International migration of health professionals and the marketization and privatization of health education in India: From push–pull to global political economy

Bilateral health agreements of South Africa: an analysis of issues covered

The bilateral agreements signed between South Africa and countries in Southern and Eastern Africa are a rare example of efforts to regulate health-related issues in a world region. As far as we know, there are no comparable bilateral health governance mechanisms in regions elsewhere. Furthermore, the rapidly growing literature on global health governance and governance for global health has to date not addressed the issue of patient mobility and how to govern it. In this study, we examine the issues included in these agreements, highlight key issues that they address, identify areas of omission and provide recommendations for improvement. This analysis should inform the development of such governance agreements both in Southern Africa and in regions elsewhere. We obtained 13 bilateral health agreements between South Africa and 11 neighbouring African countries as part of a broader research project examining the impact on health systems of patient mobility in South Africa, and thematically analysed their content and the governance mechanisms described. The agreements appear to be solidarity mechanisms between neighbouring countries. They contain considerable content on health diplomacy, with little on health governance, management and delivery. Nonetheless, given what they do and do not address, and how, they provide a rare insight into mechanisms of global health diplomacy and attempts to address patient mobility and other health-related issues in practice. The agreements appear to be global health diplomacy mechanisms expressing solidarity, emerging from a post-apartheid period, but with little detail of issues covered, and a range of important issues not addressed. Further empirical work is required to understand what these documents mean, particularly in the Covid-19 context, and to understand challenges with their implementation. The documents also raise the need for particular study of bilateral flows and experience of patients and health workers, and how this relates to health system strengthening.

The impact of international health worker migration and recruitment on health systems in source countries: Stakeholder perspectives from Colombia, Indonesia, and Jordan

INTRODUCTION

To address domestic shortages, high-income countries are increasingly recruiting health workers from low- and middle-income countries. This practice is much debated. Proponents underline benefits of return migration and remittances. Critics point in particular to the risk of brain drain. Empirical evidence supporting either position is yet rare. This study contributes to filling this gap in knowledge by reporting high-level stakeholders' perspectives on health system impacts of international migration in general, and active recruitment of health workers in specific, in Colombia, Indonesia, and Jordan.

METHOD

We used a multiple case study methodology, based on qualitative methods integrated with information available in the published literature.

RESULTS

All respondents decried a lack of robust and detailed data as a serious challenge in ascertaining their perspectives on impacts of health worker migration. Stakeholders described current emigration levels as not substantially aggravating existing health workforce availability challenges. This is due to the fact that all three countries are faced with health worker unemployment grounded in unwillingness to work in rural areas and/or overproduction of certain cadres. Respondents, however, pleaded against targeting very experienced and specialised individuals. While observing little harm of health worker migration at present, stakeholders also noted few benefits such as brain gain, describing how various barriers to skill enhancement, return, and reintegration into the health system hamper in practice what may be possible in theory.

CONCLUSION

Improved availability of data on health worker migration, including their potential return and reintegration into their country of origin's health system, is urgently necessary to understand and continuously monitor costs and benefits in dynamic national and international health labour markets. Our results imply that potential benefits of migration do not come into being automatically, but need in-country supportive policy and programming, such as favourable reintegration policies or programs targeting engagement of the diaspora.

Hiding in plain sight: the absence of consideration of the gendered dimensions in 'source' country perspectives on health worker migration

BACKGROUND

Gender roles and relations affect both the drivers and experiences of health worker migration, yet policy responses rarely consider these gender dimensions. This lack of explicit attention from source country perspectives can lead to inadequate policy responses.

METHODS

A Canadian-led research team partnered with co-investigators in the Philippines, South Africa, and India to examine the causes, consequences and policy responses to the international migration of health workers from these 'source' countries. Multiple-methods combined an initial documentary analysis, interviews and surveys with health workers and country-based stakeholders. We undertook an explicit gender-based analysis highlighting the gender-related influences and implications that emerged from the published literature and policy documents from the decade 2005 to 2015; in-depth interviews with 117 stakeholders; and surveys conducted with 3580 health workers.

RESULTS

The documentary analysis of health worker emigration from South Africa, India and the Philippines reveal that gender can mediate access to and participation in health worker training, employment, and ultimately migration. Our analysis of survey data from nurses, physicians and other health workers in South Africa, India and the Philippines and interviews with policy stakeholders, however, reveals a curious absence of how gender might mediate health worker migration. Stereotypical views were evident amongst stakeholders; for example, in South Africa female health workers were described as "preferred" for "innate" personal characteristics and cultural reasons, and in India men are directed away from nursing roles particularly because they are considered only for women. The finding that inadequate remuneration was as a key migration driver amongst survey respondents in India and the Philippines, where nurses predominated in our sample, was not necessarily linked to underlying gender-based pay inequity. The documentary data suggest that migration may improve social status of female nurses, but it may also expose them to deskilling, as a result of the intersecting racism and sexism experienced in destination countries. Regardless of these underlying influences in migration decision-making, gender is rarely considered either as an important contextual influence or analytic category in the policy responses.

CONCLUSION

An explicit gender-based analysis of health worker emigration, which may help to emphasize important equity considerations, could offer useful insights for the health and social policy responses adopted by source countries.

Factors associated with the recruitment of foreign nurses in Japan: a nationwide study of hospitals

BACKGROUND

Nurse migration under bilateral agreements is a recent global trend, although lack of consultation with the health industries has led to challenges in the recruitment of foreign nurses by hospitals. To analyze the prevailing perception of hospitals on the Economic Partnership Agreement (EPA), under which Japan opened the doors to foreign nurses, we surveyed hospitals that are yet to employ foreign nurses.

METHODS

An anonymous questionnaire was developed and distributed to eligible hospitals; it assessed managers' perception of Japan's policy on the recruitment of foreign nurses and their intentions to hire foreign nurses under the EPA (hereafter called EPA nurses). We randomly selected 1879 hospitals, or 22% of the hospitals in Japan (n = 8540), with more than 20 beds. We used descriptive statistics, a Chi-square test, and logistic regression analysis to identify the predictors and developed a model to predict the likelihood of their intention to recruit EPA nurses in the future.

RESULTS

In total, 432 hospitals were eligible for further analysis (response rate: 22.9%). Half (50%) of the hospital managers were considerably interested in Japan's policy on recruiting EPA nurses, although only 20% intended to recruit EPA nurses in the future. Willingness to recruit EPA nurses was associated with the degree of interest in the policy (OR 9.38; 95% CI 4.42-19.90) and managers' perception of EPA nurses (OR 5.32, 95% CI 2.38-11.89).

CONCLUSIONS

To attract more hospitals to recruit foreign nurses, it is essential for the Japanese government and the sending countries to review their EPA systems. Utilizing returning nurses to assist language acquisition by the forthcoming EPA nurses could be a provisional solution. For a more fundamental solution, long-term provision, from prior to their migration until their return migration, is needed to encourage brain circulation, as opposed to brain drain, between sending and receiving countries.

The dental workforce in Malaysia: drivers for change from the perspectives of key stakeholders

OBJECTIVE

The dental workforce is facing unprecedented change globally as a result of multiple influences. There is a need for research informed action to map possible drivers for change at the national level and examine their potential implications in order to shape the dental workforce to serve population needs. The objective of this study was to explore key stakeholders' views on the drivers for change for the Malaysian dental workforce and their potential implications.

METHOD

Stakeholders from key dental organisations/professions in Malaysia were purposively sampled and invited to participate in a semi-structured interview (n = 20) using a pre-tested topic guide. Interviews were recorded, transcribed verbatim and analysed using Framework Analysis.

RESULTS

Drivers for workforce were identified across four main domains: policy-politics; trends in demography; social and economic; and, technology-scientific development. The pace of change and possible interplay between drivers, most notably government policy, liberalisation of education and health services and challenges of workforce governance, followed by Malaysian demography and health trends. Implications for the future, including possible uncertainties, particularly in relation to specialisation and privatisation were identified, together in balancing and meeting public health needs/demands with professional career expectations.

CONCLUSION

Stakeholders' views on the high-level drivers for change broadly mirror those of high-income countries; however, specific challenges for Malaysia relate to rapid expansion of dental education and a young workforce with significant career aspirations, together with imbalances in the health care system. The impact of these drivers was perceived as leading to greatest uncertainty around specialisation and privatisation of the future workforce.

"Medical tourism will…obligate physicians to elevate their level so that they can compete": a qualitative exploration of the anticipated impacts of inbound medical tourism on health human resources in Guatemala

BACKGROUND

Medical tourism, which involves cross-border travel to access private, non-emergency medical interventions, is growing in many Latin American Caribbean countries. The commodification and export of private health services is often promoted due to perceived economic benefits. Research indicates growing concern for health inequities caused by medical tourism, which includes its impact on health human resources, yet little research addresses the impacts of medical tourism on health human resources in destination countries and the subsequent impacts for health equity. To address this gap, we use a case study approach to identify anticipated impacts of medical tourism sector development on health human resources and the implications for health equity in Guatemala.

METHODS

After undertaking an extensive review of media and policy discussions in Guatemala's medical tourism sector and site visits observing first-hand the complex dynamics of this sector, in-depth key informant interviews were conducted with 50 purposefully selected medical tourism stakeholders in representing five key sectors: public health care, private health care, health human resources, civil society, and government. Participants were identified using multiple recruitment methods. Interviews were transcribed in English. Transcripts were reviewed to identify emerging themes and were coded accordingly. The coding scheme was tested for integrity and thematic analysis ensued. Data were analysed thematically.

RESULTS

Findings revealed five areas of concern that relate to Guatemala's nascent medical tourism sector development and its anticipated impacts on health human resources: the impetus to meet international training and practice standards; opportunities and demand for English language training and competency among health workers; health worker migration from public to private sector; job creation and labour market augmentation as a result of medical tourism; and the demand for specialist care. These thematic areas present opportunities and challenges for health workers and the health care system.

CONCLUSION

From a health equity perspective, the results question the responsibility of Guatemala's medical education system for supporting an enhanced medical tourism sector, particularly with an increasing focus on the demand for private clinics, specific specialities, English-language training, and international standards. Further, significant health inequalities and barriers to care for Indigenous populations are unlikely to benefit from the impacts identified from participants, as is true for rural-urban and public-private health human resource migration.

Sustainable Development Goals: Leveraging the Global Agenda for Driving Health Policy Reforms and Achieving Universal Health Coverage in India

Universal Health Coverage (UHC) is now the critical yardstick for countries to measure and track progress toward the "Sustainable Development Goals (SDGs)." Being a signatory, India has started taking measures to attain the targets laid out within the SDG framework and achieving the UHC. With India's National Health Policy (NHP) - 2017 in place, the policy environment for transforming country's health landscape coincides with that of the global approach toward strengthening of health systems and achieving UHC. It is imperative that for achieving the desired outcomes laid down in the SDGs and NHP-2017, coordinated actions are required including political action for making health an individual's right; effective stewardship from the National Ministry of Health and Family Welfare; reorganization of health-care service delivery implementing a "systems approach;" ensuring financial protection against health-care costs; and enhancing community participation and accountability. Undertaking these steps, imbibing the learning, and dwelling upon global experiences can help the country strongly move forward towards achieving global and national targets, thereby ensuring UHC for all its citizens.

The Experiences of Internationally Qualified Registered Nurses Working in the Australian Healthcare System: An Integrative Literature Review

INTRODUCTION

International nurses account for 20% of the Australian nurse workforce. This review aims to identify and appraise research findings on the experiences of internationally qualified registered nurses working in the Australian healthcare system.

METHODOLOGY

The review was structured using Whittemore and Knafl modified framework for integrated reviews. A systematic database search was undertaken. Articles ( n = 48) were identified for appraisal based on set inclusion and exclusion criteria. Evaluation using the Critical Appraisal Skills Program tool resulted in ( n = 16) articles in the final data set.

RESULTS

Three broad themes were identified: (a) Transitioning-Need for appropriate, timely, and adequate supports to assist transition to practice; (b) Practicing within local contexts-How expectations were different to the reality of clinical practice; and (c) Experiencing prejudice-when racial prejudice occurred.

DISCUSSION

Appropriate programs including cultural-safety education can mitigate adverse workforce dynamics within culturally diverse health care teams to enable provision of culturally congruent health care.

"Location is surprisingly a lot more important than you think": a critical thematic analysis of push and pull factor messaging used on Caribbean offshore medical school websites

BACKGROUND

Offshore medical schools are for-profit, private enterprises located in the Caribbean that provide undergraduate medical education to students who must leave the region for postgraduate training and also typically to practice. This growing industry attracts many medical students from the US and Canada who wish to return home to practice medicine. After graduation, international medical graduates can encounter challenges obtaining residency placements and can face other barriers related to practice.

METHODS

We conducted a qualitative thematic analysis to discern the dominant messages found on offshore medical school websites. Dominant messages included frequent references to push and pull factors intended to encourage potential applicants to consider attending an offshore medical school. We reviewed 38 English-language Caribbean offshore medical school websites in order to extract and record content pertaining to push and pull factors.

RESULTS

We found two push and four pull factors present across most offshore medical school websites. Push factors include the: shortages of physicians in the US and Canada that require new medical trainees; and low acceptance rates at medical schools in intended students' home countries. Pull factors include the: financial benefits of attending an offshore medical school; geographic location and environment of training in the Caribbean; training quality and effectiveness; and the potential to practice medicine in one's home country.

CONCLUSIONS

This analysis contributes to our understanding of some of the factors behind students' decisions to attend an offshore medical school. Importantly, push and pull factors do not address the barriers faced by offshore medical school graduates in finding postgraduate residency placements and ultimately practicing elsewhere. It is clear from push and pull factors that these medical schools heavily focus messaging and marketing towards students from the US and Canada, which raises questions about who benefits from this offshoring practice.

Causes, consequences, and policy responses to the migration of health workers: key findings from India

BACKGROUND

This study sought to better understand the drivers of skilled health professional migration, its consequences, and the various strategies countries have employed to mitigate its negative impacts. The study was conducted in four countries-Jamaica, India, the Philippines, and South Africa-that have historically been "sources" of health workers migrating to other countries. The aim of this paper is to present the findings from the Indian portion of the study.

METHODS

Data were collected using surveys of Indian generalist and specialist physicians, nurses, midwives, dentists, pharmacists, dieticians, and other allied health therapists. We also conducted structured interviews with key stakeholders representing government ministries, professional associations, regional health authorities, health care facilities, and educational institutions. Quantitative data were analyzed using descriptive statistics and regression models. Qualitative data were analyzed thematically.

RESULTS

Shortages of health workers are evident in certain parts of India and in certain specialty areas, but the degree and nature of such shortages are difficult to determine due to the lack of evidence and health information. The relationship of such shortages to international migration is not clear. Policy responses to health worker migration are also similarly embedded in wider processes aimed at health workforce management, but overall, there is no clear policy agenda to manage health worker migration. Decision-makers in India present conflicting options about the need or desirability of curtailing migration.

CONCLUSIONS

Consequences of health work migration on the Indian health care system are not easily discernable from other compounding factors. Research suggests that shortages of skilled health workers in India must be examined in relation to domestic policies on training, recruitment, and retention rather than viewed as a direct consequence of the international migration of health workers.

Indian nurses in Italy: a qualitative study of their professional and social integration

AIMS AND OBJECTIVES

To investigate the lived subjective experiences of immigrant Indian nurses in Italy and specifically their professional and social integration.

BACKGROUND

To study the worldwide, nursing flux is a health priority in the globalised world. The growth in migration trends among nurses, not only from Philippines or India, has proliferated in recent years. The research on nurses' mobility for Southern European countries is underexplored, and in Italy, the out-migration flows of Indian nurses were never analysed.

DESIGN

Qualitative methodological approach.

METHODS

Semi-structured interviews (n = 20) were completed with Indian clinical nurses working in Italy for more than one year mainly in private organisations. A purposive sampling technique was used for recruitment. The data were then content-analysed using an inductive method.

RESULTS

The findings were categorised into four themes: (1) aspects of professional integration and working experience, (2) intra- and interprofessional relationships and perceptions of the IPASVI Regulatory Nursing Board, (3) initial nursing education and continuous professional development and (4) perceptions of social integration.

CONCLUSION

The results show that for Indian nurses in Italy emigration is important to gain opportunities to expand economic and social privileges as well as escape from historical assumptions of stigma associated with nursing work, especially for women. However, these conclusions have to be seen in wider socio-cultural complexities that are at the basis of transnational fluxes (Prescott & Nichter ).

RELEVANCE TO CLINICAL PRACTICE

The research offers an insight into the complicated reasons for Indian nurses out-migration to Italy. Without comprehending the interwoven textures of the political and social relations that are continually constructed and re-constructed among different nations, it is difficult to understand nurses out-migration and consequently have a better and safer collaborative teamwork in the host countries.

Austerity and the embodiment of neoliberalism as ill-health: Towards a theory of biological sub-citizenship

This article charts the diverse pathways through which austerity and other policy shifts associated with neoliberalism have come to be embodied globally in ill-health. It combines a review of research on these processes of embodiment with the development of a theory of the resulting forms of biological sub-citizenship. This theory builds on other studies that have already sought to complement and complicate the concept of biological citizenship with attention to the globally uneven experience and embodiment of bioinequalities. Focused on the unevenly embodied sequelae of austerity, the proceeding theorization of biological sub-citizenship is developed in three stages of review and conceptualization: 1) Biological sub-citizenship through exclusion and conditionalization; 2) Biological sub-citizenship through extraction and exploitation; and 3) Biological sub-citizenship through financialized experimentation. In conclusion the paper argues that the analysis of biological sub-citizenship needs to remain open-ended and relational in order to contribute to socially-searching work on the social determinants of health.

The development of the nursing profession in a globalised context: A qualitative case study in Kerala, India

In the paper, we are looking at the relationship between globalisation and the professional project, using nursing in Kerala as an exemplar. Our focus is on the intersection of the professional project, gender and globalisation processes. Included in our analysis are the ways in which gender affects the professional project in the global south, and the development of a professional project which it is closely tied to global markets and global migration, revealing the political-economic, historical, and cultural factors that influence the shape and consequences of nurse migration. The phenomenon that enabled our analysis, by showing these forces at work in a particular time and place, was an outbreak of strikes by nurses working in private hospitals in Kerala in 2011-2012.

Modelling input-output flows of severe acute respiratory syndrome in mainland China

BACKGROUND

Severe acute respiratory syndrome (SARS) originated in China in 2002, and it spread to 26 provinces in mainland China and 32 countries across five continents in a matter of months. This outbreak resulted in 774 deaths. However, the spatial features and potential determinants of SARS input-output flows remain unclear.

METHODS

We used an adjusted spatial interaction model to examine the spatial effects and potential factors associated with SARS input-output flows.

RESULTS

The presence of origin-based spatial dependence positively affected SARS input-output flows from the neighbours of the origin regions. Two components of the input-output flows, migrant and hospitalization flows, exhibited distinctive features. The origin-based and destination-based spatial dependence positively affected migrant flows (i.e., due to those seeking jobs) from the neighbours of origin and destination locations. Similarly, the destination-based spatial dependence also positively affected hospitalization flows (i.e., due to those seeking treatment) from the neighbours of destination regions. However, the origin-to-destination based spatial dependence negatively affected hospitalisation flows from the neighbours of origin-to-destination regions. The direct effects accounted for 78% of the SARS input-output flows, which was 3.56-fold greater than the indirect effects. Differences in regional income drove the SARS input-output flows. Therefore, urban income had a positive effect, whereas rural income had a negative effect. Total interregional flows increased by 3.54% with a 1% increase in urban income, and intraregional flows increased by 8.35%. In contrast, the total interregional flows decreased by 3.38% with a 1% increase in rural income, and intraregional flows declined by 2.29%. Railway capacity, per person gross domestic product (PGDP), urban rate and the law of distance decay also affected the input-output flows.

CONCLUSIONS

Our results confirm that the SARS input-output flows presented significant geographic spatial heterogeneity and spatial effects. Income differences were the major cause of the flows between pairs of regions. Railway capacity, PGDP, and urban rate also played important roles. These findings provide valuable information for the Chinese government to control the future spread of nationwide epidemics.

Policy implications of medical tourism development in destination countries: revisiting and revising an existing framework by examining the case of Jamaica

BACKGROUND

Medical tourism is now targeted by many hospitals and governments worldwide for further growth and investment. Southeast Asia provides what is perhaps the best documented example of medical tourism development and promotion on a regional scale, but interest in the practice is growing in locations where it is not yet established. Numerous governments and private hospitals in the Caribbean have recently identified medical tourism as a priority for economic development. We explore here the projects, activities, and outlooks surrounding medical tourism and their anticipated economic and health sector policy implications in the Caribbean country of Jamaica. Specifically, we apply Pocock and Phua's previously-published conceptual framework of policy implications raised by medical tourism to explore its relevance in this new context and to identify additional considerations raised by the Jamaican context.

METHODS

Employing case study methodology, we conducted six weeks of qualitative fieldwork in Jamaica between October 2012 and July 2013. Semi-structured interviews with health, tourism, and trade sector stakeholders, on-site visits to health and tourism infrastructure, and reflexive journaling were all used to collect a comprehensive dataset of how medical tourism in Jamaica is being developed. Our analytic strategy involved organizing our data within Pocock and Phua's framework to identify overlapping and divergent issues.

RESULTS

Many of the issues identified in Pocock and Phua's policy implications framework are echoed in the planning and development of medical tourism in Jamaica. However, a number of additional implications, such as the involvement of international development agencies in facilitating interest in the sector, cyclical mobility of international health human resources, and the significance of health insurance portability in driving the growth of international hospital accreditation, arise from this new context and further enrich the original framework.

CONCLUSIONS

The framework developed by Pocock and Phua is a flexible common reference point with which to document issues raised by medical tourism in established and emerging destinations. However, the framework's design does not lend itself to explaining how the underlying health system factors it identifies work to facilitate medical tourism's development or how the specific impacts of the practice are likely to unfold.