition,
trends such as the growing feminisation of the physician workforce, higher
rates of part-time working and early retirement are also likely to have
reduced hours worked by the average health personnel.
By 2000, several OECD countries were reporting shortages of doctors and
nurses, at least in some parts of the country. In this context, a recourse to
recruiting professionals from abroad has been seen as an attractive option,
at least in the short-term. Part of the recent increases in migration can
thus be explained by the fact that migration was used as a “quick fix” for
unanticipated health workforce needs, whereas training extra doctors and
nurses takes many years to have an effect.
Recently, many OECD countries have made significant efforts to increase
training rates for doctors and nurses. Since 2000, the number of nursing
graduates has increased at least by 50% in Australia, France, the United
Kingdom and has doubled in Canada. In the first three previous countries,
the number of places in medical schools have doubled since the late 1990s.The Causes of International Migration of Nurses Essay
In Canada, it was increased by more than 50%. However, as it can take more
What are the
mobility of doctors
© OECD 2010 ■ 5
international migration of health workers
What is the impact
of migration on less
than ten years to fully train doctors and from 3 to 5 years to train a qualified
nurse, in most cases the effects of these policies will only be visible in a few
From the perspective of potential migrants, the push and pull factors driving
the migration of personnel broadly coincide with those that apply to highly
skilled workers in general. Despite the lack of doctors and nurses in many
developing countries, the first motivation for migration is often linked to
more and better employment opportunities abroad (encompassing salaries,
working conditions, career advancement, etc.). Wage differentials across
countries play an important role, but is not the only determinant, as other
factors such as the possibility to offer a better and safer future to their
children may also be determinant. Very often indeed, migration of health
workers will be a symptom of the difficulties faced by the health system,
and more generally the society, of the country of origin rather than its
direct cause. n
Three main findings emerge from the OECD/WHO work with regard to the
impact of health workers’ migration on origin countries. First, a significant
share of international movements is occurring between OECD countries,
even though the bulk of migration flows is originating from developing and
emerging countries. Around 2000, nurses born in the Philippines (110 000) and
doctors born in India (56 000) accounted for the bulk of the immigrant health
workforce in the OECD, but the second and third most important origin
countries were the United Kingdom and Germany. As of 2000, slightly under
40% of all migrant doctors and 30% of migrant nurses in OECD countries
originated from another OECD country.
Secondly, the outflow of health personnel from large origin countries such
as India or Russia – albeit large in absolute terms – remains low compared
with the size of their total workforce. In addition, some countries with a
percentage of their health personnel abroad manage to maintain relatively
high numbers of health workers at home. This is the case notably for
countries that train nurses for export, such as the Philippines, some
Caribbean states and, increasingly, China.
The situation is, however, quite different in the case of some smaller
countries and African countries. Countries with expatriation rates of
doctors above 50% (which means that there are as many doctors born in
these countries working in the OECD countries as there are working in
their home country) comprise small island states in the Caribbean and the
Pacific, along with five African countries: Mozambique, Angola, Sierra Leone,
United Republic of Tanzania and Liberia. Several French-speaking
African countries also have high expatriation rates, above 40%.
Thirdly, the needs for health workers in developing countries, as estimated
by WHO, largely outstrip the numbers of immigrant health workers from
those countries working in OECD countries. In 2000, all African-born
doctors and nurses working in the OECD represented no more than 12% of
the total shortage for the region, as estimated by WHO.
This report forms the overall synthesis report of a series of studies conducted by the
International Labour Office under the DFID-sponsored project on ìSkilled labour migration
(the ëbrain drainí) from developing countries: Analysis of impact and policy issues.î
International migration of skilled persons has assumed increased importance in recent years
reflecting the impact of globalisation, revival of growth in the world economy and the
explosive growth in information and communications technology. A number of developed
countries have recently liberalized their policies to some extent for the admission of highly
The problem lies in the fact that this demand is largely met by developing countries,
triggering an exodus of their skilled personnel. While some amount of mobility is obviously
necessary if developing countries are to integrate into the global economy, a large outflow of
skilled persons poses the threat of a ëbrain drainí, which can adversely impact local growth
and development. The recent UK government (DFID) White Paper on International
Development, ìEliminating World Poverty: Making Globalisation Work for the Poorî has
rightly pointed out the need on the part of developed countries to be more sensitive to the
impact of the brain drain on developing countries. It was in this context that the Department
for International Development, United Kingdom, approached the ILO for carrying out
research relevant to the above issues.
The synthesis report prepared by Professors Lowell and Findlay addresses the issues of the
impact of high skilled emigration on developing countries, and the policy mixes and options
available to both receiving and sending countries to harness its benefits. The study argues that
the feedback or indirect effects of skilled migration can often outweigh any initial negative
impacts on developing countries. The challenge is to maximize these benefits through
appropriate policies relating to encouraging return migration, retention of manpower, tapping
diaspora networks, and productive utilization of remittances. The paper highlights the role
that receiving countries can play in the process.
ILO gratefully acknowledges the financial support of the Department for International
Development, United Kingdom, for undertaking this research programme.
Mr. Piyasiri Wickramasekara, Senior Migration Specialist, International Migration Branch,
acted as the ILO Project Coordinator and technically backstopped all the studies. ILO is most
grateful to the two lead consultants, Professors Allan Findlay and Lindsay Lowell, for their
valuable contribution. The Causes of International Migration of Nurses Essay
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