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Is care-worker migration really a

form of exploitation?

Mark Radford


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Exploitation?

1. Picture of the global health workforce.

2. The source countries, with particular reference to Sub-

Saharan Africa

3. The care workers, factors influencing the migration of Indian

nurses. Two local case studies.

4. The United Kingdom, poacher turned gamekeeper?

5. Conclusion. To what extent is this exploitation.


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An Ageing Society, Migrant Care Workers in Demand

The developed world is increasingly heavily reliant on migrants to providecare in residential homes and clients own homes.

In social care this covers formal and informal employment, including domestic

service, live in care workers, and working for home care agencies withincare homes

UK has a long history of seeking staff by drawing on relationships withCommonwealth countries. Countries such as the Philippines and Indiaencourage their citizens to work abroad.

The EU generally has been employing labour from the former sovietinfluenced states. There is some evidence this is declining as the recessionbites.

Source: Cangiano, Shutes, Spencer and Leeson 2009


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Source: Giovanni Lamura 2009


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Source: James Buchan and Julie Sochalski 2004


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Nurse Availability Data Selected SSA Countries

Adapted from WHO World health Report cited in Dovolo 2007


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Migration Push Pull Motivating Factors

in Six SSA Countries

Source: Awases et al 2004 cited in Dovolo 2007


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Impact of Migration on SSA

Health Service Delivery

Staff shortages mean systems cannot deliver critical services

Loss of staff with key skills

Loss of professionals contribution to the economy

Encourage development of private nurse training schools

Economic Effects

Loss of state investment in training of leavers

Loss to GDP

Increases in remittances


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Migration from the care worker perspective.

The international migration of Indian nurses.

In past Indian nurses have generally migrated to Middle East.

New opportunities in West have arisen in recent years.

Market pull is likely to continue

Population of richer countries is ageing whilst in poor

countries the share of young people remains high

Improvement in medical interventions which prolong life

generates a demand for trained nurses

Despite increasing nursing enrolment in rich countries women

who would have trained as nurse are opting for more

prestigious work

Adapted from Thomas 2006


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Chi-squared values showing the relationship between the

intention to migrate and selected respondent attributes (n = 448)

Source: Thomas 2006


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Case Study : Beena Joseph

Beena with husband Vinny and children

Rosemary (10) and Richard (6)

Age: 40

Religion: Roman Catholic

Mother Tongue: Malayalam

Home State: Kerala

Nursing Qualifications:

Registered Nurse and

Midwife in India

Experience: Worked in govt

hospital in India for 8 years.Moved to Saudi Arabia for 4

years, worked on medical

wards. Has worked in

private care homes in UK

since 2004.


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Case Study: Beena JosephPush and Pull Factors

bringing Beena to UK:

Income higher than

government hospital in

India. Joint income in UK

lower than Saudi Arabia

but lifestyle much better.I like the culture and

freedom here

Little opportunity to

practise RC faith in Saudi

and employment meant

Beena and Vinny lived

apart.

Facilities in hospital

comparable in all three

countries.

Stick Factors: Good work prospects. Children

anglicised and happy at school. Vinny would like

to stay in England for good, Beena misses her

wider family.


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Case Study:

Silvy Jacob

Age : 40

Religion: Roman Catholic

Mother tongue: Malayalam

State: Kerala

Nursing Qualifications: Registered

Nurse and Midwife in India.

Experience: Worked in private

hospital in India. Moved to UK in

2004 where she is Nurse in Chargeat a private care home.

Silvy at work whilst Cyril has tea


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Case Study: Silvy Jacob

Push/Pull Factors influencingSilvys decision to move to UK.

Poor pay, little promotion

prospect, the hospital I worked

in was not well maintained and

not always very well equipped.

Long waiting list to work ingovernment hospital, I had to

register at an employment

exchange

Stick Factors: Happy in job, good

working conditions and supportfrom English NMC. However,

intend to move back to India

sometime in next 10years with

husband Jose. Children Minna

(14) and Sona (7) may choose to

stay.


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The United Kingdom An exploiter?

Country has been prominent in international labour markets because ofhome shortages

Ageing population

Insufficient recruitment from home

Improved technology and types of treatment

UK government committed to expanding NHS 20,000 more nurses by2004


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Migrant Care Workers The Issues

Vacancies are high care work appears unattractive to local

potential workers

Care Agencies accused of mistreating migrant care workers

Managers lack training to deal with issues of discriminationand harassment

Migrant workers unlikely to be members of trades unions

Live in migrant care workers particularly vulnerable because

status may be unclear. Lack contracts and conditions Integration into communities, language courses,. Introduction

to local customs, colloquialisms and social expectations.


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Oxfams -Who Cares?

This report was published on 2nd December 2009. It contains

evidence of abusive practices among some agencies who

supply workers from abroad.

The report states The increasing use of migrant workers has notbeen matched by a recognition of the experiences of migrant

care workers and the ways in which employers and agencies

will exploit their vulnerabilities in order to keep costs down

and compete with other social care providers.

Oxfam calls on government to extend the Gangmasters LicensingAuthority but refuses to name the offending agencies

Source: guardian.co.uk


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The United Kingdom stands out as a country where active

international recruitment of nurses and other health

professionals , was an explicit national-level governmentpolicy response to the need to increase staffing levels in a

public sector, government funded health care system.

James Buchan 2007

Admissions to the UK Nurse Register from European Union and

Other Countries 1993/2005: J Buchan 2007


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Does a code make a difference?

The Department of Health in England

introduced a Code of Practice for

international recruitment for National

Health Service Employers in 2001

The code required National Health

Service employers not to actively recruit

from low income countries, unless there

was government to government

agreement. The code was updated in

2004.

The level of international recruitment

has dropped significantly since early

2006. Regulatory and education

changes in the UK in recent years have

also contributed to this fall.

Adapted from: Buchan 2009


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The potential to assess the English code is limited by available databases. For example,

there is not a registration system for all care workers. There is evidence the numbers

of nurses from list countries entering the country is falling. It is unclear at present to

what extent this is due to the code and to what extent it is due to a fall in demand

although it is likely both are playing a part.

Nurses: new registrants in the United Kingdom, other developed

countries, list-exempt countries and list countries, 1998 -2006 Cited in

Buchan 2009 Source: Nurses and Midwives Council, United Kingdom


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Numbers

Numbers of Zambian RNs requesting verifications from the

GNC for the top eight destination countries (1991 -2005)

Source: Hamada 2009


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An example for others to follow?

There are now numerous codes of practice following the English

initiative. Their effectiveness is yet to be demonstrated (WHO

2006)

Codes assume a permanent loss to the source country.

Temporary loss can lead to a net gain.

It may be more suited to the UK than elsewhere where there

is one large public sector employer

The code has a good level of recognition in the NHS but would

benefit from better dissemination in low income countries


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Conclusion-Exploitation?

With an ageing society the demand for care workers will increase. Care workerswithout qualifications often work in a poorly regulated environment. This provides

an opportunity for exploitation by a minority of unscrupulous employers.

Some evidence indicates unfair treatment of migrant workers in the UK amounting to

exploitation. It is likely the same is happening in other EC and western countries.

A comprehensive approach is required to tackle both the long term care of the elderly

in ageing societies and migrant challenges at an international level. The work of

the WHO is crucial to this.

In order to minimise exploitation the legal position of unqualified migrant workersshould be reviewed. Data are limited especially in source countries. Protocols have

been developed in recipient countries but these mainly apply to registered health

workers.


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Conclusion Exploitation?

.

Evidence of exploitation of trained health workers is limited. Benefits sometimes

accrue to source country, destination country and to the nurse themselves. The

case study of Indian nurses in England supports this.

In developing nations, particularly those in Sub Saharan Africa, migration has had adetrimental impact on existing hugely overstretched health care systems. These

losses can be mitigated to some extent by returning skilled workers and

remittances from those abroad. In India the disparity in resources between state

and privately run hospitals has contributed to nurse migration.

Freedom of workers to move from place to place in order to work is a desirableobjective in a free society but any abuses that result must be addressed.


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Bibliography

Department of Health 2004 Code of Practice for the International Recruitment of Healthcare Professionals

Wanless D 2001 Securing Our Future Health: Taking a Long Term View. HM Treasury London

Kingma M 2007 Nurses on the Move: A Global Overview Health Services Research 42:3 Part II

Cangiano, Shutes, Spencer and Leeson: 2009 Migrant care workers in ageing societies University of Oxford

Lamura G 2009 Opportunities and challenges of migrant care workers on the elder care sector. Department of

Gerontology University of Ancona Italy

Buchan J 2007 International Recruitment of Nurses: Policy and Practice in the United Kingdom Health ServicesResearch 42: 3 Part II

WHO 2006 The World Health Report 2006 - Working Together for Health Geneva World Health Organisation

Buchan J & Sochalski J 2004 The Migration of nurses: trends and policies Bulletin of the World HealthOrganization 82,8 587-594

Gentleman A 2009 Care agencies accused of exploiting migrant care workers www,guardian.co.uk

Thomas P 2006 The international migration of Indian nurses International Nursing Review 53, 277-283

Kingma M 2001 Nursing migration: global treasure hunt or disaster-in-the-making? Nursing Inquiry 2001: 8(4)205-212

Dovlo D 2007 Migration of Nurses from Sub-Saharan Africa: A review of Issues and Challenges Health ServicesResearch 42:3 Part II


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Bibliography

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Hamada N, Maben J, McPake B, Hanson K 2009 International flow of Zimbabwean nurses Human Resourcesfor Health 2009 7:83

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Health 7:5

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