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Migration and health: A focus on
health care worker migration.
Session overview
• Migration and health
• Migration and human rights
• Globalisation
• Health systems
• How it is in Europ...
The global picture
What effects does migration have on health?...
……5 minutes, in groups of 5!
Effects of migration on health
• Faster spread of infectious diseases
• Reduction of health care services vs increased hea...
Human rights and migration
• Freedom of movement. (UDHR)
• Right to health and well being (WHO charter
and UDHR)
• Right t...
Globalisation
Globalisation can be defined as processes that are changing
the ways in whichpeople interact across boundari...
Health care workers and health
systems.
• Back Bone
• 2/3 of health expenditure
• Health workers ‘own’ considerable
invest...
In Europe…
….. Over to you!
“I not only use all the
brains that I have, but
all that I can borrow.”
Woodrow Wilson, 28th
US President
Inequalities in HCW’s
• SSA needs 720, 000 more doctors and
670,000 more nurses to reach MDG’s.
• 700% increase in docs, 5...
Millennium Development goals:
• Millennium Development Goals
- To achieve over the period 1990-
2015
Goal 4: 2/3 reduction...
health worker density world
map
[Source: Joint Learning Initiative, 2004]
Income distribution world map
Health care worker migration…
why?
5 mins…groups of 5!
Push and pull factors!
• Wages
• Working conditions
• Future prospects (training etc.)
• Management and health system
gove...
dynamics
economic
stagnation
low respect
for staff
low
morale
poor health
outcomes
low pay for
health staff
dysfunctional
...
Summary of causes
• Migration is not the ‘problem’ but a self
perpetuating result of problems
• Inequality driving huge di...
Consequences…
Increasing Inequality
• Increasing migration
• Worse health outcomes
• Health systems effects
Increasing migration…
Number of Zimbabwean-trained doctors on UK
register
0
20
40
60
80
100
120
1999 2000 2001 2002 2003 2...
Zimbabwean-trained nurses on UK register
0
500
1000
1500
2000
2500
1998/99 99/2000 2000/01 2001/02 2002/03 2003/04
Year
Nu...
Estimated numbers of nurses trained in Ghana
registered in the UK
Source: calculated from NMC 2004
Ghanaiannurses
0
200
40...
Less health care workers – worse
outcomes.
0
1
2
3
4
5
6
7
8
9
0 1 2 3 4 5
Graph 1: Density (workers per 1,000,log)
Mortal...
Health systems effects
• In addition to worsened health
outcomes
–beheading of health system: top goes
first
–training and...
Perverse Subsidy
• Perverse….in the wrong direction
• Subsidy – someone helping someone
else by giving them money
• Why pe...
Looking at the UK and Ghana
• Ghana about 50 times poorer than the UK.
• Govt. health expenditure per capita
– Ghana £6 (Z...
• Saving of training investment in UK health services: crude
estimates of £65 million for 293 doctors and £38 million
for ...
What are the possible policy
responses?
Groups of 5…5 mins!
Possible responses…
• Health systems strengthening in the countries
of origin
• Restitution
• Self sufficiency
• Ethical r...
Restitution
Restitution represents:
• Progressive redistribution that works: health services
are highly redistributive
• P...
Ethical Recruitment
A failing policy?
• Increase over time (below) in UK nurse registration
rates, during a period when a ban on active
intern...
Partnership
• Boundaries are blurring between the UK and
low-income country health services - they are
becoming interdepen...
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Health Care Worker Migration

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Health Care Worker Migration

  1. 1. Migration and health: A focus on health care worker migration.
  2. 2. Session overview • Migration and health • Migration and human rights • Globalisation • Health systems • How it is in Europe • Inequalities • Causes • Consequences • Policy responses.
  3. 3. The global picture What effects does migration have on health?... ……5 minutes, in groups of 5!
  4. 4. Effects of migration on health • Faster spread of infectious diseases • Reduction of health care services vs increased health care services. • Lowering of human resources in sources countries • Migrant health not being cared for properly in destination country • Remittances – might improve health • Psychosocial – away from home • Refugees – poor health services.
  5. 5. Human rights and migration • Freedom of movement. (UDHR) • Right to health and well being (WHO charter and UDHR) • Right to the highest attainable standard of health (ICESC) • Individuals have a personal choice, should not be persecuted!
  6. 6. Globalisation Globalisation can be defined as processes that are changing the ways in whichpeople interact across boundaries, notably physical (such as thenation-state), temporal (such as instantaneous communication viaemail), and cognitive (such as cultural identity). The resultis a redefining of human societies across many spheres, economic,political, cultural, technological and so on. As such, globalisationaffects the health of different people in very different ways.How good or bad globalisation happens to be for you will be influenced by socioeconomic status, sex, education, age, geographical location,and otherfactors. » Lee, K et al. BMJ 2002;324:44 ( 5 January )
  7. 7. Health care workers and health systems. • Back Bone • 2/3 of health expenditure • Health workers ‘own’ considerable investment – skills financed by the health system. • 100 million health care workers in the world.
  8. 8. In Europe… ….. Over to you!
  9. 9. “I not only use all the brains that I have, but all that I can borrow.” Woodrow Wilson, 28th US President
  10. 10. Inequalities in HCW’s • SSA needs 720, 000 more doctors and 670,000 more nurses to reach MDG’s. • 700% increase in docs, 50% increase in nurses. • UK: 620 people per doctor, 185 per nurse • Liberia: 43,478 per doctor, 9,804 per nurse
  11. 11. Millennium Development goals: • Millennium Development Goals - To achieve over the period 1990- 2015 Goal 4: 2/3 reduction in child mortality Goal 5: 3/4 reduction in maternal mortality Goal 6: Halt and begin to reverse spread of HIV/AIDS, malaria and other diseases
  12. 12. health worker density world map [Source: Joint Learning Initiative, 2004]
  13. 13. Income distribution world map
  14. 14. Health care worker migration… why? 5 mins…groups of 5!
  15. 15. Push and pull factors! • Wages • Working conditions • Future prospects (training etc.) • Management and health system governance
  16. 16. dynamics economic stagnation low respect for staff low morale poor health outcomes low pay for health staff dysfunctional health system loss of training investment poor management of staff poor quality of care migration R R R HIV/AIDs personal risk to staff conflict lack of mentors
  17. 17. Summary of causes • Migration is not the ‘problem’ but a self perpetuating result of problems • Inequality driving huge differentials in working conditions • Africa has a particular set of serious causes • Poor working conditions • Demand • Increasing integration of global economy.
  18. 18. Consequences… Increasing Inequality • Increasing migration • Worse health outcomes • Health systems effects
  19. 19. Increasing migration… Number of Zimbabwean-trained doctors on UK register 0 20 40 60 80 100 120 1999 2000 2001 2002 2003 2004 Year Number of doctors
  20. 20. Zimbabwean-trained nurses on UK register 0 500 1000 1500 2000 2500 1998/99 99/2000 2000/01 2001/02 2002/03 2003/04 Year Number of nurses
  21. 21. Estimated numbers of nurses trained in Ghana registered in the UK Source: calculated from NMC 2004 Ghanaiannurses 0 200 400 600 800 1000 1200 1998/99 1999/2000 2000/01 2001/02 2002/03 2003/04
  22. 22. Less health care workers – worse outcomes. 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 Graph 1: Density (workers per 1,000,log) Mortality (per 1,000, log) LnMMR LnIMR LnU5MR Maternal Infant Under-5
  23. 23. Health systems effects • In addition to worsened health outcomes –beheading of health system: top goes first –training and management suffer –more pressure on those remaining –re-inforces migration pressures
  24. 24. Perverse Subsidy • Perverse….in the wrong direction • Subsidy – someone helping someone else by giving them money • Why perverse…money going from poor to rich…is this right??!!
  25. 25. Looking at the UK and Ghana • Ghana about 50 times poorer than the UK. • Govt. health expenditure per capita – Ghana £6 (Zim? £16) – UK £800 • Ghana trains health professionals, then loses the stream of expected health care benefits to privileged UK health service users
  26. 26. • Saving of training investment in UK health services: crude estimates of £65 million for 293 doctors and £38 million for 1021 nurses • Provides benefits to UK health service users: at salary costs if those staff were all employed in the NHS, an estimated £39 million per year – These are orders of magnitude of perverse subsidy - of the scale of the injustice
  27. 27. What are the possible policy responses? Groups of 5…5 mins!
  28. 28. Possible responses… • Health systems strengthening in the countries of origin • Restitution • Self sufficiency • Ethical recruitment • Bonding • Improving post graduate training • Training different types of health care workers • Incentives to stay • Partnership
  29. 29. Restitution Restitution represents: • Progressive redistribution that works: health services are highly redistributive • Practical response: informed policy since training location of staff is verified on registration • Non-discriminatory if detached from individuals: extent of the subsidy should inform policy • Can be managed effectively: mechanisms can be designed on a case by case basis to assure additionality and ring fencing to health care • Can help build incentives to stay
  30. 30. Ethical Recruitment
  31. 31. A failing policy? • Increase over time (below) in UK nurse registration rates, during a period when a ban on active international recruitment had just come into effect: Growth in registrations of nurses from Africa (randomly selected countries) - 200 400 600 800 1,000 1,200 1,400 in 98/99 in 99/00 in 00/01 in 01/02 in 02/03 Year Growth index (98/99 = 100) Source = NMC Zimbabwe Ghana Zambia SA Kenya Nigeria Ban Banstrengthened
  32. 32. Partnership • Boundaries are blurring between the UK and low-income country health services - they are becoming interdependent • Scope for mutual benefit and redistribution already exists e.g. in Ghana - UK health service links between professionals, associations, facilities and individuals • Policy can build onto this: effective financial support, two-way circular migration, training and research collaboration

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