Policy responses to migration of health workers: Retention, return and circulation

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Policy responses to migration of health workers
Retention, return and circulation

• Presentation
• Parallel Session VI. Return Migration Obstacles
  
• and Possible Solutions
• International Conference A Call To Action
  Ensuring Global Human Resources for Health-
  International Health Workforce Migration
• Geneva, 22-23 March 2007
• By
• Piyasiri WickramasekaraSenior Migration
  SpecialistInternational Labour Office
• Geneva
• Email wickramasekara_at_ilo.org
• ILO Migration Website http//www.ilo.org/migrant

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Structure of the presentation

• Key messages
• Challenges of health worker migration
• Policy options and good practice
• Retention
• Return
• Circulation
• Issues

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Key Messages

• Mobility and circulation are better concepts in a
  context of globalization than migration.
• Health worker migration and human resource crisis
  in health are now international issues.
• Retention, return and circulation of skills are
  not mutually exclusive options for developing
  countries.
• Circulation offers considerable promise.
• Respect for migrant rights is essential for
  ensuring and sharing benefits from migration.

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International focus on HW migration

• Global Health Workforce Alliance (GHWA)
• WHO - World Health Assembly 2004, 2005
• International Council of Nurses Global Nursing
  Review Initiative
• Commonwealth Secretariat code of practice on
  recruitment of health workers
• Trade union movement Public Service
  International (PSI)-UNISON- project on health
  worker migration
• Global Commission on International Migration
• UN High Level Dialogue on International Migration
  and Development
• World Bank programmes on the health sector
  workforce
• European Commission Communication (2005 (642)
• EU strategy for action on the crisis in human
  resources for health in developing countries
• Ethical Globalization Initiative
• Many other important initiatives by other
  agencies, civil society.

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Challenges in health worker migration

• Uneven distribution of human resources
• Quality of health services declining when needs
  are increasing 57 countries with critical
  shortages
• Countries with the lowest relative need have the
  highest numbers of health workers WHO
• Difficulty of achieving millennium development
  goals
• Fiscal burden on source countries in losing
  investments in human resources.
• Health workers in destination countries Rights
  and protection problems.
• Few feedback effects to source countries a
  vicious circle?

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Countries with critical shortages of health
service providers (WHO)
Source WHO-World Health Report 2006
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Estimated critical shortages of doctors, nurses
and midwives, by WHO region
Source WHO-World Health Report 2006
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Are there grounds for assuming medical
exceptionalism (JLI)?

• Related to right to life health workers save
  lives.
• As a matter of life and death, policies to
  address medical migration should adopt medical
  exceptionalism based on moral and ethical
  grounds (Alkire Chen, JLI).
• Human capital formation longer gestation period
  compared to IT sector.
• Mostly at public cost in developing countries
• Health workers generally need to be on site to
  provide services
• Outsourcing difficult

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Is medical migration a vicious circle compared to
knowledge worker migration?

• Virtuous circle
• (Knowledge IT workers from India, China)
• Students and unemployed often migrate.
• Return in medium/longer term term with skills,
  capital (financial and social)
• Generate exports and promote outsourcing
• High circulation and mobility
• Good supply response of qualified persons
  (private sector)

• Vicious circle
• (Health workers from Africa, Asia)
• Employed professionals with experience migrate
  (doctors, nurses)
• Few returns or returning for retirement
• Few productive linkages and declining remittances
• Limited networking
• Limited circulation
• Replacement of experienced persons costly, long
  and difficult

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Common policy measuresDestination countries

• Work force planning and investment to achieve
  self-sufficiency
• Ethical recruitment practices- Codes of practice
  Identify at-risk countries
• Protecting rights of health workers ratify
  relevant Conventions
• Targeted aid to develop health human resources
• Circulation-friendly policies to encourage
  temporary stays and diaspora mobilisation
• Bilateral agreements with source countries

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Common policy measures Source countries

• Human resource planning
• Improvement of working environment conditions
• Conducive macroeconomic policies
• Incentives
• to retain and return
• To work in rural areas
• Train new types of service providers
• Mobilise diaspora
• Bilateral agreements and exchange programmes

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Retention strategies

• Described as the best strategy in the long run
• High economic growth and creation of opportunties
  at home (necessary but not sufficient Canadian
  brain drain to USA)
• Overall conducive environment research, science
  and technology policy
• Higher educational/research opportunities at home
• Political stability, democracy, good governance
  and respect for human rights
• A vicious circle??

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Return migration

• Popular policy option reversing brain drain.
• Right of return to home country recognized in
  international instruments
• Data problem no monitoring of return or
  circulation
• Different types of return with different
  implications
• Limitations of return strategy

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Typology of return migration

• Time pattern of return
• occasional returns, seasonal returns, temporary
  returns and permanent returns (Russel King)
• Motives of return (Cerase)
• Retirement, Failure, Conservatism, Innovation
• Sequencing/timing of return
• Immediate, medium, and long term
• Method of return
• Assisted or organized return voluntary or
  spontaneous return (IOM/UN programmes-RQAN
  (Return of Qualified African Nationals)

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Why Filipino Nurses Return?

• Personal Reasons
• To get married To raise children in homeland on
  vacation Homesickness and depression To retire
• Professional Reasons
• To share expertise For professional stability
• Financial Reasons
• Made enough money set up a business at home
• Job-related and social reasons
• Contract has expired To buy a house or a car
  Plans to retire back home
• Source Lorenzo- Bellagio conference
  presentation, 2006

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Return of doctors from UK to India

• Estimated 5,000 Indian doctors have returned home
  from the U.K. between April 2006 Feb. 2007
  according to the British Association of
  Physicians of Indian Origin.
• Reasons recent changes in immigration rules
  Preference for new EU accession counties over
  non-EU countries.

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Summing up on return migration

• Limited data on health worker returns
• Overall benefits not clear depends on the type
  of return and home conditions
• May lead to lower volume of remittances
• Problems with assisted or special returns
• equity, cost effectiveness and sustainability

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Case for mobility and circulation

• Right to leave a home country and the right to
  return are fundamental human rights
• Important because few developing countries can
  create conditions conducive to return and
  retention in the short and medium term vicious
  circle
• Return is a static concept while mobility and
  circulation are better able to capture dynamics
  of current migration multilateral movements..
• Circulation implies two way flows of benefits or
  situation conducive to 2-way flows
• Access to skills remittances greater labour
  market efficiency and welfare gains promotes
  investment in human capital in source countries.

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Models of circulation

• Globalization has made circulation much easier
  with lower transport and comm. costs.
• Internal migration major example of circular
  migration China 100 million workers on the move
• Temporary Skill migration models US H1B,
  Cultural exchange J visa German Green card
  model UK work and training model
• General Agreement on Trade and Services Mode 4-
  Movement of natural persons
• Virtual circulation through exchange of idea,
  expertise
• Migration carousel- Replenishment of lost skills
  of one country by third countries Canada,
  Australia, New Zealand, South Africa

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Principal axes of international mobility of
health professionals (by country of birth)
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ILO work on health workers

• The 1977 Nursing Personnel Convention (C.149)
  Recommendation (R. 157)
• Concerned about insufficient supply, ineffective
  deployment and the worrying situation of nursing
  personnel
• ILO review on labour and social issues of health
  worker migration- 2003
• ILO on international reference group of ICN
  global nursing shortage review
• Action Programme on the International Migration
  of Health Service Workers the Supply Side (with
  IOM and WHO)
• 2004 International Labour conference Resolution
  on migrant workers and the ILO Multilateral
  Framework on Labour Migration 2006

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ILO Multilateral framework on labour migration

• Objectives
• Better management of migration protection of
  workers and promoting development linkages
• A framework of nonbinding guidelines and
  principles to serve as a tool kit for guiding
  migration policies in countries.
• Relevant Guidelines
• 15.7. adopting measures to mitigate the loss of
  workers with critical skills,including by
  establishing guidelines for ethical recruitment
• 15.8. adopting policies to encourage circular and
  return migration and reintegration into the
  country of origin, including by promoting
  temporary labour migration schemes and
  circulation-friendly visa policies

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Good practices in promoting brain gain
circulation Checklist of Dos
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Checklist of Donts
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Good practice example UK-South Africa MOU

• South Africa-United Kingdom Memorandum of
  Understanding(MOU) on Reciprocal Educational
  Exchange of Healthcare Personnel between the
  United Kingdom and South Africa 2003
• Provisions
• provides for the reciprocal exchange of skills
  and knowledge.
• promotes the recognition of the qualifications of
  South African health professionals
• enables them to work for a specified period in
  organizations providing National Health Services
  in the United Kingdom.
• Provides for return to South Africa with newly
  acquired skills and experience.
• No recent information on operation of the
  programme

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Good practice? Medical tourism

• Low cost medical services in developing countries
  to attract foreign clients growing industry
  Thailand 28 of skilled persons in the sector
• Philippines launched medical tourism as a
  flagship program of the DOH in January 2006 as a
  major retention strategy
• The Department of Foreign Affairs (Philippines)
  has commissioned the design of three business
  models for health
• creation of an international zone of health for
  health and wellness combining medical tourism,
  spa health, eco-tourism and retirement villages
• health human resources development network with
  the top nursing and medical schools/hospitals in
  the Philippines as investment areas
• health crewing (mobilising?) for specific health
  services, including tele-health, medical
  transcriptions.