The Impact of Maldistribution and Undersupply on the Accreditation of International Medical Graduates in Australia

1. The Impact of Maldistribution and Undersupply on the Accreditation of International Medical Graduates in Australia ARC Health Governance Conference (Brisbane) Professor Lesleyanne Hawthorne Associate Dean (International) OECD and Faculty of Medicine, Dentistry and Health Sciences University of Melbourne 10 December 2007

2. Australia’s Evolving Medical Workforce Who? 1. Australia-born 2. First generation migrants: a. Permanent medical migrants b. Temporary medical migrants c. The children of migrants/refugees in medicine 3. International medical students The latest Australian migration developments

3. Case Study 1: Migrant/Refugee Youth in Australian Medical and Dentistry Course Enrolments (2004)

4. Case Study 2: International Medical Students in Australia Numbers: Around 1500 per year Internship outcomes (late 1990s versus 2006) Student goals (privately funded versus scholarship students) Changing Australian policy (shortage-driven) Victoria, South Australia, NSW Potential internship ? ‘area of need’ ? permanent resident pathway New skilled migration policy: Medicine = ‘migration occupation in demand’ (20 bonus points) Variations by state Source: J Hamilton & L Hawthorne forthcoming (2008)

5. The Demographic Context of International Medical Graduates (IMGs) in Australia The Registration and Training Status of Overseas Trained Doctors in Australia: L Hawthorne, G Hawthorne & B Crotty (Department of Health and Ageing 2007) Growing global competition for doctors (West, Gulf States, Africa) Temporary flows ? Attraction to government/ employers Multiple players (eg ‘Recruit-a-Doc) Comparison: Canada, UK (NHS and Skilled Temporary Migration Program) Different accreditation requirements Permanent flows ? Migration Occupations in Demand List Differential patterns and strategies by state: Eg WA ‘adventure medicine’ Net gains versus losses in OTD retention: Highest retention for Middle East, South Asia, SE Asia, NE Asia

6. Degree of Australian Reliance on IMGs Compared to the US, UK and Canada (2005)

7. Supply-Demand Issues in Medicine in Australia Growing medical shortages: Reduction in 1996 of local university places Doctors barred from skilled migration to 2004 (25 point negative weighting) Demographic changes Medical workforce maldistribution and under-supply: Rural and regional locations Public sector medicine (eg hospital junior registrar positions) Speciality workforce: Insufficient in select fields, eg Psychiatry, Surgery, Emergency Medicine Current strategies to address medical shortages New medical schools (Notre Dame x2, Deakin, Western Sydney, Wollongong, Bond) Growing reliance on foreign medical graduates and former international medical students for at least the next 10 years Increased temporary and permanent migration

8. Case Study: Impact of Demographic Transition: Surgeon Age (42% aged 55 or older)

9. Impact of Demographic Transition: Number of Surgical Operations by Patient Age (2001 versus 1991)

10. Case Study: Australia’s Dependence on Migrant Nurses to Overcome Net Gains/Losses (1983-2000)(Source: L Hawthorne 2001, 2002)

11. The Impact of Migration on Australia’s Medical Workforce: 1991-2006 By 2001 46% of Australia’s medical workforce was overseas-born (cf 40% in 1991 and 44% in 1996) Permanent migration: By 2001 22,191 overseas-born doctors, with medical migration continuing unabated (1,263 new permanent resident arrivals in 2001-02) ‘Area of need’ arrivals: By June 2005 c5,500 temporary entrant overseas-trained doctors per year (including specialists), cf c500 mid-90s Occupational Trainees: Eg in surgery, 457 arrivals in 18 months (January 2002-June 2003); 1200 in NSW alone by June 2005 Within select specialties: Growing dependence on overseas trained doctors (eg psychiatry, emergency medicine, surgery) Sources: Birrell & Hawthorne 1997, 1999, 2004; Hawthorne & Birrell 2002; Barton, Hawthorne, Singh & Little 2003.

12. Proportion of Overseas-Born Doctors in Australia 2001 (Compared to 36% in Canada)

13. Sources of Medical Migration to Australia (1996-2001) and Employment Outcomes by 2001

14. Growth in Temporary Entry Medical Visas Visa subclass 422 (‘Area of need’): (Birrell & Schwartz 2005) 1,419 in 1999-2000 2,496 in 2003-03 2,428 in 2003-04 3,074 in June 2005 (up from 1,636 in June 2003 and 1,237 as of June 2001) Visa subclass 442 (‘Occupational Trainee’): ?2,437 in June 2005 (cf 1,237 in June 2001), primarily to Queensland, WA and Victoria Recent increase in NSW: June 2004 = 1,202 (Most as HMOs)

15. Variations in State Reliance on Temporary Medical Migration (Visa 422 ‘Area of Need’ Category)

16. Major Source Countries of ‘Area of Need’ Temporary Doctors by 2001 Over 27 countries (growing diversity): By-pass ‘mandatory’ credential examination requirements UK/Ireland (1226) India (423) Malaysia (230) Sri Lanka (191) China (94) Germany (83) USA (56) Philippines (55) South Africa (45) Canada (35) Etc!

17. Issue 1: Differential Training Systems Ranking of top 500 world universities (Shanghai Jiao Tong 2006: 206 in Europe (overwhelmingly located in North West Europe), including 43 in the UK, and 40 in Germany 197 in the Americas (167 in the US, 22 in Canada, and just 7 in all Central or South America [including 1 in the top 150]) 92 in the Asia-Pacific (32 in Japan, 16 in Australia, 14 in China (none ranked in the top 150, and with 2 of the top 4 ranked institutions in Hong Kong), 9 in South Korea, 7 in Israel, 5 in New Zealand, 4 in Taiwan, 2 in Singapore, and just 2 in India (neither ranked in the top 300) 5 in the Africas (4 in South Africa, 1 in Egypt, with no other African or Middle Eastern country listed) (Jiao Tong University 2006)

18. AMC Exam Results for Migrant Doctors by Select Country of Origin (2002)

19. Methodology of Hawthorne, Hawthorne & Crotty Study (2007) Migration Flows: Analysis of all DIMA arrivals and departures data, and Census data related to OTDs AMC Exams: Analysis of all AMC examination outcomes by key variables 1978-October 2005, plus analysis of RACGP outcomes New Data: Mailout survey of 3,000 fairly recently arrived OTDs active in AMC (ie at least one MCQ attempt) State Variations: Analysis of all categories of OTDs in State Medical Registration Board databases (NSW, Victoria and WA) to capture ‘invisible’ OTDs, plus 30 interviews

20. Number of 1st Time MCQ and Clinical Candidates by Year (1978-late 2005)

21. Number of Candidates Passing the MCQ at Each Attempt

22. AMC MCQ Outcomes 1978-2005 Candidates: 139 source countries Top 10 sources: India (14%), Sri Lanka (8%), Egypt (7%), Bangladesh (5%), China (5%), UK (5%), Iraq (4%), South Africa (4%), Philippines (4%), Pakistan (3%) Highest % of first time presenters: S Asia, N Africa/M East, SE Asia and E Europe Pass rates: 51% on 1st attempt, 47% on 2nd attempt, 81% overall Highest pass rates: UK/Ireland (95%), South Africa (86%), North America (86%) Lowest pass rates: Other Americas (67%), SE Asia non-Commonwealth (70%), East Europe (70%) Age, English, gender and recency of training highly significant: Harder to pass for older candidates

23. AMC Clinical Outcomes 1978-2005 Overall pass rate: 86% of attempters (but just 53% of all MCQ attempters go on to pass) Highest pass rates: South Africa (66%), UK/Ireland (64%) Lowest pass rates: Other Americas (41%), SE Asia non-Commonwealth (38%), South East Europe (49%), Central Asia (49%) Middle East/ North Africa: Just as likely to pass as OTDs from English speaking backgrounds (OTDs from Eastern Europe and non-Commonwealth countries the most disadvantaged) Age: Highly significant (candidates requiring 3+ attempts older!)

24. Passing the Clinical Examination by Region, Percentages (1978-2005)

25. OTDs, Age and AMC Pass Rates - MCQ

26. Accreditation Pathways and IMGs in the Context of Maldistribution and Undersupply Does full registration matter in Australia? Just 26-33% of OTDs encounter the AMC Growing use of RACGP and specialist pathways Minimal impact on employment outcomes (high demand) Future access to supervised training places? Issues: Variability of data! Number and origin of OTDs conditionally registered by states Characteristics (country of training, AMC status, actual credentials etc) Practice status

27. Which IMGs by Region of Origin are Working With Conditional Registration? (IMG Survey)

28. Major Findings: IMG Survey Focused on OTDs deemed ‘active’ in the AMC pathway: 99% had attempted the MCQ exam (68% once, 21% twice, 11% 3+ times) 83% had passed it (doctors from ME/North Africa higher pass rates than ESB doctors (UK/Ire, South Africa, US, Canada, NZ) 61% had attempted the CE (no difference by country of origin in the number of attempts made) 41% of those attempting the CE had passed it Gender matters: Males 63% less likely to have passed the CE than females) Region of origin matters: Compared with ESB doctors, OTDs from Europe twice as likely to fail, those from Asia-Commonwealth 2.8 times as likely, those from ME/N Africa 2.9 times as likely, and those from ‘other’ backgrounds 4 times as likely

29. Pathway to Medical Registration by Origin (IMG Survey)

30. RACGP Pathway Examination Outcomes: 1999-2004

31. RACGP Examination Outcomes: 1999-2004

32. Medical Employment Outcomes by Region % of OTDs working in medicine in Australia: 78% (despite only 41% holding general registration) ESB doctors (95%) compared to North Africa/ M East (82%), Asia-Commonwealth (74%), and Other doctors (68%) When compared with ESB doctors, respondents from: Europe and ME/ N Africa = 3 times less likely to have obtained work in medicine Asia-Commonwealth = 4.7 times less likely Other backgrounds = 7.6 times less likely Current key barrier to medical practice: English language testing

33. Medical Employment Outcomes for 1996-2001 Arrivals in Canada Versus Australia (2001 Census) South Africa: 81% employed in Canada (cf 81% in Australia) UK/Ireland: 48% employed in Canada (cf 83% in Australia) India: 19% employed in Canada (cf 66% in Australia) HK, Malaysia, Singapore: 31% employed in Canada (cf 59% in Australia) Eastern Europe: 8% employed in Canada (cf 24% in Australia) China: 4% employed in Canada (cf 5% in Australia) Source: Labour Market Outcomes for Migrant Professionals – Canada and Australia Compared, L Hawthorne, Citizenship and Immigration Canada (2007)

34. The Impact of OET Testing on Medical Candidates: Pass Rates 1989-1995 (Hawthorne & Toth 1996)

35. The Impact of OET Testing on Medical Candidates: Location (1989-1996 Data: Hawthorne & Toth 1996)

36. The Impact of Occupational English Testing on Medical and Nursing Registration by Select Origin & Location: 1989-1995 Data (Hawthorne & Toth 1996)

37. Predicting Those Not Employed in Medicine in Australia (IMG Survey)

38. Type of Medical Employment in Australia by Origin (OTD Survey)

39. The Link Between Accreditation Status and Employment State-specific differences: Western Australia New South Wales Victoria

40. State Variations in Relation to OTDs: NSW, Victoria, WA Data consistency: Minimal, just 10/27 variables in common (eg country of origin, AMC status) Screening and selection variability: ‘Recruit-a-doc’ versus RWAV (etc) State competition for OTDs (sticks and carrots), $ incentives Recruitment and bridging support: WA (‘adventure medicine’, invisibility, retention) NSW (65% of OTDs conditionally registered; focus x 12 OTDs per year) Victoria (RWAV focus) Future displacement of OTDs from supervised clinical training: Rank order (domestic graduates, international students, OTDs) Case study: WA

41. Financial Incentives to IMGs by State (2006)

42. Conclusion: Individual Agency and Global Health Workers Motivations: Rural ? urban Public ? private Poor ? rich Unsafe ? secure (disease, law and order) Employment conditions ? remuneration, quality of practice, training, workload, facilities, promotion, health service quality etc Living conditions Family choice ? children’s education, spouse career (etc) Medical Migration and Global Migration Trends (OECD 2007) Source: Working Together for Health – The World Health Report 2006, WHO, Geneva; International Migration Outlook, OECD 2007, Paris

43. Impacts of Migration on Health Workforce Shortages ( WHO 2006)

44. Risks: Exacerbating Undersupply in Developing Nations (WHO 2006)

45. Future Medical Migration: Migration Occupations in Demand List (2007) Skill migration: Raised from 33,000 ?97,500 per year and ? Regional migration schemes International student flows Which priority professions listed apart from health sciences? Accountant, Engineers, IT All other fields on the list = health sciences: General Practitioner, Anaesthetist, Dermatologist, O&G, Ophthalmologist, Emergency, Paediatrician, Pathologist, Psychiatrist, Specialist Physician, Radiologist, Surgeon, Registered Nurse, Midwife, Mental Health Nurse, Dentist, Dental Specialist, Hospital Pharmacist, Retail Pharmacist, Occupational Therapist, Physiotherapist, Speech Therapist, Podiatrist, Radiographer, radiation Therapist, Nuclear Medicine Technologist, Sonographer

46. The Demographic Transformation: Western and Select Asian Nations