Globalization and the Health Care Workforce Chapter 3 Globalization and the Health Care Workforce

Learning Objectives Describe the history and current trends in international migration of physicians and nurses Enumerate the factors that motivate physicians and nurses to migrate to other countries Discuss the implications of physicians and nurses migration for sending and receiving countries Understand the policy context and policy interventions that attempt to manage physicians and nurse migration Explain the issue of ethical recruitment, visa regulation, credentialing, and adaption for managers of foreign-born and trained physicians and nurses.

Introduction The International Migration of healthcare workers has caused increased debate in recent years. Issues arise with both the sending a receiving country. Specifically, developing countries lose trained personnel they have invested resources in. Managers of US Health Care systems need to understand international migration. Note: Look at training health care workers as an investment in to the economy. For developing countries the percentage of investment in training health care workers could be significant. Once a worker leaves for another country that “investment” leave with them. In addition, the country needs to spend more resources to find someone to replace the worker who left. Managers of US Health Care systems need to understand international migration – Specifically mangers need to know: In what areas do international migration of physicians and nurses occur. And why. What factors motivate international migration What are the ethical and logistical implications of physicians and nurse migration

History and Current Trends WHO Study in 1970 found International Medical Graduates practicing in the US were about 1 in 5. Significant numbers of International Nursing Graduates were also working in the US

History and Current Trends Historically sending countries were : Haiti Suriname Hong Kong Jordan Philippines More Filipino nurses were registered in the US and Canada then in the Philippines.

History and Current Trends Characteristics of the healthcare workforce migration have shifted since the WHO study Now we see migration FROM: Egypt Cuba The Caribbean Sub-Saharan Africa The Former Soviet Union

Cause of International Migration Push Factors What motivates them to leave? Pull Factors What motivates them to come? Push factors Low pay poor working conditions political instability inadequate housing lack of educational opportunities Pull factors Opportunities for growth Job opportunities Higher wages Workforce supply issues that cause an imbalance in the supply and demand

Sending Country / Region Trends Brain Drain: Sub-Saharan Africa and the Caribbean Widespread , uncontrolled departure of physicians and nurses. High rates of emigration have been seen in: South Africa Ghana In 2000, Ghana had more nurses leave the country then they graduated from nursing school that same year.

Sending Country / Region Trends Brain Drain: Sub-Saharan Africa and the Caribbean In Africa the HIV/ AID epidemic has seriously depleted the healthcare workforce 42% of nursing positions in the Caribbean are vacant The HIV/AIDS epidemic has effaced the health care workforce due to death and attrition and the increasing demand to treat HIV/AIDS patients.

Strategic Deployment: Cuba the Philippines, and India Some workforce migration is done purposely. Cuba has utilized their workforce surplus to supply other countries for decades Cuba has done this to become a global leader in healthcare

Strategic Deployment: Cuba the Philippines, and India Similar to Cuba, the Philippines has supplied the world with nurses The Philippines produces about 20,000 nurses a year In 2004, 85% of these nurses practiced abroad In second place behind the Philippines is India in deploying nurses. The benefit to any country that deploys workers and the benefit of those workers sending money back home to their families. Although, this may help the sending country financially it does not fix the problem of a worker shortage.

Strategic Deployment: Cuba the Philippines, and India Up and Coming Player: China China is relatively new to the global market Has only sent workers abroad for the last 15 years Chinese nurses are motivated to find work abroad do to a poorly funded health care system in china.

Consequences for Receiving Countries The Policy Context The receiving countries may not be addressing the root of the recruitment problem. General Agreement on Trade Services Liberalize trade in services Encourage economic growth Increase participation of developing countries in world trade NAFTA Created special visas between the US, Canada and Mexico

Consequences for Receiving Countries Policy Responses WHO Activities Treat, Train, Retrain ICN Statement Developed guide on the ethical recruitment of nurses Encourages receiving countries to correct their system problem of recruitment Domestic Policies in Sending Countries Implemented to curb “Push” issues Disincentives in the form of migration fees are sometime used Domestic Policies in Receiving Countries Turnover for nurses is estimated to be between 10% to 30% Policies implemented to reinvest in healthcare workers Government to Government Bilateral Agreements Receiving country agrees to underwrite the cost of medical training Staff are recruited only for a fixed period Compensation Schemes In addition to reimbursement for educational cost, this requires receiving country to pay additional costs to the sending country for the cost of losing the worker.

Consequences for Receiving Countries Policy Responses Managed Migration in the Caribbean Promotes regional cooperation in six areas: Terms and condition of work Recruitment, retention and training Value of Nursing Utilization of deployment Management practices Policy development Code of Practice on International Recruitment in the UK The UK is one of a few receiving countries that have set criteria for recruitment Code of Practice on International Recruitment in the UK Developing countries should not be targeted NHS employers should only use recruitment agencies that comply with this code NHS Employers should consider regional collaboration in international recruitment Staff recruited from abroad have the same legal protection a other employees Staff recruited from abroad should have the same access to training as other employees

Issues for Managers Recruitment Regulation Twinning Staff Exchange Educational Support Bilateral Agreement Regulation While in training = J-1 visa After training some convert to a H-1B or O temporary visa H-1B applies to specialty occupations O visas apply to physicians with Outstand abilities in their field Permanent residency through Labor certification National interest waiver

Issues for Managers Credentialing IMGs must have a diploma from a school listed in the International Medical Education Directory Must pass step 1 and 2 of the US Medical Licensing Exam Must have acceptable scores on the TOEFL

Issues for Managers Adaptation Must learn the culture of US Medicine IE: patient centered care for mental illness Must Also learn American family culture Certain family relationships will effect diagnosis and treatment (IE: single parent home)