Many students migrate from small towns to big cities to pursue a university course in health-related areas. Once trained, many health professionals remain in large urban areas for their professional life. This leads to villages and towns suffering from a lack of health professionals to care for the population and high vacancy rates for medical doctors. As part of the strategies to reduce this problem, in 2013 the federal government instituted a program called “More Doctors” (Mais Médicos) which aimed to improve the primary care infrastructure, to increase availability of university courses for medicine, and to provide emergency supply of doctors to work in priority areas for the SUS (Giovanella et al., 2016; Girardi et al., 2016). The program More Doctors was substituted by the program “Doctors for Brazil” (Médicos pelo Brasil) in 2019. The new program “Doctors for Brazil” aims to supply remote areas of Brazil with doctors. There is an estimate that a total of 18,000 places will be created, with 4,000 located in the North and North-eastern areas of the country. Both Brazilian and foreign doctors are allowed to participate if their medical certificates are valid in Brazil. Other changes brought by the new program include doctors selection through admission tests and the establishment of work contracts in accordance with the Brazilian working laws (Confederação das Leis Trabalhistas – CLT) with two-year probationary period (Brazilian Ministry of Health, 2019e), as opposed to informal (hourly paid) jobs.

References:

Brazilian Ministry of Health. (2019e). Médicos pelo Brasil é aprovado pelo Congresso Nacional [Government]. http://saude.gov.br/noticias/agencia-saude/46092-medicos-pelo-brasil-e-aprovado-pelo-congresso-nacional

Giovanella, L., Mendonça, M. H. M. de, Fausto, M. C. R., Almeida, P. F. de, Bousquat, A., Lima, J. G., Seidl, H., Franco, C. M., Fusaro, E. R., & Almeida, S. Z. F. (2016). A provisão emergencial de médicos pelo Programa Mais Médicos e a qualidade da estrutura das unidades básicas de saúde. Ciência & Saúde Coletiva, 21(9), 2697–2708. https://doi.org/10.1590/1413-81232015219.16052016

Girardi, S. N., Stralen, A. C. de S. van, Cella, J. N., Wan Der Maas, L., Carvalho, C. L., & Faria, E. de O. (2016). Impacto do Programa Mais Médicos na redução da escassez de médicos em Atenção Primária à Saúde. Ciência & Saúde Coletiva, 21(9), 2675–2684. https://doi.org/10.1590/1413-81232015219.16032016

Locally trained health care workers usually stay in Hong Kong for practice. Migration does not play a significant role in the availability of health care workers in Hong Kong. In particular for doctors, up to the end of 2018, overseas-trained doctors constituted 24.9% of the total doctor supply in Hong Kong. This proportion is expected to continue to shrink due to retirement or other reasons as the criteria for overseas-trained doctors to practice in Hong Kong had become very stringent since September 1996. Among the doctors in practice, the number of overseas-trained doctors who became qualified after 1996 (i.e., 506) is only one-sixth of that before 1996 (i.e., 3152) (Legislative Council Secretariat, 2019a). If the existing policy for overseas-trained doctor remains unchanged, locally trained doctors will continue to be the main source of medical practitioners in Hong Kong.

References:

Legislative Council Secretariat. (2019a). Admission of overseas-trained doctors in Singapore and Australia.  Retrieved from https://www.legco.gov.hk/research-publications/english/1819in13-admission-of-overseas-trained-doctors-in-singapore-and-australia-20190509-e.pdf.

Migration of Indian nurses to other countries has long been documented, but recently, the trends have increased. Increasing international demand, desire for a more respectable and successful life, aggressive recruitment and increasing number of institutions providing training in line with international curriculum and placement support have contributed to this. Traditionally, migration  has been to nearby countries, especially to the Middle East because these countries are less expensive to immigrate to and have easier employment criteria in comparison to Western countries (Gill et al, 2011). However, the geographic expanse of migration has increased to Canada, the USA and the UK, Australia, and New Zealand (Garner, Conroy, & Bader, 2015). Although, due to changes in immigration policies there has been a decline in Indian nurses migrating to the USA and UK (World Health Organization (WHO), 2017). Within the country, there is a huge gap in the availability of nurses. The South trains more nurses (as they have significantly more nursing colleges) giving an impression of ‘surplus’ while the North faces a shortage of nurses and, hence, it serves as potentially attractive job market for the nurses trained in the South.

It is suggested that since the number of undergraduate places far outnumber those for post-graduates, young doctors leave the country for advanced training, fellowships, and job opportunities. There is a trend of returning to the country after training abroad; however, the drain is undercompensated and a large share of those returning settle in metropolitan cities. The urban centricity of the health workforce continues, especially in the private sector. Migration patterns among other health personnel in India have not been adequately studied.

References:

Garner, S. L., Conroy, S. F., & Bader, S. G. (2015). Nurse migration from India: A literature review. International Journal of Nursing Studies, 52(12), 1879–1890. https://doi.org/10.1016/j.ijnurstu.2015.07.003

Gill, R. (2011). Nursing shortage in India with special reference to international migration of nurses. Social Medicine, 6(1), 52-59. Available from: https://socialmedicine.info/index.php/socialmedicine/article/viewFile/517/1088

World Health Organization (2017). From Brain Drain To Brain Gain Migration Of Nursing And Midwifery Workforce In The State of Kerala. World Health Organization.

Emigration of health professionals has doubled between 2011 and 2013 to more than 5,600 across professions. This suggests that migration does affect the availability of healthcare workers in Indonesia, given that the number of healthcare workers across the population, and particularly in remote, rural parts or the country are already very low (Pusat Data dan Informasi Kementerian Kesehatan RI, 2014).

References:

Pusat Data dan Informasi Kementerian Kesehatan RI. (2014). Situasi dan analisis lanjut usia (pp. 1–7).

Migration of health care workers such as: (i) rural to urban or vice versa; (ii) private to public or vice versa; (iii) exit from the health sector to other sectors can reduce the number of health workers available to serve a certain population. Between 2005 and 2009, majority of those who left the service were enrolled nurses, followed by medical doctors (Ministry of Health, 2014c). It is clear that migration both within the country and out of the country play a role in the availability of health workers.

Migration to other countries

The rate of migration is higher than the rate of absorption after training. In 2006, Kenya indicated that 51% of doctors and 8.3% of nurses emigrated, most of them to the UK (Clemens & Pettersson Gelander, 2006). For every 4.5 nurses Kenya adds to the nursing workforce through training, one nurse in the workforce applies to out-migrate, with 70% of them aged between 21 – 40 years. This pattern poses a threat to Kenya’s ability to increase the number of nurses in the workforce through training by 22% (Gross et al., 2011).

Rural-Urban Migration

The national census held in 2009 indicated that Kenya had a population of 38.6 million with 26.1 million and 12.1 million living in rural and urban areas, respectively (Kenya National Bureau of Statistics, 2010). However, this marks different in terms of the health professionals distribution, as more than half of health workers and 80% of doctors were based in urban regions (Gondi, Otieno, & James, 2006). Rural dispensaries report only 20% staffing rates in their nursing establishments, while district/urban hospitals report staffing rates of 120% (Luoma et al., 2010). The migration to urban areas is influenced by the housing allowances, which are much higher for those living in urban regions compared to those living in remote rural settings (Luoma et al., 2010). Further intensifying the misdistribution of healthcare workers by cadre is the employment of 42% of Kenya’s doctors and 13% of all nurses in the two national referral hospitals (Luoma et al., 2010).

Migration from public to private sector

A number of Kenyans seek health services in the public sector because of the subsidized medical fees and free services such as maternity care and HIV and AIDS treatment. However, a study conducted in Kenya revealed that 50.9% of health workers preferred working in Non-Governmental Organizations (NGO’S), 26.9% in government institutions, 11.7% out of the country, 6.3% in Faith Based Organizations (FBO) and 4.2% in private institutions (Ojakaa, Olango, & Jarvis, 2014). One of the strengths of the public health facilities is the stability of employment. However, a recent study conducted in public hospitals in three counties revealed that nearly 90% of health care workers were employed on permanent terms but about three quarters experienced low levels of job satisfaction (Tengah & Otieno, 2019). The poor remuneration, understaffing, inadequate medical supplies and poor working conditions  in the public sector has contributed to health care workers migrating to private clinics/hospitals (Ndetei, Khasakhala, & Omolo, 2008).

There is limited data on the salaries of health care workers in Sub-Saharan Africa. However, it is important to note that increased salary is not the only issue contributing to retention of workers. The following non-financial incentives have been considered a priority by health care workers in Kenya and Sub-Saharan Africa (McCoy et al., 2008; Ndetei et al., 2008):

• Enhanced working conditions such as medical supplies and upgrading of facilities
• Training e.g., Continuous Medical Education and improving the quality of supervision
• Good living conditions and opportunities for health workers to further their education and their children.
• Addressing job safety and security concerns

References:

Clemens, M., & Pettersson Gelander, G. (2006). A New Database of Health Professional Emigration from Africa. Human Resources for Health (Vol. 6). http://doi.org/10.2139/ssrn.924546

Gondi, O., Otieno, A., & James, J. (2006). Report on Human Resources Mapping and Verification Exercise. Nairobi, Kenya.

Gross, J. M., Rogers, M. F., Teplinskiy, I., Oywer, E., Wambua, D., Kamenju, A., … Waudo, A. (2011). The impact of out-migration on the nursing workforce in Kenya. Health Services Research, 46(4), 1300–1318. https://doi.org/10.1111/j.1475-6773.2011.01251.x

Kenya National Bureau of Statistics. (2010). The 2009 Kenya Population and Housing Census. Home Healthcare Nurse. 371–372. https://s3-eu-west-1.amazonaws.com/s3.sourceafrica.net/documents/21195/Census-2009.pdf

Luoma, M., Doherty, J., Muchiri, S., Barasa, T., Hofler, K., Maniscalco, L., … Maundu, J. (2010). Kenya Health System Assessment 2010. Health Systems 20/20 Project, 20(August), 1–133. https://www.hfgproject.org/wp-content/uploads/2015/02/Kenya-Health-Systems-Assessment-2010.pdf

Ministry of Health. (2014c). Health Sector: Human Resources Strategy: 2014-2018. Nairobi, Kenya. https://www.health.go.ke/wp-content/uploads/2016/04/Kenya-HRH-Strategy-2014-2018.pdf

Ndetei, D. M., Khasakhala, L., & Omolo, J. O. (2008). Incentives for health worker retention in Kenya: An assessment of current practice. EQUINET, 62, 29. https://www.equinetafrica.org/sites/default/files/uploads/documents/DIS62HRndetei.pdf

Ojakaa, D., Olango, S., & Jarvis, J. (2014). Factors affecting motivation and retention of primary health care workers in three disparate regions in Kenya. Human Resources for Health, 12(1), 33. http://doi.org/10.1186/1478-4491-12-33

Tengah, S. A., & Otieno, O. J. (2019). Factors Influencing Job Satisfaction among Nurses in Public Health Facilities in Mombasa, Kwale and Kilifi Counties, Kenya. Advances in Social Sciences Research Journal, 6(5). https://doi://doi.org/10.14738/assrj.65.6389

While Mexico City is still the major point of attraction for medical students and specialty medical doctors, other major cities and metropolitan areas follow as large migration pull factors. However, other health professionals such as nurses, have not followed these patterns as they usually work in the same state where they receive their professional education.

Professional migration between Mexico and the United States has historically been present within both countries. However, few studies have documented this migration by type of profession or occupation, besides that of non-professional agricultural migration. With respect to health professionals, migration of nurses has been scarcely documented (Arroyo-de Cordero & Jiménez-Sánchez, 2005). Moreover, migration of medical professionals from Mexico to other countries (U.S. and Europe mostly) has been defined as highly difficult or problematic due to regulatory terms and differences in skills and language barriers that make it difficult to practice elsewhere. For example, a news report stated that out of approximately 19,000 nurses that present exams each year looking for placement in their state hospitals, less than 100 are from Mexico (Nájar, n.d.).

In addition, given current anti-immigration policies in place in the U.S., the reduction in total number of formal work permit and visas (work-visa bans) as well as more restrictions to those issued (such as being required to pay for health care) could hinder the increase of migration of health professionals in the near future.

References:

Arroyo-de Cordero, G. & Jiménez-Sánchez, J. (2005). Repercusiones de la escasez versus migración de enfermeras como fenómeno global. Rev Enferm IMSS, 13(1), 33–40.

Nájar, A. (n.d.). Enfermeras: las mexicanas más cotizadas en EE.UU. BBC Mundo.

There were 14,475 practising internationally qualified nurses on the Register on the 31^st of March 2019: 104 Nurse Practitioners, 14,180 Registered Nurses, and 191 Enrolled Nurses. This represents 27% of the overall practising nurse workforce, 28% of Nurse Practitioners, 27% of Registered Nurses, and 8% of Enrolled Nurses (Nursing Council of New Zealand, n.d.).

MCNZ registration data indicate that the proportion of IMGs in the workforce as of 30 June 2017, was 42.6 percent. Although some IMGs only come to New Zealand for short periods, many are relocating permanently (Medical Council of New Zealand, 2018). The distribution of hospital doctors and GPs throughout the country is largely consistent with the NZ population spread. However, regions that are harder to staff tend to have a higher proportion of IMGs.

References:

Medical Council of New Zealand. (2018). The New Zealand Medical Workforce in 2018. Wellington Medical Council of New Zealand. Available from: https://www.mcnz.org.nz/assets/Publications/Workforce-Survey/434ee633ba/Workforce-Survey-Report-2018.pdf

Nursing Council of New Zealand. (n.d.). Tatauranga Ohu Mahi, Workforce Statistics. Available from: https://www.nursingcouncil.org.nz/Public/Publications/Workforce_Statistics/NCNZ/publications-section/Workforce_statistics.aspx?hkey=3f3f39c4-c909-4d1d-b87f-e6270b531145.

Migration of health workers has been a major concern in South Africa for many years (Mahlathi & Dlamini, 2015; Rawat, 2012). There is no systematic means of monitoring and collecting data to monitor the movement of professionals within and out of the country – 2 processes that have contributed to a high turnover of specifically South African nurses (Mahlathi & Dlamini, 2015). A third of doctors (i.e., 8921) registered with the country’s regulating body, the Health Professions Council of South Africa (HPCSA), were abroad in 2006 as well as 6844 nurses, and 7642 other health professionals (DOH, 2011).

References:

DOH. (2011). HUMAN RESOURCES FOR HEALTH SOUTH AFRICA (HRH) Department of Health. Available from: http://www.hst.org.za/publications/NonHST Publications/hrh_strategy-2.pdf

Mahlathi, P., & Dlamini, J. (2015). MINIMUM DATA SETS FOR HUMAN RESOURCES FOR HEALTH AND THE SURGICAL WORKFORCE IN SOUTH AFRICA’S HEALTH SYSTEM: A rapid analysis of stock and migration. Available from: http://www.prographic.com/wp-content/uploads/2016/07/0316-south-africa-case-studies-web.pdf

Rawat, A. (2012). Gaps and shortages in South Africa’s health workforce. Backgrounder, 31(June), 1–8. https://doi.org/10.13140/RG.2.1.4424.0805