Health Workforce Mobility in the Asia-Pacific Region:

Current Trends + Challenges for Australian Health

Workforce Planning

Lesleyanne Hawthorne

Professor – International Health Workforce

Canadian Health Workforce Conference –

Optimizing the Canadian Health Workforce

3-5 October 2016

Shaw Centre Ottawa

Policy Context: Transforming Global/ National Attitudes to High

Skilled Migration

Global bodies universally:

1. Endorse the value of high-skilled migration (win-win): UN, WHO,

IOM, ILO, ASEAN (etc) + the individual’s right to move

2. Aim to facilitate flows (in particular circular and return

migration)

BUT - Variation in national government attitudes to out-

migration:

1. Highly restrictive (eg Singapore)

2. Laissez-faire (eg India, China)

3. Over-production for export + remittance-generation (eg

Philippines)

Case study - Filipino nurses: Positions for 29,467 registered nurses nationally

Compared to 163,756 RNs overseas (85%)

Challenge 1: Growth in Scale of Health Migrant Arrivals to

Australia by Field (2006-11 Compared to 2001-05)

Field

2001-2005 Arrivals

2006-2011 Arrivals

Engineering 18,790 41,407 Accounting 26,145 35,423 IT 22,630 31,968 Education 15,400 29,464 Registered Nursing 14,233 26,328

Medicine 7,241 12,696

Pharmacy 1,798 3,005 Dentistry 1,063 2,343

Physiotherapy 755 1,556

Total (All Degrees) 192,940 347,611

1. Bilateral/multilateral agreements (eg EU, NAFTA)

2. International students (study-migration pathway)

3. Temporary sponsored migrants

4. Permanent skilled migrants

5. Partners of skilled migrants

6. Family and Humanitarian category migrants

Challenge 2: Global Competition to Attract and Retain ‘The Best’

Skilled Migrants (Which Entry Pathway to Prioritise?)

Challenge 3: Facilitating Labour Market Integration for

‘Traditional’ Points-Tested Skilled Migrants (as in Canada)

1. Migration mode:

Permanent

2. Selection strategy:

Points-testing dominant

3. Control:

Federal government

4. Employment access:

Integration support services

Migrant seeks work (‘independent’)

5. Issue:

Highly differentiated employment outcomes

Significant risk of de-skilling)

Work Rates @ 6 Months for Permanent Economic Migrants:

By Sub-Category 2009-11 (Government Data)

Visa Reporting

Category

Skilled

Job

Other

Job

Not

Working

Working

Full-time

Particip.

Rate

Unemploy. Median

Full-time

Earnings

6 Months Job ($'000)

Employer

Sponsored

90 7 3 92 98 0.5 71.3

Family/State

Sponsored

60 31 9 72 98 7 50.0

Offshore

Independent

75 12 12 76 97 10 74.6

Onshore

Independent

55 37 8 69 98 6 44.4

Skilled

Graduates

58 36 5 65 98 3 40.0

Other Skilled 47 33 20 61 86 7 43.0

All Skilled 68 24 8 75 96 5 52.0

Challenge 4 – Diversity in the Context of Employer Preference for OECD

Trained Migrants (Nursing Case Study 2014-15)

Permanent

(Government Selected)

1. Philippines (863)

2. India (689)

3. China (348)

4. UK (313)

5. Ireland (164)

6. Nepal (150)

7. Korea (124)

Total = 3,206 Total

Temporary

(Employer Selected)

1. UK (680)

2. India (600)

3. Philippines (480)

4. Ireland (400)

5. Canada (40)

6. Zimbabwe (40)

7. South Africa (30)

Total = 2,540 Total

Australian Employer Preference for OECD Training:

Top 15 Source Countries for New 457 Visa Grants: 2008-09 to

2014-15 (All Fields)

1. UK: 77,069

2. India: 69,568

3. Ireland: 27,275

4. USA: 24, 429

5. Philippines: 21,196

6. China: 17,541

7. Canada: 10,428

8. South Africa: 9,197

9. Germany: 8,458

10. France: 8,127

11. Malaysia: 6,126

12. Japan: 5,644

13. South Korea: 5,511

14. Italy: 5,480

15. Netherlands: 4,849

Impact of Employers on Selection:

Preference for OECD Trained Registered Nurses (Australia 2015)

Permanent

(Government Selected)

1. Philippines (863)

2. India (689)

3. China (348)

4. UK (313)

5. Ireland (164)

6. Nepal (150)

7. Korea (124)

Total = 3,206 Total

Temporary

(Employer Selected)

1. UK (680)

2. India (600)

3. Philippines (480)

4. Ireland (400)

5. Canada (40)

6. Zimbabwe (40)

7. South Africa (30)

Total = 2,540 Total

Challenge 5: Which Countries of Training to Target?

Elkin (2015) registration + protection study on IMGs:

Australia

Analysis of complaints data to Medical Boards

5,000 complaints analysed (PhD)

Significantly higher complaints against IMGs

Issues:

Racial prejudice? OR

Do ‘some groups of IMGs have more interactions with

patients that are of inferior quality’

So such interactions ‘expose patients to greater risk’?

Challenge 6: Who Should be Exempt from Host Country Exams?

(Australia’s Medical Council Competent Authority Pathway)

•Places of training: 55+ (growing!)

•Place of prior registration:

1.PLAB Professional and Linguistic Assessments Board

examination of the United Kingdom

2.MCC Medical Council of Canada Licensing Examination

3.USMLE United States Medical Licensing Examination

4.NZREX New Zealand Registration Examination

5.GMCUK General Medical Council–accredited medical

school in the United Kingdom

6.MCI Medical Council of Ireland–accredited medical school

in Ireland

•Places of training: 55+ (growing!) – never sit exams!

•Case study: Doctor qualified in China

Trend 1: Allow Employers to Select Permanent Skilled Migrants

On and Offshore (2011 Onshore Rates Rising to 91% by 2015)

Where are Permanent Skilled Migrants Selected by Employers

(All Health Fields)? Skilled Category 2008-09 to 2014-15

Impact of Employer Selection of Permanent Economic Migrants:

New Zealand Compared to Australia

NZ (past decade):

80-88% of permanent skilled migrants: Already working in NZ or

resident with NZ job offer when selected

Australia 2015-16

Skilled category: 128,550 (= around 34,000 primary applicants)

Employer-sponsored: 48,250

Independent points-tested: 43,990

Regional sponsorship: 28,850

Total (including special talent etc): 128.550

AND Temporary 457 visa: Fluctuates (around 177,000 resident

mid-2016)

Family: 60,885 + Humanitarian: 13,000 + 12,000 (Syria)

Trend 2: Let Market Forces Dictate Scale of Temporary

Sponsored Entry

1. Entry mode: Temporary labour dominates

Demand-driven

2. Scale of skilled migration: Unprecedented

Quota = Around 60-68% of permanent migrants

No quota = Temporary skilled migrants

Paradigm shifts:

Employer and State/ Province selection

Two-step + Three-step migration the new norm

Priority processing for sponsored migrants

3. Place of selection: On-shore

Trend 3: Maximise Workforce Distribution (Medicine Temporary

‘Area of Need’ Compared to Permanent Grants 2008-09 to 2014-15)

Year /

Total Number

Permanent

Medical Migrants

Number Selected

Temporary

Medical Migrants

Number Selected

2008-09

3,758 446 3,312

2009-10 1070 2,673

2010-11 508 2,927

2011-12 1037 3,299

2012-13 1289 2,855

2013-14 1134 2,440

2014-15

3,139 To March only 1076 2,063

TOTAL 6,560 19,569

Trend 4 – Ensure Responsiveness to Actual Employment Demand

(457 Temporary Visa Tap-On Tap-Off as Health Graduates Grow)

Field 2012-13 2014-15 Total 2008-09 to

2014-15

Non-Food Trades 13,541 6,016 62,716

IT 8,604 6,702 51,109

Health 6,517 3,230 41,335

Engineering 3,583 1,151 22,170

Education 2,345 1,499 11,174

Accounting 1,530 878 7,646

Total Fields 68,481 38,134 360,391

.

Tap-On Tap-Off – Recent Nurse Migration to Australia

Policy justification:

Responsiveness to employment demand and location

Guaranteed employment outcomes

Nursing (457 visa new grants):

2009-10 = 2,707 (and 4,073 in 2008-09!)

2014-15 = 814 Top source countries = India (29%), UK (26%),

Philippines (14%), Ireland (8%), China (5%)

Nursing (new permanent skilled migrant grants):

2009-10 = 1,700

2014-15 = 3,273 (pipeline harder to control)

Top source countries = UK (19%), India (18%), China (15%),

Philippines (14%), Nepal (6%)

Policy Impacts on Health Workforce Migration:

8 Years to 30 June 2015

Australia:

Temporary skilled migrants – 41,335

Permanent skilled migrants – 17,808

Total - 58,143

NZ:

Temporary skilled migrants – 28,895

Permanent skilled migrants – 10,053

Total - 38,948

Trend 5: More Flexible Pre-Registration Assessment (Case Study –

Medicine)

MCQ Exam (N=2,060, 62% pass)

Singapore: 100%

Germany: 91%

Malaysia: 87%

Sri Lanka: 80%

Iran: 75%

PNG: 75%

Fiji: 74%

South Africa: 74%

Egypt: 66%

Bangladesh: 65%

Myanmar: 63%

India: 62%

South Korea: 67%

Vietnam: 40%

Pakistan: 61%

Poland: 60%

China: 49%

Philippines: 46%

Romania: 33%

Clinical Exam (N=1,657, 35% pass)

Singapore 100%

Germany: 60%

Myanmar: 46%

South Africa: 45%

Vietnam: 45%

Malaysia: 44%

Pakistan: 41%

Bangladesh: 39%

Sri Lanka: 35%

China: 35%

Fiji: 33%

South Korea: 33%

Iran: 31%

Egypt: 30%

India: 34%

Philippines: 23%

Poland: 20%

Romania: 0%

PNG: 0%

Migrant Doctors 2008+:

Variable Registration Pathways

Specialists

? X

Fast

Me

diu

m

Slo

w

Impact of Diversity on English Language Pass Rates to 2011:

Australia + NZ Outcomes

53%

20%

40% 38% 39%

46%

37%

43%

19%

47%

34%

28%

32% 34%

52%

17%

62%

32%

38% 40% 41%

-10%

0%

10%

20%

30%

40%

50%

60%

70%

Ca

nd

ida

te p

as

s r

ate

(%

)

2005

2010

2011

Trend 6: Bridging Migrant Health Professionals into

Employment (Nursing)

•Model = Competency-based clinical training:

•Number: 36+ models (catering to up to 10,000 students)

•Providers: Universities, hospitals, private colleges

•Students: Permanent + temporary migrants

•Fees: Loans (permanent migrants), $12,000-$25,000 (students)

•Location: Urban and rural

•Options: Apply for migration

•Trainers: Potential to hire

•Outcome: Fullly registered or enrolled nurse status

Trend 7 – The Productivity Premium of Former International

Students

Potential merits:

Young

Self-funded education (economic ‘win-win’)

Host country language ability and qualifications

Acculturation

Length of future productivity – age relative to labour migrants

Demographic context by 2005:

‘Over the next couple of decades nothing will impact on

(member) economies more profoundly than demographic

trends and, chief among them, ageing’ (Chief Economist,

OECD)

Canadian Evidence in 2006:

Value of Canadian Qualifications to Health Employment

(Owusu & Sweetman 2015)

Field of Employment in

Canada (2006 Census)

Canada-

Born

Canada-

Trained

Canada-

Born

Foreign-

Trained

Foreign-

Born

Canada-

Trained

Foreign-

Born

Foreign-

Trained

Physician 89% 62% 87% 41%

Dentist 86% 36% 86% 31%

Registered Nurse 64% 53% 64% 45%

Impact of Demand by Field on Former International Students’

Full-Time Employment Rates @ 6 Months in Australia (2007-11):

After Completing Bachelor Degrees Compared to Domestic Students

Qualification Field Australian

Graduates

(Sample = 371,000)

International

Students

(Sample = 79,000)

Accounting 83% 35%

Business 76% 40%

IT 78% 42%

Engineering 86% 44%

Medicine 100% 99%

Dentistry 94% 96%

Pharmacy 98% 96%

Physiotherapy 94% 67%

Nursing 92% 71%

Australia’s Refinement of the Study-Migration Pathway to 2016:

Key Policy Measures

1. Enforce independent English language assessment:

Mandate higher levels in select fields

2. Focus on degrees and higher degrees:

NOT training college qualifications

3. Expand use of three-step migration: 2-4 year right to stay and secure work post-study

Solely for degree-qualified students

4. Increase demand-driven employer sponsored migration:

Student visa 457 visa Permanent skilled migration

Who is Most Likely to Participate in Two-Step Migration in

Australia: Temporary Foreign Workers or Former International

Students? (2014-15)

Temporary foreign workers (457 visa 4+ years):

Scale: 4,388 PA’s

Status: Professionals (89%), Trade workers (9%)

Former international students:

Scale = PA’s 6,136

Status: Professionals (74%), Trade workers (12%)

Skilled Migration Sub-Category Pathways:

Which Do Former International Students Use for Two-Step Migration?

(2008-09 to 2014-15)

Category 2008–09 2009–10 2010–11 2011–12 2012–13 2013–14 2014–15 Total

Skilled Independent 8,028 3,934 11,905 9,582 8,576 2,871 3,142 48,038

Skilled Regional 2,037 576 3,541 2,496 2,793 1,313 340 13,096

State/Territory Nominated

1,798 1,181 2,050 1,500 1,465 964 1,330 10,288

Employer Sponsored 565 332 1,204 1,902 2,213 1,474 1,291 8,981

Business Innovation and Investment

11 7 7 24 69 18 13 149

Distinguished Talent 15 18 5 17 29 16 20 120

Grand Total 12,454 6,048 18,712 15,521 15,145 6,656 6,136 80,672

Source: Based on Department of Immigration and Border Protection data, 2008-09 to 2014-15

Conclusion: Scale of Future Global and Regional Demand

for Migrant Health Professionals

Traditional population structure Emerging population structure