Healthcare labour market in the emerging market economies:
A literature review
Manisha Nair
Premila Webster
Abstract
Background:Currently there is an increased demand for human resources which has led to the growth of the healthcare labour market. The emerging market economies (EME), such as India and Philippines are the major exporters of health professionals to the industrialised countries such as UK, US, Canada and Australia. The aim of this study is to identify the issues related to the healthcare labour market and find evidence of successful national and international measures to address these issues.
Methodology: Review of published literature of last 10 years.
Results:The major issues of the healthcare labour market are – migration and shortage of health workers. Several innovative approaches have been used in EME to control migration and address the shortage of health professionals.
Acknowledgements
We are grateful to Professor Harold Jaffe, Dr Kenneth Fleming and Mr. Ian Scott for their invaluable insights and guidance during this literature review.
Table of contents
Background...... 1
Methodology...... 1
Results...... 1
1. Patterns of migration...... 2
2. Reasons for migration...... 3
a. Employment opportunities...... 4
b. Wages and work environment...... 4
3. Role of medical education in migration of health professionals...... 4
4. Growing demands in high income countries...... 4
5. Favourable country policies on financial remittances by migrant workers...... 5
6. Shortage of healthcare workers...... 5
Arguments in favour of health workforce migration...... 6
Possible solutions...... 6
Conclusion...... 7
Appendix-1...... 8
Appendix-2...... 9
References...... 12
1
Background
The global healthcare labour market comprises of 59.2 million health workers [3]. The biggest supplier of physicians to the world is India [4-6] and Philippines is the largest supplier of nurses [5, 7]. Other major exporters among the emerging market economies(EME) are China, Mexico, Malaysia, Colombia, Egypt and Pakistan [5, 7-11]. The largest importers are New Zealand, USA, UK, Canada and Australia [5, 7]. Hagoplan et al. ([12]) showed that more than 770,000 (approximately 23%) doctors licensed to work in the USA in 2002 were imported from other countries. Poland, South Africa and Chile export as well as import nurses from the global healthcare labour market [13].
The labour market tries to reach equilibrium by balancing the demand and supply which mainly occurs through migration of health workers [1, 2].
The aims of this literature review are to:
(i)identify issues related to the healthcare labour market in the EME
(ii)find evidence of successful national and international measures to address these issues.
Methodology
This review is through a systematic search of literature published in last ten years. Studies and reviews that focus exclusively on healthcare labour markets are included. Though the aim of the study is to review the healthcare labour market in EME, a few examples have been drawn from studies conducted in high-income and low-income countries as research conducted in EME are limited. Studies conducted in these countries also contribute to gain an understanding of the factors that ‘pull’ health professionals to high-income countries
Results
There is a dearth of good quality research on healthcare labour market, especially in the EME[14]. The existing research publications and reviews indicate two major issues related to the healthcare labour market – (i) migration and (ii) shortage of health workers. In the context of these issues it is important to understand the patterns of migration and its causes, and the impacts of health worker shortage.
1. Patterns of migration
Migration of heath workers both within country and across borders is a well recognised problem in the health care sector in both developing and developed countries. A study undertaken in 1972 by WHO showed that about 6% of the doctors and 5% of the nurses were living outside their home countries[15]. Pacific island and Sub Saharan Africa (SSA) have the highest rates of migration (about 13%), followed by Latin America and Caribbean islands (about 11%) and the Middle East and North Africa (about 10%) [3].
The direction of movement of health professionals within countries is from rural to urban [3]and from public sectors to private and Non-Governmental Organisations (NGO) [16], and across countries is south to north [3, 15, 17]. However globalisation has made “brain drain” multi-directional instead of unilateral and the term “brain circulation” appears to replace “brain drain” [3]. For example many health professionals from Canada migrate to the US and the vacancies left behind in Canada are filled by health professionals from India, Philippines, South Africa and other low and middle income countries [3].
Another form of “brain drain” is the “internal brain drain” which causes the health workers to move from public sectors to private sectors, NGOs and to research within the same country [18, 19]. NGOs and humanitarian agencies mostly implement vertical programmes that require high intensity and accelerated performance. Human resource and time are the major determinants for their success. Hence they often adopt shortcuts by hiring efficient health workers from the public health system through generous remuneration [16, 18]. Studies have shown that more than 80% of nurses in SSA have left their government jobs to join NGOs and the private sector [18], further weakening the health system already devastated by HIV/AIDS [3, 16].
In recent years a new pattern of migration is becoming prevalent. In Philippines many doctors are re-training as nurses owing to the high international demand for nurses [20] and in China local doctors who are unable to compete in the growing market for physicians trained abroad are shifting to research and jobs in the pharmaceutical companies [21, 22].
Migration not only has implications on health but also on the economy of the source country [3]. Countries spend a vast amount of money to train their doctors and nurses and often the brightest migrate, and subsequently to fill the gaps left behind, these countries hire consultants from high-income countries [3]. It is estimated that low income countries lose approximately US$500 million annually [12]. On the other hand recipient countries profit because by hiring personnel trained abroad, they do not invest on training these health professionals (known as free-riding) [12]. While Ghana lost more than $US60 million in about 50 years by exporting health workers, UK had saved about £103 million in training health workers over the same period by importing from Ghana [23].
2. Reasons for migration
Migration is an “individual, spontaneous and voluntary act that is motivated by the perceived net gain of migrating”[2]. However it may not be always favourable as many immigrants are underutilised in the recipient country leading to “brain waste” [24]. Studies conducted in several EME such as India, Philippines, Pakistan, Peru and South Africa identified a number of “push and pull” factors for migration of health professionals [12, 25-27].
Push and pull factors
The most common factors prevalent for more than sixty years that potentiate migration have been described as the external “pull” and the internal “push” factors (table-1) [6, 28, 29]. These factors have become even more powerful in the backdrop of globalisation and free market economy [6].
Table 1: Push and pull factors
Push factors / Pull factors- Low employment opportunities [15, 28]
- High employment opportunities due to shortage of health staff in the destination countries [15, 17, 30]
- Low wages [3, 16] and poor work environment in home country [3, 15, 17]
- Higher wage, Filipino nurses earn about twenty times more in the United States than in Philippines [17]
- Lack of professional development and specialist training especially in advanced medical technologies [3, 15, 17, 30]
- Proximity and family links in destination countries [3, 10]
- Political instability and poor socioeconomic conditions [3, 10, 28]
a. Employment opportunities
There is an increased rate of unemployment among health professionals due to the high annual turnover of doctors and nurses from the growing number of public and private medical schools [10, 15]. In addition,the structural adjustment policies (of the World Bank) adopted by most EMEresulted in reduction of jobs and inadequate investment in the healthcare sector[17, 31].
b. Wages and work environment
Studies in different countries have emphasised one major factor, “wage” that acts as both push and pull factor [3, 10, 16, 32-34]. Health professionals who do not have proper work environments or are victims of bureaucracy and politics in the home country often go out in search of opportunities to other countries [3, 32-34]. The level of stress due to high responsibility and poor compensation has led to extensive mental and physical exhaustion among young nurses in China [35]. Two studies conducted on nurses in India and Philippines [25] and on doctors in South Africa [12] and another study conducted in Jordan and Georgia in 2004 [36], have identified better wage, job opportunity and work environment as the majors reasons for migration.
3. Role of medical education in migration of health professionals
While most studies have focused on the differences in the organisation and salary or remuneration structures as important correlates for migration of highly skilled professionals [17, 37], the structure of the medical education system of the source countries has not received adequate attention.
The three main factors that influence this issue are [1, 10]:
- Increasing numbers of medical schools
- Quality of medical training
- Gap between health needs and medical education
This is covered in the paper “Education and training for health professionals in the emerging market economies: A literature review”
4. Growing demands in high income countries
Most developed countries such as the US, Canada, Australia, and countries in Western Europe are undergoing demographic transition which has started to have its impact on the work force. These countries have an ageing population of doctors and nurses [3, 33]. The current policies of investment in education of health professionals in these countries are insufficient to meet the demands of their growing healthcare market [3, 38, 39] so they try to meet the demands by recruiting health professionals from resource poor countries and from the EMC [3, 38].
5. Favourable country policies on financial remittances by migrant workers
EME like Philippines, Turkey and Mexico have developed policies for migrant health professionals to remit money to the country in the form of tax [3, 13]. The growing number of nursing schools in Philippines produce a huge workforce and its government encourages migration especially to collect remittances irrespective of the fact that this is crippling the country’s own health system [13, 20]. Two immediate advantages are seen by these countries, while the first one is explicit, “remittances”, the second is implicit, “ it does not have to create job opportunities for the growing number of health professionals” [20, 28].
6. Shortage of healthcare workers
Globally there is a shortage of 2.4 million physicians, nurses and midwives and 1.9 million pharmacists and other para-medical workers [1, 3]. WHO estimates, the basic healthcare system of 57 low and middle income countries is affected by shortage of human resources [1, 3]. The health systems of 36 countries in SSA have reached a crisis situation due to combination of two factors, brain drain and HIV/AIDS [3]. These are also countries with high rates of maternal, infant and child mortality and shortage of health providers especially for the rural and underserved population [3]. A similar crisis is seen in Mexico after its North American Free Trade Agreement (NAFTA) with USA[9].
Migration of health professionals has led to two types of discrepancies between health needs and healthcare workers, the first is within country (urban-rural, public-private or government healthcare sector-private sector) and the second between countries [40].
Though the number of medical and nursing schools is growing in the EME producing a substantial number of health professionals, the ratio of health professional to population in rural areas is grossly inadequate [8, 41]. India produces about 27,000 medical graduates every year and more than 75% of these work in cities whereas about 70% of the patients are from rural areas [42]. Major reason for this is better living conditions, facilities and opportunities in cities than in villages [6]. This has resulted in inequity of health services and the disproportionate distribution of the health workforce between urban and rural areas [34].
Another discrepancy commonly visible in the growing markets like India, Thailand and China is the public-private discrepancy. In the free market economy , with the growth of medical tourism there is a sudden upsurge of private and multinational hospitals [34, 43]. To compete for status and quality these hospitals hire the best specialists from within the country, thereby increasing the internal brain drain [34, 42, 43]. Due to lack of insurance and high out-of-pocket expenditure, the general population cannot afford these private hospitals [42]. They are dependent on the public hospitals for their health needs which do not have adequate human and technical resources resulting in a huge unmet need [42].
The biggest irony is the inverse relationship between disease burden and density of health workers seen in most of the WHO regions (Table-2). Though Africa has a large share of the disease burden (24%), the number of health workers available is 2.3 per 1000 population, while in the Americas the fraction of global disease burden is 10% and there are 24.8 health workers per 1000 population [1, 3].
Table-2: Discrepancies between heath needs and healthcare workers
WHO regions / Disease burden (as fraction of the global disease burden) / Density of health workers (per 1000 population)Africa / 24% / 2.3
Eastern Mediterranean / 10% / 4.0
South East Asia / 29% / 4.3
Western Pacific / 17% / 5.8
Europe / 10% / 18.9
Americas / 10% / 24.8
Source: Working together for health: World health report 2006 (WHO) [1]
Arguments in favour of health workforce migration
While the general consensus is that, migration of health workforce is detrimental for the health systems and health of population, there are some who consider it favourable. While the NGO pull factor has led to unequal distribution of human resource, it has also prevented cross country migration [16]. Most NGOs and private sectors work closely with governmentsespecially in the EME as a result of liberalisation of the economy. This could be a win-win situation for both health professionals (better remuneration and work environment) and the nation (preventing external brain drain) [16]. Another question that needs to be answered is whether emigration control is the panacea for health systems. Studies have shown factors such as non availability of technical resources, logistics and infrastructure to be the primary reasons for the failure of public healthcare system [44]. There are many unemployed nurses in South Africa and India, despite being among the major exporters [44]. .
Possible solutions
The first step to resolve the problem of migration is to measure the problem through regular updating of databases of health workers for all countries [3]. Measures to control migration should be country specific and designed in accordance with the push and pull factors existing in the donor and recipient countries respectively.
Measures taken by donor countries to mitigate the push factors include (See appendix 2 for more details):
- NGO code of conduct
To control the internal brain drain caused by the movement of government health workers to NGOs, the “NGO code of conduct” was launched in May, 2008 in Washington DC with more than 25 signatories [45].
- better wages and work environment[16]
- need based medical and nursing education[14]
- improved quality of health education and opportunities for professional development[14]
- compensation for brain drain[23, 46]
- retaining health workers in rural areas[47].
Other examples of innovative measures taken to combat shortage of health workers found in the literature include:
- ‘task shifting’ i.e. training community workers and paramedics to provide basic healthcare for disease prevention and progression [3, 48].
- encouraging ‘lost talent’ from host countries to return for short term assignments or hold concurrent positions at home and abroad to aid research and development in the host country [21, 49].
In addition, a “Global Code of Practice” was adopted by the executive board of WHO to address the migration of health workers in January 2009 [23].
Conclusion
Migration is a human right but its unidirectional pattern has caused concern especially due to its adverse impact on the healthcare systems. Several national and international commitments have been made, but the basic requirement is to implement the plans through coordinated efforts by governments, development partners, NGOs, civil societies, private sector and the academic world[50]. Concurrent with such efforts is the requirement of data and research in EME to show trends and patterns of migration, and understand the issues in the healthcare labour market.
Appendix 1
Search engines/databases used
Scopus, Eldis, Pubmed, Popline and Google scholar
Key words used
Migration, “health workers”, “health professionals”, immigration, emigration, “shortage health workers”, “task shifting”, labour, “labour market”, “healthcare market”.
Appendix 2
Examples of successful interventions/policies
1. Measures taken by donor countries to mitigate the push factors
a. NGO code of conduct
To control the internal brain drain caused by the movement of government health workers to NGOs, the “NGO code of conduct” was launched in May, 2008 in Washington DC with more than 25 signatories [45]. The objectives of this code of conduct are “to provide a framework of good practice and discourage hiring of health workers from the struggling public health systems” [45]. Further it urges the NGOs to replenish the loss by supporting training and capacity building of workers in the health systems [45].
b. Better wages and work environment
While it is easy to blame the NGOs and private sectors for paying high wages and providing better work environment, it is difficult to address the root cause of the problem [16]. In United Kingdom, it is prestigious for doctors and nurses to work for the government [16]. This prestige can be linked to decent remuneration, pension and opportunity for professional growth [16]. A study in Malawi showed that on increasing the remuneration of health professionals in the government sector, there was a reversal of the brain drain from NGOs and private sector to the public healthcare systems [16]. A study conducted by Vujicic et al. [51] analysed the wage difference between the source countries in Africa and the recipient countries and have found a huge gap which cannot be narrowed by a small increase in the salary of the health professionals in these source countries [51]. They suggest non-wage instruments such as improved working and living conditions to be more effective in controlling migration in such countries [51]. Partners in Health in Haiti has been able to retain health professionals in rural areas by providing them a suitable work environment with appropriate resources to treat patients [3]. Apart from this, hardship allowance paid to health workers in rural areas of Zambia has been favourable in decreasing the shortage in remote rural areas [3]