Migration and health: A focus on health care worker

migration.

Session overview• Migration and health• Migration and human rights• Globalisation• Health systems• How it is in Europe• Inequalities• Causes• Consequences• Policy responses.

The global picture

What effects does migration have on health?...

……5 minutes, in groups of 5!

Effects of migration on health

• Faster spread of infectious diseases• Reduction of health care services vs

increased health care services.• Lowering of human resources in sources

countries• Migrant health not being cared for

properly in destination country• Remittances – might improve health• Psychosocial – away from home• Refugees – poor health services.

Human rights and migration

• Freedom of movement. (UDHR)• Right to health and well being

(WHO charter and UDHR)• Right to the highest attainable

standard of health (ICESC)

• Individuals have a personal choice, should not be persecuted!

Globalisation Globalisation can be defined as processes that are

changing the ways in which people interact across boundaries, notably physical (such as the nation-state), temporal (such as instantaneous communication via

email), and cognitive (such as cultural identity). The result is a redefining of human societies across many spheres, economic, political, cultural, technological and so on. As such, globalisation affects the health of different people in very different ways. How good or bad globalisation happens to be for you will be influenced by socioeconomic status, sex, education, age, geographical location, and other factors.

»Lee, K et al. BMJ 2002;324:44 ( 5 January )

Health care workers and health systems.

• Back Bone • 2/3 of health expenditure• Health workers ‘own’

considerable investment – skills financed by the health system.

• 100 million health care workers in the world.

In Europe…

….. Over to you!

“I not only use all the brains that I have, but all that I can borrow.”Woodrow Wilson, 28th US President

Inequalities in HCW’s• SSA needs 720, 000 more doctors

and 670,000 more nurses to reach MDG’s.

• 700% increase in docs, 50% increase in nurses.

• UK: 620 people per doctor, 185 per nurse

• Liberia: 43,478 per doctor, 9,804 per nurse

Millennium Development goals:

• Millennium Development Goals- To achieve over the period 1990-

2015Goal 4: 2/3 reduction in child mortalityGoal 5: 3/4 reduction in maternal mortalityGoal 6: Halt and begin to reverse spread of HIV/AIDS, malaria and other diseases

health worker density world map

[Source: Joint Learning Initiative, 2004]

Income distribution world map

Health care worker migration…why?

5 mins…groups of 5!

Push and pull factors!• Wages• Working conditions• Future prospects (training etc.)• Management and health system

governance

dynamicseconomic stagnation

low respect for staff

low morale

poor health outcomes

low pay for health staff

dysfunctional health system

loss of training

investment

poor management

of staff

poor quality of care

migration

R

R

R

HIV/AIDs

personal risk to staff

conflict

lack of mentors

Summary of causes• Migration is not the ‘problem’ but a self

perpetuating result of problems• Inequality driving huge differentials in

working conditions• Africa has a particular set of serious

causes• Poor working conditions• Demand• Increasing integration of global

economy.

Consequences…Increasing Inequality

• Increasing migration• Worse health outcomes• Health systems effects

Increasing migration…Number of Zimbabwean-trained doctors on UK

register

020406080

100120

1999 2000 2001 2002 2003 2004

Year

Number of doctors

Zimbabwean-trained nurses on UK register

0

500

1000

1500

2000

2500

1998/99 99/2000 2000/01 2001/02 2002/03 2003/04

Year

Number of nurses

Estimated numbers of nurses trained in Ghana registered in the UK

Source: calcula ted from NMC 2004

Ghanaian nurses

0200400600800

10001200

1998/99 1999/2000 2000/01 2001/02 2002/03 2003/04

Less health care workers – worse outcomes.

0

1

2

3

4

5

6

7

8

9

0 1 2 3 4 5

Graph 1: Density (workers per 1,000, log)

Mortality (per 1,000, log)

LnMMRLnIMRLnU5MR

Maternal

Infant

Under-5

Health systems effects• In addition to worsened health

outcomes– beheading of health system: top goes

first– training and management suffer– more pressure on those remaining– re-inforces migration pressures

Perverse Subsidy• Perverse….in the wrong direction• Subsidy – someone helping

someone else by giving them money

• Why perverse…money going from poor to rich…is this right??!!

Looking at the UK and Ghana

• Ghana about 50 times poorer than the UK.• Govt. health expenditure per capita

– Ghana £6 (Zim? £16)– UK £800

• Ghana trains health professionals, then loses the stream of expected health care benefits to privileged UK health service users

• Saving of training investment in UK health services: crude estimates of £65 million for 293 doctors and £38 million for 1021 nurses

• Provides benefits to UK health service users: at salary costs if those staff were all employed in the NHS, an estimated £39 million per year– These are orders of magnitude of perverse

subsidy - of the scale of the injustice

What are the possible policy responses?

Groups of 5…5 mins!

Possible responses…• Health systems strengthening in the

countries of origin• Restitution• Self sufficiency• Ethical recruitment• Bonding• Improving post graduate training• Training different types of health

care workers• Incentives to stay• Partnership

RestitutionRestitution represents:• Progressive redistribution that works: health

services are highly redistributive• Practical response: informed policy since

training location of staff is verified on registration

• Non-discriminatory if detached from individuals: extent of the subsidy should inform policy

• Can be managed effectively: mechanisms can be designed on a case by case basis to assure additionality and ring fencing to health care

• Can help build incentives to stay

Ethical Recruitment

A failing policy?• Increase over time (below) in UK nurse registration

rates, during a period when a ban on active international recruitment had just come into effect:

Growth in registrations of nurses from Africa(randomly selected countries)

-

200

400

600

800

1,000

1,200

1,400

in 98/ 99 in 99/ 00 in 00/ 01 in 01/ 02 in 02/ 03

Year

Growth index (98/99 = 100)

Source = NMC

ZimbabweGhanaZambiaSAKenyaNigeria

Ban Ba

n st

reng

then

ed

Partnership• Boundaries are blurring between the UK

and low-income country health services - they are becoming interdependent

• Scope for mutual benefit and redistribution already exists e.g. in Ghana - UK health service links between professionals, associations, facilities and individuals

• Policy can build onto this: effective financial support, two-way circular migration, training and research collaboration