Migration of health workers
- There are about 60 million health workers worldwide.
- Many health workers migrate to high-income countries for greater income, job satisfaction, career opportunities and management quality.
- Demand for health workers is increasing in high-income countries, where health systems can depend heavily on doctors, nurses and other health workers who have been trained abroad.
- Migration of health workers may result in financial loss and weakens health systems in the countries of origin.
- WHO has developed a Global Code of Practice on the International Recruitment of Health Personnel to achieve an equitable balance of the interests of health workers, source countries and destination countries.
Health workers are people engaged in actions whose primary intent is to enhance health. These include people who provide health services – such as doctors, nurses, midwives, pharmacists, laboratory technicians – as well as management and support workers – such as hospital managers, financial officers, cooks, drivers and cleaners.
Worldwide, there are around 60 million health workers. About two-thirds provide health services; the other one-third are management and support workers. Without them, prevention and treatment of disease and advances in health care cannot reach those in need.
Why health workers migrate
Health workers, like workers in all sectors, tend to go where the working conditions are best. Income is an important motivation for migration, but not the only one. Other reasons include:
- greater job satisfaction
- career opportunities
- the quality of management and governance
- moving away from political instability, war, and the threat of violence in the workplace.
Migration is often stepwise. People tend to move from the poorest regions to richer cities within a country, and then to high-income countries. In most countries, there is also movement from the public to the private sector, particularly if there are considerable differences in income levels.
Globalization has helped to drive international migration. At the same time, demand for health workers has increased in high-income countries where not enough health workers are being trained locally and where the existing workforce is ageing. Demand for health services is also increasing because of ageing populations and the rise of chronic illnesses like diabetes and heart disease, especially in rural areas.
In a number of middle-income countries with good health education systems – such as Fiji, Jamaica, Mauritius and the Philippines – a significant proportion of students, especially in nursing school, begin their education with the intention of migrating, usually in search of a better income. Some countries, notably the Philippines, are seeking to capitalize on the demand for imported health workers by deliberately training graduates for international careers.
Impact of migration
The movement of health workers abroad has both negative and positive consequences.
When significant numbers of doctors and nurses leave, the countries that financed their education lose the return on their investment.
Financial loss is not the most damaging outcome, however. When a country has a fragile health system, the loss of its health workforce can bring the whole system close to collapse, with the consequences measured in lives lost.
On the positive side, each year, migration generates billions of dollars in remittances (the money sent back to home countries by migrants) to low-income countries and has been associated with a decline in poverty. Health workers also may return and bring significant skills and expertise back to their home countries.
Scope of migration
Health systems in a number of high-income countries depend heavily on doctors and nurses who have been trained abroad. Over the last 30 years, the number of migrant health workers increased by more than 5% per year in many European countries. In countries of the Organisation for Economic Co-operation and Development (OECD), around 20% of doctors come from abroad. In some Gulf States, such as Kuwait or the United Arab Emirates, more than 50% of the health workforce are migrants.
Nurses from the Philippines (110 000) and doctors from India (56 000) account for the largest share of migrant health workforce in OECD countries. However, countries with smaller populations than India and the Philippines may suffer from a larger impact in terms of expatriation rates. Over 50% of highly-trained health workers leave for better job opportunities abroad in some low-income countries. The graph below shows the top 10 countries with highest expatriation rates for doctors.
Addressing the negative effects of health worker migration
Highly trained and skilled health workers from developing countries continue to emigrate at an increasing rate to certain countries, thereby weakening health systems in the countries of origin. The following actions are required to address the negative effects of migration.
In source countries:
- better health workforce retention, especially in rural and remote areas;
- stronger protection and fairer treatment of health workers, who may face difficult and often dangerous working conditions and poor pay; and
- improved domestic training of health workers and development of policies that facilitate the return of migrants.
In destination/receiving countries:
- reduced dependency on migrant health workers notably through educating and training of more health workers domestically and by making better use of the existing health workforce; and
- responsible recruitment policies by destination/receiving countries and fair treatment of migrant health workers.
WHO has developed global recommendations on health workforce retention in remote and rural areas, so that countries can see what options have worked in different settings around the world to attract and retain health workers.
WHO Global Code of Practice on the International Recruitment of Health Personnel
In 2004, the World Health Assembly requested WHO to develop a code of practice on the international recruitment of health personnel. In response, WHO initiated a global consultation process to produce a draft code. The Code was adopted by the World Health Assembly in May 2010.
The Code of Practice is voluntary, global in scope and applies to all health workers and stakeholders. It sets out principles and encourages the setting of voluntary standards. The equitable balance of the interests of health workers, source countries and destination countries is promoted, with a particular emphasis on redressing the negative effects of health worker migration on countries experiencing a health workforce crisis. Key components of the Code include:
- greater commitment to assist countries facing critical health worker shortages with their efforts to improve and support their health workforce;
- joint investment in research and information systems to monitor the international migration of health workers in order to develop evidence-based policies;
- Member States should meet their health personnel needs with their own human resources as far as possible and thus take measures to educate, retain and sustain their health workforce; and
- migrant workers' rights are enshrined and equal to domestically-trained health workers.