The number of international migrants on the move every year continues to increase. While they represent a steady three percent of the world’s population, their numbers have doubled in the last four decades, reaching a total of 191 million international migrants in recent years (IOM 2005, UN 2006). There is a feminization of migration flows, with women representing almost half of today’s international migrants. Patterns of migration are evolving with many more women migrating independently of partners or families (Timur 2000), thus changing family dynamics and community networks in both source and destination countries.
Today’s search for labour is a highly organized global hunt for talent and nurses are increasingly part of the migratory stream. Critical nursing shortages in industrialized countries are generating a demand that is fuelling international recruitment campaigns. At the same time, structural adjustments in the developing countries have resulted in severe workforce imbalances - shortfalls often coexisting with large numbers of unemployed health professionals.
Most of countries are dependent on foreign nurses
Available studies on the international migration of health professionals have consistently found four reasons motivating the decision to work in another country:
- learning opportunities or professional development
- professional or career advancement
- improved quality of life
- increasingly personal safety
Migration Patterns
Traditionally, international nurse migration tended to be a North-North or South-South phenomenon, e.g. German nurses working in Switzerland, Canadian nurses practicing in the US, Fijian nurses migrating to Palau. However, it is the rapid growth in international recruitment from developing countries to industrialized countries that has gained most media and policy attention in recent years (Dugger 2006, WHO 2006). The number of countries sending international nurse recruits to the UK has increased from 71 in 1990 to 95 in 2001 (Buchan and Sochalski 2004). In 2005, 84 per cent of the new entrants to the Irish nursing register were foreign-educated; a total of 60 per cent if European Union source countries are excluded (An Bord Altranais 2005).
In 2000, over 500 nurses left Ghana for employment in the industrialized countries. That was more than twice the number of new graduates from nursing programs in the country that year (Zachary 2001). In Malawi, between 1999 and 2001 over 60 per cent of the registered nurses in a single tertiary hospital (114 nurses) left for employment in other countries (Martineau et al 2002). In 2003, a hospital in Swaziland reported that 30 per cent of their 125 nurses were lost to work abroad (Kober and Van Damme 2006) and, between 1999 and 2001, Zimbabwe lost 32 per cent of their registered nurses to employment in the UK (Chikanda 2005).
The emigration of qualified employees puts the health care system at risk in the home countries
Impact of Nurse Migration
International nurse migration may be perceived as a problem or as part of the solution for source and destination countries.
Problem
International migration is fuelled by the recruitment efforts motivated by critical shortages experienced in the destination countries. Recruiting nurses from abroad however does not address the basic causative factors for the local shortage and represents merely a redistribution of shortage globally. Foreign-educated nurses must be properly oriented and integrated into the health care team if quality care is to be provided. If this is not done properly, patient safety is threatened. Society must also accept these nurses, welcoming them into their communities and facilitating their integration into social networks which may be more difficult when cultural differences are greater. The marginalisation of migrant populations has generated great concern in recent times and public monies must be allocated to address these issues.
If the nurses’ education was publicly funded in the source country, there is concern that this represents a significant loss of investment for the population and government left behind. As the majority of nurses are women and migrant populations are known to be more vulnerable, issues of gender exploitation may need to be addressed, i.e. effective prevention and protection measures must be put in place.
Solution
No discussion of nurse migration can exclude a look at the economic impact on countries from which nurses migrate. Migrant workers send money home to their families and this income is often an incentive for source countries to initiate, maintain or increase the export of their nationals. In aggregate, remittances sent through formal channels are more than twice the size of international aid flows (World Bank 2006) and estimated to be US$ 232 billion in 2005 (UN 2006). Econometric analysis and household surveys suggest that unrecorded remittances sent through informal channels may conservatively add 50 per cent (World Bank 2006).
There is evidence that remittances more than compensate for the economic losses connected with the departure of health professionals (OECD 2002), although some studies assuming permanent migration conclude the loss to the source country is more substantial (Kirigia 2006).
International migration is often seen as a strategy to promote the redistribution of global wealth. Women migrants are becoming agents of economic change as they enter the international labour market (IOM 2003). Nurse migrants are not only contributing to the generation of new wealth but may be pioneers in an informal social movement towards gender emancipation.
Filling the nursing position vacancies in the destination countries is considered a quick “fix” strategy and promotes trans-cultural exchange. With an ever increasingly diverse patient population, health systems should expect, and perhaps promote, a multi-cultural workforce.
Finally, the decision to migrate is motivated by the desire to improve an individual's quality of life. In many cases, the move will provide opportunities for professional development, the ability to practice acquired skills, improving work and living conditions, and accessing finances that will help their families.
Nurse Migration – Nurse Shortage: A Conflict?
Migration in a context of supply surplus would not be an issue. In such situations, it may even be considered a positive strategy to reduce unemployment, improve the national economy through the transfer of funds between migrant workers and their families left behind and advance health care through the global exchange of knowledge and skills. It is within a context of critical staff shortages affecting access to health care that international migration becomes a challenge that needs to be urgently addressed. Migration is increasingly recognized as a symptom of our failing health systems and not the primary disease.
Realities
International migration is an exaggeration of the larger systemic problems that make nurses leave their jobs and, at times, the health sector. The data clearly show that no matter how attractive the pull factors of the destination country, little migration takes place without substantial push factors driving people away from the source country (Kingma 2007). Which comes first – the recruitment factor or the wish to migrate?
Migration is frequently a decision individuals make because of the constraints experienced in the workplace or the broader society.
Nurse migration is pushed, pulled and shaped by a constellation of social forces and determined by a series of choices made by a multitude of stakeholders. International mobility is a reality in a globalized world, one that will not be regulated out of existence. It becomes an issue only in the context of shortages or migrant exploitation and abuse (Kingma 2006). If South-North migration is to be reduced, the need to migrate must be addressed rather than artificially curb the flows.
Literature / Links:
An Bord Altranais: Registration Information 2005. www.nursingboard.ie
Buchan, James / Sochalski, Julie (2004): Nurse migration: Trends and the Policy Context. (Unpublished manuscript)
Chikanda, Abel (2005): Nurse migration from Zimbabwe: analysis of recent trends and implications, Nurse Inquiry 12(3), pp. 162-174.
Dugger, Celia (2006): U.S. Plan to Lure Nurses May Hurt Poor Nations. New York Times. May 24.
International Organization for Migration (2003): World Migration 2003 - Managing Migration – Challenges and Responses for People on the Move, Geneva.
International Organization for Migration (2005): World Migration 2005 - Costs and Benefits of International Migration, Geneva.
Kingma, Mireille (2006): Nurses on the Move: Migration and the Global Health Care Economy, Ithaca.
Kingma, Mireille (2007): Nurses on the Move: A Global Overview. Health Services Research 42(3): pp. 1281-1298.
Kirigia, Joses / Gbary, Akpa / Muthuri, Lenity / Nyoni, Jennifer and Seddoh, Anthony (2006): The cost of health professionals brain drain in Kenya. BMC Health Services Research, vol. 6, p. 89. www.biomedcentral.com/1472-6963/6/89/abstract
Kober, K / Van Damme, Wim (2006): Public sector nurses in Swaziland: can the downturn be reversed? Human Resources for Health, vol. 4, p. 13. www.human-resources-health.com/content/4/1/13
Martineau, Tim / Decker, Karola and Bundred, Peter (2002): Briefing note on international migration of health professionals: leveling the playing field for developing country health systems. Liverpool.
OECD (2002): International Migration of Physicians and Nurses: Causes, Consequences and Health Policy Implications, Paris.
Timur, Serim (2000): Changing Trends and major issues in international migration: An overview of the UNESCO programmes, International Migration 165, pp. 255-269, Center for Migration Studies, New York.
UN (2006): International migration facts and figures, New York
http://www.un.org/esa/population/migration/hld/Text/Migration_factsheet.pdf
World Health Organization (2006): The world health report 2006 – Working together for health, Geneva.
World Bank (2006) Global Economic Prospects: Overview and Global Outlook. Washington DC: The International Bank for Reconstruction and Development/The World Bank.
Zachary, Gary (2001): Call them the ghost wards. Wall Street Journal January 24.
State: January 2010
