Migration and health: A focus on health care worker
migration.
Session overview• Migration and health• Migration and human rights• Globalisation• Health systems• How it is in Europe• Inequalities• Causes• Consequences• Policy responses.
The global picture
What effects does migration have on health?...
……5 minutes, in groups of 5!
Effects of migration on health
• Faster spread of infectious diseases• Reduction of health care services vs
increased health care services.• Lowering of human resources in sources
countries• Migrant health not being cared for
properly in destination country• Remittances – might improve health• Psychosocial – away from home• Refugees – poor health services.
Human rights and migration
• Freedom of movement. (UDHR)• Right to health and well being
(WHO charter and UDHR)• Right to the highest attainable
standard of health (ICESC)
• Individuals have a personal choice, should not be persecuted!
Globalisation Globalisation can be defined as processes that are
changing the ways in which people interact across boundaries, notably physical (such as the nation-state), temporal (such as instantaneous communication via
email), and cognitive (such as cultural identity). The result is a redefining of human societies across many spheres, economic, political, cultural, technological and so on. As such, globalisation affects the health of different people in very different ways. How good or bad globalisation happens to be for you will be influenced by socioeconomic status, sex, education, age, geographical location, and other factors.
»Lee, K et al. BMJ 2002;324:44 ( 5 January )
Health care workers and health systems.
• Back Bone • 2/3 of health expenditure• Health workers ‘own’
considerable investment – skills financed by the health system.
• 100 million health care workers in the world.
In Europe…
….. Over to you!
“I not only use all the brains that I have, but all that I can borrow.”Woodrow Wilson, 28th US President
Inequalities in HCW’s• SSA needs 720, 000 more doctors
and 670,000 more nurses to reach MDG’s.
• 700% increase in docs, 50% increase in nurses.
• UK: 620 people per doctor, 185 per nurse
• Liberia: 43,478 per doctor, 9,804 per nurse
Millennium Development goals:
• Millennium Development Goals- To achieve over the period 1990-
2015Goal 4: 2/3 reduction in child mortalityGoal 5: 3/4 reduction in maternal mortalityGoal 6: Halt and begin to reverse spread of HIV/AIDS, malaria and other diseases
health worker density world map
[Source: Joint Learning Initiative, 2004]
Income distribution world map
Health care worker migration…why?
5 mins…groups of 5!
Push and pull factors!• Wages• Working conditions• Future prospects (training etc.)• Management and health system
governance
dynamicseconomic stagnation
low respect for staff
low morale
poor health outcomes
low pay for health staff
dysfunctional health system
loss of training
investment
poor management
of staff
poor quality of care
migration
R
R
R
HIV/AIDs
personal risk to staff
conflict
lack of mentors
Summary of causes• Migration is not the ‘problem’ but a self
perpetuating result of problems• Inequality driving huge differentials in
working conditions• Africa has a particular set of serious
causes• Poor working conditions• Demand• Increasing integration of global
economy.
Consequences…Increasing Inequality
• Increasing migration• Worse health outcomes• Health systems effects
Increasing migration…Number of Zimbabwean-trained doctors on UK
register
020406080
100120
1999 2000 2001 2002 2003 2004
Year
Number of doctors
Zimbabwean-trained nurses on UK register
0
500
1000
1500
2000
2500
1998/99 99/2000 2000/01 2001/02 2002/03 2003/04
Year
Number of nurses
Estimated numbers of nurses trained in Ghana registered in the UK
Source: calcula ted from NMC 2004
Ghanaian nurses
0200400600800
10001200
1998/99 1999/2000 2000/01 2001/02 2002/03 2003/04
Less health care workers – worse outcomes.
0
1
2
3
4
5
6
7
8
9
0 1 2 3 4 5
Graph 1: Density (workers per 1,000, log)
Mortality (per 1,000, log)
LnMMRLnIMRLnU5MR
Maternal
Infant
Under-5
Health systems effects• In addition to worsened health
outcomes– beheading of health system: top goes
first– training and management suffer– more pressure on those remaining– re-inforces migration pressures
Perverse Subsidy• Perverse….in the wrong direction• Subsidy – someone helping
someone else by giving them money
• Why perverse…money going from poor to rich…is this right??!!
Looking at the UK and Ghana
• Ghana about 50 times poorer than the UK.• Govt. health expenditure per capita
– Ghana £6 (Zim? £16)– UK £800
• Ghana trains health professionals, then loses the stream of expected health care benefits to privileged UK health service users
• Saving of training investment in UK health services: crude estimates of £65 million for 293 doctors and £38 million for 1021 nurses
• Provides benefits to UK health service users: at salary costs if those staff were all employed in the NHS, an estimated £39 million per year– These are orders of magnitude of perverse
subsidy - of the scale of the injustice
What are the possible policy responses?
Groups of 5…5 mins!
Possible responses…• Health systems strengthening in the
countries of origin• Restitution• Self sufficiency• Ethical recruitment• Bonding• Improving post graduate training• Training different types of health
care workers• Incentives to stay• Partnership
RestitutionRestitution represents:• Progressive redistribution that works: health
services are highly redistributive• Practical response: informed policy since
training location of staff is verified on registration
• Non-discriminatory if detached from individuals: extent of the subsidy should inform policy
• Can be managed effectively: mechanisms can be designed on a case by case basis to assure additionality and ring fencing to health care
• Can help build incentives to stay
Ethical Recruitment
A failing policy?• Increase over time (below) in UK nurse registration
rates, during a period when a ban on active international recruitment had just come into effect:
Growth in registrations of nurses from Africa(randomly selected countries)
-
200
400
600
800
1,000
1,200
1,400
in 98/ 99 in 99/ 00 in 00/ 01 in 01/ 02 in 02/ 03
Year
Growth index (98/99 = 100)
Source = NMC
ZimbabweGhanaZambiaSAKenyaNigeria
Ban Ba
n st
reng
then
ed
Partnership• Boundaries are blurring between the UK
and low-income country health services - they are becoming interdependent
• Scope for mutual benefit and redistribution already exists e.g. in Ghana - UK health service links between professionals, associations, facilities and individuals
• Policy can build onto this: effective financial support, two-way circular migration, training and research collaboration