1. 1 Migration and the Global Healthcare Workforce: Balancing Competing Demands Peter Scherer: Counsellor, Directorate for Employment, and Social Affairs Organisation for Economic Cooperation and Development

2. 2 The Sources of Demand The reasons some countries are net recruiters of health professionals lies in their domestic markets. One of the main drivers seems to be the extent to which countries have restricted the number of places in tertiary institutions Those which have held down training places are turning to foreign suppliers to compensate for their under- investment

3. 3 Countries that dont or recently started to regulate medical school intake Countries that regulate medical school intake Impact of planning and market regimes on physician density

4. 4 Graduation Rates It is clear that many OECD countries are not training enough nurses or physicians to compensate for the outflow into other occupations and into retirement.

5. 5 Graduated nurses as a percentage of practising nurses, 2000

6. 6 Graduated physicians as a percentage of practising physicians, 2000

7. 7 The variation in domestic supply Although he data are only indicative (given definitional problems) the difference between the densities of doctors and nurses (as a percentage of the population) across member countries are striking. Spain constitutes a notable paradox: there is high unemployment amongst Spanish nurses, and official policy is that there is a surplus and foreign recruitment is welcome. Yet the density of nurses in that country is one of the lowest in the OECD

8. 8 Nurse density, 2000

9. 9 Physician density, 2000

10. 10 Changes in Density There is no apparent evidence that countries with higher density are reducing their nursing workforce (Canada is the exception) Hence the sources of demand for foreign nurses need to be sought in areas other than overall shortages,

11. 11 Change in nurse density from 1990 to 2000

12. 12 Outflows from the profession It is the tendency of nurses to leave the nursing workforce which is the perhaps the main driver of the perceived shortages to which employers respond, In the slide which follows, the net inflow/outflow rate relates the absolute number of nurses in a particular age band in a specific year to that of the previous age group five years earlier.

13. 13 Net inflow/outflow rates of nurses, 1996-2001 Age band 30-3435-3940-4445-4950-5455-5960-64 Austria12210688102803439 Belgium928987898667 Denmark266131101916255 France1049199107926228 Germany8494101106729426 Italy14511410992905350 Netherlands81808510612011326 New Zealand1391029990817280 Spain77690100797212152

14. 14 South African Case Study

15. 15 Flow chart of the production of health care New graduates Immigrants Re-entrants Leavers Emigrants Retirees Stock and productivity of physicians Volume and quality of health care Derived Demand Supply Patients Outflow Inflow Stock and productivity of other health care resources Supply Derived Demand Policies on: Education Pay Work conditions Migration Retirement Stock and productivity of nurses SKILL MIX

16. 16 Principal axes of international mobility of health professionals (by country of birth)

17. 17 Main message Cross-border migration is just one aspect of normal movements in labour markets The same issues of policies to improve retention which apply domestically apply to national policies Excessive rates of movement indicate a malaise in employment conditions In South African case, re-orienting training to address South African needs may help to reduce the role of the profession as a conduit for immediate migration But the aim should be to encourage retention for a reasonable number of years, not prevent movement.