Chapter 3

1. Chapter 3 Globalization and the Health Care Workforce

2. Learning Objectives • Describe the history and current trends in international migration of physicians and nurses • Enumerate the factors that motivate physicians and nurses to migrate to other countries • Discuss the implications of physicians and nurses migration for sending and receiving countries • Understand the policy context and policy interventions that attempt to manage physicians and nurse migration • Explain the issue of ethical recruitment, visa regulation, credentialing, and adaption for managers of foreign-born and trained physicians and nurses.

3. Introduction • The International Migration of healthcare workers has caused increased debate in recent years. • Issues arise with both the sending a receiving country. • Specifically, developing countries lose trained personnel they have invested resources in. • Managers of US Health Care systems need to understand international migration.

4. History and Current Trends • WHO Study in 1970 found International Medical Graduates practicing in the US were about 1 in 5. • Significant numbers of International Nursing Graduates were also working in the US

5. History and Current Trends • Historically sending countries were : • Haiti • Suriname • Hong Kong • Jordan • Philippines

6. History and Current Trends • Characteristics of the healthcare workforce migration have shifted since the WHO study • Now we see migration FROM: • Egypt • Cuba • The Caribbean • Sub-Saharan Africa • The Former Soviet Union

7. Cause of International Migration • Push Factors • What motivates them to leave? • Pull Factors • What motivates them to come?

8. Sending Country / Region Trends • Brain Drain: Sub-Saharan Africa and the Caribbean • Widespread , uncontrolled departure of physicians and nurses. • High rates of emigration have been seen in: • South Africa • Ghana

9. Sending Country / Region Trends • Brain Drain: Sub-Saharan Africa and the Caribbean • In Africa the HIV/ AID epidemic has seriously depleted the healthcare workforce • 42% of nursing positions in the Caribbean are vacant

10. Strategic Deployment: Cuba the Philippines, and India • Some workforce migration is done purposely. • Cuba has utilized their workforce surplus to supply other countries for decades • Cuba has done this to become a global leader in healthcare

11. Strategic Deployment: Cuba the Philippines, and India • Similar to Cuba, the Philippines has supplied the world with nurses • The Philippines produces about 20,000 nurses a year • In 2004, 85% of these nurses practiced abroad

12. Strategic Deployment: Cuba the Philippines, and India • Up and Coming Player: China • China is relatively new to the global market • Has only sent workers abroad for the last 15 years

13. Consequences for Receiving Countries • The Policy Context • The receiving countries may not be addressing the root of the recruitment problem. • General Agreement on Trade Services • Liberalize trade in services • Encourage economic growth • Increase participation of developing countries in world trade • NAFTA • Created special visas between the US, Canada and Mexico

14. Consequences for Receiving Countries • Policy Responses • WHO Activities • Treat, Train, Retrain • ICN Statement • Developed guide on the ethical recruitment of nurses • Encourages receiving countries to correct their system problem of recruitment • Domestic Policies in Sending Countries • Implemented to curb “Push” issues • Disincentives in the form of migration fees are sometime used • Domestic Policies in Receiving Countries • Turnover for nurses is estimated to be between 10% to 30% • Policies implemented to reinvest in healthcare workers • Government to Government Bilateral Agreements • Receiving country agrees to underwrite the cost of medical training • Staff are recruited only for a fixed period • Compensation Schemes • In addition to reimbursement for educational cost, this requires receiving country to pay additional costs to the sending country for the cost of losing the worker.

15. Consequences for Receiving Countries • Policy Responses • Managed Migration in the Caribbean • Promotes regional cooperation in six areas: • Terms and condition of work • Recruitment, retention and training • Value of Nursing • Utilization of deployment • Management practices • Policy development • Code of Practice on International Recruitment in the UK • The UK is one of a few receiving countries that have set criteria for recruitment

16. Issues for Managers • Recruitment • Twinning • Staff Exchange • Educational Support • Bilateral Agreement • Regulation • While in training = J-1 visa • After training some convert to a H-1B or O temporary visa • H-1B applies to specialty occupations • O visas apply to physicians with Outstand abilities in their field • Permanent residency through • Labor certification • National interest waiver

17. Issues for Managers • Credentialing • IMGs must have a diploma from a school listed in the International Medical Education Directory • Must pass step 1 and 2 of the US Medical Licensing Exam • Must have acceptable scores on the TOEFL

18. Issues for Managers • Adaptation • Must learn the culture of US Medicine • IE: patient centered care for mental illness • Must Also learn American family culture • Certain family relationships will effect diagnosis and treatment (IE: single parent home)