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"Looking for greener pastures": Nurses and doctors on the move

The global health care profession employs an estimated 100 million people, but is not attracting enough new recruits in both developed and developing countries alike. So fierce is the competition to secure scarce health care professionals, that private recruitment agencies stage promotional events and aggressive recruitment campaigns in supplying countries. A recent ILO study examines these shortages of health care professionals and the role played by private recruitment agencies in the flows of international migration.

Article | 16 March 2006

LONDON (ILO Online) - Conrado, a highly qualified nurse from Asia, was among many who were approached by a United Kingdom (UK) based company with offices in an Asian city. Interviews by agency staff and a pre-selection test cost some £200 each. They were then told that they had to pay a further £300 for the work permit and placement fee.

Having paid a total of £700 - for which no receipts were given - they were then informed that they needed to raise one month's deposit and one month's rent for their accommodation on arrival in the UK. The nurses were not told that the National Health Services Trust has a policy of giving migrant nurses an advance payment of £500 on arrival. Nor were they told that their accommodation was in fact provided for them by the agency.

"We were all drained in terms of the finances and this was the exact timing a finance company offered a loan of £1,500 ... desperate to grab the opportunity we took the loan though we knew that almost nothing would be left from our salary and besides we're not in the position to decline the offer", explains Conrado.

When the nurses arrived in the UK they were given tenancy agreements to sign for accommodation not yet seen. After two months the nurses found that they were unable to pay for the accommodation and give themselves an adequate diet. "I lived on £5 worth of food a week, having an apple for breakfast, a snack in the canteen for lunch, and rice for dinner", he says.

"When describing the new nurse migration, observers often invoke the image of a global treasure hunt. The implication is that nurses will discover the treasure at the end of the hunt. That is not always the case, as Conrado's example shows", comments Susan Maybud, ILO Health Services Specialist and co-author of the study.

Brain drain, brain gain or brain waste?

The adequate supply of health care professionals has been a serious issue for developed countries in the last few decades. In the United States (US) a 20 per cent deficit in the registered nurse workforce has been forecasted by 2020 if current trends are not reversed. In the UK, 100,000 nurses are due to retire by 2010. Across the European Union, more than half of the physicians were aged over 45 in 2000; in Norway, the average age of dentists was 62.

Developing countries, on the other hand, struggle to produce and retain a sufficiently qualified health care workforce. Around 36 African countries do not meet targets of one doctor per 5,000 people and even in non-conflict affected countries such as Zambia and Ghana, there is only one doctor for more than 10,000 people.

Health care professionals who leave most often do not return. A nurse in Uganda would typically earn US$38 per month and a nurse in the Philippines would earn US$380, but in the United States the average monthly wage for nurses is about US$3,000.

"With the difficult situation in the African health system, I can't condemn doctors who leave to look for pastures greener... but I feel very sad for the poor people who are left behind without quality health care", comments an African doctor.

"Migration is embedded in the personal human right to freedom of movement, and the use of an individual's knowledge and skills to seek a better life. But the adverse effects that the international recruitment of health care workers have on strained health systems of poor countries raises moral concerns. The migration flows from poor to better-off countries increase worldwide inequities in health by jeopardizing the capacities of weak health systems to provide adequate health services in today's globalized labour markets", explains Susan Maybud.

"While remittances generated by migrants are welcome national income sources for poorer countries - US$1 in remittances generates US$2 in local economic activity - they do not compensate governments for their investment in the education and training of health care workers" she adds.

Regulating international recruitment

To deal with migration of health professionals, countries have set up national, regional and international commissions, proposed or implemented regulations, and even tried to enact bans limiting migration. Reports on unscrupulous private agencies raised calls for better regulation mechanisms. In many countries recruitment agencies have to register with government authorities. Legally registered agencies may accept admission fees from nurses and charge them for services, but the amounts involved are prescribed.

In India, only agencies with a license from the Ministry of Labour can execute overseas recruitment. Irish law requires that costs be borne by the employers and states clearly that deduction from wages by recruitment agencies was an illegal practice. The Companion Document of the Commonwealth Code of Practice recommends that governments enter "auditable" arrangements with recruitment agencies and set up monitoring mechanisms.

As an example of good practice, the study cites the Code of Practice for the International Recruitment of Healthcare Professionals for National Health Service (NHS) employers by the UK NHS. The Code recommends that employers only cooperate with agencies that apply the standards set out in the Code of Practice and states that developing countries should not be targeted for the recruitment of health care professionals. Currently, the Code applies to 178 agencies with an intention to extend coverage to 200 more from 2005 onwards.

Adopted in 1977, ILO Recommendation 157 tries to facilitate the harmonization of education, training and practice regulations, as well as the mutual recognition of qualifications and nursing personnel exchange programmes on the basis of bilateral and multilateral agreements for migrating nursing personnel.

"Governments are responsible for ensuring adequate workforce planning and development in the health sector; employers and recruiters are critical for implementing international recruitment according to quality standards; unions and professional associations have an important role in preventing migrant worker exploitation by disseminating information and giving support to victims of abuse", concludes Maybud.

"Care trade": The international brokering of health care professionals, by Susan Maybud and Christiane Wiskow, in: Merchants of Labour, edited by Christiane Kuptsch, International Institute for Labour Studies, ILO, Geneva, 2006.
Example taken from Anderson, B. and Rogaly B., "Forced Labour and Migration to the UK", Centre on Migration, Policy and Society, Oxford University and Trade Union Congress, 2005.