THE GLOBAL NURSING REVIEW INITIATIVE

Burdett Trust
for Nursing

Issue

International migration
of nurses: trends and policy
implications
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ISBN: 92-95040-25-2
Issue paper

International migration of nurses:

trends and policy implications

James Buchan
Mireille Kingma
F. Marilyn Lorenzo
Table of Contents

Acknowledgements 2
About the Authors 2
Executive Summary 3
Introduction 5
General trends in migration 6
Section One: Trends in Nurse Migration 8
Source countries 9
Destination countries 16
Section Two: Nurse Migration – Policy Implications and Knowledge Gaps 20
Policy issues 20
Source countries 21
Destination countries 24
Section Three: Conclusions and Recommendations 28
References 30
Abbreviations 32

1
Acknowledgements
This report is based on data and information from a range of sources and informants.
The authors alone are responsible for the content of this report.

About the Authors

James Buchan, MA (Hons) PhD DPM
James Buchan is currently professor at the Faculty of Health and Social Sciences, Queen Margaret University
College in Edinburgh, Scotland. He has 20 years experience of practice, policy research and consultancy on
Human Resource strategy and planning in health care human resources, specialising in the nursing workforce.
He has worked in Africa, Asia, West Indies, North, Central and South America, Australasia and most countries
of the European Union. His previous employment includes work as a Senior Human Resources Manager in the
NHS Executive in Scotland, and as Policy Advisor at the Royal College of Nursing in the United Kingdom (UK).

Mireille Kingma, RN, BS, MA, PhD

Mireille Kingma is a Consultant for Nursing and Health Policy with the International Council of Nurses, a
federation of 125 national nurses’ associations. She was awarded a Bachelor in Nursing and has a Masters in
Human Resources Development. Her doctoral thesis focused on Economic Policy: Incentive or disincentive for
community nurses? and was granted by the London School of Hygiene and Tropical Medicine, UK. During the
past 20 years, she has been responsible for international consultations and training programmes in more than
60 countries. Her current job portfolios include the socio-economic welfare of nurses, work life quality, human
resources development, occupational health and safety, care of the older person, refugees,
nursing students, and international trade in health services.

Fely Marilyn Elegado-Lorenzo, RN, PhD

Fely Marilyn Elegado-Lorenzo is currently professor of Health Policy and Administration at the College of Public
Health, and concurrently the Director of the Institute of Health Policy and Development Studies of the National
Institutes of Health, Philippines, both at the University of the Philippines, Manila. She earned her PhD from the
University of California at Berkeley majoring in Health Policy and Administration. She acquired her MPH from the
University of the Philippines, College of Public Health and her Bachelor of Science in Nursing from the University
of the Philippines College of Nursing. Her present responsibilities include policy analysis, health policy and
systems/services research and policy advocacy.

2
Executive Summary
This report focuses primarily on the policy implications of the international migration of nurses, and highlights
recent trends. International recruitment and migration of nurses has been a growing feature of the global
health agenda since the late 1990s. Nurses have always taken the opportunity to move across national borders
in pursuit of new opportunities and better career prospects, but in the last few years nurse migration appears
to have grown significantly, with the potential to undermine attempts to achieve health system improvement
in some developing countries.

Whilst the issue of international migration of nurses is sometimes presented as a one-way linear "brain drain",
the dynamics of international mobility, migration and recruitment are complex, covering individual rights and
choice; motivations and attitudes of nurses to career development; the relative status of nurses (and women) in
different systems; the differing approaches of country governments to managing, facilitating or attempting to
limit outflow or inflow of nurses; and the role of recruitment agencies as intermediaries in the process. This
report provides an overview of this dynamic situation.

Country-level data are used to examine trends in nurse migration. Both "source" and "destination" countries
are used to provide comprehensive background information. As there are no common or "standard" data or
methods of tracking trends in migration of nurses, there can be no universal assessment of flows between
countries. Any analysis of trends in migration of nurses is therefore constrained by data limitations and gaps.

The report emphasises that, in order to undertake an accurate assessment of the impact and policy implications
of migration of nurses, it is necessary to assess the level of migration within the broader context of trends and
dynamics in the national nursing workforce. For example, it is important that any examination of out-migration
of nurses relates the numbers leaving the country to the overall numbers leaving the nursing workforce – many
nurses may actually remain in the country, but leave nursing. Out-migration may be the most obvious and
media-worthy aspect of outflow of nurses, but it will not necessarily be the biggest flow of nurses from the system.

It is also important to note that migration is not just about a one-way flow from "source" to "destination" –
nurses may leave one country to work in a second, and then either return to their home country, or move
onto a third. They may even live in one country and cross a national border on a regular basis to work in
another. Improvements in travel and communication, combined with availability of employment, can encourage
this circulation.

The increases in flows of nurses across national boundaries create a series of policy questions for national
governments and international agencies. The report assesses the main policy issues, and also discusses where
the current knowledge gaps are most critical in preventing a full assessment and understanding of the dynamics
of nurse migration. The main gaps, and recommendations for policy action, are summarised below:

● One crucial gap is the absence of accurate data on the flows of international nurses; this is a constraint
on any effective monitoring, and also limits the ability to assess impact. Stakeholders at national level,
and international agencies, need to collaborate to agree and implement improved systems to monitor
international flows of nurses and other health workers.

3
● The position of many developing countries, which are sources of international nurse workers, is weakened
by inadequate workforce data and planning capacity, and it is difficult to assess how much of a "problem"
outflow to other countries is in comparison to the numbers of underemployed or unemployed nurses in the
country. These countries must assess and improve their planning systems, and give more policy attention to
encouraging and supporting non-practising nurses to return to nursing employment.

● The overall impact of out-migration of nurses on source countries, in terms of its effect on health systems
and on remaining staff, requires more systematic assessment. More research and evaluation are required to
inform national stakeholders and international agencies of the true costs (and/ or benefits) and impact of
nurse migration.

● Relatively little is know about the experiences of international nurses now working in destination countries,
in terms of their profile and future career plans (including likelihood of return to source countries or onward
movement to other countries), and equality of treatment. Research and evaluation are required to highlight
good practice and expose poor practice in the treatment of migrant nurses.

● The gender issue in relation to the migration of nurses is an important factor; there is a need for donors
to support strengthened professional nurses associations in source countries, so that the position of nurses
in society can be promoted by stronger advocacy. Donors need to focus attention on supporting the
strengthening of representative organisations for nurses.

● The issue of how – or if – to "manage" migration is important, and requires more considered investigation,
with systematic assessment of the various models of managed migration. The various policies and models of
managed migration, bilateral agreement, ethical codes, return migrant schemes and possible models of
"training for export" require examination and evaluation to support a more effective approach to international
recruitment of nurses at national and international levels.

4
Introduction

“The loss of human resources through migration of professional health staff to developed countries usually
results in a loss of capacity of health systems in developing countries to deliver health care equitably. Migration
of health workers also undermines the ability of countries to meet global, regional and national commitments,
such as the health-related United Nations Millennium Development Goals, and even their own development.
Data on the extent and the impact of such migration are patchy and often anecdotal and fail to shed light on
the causes, such as high unemployment rates, poor working conditions and low salaries.”
(WHO 2004a:1).

This report focuses primarily on the policy implications of the international migration of nurses, and highlights
recent trends. It is one of a series of papers prepared in a programme of work on the global nursing workforce.
The programme is led by the International Council of Nurses (ICN) and supported by the Burdett Trust for
Nursing. These papers provide the background material to inform a meeting of experts and a global summit
on the nursing workforce, to be held in 2005.

International recruitment and migration of nurses has been a growing feature of the global health agenda
since the late 1990s.1 Nurses have always taken the opportunity to move across national borders in pursuit of
new opportunities and better career prospects,2 but in the last few years nurse migration appears to have
grown significantly, with the potential to undermine attempts to achieve health system improvement in some
developing countries.

Whilst the issue of international migration of nurses is sometimes presented as a one-way linear "brain drain",
the dynamics of international mobility, migration and recruitment are complex, covering individual rights and
choice; motivations and attitudes of nurses to career development; the relative status of nurses (and women)
in different systems; the differing approaches of country governments to managing, facilitating or attempting
to limit outflow or inflow of nurses; and the role of recruitment agencies as intermediaries in the process. This
report provides an overview of this dynamic situation.

It is important to note that it is not just nurse migration that appears to be on the increase. The migration
of other skilled occupations is also growing, facilitated by globalisation, easier transport and communications,
and active recruitment by some developed countries that are facing skills shortages. Nurses are one of the
occupational groups whose skills are in short supply in both developing and developed countries, to the extent
that there now exists a global market for their skills (Findlay 2002).

1
See e.g. Kingma (2001), Buchan (2001), OECD (2002), Stilwell et al. (2003), Buchan et al. (2003), Bach (2003), Padarath et al. (2003),
Stilwell et al. (2004), Oulton (2004), Global Equity Initiative (2004).
See e.g. Mejia et al. (1979).
2

5
General trends in migration
It should also be noted that there are different reasons why individuals migrate, and different types of
migration – some temporary, some permanent. The available data make it difficult to identify and delineate
different types of migrants. The different types of migration are summarised below by Stilwell et al. (2003).

Typology of different types of migrants

● Permanent settlers are legally admitted immigrants who are expected to settle in the country, including
persons admitted to reunite families.
● Documented labour migrants include both temporary contract workers and temporary professional transients:
Temporary migrant workers are skilled, semiskilled or untrained workers who remain in the receiving
country for finite periods as set out in an individual work contract or service contract made with an agency.
Temporary professional transients are professional or skilled workers who move from one country to
another, often with international firms.
● Undocumented labour migrants are those who do not have a legal status in the receiving country
because of illegal entry or overstay.
● Asylum seekers are those who appeal for refugee status because they fear persecution in their country
of origin.
● Recognised refugees are those deemed at risk of persecution if they return to their own country.
Decisions on asylum status and refugee status are based on the United Nations Convention Relating to
the Status of Refugees, 1951.
● Externally displaced persons are those not recognised as refugees but who have valid reasons for
fleeing their country of origin (such as famine or war).

Source: Stilwell et al. (2003).

Recent research findings indicate five main trends in general migration:

● The numbers of international migrants is increasing (Organisation for Economic Cooperation and
Development, OECD, 2004). In terms of actual figures, the number of persons migrating has more than
doubled from 75 million in 1965 to an estimated 175 million in 2003 (United Nations data, quoted in
International Organization for Migration, IOM, 2003) when international migrants are defined as "those
who reside in countries other than those of their birth for more than one year". The International Labour
Organization (2004) estimates that there are approximately 81 million migrant workers worldwide (excluding
refugees) – 2.5 million in Latin America and the Caribbean, 3 million in Oceania, 5 million in Africa,
21 million in North America, 22 million in Asia, and 28 million in Europe.
● There has been a growth in the migration of skilled and qualified workers (OECD 2004a).
● Migration flows are becoming more diverse and complex for a range of reasons: for example, communications
improvements facilitate greater information exchange; easier transport links (Stalker 2000); international
trade agreements; and immigration policies that have at times supported the entry of foreign workers needed
to fill national or local skill shortages.
● Previously distinct categories of migrants have begun to blur (Stalker 1997). There has been an increasing
mix of temporary/permanent migrants (Timur 2000), including a recent reported growth in temporary
migration (Findlay and Lowell 2002).
● Female migrants have accounted for a high and increasing proportion of all migrants over the last 40 years,
and growth has been particularly marked in labour migration flows to developed countries (Zlotnik 2003).
Increasing numbers of females are now reported to be migrating independently of partners or families
(Timur 2000).
6
Migration of nurses and other health workers is also likely to be affected by the General Agreement on Trade
in Services (GATS).3 Mode 4 of GATS concerns the movement of natural persons and, in relation to trade in
health services, it focuses particularly on the provision of health services by individuals from another country,
on a temporary basis (Stilwell et al. 2004). It is not yet clear what the overall impact of GATS Mode 4 on nurse
migration will be, but it is likely to stimulate further growth, perhaps through bilateral agreements between
countries, and will also encourage further cross national harmonisation of nursing qualifications.4

Against this backdrop of increased migration of skilled workers and increased numbers of women who are
migrating, this report focuses on the migration of nurses. It is divided into two further sections:
● Section One examines trends in the migration of nurses in selected "source" and "destination" countries.
● Section Two discusses the dynamics of nurse migration in relation to the international policy context,
identifies current knowledge gaps, and highlights key policy considerations.

See e.g. Chanda (2002) and Bach (2003).

3

See e.g. ICN (2003); Padarath et al. (2003).

4

7
Section One: Trends in Nurse Migration

This section uses country level data to examine trends in nurse migration. Data from both "source" and
"destination" countries are used. Country case studies are utilised because there are no common or standard
data or methods of tracking trends in migration of nurses, and therefore there can be no universal assessment
of flows between countries.

A recent review by World Health Organization (WHO) noted that most data on the migration of nurses and
other health workers is "neither complete nor fully comparable, and they are often underused, limited…and
not as timely as required" (Diallo 2004:601). A recent study of migration of health personnel in Africa (Padarath
et al. 2003:14) noted, "The precise directions and volumes of health personnel movement within each of the
southern Africa countries, their impact on equity and performance of health services, the factors influencing
these flows and the extent to which they are linked with wider between- and out-of-country flows is not well
documented". Any analysis of trends in migration of nurses is therefore constrained by data limitations and gaps.

There are two main indicators of the relative importance of international migration of nurses to a country –
the "inflow" of nurses into the country from other source countries (or "outflow" to other countries), and the
actual "stock" of international nurses (as compared to the home-educated nurses) in the country at a point in
time. To undertake an accurate assessment of the impact and policy implications of migration of nurses, it is
necessary to assess the level of migration within the broader context of trends and dynamics in the national
nursing workforce.

For example, it is important that any examination of out-migration of nurses relates the numbers leaving the
country to the overall numbers leaving the nursing workforce – many nurses may actually remain in the country,
but leave nursing. Out-migration may be the most obvious and media worthy aspect of outflow of nurses, but
it will not necessarily be the biggest flow of nurses from the system. Data are often more difficult to collect in
private employment settings, and this can lead to an incomplete or distorted statistical overview of the nursing
workforce.

It is also important to note that migration is not just about a one-way flow from "source" to "destination" –
nurses may leave one country to work in a second, and then either return to their home country, or move onto
a third. They may even live in one country and cross a national border on a regular basis to work in another.
Improvements in travel and communication, combined with availability of employment, can encourage this
circulation; examples include Indian nurses being actively recruited from the Middle East to work in Scotland
and Filipino nurses being actively recruited from Ireland to Australia (Marino 2002).

Another contextual issue that is of importance is national-level regulation of the nursing profession, in terms
of the requirement to be able to practice in that country. The existence of any international agreements that
facilitate cross-border movement of nurses through mutual recognition of qualifications, or by automatic
registration in the destination country, will increasingly influence migration flows.

8
The issues of regulation of nursing are examined in greater detail in a companion paper, but it should be
recognised that the standards, competencies and qualifications required to practice as a nurse vary in different
countries. This variation may be a barrier to migration of individual nurses, if they do not meet the criteria to
practice in the destination country. These criteria could include language proficiency as well as qualifications in
nursing (Hawthorne 2001). Some countries, such as Ireland and the United Kingdom (UK), may require nurses
from other countries to work a period of time under supervision, or undertake additional training or education
in order to practice independently.

An example of a bilateral mutual recognition is the Trans-Tasman agreement, which enables nurses from Australia
and New Zealand to practice in either country. An example of a multilateral agreement is the Directives in the
European Union (EU), which mean that a registered nurse qualified in one country of the EU should be able to
move to and work in another EU country. The entry of 10 new countries into the EU in May 2004 has made it
easier for suitably qualified nurses in these countries to migrate to Western Europe, provided their qualifications
meet minimum EU training standards.

Changes in the regulatory and legal framework at national or international level may have a significant impact
on migration of nurses – either making it more difficult or easier to move between countries to work as a
nurse. Recently, for example, changes in visa requirements in the United States of America (USA) meant that
Canadian nurses were required to apply for a visa (they had previously been exempt from the need to have a
visa or take the licensing exam under the North Atlantic Free Trade Agreement (NAFTA) [ICN SEW News 2004].

"Source" countries
This section looks first at data from some source countries to illustrate trends in the level of international
out-migration of nurses. As noted above, the limited data available for many countries restricts the focus of
analysis. Five "source" countries are illustrated in this section: Ghana, Swaziland, Barbados, the Philippines
and South Africa.

Ghana
Ghana is a mid-sized sub-Saharan country, which has been impacted by the outflow of nurses to the UK and to
other English speaking countries. Approximately 6,500 nurses were re-employed in the public sector in Ghana
in 2002 (Table 1) and nurse vacancy rates are estimated to have increased significantly over the period between
1998 and 2002 (Table 2).

Table 1: Nurses in Ghana

Cadre 2002 Total Public Private NGO

Registered Nurses/Midwives 10,265 6,481 3,784 not known
Source: Buchan and Dovlo (2004).

Table 2: Estimated vacancy levels in Ghana, Ministry of Health 1998, 2002

1998 2002
Registered Nurses Vacancy 25.5% 57.0%
Source: Buchan and Dovlo (2004).

9
There are different sources of data on outflow of nurses from Ghana to other countries. As in many countries,
these different data sources are not always in alignment. Buchan and Dovlo (2004) cited Ghanain data
estimating that in 2001, 2,972 nurses left Ghana compared to 387 in 1999; mainly, in this case to the UK, USA
and Canada, whilst the General Secretary of the Ghana Registered Nurses Association (GRNA) reported that
membership had reduced from over 12,000 in 1998 to under 9,000 in 2003. Verification data from the Nurses
and Midwives Council for Ghana show an upward trend in verifications issued to other countries to the year
2001, a dip in 2002, and apparent increase in 2003 (data for the first five months only of this year). The UK is
the main source of verification requests, accounting for three quarters of the total.

Table 3: Ghana nurses verification: Country of destination and year

Country of Destination Number and Year of Seeking Verification

1998 1999 2000 2001 2002 2003* Total
USA 50 42 44 129 81 80 426
UK 97 265 646 738 405 317 2,468
Canada 12 13 26 46 33 10 140
South Africa 9 4 3 2 6 - 24
Other 4 4 8 8 5 - 29
Total: 172 328 727 923 530 407 3,087
*Jan-May, 2003 only
Source: Ghana Nurses and Midwives Council/ Buchan and Dovlo (2004).

Buchan and Dovlo (2004) report that Ghanain nurses prefer the UK as a destination because it does not require
the nurse to sit pre-entry examinations and only requires an adaptation once registration and qualification in
Ghana have been verified and accepted. For Ghanain nurses, the need to write examinations and other higher
costs (exam fees, air ticket costs, etc.) makes the USA less attractive (Note: in 2005, the US NCLEX examination
will be available for the first time in three non-USA locations: South Korea, Hong Kong and the UK).

Focus groups’ discussions with nurses and doctors in Ghana conducted for Buchan and Dovlo (2004) highlighted
various key reasons for outflow to other countries, which may be grouped into the following key areas:

Table 4: Reasons for considering migration: Focus groups, Ghana, 2004

● Low salary and remuneration.

● Limited career prospects.
● Feelings of lack of respect/value placed in health workers by country/system.
● Concern about poor governance and management of the health system.
● Concern about poor retirement benefits and prospects.

Source: Buchan and Dovlo (2004).

10
Focus group respondents told of problems with "handing-over" at the end of shifts because qualified nurses
were unavailable, and of extremely low staffing levels – a single professional nurse required to oversee a full
ward of some 30-40 beds with only small numbers of enrolled nurses or untrained attendants. Buchan and
Dovlo (2004) also reported that the Nurses Council (also responsible for nurse education) estimates that they
have lost 20-30% of tutors over the past few years, predicted to severely limit the country’s capacity to educate
future generations of nurses.

Swaziland
A report conducted on behalf of WHO (Dlamini, undated, but 2003 or more recent) examined nurse migration
from Swaziland, a small sub-Saharan African country. The report noted that 3,200 nurses were registered in
the country. A small survey of nurses who had left Swaziland (n = 20) reported that half (50%) were working
in South Africa (highlighting the significant intra-regional migration flows), and 40% were working in the UK.
Main reasons for leaving Swaziland were reported to be relatively low salaries and benefits, poor working
conditions and lack of career opportunities.

Barbados
Migration is a widely accepted social phenomenon and part of the social and economic fabric of Caribbean life.
As a relatively small country, with well-educated English speaking health professionals, Barbados, like other
Caribbean islands, can be vulnerable to the effects of out-migration. The vulnerability of the Caribbean to the
possible negative effects of out-migration of health professionals is exacerbated by its geographical proximity
to North America and by its long established migratory paths both to North America and the UK (Thomas Hope
2002). In 2003, the draft nursing strategy for Barbados noted, "Records show that between 2000 and 2001
approximately 10% of nurses have left the nursing sector, with a significant percentage seeking employment
overseas" (Ministry of Health, Barbados 2003: 11).

Research conducted in 2003 (Buchan and Dovlo 2004) estimated the annual number of general nurses resigning
from the Queen Elizabeth Hospital (QEH) (the only general hospital on the island), reportedly to migrate, over
the period 2000-2003 (see Table 5).

Table 5: Annual number of nurses resigning to emigrate, QEH, Barbados

2000 2001 2002 2003 (partial)

26 16 18 14
Source: Buchan and Dovlo (2004).

Measured against a working ‘stock’ of approximately 500 nurses employed in the hospital, this represents an
average outflow due to migration of approximately 4% per annum in recent years. These nurses were
reported to have gone to the UK, US, Canada and other Caribbean Islands (e.g. Bahamas).

It should be noted that these data relate only to nurses who are known to have migrated. Some nurses do not
resign prior to having emigrated – they may take holiday or sick leave, and then travel abroad, only actually
"resigning" at a later date. In some individual cases it will be unclear if the nurse has actually left the country,
or just left the hospital. The Caribbean is known for its circular migration patterns (back and forth flow),
and these statistics do not show how many nurses returned to their homeland after a temporary period of
employment abroad.

11
The Caribbean office of the Pan American Health Organisation (PAHO) audited the nursing workforce and
migration factors as part of its work on managed migration. Focus group interviews of nurses were conducted
in different countries across the Caribbean. The PAHO assessment identified the following key factors
influencing nurses’ decisions to stay or leave employment in the Caribbean:

Table 6: "Push" factors encouraging Caribbean nurses to emigrate

● Financial.
● Poor working conditions.
● Lack of professional development opportunities.
● Lack of promotion opportunities.
● Non-involvement in decision-making.
● Lack of support from supervisors.

Source: PAHO (2001).

Focus groups of nurses in Barbados revealed that some of the participants were critical of the current career
and development opportunities available to them in Barbados; several alluded to the fact that promotion was
based on seniority rather than merit and that it was extremely difficult to achieve flexible working hours
because of the rigid management (similar findings have been reported from Trinidad and Tobago, Schmidt
2003). The focus group participants also identified the main factors facilitating migration:

Table 7: Main factors enabling out-migration of nurses, Barbados, 2003

● Tradition of migration, with Barbadian communities/relatives in destination countries.

● Recruitment visits to Barbados by agencies (mainly USA).
● Recruitment facilitated by Barbados-based agencies.
● Personal contacts with Barbadian health professionals in destination country.
● Internet search/web-based recruitment by agencies.

Source: Buchan and Dovlo (2004).

The opportunities to connect with well-established communities in destination countries, and the role of the
Internet in facilitating the identification of career opportunities in other countries, have also been noted as
factors in general trends of skilled worker migration from the Caribbean (Thomas Hope 2002).

12
South Africa
As one of the largest countries in sub-Saharan Africa, and also one of the most developed, South Africa has
experienced both in-migration and out-migration of nurses. DENOSA, the national nursing association and
professional union in South Africa, commissioned a report on nurse emigration, which was published in 2001
(Xaba and Philips 2001). The report authors cautioned about differences in emigration data collected by
different institutions in South Africa. They report that it was not possible to determine the actual number
of nurses leaving South Africa, or to which countries they had moved. This limitation has also been noted in
relation to broader based examinations of skilled worker migration from South Africa; one recent report
suggested that official data underestimates actual outflow from the country (Bhorat et al. 2002).5

The DENOSA report assessed verification data held by the South African Nursing Council (SANC) (see Table 8).
This showed applications to work as a nurse in another country, but did not necessarily mean that the nurse
actually left (it could also include double counting). There was a clear upward trend in verifications issued,
until the year 2000. (Note: whilst not commented on by the authors, the reduction in verifications in the year
2000 may be linked to the reduced ‘outflow’ from South Africa to the UK in 2000 as a result of the introduction
of ‘ethical’ recruitment guidelines in England in November 1999, although a completely unrelated dip in
numbers is also seen in 1994 and 1995.)

Table 8: Verifications issued by the South African Nursing Council, 1991-2000

Year No. of applications for Percentage change

verifications of qualifications year on year
1991 455 –
1992 578 27.0%
1993 595 2.9%
1994 547 - 8.1%
1995 511 - 6.6%
1996 957 87.3%
1997 1,359 42.0%
1998 1,746 28.5%
1999 3,672 110.3%
2000 2,543 - 30.7%

Source: Xaba and Phillips, SANC (2001).

The report also examined data on actual outflow reported by other governmental agencies – Statistics South
Africa and the Department of Home Affairs. It noted that the data from these other sources is ‘likely to release
inaccurate figures’ and is contradictory. The UK, Saudi Arabia, New Zealand and Australia were reported to be
the most common destinations for emigrating nurses, on the basis of the incomplete data that was available.

The main impacts of nurse emigration were reported to be:

● Frustration/de-motivation of nurses remaining in South Africa.
● Loss of skills (and of quality of service).
● Increased staff shortages (60% of institutions surveyed reported it was difficult to replace nurses who have left).

See also Padarath et al. (2003).

5

13
DENOSA conducted a workshop to consider the implications of emigration. Noting that ‘migration is a non-
negotiable right of the nurse embedded in the Constitution’, it raised concerns about shortages, poor working
conditions and ‘exploitation’ within and outside South African borders. It argued that remuneration and
service conditions of nurses in South Africa must be improved. The main ‘push’ factors identified by the report
commissioned by DENOSA included:

Table 9: Main push factors encouraging nurses to leave South Africa

● Lack of competitive incentives in the public sector.

● Work pressures – long hours, poor resources and high ratios of patients per nurse.
● Few opportunities for career development.
● Escalating crime and the rise of HIV/AIDS in South Africa.

Source: Xaba and Philips (2001).

The report also noted that South Africa had recruited unspecified numbers of foreign nurses, who were working
in South Africa. The small survey of nurses who had migrated from Swaziland (Dlamini, reported above)
indicated that some were working in South Africa; another report highlighted a "brain drain" of nurses from
Lesotho to South Africa (Bhorat et al. 2002) and a third reported on movement to South Africa from other
countries in Africa and from Cuba (Padarath et al. 2003).

The South African Department of Health, which finances public sector nursing education, estimates the cost of
training a nurse at 10 times the GDP per capita, and training a physician at 23 times the GDP per capita (OECD
2002). Based on South African migration statistics, the Department estimates that the cost impact of migration
of nurses and doctors is equivalent to total foregone investment of around US$1 billion, equivalent to 17
percent of national public health expenditures in 2000.

The Philippines
The Philippines is well known as a source country for nurse migrants, and other types of migrant worker. While
there is no explicit policy that encourages migration, there are a number of government agencies established
to facilitate the deployment and the protection of its citizens abroad: the Philippine Overseas Employment
Authority (POEA) and the Office of Workers Welfare Administration (OWWA). These have been cited as "good
practice" in handling the needs of workers deployed overseas. These organisations also facilitate worker
migration.

Filipino overseas migration reflects the issues of Philippine socio-political and economic life. Overseas migration
results in the loss of millions of skilled and unskilled Filipino workers to first world countries due to the limited
employment opportunities and relatively low wages in the country.

With persistent but fluctuating 10-year trends of health worker migration since the 1950s, it has been shown
that the country has become dependent on health human resource out-migration to address surpluses and
other employment related issues. Over the years, health worker migration patterns have largely been driven
by economic and career development opportunities overseas.

14
The Department of Foreign Affairs in the Philippines reports that there are approximately 7.2 million Filipino
migrants all over the world. A recent estimate is that 85% of employed Filipino nurses are working
internationally – over 150,000 nurses (Lorenzo 2002). After stagnating in the mid 1990s, (due to a reduction in
demand from destination countries, particularly the USA) annual outflow of nurses in recent years appears to
have increased (see Figure 1).

Figure 1: Outflow of professional nurses from the Philippines

15,000

Number of Filipino Nurses - Outflow

12,000

9,000

6,000

3,000

0
1996 1997 1998 1999 2000 2001

Note: Filipino sources suggest these data may be underestimated.

Source: POEA/Lorenzo (2002).

The top three countries of destination for Filipino nurses for the last decade include Saudi Arabia, the USA, and
the UK. Other preferred destinations include Libya, United Arab Emirates, Ireland, Singapore, Kuwait, Qatar
and Brunei (POEA 2003). In recent years, Saudi Arabia has been the main destination of nurses. The USA
market was dominant in the early 1990s, but after 1995, nurse deployment in the USA declined significantly,
dropping to a low of 0.1 percent of all nurse deployment in 1998. The UK has increased in prominence since
2001 – being the "top" destination in 2001 when deployment to the UK accounted for a high of 40% of all
Filipino nurse deployment.

In 2001, the UK, Saudi Arabia, Ireland and Singapore were the four most important destinations for Filipino
nurses (see Table 10).

15
Table 10: Outflow of professional nurses from the Philippines 2001

Destination Country Male Female Total

UK 1,152 4,231 5,383
Saudi Arabia 483 4,562 5,045
Ireland 311 1,218 1,529
Singapore 45 368 413
USA 56 248 304
United Arab Emirates 79 164 243
Other 143 476 619
TOTAL 2,269 11,267 13,536

Source: POEA/Lorenzo (2002).

Lorenzo (2002) noted that the ‘pull’ factor of demand for Filipino nurses from other countries had varied
markedly over time, with huge outflow to the USA and Middle East in the 1980s, but lower demand from these
countries in the 1990s. Recently, this has been replaced by heavy recruitment from the UK and Ireland.

The Philippines is relatively unusual in the extent to which agencies and organisations in the country facilitate a
high level of active recruitment from ‘destination’ developed countries. One factor is the opportunity to
encourage remittances – regular transfer of significant amounts of foreign currency being returned from
Filipino nationals working abroad. Remittance income can represent a significant source of "hard" currency for
developing countries (IOM 2004), and nurses from the Philippines, the Caribbean and other source countries are
important generators of funds back to their home countries. Recent research on Tongan and Samoan nurses
working in Australia suggests they make a major contribution to the economies of their home countries, which
far surpasses the initial financial investment of educating the nurses (Connell and Brown 2004).

With the exception of the Philippines, and, to an extent India and Cuba, in most developing countries, outflow
of nurses is the result of the individual decisions of nurses and their responses to push and pull factors rather
than being policy led. However, it is reported that several other countries in the Caribbean, Africa and Asia are
now considering developing the capacity to "train for export" of nurses.

"Destination" countries
In a recent report on health systems, the OECD (2004b) highlighted that "there are increasing concerns about
nursing shortages in many OECD countries". There appears to be an upward trend in inflow of nurses to some
developed countries, as a response to these nursing shortages. Recent research (Buchan, Parkin and Sochalski
2003) used registration data from five destination countries – Australia, Ireland, Norway, the UK and the USA –
to examine the international flows of nurses.

Analysis of registration data found that the inflow of nurses from developing countries to these destination
countries has risen in recent years, in some case quite substantially, in terms both of actual numbers and as a
proportion of all "new" nurses becoming eligible to practice. Ireland and the UK are two countries where the
increase in inflow of international nurses was most pronounced. Figures 2 and 3 show the registration of
domestic and international nurses in these two countries in recent years.

16
Figure 2: Source of newly registered nurse registration, Ireland

2,000 Ireland European Union (EU) Non-EU

1,800

1,600

1,400

1,200

1,000

800

600

400

200

0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Source: An Bord Altranais, Dublin, Ireland (Various years).

In Ireland, the relative importance of non-Irish, non-EU sources rose rapidly to the extent that, in 2001,
about two thirds of new entrants to the Irish nursing register were from other EU and international sources.
The principal contributors were the UK, the Philippines, Australia, South Africa and India. The number of
international nurses first registering in Ireland has since dropped back, but has remained at a level above that
noted in the middle of the last decade.

Figure 3 shows the comparative importance of non-UK source countries, in relation to the annual total number
of all new nurses entering the UK register.

Figure 3: International and UK sources as a % of total new nurses admitted to the UK Register,
1989/90-2002/03 (Initial Registrations)

100 International UK

90

80

70

60

% 50

40

30

20

10

0
1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
-1990 -1991 -1992 -1993 -1994 -1995 -1996 -1997 -1998 -1999 -2000 -2001 -2002 -2003

Source: UKCC/NMC data (Various years).

17
This relative importance of non-UK sources has increased year on year since the mid 1990s, peaking in 2001-2,
when more than half the new entrants to the register were from abroad. (Note: the apparent drop back to
43% of the total in 2002-3 may be related to the registration backlog in that year). The main source countries
for international nurses have been the Philippines, Australia, South Africa and India.

These examples of Ireland and the UK highlight that some developed countries have become much more active
in international recruitment of nurses. Similar patterns of growth are predicted in other developed countries
such as the USA (Brush, Sochalski and Berger 2004), and the Netherlands (de Pasch 2002). Whilst some recruitment
is from one developed country to another (e.g. Canada to USA, Australia to the UK, UK to Ireland), the increase
of nurse recruitment from the developing world to the developed is more significant. For example, in countries,
such as the UK, growth in recruitment from other developed countries (e.g. Scandinavian or EU countries) has
remained static or has fallen, whilst there appear to be increased flows of nurses from developing countries.

Some countries in the Middle East and elsewhere have also traditionally relied on recruiting nurses from other
countries. In 2000, two thirds of staff nurses working in Oman were non-Omanis. The country is currently
pursuing a policy of "Omanization" of its workforce to reduce reliance on recruits from other countries
(Ministry of Health, Oman 2000). Another example is Singapore, which recruits from China, the Philippines
and Malaysia. One fifth (20%) of the nurses on the Singapore register in 2003 were "non-resident", and a
further 10% were resident non-Singapore nationals (Singapore Nursing Board 2003).

The extent to which different destination countries rely on recruiting from different "mixes" of source
countries is highlighted in Figure 4 below. Data for Australia (Victoria State), Ireland, Norway, the UK and
the USA are used to illustrate the source countries, by level of development, as measured by the World Bank.
The UK, the USA and, to a lesser extent, Ireland are recruiting significant proportions of international nurses
from lower middle income and low-income countries, as defined by the World Bank. In contrast, Norway and
Victoria State are primarily registering nurses from other high income or high middle-income countries.

Figure 4: Inflow of international nurses to UK, Norway, Ireland, Victoria State (Australia) and USA
with source countries defined by World Bank classifications

100

90

80

70

60

% 50

40

30

20

10

0
UK Norway Ireland Victoria State USA
2001/02 2002 2001 Australia 2002 2002

High Income/High Middle Income Lower Middle Income Low Income

Source: Buchan and Sochalski (2004).

18
The growth in active recruitment by some developed countries, as they attempt to address nursing shortages,
is a key driver in the current growth in nurse migration. The number of source countries, the target for
international nurse recruitment, has steadily increased over the years. In the UK, the number of countries
sending recruits has increased from 71 in 1990 to 95 countries in 2001 (Buchan and Sochalski 2004).

Some countries, such as the UK, have made international recruitment an explicit national policy (i.e. it is
government led); in others, such as the USA, it is primarily driven by individual employers. One significant element
in the dynamic of international recruitment is the role of recruitment agencies, who act as intermediaries in
the process. Some are based in the source countries; others are located in destination countries but work
internationally. These agencies act on behalf of employers, charging fees to employers (and in some cases to
nurses) to recruit and transport the nurses to the destination countries. They often also act on the nurses’
behalf in obtaining the necessary work permits and registration.

Agencies thus both stimulate and ease the process of migration for individual nurses. There have been reports
of some agencies providing misleading information to nurses about conditions in destination countries, or
charging nurses unnecessary or inflated fees for travel. Concern about "unethical" behaviour from some
recruitment agencies led the Department of Health in England to establish a list of "preferred provider" agencies
that agreed to abide by a Code of Practice (Department of Health 2001). The ICN, in its Position Statement
on Ethical Nurse Recruitment, calls for a regulated recruitment process based on ethical principles that guide
informed decision-making and reinforce sound employment policies.

There are also international instruments (conventions) which provide some protection to nurses and other
migrant workers: the 1990 UN Convention and the two International Labour Office (ILO) migrant worker
Conventions (C.97 and C.143). These Conventions provide international good practices for ensuring protection
to migrant workers. Several European countries have ratified one or both of these ILO Conventions. The
majority of the signatories, however, are from the developing world, also their citizens being most directly
implicated and in need of protection against exploitation or abuse. There are other ILO Conventions on nursing,
which are relevant to improving working conditions and retention.

19
Section Two: Nurse Migration – Policy Implications and
Knowledge Gaps

The previous section has highlighted a trend of growth in migration of nurses from some developing countries,
stimulated by poor working conditions, poor pay and career prospects, and facilitated by active recruitment in
some developed countries. Given data limitations and incompatibility, it is not possible to develop a detailed
overview of all flows of nurses between countries. There are also aspects of the dynamics of nurse migration
that are little understood, because of current knowledge gaps.

International recruitment of nurses creates challenges for "source" and "destination" countries, and for
individual nurses themselves. Some of the key issues for country governments and nurses are summarised
in Table 11. It also highlights some of the potential opportunities created when nurses are, or can be,
internationally mobile.

Table 11: International recruitment of nurses: Possible opportunities and challenges

Opportunities Challenges

Destination countries Solve skills/ staff shortages. How to be efficient, and ethical
"Quick fix". in recruitment.

Source countries Remittances. Outflow may cause shortages; negative

Upskilled returners impact on delivery of care.
(if they return). Costs of "lost" education. Increased costs
Lower unemployment in of recruitment of replacements.
certain cases. "Manage" migration?

Internationally mobile nurses Improved pay, career Achieving equal treatment in destination
opportunities, education. country.

Static nurses Improved job and career Increased workload as other nurses leave.
opportunities (if worker Lower morale.
oversupply).

Policy issues
The increases in flows of nurses across national boundaries create a series of policy questions for national
governments and international agencies. This section assesses some of these main policy issues, and also
discusses where the current knowledge gaps are most critical in preventing a full assessment and understanding
of the dynamics of nurse migration.6

See also e.g. Stilwell et al. 2003; Bach 2003; Padarath et al. 2003.
6

20
"Source" countries

Source countries: Policy questions and likely knowledge gaps

Policy questions (in source countries)

● Should outflow be supported or encouraged (to stimulate remittance income or to end oversupply)?
● Should outflow be constrained or reduced (to reduce brain drain)? If so, how (what is effective and ethical)?
● Should recruitment agencies be regulated?

Knowledge gaps (in many countries)

● What are the destination countries for outflow?
● How much outflow is permanent or temporary (short or long term)? If temporary, how can "returners"
be encouraged?
● How much outflow is going to health sector-related employment and education in other countries? What
proportion is going to non-health-related destinations?
● What is the size of outflow to other countries compared with outflow to other sectors within the country?
● What is the impact of outflow?
● Why are nurses leaving?
● What retention measures are required to address the need to migrate?
● What measures encourage and facilitate return migration?
● How should flows be monitored?

Source: adapted from Buchan, Parkin and Sochalski (2003).

Countries that are experiencing a net outflow of nurses need to be able to assess why this is happening and
evaluate what impact it is having on the provision of health care in the country. Reliance on incomplete data
or incompatible data from different sources often means that it is not possible even to have an accurate picture
of the trend in outflow of nurses, let alone any assessment of the impact of this outflow on the health services.

It is important that the available information base enables policy-makers to assess the relative loss from outflow
to other countries in comparison with other internal flows, such as nurses leaving the public sector to work
in the private sector or leaving the profession to take up other forms of employment. For example, nurses
working in the private sector in Zimbabwe reportedly earn about 40% more than those in the public sector
(Padarath et al. 2003). International outflow may be a very visible but relatively small numerical loss of workers
compared with flows of nurses leaving the public sector for other sources of employment within the country.

Unmanaged outflow of nurses may damage the health system or erode the current and future skills base.
Various countries (e.g. Ghana) have initiated policy responses, including bonding nurses to home employment
for a specified period of time after completion of training. This does not appear to have been effective – with
compliance not being effectively monitored, and with scope to buy out of the bond.7 Preventing nurses from
leaving through the use of monetary or regulatory barriers is likely to be an ineffective policy response, and

7
See also South Africa: Padarath et al. (2003); and Malawi: Muula et al. (2003).

21
does nothing to alleviate the push factors that stimulated the nurse’s desire to leave; it also cuts across notions
of free mobility of individuals.

Other policy responses to reducing outflow relate to a more direct attempt to reduce the push factors: by
dealing with matters concerning poor pay and career prospects, poor working conditions and high workloads,
responding to concerns about security, and improving educational opportunities, etc. The managed migration
initiative in the Caribbean (see box below) is a broader based attempt to take a more proactive stance on
migration – recognising that it is not possible to stop it where there are severe push/ pull imbalances.

Managed migration of nurses in the Caribbean

The "Managed Migration" project was initiated by the Caribbean Nurses Organization (CNO) and the
Caribbean office of the Pan American Health Organization (PAHO). CNO and PAHO have joined with other
organisations including the Regional Nursing Board (the umbrella body for the chief nurses from Caribbean
countries) to develop a framework, which is intended to provide a regional strategy for retaining sufficient
nurses in the Caribbean whilst also respecting the individual nurse’s right to choose where they work and
live. There is a six-part framework to the initiative:

1. Recruitment and Retention Recruitment video/TV advertising.

"Year of the Caribbean Nurse" Mentorship programme.

2. Education and Training Study to evaluate current training capacity.

Development of distance learning, base nursing degree at
University of West Indies (UWI).

3. Utilisation and Deployment Introduction and evaluation of workload measurement tool.

4. Terms and Conditions of Employment Healthy Workplace Initiative.

Promotion of ILO resolutions on nursing.

5. Management Practices "Magnet Hospital" Programme.

Leadership for Change Programme.
Nursing/HR database.

6. Policy Development Evaluation/ country "report card".

Sources: Yan (2001); Buchan and Dovlo (2004).

22
Events in the Caribbean highlight another policy response based on the recognition that outflow cannot be
halted where principles of individual freedom are to be upheld, but that interventions can be developed to
ensure that such outflow is managed and moderated.

The scope to encourage "returners" – temporary migrants who may be in a position to return to the source
country – should also be examined (Wickramasekara 2003). This issue requires more consideration, as there
may be possibilities of harnessing the skills and contribution of "diaspora" of health professionals who have
migrated.8

Source countries: Knowledge gaps

The ability to determine the actual impact of out-migration in many developing countries is limited by the lack
of complete data on the size of outflow, trends and destination countries.9 There is a need to "place" the level
and impact of international out-migration of nurses in a broader labour market context. For example, in many
countries, there is a need for a more detailed assessment of the actual impact of outflow of health workers to
other countries, in comparison to that caused by outflow from the health sector, but remaining in-country.

The other main issue, which is under-explored, is a more detailed evaluation of the various attempts to
constrain outflow, or encourage returners. Case study research would provide more evidence on "what works"
(and is appropriate); such research could be linked to broader based studies, which look at all interventions to
improve the recruitment and retention of health workers in the country.10 This, in turn, is related to issues of
capacity, governance and planning within the country.

Another important associated issue is gender within nursing and the broader health care workforce. There
may be differing patterns of migration and migration experiences, for male and female health workers. For
example, the multi-country study of migration of health workers in the 1970s, by Mejia et al (1979), suggested
that, at that time, nurses (predominantly female) were likely to migrate over shorter geographic distances than
doctors (mainly male). There may also be an issue of whether particular occupations or professions receive
differential treatment because they are perceived to be gender specific. In particular the undervaluing of
nursing as "women’s work" in some countries may be both a direct driver for internationally mobile nurses to
leave that country, and an indirect reason why interventions to reduce outflow may be ineffective.

As well as being the focus of policy research studies, these topics could also be the focus of regional workshops,
bringing together the Ministry of Health and human resource planners, health sector employers, national
nurses associations, NGOs and representatives of civil society to share knowledge and develop a better
understanding of which policy interventions can assist in ameliorating the negative impacts of outflow of
nurses. International organisations such as ICN, ILO, WHO and the Commonwealth Secretariat have already
been instrumental in raising awareness of these issues by sponsoring research and by supporting stakeholder
meetings and conferences.

See e.g. Padarath et al. (2003); Saravia and Miranda (2004).

8

See e.g. Buchan et al. (2003); Padarath et al. (2003).

9

10
See e.g. EQUINET/ Health Systems Trust (2004).
23
"Destination" countries
The policy challenges for destination countries mirror those of source countries. The first concern is monitoring
and assessment, as the ability to monitor trends in inflow of nurses (in terms of numbers and sources) is vital if
the country is to integrate this information into its planning process. Equally important is an understanding of
why nursing shortages are occurring – is it because of poor planning, unattractive pay or career opportunities,
early retirements, etc.?

Destination countries: Policy questions and likely knowledge gaps

Policy questions (in destination countries)

● Why is an inflow of nurses necessary?
● Is inflow sustainable?
● Is inflow a cost-effective way of solving skills shortages?
● Is inflow ethically justifiable?
● Should/ how can recruitment agencies be regulated?

Knowledge gaps (in many countries)

● What are the source countries for inflow?
● How much inflow is permanent or temporary?
● How much inflow is going to health sector-related employment and education in the country?
What proportion is going to non-health-related destinations?
● Is inflow effectively managed?
● Why are nurses coming?
● How should flows be monitored?
● What measures are in place to protect migrant nurses from abuse and exploitation?
● Do migrant nurses require specific support to be effective health care providers?

Source: adapted from Buchan, Parkin and Sochalski (2003).

An initial assessment of the contributing factors for the staffing shortages in any country needs to be
undertaken and those factors taken into account. This assessment would include that of nurse "wastage"
to other sectors or regions within the country. In most countries, both developed and developing, there are
"pools" of individuals with nursing qualifications who are not currently working in nursing (some may be
retired), e.g. in the USA, there are over two million nurses fully registered, but several hundred thousand are
not in the health sector.

Solving the nursing shortage by tapping into this "pool" in developed countries would significantly reduce the
international labour market demand and, in turn, eliminate many of the challenges of mass nurse migration.
The migration push factors found in developing countries are a reflection of the key causes identified for the
nursing shortage in developed countries. Both need to be addressed if effective policies are to be applied.

24
It is crucial to assess the relative contribution of international recruitment of nurses compared with other
key interventions (such as home-based recruitment, improved retention, and return of non-practising health
professionals) in order to identify the most effective balance of interventions. This assessment has to be
embedded in an overall framework of policy responses to health sector workforce issues if it is to be relevant.

The second policy challenge for destination countries can be characterised as the "efficiency" challenge. If
there is an inflow of nurses from source countries, how can this inflow be moderated and facilitated so that it
makes an effective contribution to the health system? Policy responses have included "fast tracking" of work
permit applications; developing coordinated, multi-employer approaches to recruitment; developing multi-agency
approaches to coordinated placement; and providing initial periods of supervised practice or adaptation as
well as language training, cultural orientation and social support.11

The third policy challenge of destination countries concerns ethics. Is it justifiable, on moral and ethical grounds,
to recruit nurses from developing countries?12 The simple response may be that it should not be justifiable to
contribute to "brain drain" in other countries, but a detailed examination of the issue reveals a more complex
and blurred picture. One fundamental issue is the ability of individual nurses to migrate if they so wish. It can
also be argued that countries that do not attempt to address the negative push factors, which make some
nurses migrate, could also be behaving in an "unethical" manner.

Account must also be taken of the development of bilateral and multilateral agreements, where source and
destination countries reach agreement on the managed flow of nurses or other workers.13 A few countries, such
as England (Department of Health 2001) have introduced "ethical" codes of conduct for public sector employers
who are recruiting internationally, whilst other countries such as the Netherlands have adopted an approach
where international recruitment is the "last resort", only used if vacancies have not been filled by home based
action (de Veer et al. 2004). The Commonwealth has also introduced a multilateral code to underpin the
recruitment of health workers within the Commonwealth countries (Commonwealth Secretariat 2003). There
has been little independent evaluation of the impact and effectiveness of such approaches. Such evaluation
is often constrained by inadequate data,14 and would require clarity about the content of any such code, detail
about coverage (i.e. which sectors/ work locations does it cover?) and also systems to monitor compliance.

Destination countries: Knowledge gaps

As noted above, various types of bilateral and multilateral recruitment agreements are being developed by
different recruiting countries. Some of these approaches have an explicit "ethical" dimension, or attempt to
focus on encouraging a "win-win" situation for the source as well as the destination country.15

Detailed case studies examining the content and actual operation of some of these agreements would highlight
the pros and cons of different approaches, and would assist in identifying which appeared to be most
effective and appropriate for source countries. Some of the possible interventions for "win-win" situations
are summarised in Table 12 on the next page. Some are drawn from initiatives already underway.16 Few have been
tested or evaluated to any extent. Future research on the trends and impact of nurse migration should focus
on assessing these current and future interventions.

See e.g. Hawthorne (2001); Buchan et al. (2003); Brush et al. (2004).
11

See e.g. Muula et al. (2003).

12

See e.g. ICN (2001); Tjadens (2002).

13

See e.g. Buchan and Dovlo (2004).

14

See e.g. IOM (2003); Buchan and Dovlo (2004); Stilwell et al. (2004).
15

See e.g. Commonwealth (2003); Department of Health (2003); Physicians for Human Rights, PHR (2004) and the Caribbean
16

managed migration project.

25
Table 12: Examples of potential policy interventions in international recruitment

Level Characteristics/examples
ORGANISATIONAL
"Twinning" Hospitals in "source" and "destination" country develop links, based on staff
exchanges, staff support and flow of resources to source country.
Staff exchange Structured temporary move of staff to other organisations, based on career
and personal development opportunities/organisational development.
Educational support Educators and/or educational resources and/or funding in temporary move
from "destination" to "source" organisation.
Bilateral agreement Employer(s) in "destination" country develop agreement with employer(s)
or educator(s) in "source" country to contribute to, or underwrite costs of,
training additional staff, or to recruit staff for fixed period, linked to training
and development prior to return to "source" country.
NATIONAL
Government-to-government "Destination" country develops agreement with "source" country to
bilateral agreement underwrite costs of training additional staff, and/ or to recruit staff for fixed
period, linked to training and development prior to staff returning to
"source" country, or to recruit "surplus" staff in "source" country.
Ethical recruitment code Destination country introduces Code that places restrictions on employers
- in terms of which source countries can be targeted, and/or length of stay.
Coverage, content and compliance issues all need to be clear and explicit.
Compensation Much discussed, but not much evidence in practice - destination country pays
compensation - in cash or in form of other resources - to source country.
Possibly some type of sliding scale of compensation related to length of stay
and/ or cost of training, or cost of employment in destination country; possibly
"brokered" via international agency?
Managed migration Country (or region) with outflow of staff initiates programme to stem
(can also be regional) unplanned out-migration, partially by attempting to reduce impact of push
factors, partially by supporting other organisational or national interventions
that encourage planned migration.
Train for export [can be a subset of managed migration] Government or private sector makes
explicit decision to develop training infrastructure to train health professionals
for export market - to generate remittances, or up-front fees.
INTERNATIONAL
International code As above, but covering a range of countries, its relevance will depend on
content, coverage and compliance. The Commonwealth code is an example.
Multilateral agreements Similar to bilateral agreements (above), but covering a number of countries
(regions). Possibility of brokering/monitoring role by international agency.

Source: Derived from Buchan and Dovlo (2004).

26
Further research should also include undertaking more detailed cohort studies of international recruits in the
destination countries, to develop a better understanding of their career plans, reasons for moving, how long
they plan to remain in the destination country, level of remittances sent home, etc. This would enable a
better understanding of their experiences, and the extent to which they have received fair and equal treatment
in the destination country. Some studies have been conducted (e.g. Yi and Jezewski 2000; Daniel et al. 2001;
Royal College of Nursing 2003), but these tend to be small scale or "one off" snapshot surveys, rather than
cohort studies tracking nurses over time.

Finally, it is evident that, both for national governments and for international agencies, there is a need to
develop a better understanding of the level and dynamics of the flows of nurses. Further research could also
be supported in source and destination countries to improve monitoring of flows; this could be undertaken
in association with other agencies with an interest in this issue (e.g. ICN, WHO, ILO).

The ILO’s Plan of Action 2004 includes ethical recruitment of migrant workers, especially in health and education,
as one of the areas for development of guidelines and good practices: "promoting guidelines for ethical
recruitment of migrant workers and exploring mutually beneficial approaches to ensure the adequate supply
of skilled health and education personnel that serve the needs of both sending and receiving countries,
including through bilateral and multilateral agreements" (ILO 2004: 17).

27
Section Three: Conclusions and Recommendations

Many nurses will continue to be interested in crossing national borders to access "pull" factors – which may be
better pay, professional development and improved career opportunities, or the opportunity to experience life
and work in a different culture. The demographics in many developed countries – a growing, ageing population
and an ageing nursing workforce – make it likely that many of these countries will continue to be active in
encouraging inflow of nurses from other countries (Buchan 2002). Given the historically high levels of nurse
migration, country governments and international agencies have two policy options: non-intervention; or some
level of intervention to attempt to manage the migration process so that it is nearer a "win–win" situation, or
at least is not exclusively "win-lose", with the countries that can least afford it being the biggest losers.

The root cause of the current relatively high level of nurse migration is nursing shortages in developed countries,
combined with the existence of "push" factors of low pay, poor career prospects, unsafe work environments
and instability in some developing countries. Nurse migration is often a symptom of more deep-seated problems
in country nursing labour markets. The pattern that is emerging is a trend of increase in inflow of nurses to
developed countries from a wider range of developing countries, as these countries become more active in
using international recruitment to combat nursing shortages. Shared language, common educational curriculum,
and post colonial ties between countries, as well as large diaspora or trans-national communities, tend to be the
factors determining which developing countries are being targeted as sources of nurses.

The dynamics of the current pattern of migration can change quickly, but generally reflect a trend towards higher
levels of mobility across national boundaries. As the level of migration has increased, so has the debate about its
implications and the desirability and scope for policy interventions. Some countries have developed "ethical"
elements to their recruitment activities and, at an international level, the International Council of Nurses (ICN 2001)
has also set out a position statement arguing for ethics and good employment practice in international recruitment.
More recently, the Commonwealth (Commonwealth Secretariat 2003), the World Health Assembly (WHO 2004a), and
the Global Equity Initiative have all highlighted the need for better monitoring of, and a more "ethical" approach to,
the migration of health workers.

Some developing countries are also intervening to try to add a counter balance. For example, the Caribbean
approach to "managed migration" of nurses essentially recognises that out-migration cannot be prevented, but
a package is being developed to ameliorate its worst effects, and to seek compensation from importer countries.

Given the underlying demographic, labour market and economic drivers, the current historically high levels of
cross border flows of internationally recruited nurses are likely to continue. The problems caused for some
developing countries by this migration will continue to be severe. They are losing scarce and relatively expensive
to train resources. Levels and quality of care are suffering. Many of the nurse recruits are relatively young, and
these countries could also lose out on future leaders in the profession.

At the aggregate level, the challenges are obvious. At the level of the individual, it is less easy to be critical.
Who can blame a nurse for claiming freedom of movement, to gain security, better quality of life, or career
development? Whilst the debate continues, there is a clear need for the active recruiting countries to examine
their own practices, because it is they who are the drivers of the process.

Recruiting internationally may be a quick fix solution for some developed countries, but it is far from clear that
it is a cost effective solution in many situations. Importer countries need to ensure that they have developed

28
their own "home grown" sustainable solutions to achieving greater self-sufficiency, investing in attractive career
structures, and improving retention and return of home-based nurses. They should also encourage co-operation
at organisational and governmental levels to identify scope for a "win-win" approach to international recruitment,
when it is used as a policy instrument.

Recognising that international nurse migration will continue to exist, mechanisms need to be put in place that will
safeguard migrants’ rights and facilitate their integration into society and their workplace. It is likely that this will
need a multi-prong approach incorporating the financial and human resources of stakeholders from both the source
and destination countries. Government, professional organisations, trade unions, employers and the for-profit sector
(e.g. recruitment agencies) must be held accountable to develop the appropriate structures and procedures.

The recommendations set out in this section are made on the basis of identified key current knowledge gaps.
They are also made on the basis that it is unlikely that there will be any slackening in the prominence of
international recruitment activity in the next few years. This activity will continue to be stimulated by the
significant inter-country imbalances in the pay and career prospects for nurses.17

Drawing from the issues and main knowledge gaps highlighted in this report, the key recommendations are:
● One crucial gap is the absence of accurate data on the flows of international nurses; this is a constraint on
any effective monitoring, and also limits the ability to assess impact. Stakeholders at national level and
international agencies need to collaborate to agree and implement improved systems to monitor international
flows of nurses and other health workers.
● The position of many developing countries that are sources of international nurse workers is weakened by
inadequate workforce data and planning capacity, and it is difficult to assess how much of a "problem"
outflow to other countries is in comparison to the numbers of underemployed or unemployed nurses in the
country. These countries must assess and improve their planning systems, and give more policy attention to
encouraging and supporting non-practising nurses to return to nursing employment.
● The overall impact of out-migration of nurses on source countries, in terms of its effect on health systems and on
remaining staff, requires more systematic assessment. More research and evaluation is required to inform national
stakeholders and international agencies of the true impact and costs (and/or benefits) of nurse migration.
● Relatively little is know about the experiences of international nurses now working in destination countries,
in terms of their profile and future career plans (including likelihood of return to source countries or onward
movement to other countries), and equality of treatment. The structures and services required to protect
migrant nurses from exploitation and abuse, while promoting their general well being and integration, need
to be further developed and made easily accessible. Research and evaluation is required to highlight good
practice and expose poor practice in the treatment of migrant nurses.
● The gender issue in relation to the migration of nurses is an important factor; there is a need for donors
to support strengthened nurses’ professional associations in source countries, so that the position of nurses
in society can be promoted by stronger advocacy. Donors need to focus attention on supporting the
strengthening of representative organisations for nurses.
● The issue of how – or if – to "manage" migration is important, and requires more considered investigation,
with systematic assessment of the various models of managed migration. The various policies and models of
managed migration, bilateral agreement, ethical codes, return migrant schemes and possible models of
"training for export" require examination and evaluation to support a more effective approach to international
recruitment of nurses at national and international level.
17
See e.g. Vujicic et al. (2004).

29
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Abbreviations DFID Department for International
Development
3x5 Global Initiative Strategic and DH Department of Health
Operational Framework DJCC Directors Joint Consultative
AC Audit Commission Committee
ACETERA Argentinean Civil Association of DOT Directly Observed Treatment
Non-University Schools of ECN Enrolled Community Nurse
Nursing in Argentina ECSA East, Central and Southern Africa
ACHIEEN Chilenean Association of Nursing ECSACON East, Central and Southern Africa
Education College of Nursing
ACOFAEN Colombian Association of Schools of ECSA-HC East, Central and Southern Africa
Nursing Health Community
ADHA Additional Duty Hour Allowances EN Enrolled Nurse
AEUERA Argentinean Association of University EPI Expanded Programme on Immunisation
Schools of Nursing EU European Union
AFRO AFRICA Regional Office FAE Argentinean Federation of Nursing
AHRQ American Health Research and Quality FEMAFEN Mexican Federation of Associations
AHSN Africa Honour Society for Nurses of Schools of Nursing
ALADEFE Latin American Association of FEPPEN Pan American Federation of
Faculties and Nursing Schools Nursing Professionals
ANA American Nurses Association FIM Functional Independence Measure
APE Paraguayan Association of Nursing FNHP Federation of Nurses and Health
ARVs Anti Retroviral drugs Professionals (USA)
ASEDEFE Ecuatorian Association of Schools FP Family Planning
of Nursing FTE Full-Time Equivalents
ASOVESE Association of Schools of Nursing FUDEN Nursing Development Foundation
of Venezuela (Spain)
ASPEFEN Peruvian Association of Schools GATS General Agreement on Trade in Services
of Nursing GAVI Global Alliance for Vaccines and
AU Africa Union Immunizations
AWG Africa Working Group GDP Gross Domestic Product
CEDU Uruguay College of Nurses GNP Gross National Product
CHI Commission for Health Improvement GP General Practitioner
CHN Community Health Nurse GRNA Ghana Registered Nurses Association
CHSRF Canadian Health Services Research HC Healthcare Commission
Foundation HIPC Highly Indebted Poor Countries
CIPD Chartered Institute of Personnel HPCA Health Professionals’ Competency
and Development Asssurance Act
CM Community Midwifery HPPD Hours per Patient Day
CN Community Nursing HR Human Resource
CNO Caribbean Nurses Organization HHR Health Human Resource
COFEN Federal Council of Nursing, Brazil HRM Human Resource Management
CREM Mercosur Regional Council of Nursing HSR Health Sector Reform
CRHCS Commonwealth Regional Health ICN International Council of Nurses
Community Secretariat ICNP® International Classification of
DENOSA Democratic Nursing Organization Nursing Practice
of South Africa ICU Intensive Care Units

32
IDB Inter-American Development Bank PRODEC Nursing Development Programme in
IES Institute for Employment Studies Central America and the Caribbean
ILO International Labour Office PRSCs Poverty Reduction Support Credits
IMR Infant Mortality Rate PRSP Poverty Reduction Strategy Papers
IOM International Organization for QA Quality Assurance
Migration RBM Roll Back Malaria
IOM Institute of Medicine (USA) RC Regional Committee
IPC Infection, Prevention and Control RCHN Registered Community Health Nurse
IUCD Intra Uterine Contraceptive Device REAL Latin American Nursing Network
IWL ‘Improving Working Lives’ RHMC Regional Health Ministers Conference
JLI Joint Learning Initiative RM Registered Midwife
LPNs Licensed Practical Nurses RN Registered Nurse
MCH Maternal and Child Health RPN Registered Psychiatry Nurse
MDGs Millennium Development Goals RSA Republic of South Africa
MMR Maternal Mortality Rate SADC Southern Africa Development
MoH Ministry of Health Community
MSF Médecins Sans Frontières SANC South African Nursing Council
MTEF Medium Term Expenditure S&T Science and Technology
Framework SARA-AED Support for Analysis and Research in
NAFTA North Atlantic Free Trade Agreement Africa - Academy for Educational
NCDs Non Communicable Diseases Development
NDNQI National Database of Nursing Quality SEW Socio-economic Welfare
Indicators SSA Sub-Saharan Africa
NEPAD New Partnership for Africa’s TB Tuberculosis
Development UAP Unlicensed Assistive Personnel
NGOs Non-governmental Organisations UK United Kingdom
NHA National Health Accounts UNAM Autonomous National University
NHS National Health Service of Mexico
NNAs National Nurses Associations UNESCO United Nations for Education, Science
OAS Organization of American States and Culture Organization
OCB Organisational Citizenship Behaviour USA United States of America
OECD Organization for Economic UWI University of West Indies
Co-Operation and Development VCT Voluntary Counselling and Testing
OPSNs Outcomes Potentially Sensitive VF The Vaccine Fund
to Nursing WHO World Health Organization
OWWA Office of Workers Welfare
Administration
PAHO Pan American Health Organization
PBN Post Basic Nursing
PDP Performance Development Plan
PEPFAR President’s Emergency Program for
AIDs Relief
PHC Primary Health Care
POEA Philippine Overseas Employment
Authority
PPP Purchase Parity Pay

33
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