GLOBAL INEQUITIES AND

HEALTH PROFESSION MIGRATION

Janet Hatcher RobertsAnita A. DaviesInternational Organization for MigrationGeneva, Switzerland

Global Inequities

Health Profession MigrationHealth Profession Migration

What is Migration

Origin

Transit

Destination

Return

What are the Global What are the Global Health Determinant Health Determinant

Inequities?Inequities?

Total Population

Source: worldmapper.org

Global Inequities: WealthDistribution of the World’s Wealth

USA

India

Indonesia

Bangladesh

Philippines

China

Japa

n

Russian Federation

Australia

Germany

Spain

Switzerland

Fr Guyana

UK

Italy

Source: worldmapper.org

Global Inequity: PovertyDistribution of Poverty in the

World

www.worldmapper.org

USA

Canada

Nig

eria Ethiopia

Egypt

Kenya

India

Indonesia

Bangladesh

Philippines

China

Japa

n

Russian Federation

Australia

Pak

ista

n

Thailand

South Africa

Access to Water: Privatization of a public good

http://hdr.undp.org/

Access to Water

http://hdr.undp.org/

What are the global health burden disease inequities?

Proportional distribution of diseases and Proportional distribution of diseases and deathsdeaths

Those who suffer or who benefit least deserve help from those who benefit most.”

Quote from the Millennium Declaration’s statement about the challenge of globalization

Proportional Distribution of people living with HIV, 15 -49

years (2003)

www.worldmapper.org

Nigeria Ethiopia

Kenya

India

South

Africa

Tanzania

BotswanaZimbabwe

Russian Federation

N=29.2 million www.worldmapper.org

Proportional Distribution of Malaria Deaths, 2003

www.worldmapper.orgN=109612

Sudan

Uganda

India

Malawi

Tanzania

MozambiqueZimbabwe

Demo Rep Congo

Gha

naAngola

www.worldmapper.org

Proportion of Cholera cases, 2003

www.worldmapper.orgN=152,929

Sudan

Som

alia

Pakistan

Zambia

Tanzania

Mozambique

Demo Rep Congo

Gha

na

Ang

ola

www.worldmapper.org

Deaths from all Disasters

www.worldmapper.org

Deaths caused by Drought

www.worldmapper.org

Deaths caused by Floods

www.worldmapper.org

Deaths from Extreme Temperature

www.worldmapper.org

Distribution of Underweight Children

Half of all children under the age of 5 years old that are Half of all children under the age of 5 years old that are underweight live in Southern Asia. Almost half of all children underweight live in Southern Asia. Almost half of all children under 5 in Bangladesh, Nepal and India are underweight.under 5 in Bangladesh, Nepal and India are underweight.

Southeastern Africa, Asia Pacific, Northern Africa and Eastern Asia Southeastern Africa, Asia Pacific, Northern Africa and Eastern Asia are also home to relatively large numbers of underweight children. are also home to relatively large numbers of underweight children. Within these regions the territories with the largest populations of Within these regions the territories with the largest populations of underweight children are: Ethiopia, Indonesia, Nigeria and Chinaunderweight children are: Ethiopia, Indonesia, Nigeria and China

www.worldmapper.org

http://www.who.int/mediacentre/factsheets/fs310.pdf

Source: WHO World Health Report 2002

Morbidity by Risk Factor: Opportunities for Intervention

0

10000

20000

30000

40000

50000

60000

High C& A

High C/V High

A

V LowC & A

Low C& A

High C& A

Low C& A

High C& A

V LowC & A

Low C& A

Low C/High A

Low C& A

High C& A

V LowC & A

Low C& A

AFRICA AMERICAS EAST MED. EUROPE SOUTH-EASTASIA

WEST PACIFIC

Region and Mortality Stratum

DA

LYs

(000

s)

Childhood and maternalundernutrition - Underweight

Diet-related risks and physicalinactivity - Blood pressure

Sexual and reproductive healthrisks - Unsafe sex

Addictive substances - Tobacco

Environmental risks - Unsafewater, etc.

Environmental risks - Indoorsmoke from solid fuels

Occupational risks - Risk of injury

Occupational risks - Airborneparticulates

Other - Unsafe health careinjections

Source: WHO World Health Report 2002

Mortality by Risk Factor: Opportunities for Intervention

0

200

400

600

800

1000

1200

1400

1600

1800

2000

Hig

h C

& A

Hig

h C

/ VH

igh

A

V Lo

w C

& A

Low

C &

A

Hig

h C

& A

Low

C &

A

Hig

h C

& A

V Lo

w C

& A

Low

C &

A

Low

C/

Hig

h A

Low

C &

A

Hig

h C

& A

V Lo

w C

& A

Low

C &

A

AFRICA AMERICAS EAST MED. EUROPE SOUTH-EASTASIA

WESTPACIFIC

Region and Mortality Stratum

Dea

ths

(000

s)

Childhood and maternalundernutrition - Underweight

Diet-related risks and physicalinactivity - Blood pressure

Sexual and reproductive healthrisks - Unsafe sex

Addictive substances - Tobacco

Environmental risks - Unsafewater, etc.

Environmental risks - Indoorsmoke from solid fuels

Occupational risks - Risk ofinjury

Occupational risks - Airborneparticulates

Other - Unsafe health careinjections

What about the What about the distribution of health distribution of health

workers?workers?

Can they address these Can they address these growing inequities?growing inequities?

Global Inequities: World distribution of health workers

(2006)

http://www.who.int/mediacentre/factsheets/fs302/en/index.html

The Health Workforce in the Americas vs. Sub-Saharan Africa,

2006

http://www.who.int/mediacentre/factsheets/fs302/en/index.html

0

10

20

30

40

50

60

World Population Global Burden of Disease World's Health Workers Global Health Expenditure

Per

cent

(%

)Americas Sub-Saharan Africa

The PUSH for Migration of Health Professionals

Poverty Employment Education Safe clean water: ability to deliver good quality care Social exclusion

Urban / Rural: huge disparities in health worker distribution

Gender: power relationships within the professions Poor infrastructure Poor, dysfunctional health systems: impact of SAP, no

solid investment in the health system, no professional growth

The PULL for Migration of Health Professionals

Sharp rise in demand for health workers in countries of Sharp rise in demand for health workers in countries of

destination: who is recruiting; why are they recruiting, the destination: who is recruiting; why are they recruiting, the

role of private sector recruitment ….one hundred percent of role of private sector recruitment ….one hundred percent of

graduating class in Guyana had tickets to leave the next daygraduating class in Guyana had tickets to leave the next day

Factors that drive migration also drives the mobility of health Factors that drive migration also drives the mobility of health

workersworkers

the role of private sector and international organizationsthe role of private sector and international organizations

Brain waste: the driver is a trained doctor/ the maid is a Brain waste: the driver is a trained doctor/ the maid is a

trained orthopaedic surgeontrained orthopaedic surgeon

Determinants of health are inequitably Determinants of health are inequitably distributed distributed

Health professionals are inequitably Health professionals are inequitably distributeddistributed

Many diseases and causes of death are Many diseases and causes of death are also inequitably distributed with a also inequitably distributed with a greater burden in low income countries greater burden in low income countries

How can there be a better balance with How can there be a better balance with more responsive health and human more responsive health and human resourcing?resourcing?

Strategies

Addressing the inequitable Addressing the inequitable distribution of health distribution of health

professionalsprofessionals National code of practiceNational code of practice

UK code of practice on UK code of practice on international recruitmentinternational recruitment

Multilateral code of practiceMultilateral code of practiceCommonwealth code of conductCommonwealth code of conduct

Bilateral agreements-MOUsBilateral agreements-MOUsUK / South AfricaUK / South Africa

Lessons learnt Codes of conduct not legally bindingCodes of conduct not legally binding Bilateral agreements encourage Bilateral agreements encourage

circular migration and transfer of skillscircular migration and transfer of skills Stakeholders must have common goalsStakeholders must have common goals National interests need to be in line National interests need to be in line

with wider development objectiveswith wider development objectives We need to think beyond national We need to think beyond national

bordersborders More emphasis needs to be placed on More emphasis needs to be placed on

retentionretention

How can the migration of How can the migration of health professionals be health professionals be

better managed ?better managed ?

Intersectoral Collaboration is Key

Interact with related policy domains

Migration&

Health Professional Policies

Development

Trade

Labour

Human Rights

Security

Health

Education

Foreign Affairs

Need for coherence

Harmonize policies on retention and Harmonize policies on retention and recruitment of health professionals, recruitment of health professionals, nationally, regionally and globallynationally, regionally and globally Policy researchPolicy research Policy coherence & comprehensivenessPolicy coherence & comprehensiveness

Capacity Building: training; scholarships; Capacity Building: training; scholarships; graduate programmes and creative graduate programmes and creative opportunities for researchopportunities for research

Who Are TheStakeholders?

Donors for Development

International Organizations

Diaspora

Private Sector/Civil Society

Country of Origin

Host Countries

Academic/Health Institutions

Health Professional Orgs

Diaspora professionals address health inequity

through: Financial remittances Financial remittances Social remittances Social remittances Technological remittancesTechnological remittances Political remittancesPolitical remittances Structural remittancesStructural remittances Human resources for health Human resources for health

remittancesremittances

Diaspora

IOM experience: Migration for Development in Africa

(MIDA) The MIDA initiative is an The MIDA initiative is an

innovative framework that engages innovative framework that engages with the diaspora and facilitates with the diaspora and facilitates the transfer of skills for capacity the transfer of skills for capacity development in Africadevelopment in Africa

Dialogue and migration policy

option

Assessment database

development

Skills transfer

Remittances programmes

Information Campaigns

-

Small-scale enterprise

development

Migration for Development in Africa (MIDA)

Ethical Practices

MIDA projects

77 Ghanaian health sectorGhanaian health sector

Sierra Leonean and Sierra Leonean and Ghanaian diasporasGhanaian diasporas

6

5/6/7 5/6/7 3/3/

44

Ethiopian and Ghanaian Ethiopian and Ghanaian expatriates in Italyexpatriates in Italy

55

Guinean womenGuinean women11

East African Community East African Community (EAC)(EAC)

22

The Great LakesThe Great Lakes33

The Great Lakes regionThe Great Lakes region 4

1166

77

3/43/4

55

55

22

Ghana MIDA Health Project A bilateral programme of the governments of Ghana A bilateral programme of the governments of Ghana

and The Netherlands and The Netherlands A feasibility study identified the interest of Ghanaian A feasibility study identified the interest of Ghanaian

diaspora in Europediaspora in Europe Skill gaps identified in GhanaSkill gaps identified in Ghana Skill needs matched with Diaspora skillsSkill needs matched with Diaspora skills IOM facilitated temporary return of health IOM facilitated temporary return of health

professionalsprofessionals IOM facilitated internships and training from Ghana to IOM facilitated internships and training from Ghana to

the Netherlands and UKthe Netherlands and UK Diaspora professionals can contribute to strengthening Diaspora professionals can contribute to strengthening

the health systemthe health system

What Do We Mean By What Do We Mean By Strengthening Health Strengthening Health

SystemsSystems

Frameworks: Population Health/Health PromotionEquity/Determinants of Health

Inter Sectoral Policy Development

Research for Development: Capacity, Funding andPolicies support evidence based policies

Capacity Building for Planning Evidence Based Resource Allocation

Integrated health information systems: data for decision making

Human Resource Development/Continuing Education

Equitable access to treatment, services and programs

Community Interventions andHealth Promotion Programs

Evidence based Decision Making (Clinical and Community based)

Strong and vibrant civil societyAccountable and Transparent Public /Private Sector

The Impact of Decentralization on Human Resource Response

National

Local Community

Continuum of Health Response

Problem Identification

Data Analysis

Intervention, Prevention Strategies Policy

Devt

Local Needs coordination

Programs &

Services

Capacity is not being developed and sustained at the right level

Money remains at the national level

Data Collection

Policies that influence the migration of health

professionals The factors that shape immigration

policies are complex and intertwined as governments struggle to balance economic, labor market, social, demographic, human rights, humanitarian, international, and political goals

The way forward Target-oriented, training and education of Target-oriented, training and education of

health professionals to enhance knowledge health professionals to enhance knowledge of global health and migration issuesof global health and migration issues

Identify a comprehensive matrix of health Identify a comprehensive matrix of health professionals that can reinforce and sustain professionals that can reinforce and sustain health systems capacity building and health systems capacity building and facilitate exchange and return of diaspora: a facilitate exchange and return of diaspora: a balanced approach: gender, professionals balanced approach: gender, professionals not just doctors; community basednot just doctors; community based

Promote and support ethical recruitment Promote and support ethical recruitment and retention strategies, agreements, and retention strategies, agreements, guidelinesguidelines

Promote and support dialogue on exchange Promote and support dialogue on exchange of experiencesof experiences

Global Health Workforce Alliance

Addresses the recruitment and Addresses the recruitment and retentionretention of health workers of health workers

Addresses the need for rapid scaling up Addresses the need for rapid scaling up of health workersof health workers

Addresses the tools and methods for Addresses the tools and methods for trainingtraining

Developing processes for advocacy for Developing processes for advocacy for receiving and sending countriesreceiving and sending countries

A global approach is needed

We need to: We need to:

work together work together

learn from each learn from each other other

Thank you

http:www.iom.int