# Session Overview According to some predictions, by 2030, the global demand for health workers will rise to 80 million workers, representing a doubling since 2013. It is further predicted that the future supply of health workers will not meet the demand; estimates suggest that 65 million health care workers will be available by 2030, indicating a global shortage of almost 15 million health workers (Liu et al., 2017) This shortage of health workers is not evenly distributed across the world, and therefore results in the global movement of health workers between countries due to pull and push factors. We will discuss healthcare worker migration in this session, in the context of trade and its economic perspectives. You will be introduced to the types, causes, processes and economic and health-related outcomes of global health worker migration. We will also consider the associated benefits and consequences, and refer to policy interventions targeting migration of healthcare workers. ## Learning outcomes By the end of this session you should be able to: · Describe the key factors leading to migration, for skilled health workers in particular. · Present historical data illustrating global health worker migration as the key means by which health and trade are linked. · Discuss the issues and concerns surrounding global health workforce migration trends, with particular reference to impacts on national health and health systems. · Summarise the key economic models/ frameworks used to analyse migration decisions. · Identify the economic factors which influence health worker migration decisions. · Assess economic policies intended to influence health workforce migration. · Appraise the strengths and weaknesses of the body of knowledge on this topic. # 1. Introduction According to WHO’s Global Health Workforce Alliance, 2.28 professional health workers (doctors, nurses, midwives only) per 1000 people are needed to cover essential health services (WHO, 2013). This type of measure is termed a needs-based measure, as it estimates health care workers needed based on the adequate provision of essential health service functions. At this health worker density threshold, falling below 80% coverage (considered a minimum standard) of essential health interventions, such as skilled birth attendants and measles immunisation, is very unlikely. The WHO report states that there are 6.9 million and 4.2 million needs-based shortage of health workers in South-East Asia and Africa respectively. The global needs-based shortage of health workers is predicted to be more than 14 million by 2030 (representing only 17 percent decline from 2013) (WHO, 2017). One of the primary drivers of health worker shortages, in crisis-hit countries, is loss due to international health worker migration. The impact of health worker shortages is felt in the availability and standard of healthcare. The required level and mix of specialized skills to administer good health care implies a need not only for large numbers of trained health workers, but also for a balance among different health worker types, in order to achieve better health outcomes (WHO, 2017). This can be illustrated, in part, by the example of countries with increased HIV prevalence. These countries are typically associated with lower physician, nurse and pharmacist densities. Concerns have been raised on the aggressive recruitment of healthcare staff by developed countries with ageing populations. "Ethical" codes of recruitment, often voluntary in terms of adoption, are yet to produce much impact (WHO, 2010). Issues are raised on trade agreements (e.g. WTO GATS (Mode 4 – Movement of natural persons), liberalisation of labour markets (e.g. EU/EEA or ASEAN/AFAS) and selective immigration policies, which often fortify individual rights to migrate and are usually founded in law. ==The success of the various options for codes of practice in training and recruitment depends on active adherence and enforcement, but also sustained, complementary action to address the causes of health worker shortages and movement.== Policies designed to affect the production or retention of new health workers take time and resources to implement, with results unlikely to be visible for several years. In the short-term, to address the effects of international migration of health care workers, the development of planning and coping strategies is required. The long-term challenges are to develop and implement policies that address the root causes of dissatisfaction and attrition amongst health workers (Allutis et al., 2014). In this session, ==our focus is on a form of international trade which is related to the provision of health services==. We are concerned with the international movement of economic agents who are central to healthcare provision: they are the global health professional workforce. It is important to mention here the related issue of internal migration, which is facing national policymakers. This type of migration, usually from rural to urban areas, can represent internal imbalances in the distribution of health workers, with skilled staff increasingly concentrated in urban areas, even when populations are predominantly rural. In many cases, parallels can be drawn between policies targeting international migration and incentives intended to redistribute healthcare workers towards rural or remote areas. In line with the global focus of this module, we will emphasise international migration in the following discussion. In the next section we will look at global trends in skilled health worker migration, in order to develop a sense of the scale of the issue. # 2. Global trends in skilled health worker migration Disproportionate loss of skilled workers from a country is often called “brain drain”, this reflects the idea that there is a loss of educated workers from a country (Cometto et al., 2013). There are various factors that facilitate this flow. Specifically, highly educated and skilled professionals are given immigration priority into recipient countries – note that this category usually includes health providers. If we focus on skilled health worker migration, we find that sector-specific data are even more scarce, but what data does exist reflects the overall trends. Historically there have been large and increasing flows from Asia, Africa and to a lesser extent the Caribbean and South America, towards North America and Europe. In 1978, the first WHO-sponsored study on health care workers found that developing countries had 67% of the world’s population, but only 26% of the world’s stock of physicians. Almost three-quarters of migrant physicians resided in just three countries: the USA, the UK and Canada. The ageing populations of developed countries have increasingly relied on immigrant health workers to supplement locally trained workers. Ageing populations result in increased need for health care workers as there is increased need for health care with older age to address accompanying health conditions. ## Contributing factors to health worker migration trend Positive outcomes sought from such migration: 1. Incentives to migrate to higher income countries may be strong, e.g., higher income, assured job security, and improved quality of life, better opportunities and environments for their children, more job satisfaction or training opportunities 2. Health workers might seek to be in a position to send substantial financial remittances to relatives and friends back home, or to invest in business and infrastructure in their home country. These financial flows can be enormous and even constitute a large proportion of a developing country's income The World Bank figures show that total remittances by skilled workers reached 530 billion US dollars in 2018. ![[Remittance flows to low- and middle-income countries, official development assistance, and private capital flows, 1990–2018.png]] Figure 2 compares remittance flow with FDI, ODA and portfolio debt and equity flows. A [[Foreign Direct Investment (FDI)]] is an investment made by a firm or individual in one country into business interests located in another country. Generally, FDI takes place when an investor establishes foreign business operations or acquires foreign business assets in a foreign company. Equity flows comprise foreign direct investment (FDI) and portfolio equity. Debt flows are financing raised through bond issuance, bank lending, and supplier credits. Official development assistance (ODA) is a term coined by the Development Assistance Committee (DAC) of the Organisation for Economic Cooperation and Development ([[OECD]]) to measure foreign aid. It is used as an indicator of international aid flow which includes some loans. A further benefit is that of national capacity building. Return migrants and diasporas (migrant networks abroad), could enhance knowledge and innovation transfer particularly to low and middle income countries and can strengthen international trade links and exports thus also benefiting high income countries. Finally, the benefits to receiving countries should not be ignored. The availability of skilled immigrant health workers saves these countries both time and money in training local health workers. Immigrants may also be more willing to work in areas which are currently under-served, because the local health workers consider them less desirable. An example of this would be in the USA where ==foreign-trained doctors have easier access to the labour market if they opt to work in the rural and underserved areas of the country==. All of these outcomes help to explain why migration takes place and how migration can benefit both sending and receiving countries, as well as the migrants themselves. ## 2.1 Activity 1 Watch the following video, ‘Why the US has so many Filipino nurses’. This video runs for 11 minutes and is produced by Vox Media. This is uploaded on YouTube on 29 June 2020. Please note there is one image which some viewers may find disturbing. This is on the 55th second. https://www.youtube.com/watch?v=yw8a8n7ZAZg Provide two pull factors and two push factors why there are many Filipino nurses in the US. Highlight three historical developments that led to this substantial migration of nurses. Write your response in the Moodle. # 3. Issues specific to the health sector Why production of health is important to society from an economic perspective and why health is different to other types of goods and services which are produced? Health is a unique good. It complements ability and knowledge in an individual and permits the functional use of such “human capital”. In this way, health is very important for its multiplier effects on productivity in the economy. Recognising this, society, or the state, invests in and subsidises health worker training with the ultimate aim of producing good health in the population and hence, increased productivity. However, the expectations and rights of society, or the state, with respect to health provision as a return on investment in health worker education, do not necessarily coincide with health workers’ own individual rights and expectations, including their freedom of movement. Health economists refer to the results of these tensions between public and private interests, and the social effects of individual decisions, as “externalities”. An externality is a cost or benefit caused by a producer that is not financially incurred or received by that producer. An externality can be both positive or negative and can stem from either the production or consumption of a good or service. You will learn more about how health, and access to health, can be public goods in some types of health care systems, in a later session of this module. We now consider the reasons that health workers are so important to effective health systems and the production of health (McPake et al., 2013). As we saw earlier in the session, it has been demonstrated that health worker density, that is, ==the number of health workers per 1,000 head of population, is associated with the delivery of health coverage and the achievement of desirable health outcomes==, including the health-related Sustainable Development Goals (SDGs). The WHO has determined a threshold: ==a minimum health worker density of 2.3 doctors, nurses and midwives per 1,000 people. This health worker density is the minimum required to deliver adequate coverage (set at 80%) of essential health interventions, such as skilled birth attendance.== Finally, in this section, we reflect on what makes health workers different to other types of skilled worker. One aspect is the availability of training - there are few accredited training sites. For example, several countries do not have their own medical schools. Health professionals must undergo lengthy training, commonly requiring special equipment and access to health facilities. This training is usually heavily subsidised by the state, but free for the individual receiving the training. On the other hand, there is often the possibility of bonding or compulsory public service, which commits the individual to providing state-sponsored healthcare following the completion of their training, and aspects relating to retention of health care workers are explored in more detail in the elective module GHM201 Health Systems. Healthcare skills can be easily transferred to other settings and they are valuable and required in almost every setting. Specialist health skills are complementary, which means that a successful health-giving team comprises several different cadres and members. Most countries have a transparent conversion and recognition infrastructure for foreign qualifications in healthcare, easing employment for immigrant workers. Most countries also give formal immigration priority to health workers, since their high level of skill is recognised. Local health professional bodies are generally well organised, highly vocal and influential. There are clear knock-on effects on the education of future health professionals in the sending country, when future potential teachers are lost through international migration. # 4. Economic models of skilled migration ![[Complexity of health worker migration.png]] The essential elements of demand and supply as for any labour market, but there are several aspects which are unique to health, and it is useful to think about these in this context. First, we will consider labour demand. Skilled health labour demand is derived from the demand for healthcare, modulated by the financial constraints on the healthcare system, namely health budgets. Secondly, and perhaps more complex with respect to health labour markets, we will consider aspects of labour supply. Skilled health labour supply is determined by elements such as: - labour market participation; - training capacity, costs and returns to education; - labour market exit, which includes people who stop working due to international migration and death. We will now examine these determinants of skilled labour supply in more detail. We will use the human capital model to explain the level of investment in education by individuals, which, in turn, predicts the proportion of skilled workers in the total population. In the human capital model, individuals are initially endowed with certain human capital stocks: namely ability and knowledge. These factors respond to and increase with education. Higher skills (ability) increase productivity and so more highly trained individuals are rewarded with higher returns. These returns can take various forms, the most obvious being higher wages, but they can also be non-financial returns, such as job satisfaction or status. Therefore, individuals may have incentives to increase their years of education and training, in order to earn correspondingly higher returns, depending on their ability and associated costs of training. In understanding the dynamics of the health workers labour market, we have to consider a number of elements as presented in Figure 4. Based on the framework of analysis of health workers labor market dynamics, we can see that the performance of the health systems depends on the many dimensions of the health workforce, including the input from migrant health workers (McPake et al., 2013). ![[Dynamics of health workers labour market.png]] We now consider the impact on health labour markets of introducing selective migration. If we assume that there are higher returns, that is, wages, available abroad; and if we assume that higher skill, obtained via additional education, is associated with a higher probability of migration, then, a simple “brain drain” model can show that there will be an overall negative effect from skilled migration for populations and society in the source country. This is because individual financial gain is held more important (by the individual migrating) than social welfare and more people migrate than is socially optimal (in terms of health of the population) for the source country (Cometto et al., 2013). In other words, we can predict classic negative outcomes of a “brain drain” for the home country, such as: - lost skills and productivity; - lost investment in education; - lost productivity from future generations; - lost future investment in the economy. There are some fundamental assumptions involved in the application of these human capital models, and we now consider further whether these may over-simplify the situation. Some economic models consider the possibility of overall net gains to the home country, by incorporating some of the positive consequences of migration, such as: - return migration, also known as “brain circulation”; - financial remittances from overseas migrants; Such “brain gain” models can demonstrate how the positive effects of human capital formation can outweigh the negative “brain drain” effects, under certain conditions. These conditions include the following aspects: 1. the possibility of migration must increase expected returns to education, such that the total number of educated individuals also increases. 2. If there is an ineffective screening of migrants in the receiving country, a sufficient number of educated individuals will remain in their home country and do not migrate. 3. education must be associated with positive externalities towards other workers and/or future generations. (Positive externality is when the consumption of a good or service benefits a third party not directly involved in the market transaction. In this example, education directly benefits the individual and also provides benefits to the others or the society as a whole.) # 5. Factors affecting health worker migration decisions The next part of this session focuses on the factors affecting individual health worker migration decisions. Motivation studies show that health professionals value both financial and non-financial incentives. Higher income is important, but it is not the only motivator. Although there are commonly held expectations that health workers display higher than average levels of altruism, or selflessness, it is not clear whether these expectations are supported. There appears to be reluctance amongst health workers to work in more rural or remote areas. This compounds health worker shortages by leading to imbalances in the skill mix and distribution of health workers within a country (Labonté et al., 2015). Studies have dentified major motivational themes that are important to health workers in their jobs (Aluttis et al., 2014; Castro-Palaganas et al., 2017; Cometto et al., 2013; Labonté et al., 2015): - financial reward and remuneration; - career development; - continuing professional education; - health facility infrastructure; - resource availability; - relationship with management; - personal recognition and status. Having considered the factors that influence job satisfaction among health workers in general, we will now think about the additional factors that influence migration among this group of workers. It is common to group the wider economic, social, professional, political/legal and personal factors which encourage individual migration into factors present in the home country - “push factors”; and factors characteristic of the receiving country - “pull factors”. The push-pull framework can also be extended to include “retain” factors in the home country and “deter” factors in the receiving country. Push factors can include low pay, poor working conditions, unemployment, under-resourced work environments, limited educational opportunities, economic instability, or even war in the home country. Pull factors can include higher pay, better working conditions and career opportunities, better resources for the health system, a higher standard of living, economic stability and peace in the receiving country. ## 5.1 Activity 2 Give an example of a destination country for health workers. Discuss why this is a favoured country. Try to identify a country where many health workers migrate for work. Explain three pull factors, provide a short explanation for each and post your response in the Moodle. # 6. Policies targeting migration of health workers There are unilateral codes, such as the UK’s Code of Practice (CoP) for the International Recruitment of Healthcare Professionals. The CoP, represents a good example of the factors to consider (since UK is a favoured destination country), is updated regularly has the following Guiding Principles (NHS UK, 2019): - International recruitment is a sound and legitimate contribution to the development of the healthcare workforce. - Extensive opportunities exist for individuals in terms of training and education and the enhancement of clinical practice. - Developing countries will not be targeted for recruitment, unless there is an explicit government-to-government agreement with the UK to support recruitment activities. - International healthcare professionals will have a level of knowledge and proficiency comparable to that expected of an individual trained in the UK. - International healthcare professionals will demonstrate a level of English language proficiency consistent with safe and skilled communication with patients, clients, carers and colleagues. - International healthcare professionals legally recruited from overseas to work in the UK are protected by relevant UK employment law in the same way as all other employees. - International healthcare professionals will have equitable support and access to further education and training and continuing professional development as all other employees. There are also bilateral, or intergovernmental, codes and agreements, in addition to multilateral codes, the most important of the latter being, perhaps, the 2003 Commonwealth Code of Practice for the International Recruitment of Health Workers and the 2010 WHO Global Code of Practice on the International Recruitment of Health Personnel. These codes are based on voluntary agreements, and the aim of the WHO code is given in the quote below. > “The Code aims to establish and promote voluntary principles and practices for the ethical international recruitment of health personnel and to facilitate the strengthening of health systems. Member States should discourage active recruitment of health personnel from developing countries facing critical shortages of health workers. The Code was designed by Member States to serve as a continuous and dynamic framework for global dialogue and cooperation.” — (WHO, 2010) The underlying principle behind the code is that both health systems of the sending and destinationa countries should benefit from the international movement of healthcare workers. Policies that have been suggested for countries losing health workers to migration include: - improving recruitment and retention of existing health workers; - introducing or strengthening bonding and compulsory public service - schemes; - scaling up training capacity; - creating appropriate mid-level health cadres with unique qualifications; - increasing task-shifting; - increasing recruitment capacity; - ring-fencing and decentralising health spending; - raising the status and influence of health workers, addressing gender - issues; - encouraging and supporting return migration. # 7. Knowledge gaps In discussing the economic perspective of international and national migration of health workers in this session we have identified various knowledge gaps. These relate to data, research and policy evaluation. There is a need for better stock and flow migration data, especially in low and middle income countries, in order to improve our understanding of the nature and magnitude of the issue. Research into migration factors is generally lacking for health workers other than physicians. A better understanding of health worker job preferences and their reasons for dissatisfaction and migration is required to address some of the negative impacts. It is not yet clear which potential policies might be effective in influencing migration and return of health workers. Other important issues for researchers and policy makers involved in health workforce planning include: - rural-urban migration, and its impact on healthcare in rural communities; - monitoring and enforcement of international ethical codes of recruitment, including that of the WHO, which is the widest-reaching; - increasing density and complexity of world trade and its interaction with health issues - the core concern of this module. ## 7.1 Integrating activity Provide three major learnings from this session. Discuss each learning in 2-3 sentences. These learnings can be on any aspect of the topic of the session. It would be good if you are able to link some of these learnings and come up with a concluding statement. Write your response in the Moodle. # 8. Summary Health worker shortages and migration flows are high both in absolute terms and relative to other workers. Health worker migration is associated with negative consequences throughout the source country's economy, via losses in education investment, health provision, productivity of other workers, and education of future health professionals. Lower income countries, with already fragile health systems, are likely to suffer the worst effects of health worker migration. Economic models of migration suggest that individual incentives to migrate can outweigh social preferences - this is known as "[[brain drain]]". However, it is possible that education policy, remittances and return migration could be harnessed to drive net benefits back to source countries and result in a "[[brain gain]]". Factors affecting individual health worker migration decisions include financial, family, social, education, job-related, legal, cultural, health and civil issues. These can be categorised into "push factors" present in the source country and "pull factors" attracting workers to the receiving country. Few policies attempting to target migration specifically by health workers have been implemented. Legal enforcement and formal monitoring and evaluation of migration policies and voluntary codes are also lacking. More data are urgently needed about all aspects of health worker migration, including migration stocks and flows, health worker preferences and the effects of migration policy interventions. Increasing globalisation, the interaction of trade and health, and local imbalances in health worker distribution are also critical issues for health workforce planning going forward. # 9. References ## 9.1 [[Essential readings]] [[@aluttisWorkforceHealthGlobalized2014]] [[@comettoHealthWorkforceBrain2013]] [[@mcpakeWhyHealthLabour2013]] ## 9.2 [[Recommended reading]]