POLICY BRIEF - PRE-PUBLICATION VERSION - World … · the Philippines account for the largest number of migrant doctors and nurses working ... Excerpts from the WHO Global Code of
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
1
POLICY BRIEF - PRE-PUBLICATION VERSION
TITLE: International migration of doctors and nurses to OECD countries: recent trends and policy
implications
AUTHORS: Dumont Ja, Lafortune Ga
AFFILIATION
a Organisation for Economic Co-operation and Development
The designations employed and the presentation of the material in this manuscript do not imply the expression
of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any
country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries.
Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full
agreement.
The mention of specific companies or of certain manufacturers’ products does not imply that they are
endorsed or recommended by the World Health Organization in preference to others of a similar nature that
are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by
initial capital letters.
All reasonable precautions have been taken by the World Health Organization to verify the information
contained in this manuscript. However, the material is being distributed without warranty of any kind, either
expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In
no event shall the World Health Organization be liable for damages arising from its use. The manuscript does
not necessarily represent the decisions or policies of the World Health Organization.
The opinions expressed and arguments employed herein are solely those of the author(s) and do not
necessarily reflect the official views of the OECD or of its member countries.
This pre-publication version was submitted to inform the deliberations of the High-Level
Commission on Health Employment and Economic Growth (the Commission). The
manuscript has been peer-reviewed and is in process of being edited. It will be published
as part a compendium of background papers that informed the Commission. The
manuscript is likely to change and readers should consult the published version for
accuracy and citation.
2
INTERNATIONAL MIGRATION OF DOCTORS AND NURSES TO OECD COUNTRIES:
RECENT TRENDS AND POLICY IMPLICATIONS
By Jean-Christophe Dumont (OECD) and Gaétan Lafortune (OECD)1
Table of contents2
Key messages
Introduction
1. Findings: Destination country perspective
1.1 Foreign-born health workers to OECD countries
1.2 Foreign-trained health workers to OECD countries
2. Findings: Sending country perspective
2.1 Countries of origin of migrant health workers in OECD countries
2.2 Expatriation rates from countries of origin
2.3 Impact of emigration on health systems in countries of origin
3. Impact of health and migration policies on international mobility of health workers
3.1 Impact of domestic education and training policies on international migrations
3.2 Impact of European Union enlargement on international mobility of health workers
3.3 Impact of the economic crisis and health spending reductions on the international migration
of health workers in Europe
3.4 Impact of bilateral agreements on the training and employment of health workers
Conclusions
Notes
References
1 The authors would like to thank Professor James Buchan (School of Health Sciences, Queen Margaret University) and
Ibadat S. Dhillon (Department for Health Workforce, World Health Organization) for their useful comments and suggestions
on a draft version. The opinion expressed and arguments employed here are the responsibility of the authors and do not
necessarily reflect those of the OECD or of its member countries. 2 The statistical data for Israel are supplied by and under the responsibility of the relevant Israeli authorities. The use of such
data by the OECD is without prejudice to the status of the Golan Heights, East Jerusalem and Israeli settlements in the West
Bank under the terms of international law.
3
Key messages
This policy brief examines recent trends in the international migration of health workers to OECD
countries since 2000. It analyses these trends against the background of changes in migration and
health policies, as well as changing economic and institutional circumstances. In total, the number of
migrant doctors and nurses working in OECD countries has increased by 60% over that last decade.
This rate is higher for those emigrating to OECD countries from countries with severe health
workforce shortages, with an 84% increase over that same time period.
In a context when skilled migration is on the rise, immigrant doctors and nurses account for growing
shares of health professionals working in OECD countries. Foreign-born doctors accounted for 22% of
active doctors in OECD countries in 2010/11 (up from 20% in 2000/01), whereas foreign-born nurses
represented 14% of all nurses (up from 11% in 2000/01). The share of foreign-trained health workers
is lower (17% for doctors and 6% for nurses in 2012-14), suggesting that host countries provide some
of their training. The share of foreign-trained doctors and nurses in the two main destination countries
– the United States and the United Kingdom -- has decreased slightly since around 2006. India and
the Philippines account for the largest number of migrant doctors and nurses working in OECD
countries. Some countries, like the Philippines, have trained a large number of nurses who intend to
migrate. Some countries in Africa facing severe shortages of skilled health workers, such as Nigeria,
have seen the number of expatriates continue to grow over the past decade, nearly doubling.
These findings point towards three policy options:
1. By increasing their domestic education and training capacity to respond to current and future
projected demand, as well as promoting greater retention rates of currently active health
professionals, OECD countries can achieve greater self-sufficiency and reduce their reliance
on foreign-trained doctors and nurses.
2. At the same time, lower-income countries that are losing many of their skilled health workers
need to address some of the “push” factors and increase their efforts to try to retain them by
improving their working conditions and pay rates. These retention measures will require good
governance of the health system and long-term financial commitment, which in many cases
may require the support of the international community as called for by the WHO Global
Code of Practice on the International Recruitment of Health Personnel (‘WHO Global Code’).
3. In the spirit of the WHO Global Code, countries may also seek better ways to manage health
workforce migration by negotiating mutually beneficial agreements and assessing their
impact, and considerations might also be given to more ambitious approaches to global
governance building on the recent example in the area of climate change agreements.
4
Introduction
The international migration of doctors, nurses and other health workers is not a new phenomenon, but
has drawn a lot of attention in recent years because of concerns that it exacerbates shortages of skilled
health workers in some countries, particularly in those countries that are already suffering from critical
shortages. The WHO Global Code of Practice on the International Recruitment of Health Personnel
(‘WHO Global Code’), was adopted by the World Health Assembly in 2010, to support improved
management of international health personnel migration according to globally accepted ethical norms
and standards. It encourages greater international cooperation and support in the area and encourages
countries to achieve greater “self-sufficiency” in the training of health workers, while also recognising
basic human right of freedom of movement (see Box 1).
Box 1. Excerpts from the WHO Global Code of Practice on the International Recruitment of Health
Personnel
Ethical international recruitment
The Code discourages the active recruitment of health workers from developing countries with critical workforce shortages.
Equal treatment of migrant health care workers
The Code highlights the importance of equal treatment of foreign-trained health workers and their locally-trained
counterparts. All health care workers should have the opportunity to assess the benefits and risks associated with employment
positions, and to make informed decisions about vacancies.
Health workforce development and sustainable health systems
Member States should develop strategies for workforce planning, training and retention, adapted to the specific
circumstances of each country, so that there is less of a need to recruit migrant health workers.
International cooperation
The Code encourages collaboration between health workers’ countries of origin and countries of destination, so that both
benefit from the migration of health professionals.
Technical collaboration and financial support
Developed countries should provide technical and financial assistance to developing countries experiencing a shortage of
health workers.
Data Gathering
Member States are encouraged to strengthen or establish health personnel information systems, including information on
health personnel migration, in order to collect, analyse and translate data into effective health workforce policies and plans.
Source: User’s Guide to the WHO Global Code of Practice on the International Recruitment of Health Personnel, WHO (2010).
The 2007 OECD study on “Immigrant Health Workers in OECD countries in the Broader Context of
Highly-Skilled Migration”, published in the International Migration Outlook, presented for the first
time a complete picture of the migration flows of health personnel to OECD countries by countries of
origin and destination (OECD, 2007). This work was recently updated in a chapter on “Changing
Patterns in the International Migration of Doctors and Nurses to OECD Countries”, published in the
2015 edition of the International Migration Outlook (OECD, 2015a). This policy brief presents some
of the main results from these chapters and additional information on health workforce policies from
the 2016 publication on Health Workforce Policies in OECD Countries: Right Jobs, Right Skills, Right
Places (OECD, 2016) and the 2008 publication on The Looming Crisis in the Health Workforce. How
can OECD countries Respond? (OECD, 2008). It addresses the following questions:
What is the scale of the international migration of doctors and nurses to OECD countries, and
who heads where?
5
What is the contribution of migrant health workers to their destination countries and what are
the consequences on their countries of origin?
How much do immigration and health policies affect migration grows and what is the scope of
bilateral agreements and new possible global governance arrangements to better manage
health workforce migration?
1. Findings: Destination country perspective
Immigration patterns can be measured based on nationality, place of birth or place of
education/training. The first approach, based on nationality, faces a number of shortcomings, with the
main one being that foreigners disappear from the statistics when they are naturalized. The second
approach, based on place of birth, is more meaningful because when the country of birth differs from
the country of residence, it implies that the person did cross the border at some point in time.
However, the main question that arises to evaluate the impact of highly skilled migration on origin
countries is where the education took place. Some foreign-born people arrived at younger ages, most
probably accompanying their family, while others came to the country to pursue tertiary education and
have stayed after completion of their study. In this context, most of the cost of education will have
been supported by the destination country, and/or by the migrants themselves, not by the country of
origin. The third approach, based on the place of education/training, is probably the most relevant
from a policy perspective, although it does raise a number of measurement issues related to the fact
that medical and nursing education and training can be very long and go through different stages that
may be occurring in both origin and destination countries (Dumont, Lafortune and Zurn, 2014).
This section uses two different datasets to monitor trends in the number of foreign-born
doctors and nurses working in OECD countries (based mainly on population-census data available in
many countries at 10 years intervals) and the number of foreign-trained doctors and nurses working in
OECD countries (based mainly on data from professional registries available each year).
It focusses only the migration of doctors and nurses given the preeminent role that these have
traditionally played in health service delivery in OECD countries.
1.1 Foreign-born health workers in OECD countries
Foreign-born doctors and nurses account for a significant and growing share of health
professionals in OECD countries. The share of foreign-born doctors increased in most countries
between 2000-01 and 2010-11 with the total number increasing from 19.5% to 22% across 23 OECD
countries, while the share of foreign-born nurses rose from 11% to 14.5% across 22 OECD countries.
In total, the number of migrant doctors and nurses working in OECD countries has increased by 60%
over that last decade. To a certain degree, the share of migrants among health professionals mirrors
that of highly-skilled immigrants in the workforce as a whole. However, the percentage of foreign-
born doctors tends to be greater than the percentage of immigrants among highly educated workers,
whereas the share of foreign-born nurses is similar or lower.
Although the United States receives the highest number of migrant doctors and nurses in absolute
terms, the steepest rises in foreign-born doctors between 2000-01 and 2010-11 were in the United
Kingdom and Germany. There were also significant increases in Ireland, Australia, New Zealand and
Switzerland, while numbers continued at their relatively high levels in Canada and the United States.
There were important variations across OECD countries in the proportion of health personnel
born abroad in 2010-11. For doctors, the share ranges from less than 3% in Poland and Turkey to over
6
50% in Australia and New Zealand. The share of foreign-born nurses is insignificant in Poland and the
Slovak Republic, but over 30% in Switzerland, New Zealand, Australia and Luxembourg. In almost all
countries, with the exception of Turkey, Italy and Estonia, immigrants make up a higher proportion of
doctors than of nurses. This is particularly the case in Ireland, Australia and New Zealand.
Not surprisingly, the proportions of foreign-born doctors and nurses are highest in the main
settlement countries (e.g. Australia, Canada, Israel and New Zealand) and European countries like
Luxembourg and Switzerland. Other countries too – such as the United Kingdom and Belgium – also
near the top of the list in terms of the share of foreign-born health professionals, as do some Nordic
countries when it comes to doctors, and as does Ireland for both doctors and nurses.
7
Table 1. Practising doctors by place of birth in 30 OECD countries, 2000/01 and 2010/11
Notes: Countries for which data for 2000/01 are derived from a census: AUS, AUT, CAN, CHE, ESP, FIN, FRA, GBR, HUN, IRL, LUX, MEX, NZL, POL, TUR, USA; countries for which data for 2000/01 are derived from LFS: BEL, DEU, NLD, NOR. Countries for which data for 2010/11 are derived from a census: AUS, CAN, CZE, DNK, ESP, EST, FIN, FRA, HUN, ISR, LUX, NLD, NOR, NZL, POL, PRT, SVK, SVN, USA; countries for which data for 2010/11 are derived from LFS: AUT, BEL, CHE, CZE, DEU, GBR, GRC, HUN, IRL, ITA, SWE, TUR. The percentage of foreign-born doctors whose place of birth is unknown are excluded from the calculation of the percentage of foreign-born doctors. Countries marked with an asterisk (*) are not counted in the total (OECD23) due to data gaps at least for one year.
1. Other sources indicate a slightly higher increase in the number of doctors in Belgium during this period.
2. Some doctors undergoing specialty training may not be counted in 2011.
3. In 2001, doctors are only partially covered.
4. Other sources indicate a slightly lower increase in the number of doctors in Sweden during this period.
5. Some doctors undergoing specialty training may not be counted in 2000.
Source: OECD (2007) for 2000/01 data, DIOC 2010/11 and LFS 2009/12 for 2010/2011 data.
Table 2. Practising nurses by place of birth in 30 OECD countries, 2000/01 and 2010/11
Notes: Countries for which data for 2000/01 are derived from a census : AUS, AUT, CAN, CHE, ESP, FIN, FRA, GBR, HUN, IRL, LUX, MEX, NZL, POL, PRT, TUR, USA ; countries for which data for 2000/01 are derived from LFS: BEL, DEU, NLD, NOR ; countries for which data for 2000/01 are derived from a register : DNK. Countries for which data for 2010/11 are derived from a census: AUS, CAN, ISR, NZL, USA; countries for which data for 2010/11 are derived from LFS : AUT, BEL, CHE, CZE, DEU, DNK, ESP, EST, FIN, FRA, GBR, GRC, HUN, IRL, ITA, LUX, NLD, NOR, POL, PRT, SVK, SVN, SWE, TUR. Foreign-born nurses whose place of birth is unknown are excluded from the calculation of the percentage of foreign-born nurses. Countries marked with an asterisk (*) are not counted in the total (OECD23) due to data gaps for at least one year.
1. Other sources indicate that the number of nurses in Denmark may be about 25% higher in 2002 and in 2012. Some associate professional nurses may not be counted.
2. Other sources indicate that the number of nurses in Switzerland may be about 50% higher in 2000 and 20% higher in 2010.
Source: OECD (2007) for 2000/01 data, DIOC 2010/11 and LFS 2009/12 for 2010/2011 data.
1.2 Foreign-trained health workers in OECD countries
In most OECD countries, the proportion of health workers trained abroad is lower than that of
health workers born abroad, indicating that host countries provide part of migrants’ education and
training.
In 2012-2014, foreign-trained doctors accounted for 17% of all doctors across 26 OECD
countries, and foreign-trained nurses for 6% of all nurses across 25 countries. While the number of
foreign-trained health workers are usually lower than the foreign-born, in some countries (e.g. Israel),
the share of foreign-trained health workers is higher, reflecting the fact that many people born in the
country have gone to study abroad before returning back to practice in their home country.
Israel, New Zealand, Norway, Ireland and Australia have the highest share of foreign-trained
doctors, with more than 30% of doctors trained abroad. Following these countries are the United
Kingdom, Switzerland, the United States, Canada and Sweden, with rates between 24% and 30%. The
very high proportion of foreign-trained doctors in Israel reflects not only the importance of
immigration in this country, but also the fact that an increasing number of new licenses are issued to
people born in Israel but trained abroad (about one-third in 2014). Similarly, in Norway, large
numbers of Norwegians study medicine abroad, with the vast majority of them returning to practice in
Norway.
In absolute numbers, the United States has by far the highest number of foreign-trained health
workers, with more than 200 000 doctors trained abroad in 2013 and almost 250 000 nurses.
Following the United States is the United Kingdom (with more than 48 000 foreign-trained doctors
and 86 000 foreign-trained nurses in 2014), and Germany (with nearly 29 000 foreign doctors in 2014
and 70 000 foreign nurses in 2010, latest year available).
In most OECD countries, the proportion of nurses trained abroad tends to be much lower than
that of doctors. Only Switzerland, New Zealand, Australia and Israel report figures higher than 10% in
2012-14. Recent trends in the migration of foreign-trained nurses also vary across countries. There has
been a strong rise in the immigration of foreign-trained nurses in Italy, primarily driven by the arrival
of nurses trained in Romania. However, in some other countries (e.g., the Netherlands, Portugal and
the United Kingdom), there has been a reduction in the number and proportion of foreign-trained
nurses between 2006 and 2012-2014.
Most OECD countries have stepped up their education and training efforts of doctors and nurses
since 2000 in response to expected shortages in the context of population ageing generally (which is
expected to increase the demand for health services) and the ageing of the medical and nursing
workforce (which is expected to reduce their supply). These efforts have partly slowed down the
increase in international recruitment (see the section below on the impact of domestic education and
training policies on migration flows).
10
Table 3. Foreign-trained doctors working in 26 OECD countries, 2000, 2006 and 2012-14
Note: Doctors whose place of training is unknown have been excluded from the calculation of the percentage of foreign-trained doctors (Netherlands, Slovak Republic, Slovenia and United Kingdom).
1. The data refer to foreign citizens (not necessarily foreign-trained).
2. Data cover England, Wales and Scotland (but not Northern Ireland).
3. The percentage in 2000 is calculated based on all doctors registered to practise. Data for 2006 and 2013 refer to doctors who are professionally active.
e: estimation.
Source: See Annex 4.A1 in chapter 4 of OECD (2016), Health Workforce Policies in OECD countries: Right Jobs, right Skills, Right Places.
Table 4. Foreign-trained nurses working in 25 OECD countries, 2000, 2006 and 2012-14
Note: Nurses whose place of training is unknown are excluded from the calculation of the percentage of foreign-trained nurses (e.g. Switzerland).
1. The data only include professional nurses (and exclude associate professional nurses).
2. The data refer only to general nurses.
3. The data refer to citizens born abroad, not German by birth (except ethnic German repatriates) and the highest degree in nursing acquired in a foreign country.
4. Different source in 2001 (Aiken et al., 2004).
5. Data refer to all nurses registered to practice.
e: estimation.
Source: See Annex 4.A1 in chapter 4 of OECD (2016), Health Workforce Policies in OECD countries: Right Jobs, right Skills, Right Places.
86 680 (2010/11) and 55 794 (2000/01) 221 344 (2010/11) and 110 774 (2000/01)
// //
14
Table 5. Trends in the expatriation rates of doctors and nurses to OECD countries, 2000/01 and 2010/11
Notes: The average expatriation rate corresponds to the unweighted average of each country's expatriation rate (and therefore does not take into account the demographic weight of each country) whereas the overall expatriation rate indicates the share of expatriates in OECD countries in the total number of doctors and nurses of the countries examined. The average expatriation rate is higher than the global rate, because countries with the lowest populations and those that are islands show the highest rates of emigration. Countries for which expatriates are under 10 for nurses (5 for doctors) or resident in the origin country are below 50 for nurses (10 for doctors) are not included in the calculations. Expatriation rates are only calculated for countries for which data back to 2005 at the latest are available. 149 countries of origin are therefore included for doctors and 141 for nurses. Data on the expatriation rates in 2000/01 of nurses born in Brazil, India and South Africa have been updated on the basis of new data on the number of nurses working in these countries in 2000/01. The revised expatriation rates in 2000/01 are: Brazil: 1.5%, India: 2.9% and South Africa: 12.6%.
Source: OECD (2007); DIOC 2010/11, LFS 2009/12 and Global Health Observatory (WHO).
In Africa, the expatriation rate for nurses in South Africa rose from 12.6% in 2000/01 to 16.5% in
2010/11, in Nigeria from 10% to 17%, and in Zimbabwe from 28% to 43%. For the two main origin
countries of doctors in Africa who have migrated to an OECD country (South Africa and Nigeria),
expatriation rates have also risen:- in South Africa (from 17% to 22%), and a lower rise in in Nigeria
(from 11.7% to 12.3%). In some cases, the changes observed in the expatriation rates are not so much
related to an increase or a decrease in migration flows, but rather with a change in the national ‘stock’
of health workers. For example, the expatriation rate for doctors in Angola dropped from 63% to 34%,
while the number of expatriate doctors remained stable. This reflects a sharp increase in the number of
doctors registered by the WHO as working in Angola over the last decade. For Nigeria, the number of
expatriate doctors nearly doubled in ten years (from around 4 600 to 8 200), whereas the expatriation
rate remained stable at around 12%. This again reflects the growth in the number of doctors working
in the country. On the other hand, the increase in the expatriation rate of doctors in Zimbabwe (from
28% to 56%) is in large part attributable to the fact that the number of doctors practising in the country
fell by more than half.
Despite the sharp increase in the number of health professionals emigrating from India and the
Philippines, their expatriation rates remained relatively constant. For example, the number of
expatriate Indian doctors jumped from 56 000 in 2000/01 to around 87 000 in 2010/11, but the
corresponding expatriation rates rose only by one-half of a percentage point to 8.6%. In China, the
number of expatriate nurses doubled in ten years (from around 12 200 to 24 400), but the expatriation
rate remained at only 1%.
2.3 Impact of emigration on health systems in countries of origin
In its 2006 World Health Report, WHO estimated that 2.4 million health workers were needed in
the 57 countries considered to be suffering from critical shortages.5 In 2010/11, WHO estimated that
5 Countries with critical shortages were defined in the World Health Report 2006 as those with less than
22.8 health professionals (doctors, nurses and midwives) per 10 000 people and where less than 80%
of childbirths were delivered by skilled birth attendants.
2000/01 2010/11 2000/01 2010/11
Overall expatriation rate 5.3 5.9 4.5 5.7
Average expatriation rate 19.5 21.8 16.6 21.8
Median expatriation rate 13.0 13.6 6.4 10.4
Doctors Nurses
15
54 countries were still facing critical shortages of about 2 million health workers. Most of these
countries (31 countries) were in Africa. Progress made in India to close the gap between health worker
supply and demand accounted for much of the reduced shortage in 2010/11. In Africa and the
Americas, however, the gap widened (WHO, 2013). It should be noted that WHO no longer uses the
categorization of countries with critical shortages.
Table 7 assesses the relative contribution of emigration for those countries where the density of
health workers was considered too low and to what extent such emigration contributed to these critical
shortages. It presents data at a broad WHO region level; it is important to keep in mind that the actual
impact in different countries can vary significantly.
Table 7. Estimated critical shortages of doctors, nurses and midwives, by WHO region, 2000/01 & 2010/11
Note: WHO no longer uses the categorization of countries with critical shortages
Source: OECD (2007), DIOC 2010/11 and LFS 2009/12, Global Health Observatory (WHO).
The slightly smaller group of countries suffering from critical shortages have seen their health
workers continue to emigrate in growing numbers between 2000/01 and 2010/11. Emigration therefore
appears to have contributed to these critical shortages over the past decade. It accounted for 20% of
estimated critical shortages in 2010/11, compared with 9% in 2000/01. In the decade preceding the
adoption of the WHO Global Code, the number of doctors and nurses originating from countries with
severe shortages who emigrated to OECD countries grew by 84%, while the total number of migrant
health workers increased by 60%.
In African countries assessed as facing critical shortages, the number of health professionals born
in these countries working in OECD countries doubled between 2000/01 and 2010/11. At the same
time, the critical shortages in their origin countries grew, so the migration’s share of the estimated
shortage rose from 7% in 2000/01 to 13% in 2010/11. However, the picture varies from one country to
another. Ethiopia was the African country with the most severe critical shortage. There was an
estimated shortfall of 175 000 health workers in 2010/11, but only 6 000 doctors and nurses had
emigrated. In Nigeria, by contrast, emigrant workers accounted for over 40% of the critical shortage,
with 36 000 expatriates for a shortfall estimated at 81 000 health workers.
In the Americas, the high share of the estimated shortage attributed to migrant health personnel is
due mainly to the high emigration of nurses from the Caribbean. In absolute terms, the greatest
shortage is in the South-East Asia region. Shortages are particularly acute in Bangladesh and
Indonesia, with health worker shortfalls estimated at 260 000 and 240 000 respectively. In the Eastern
Mediterranean region, the increase in emigration – particularly of Pakistan-born doctors – to the
Sources: OECD (2007), DIOC 2010/11 and LFS 2009/12, Global Health Observatory (WHO).
WHO region
Number of countries In countries with critical shortagesForeign-born doctors and nurses in OECD countries by
region of origin
With critical shortages Total stock Estimated critical shortage NumberPercentage of the estimated
critical shortage
16
OECD area accounted for 17% of the region’s estimated critical shortage in 2010/11, up from 10% in
2000/01. Cambodia, Laos, and Papua New Guinea are the countries where the shortfalls in health
personnel are the greatest in the Western Pacific region. In this region, migration also accounted for a
higher share of the shortage in 2010/11 compared with 2000/01.
There are many possible causes behind the international migration of health workers and
consequences for the health system of origin countries. On one hand, this migration may be interpreted
as a symptom rather than a determinant of the problems facing these health systems. The fact that
there is a shortage does not necessarily mean that there is a lack of health workers with the required
qualifications and skills: it may also reflect the reluctance of these people to work under existing
conditions (Buchan and Aiken, 2008). On the other hand, the emigration of health workers can indeed
be a problem when the volume of outflows is significant, particularly when it concerns skills that are
in short supply or when migrants come from regions that are already undersupplied (Wismar et al.,
2011). The emigration of even a limited number of specialists can have an important impact on the
delivery of health care, especially in rural areas where there is a dearth of health workers (Eke et al.,
2011; Galan et al., 2011).6
3. Impact of health and immigration policies on international mobility of health workers
The growing international mobility of health professionals must be viewed in relation to other
elements that also affect the supply of health workers, primarily the entry on the labour market of new
graduates on the inflow side, and the retirement or exit of certain workers on the outflow side. The
main factors influencing inflows and outflows are education and training policies, immigration
policies, and changes in economic and institutional circumstances.
3.1 Impact of domestic education and training policies on international migration
Policies relating to the education and training of doctors, nurses and other health professionals are
among the most powerful tools that countries can use to adjust the supply to projected needs. Training
sufficiently large numbers of health workers to curb any dependence on immigration is in fact one of
the key principles of the WHO Global Code of Practice. Most OECD countries control in some ways
the number of students admitted to medical and nursing schools, mainly through numerus clausus
policies, and several countries have raised admission levels in these programmes since 2000, either to
meet expected growing needs for health services or to reduce their dependence on foreign-trained
doctors or nurses.
The efforts to train new doctors have intensified in most OECD countries since 2000, including in
the United Kingdom, Australia, Canada and to a lesser extent the United States. The number of
students admitted and graduating from nursing programmes also rose sharply in many countries since
2000.7
The United States provides a striking example of how a substantial increase in domestic training
efforts for nurses have reduced the need to recruit foreign-trained nurses. Between 2001 and 2012, the
number of domestically-trained nurses passing the certification exam more than doubled, rising from
6 Remittances is also often mentioned as a benefit of emigration that might be increased. The International
Monetary Fund recently suggested that reducing remittance costs could increase the net revenues that
private households receive in source countries (IMF, 2015).
7 See, for example, Figures 3.18 and 3.19 in the International Migration Outlook 2015 and Figures 5.7 and 5.16
in Health at a Glance 2015).
17
less than 70 000 in 2001 to nearly 150 000 in 2012 (Figure 3, right panel). This was accompanied by a
sharp drop in the number of foreign-trained nurses who passed that exam, coming down from a peak
of around 23 000 in 2007 to only about 5 000 in 2012. For doctors, up until now, the number of newly-
registered doctors who got their initial degree in another country has remained more stable but if the
number of domestically-trained doctors continues to go up, it is possible that fewer foreign-trained
doctors will become registered in the United States in the coming years (Figure 3, left panel).
Figure 3. Changes in the number of domestic graduates and inflow of foreign-trained health workers, United States, 2001-13
Doctors Nurses
Source: The US Nursing Workforce: Trends in Supply and Education, Health Resources, Services Administration (HRSA), 2013; American Medical Associations, National Centre for Health Statistics.
In the United Kingdom, the steady rise in the number of domestic medical graduates since 2002
has also reduced the need to recruit abroad (Figure 4), although the annual inflow of foreign-trained
doctors seems to have stabilised in recent years. But the countries of origin of foreign-trained doctors
in the United Kingdom has changed considerably over the past decade, with a growing proportion of
doctors trained in other EU countries. Regarding nurses, the inflow of foreign-trained nurses fell
sharply between 2004 and 2009, but it has gone up since then, driven mainly by the migration of
nurses trained in other EU countries (e.g., Spain and Portugal), to meet growing demands for nurses
that are not fully met by the growing supply of domestically-trained nurses. It is important to keep in
mind that there are also large outflows of nurses trained in the United Kingdom, who are emigrating in
other English-speaking countries such as Australia, Canada, New Zealand and the United States
Figure 4. Changes in the numbers of domestic graduates and inflow of foreign-trained health workers, United Kingdom, 2000-14
Doctors Nurses
Note: Between 2005 and 2008, data on staff trained abroad correspond to the administrative period ending 31 March of the year indicated. Break in 2008 for the graduate series. Data from 2008 onwards are estimated.
Source: UK Graduate Output 1991/92 to 2012/13, Health and Social Care Information Centre. Nursing and Midwifery Council.
In most OECD countries, the number of medical and nursing graduates is expected to continue to
rise in the coming years, possibly further reducing the need to recruit foreign-trained doctors and
nurses, unless the demand for their services exceeds the growth in domestic supply.
3.2 Impact of European Union enlargement on international mobility of health workers
The free movement of people and workers has been a cornerstone of efforts to build the EU since
the Treaty of Rome was signed in 1957. Prior to the accession of the ten new member countries in
2004, there were concerns about a possible massive inflow of health workers from these countries.
These concerns were based primarily on the results of surveys of health workers' intentions to migrate,
conducted before enlargement. For example, more than a third of Polish health workers and more than
half of Estonian health workers expressed their intention to emigrate to find work (Vörk et al., 2004).
Yet migration flows have been more modest, all things considered.
Following accession, a substantial number of Polish doctors obtained a registration in another EU
country in 2004, particularly in Germany (Figure 5). However, this number (fewer than 200) still
remained very low in comparison to the total number of doctors practising in Poland then (over
80 000). Furthermore, from 2005, admission plummeted and have remained very low, despite a slight
increase in recent years.
Since 2010, Polish doctors have been returning home in sizeable numbers. This trend may reflect
the substantial increase in doctors' incomes in Poland following the strikes in 2006/07, and the