Orvill AdamsI; Barbara StilwellII,1
IDirector, Department of Human Resources for Health, World Health Organization, Geneva, Switzerland
IICoordinator, Performance Improvement and Education, Department of Human Resources for Health, World Health Organization, 1211 Geneva 27, Switzerland (email: firstname.lastname@example.org)
Migrant health workers are faced with a set of options that are a combination of economic, social and psychological factors and family choices (1). They trade decisions related to their career opportunities and to financial security for their families against the psychological and social costs of leaving their country, family and friends. The comments of health workers themselves reflect the "push and pull" nature of the choices underpinning these "journeys of hope" as, for example, those collected in Ghana by Dovlo (2). Demotivating working conditions, coupled with low salaries, are set against the likelihood of prosperity for themselves and their families (by remittances), work in well-equipped hospitals, and the opportunity for professional development. In this issue of the Bulletin, Saravia & Miranda (pp. 608615) point out that young, well-educated individuals are most likely to migrate, especially in pursuit of higher education.
Employers in the countries of origin have their own perspective. They are unable to fulfil their mandates to provide equitable access to health care because the necessary health workers are not available. In many cases, the country is losing its investment in the education of health professionals, as well as losing the contribution of these workers to health care. Governments have to compete for health workers by making their conditions of work more attractive; they may also highlight the imbalance in competition between themselves and the receiving employers. Arguments from this perspective will inevitably include ethical and moral dimensions.
Employers in receiving countries take a different position, driven by their need to provide sufficient health workers to meet the demand for services within the constraints of budget planning and the imperfections of the labour market. Kupfer et al. (pp. 616619) discuss strategies to discourage migration to the USA, a major recipient country, and the wider applicability of these ideas. International recruiters currently have the freedom to work outside any codes of practice to make a profit. Without the prevailing conditions, however, they would be out of business.
In both the countries of origin and the receiving countries, consumers of health services have similar concerns. To the extent that migration of health workers reduces or increases their access to services for themselves, their families and their communities, they will support or oppose migration. There are also other influential factors, such as the continuation of vital financial support from migrant family members (1).
Governments represent the collective voices of consumers and employers, but their perspectives are often internally diverse. In the countries of origin, there may be different views held by the ministry of health (concerned with questions of access) and the ministry of finance (concerned with overseas revenue in the form of remittances). In receiving countries, the department for foreign aid may be uncomfortable with the importation of health workers from developing countries, while for the ministry of health it is a fast way to increase the health workforce.
Others have an interest in the migration of health workers: labour unions may be concerned because increasing the numbers of foreign workers puts downward pressure on wages, and the international development community finds its investments in health and associated targets are at risk because of shortages of health workers. These realizations have prompted a resurgence of interest in international migration and in human resources development in general (3). This issue includes a classic paper on health worker migration by Mejía, with an up-to-date commentary by Bach, who acknowledges the changing historical dimension (pp. 624630).
With many different voices raised in concern, the migration of health workers is newsworthy, and the difficulties of collecting accurate data mean that unsubstantiated claims may be made in the media. Diallo (pp. 601607) notes that, though difficult, accurate data collection is certainly possible.
The papers in this issue remind us of the many ways of looking at migration and its effects. Stilwell et al. (pp. 595600) point out the broad range of issues involved and the challenges of developing policy options that can be effective, while Buchan & Sochalsky (pp. 587594) focus on the specific case of nursing and outline the policy aspects of workforce planning and health system infrastructure design.
Because of its inherent complexities, the migration of health workers benefits from multidisciplinary research: solutions must be informed by a better understanding of the perspectives and underlying motivations of the many stakeholders.
1. Connell J, Brown R. The remittances of migrant Tongan and Samoan nurses from Australia Human Resources for Health 2004;2:2. Available from: http://www.human-resources-health.com/content/2/1/2/abstract
2. Dovlo D. Causes of health worker migration: perspectives from Ghana. Voices of health workers. Paper presented at: Institute of Futures Studies Workshop on Global Migration, Stockholm, Sweden, 13 June 2004. Available from: http://www.framtidsstudier.se/eng/global/MobReg/Dovlopaper.pdf
3. Narasimhan V, Brown H, Pablos-Mendez A, Adams O, Dussault G, Elzinga G, et al. Responding to the global human resources crisis. Lancet 2004;363:1469-72. Available from: www.thelancet.com
1 Correspondence should be sent to this author.