Healthcare Provider Migration: a Global Crisis
Chad, according to the World Health Organization (WHO), has the worst public health infrastructure of any country in Sub-Saharan Africa – maybe in the world. Life expectancy is estimated to be 45, and over a third of Chadians are malnourished. The population is plagued by infectious and parasitic diseases, respiratory afflictions and nervous disorders, mainly from poor sanitation and limited access to potable water. In 2001, the country’s HIV infection rate was 3.6 percent of the sexually active population. To make matters worse, the country must deal with over 200,000 refugees from the ongoing civil conflict in neighboring Sudan, many of whom arrive afflicted with chronic diarrhea, fever, and respiratory infections.
With a population of more than 8 million, Chad has around 3,600 health workers: 50 percent of these are unskilled, and 35 percent are nurses and midwives. And yet one recent survey revealed that over 10 percent of the Chadian-trained nurses were working outside the country – mostly in France, some in the United States.
Chadian healthcare figures are replicated throughout Sub-Saharan Africa, which has 25 percent of the world’s disease burden, and only 1.3 percent of the world’s healthcare workers.
Nor is the problem confined to Africa. World wide there is a shortage of trained healthcare personnel in the places most desperately in need.
According to the United Nation’s International Migration and Millennium Development Goal, “Poor countries, many of them with the fewest healthcare workers, but the highest infectious disease burdens are ‘subsidising’ the health care systems of wealthier countries.”
Billions of dollars have been invested in efforts to prevent the spread of HIV and other diseases in the world’s poorest countries. Yet at the same time, qualified health workers are leaving the same areas to work in the world’s richest countries.
The situation is particularly acute in Africa. More Malawian doctors are said to be practicing in Manchester, England than in the whole of Malawi. And only 50 of the 600 doctors trained since independence are still practicing in Zambia. In Central African Republic, Liberia and Uganda, there are fewer than 10 nurses per 100,000 people, compared with more than 2,000 per 100,000 in countries such as Finland and Norway.
Experts say there is a global shortage of at least four million healthcare workers. Health system weaknesses mean that death rates are rising and life expectancy is falling in the poorest countries, despite the global health advances of recent years. Healthcare workers hold the key to tackling these challenges. But urgent action is needed to improve the supply, capacity and distribution of the global health workforce.
The Joint Learning Initiative, an enterprise involving over 100 global health leaders, list three major factors as exacerbating the problem faced by healthcare workers in the most understaffed areas of the developing world:
- HIV – which increases their workloads, exposes them to infection and lowers their morale.
- Labor migration that is accelerating from countries that can least afford the brain drain.
- Two decades of health sector “reform” that has lead to chronic underinvestment in human resources.
The problem of the migration of nurses and other healthcare providers has become an issue not only in the countries negatively affected but in the nations receiving the immigrants. Increasingly, governments and the healthcare industry in major industrial countries are turning to immigration as a way to solve – or avoid solving – shortages that have resulted largely from the “reforms.”
Vicky Lovell of the Institute for Women’s Policy Research, told Registered Nurse “It is immoral of the United States to ignore the impact of it [immigration of healthcare workers] on the countries where these nurses come from.”
Writing in the “American Journal of Nursing,” Diana Mason argues that the issue is a “primary moral” one of “draining these countries of their much-needed nursing resources and further undermining their healthcare infrastructure and the health of their people (and thus the health of their economies).”
World public health specialists acknowledge the problem, but a major stumbling block, they say, is providing sufficient motivation for healthcare providers to remain within their countries. It’s a problem faced by scores of other countries, particularly in Asia, Africa and Latin America.
South Africa, for instance says it has spent $1 billion educating health workers who emigrated – the equivalent of a third of all development aid it received from foreign agencies between 1994 and 2000. At the same time public health experts say the countries of sub-Saharan Africa should double their nursing work forces, adding at least 620,000 nurses to deal with the spread of Aids, tuberculosis and malaria.
“The massive outflow of nurses, midwives and doctors from poorer to wealthier countries is one of the most difficult challenges posed by international migration,” according to the U.N. Population Fund’s (UNFPA) latest annual report released September 6, 2006. The group said countries losing healthcare providers are facing a healthcare crisis “unprecedented in the modern world.”
The UNFPA “State of World Population” report, UNFPA said nowhere is the effect of the “brain drain” more acutely felt than in the already fragile health systems of developing nations.
“The problem with the brain drain is that health systems are already collapsing in poor countries that face massive health care needs. The outflow of doctors and nurses aggravates this situation,” Maria Jose Alcala, the report’s principal author, told Inter Press Service (IPS). She pointed out that while nursing is one of the few occupations that offer migrant women decent work with decent pay, “In their countries of origin, nurses face poor working conditions, while richer countries become appealing destinations for them because of higher wages.”
For instance, a surgical nurse in South Africa makes about $13,000 a year. The same nurse can earn $66,000 a year in Britain.
The exodus of nurses from poor to rich countries has strained health systems in parts of the developing world, which are already facing severe shortages of their own. In May 2004, African countries at the annual assembly of the World Health Organization urged developed nations to compensate them for their lost investment in training nurses, and won a pledge to study ways to reduce the damage from the emigration of nurses.
Two years ago, the international organization, Physicians for Human Rights, called on industrial nations to reimburse African countries for the loss of health professionals educated at African expense and to try harder to meet their own worker shortages by training more people domestically rather than recruiting abroad.
The group pointed to a trade off between the rights of African health professionals to seek a better life and the rights of people in their home countries to decent health care. It did not recommend that African governments try to prevent the emigration of health care workers, but did recommend that industrial countries not recruit actively in Africa.
In 2001, in response to such calls, the British National Healthcare System (NHS) promised not to engage in “aggressive recruitment” of African nurses. However, the National Health Service policy does not cover private facilities and private British hospitals. Over 12,000 African nurses have registered to work in Britain over the past seven years.
Percy Mahlati, a high official of the South African Department of Health told the British medical magazine, The Lancet, that the NHS were using private agencies to do their recruiting, “so that rather than doing it directly, they (the NHS) is doing it indirectly.”
A Lancet study found that many nurses from Africa who are recruited by private agencies start off working at nursing homes and private hospitals, but quickly move on to the higher paying NHS jobs.
Despite having the resources to do so, the United States and other developed countries have simply failed to produce enough medical and nursing staff to meet their healthcare demands. A study by the Guardian found that Britain only trains 70 percent of the doctors it needs, and that the U.S. trains 50 percent of the nurses it will need.
Instead they actively recruit them from already depleted developing country health workforces, thus contributing to the healthcare personnel crisis elsewhere, particularly in parts of Asia and Africa.
The increasing migration of healthcare providers represents another faucet of the globalization of the healthcare industry.
This past summer Senator Sam Brownback, (R- Kansas), inserted a proposal into immigration legislation that would facilitate increased immigration of nurses into the U.S. The measure was intended to deal with what he described as a nursing shortage in the country. Accoding to the New York Times, public health experts in poor countries, “reacted with dismay and outrage, coupled with doubts that their nurses would resist the magnetic pull of the United States, which sits at the pinnacle of the global labor market for nurses.”
Smita Baruah, Senior Government Affairs Advisor for Physicians for Human Rights, told Registered Nurse that, “Kansas is facing a nursing shortage and the Senator saw this would be of great economic benefit to his own state. He was looking for a fast and easy solution.”
Senator Brownback, who has been an advocate for programs to combat AIDS and malaria in Africa, has suggested that relaxing nurse immigration rules would have little impact on Africa because of the absence of major recruiting efforts there and the fact that arriving African nurses would not have a big community there to plug into.
However, Eric Buch, the top health adviser to the New Partnership for Africa’s Development, an Africa-wide undertaking initiated by the continent’s heads of state, said he expected that recruiting agencies would set up in African countries where nurses were trained in English and that they would advertise the change in the American law. “You’ll see that emerge, that’s my guess,” said Professor Buch, who teaches health policy at the University of Pretoria, in South Africa, said in a telephone interview. “The United States could become a place where we bleed our healthcare workers.”
Holly Burkhalter, with Physicians for Human Rights, said the nurse proposal could undermine the United States’ multibillion-dollar effort to combat Aids and malaria by potentially worsening the shortage of health workers in poor countries. “We’re pouring water in a bucket with a hole in it, and we drilled the hole,” she said.
The nurse proposal has strong backing from the American Hospital Association. “There is no reason to cap the number of nurses coming in when there’s a nationwide shortage, because you need people immediately,” said Bruce Morrison, a lobbyist for the hospital association and a former Democratic congressperson.
Cited as justification for the Brownback measure and the continuing effort to lure nurses from abroad is the contention that there is an accelerating shortfall of nurses in the country, which will increase to over 800,000 by 2020. The hospital industry has employed such statistics in its effort to fend off drive for mandatory standardized nurse-to-patient staffing ratios.
However, nurse union leaders say just how much of nurse shortage exists is open to question. They say changes brought about by healthcare industry restructuring over the past 20 years have resulted in many nurses working in non-hospital settings or out of the field altogether.
“There is the continuing problem of the absence of RNs working at the bedside,” said Deborah Burger, president of the California Nurses Association. “This is particularly true in states that, unlike California, do not have adequate staffing ratios and where wages are substandard and working conditions deficient. All sorts of non-healthcare business are actively recruiting nurses away from healthcare. This is true of things like legal consultancies and insurance firms that are anxious to hire nurses because of their knowledge and their respect by the public. It’s tempting because in these other arenas you probably would be treated better and do better financially.”
According to Berger, “There would be no need to lure nurses from abroad if we were willing to spend the necessary resources to attract and educate a sufficient nurse workforce and provide the compensation and working conditions to retain it.”
The question nurse compensation and working conditions has been raised strongly by Lovell, principle author of “Solving the Nursing Shortage through Higher Wages.” Lovell says, “The issue of wages, she said, has been kept under the surface for a long time.”
There are “a lot of players in healthcare” that don’t want to see higher wages as an avenue out of the current situation and propose other means such as more nursing schools and immigration, she said, “But these other avenues won’t be effective.”
“I think the public would really be shocked if they knew about the working conditions for nurses,” said Lovell, citing things like inadequate staffing and mandatory overtime, and “the fact that many nurses work without breaks.” “If the public knew they would really care about” it but “a lot of these conditions are hidden from the public. It isn’t what people see when they go to visit someone in a hospital.”
Lovell said she sees increased recruiting from abroad as way to essentially avoid dealing with the central problem of wages and working conditions, but is careful to say that no one can object to someone coming from another country and getting a better standard of living. It is just that immigration is not the solution to the nursing shortage. Still, “It is immoral of the United States to ignore the impact of it on the countries where these nurses come from,” she said. “Labor supply is a problem in other nations as well.”
“Immigration is not the only way we can get more nurses,” said Lovell, “Raising wages is easier and more effective.” The aim, she said, should be to work toward raising nurse wages in other countries.
The key to raising wage levels and improving on the job conditions in the U.S., said Lovell, is collective bargaining. A stumbling block is that “labor laws are so weak on protecting workers and unionization.”
Yes, more nurses will be needed in the coming years, said Burger, but the response to the challenge should be to improve the well-being of nurses employed in hospitals and stepped up efforts to provide more access to nurse education. “When CNA developed its position in nurse migration a central element was our conclusion that at present the U.S. is not really interested in providing the kind of healthcare workforce that is needed. The same can be said for other industries as well. Our thinking is that we should be educating sufficient nurses for the future. But we are not doing so. There are three to four times more applicants for positions in nursing schools than there are slots available. What we are essentially doing is splitting the cost of training healthcare personnel with other, poorer countries.”
Some limited steps have been taken to deal with the education problem. Fourteen nursing schools have launched doctoral programs to prepare nurses to teach or work as supervisors in hospitals, and an additional 190 programs are said to be in development. In addition, 31 nursing schools since 2000 have launched fast-track programs that reduce the time required to earn a doctorate by at least one year, and an additional 13 programs are in development.
However, there are now many more Americans seeking to be nurses than places to educate them. In 2005, American nursing schools rejected almost 150,000 applications from qualified people, according to the National League for Nursing. One of the most important factors limiting the number of students, said the group, is a dearth of faculty. Professors of nursing earn less than practicing nurses, damping demand for teaching positions.
According to the American Association of Colleges of Nursing, nursing schools nationwide rejected more than 41,000 qualified applicants last year compared with 33,000 in 2004 and 18,000 in 2003. The group’s annual survey, released in October, revealed that three out of four schools attributed the increased rejections in large part to an insufficient number of faculty members. At present, the report said, 7.9 percent nursing school faculty slots are vacant.
“We have increased interest in the profession at exactly the time when we need to ratchet up our preparation of staff nurses, but we have too few faculty, and the ones that we have are gray and contemplating retirement in droves over the next few years,” Sally Lundeen, dean of the University of Wisconsin-Milwaukee School of Nursing told USA Today October 4.
Based on past trends, healthcare industry lobbyist Morrison predicts that lifting the restrictions on immigration would incresase the number of nurses coming by 5 to 10 percent a year. Recruiters would focus on countries with large numbers of well-trained nurses, mainly the Philippines, India and China,” he said. “But it’s certainly true that the longer the United States puts off investing in training nurses, the more pressure there will be to find nurses abroad,” he adds.
Opponents of the plan say it would hit the Philippines particularly hard. That Asian country sends more nurses to the United States than any other country, at least several thousand a year. As a result, Philippine healthcare has deteriorated in recent years as tens of thousands of nurses have moved abroad. Thousands of ill-paid doctors have even abandoned their profession to become migrant-ready nurses themselves, Filipino researchers say.
“The Filipino people will suffer because the U.S. will get all our trained nurses,” said George Cordero, president of the Philippine Nurse Association. “But what can we do?”
Cortez, who has worked with Philippine-trained doctors who became RNs in order to emigrate to the U.S. said, they, like the nurses who have left, did so “for the very simple reason: to get away from a situation of relatively low wages and poor working conditions.”
“A lot of young Filipinos are going into nursing as preparation for leaving the country is search of a better life. As a result of the emigration a lot of hospitals – especially in rural areas – have been forced to close because a shortage of both doctors and nurses,” said Cortez. “In more urban areas the hospitals are able to avoid being closed because people there are more affluent and able to afford preventive care.”
He says , “The problem is that the government cannot offer the compensation levels that would attract healthcare providers to stay in the country because most of the money there is being spent on business rather than things like healthcare.”
A nurse in the Philippines would earn a starting salary of less than $2,000 a year compared with at least $36,000 a year in the United States, said Dr. Jaime Galvez Tan, a medical professor at the University of the Philippines who led the country’s National Institutes of Health. He said the flight of nurses had had a corrosive effect on health care. Most Filipinos died without medical attention in 2003, just as they had three decades earlier.
Based on surveys, Dr. Tan estimates that 80 percent of the country’s government doctors have become nurses or are enrolled in nursing programs, hoping for an American green card. “I plead for justice,” he told Registered Nurse “There has to be give and take, not just take, take, take by the United States.”
Cortez tells of a recent flight home from the East Coast during which she encountered an in-flight attendant who had graduated from nursing school and subsequently decided her present job was more attractive. The woman related a number of reasons for her career decision, including better wages and working conditions, the opportunity to travel and avoidance of the stresses of working with critically ill people. “One of the things she said was that a lot of the good thing about her job was a result of have the protection of belonging to a union.”
“In order to deal with the problems confront nursing,” says Cortez, “Congress should be concentrating on strengthening the country’s healthcare infrastructure and improving the wage and bettering the working conditions for nurses. And they should step in and undo the recent decision by the National Labor Relations Board making it harder for nurses and others to join unionize. If they could have union protection I think many of the nurses not working in hospitals could be convinced to do so.”