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

2. 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.

3. 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

4. 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

5. 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.

6. 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

7. 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

8. 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.

9. 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.

10. 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

11. 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.

12. 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.

13. 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

14. 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.

15. 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

16. 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

17. 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

18. 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)