Health care workers are backbone of a health care system. Shortage of human resources has direct impact on the quality of care. Migration of health care professionals from developing countries to developed countries is a global health issue. In 2006, 57 countries faced shortage of health care workers, out of these 37 countries were in Sub-Saharan Africa (Oligvia el al, 2007). Migration of health care professionals from developing countries is weakening their health care systems. It affects health equity in the region as more and more healthcare professionals leave their countries to work in high income countries Among OECD countries 18 percent of physicians and 11 percent of nurses were born in different country. These statistics indicate that migration of health care workers is common (Stilwel et al, 2004).
This issue is important because it affects health care access and availability in developing countries. Migration or "brain drain" of health care professionals from developing countries results in shortage of health care workers, affecting quality of care provided to patients. Health service delivery is affected by migration of worker as few health care workers are left in the home country. Health care workers who stay prefer to practice in urban and private sector leading to more shortage in rural sectors. Therefore, people living in rural area have less accessibility to health care services. It also has an effect on the workplace environment as for that working in such environment more workload is placed. The issue requires a close look at individual rights and the need for social justice. The purpose of this paper is to discuss about migration of health care workers from developing countries, its causes, effects and strategies to ensure health care. The paper also presents a comprehensive analysis of literature on balancing individual rights of health care professionals and the societal right to health.
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International migration of health care workers is not new. Nurses and physicians have sought jobs internationally for a variety of personal and professional reasons. These reasons will be discussed further in the paper. Gostin (2008) identified three main causes for migration of nurses which include: supply-demand, globalization, and push-pull factors. Modern technology has impacted communication globally. Job opportunities are easily accessible on internet which encourages health care workers to seek job internationally. Distance education has also opened doors for education for these jobs electronically. Therefore, communication technologies have been a catalyst in promoting and shaping global labour market in health care by making information easily accessible and making the process of migration easier than before.
In developed countries demand of nurses is increasing because of aging population, inadequate physicians, shortage of nurses. On the other hand demand, of nurses in developing countries is due to epidemic, poverty and chronic non communicable diseases. The demand of nurses in developed countries is even higher than before due to their increasing shortage. It is estimated that United Kingdom and United states will experience increase in shortage of health care professionals in next two decades (Stilwel et al, 2004). A common way to compensate with this shortfall is international recruitment of workers. There is need to understand that there is difference in labour market in health depending on location and profession. Member countries of Organization of Economic Co-operation and Development found out that that immigration of physicians in their countries is decreasing. Global labour market is not same for all workers; there are difference in job market especially between nurses and physicians (Stilwel et al, 2004). Therefore, when developing strategies for balancing migration of health care workers between countries, it is important to take this difference in consideration.
Around 20 percent of practicing physicians in developed countries such as the United States, Canada, Australia have been trained in developing countries. This means that developing countries suffer from lack of health care human resources that has direct impact on the delivery of health services in these countries. Ethics comes into place when we discuss about this issue because it affects equity of health services. Misdistribution of health care workers globally results in lack of equality. Poor countries are left with less human resources and richer countries benefit from migration health care workers. There some countries where migration is higher than other countries For examples, Zambia has one of the highest migration of health care professionals.
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Caribbean countries are also facing critical shortage of health care workers, especially nurses due to migration. In Caribbean two types of migration is affecting the health care system. Migration within Caribbean countries and migration to developed countries have created challenges in health care delivery. International recruitment is the primary cause of migration in these countries. Availability of higher income job opportunities and better working and living conditions attracts workers to developed countries. Jamaica is facing major challenges due to migration of nurses. Nurses that are leaving are highly qualified and skilled. Nurses with specialty in critical care, public health, and who have training in both midwifery and nursing are have higher migration rate. This has a huge impact on the loss of public investments in training these health care professionals. In developing countries this increase financial burden on already fragile health care system. Health care workers who remain in their country face harsh working conditions with more patient workload and stressful workplace environment. This impacts health of worker and lead to higher absenteeism rate. Migration of health care workers affects the health care system at all levels.
In order to examine the issue it important to explore factors that cause migration. Pull factors that affect migration include, higher income, better working conditions, better lifestyle and better social, economic and political conditions in developed countries. Working conditions and opportunities for professional development has important role attracting health care workers to developed or richer countries. Working conditions and higher wages are two pull factors. Another factor that encourages migration is the shortage of health care workers in developed countries. More job opportunities in Canada and Unites States have lead to an increase the number of nurses leaving Philippines and some African countries. This shows how shortage of health human resources in developed have global impact on migration of workers. Push factors that affect migration include lack of infrastructure, socio-political situations and poor working conditions in the developing country. It is estimated that this will only increase in future unless developed countries take initiative in training health care workers in their own countries. War, deprivation, and social and political unrest encourage migration to developed countries where quality of living is better (Stilwell, 2004). To tackle the problem of migration, there is a need to solve root issues that encourage and promote migration.
Global justice calls for fait allocation and distribution of health human resources in both developing and developed countries. Poor countries are already dealing with disease burden, poverty and early death. With migration of health care workers it burdens their health care system. With fragile system losing more health care workers can directly affect delivery of health care services and causes system to become dysfunctional. There are benefits of migration; these include supporting family in home country and strengthening the economy. They may also form alliance or partnership between countries and come back home with advance skill and practice. It also has empowering affect on workers who migrate as it positively influences economically, culturally and professionally
Health care workers also have right to seek better opportunities in developed countries where living conditions are better than their home country. Also they have right to safety from socio-political environment that might put them at risk for abuse, persecution and torture. When developing policies for migration these individual rights have to be kept in mind.
Rich countries do not necessarily act unethical when they recruit health care workers. It becomes unethical when resources i.e workers are being utilized when there is need in their own country. Health care workers have both rights and duties. Duties lies towards the country they born and educated in. They also have human rights which include seeking better opportunities than impoverished working and living environment.
In 2004 WHO adopted resolution 57.19 to reinforce responsible recruitment of health care workers. These bilateral agreements help in setting standard for recruitment of health care workers. An example of bilateral agreement includes, South Africa/United Kingdom Memorandum and Caribbean Community agreement. United Kingdom has also signed in similar agreement with other countries including India, Indonesia, Philippines and Spain. In 2003, Commonwealth ministers adopted code of practice for international recruitment of health care workers.
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The Pacific Code of Practice was adopted by Pacific Ministers to ensure that recruitment of health care workers is ethical and fair. The Code of Practice adopted by WHO ensures that with cooperation between nations migration of health care workers is ethical and fair to all. Especially it is made to protect and strengthen health care systems of poor and developing countries. The two main guiding principles of the Code are: achieving balance between rights and obligations of source country and recruiting countries, and fairness/mutual benefits. Exploitation of recruits calls for more clarity and transparency in agreement between countries. Terms of employment must be shared with the recruits including, wages, job expectation, and accurate description of job. Recruits might face challenges in adapting to new culture and lifestyle. The Code of Practice recommends the host country to provide labour and licensing laws. This will ensure rights of health care workers respected with terms of employment.
To Manage migration of health care workers both government and agencies need to develop strategic plan to regulate flow of health care workers. Oligvia el al (2007) suggests that creative policy approach can provide solution to achieve the balance between individual rights of health care professionals and societal needs. Health care system of a country affects migration; therefore, there is need for policies and strategic plan that affect retention, recruitment, deployment of health care workers within country's system. This could mean bringing a change in current policy or developing new ones to address the issue. The World Medical Association emphasis on educating enough workers to meet health care demands each country. Implementation of effective retention strategies is also important in retaining health care workers. Four main strategies for retention of workers include enabling work environment, monetary and non-monetary incentive and capacity building. Successful retention strategies are based on individual worker's needs and organization needs. This can include providing incentives such as housing, fair wages, transportation, child care. Professional autonomy and increasing scope of practice can also lead to job satisfaction and retention.
To measure the extent of the problem it is crucial to have data on migration rates in both developing and developed countries. There is a lack of quantitative and qualitative data on the issue. It is also found that data available from destination countries is more reliable than the sending country. However, inconsistency of data related to education and skill between countries makes it challenging to compare results. The existing data is not consistent, therefore, it is challenging to find exact changes in migration. Information available on migrants that return to their country is also very less, it is even more challenging to gather information on emigration than migration. In order to monitor and evaluate the phenomenon of migration of health care workers reliable data is crucial for decisions makers. Statistical evidence in countries, especially developing countries had also declined in few years. With few workers life in the source countries, the data available is uncoordinated and insufficient. Due to rigid rule for recruiting health care workers, migration in destination countries can provide quality data, i.e., record of visas, registration with professional organizations, population census and economic census (Diallo, 2004). Even with limitations in research data it is sure that migration from developing countries to developed countries is increasing.
Low job motivation and satisfaction affects worker's performance in the workplace and act as push factor for migration. Financial and non-financial incentives in terms of study opportunities, working in team, support and motivation from managers can increase morale of workplace and give job satisfaction. Stilwell et al (2004) offers another strategy for retention of health care workers which include training community based workers to provide health care services in rural areas. This can improve health care access and such workers are less likely to migrate.
In order to maintain balance of health care workers both in developing and developed there is need for agreement between countries. By allowing for limited time for migration by granting temporary visa and negotiating between organization about taking workers or exchanging workers can be effective ways of dealing with the issue. The destination country can pay compensation to the sending country as financial investment. Destination countries play an important role in decreasing migration. They can implement retention strategies by improving working conditions, and paying overtime for extended hours. When these countries have enough workers in health care there would be fewer vacancies and less migration.
Monitoring and evaluation of strategies on timely basis is crucial in order to achieve best outcomes. Monitoring and evaluation framework can be used to guide decision making process based on evidence. This not only benefits the country recruiting worker but also guards health care system of the country that provides workers.
The issue of global migration of health care workers affects delivery of health care service, staff distribution and quality of care. Often time, it is developing countries who suffer due to migration of health care workers towards developed countries. Loss of workers put more burden on the health care system which already faces challenges. This issue requires ethical consideration because health of people in these countries is affected directly and indirectly. Pull and push factors play an important role that helps in decision making for migration. There are strategies such as bilateral agreement, partnership between government and agencies that are currently in place to help solve the issue but there is need for more insistent approach. Improving monitoring and evaluation of the phenomenon by gathering reliable quantitative and qualitative data is also crucial. Most importantly, this issue calls for balancing of human rights of workers and societal rights to health care. Strategies that respect both worker's rights and societal rights and responsibility can be effective in balancing migration of workers.