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GLOBALIZATION AND THE HEALTHCARE WORKFORCE
Leah E. Masselink
CHAPTER
3
47
Learning Objectives
After completing this chapter, the reader should be able to
• 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 physician and nurse migration for sending and receiving countries;
• understand the policy context and policy interventions that attempt to manage physician and nurse migration; and
• explain the issues of ethical recruitment, visa regulation, credentialing, and adaptation for managers of foreign-born and -trained physicians and nurses.
Introduction
In an increasingly interconnected world, the movement of people and infor- mation across international borders has become a phenomenon that is often taken for granted. As skilled healthcare providers, physicians and nurses have had opportunities to seek employment internationally for several decades, and foreign-trained professionals are important parts of the healthcare systems in many countries. In the United States alone, about 25 percent of physicians are foreign born and educated and about 4 percent of nurses were educated over- seas (Cooper and Aiken 2006; Aiken et al. 2004).
The implications of international migration of physicians and nurses are complex, becoming a source of increasing debate in recent years. While physicians and nurses who migrate to other countries can benefit from better working conditions or salaries in their destinations, their movement can exacer- bate inequalities in the worldwide distribution of healthcare workers. Migration
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C o p y r i g h t 2 0 0 8 . H e a l t h A d m i n i s t r a t i o n P r e s s .
A l l r i g h t s r e s e r v e d . M a y n o t b e r e p r o d u c e d i n a n y f o r m w i t h o u t p e r m i s s i o n f r o m t h e p u b l i s h e r , e x c e p t f a i r u s e s p e r m i t t e d u n d e r U . S . o r a p p l i c a b l e c o p y r i g h t l a w .
EBSCO Publishing : eBook Academic Collection (EBSCOhost) - printed on 2/1/2022 4:15 PM via WESTERN KENTUCKY UNIVERSITY AN: 237620 ; Fottler, Myron D., Fried, Bruce.; Human Resources in Healthcare : Managing for Success Account: s8993066.main.ehost
of healthcare workers from developing countries has particularly far-reaching implications. These developing countries not only lose their investments in ed- ucation and training, income tax revenue, and potential for national growth, buy they also see adverse health effects on their populations. In nations where healthcare workforce shortages are already severe, the need to replace healthcare professionals who have left for other countries only further depletes the health system’s resources—funds that normally go toward fighting diseases and pro- moting public health. In addition, the lack of highly skilled care providers pre- vents these countries from meeting their own needs for healthcare innovation and problem solving. These factors exacerbate the existing inequalities in health- care between developed and developing countries.
Given that foreign-trained physicians and nurses play an important role in many healthcare organizations in the United States, healthcare managers in this country must understand several issues related to the globalization of the healthcare workforce:
• In what areas do international migration of physicians and nurses occur? What can explain these patterns?
• What factors motivate the international migration of physicians and nurses?
• What are the ethical and logistical implications of physician and nurse migration for sending and receiving countries?
International migration of physicians and nurses is inherently difficult to manage because policies designed to direct and oversee it must balance two often competing objectives: (1) to protect the inherent right of people to mi- grate and (2) to ensure that quality healthcare services are available to all. This chapter describes past and current migration trends, causes, policy context, and responses. It also explores several international migration issues, such as ethical recruitment, visa regulation, credentialing, and adaptation. All of these topics are essential knowledge for U.S. healthcare managers.
History and Current Trends
Anecdotal accounts of international migration of physicians and nurses began to circulate in the 1960s. Initial reports mostly documented migration be- tween developed countries, such as from Canada to the United States (BMJ 1968). In the 1970s, the World Health Organization (WHO) commissioned The Multinational Study of the International Migration of Physicians. This no- table study found that, at the time, significant numbers of international med- ical graduates (IMGs) were practicing in the United States (about one in every five physicians), the United Kingdom (more than one in every four physicians), and Canada (one in every three physicians). Germany also had
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substantial numbers of migrant physicians, including many from Iran and the Middle East (Mejía 1978). In addition, the study reported that significant numbers of international nursing graduates (INGs) worked in the United States, European countries, and other developed nations. Sending countries (the countries from which healthcare professionals migrate) with particularly high proportions of nurses who go abroad to work include Haiti, Suriname, Hong Kong, Jordan, and the Philippines. In absolute numbers, more Filipino nurses were registered in the United States and Canada than in the Philippines in 1970 (Mejía 1978).
The characteristics of healthcare workforce migration have shifted since the WHO study was conducted in the 1970s. New sending countries have be- come significant sources of migrant physicians, including Egypt, Cuba, and nations in the Caribbean; sub-Saharan Africa; and the former Soviet Union. New receiving countries (the destinations of migrant healthcare professionals), such as the Persian Gulf states, have begun to draw physicians and nurses from all over the world, including Europe and India. Migration between the Euro- pean Union and African countries has also increased (Martineau, Decker, and Bundred 2004). Some countries—particularly South Africa—have emerged as “holding grounds” for migrant workers who stay temporarily on their way to their final destination country (Vujicic et al. 2004).
According to Mullan (2005), the countries that send the largest num- bers of physicians abroad are India, the Philippines, and Pakistan, while the countries that receive the greatest numbers of IMGs are the United States, the United Kingdom, Canada, and Australia. IMGs compose approximately 25 percent of the physician workforce in the United States, 28 percent in the United Kingdom, 23 percent in Canada, and 27 percent in Australia (Mullan 2005). In the United States, the three largest sending countries or regions for INGs are the Philippines, Canada, and Africa (especially South Africa and Nige- ria). Between 1997 and 2000, 33 percent of foreign-born nursing-licensure ap- plicants were Filipino, 22 percent were Canadian, and 7 percent were African (Buchan, Parkin, and Sochalski 2003).
Migration streams, particularly between English-speaking countries, appear to be well established: While IMGs make up more than 20 percent of the total physician workforces in the United States, the United Kingdom, Australia, and Canada, they represent only a tiny proportion of the physician workforces in France (3 percent) and Japan (1 percent) (Mullan 2005). In sub-Saharan Africa, rates of nurse migration are also markedly higher in An- glophone countries than in French- and Portuguese-speaking countries (Dovlo 2007). Many sending countries tend to have historical relationships with English-speaking receiving countries. For example, physicians from India and Pakistan make up the largest and third-largest groups, respectively, of IMGs in the United Kingdom, and doctors from the Philippines are the second- largest group of noncitizen IMGs in the United States (Mullan 2005).1
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Many policymakers in both sending and receiving countries have ex- pressed concern about the fact that the largest receiving countries draw sig- nificant proportions of their IMG workforces from lower-income countries. More than 75 percent of the IMGs in the United Kingdom come from lower- income countries, and other receiving countries have substantial proportions as well: Sixty percent of IMGs in the United States and about 40 percent of those in Canada and Australia are from developing nations (Mullan 2005).
Causes of International Migration
Determinants of physician and nurse migration are often discussed in terms of “push” and “pull” factors. Push factors motivate physicians and nurses to leave their home countries, while pull factors cause them to choose particular receiv- ing countries. The reasons are chiefly discussed within an economic framework, considering a variety of factors as potential determinants. These include per capita gross domestic product, physician coverage, manpower production rates, rural/urban distribution of physicians and nurses, and workforce imbalances.
Push factors cited by the majority of studies include low pay, poor working conditions, political instability and insecurity, inadequate housing and social services, and lack of educational opportunities and professional de- velopment. Job dissatisfaction, lack of motivation, and weak professional lead- ership are also mentioned as contributing factors (Saravia and Miranda 2004). Pull factors, on the other hand, include opportunities for professional train- ing, better job opportunities, and higher wages (Forcier, Simoens, and Giuf- frida 2004). Other pull factors relate to workforce-supply issues that have cre- ated an imbalance between the demand for services and the supply of workers in receiving countries, such as aging of both the general population and the nursing workforce and the slowdowns in enrollment in training programs (Buchan and Sochalski 2004). The nursing workforces in receiving countries are vulnerable to such shortages, particularly with the opening of male-dom- inated careers to women (Marchal and Kegels 2003). IMGs and INGs are par- ticularly needed in some receiving countries where domestically trained providers are reluctant to serve in certain capacities, such as in remote areas or in nursing homes.
Sending Country/Region Trends
Physician and nurse migration can be managed to varying degrees by sending countries. Some regions (such as sub-Saharan Africa and the Caribbean) con- tinue to lose workers in the face of severe shortages, while other nations (such as Cuba, India, and the Philippines) purposely train surplus physicians and
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nurses for overseas employment. Still other countries (particularly China) are currently looking to shift into a training-for-export mode. This section sheds light on the diverse situations faced by sending countries and describes in de- tail the factors that contribute to each situation.
Brain Drain: Sub-Saharan Africa and the Caribbean
The situation in sub-Saharan Africa and the Caribbean is often referred to as brain drain—the widespread, uncontrolled departure of physicians and nurses from countries that already suffer healthcare worker shortages.
In sub-Saharan Africa, the largest sending countries are South Africa and Nigeria. In 2005, nearly 7,000 South African physicians and more than 4,000 Nigerian physicians were practicing in the United States, the United Kingdom, Canada, and Australia (Mullan 2005). Ghana has also experienced high rates of physician and nurse emigration: In 2000, that country lost more practicing nurses than the number of nursing graduates it produced (Dovlo 2007). As a relatively wealthy sub-Saharan African state, South Africa is unique in that it acts as both a sending and a receiving country for migrant physicians and nurses, many of whom come from other countries in the region.
In Africa, among the factors that influence health professionals’ deci- sions to leave are low quality of life, high crime rates, conflict, political repres- sion, and lack of educational opportunities for children. The HIV/AIDS epi- demic has seriously depleted the healthcare workforce through death and attrition, and caring for growing numbers of patients with HIV/AIDS has overburdened the remaining providers. Nurses in this region are poorly paid, and this lack of adequate compensation also contributes to the workforce shortage. Sub-Saharan Africa suffers from a serious maldistribution of healthcare workers, with uneven supply between the public and private sectors, urban and rural areas, and tertiary and primary levels of care (Padarath et al. 2004).
A lack of higher education and career-development opportunities is an- other major push factor in this region. This dearth reflects a pattern of under- investment in higher education by governments and outside donors. Health- professional education and training not only subsist on very limited material resources but are also plagued by a shortage of qualified teachers.
Similarly, countries in the Caribbean are overwhelmed by extremely high rates of HIV infection that are second only to the epidemic in sub-Saharan Africa. This region has also experienced crippling losses of nurses in recent years: 42 percent of all nursing positions across the Caribbean are vacant, and the lack of nursing educational capacity serves only to perpetuate the massive losses of nursing educators and experienced nurses. Jamaica is particularly af- fected, with a 58 percent average nursing vacancy rate in 2003. Many Ja- maican nurses left to work in the United States, the United Kingdom, and Canada, and Jamaican healthcare leaders have begun to recruit from other countries in the Caribbean to make up for losses (Salmon et al. 2007).
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Strategic Deployment: Cuba, the Philippines, and India
Some developing countries train surplus physicians and nurses for overseas employment, and both state and business interests promote and manage this practice. Cuba has a long-standing program of physician deployment, and the Philippine government has worked to manage nurse migration for many years. Recently, strategic deployment programs have also arisen in India.
For several decades now, Cuba has made the provision of healthcare workers to developing countries a part of its foreign policy, sending physicians to developing countries as participants in a Peace Corps–style international medical-aid program (Feinsilver 1989). These efforts are part of a larger ef- fort by the Cuban government to promote its political agenda and to position itself as a “world medical power.” Dozens of countries have received Cuban physicians over the years, including Algeria, South Africa (Lee 1996), and more recently Venezuela (Muntaner et al. 2006). Cuban physicians who par- ticipate in the program often provide services in isolated rural areas and are often involved in training their host countries’ indigenous healthcare workers (Feinsilver 1989).
The Philippine government has been particularly active in establishing policies that aim to make the country the niche producer of nurses in the global economy (Ball 1996). The Philippines produces about 20,000 new nurses every year (Lorenzo et al. 2007), and the vast majority of these grad- uates eventually find work overseas: In 2004, 85 percent of all Filipino nurses practiced abroad (Aiken et al. 2004). A government agency regulates recruit- ment of Filipino overseas workers and processes documents for those bound to work in other countries. The emergence of nursing as a pathway to migra- tion has led to unprecedented demand for nursing education in the Philip- pines. The number of nursing schools has grown exponentially in the past few decades, from 40 schools in the 1970s to 460 schools in 2006 (Lorenzo et al. 2007). This growth has led to concerns about the quality of nursing educa- tion, as schools compete with each other for faculty and hospital training space (Lorenzo et al. 2007).
Historically, India has been one of the largest sending countries of physicians to developed nations, including the United States and the United Kingdom (Mullan 2006). In recent years, it has also become a popular source country for nurses. Since the 1990s, it has moved from sixth to second posi- tion (after the Philippines) among countries that send nurses to the United States. Like the Philippines, India has a huge overall labor surplus, although it also has a very low nurse-to-population ratio. It has also become the site of increasing commercial activity around nursing education and migration. In- dian hospitals have become involved in recruiting and training nurses for over- seas markets, and local recruitment agencies that partner with U.S.-based re- cruiters have appeared in many urban areas. In recent years, some state
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governments have also begun to engage in international deployment of nurses (Khadria 2007).
The most frequently cited reason for the strategic deployment of physi- cians and nurses is the remittance income that migrant workers send to their home countries. Remittances can be a substantial source of revenue for send- ing countries. For example, Filipino migrant workers remitted $10.7 billion in 2005 (Lorenzo et al. 2007). Remittance income is often considered a po- tentially positive outcome of emigration. However, while such income may offset sending countries’ financial losses, it may not make up for the staffing issues and poor outcomes associated with workforce migration.
Up-and-Coming Player: China
China is a relative newcomer to the global nursing market. It has sent nurses abroad for about 15 years, when the government began deploying groups of English-speaking nurses to Singapore and Saudi Arabia under temporary gov- ernment-arranged contracts (Fang 2007). Since the early 2000s, this migra- tion has shifted to countries such as Australia and the United Kingdom, where it is usually arranged by private agencies. U.S. healthcare organizations have begun to express interest in recruiting nurses from China.
For some Chinese nurses, the desire to seek employment abroad is in- fluenced by several domestic factors. First, China has not invested enough in healthcare to employ all of its trained and educated nurses. Like the Philip- pines, China has a surplus of nurses based on the number of budgeted posi- tions. Many nurses are unable to find work, or they are forced to retire early to make room for new graduates who are entering the workforce. Also, China has more physicians than nurses, contrary to recommendations by the WHO. In this context, overseas markets are becoming a desirable alternative for some Chinese nurses.
Consequences for Receiving Countries
The presence of IMGs and INGs has several important consequences for re- ceiving countries. Some of the consequences of physician and nurse migration relate to larger issues of recruitment and retention. International recruitment is suggested to be a quick fix for recruitment and retention problems in re- ceiving countries, allowing domestic supply lines to avoid developing their own solutions to unmet health-system needs. International migration may help receiving countries to fill positions in areas that are not as attractive to domestic workers. This leads to concerns that foreign-trained professionals may be subject to exploitation or may be forced to work in positions that are below their expertise—a phenomenon referred to as “brain waste” (Marchal and Kegels 2003).
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The effects of having immigrant physicians and nurses on accessibility and quality of care are unclear: Some suggest that the quality and safety of care provided by internationally trained providers may be cause for concern, while others argue that the presence of these professionals may improve access to care, lower prices, and induce competition and higher quality (Forcier, Simoens, and Giuffrida 2004). The “safety net” use of immigrant healthcare workers has been demonstrated to be a real phenomenon (Forcier, Simoens, and Giuffrida 2004). The presence of immigrant health workers may prevent receiving healthcare systems from solving their own training and staffing problems. For example, while U.S. hospitals hire thousands of IMGs each year, thousands of domestic medical-school applicants are turned away (Mar- tineau, Decker, and Bundred 2004).
The Policy Context
International migration occurs in the context of several important trade agreements. One such agreement that could affect future migration dynam- ics is the General Agreement on Trade in Services (GATS), which was imple- mented in 1995. GATS is an international treaty that governs the trade of services, including health services, among member countries of the World Trade Organization. GATS has three main objectives: (1) to liberalize trade in services, (2) to encourage economic growth through liberalizing trade in services, and (3) to increase the participation of developing countries in the world trade in services. The four modes of trade governed by GATS are (1) cross-border supply (services provided by workers in one country for organ- izations in another country), (2) consumption abroad (including medical tourism and education of foreign students), (3) commercial presence (invest- ment of capital from one country into another), and (4) movement of natu- ral persons (temporary cross-border migration of workers to provide services in another country [Kingma 2006]). While the GATS provision for tempo- rary migration has caused concern that it would encourage further migration of health workers from developing countries to developed countries, this el- ement is still being negotiated, and its final effects remain unclear (Kingma 2007).
Another agreement that particularly affects migration patterns in the United States is the North American Free Trade Agreement (NAFTA), which was implemented in 1994. NAFTA provides for the movement of workers be- tween Canada, the United States, and Mexico, including special visa cate- gories and mutual recognition of nurse licensure in the United States and Canada. This agreement has raised Canada’s profile as a sending country of nurses in the United States, but movement between the two countries has been mostly unidirectional: About 15,000 Canadian nurses have moved to the United States under NAFTA, but relatively few U.S.-trained nurses have moved to Canada (Kingma 2006; Mautino 2003).
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Policy Responses
A broad variety of policy initiatives have been proposed and implemented by sending and receiving countries to manage international migration of physi- cians and nurses. These include programs instituted by worldwide bodies such as the WHO and the International Council of Nurses (ICN), domestic policy changes in sending and receiving countries, government-to-government bi- lateral agreements, and proposed compensation schemes. Some countries or regions have adopted unique policies to manage the effects of physician and nurse migration: The Caribbean, as a sending region, has adopted a program called Managed Migration, and the United Kingdom, as a receiving country, has established the “Code of Practice on International Recruitment.”
The WHO (2007) has developed a variety of initiatives to manage the migra- tion of healthcare workers. It is working with the Global Health Workforce Alliance Task Force to support efforts to scale up health-worker education, particularly in countries faced by workforce crises. It also provides technical support to countries and assists regional human resources for health observa- tories. Additionally, the WHO supports the Treat, Train, Retain (TTR) initia- tive, begun in 2006 to curb the effects of HIV/AIDS on the healthcare work- force and health systems in low- and middle-income countries. The goals of TTR are threefold: (1) to provide treatment, prevention, and support to health workers affected by HIV/AIDS; (2) to train providers (including com- munity health workers) to maximize existing capacity to treat HIV/AIDS; and (3) to retain health workers in rural areas and the public sector in un- derresourced countries. The WHO will provide assistance to participating countries in developing TTR plans and budgeting for proposed changes, but TTR’s implementation and financing will be managed by individual countries.
The ICN—the federation of national nurses associations (e.g., American Nurses Association, Philippine Nurses Association)—has developed a position statement on ethical recruitment of nurses to guide the recruitment efforts between its member countries. While acknowledging nurses’ inherent right to migrate, the statement also calls for receiving countries to work toward build- ing self-sustainable, domestically trained nursing workforces. The statement also aims to protect migrant nurses, calling for several measures such as good- faith contracting, freedom of employment and association, and fair pay and working conditions (ICN 2007).
Some sending countries have implemented domestic policy changes to reduce the effects of push factors that motivate physicians and nurses to seek overseas employment. These changes include improvement in pay, career opportunities, and working conditions; provision of incentives to induce overseas workers to
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WHO Activities
ICN Statement
Domestic Policies in Sending Countries
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return home; and the development of private-sector opportunities. Other meas- ures focus more specifically on medical education, including pre-education screening of candidates likely to stay in-country, shortening of domestic train- ing programs, and adaptations of curriculum to local conditions.
Still other policies aim to use financial disincentives to keep workers in- country, requiring emigrants to pay fees upon departure. For example, Eritrea has a bond program in which departing physicians are required to make up- front payments that guarantee their return from studies in South Africa (Mar- chal and Kegels 2003). This type of system could be particularly useful if rev- enues generated were used to fund human resources development in sending countries (Saravia and Miranda 2004).
Some receiving countries have adopted domestic policy changes to address the underlying human resources imbalances that contribute to the demand for foreign-trained workers. In many developed countries, nursing short- ages are exacerbated by difficulties in retaining domestically trained nurses—difficulties that are often related to poor working conditions and low salaries (Janiszewski Goodin 2003). Turnover rates for nurses in U.S. hospitals were estimated at between 10 percent and 30 percent in 2000 (HSM Group 2002). To improve domestic retention, receiving countries, such as the United Kingdom and Australia, have implemented programs to recruit and retain domestic healthcare workers (Martineau, Decker, and Bundred 2004). Other countries have begun recruiting nonconventional workers, such as firefighters, to the healthcare field (Marchal and Kegels 2003).
In 2002, the U.S. Congress passed the Nurse Reinvestment Act, a piece of legislation that uses a combination of expanded eligibility for loan re- payment, education vouchers, and other measures to improve retention of nurses (Andrews 2004). While this legislation represents a positive step in im- proving retention of domestically trained nurses, its funding stream has been subject to frequent cuts in the past few years, so its overall impact is unclear (Janiszewski Goodin 2003).
Some sending and receiving countries have attempted to regulate the migration of healthcare workers between them by signing government-to-government bilateral agreements. Under this agreement, a receiving country pledges to underwrite the costs of training additional staff; to recruit staff for a fixed pe- riod (often providing training before staff return to the sending country); or to recruit surplus staff from a sending country (Buchan 2007). For example, the United Kingdom has bilateral agreements with the Philippines and Spain that allows the United Kingdom to recruit nurses from these two countries for temporary work in the National Health Service (Kline 2003). Bilateral agreements can help to manage the flow of physicians or nurses between
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Domestic Policies in Receiving Countries
Government-to- Government
Bilateral Agreements
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sending and receiving countries by mandating short-term rather than perma- nent migration.
Another policy intervention that has been proposed requires receiving coun- tries to compensate sending countries for the financial losses associated with worker migration. Various versions of this plan call for remuneration of the costs of educating migrant workers, for assistance with human resources de- velopment in sending countries, and for additional compensation for sending countries’ lost tax revenue. Although well intended, these measures are diffi- cult to implement because administrative costs would likely be high and be- cause determining payment amounts, procedures, and enforcement would present further challenges to sending and receiving countries (Marchal and Kegels 2003).
The Managed Migration program in the Caribbean is one of the most sophis- ticated policy responses to the issue of nurse migration in a sending country or region. Managed Migration aims to promote regional cooperation and strategic planning in six critical areas:
1. Terms and conditions of work 2. Recruitment, retention, and training 3. Value of nursing 4. Utilization and deployment 5. Management practices 6. Policy development
This program was developed by a partnership among national, re- gional, bilateral, and international stakeholders. Initiatives developed under the program include efforts to promote temporary or part-time migration of Caribbean-trained nurses to developed countries, agreements requiring re- ceiving countries to invest in sending countries’ health-professions education systems, and promotion of health tourism in Caribbean countries (Salmon et al. 2007).
The United Kingdom is one of the few major receiving countries to develop a specific policy to guide the recruitment of internationally trained physicians and nurses. Its National Health Service (NHS) has created the Code of Prac- tice on International Recruitment, which includes the following provisions (Buchan 2007):
• Developing countries should not be targeted for active recruitment by the NHS unless the government of that country formally agrees.
• NHS employers should only use recruitment agencies that have agreed to comply with the Code.
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Compensation Schemes
Managed Migration in the Caribbean
Code of Practice on International Recruitment in the United Kingdom
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• NHS employers should consider regional collaboration in international recruitment activities.
• Staff recruited from abroad have the same legal protection as other employees.
• Staff recruited from abroad should have the same access to further training as other employees.
While the Code has been touted as an example for other countries to follow, its effectiveness is somewhat limited by the fact that it only applies to the public sector (not to independent or private employers or recruitment agencies), and employers and migrant healthcare workers have found many ways to work around it. Nonetheless, the Code represents a deliberate effort by a receiving country to reduce the negative effects of healthcare worker re- cruitment from developing countries.
Issues for Managers
The movement of IMGs and INGs into the U.S. healthcare system raises sev- eral important issues for managers and leaders. In particular, managers must be aware of issues of ethical recruitment, regulation (visas), credentialing, and adaptation for internationally trained physicians and nurses. (For a sum- mary of the elements in these issues, see Table 3.1.) Careful consideration of all of these areas is necessary to facilitate the successful recruitment and in- corporation of internationally trained healthcare professionals into the U.S. healthcare system and to minimize the migration’s negative effects on send- ing countries.
Recruitment
Healthcare organizations can recruit workers from overseas through several mechanisms. These include, but are not limited to, the following (Buchan and Perfilieva 2006):
• Twinning. Hospitals in sending and receiving countries develop links, based on staff exchanges, staff support, and flow of resources.
• Staff exchange. Healthcare workers temporarily move between organizations in sending and receiving countries for career and personal development opportunities or for organizational growth.
• Educational support. Educators and/or educational/funding resources temporarily move from receiving to sending organizations.
• Bilateral agreement. Employers in the receiving country develop an agreement with employers or educators in the sending country to help pay the costs of training additional staff or to recruit staff for training and development before returning staff to the sending country.
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60 H u m a n R e s o u r c e s i n H e a l t h c a r e
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Additionally, IMGs and INGs also find jobs through informal mecha- nisms, such as personal and professional contacts (Bagchi 2001). In all of these models, the recruitment process can be conducted directly by the employer or mediated by either domestic or overseas recruitment agencies. A recruitment agency typically charges a hiring organization between $5,000 and $10,000 per nurse. In return, nurses agree to work for the hiring organization for a fixed period of time—usually two to three years. For-profit recruitment agen- cies represent an important and growing presence in overseas hiring of nurses in particular; many of them set up both domestic and sending-country offices to facilitate the process (Brush, Sochalski, and Berger 2004).
Employers in receiving countries must consider the implications of their recruiting practices for the countries and organizations from which they are recruiting. They must also be aware of the rights of the workers them- selves. The United States has no overarching code of practice for international recruitment of healthcare workers, so the decisions about how to balance eth- ical concerns with domestic staffing needs are the responsibility of individual employers and the recruitment agencies with which they work. Recruitment agencies’ behavior has improved since a rash of abuses was documented in the 1980s. Today, efforts toward better practice are fueled by market competition between agencies (Kingma 2006). Employers and recruiters must take re- sponsibility for not recruiting from countries with severe shortages and for providing a safe and transparent recruitment process for migrant workers.
Regulation (Visas)
Because most IMGs enter the United States as residents, the first type of visa that they commonly obtain is the J-1 visa, a category for trainees. The Edu- cational Commission for Foreign Medical Graduates (ECFMG 2007) is au- thorized by the U.S. Department of State to sponsor J-1 visas for IMGs. Af- ter completing their training, some physicians obtain permanent residency status, while others remain in the country on H-1B or O temporary visas.
H-1B visas apply to immigrants in “specialty occupations,” which usu- ally require at least a bachelor’s degree. These visas allow for a three-year length of stay, which can then be extended for three additional years. O visas can be obtained by physicians who have “outstanding” abilities in their field; these are usually researchers or specialists. O visas are more loosely tied to em- ployers than H-1B visas and allow their holders to stay in the United States indefinitely (Mautino 2002).
IMGs who wish to work permanently in the United States can pursue permanent residency through one of two main avenues: going through a la- bor certification process or obtaining a national interest waiver. The labor cer- tification process requires that an IMG’s employer demonstrate a shortage of qualified workers to fill the position in the geographic area; if approved, the physician is obligated to remain with his or her employer for 18 months to
61C h a p t e r 3 : G l o b a l i z a t i o n a n d t h e H e a l t h c a r e W o r k f o r c e
Physicians
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5 years after the application is approved. The national interest waiver requires the IMG to demonstrate that he or she has exceptional abilities in a field, such that his or her admission to the workforce is in the national interest of the United States. Physicians who seek a national interest waiver need not be linked to a specific employer, but they must demonstrate unique abilities that contribute to the country’s quality of life, which may include service in a med- ically underserved area for five years or more (Mautino 2002).
From 1990 to 1995, many INGs entered the United States under H-1A visas, which were aimed at encouraging the migration of overseas-educated nurses. This visa category was withdrawn after many U.S. healthcare organizations downsized in the mid-1990s. Since 1995, nurses have entered the country un- der one of four visa categories:
1. H-1B: See the provisions described in the physicians visa section earlier. 2. H-1C: Established under the Nursing Relief for Disadvantaged Areas Act
of 1999, this visa allows INGs to work in underserved areas. It has a yearly cap of 500 nurses and permits a three-year length of stay (Bieski 2007).
3. TN: Linked to NAFTA, this visa applies to nurses from Mexico and Canada. It is good for a one-year stay in the United States and is renewable.
4. EB-3: A permanent employment-based visa, this was made available in 2005 to nurses and other healthcare workers from sending countries such as India, the Philippines, and China. Although the EB-3 visa quotas had been reached, the visa was extended to 50,000 more workers, enabling U.S. healthcare organizations to hire many overseas-trained nurses (Kingma 2006). Employers that hire nurses are not subject to the usual provision that requires them to prove that no U.S. workers are available to take jobs to be filled by visa recipients (Arends-Kuenning 2006).
Many of these visa categories either have very specific requirements or are difficult to obtain. Thus, many INGs apply for permanent residency permits (green cards) when coming to the United States (Kingma 2006). INGs can pur- sue permanent residency through the employer-dependent labor certification process, which is described earlier in the IMG visa section (Mautino 2003).
Credentialing
IMGs who desire to work as physicians in the United States must complete their residency training in a U.S. healthcare organization before they can prac- tice. Their entry into these training programs must be certified by the ECFMG, which has been managing the entry of IMGs into the U.S. work- force since 1958 (Whelan et al. 2002). Applicants must submit a verifiable
62 H u m a n R e s o u r c e s i n H e a l t h c a r e
Nurses
Physicians
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diploma from a medical school listed in the International Medical Education Directory published by the Foundation for Advancement of International Medical Education and Research. They must also show a passing score on Step 1 and Step 2 (clinical knowledge and clinical skills) of the U.S. Medical Licensing Examination (USMLE), along with acceptable scores on the Test of English as a Foreign Language (TOEFL). The USMLE Step 1 and Step 2 examination and the TOEFL are given at test centers worldwide, while the USMLE Step 2 examination is given at regional test centers in the United States (ECFMG 2007).
IMGs must obtain a USMLE/ECFMG identification number to take the required examinations. They are certified by the ECFMG after comple- tion of (and acceptable scores in) all examinations and meeting all other re- quirements, including school/diploma verification. Candidates may apply to residency programs before their certification is completed, but they must be fully certified before their programs begin. IMGs follow the same residency application and matching process as followed by U.S. medical graduates, al- though IMGs are also eligible to sign residency contracts outside of the matching system (ECFMG 2007).
Credentialing of INGs in the United States is managed by the Commission on Graduates of Foreign Nursing Schools (CGFNS), which was established in 1977 to standardize the examination process for internationally trained nurses. The CGFNS conducts mandatory reviews of incoming nurses’ educa- tional backgrounds and credentials, documentation of English proficiency, and successful completion of the National Council Licensure Examination for Registered Nurses (NCLEX-RN) (Bieski 2007). The CGFNS credential re- view ensures that nurses have at least the minimum credentials required for li- censure within the United States, although precise licensing requirements are still managed by state boards of nursing and may vary. The English-language proficiency requirement can be fulfilled through the submission of test scores on the TOEFL or another test of English proficiency.
The CGFNS offers a pre-immigration examination in more than 30 countries around the world. While the examination is not a substitute for the NCLEX-RN, it is an important predictor of success on the NCLEX-RN, which is required for employment in the United States. The NCLEX-RN is given at testing locations nationwide and in testing centers throughout Eu- rope, Asia, and South America.
Adaptation
IMGs in the United States face a variety of barriers that may inhibit their successful adaptation to working in the healthcare system. These barriers in- clude the culture of medicine in this country—for example, patient-centered care and more accepting views of mental illness—that is most likely different
63C h a p t e r 3 : G l o b a l i z a t i o n a n d t h e H e a l t h c a r e W o r k f o r c e
Nurses
Physicians
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from that in the IMG’s homeland. The IMG will also need to adjust to var- ious models of the American family—for example, single-parent and step families—that can influence physician–patient/family interactions (Whelan 2006). Also, some IMGs may encounter language difficulties when commu- nicating with patients, some of whom may be suspicious of being treated by “foreign” physicians, and when working with nursing and support staff. IMGs’ professional experiences, attitudes, and practices in their home coun- tries may also cause misunderstanding or conflict with American staff mem- bers (Kuczkowski 2004).
Managers must take into account these and other potential adaptation issues when designing orientation and ongoing support programs to help for- eign-trained physicians to adapt to their new roles within the U.S. healthcare system.
Once INGs, who have a broad variety of job experiences and expectations, ar- rive at their jobs in the United States, their organizations must provide ade- quate information and training to ensure that they can successfully perform their new roles within the American healthcare system. Managers who hire INGs have found the following areas in which training is especially useful:
• Culture (e.g., relative independence of nurses, work with professional care staff rather than with patients’ family members) and communication
• Supervision and delegation of care • Hospital systems, technology, and documentation • Clinical skills and drug administration
Many healthcare organizations have found that INGs require addi- tional orientation relative to U.S.-trained nurses, and to this end, organiza- tions have initiated longer orientation programs that include elements such as those listed above. Nurse managers who supervise INGs will also benefit from educational programs that address many of the same areas. Such training will enable managers to facilitate the quick adaptation of their nurses and head off potential problems (Sherman 2007).
The Future of International Health Workforce Migration
The international migration of physicians and nurses is a long-standing phe- nomenon that is likely to continue for many years in the future. Healthcare organizations in many developed countries rely on these physicians and nurses to offset domestic staffing shortages. In some cases, this migration can exac- erbate healthcare workforce shortages in sending countries. In other cases, however, this migration is anticipated, moving sending countries to educate and train surplus physicians and nurses for export.
64 H u m a n R e s o u r c e s i n H e a l t h c a r e
Nurses
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While some receiving countries, such as the United Kingdom, have taken steps to minimize the negative effects of international recruitment on sending countries, the United States has not enacted similar policies. American healthcare workforce planners have made little effort to ensure that the supply of U.S.-trained physicians and nurses is self-sufficient. As a result, at least for the moment, this country will likely continue to need foreign-trained health- care professionals to meet the demand. Although this reliance on international migration is unlikely to be a sustainable long-term strategy, it is and will be an essential part of the U.S. healthcare system for many years to come. Because the federal government has yet to develop a coherent workforce policy on this issue, the responsibility for managing the effects of international recruitment lies with leaders of individual healthcare organizations.
Issues of ethical recruitment will also continue to be important for healthcare workforce planners and organizational managers. These leaders must carefully consider how domestic needs place burdens on other countries’ healthcare systems, healthcare professions’ educational needs, and healthcare workforce supplies. They must also provide adequate support to IMGs and INGs once they arrive to work and train in the United States.
Summary
This chapter discusses several aspects of a critical issue to U.S. healthcare man- agers: the globalization of the physician and nursing workforces. Given the es- sential role that foreign-trained physicians and nurses play in many U.S. healthcare organizations, an understanding of the history, current patterns, and factors that motivate physician and nurse migration is vital for managers. Physicians and nurses have sought work across international borders for sev- eral decades, and their movement is likely to continue long into the future, particularly in light of current healthcare workforce shortages in many receiv- ing countries.
Many internationally trained physicians and nurses who work in the United States and other developed countries are trained in developing coun- tries. Some of these sending countries—particularly those in sub-Saharan Africa and the Caribbean—face an uncontrolled “brain drain” of skilled health workers, while other countries such as India, Cuba, the Philippines, and pos- sibly China purposely train physicians and nurses to work overseas. While these workers play a vital role in the health systems of many developed coun- tries, their departure can have serious implications for the healthcare system in their home countries. Several international bodies and individual countries have adopted policies that attempt to manage the movement of physicians and nurses from developing to developed nations, but thus far no universal prac- tices have been adopted.
65C h a p t e r 3 : G l o b a l i z a t i o n a n d t h e H e a l t h c a r e W o r k f o r c e
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In this context, U.S. healthcare organizations can recruit internation- ally trained physicians and nurses through a variety of mechanisms. Because the United States has not yet established a specific code of practice that gov- erns international recruitment, employers themselves are responsible for pro- viding a safe and transparent recruitment process for migrant workers. Addi- tionally, managers must understand visa and credentialing regulations that apply to internationally trained healthcare workers as well as the challenges that these newly hired workers face as they adapt to working in the United States. Careful consideration of all these issues will help to ensure the fair hir- ing and successful incorporation of internationally trained physicians and nurses into the U.S. healthcare workforce.
66 H u m a n R e s o u r c e s i n H e a l t h c a r e
Discussion Questions
1. Why is it important for healthcare managers to be aware of the trends in international migration of physicians and nurses?
2. What impact do these trends have on the U.S. healthcare system?
3. Sending countries experience two distinct situations as a result of international migration—brain drain and strategic deployment. What are the differences between the two? What are the advantages (if any) and disadvantages of each situation?
4. Suppose that U.S. policymakers are developing ethical international recruitment guidelines based on the National Health Service’s Code of
Practice on International Recruitment. What elements of the Code can be included in the guidelines, and what can be implemented in the context of the U.S. healthcare system?
5. What are the ethical issues that healthcare leaders and managers must consider when recruiting IMGs and INGs? What steps can be taken to deal with these issues?
6. Discuss the importance of orienting IMGs and INGs to their roles in the U.S. healthcare system. What obstacles (cultural, organizational, and professional) do they face, and what are the implications if these barriers are not addressed?
Experiential Exercise
For the Philippines, ex- porting nurses has been a
long-standing government strategy, part of a broad and concerted program of labor migra- tion introduced in the 1970s during the ad-
ministration of President Ferdinand Marcos (Tyner 2004). Although intended initially as a short-term solution to domestic unemploy- ment and high foreign debt, this program has become a permanent strategy for generating
Case
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income for the country through regular re- mittances from migrant workers.
The Philippines has a net surplus of nurses because of high production and rela- tively low demand, mainly because of under- funding of the country’s health system. Be- cause of nurse migration, the country has lost many of its most skilled nurses. For the last several years, the Philippines has been expe- riencing two trends that are causing concern among nursing leaders:
1. An explosive growth in the number of nursing programs. In the 1980s, only 40 nursing schools were in existence throughout the country; in 2007, the number was much higher: 460 programs in total. Some schools have sought rapid, drastic expansions to their enrollment, contributing to the vast and steady increase in the number of nursing students. The Philippines currently produces about 20,000 nurses per year (Lorenzo et al. 2007).
2. A movement of physicians into “second course” nursing education. Physicians are leaving their posts in public hospitals and rural areas to work abroad as nurses. Demand for medical education has declined, and some nursing schools have created special programs that allow physicians to pursue nursing education while continuing to practice as physicians.
67C h a p t e r 3 : G l o b a l i z a t i o n a n d t h e H e a l t h c a r e W o r k f o r c e
Policymakers in the Philippines are concerned that the growth in the number of nursing programs has been accompanied by a decline in quality of education: In recent years, fewer than half of the nursing graduates passed the nursing licensure examination. This means that many nursing graduates can- not even work as nurses in the Philippines, much less in the United States and other overseas markets. Nonetheless, thousands of students enter nursing programs every year.
In this context, nursing leaders in the Philippines are struggling to maintain quality education and a sense of public service in a profession that is increasingly governed by business interests and influenced by individual aspirations for overseas employment. The country’s Department of Health (DOH) has developed the Master Plan for Health Human Resources to address domestic healthcare hu- man resources distribution, motivation (com- pensation—provision of living wages for gov- ernment workers), and production. The DOH has attempted to be directly involved in im- proving the quality of nursing education and the process of nurse migration, but the de- partment’s efforts have been rebuffed by the president, who wants these issues to be han- dled by the Philippine Overseas Employment Administration, the division of the Depart- ment of Labor and Employment that manages overseas deployment of Filipino workers.
You are a consultant to a task force charged with
overhauling nursing education and migra- tion practices in the Philippines. You have been asked to recommend short-term and long-term strategies to achieve sustainable improvements in nursing education and to
harmonize the nursing-deployment policy with domestic health system needs.
1. Who are your stakeholders, and from whom will you seek perspectives? What questions will you ask each of them?
Exercise
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2. Which issue—explosive growth of programs, declining quality, training of physicians to be nurses—will you address first? How will you engage the labor and health departments to
68 H u m a n R e s o u r c e s i n H e a l t h c a r e
implement your recommendations successfully?
3. What obstacles do you expect to face in this process? What strategies will you use to overcome them?
Note
1. IMGs who are U.S. citizens make up approximately 3 percent of the physician work- force in the United States (Mullan 2005). Many of these physicians are trained in “off- shore” medical schools in the Caribbean or Central America. This phenomenon is not discussed in this chapter.
References
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